Traumatic brain injury (TBI) is the most common cause of death and disability in the pediatric population in North America. Management of TBI can be challenging in children and its workup should follow evidence-based guidelines. Children with severe TBI need cross-sectional imaging and admission in most cases, while patients with very mild TBI do not need advanced imaging. While practice guidelines seem straight forward for these two edges of the spectrum, decision making in mild to moderate TBI seems to be more controversial. This chapter describes current knowledge and practice guidelines, based on PECARN and other pediatric trauma societies, and most recent research to guide decision making, based on patient demographics, clinical findings and acknowledgment of the potential risk of radiation, while avoiding missed injuries. For this purpose, two main questions will be systematically addressed: (1) In pediatric patients at intermediate risk for having TBI, is observation safe and valuable in order to reduce the number of unnecessary head CT (hCT)? (2) In pediatric patients at intermediate risk for having TBI, are there specific signs or symptoms able to identify those patients at higher risk? Our evidence-based review shows that a planned observation approach is safe and reduces the ratio of hCT in this group of patients significantly. In addition, we describe that within this intermediate risk group, young age and the presence of isolated scalp hematomas (ISH) are associated with higher risk of having clinically important TBI or TBI findings on imaging. We therefore recommend that hCT should be strongly considered in asymptomatic patients under the age of 3 month of age, patients younger than 24 months of age presenting with medium-large size (>1 cm) ISH, and patients older than 24 months of age with large (>3 cm) ISH after having suffered a TBI. The presence of medium ISH and ISH in non-frontal location in children older than 24 months of age is also associated with a mild increased risk for TBI, however no evidence-based indication for hCT can be recommended in this setting.