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                              Head injury

Head injury is a common reason why children are brought to an ER. According to the Institute for Neurology and Neurosurgery:

• approximately one of ten children will experience loss of consciousness from head injury during childhood. 
  
• annually, over 500,000 children are hospitalized following a head injury.
  
• the majority of head injuries, however, are of a mild nature only (result in injury to the scalp rather than the brain) with outpatient management or a simple overnight stay in the hospital being all the treatment needed.
  
• falls are the most common cause of head injuries in children less than 10 years of age while motor vehicle accidents are responsible for the majority of head injuries in adolescents.

A closed head injury (CHI) in children occurs when the head receives a blow, usually from a collision with an object (e.g., the floor, the road, furniture, another person’s head) in which the skin remains intact and there is no penetration of the head by a foreign object.

These injuries can range from a small bruise on the head to a serious brain injury. This may result from bleeding around or within the brain or swelling of the brain itself.

What is a concussion?

• A concussion is a head injury associated with a temporary loss of brain function in which the victim will have a loss of consciousness or awareness (e.g., confusion, disorientation) for a few minutes up to a few hours after the traumatic event. In rare cases, a concussion can last for months.

What causes head injuries in children?

• There are many causes of head injury in children. The more common injuries are falls, motor vehicle accidents (where the child is either riding as a passenger in the car or is struck as a pedestrian), or a result of child abuse.
  
• The risk of head injury is high in adolescents and is twice as frequent in males than in females.
  
• Studies show that head injuries are more common in the spring and summer months when children are usually very active in outdoor activities such as riding bicycles, in-line skating, or skateboarding.

What are the signs and symptoms of a head injury in a child?

The signs of a head injury can occur immediately or develop slowly over several hours. The head may look fine, but complications could result from bleeding inside the skull.

On the other hand, swelling or a “goose egg” may appear on the scalp after a blow to the head without bleeding inside the skull. This swelling is the result of broken blood vessels beneath the skin and may take days or even weeks to completely disappear.


The following signs and symptoms may suggest a serious head injury that requires emergency medical evaluation and treatment:

• Severe headache
  
• Stiff neck
  
• Repeated vomiting (more than 2 – 3 times)
  
• Loss of consciousness
  
• Irritability, personality changes, or unusual behavior
  
• Seizures
  
• Drowsiness
      o may occur even without serious brain injury
  
• One pupil (dark area in the center of the eye) is larger than the other
  
• Swelling at the site of the injury (scalp wound)
      o may occur even without serious brain injury
  
• Large laceration (cut) on the head
  
• Fluid drainage from the ears (may be clear or bloody)
  
• Loss of balance while walking
  
• Slurred speech
  
• Blurred vision
  
• Weakness in one side or area of the body

Signs and Symptoms of a Concussion

Mental:  Headache, confusion, feeling mentally foggy, seeing stars or flashing lights, impaired consciousness, poor concentration and attention.

Physical:  Vacant or glassy-eyed stare, double or blurry vision, poor balance and coordination, dizziness, fatigue, nausea or vomiting, incoherent speech, ringing in ears.

Behavioral: Inappropriate play on the field (running the wrong way), mood swings, trouble sleeping, irritability, changes in personality, nervousness or sadness, impaired academic performance.

What should I do if my child has a head injury?

For a mild head injury, in which none of the potential signs or symptoms for a serious injury listed above are present:

Ice: If your child will let you, gently hold an ice pack to the bump to lessen the swelling on their head. Apply the ice for 20 minutes and then take a 5-minute break, then 20 minutes again. Do not apply the ice directly to the skin.

Pain medication (e.g., acetaminophen or ibuprofen) may be used for a mild headache. DO NOT take aspirin, because it can increase the risk of bleeding.

Observe your child. The reason for the period of observation is because doctors often rely more on how the child behaves after the injury than what happened at the time of the injury. If the brain has been injured, signs may show immediately, or they may appear slowly during the next 24 hours.

If a head injury occurs near night or nap time in an already tired child, you may be confused about whether the drowsiness is due to the injury or whether its just time for your child to sleep.

It’s ok to let your child fall asleep, but awaken yourself every 2 - 3 hours and check on your child. This is what to look for:

• Change in color. Your child should be their usual color – paleness and certainly becoming blue is a real concern.
  
• Change in breathing. Your child should not have periods of very shallow breathing, 10 – 20 second periods of stop-breathing episodes followed by irregular breathing, or gasping episodes.
  
• Twitches. Your child should not twitch on one side of the body involving a whole limb.
  

If your child’s color and breathing patterns are normal and there are no signs or symptoms of brain injury as listed above, there is no need to awaken your child unless advised to do so by your pediatrician.

If, however, you are uncertain or your child’s appearance does not look right to you, sit or stand your child up and then put them back down. Normally, a child will fuss a bit and thrash around in the bed to resettle.

If your child does not act like this, try to fully arouse them by sitting or standing them up, opening their eyes, and calling their name. If they awaken, look at you, fusses or smiles, and struggles to be left undisturbed, it will be ok for you to go back to sleep and recheck them in 2 – 3 hours. 

If, on the other hand, they do not protest, can’t be awakened enough to begin fussing, is pale, shows irregular breathing, or shows any of the signs or symptoms of brain injury listed above, call your pediatrician and seek medical attention immediately.


For a moderate to severe head injury in a child that has loss consciousness, take the following steps:

1. Do not try to move him or her in case of neck or spine injury.
   
2. Call for help (911).
   
3. Check the child’s airway, breathing, and circulation. If necessary, begin rescue breathing and CPR.
   
4. If the child is vomiting or has a seizure, turn them on their side while trying to keep the head and neck straight.
   
5. Stop any bleeding by firmly pressing a clean cloth on the wound. If blood soaks through the cloth, do not remove it. Place another cloth over the first one.
   

How will the doctor evaluate a child with a head injury?

This of course will depend on several factors, such as was there loss of consciousness after the injury and the condition of the child. Among children with minor closed head injury, loss of consciousness is uncommon but is associated with an increased risk for brain injury.

According to the American Academy of Pediatrics, “for children with minor closed head injury and no loss of consciousness, a thorough history and appropriate physical examination should be performed.

• Observation in the clinic, office, emergency department, or at home, under the care of a competent caregiver is recommended for children with minor closed head injury and no loss of consciousness.
  
• The use of a computed tomography scan (also called a CT or CAT scan) or a skull x-ray is not recommended for the initial evaluation and management of the child with minor closed head injury and no loss of consciousness.”
  
• The CT scan can detect skull fractures and bleeding in or around the brain. A CT scan will most likely be performed in the case of any signs of potentially serious head injury as listed above.
  
• The decision to send your child home or stay at the hospital for further observation and care will depend on several factors such as how your child looks and the results of any imaging studies.

When can my child return to sports following a concussion?

An injured brain undergoes metabolic changes that affect its energy levels, meaning physical and
mental exertion might add more strain.

Returning your child to a normal routine too soon, even if he or she has a mild concussion, can prolong symptoms, potentially causing brain damage or more severe problems.

Each concussion brings greater risk for more serious injuries, including additional symptoms and/or longer recovery periods.

Only a medical professional can offer guidance to help parents know when it’s safe for a child to return to regular activities.

A general rule of thumb is that the child must be completely symptom-free for at least 1 week before gradually returning to full activity. A medical professional can provide an activity plan for slowly returning to full speed.



How can head injuries in children be prevented?

• Supervise children during play.
  
• Have your child always wear appropriate headgear and safety equipment when biking, in-line skating, skateboarding, snowboarding or skiing and playing contact sports.

              o Wearing a proper fitting helmet can significantly decrease a
                 child’s risk of brain injury from a fall during a recreational
                 activity.

              o See the following website for detailed information on the use
                 of helmets for children
                 (http://www.aap.org/family/thelmabt.htm).

• Always buckle your child up and use age-appropriate car seats or boosters while riding in the car.
  
• Make sure that children have a safe area in which to play, including the inside and outside of your home.