As a parent, I can't tell you the number of times my children have bonked their heads.  I'm sure I hit my head a few times as a child also.  Head injury is very common in children.  Small bumps, bruises and knots typically don't require special treatment.  More severe head trauma may be life threatening.  It is often difficult for a parent or pediatrician to determine the extent of injury, especially when the trauma was unwitnessed.  So when does a child need to be seen by a doctor?  When does a child need an ambulance or a visit to the emergency department?  What is the risk of developing complications after a head injury?  Is the skull fractured?  Is there bleeding inside or outside the skull?  Was there any brain damage?  What is a concussion?  What if my child gets "knocked out?" I will address these questions with a discussion about common approaches to minor head injury in children.

What are the types of head injury?

Soft tissue damage - Cuts, bruises, "knots," swelling... these are the things you can see from the outside.

Blunt force - When either an object hits the head or the head hits an object (such as in a fall), visible signs of injury may not be present.  Fractures of the skull, internal bleeding, or brain damage may be completely hidden from view.

Acceleration or deceleration - When a head stops or starts moving quicky.  Brain or tissue damage can occur without any contact with an object or surface.  This type of injury includes "shaken baby syndrome" and can cause life-threatening damage.

How common is head injury in children?

Minor head injury is extremely common.  It is difficult to provide statistics on injuries that are never reported or seen by a doctor.  About 400,000 pediatric ER visits are due to head injuries.  Only about 3-5% of these cases involve internal injury and only a small proportion (less than 1%) of children with intracranial injury require surgery.

What are the causes of head injury?

There are many causes of head injury in children.  Some common causes are listed below.

Falls - Perhaps the most common cause of cases seen in the ER are those caused by falls.  This is especially true for infants (i.e., falls from beds, stairs, tables, grocery carts, bath tubs, accident drops from parents arms). 

Car accidents or contact with objects - Older children are more likely to be involved in trauma from car accidents or thrown/swung objects (i.e., baseballs and golf clubs).

Infant walkers - Many children have been seriously injured by falls down stairs in mobile infant walkers.  The American Academy of Pediatrics recommends a ban on manufacture and sale of mobile infant walkers.

Stairs - Crawling and walking young children may be injured from falls when stairways are not protected by an infant gate.

Bicycles - The appropriate use of bicycle helmets has reduced the incidence and severity of head injuries in children who crash or fall from bicycles.  Nonetheless, approximately 650 children die each year in bicycle accidents.

What is a "concussion"?

The term concussion may mean different things to different people but typically is used to describe minor injuries that cause a change in mental status.  The term is defined by the American Academy of Neurology as ‘‘a trauma-induced alteration in mental status that may or may not involve loss of consciousness. Confusion and amnesia are the hallmarks of concussion.’’

What is injured in a head injury?

Skin and soft tissue - this type of injury is usually obvious.  Bruises, swelling, cuts and bleeding can be easily seen from the outside. 

Skull - Skull fractures may be obvious with a "step-off" that can be felt from the inside.  This is similar to what you feel when you rub a cracked egg with your fingers.  Young children have relatively soft skull that can lead to a compression fracture.  This is similar to what happens when you push a dent into a ping pong ball.

Brain and nerves - Brain and nerve injury may not be visible even with imaging tests.  Confusion, getting knocked out, and/or forgetfulness may be the only signs of brain injury.  Brain swelling is a life-threatening problem since the skull cannot expand to accomodate an enlarged brain.

Blood vessels - Bleeding in the brain can cause life-threatening problems.  Slow bleeding can lead to symptoms many hours (or longer) after a head injury.

How is a head injury evaluated?

Your doctor can perform an exam of the head to determine if there is any obvious soft tissue injury or any bone injury that can be felt from the outside.  A mental status and neurologic exam can help determine if the brain or nerves were damaged.

Skull X-rays - X-rays may be able to identify fractures of the skull but are not helpful for determining more important information such as the degree of brain swelling or bleeding.

CT scan - A CT scan ("cat scan") of the head is likely the most useful test for identifying internal injury of the head.  Swelling and bleeding of the brain can be seen.  The shape and locations of blood collections can provide helpful information on the possible need for surgical drainage.

When should I worry about a head injury?

Red flags (seek medical care immediately)

• An unwitnessed event with possible significant injury

• Suspected abuse

• Any infant or young child (especially children less than 2 years of age)

• Any moderate or severe injury

• Any change in level of consciousness

• Persistent or abnormal: confusion, headache, vomiting, drowsiness, seizures, irritability, amnesia, visual disturbance, weakness, or dizziness.

• Signs of a fracture or damage to other organs (i.e., eyes, ears, etc.)

When can I worry less?

• Low-energy mechanisms (fall less than 3 feet)

• No signs or symptoms more than 2 hours since injury

• Older age is more reassuring (especially age more than 2 years)

What should I do after a head injury?

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