Head injury

What is a Head Injury

At some time before reaching adulthood, almost every child suffers some kind of a head injury. These injuries range from the mildest “head bonk” with no symptoms at all, to major trauma that can cause brain damage and permanent loss of function. In this Aftercare Instruction, we will focus on the mild end of the spectrum – children who have head injuries that allow them to be sent home from the doctor’s office or emergency room.

Mild head injury in children can cause several different kinds of symptoms. In many cases the child suffers nothing more than a bruise or a small bump on the head. These are typically the kinds of injuries that toddlers get from crashing into tables, walls, or floors. Because they aren’t moving fast and because the things they run into aren’t very hard, these kinds of injuries are rarely serious enough to cause brain injury. Injuries that involve more energy, like falls down stairs or out of shopping carts can cause more severe injuries. Older children who are more active, and may be involved in sports are also more likely to have more significant injuries.

What is the biggest concern?

The biggest concern in any head injury is the condition of the child’s brain. We can get a fairly good idea of that from our observation of the child immediately after the injury, and then over the next few days. Mild bumps produce no injury inside the skull at all. Harder hits can cause shaking of the brain without any damage that we can see on X-rays or CT scans. These injuries are called “concussions,” and they come in four different grades (discussed below under “treatment”). Even more violent injuries can cause bleeding or bruising of the brain itself (a “cerebral contusion”), or bleeding into the space between the brain and the skull (an “intracranial hemorrhage). Some injuries can also cause fractures of the skull. A skull fracture alone, while worrisome to the parent, is not necessarily a cause for alarm. Please remember that the skull is just the container for the important part – the brain.

Over the years we have learned that children with apparently minor head injuries can have some subtle long-term effects. They can perform less well on certain tests of thinking and performing tasks. We do not yet know how significant these problems may be in the long term, but many doctors are beginning to recommend cognitive testing at around 6 months after any significant head injury.

Head Injury treatment

We treat very mild head injuries (those without concussions) with pain relief and observation, after an evaluation by a doctor. Many doctors are comfortable having a conversation with the parents by phone, and recommending observation at home. After you speak with or see your doctor, you can give your child acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) as directed for the next 24 hours to help relieve any pain. An ice pack wrapped in a moist washcloth can help relieve pain at the site of the bump. Bumps on the head can last for up to three weeks, and like any other bruise, may go through a series of color changes from reddish-blue to greenish yellow as they get older.

“Concussions” are head injuries that have some temporary effects on consciousness, memory, or behavior. The symptoms of concussion include headache, confusion, ringing in the ears, dizziness, balance disturbance, blurred vision, nausea, and amnesia. Doctors treat concussions with rest, pain medications, and observation for different amounts of time, depending on how bad the concussion was. By “rest,” doctors mean starting off with bed, couch, or chair rest until the child can walk without dizziness or nausea. After that, the child should do only normal household activities – no active play and no sports. After the period of rest is over, doctors ask that children return to “limited” or “gentle” activities. This means activities where they have little chance of getting another head injury, and where some adult supervision is present.

Doctors classify concussions into four grades, based on the severity of the symptoms and how long they last. There are many different guidelines for returning to sports – your doctor may use those we list below, or s/he may use a system with slightly different instructions.

  • Grade 0 concussions are not really concussions at all. If a child with a head injury has no complaints, and has a normal physical examination by a trained person, s/he has a Grade 0 concussion. We treat these with observation only. If the child remains free of symptoms for 20 minutes, s/he can go back to normal activity, including sports. Please follow-up as your doctor instructs.
  • Grade 1 concussions produce brief confusion, dizziness, blurred vision, or nausea. These last for less than 30 minutes and clear up. Children with Grade 1 concussions do not have loss of consciousness or memory loss. Children with Grade 1 concussions can usually return to gentle sports or play if they are free of symptoms both at rest and with exertion for two days. If they continue well for one more day, they can return to unrestricted activity. Please communicate with your doctor before returning your child to any level of activity.
  • Grade 2 concussions may have any of the symptoms of Grade 1 injuries, with the addition of brief (less than 30 seconds) loss of consciousness or mild amnesia. These children may appear confused for up to several hours, and may forget things that have happened since the injury occurred. Children with Grade 2 concussions should have careful observation for a few hours by a doctor or nurse before going home. They can return to gentle physical activity when they have been free of symptoms at rest and with exertion for 4 days, and after their doctor has seen them. If they remain without symptoms for 2 more days, children with Grade 2 concussions can return to normal activities.
  • Grade 3 concussions are the most severe. They always involve loss of consciousness for more than 30 seconds and some amount of amnesia, vision changes, confusion, or changes in gait. Children with Grade 3 concussions should have several hours of careful observation by a doctor or nurse, and sometimes will need a CT scan of the brain to rule out any other injury. If their symptoms go away completely within the first week, these children can return to mild activity when they have been free of symptoms for ten days. For example, if symptoms clear up completely on day 3 following the injury, the child can return to mild activity on day 13. S/he can return to full activity after another 3 symptom-free days. If the child’s symptoms do not clear up in the first week, s/he should remain out of any active sport or play 17 days after the last symptom. For example: symptoms clear up on day 9, return to limited activity on day 26. After three more days of no symptoms, the child may return to full activity.


When should I be worried?

Head injuries without concussions do not produce many worrisome symptoms. Many children with head injuries, even minor ones, will vomit once or twice after the injury, usually within an hour or two. It is not necessary to keep a child awake after a head injury if s/he can be seen by a doctor within a few hours, or after s/he has been seen by the doctor. Most children want to go to sleep following a head injury – this is the body’s normal response. Because some apparently mild injuries can get worse in the first hours to days after the injury, please watch your child carefully for any of the following:

  • Vomiting more than twice, or vomiting that happens more frequently over time, rather than less
  • Being excessively sleepy or difficult to wake up (most doctors recommend checking on the child at the parents’ own bed-time on the first day of the injury)
  • Headache that lasts more than 2 days or that gets worse over time
  • Blurred vision that does not clear up after 24 hours, or new onset of blurred vision
  • Dizziness that lasts more than 2 days, or vertigo (feeling that the room is spinning)
  • Stiff neck or neck pain
  • Confusion or amnesia that is new, or that lasts more than 3 days after the injury
  • Seizure
  • Numbness, tingling, or weakness of a limb or part of the face
  • Any new complaint about pain in a new location can indicate an injury that was missed because of concern about the head injury.

If any of these occur, please be sure to call your doctor’s office right away. If your child or teen is difficult to awaken or seems unconscious, go directly to the emergency room.

Other points of concern

The guidelines we have given above for return to sports are just those – general guidelines. Please check with your doctor before authorizing your child or teen to return to competitive sports or any other activity where a head injury could occur again. A second head injury that happens while a child or teen still has symptoms from the first can cause “second impact syndrome.” Second impact syndrome can result in sudden death. Please be certain that your doctor agrees with your child or teen that s/he is free of symptoms. Competitive children and teens often believe they are better long before they really are. It is usually not effective to try to scare them into not playing – what often works better is to point out to them that they can’t give the team their best effort if they still have symptoms. They will not want to let their teammates down. Professional athletes understand this, and sit out a game rather than causing the whole team to lose.

Of course, the best way to reduce problems and risk from head injuries is to prevent them in the first place. These days most towns have laws that require helmets for bicyclists, skateboarders, in-line skaters, and others. Good helmet habits develop early, and teens often want to skip the helmet so as to be “cool.” Most helmet makers now have an assortment of “hip” helmets in great colors and styles. You can try to appeal to your teen’s sense of style as a means of motivating him or her to use a helmet. It is best to adopt a very strict policy about helmet use with any activity where a head and a hard object are likely to come into contact.

Other Conditions that Might Be Present with a Head Injury

Although the head injury often gets the most attention from parents, children, and doctors, other injuries can be present after a fall, a crash, or another accident. Neck injuries are common along with head injuries. Especially if the child lost consciousness during the event, an abdominal injury can be missed in the first few hours. If your child develops neck pain, numbness, tingling, or weakness, or abdominal pain or tenderness, please be sure to call your doctor. Also, please remember that a laceration (cut) to the face is also at least technically a head injury. Even after the cut has been repaired, it is worthwhile watching for the warning signs we listed above.