Head Injury In Children

What Is It?

Trauma to the head can cause different medical and surgical problems, ranging from mild to severe. Each year, childhood head injuries result in tens of thousands of emergency room visits and hospitalizations in the United States.  Although 90 percent of all childhood head injuries are minor, thousands of children die and many more develop permanent disabilities each year from head trauma.  

The most common causes of childhood head injuries in the United States are motor vehicle accidents, falls, assaults, bicycle accidents and trauma related to sports. In infants younger than 1 year old, most serious head injuries are related to child abuse. 

Children often bump their heads accidentally, resulting in minor bumps, bruises, or cuts in the scalp, but no damage to the brain inside. Sometimes, more serious injuries happen. 

Injuries to the head can cause a concussion, which is a mild traumatic brain injury or TBI. Symptoms of concussion can include headache, confusion, problems with concentration and fatigue, and can be mild or severe.  

In most cases of concussion, X-rays or brain scans do not show any damage. Concussions do not usually cause long-term brain damage, but repeated concussions can be very dangerous, putting the child at risk of serious brain damage. 

Childhood head trauma is rarely more serious than a concussion. However, when it is severe, the injury usually is from a direct blow to the skull. Sometimes, the injury can be caused indirectly, such as when blood vessels stretch and tear, the brain "bounces" against the inside wall of the skull, or the brain swells as a result of chemical changes. 

Other types of serious brain injury include: 

• Skull fracture – A skull fracture is a crack or break in one of the skull's bones. In most cases, a skull fracture causes only a bruise on the surface of the brain. If the skull is dented inward (a depressed skull fracture), pieces of the broken bone are pressing down against the surface of the brain. This may need more immediate attention and special surgery to fix. 
• Epidural hematoma – This is one of the most serious types of bleeding that can occur inside the head as a result of a skull fracture. It happens when a sharp fragment of bone cuts through one of the major blood vessels in the skull. As the injured vessel bleeds, a collection of blood called a hematoma forms in the space between the skull and the outermost membrane (dura) covering the brain. The blood vessel that ruptures is usually an artery, and the hematoma expands rapidly and presses on the brain. This can cause severe injury and even death. Epidural hematomas are especially common after significant injuries to the temple, such being hit by a baseball or baseball bat. 
• Subdural hematoma – This is a collection of blood between the coverings of the brain and its surface. It occurs when a head injury tears any of the large veins that carry blood away from the brain's surface. Subdural hematomas tend to get larger slowly, sometimes over days or weeks, with symptoms gradually worsening. This type of bleeding leads to serious brain injury and even death if not diagnosed and treated promptly. 
• Intraparenchymal hemorrhages and contusions (bleeding and bruising of the brain) – These injuries involve the brain itself. Both types of injury are caused by either a direct blow to the head or indirectly when the force of an injury to one side of the skull causes the brain to bounce against the other side. This causes an area of damage on the side of the brain opposite from the blow to the head.  

After each of these serious head injuries, there can be swelling inside the brain, which increases the pressure inside the skull. Severe head injuries – especially those caused by motor vehicle accidents and falls from high places – also can be accompanied by damage to the neck bones or to important organs inside the body. These additional injuries often cause blood loss, breathing difficulties, very low blood pressure (hypotension), and other problems that can complicate the child's treatment and make recovery more difficult.

Symptoms

Head injuries cause many symptoms, depending on the type of injury, its severity and its location on the head and the brain inside. The child's neurological symptoms can include: 

• Passing out (loss of consciousness)  
• Unresponsiveness  
• Headache  
• Dizziness  
• Drowsiness  
• Nausea and vomiting  
• Confusion  
• Difficulty walking  
• Slurred speech  
• Loss of memory (amnesia)  
• Poor coordination  
• Irrational behavior  
• Aggressive behavior  
• Seizures (convulsions)  
• Numbness or weakness (paralysis) of part of the body 

In addition, physical signs can include:  

• A bump, bruise, or cut on the head  
• A visible dent at the site of impact  
• A black and blue discoloration around the eyes or behind the ear  
• Blood coming out of the ear  
• Clear fluid oozing from the nose (this may be the clear fluid that bathes the brain leaking through a skull fracture near the nose)  
• A bulging soft spot between the skull bones (fontanelle) in an infant 

Diagnosis

In most cases of mild childhood head injuries, parents call the doctor's office first to determine whether their child needs to be evaluated in person. If you contact your child's doctor about a head injury, the doctor will want to know: 

• How and when your child hurt his head – If your child has fallen, the doctor will want to know the height of the fall and the surface on which he or she landed.  
• A physical description of your child's head injury – Is there bruising, swelling, a dent in the skull, discoloration around the eyes or behind the ear, fluid leaking from the nose, or bleeding from the ear?  
• Your child's immediate reaction to the injury, especially whether or not your child 
  • passed out 
  • is aware of everything around him 
  • has any loss of memory 
  • is able to talk with you as he normally does  
• Any symptoms that occurred since the injury, such as vomiting, headache, confusion, sleepiness or seizures (convulsions) 
• The location of any swelling or bruising on other parts of the body besides the head 

Based on your answers to these questions, the doctor may decide that no further medical evaluation is necessary. If this is the case, the doctor will give you detailed instructions about symptoms to watch for at home and what to do if your child's condition changes.  

If your doctor tells you to bring your child to the office or to go to an emergency room immediately, you will be asked the same questions there. Emergency room personnel also will want to know about any medications your child is taking and his or her medical history, including any prior head trauma or brain (neurological) problems, such cerebral palsy, epilepsy or developmental disabilities.  

These questions will be followed by a thorough physical and neurological examination. If the results of these exams are normal, no further tests may be necessary. However, the doctor may decide to monitor your child's condition for several hours in the emergency room. After that time, the doctor may send you home with instructions about specific signs and symptoms to watch for during the next 24 to 48 hours.  

If your child's history, symptoms or physical findings point to a significant head injury, then further evaluation, monitoring and treatment are needed.  

Expected Duration

How long symptoms last depends on the type and severity of the injury. For example, pain from mild head injuries usually lasts for only a few minutes. Symptoms from a concussion often go away within minutes or hours after the injury, but a child may have some confusion, memory loss, difficulty concentrating, headaches, dizziness or fatigue that lasts for several days or even longer. This collection of symptoms, called post-concussion syndrome, sometimes can last for weeks or even months. The most severe forms of head injury may require long hospital stays for rehabilitation. Rarely, they can cause death. 

Prevention

To help prevent head injuries in children: 

• Never leave your baby alone on a changing table, bed, chair or raised surface. Instead, place your baby in a crib or playpen or on the floor if you must leave him or her unattended. 
• Do not use baby walkers, because these devices can cause falls and serious injuries. 
• Install window guards on windows and place safety gates near doors and stairs.  
• If you have a toddler, remove throw rugs and furniture with sharp edges from the child's play areas. 
• If your child uses a playground, make sure that there is a shock-absorbing surface (a thick piece of rubber or a deep layer of sand, sawdust or woodchips) under all play equipment. 
• Use car safety seats that are appropriate for your child's age and weight until he or she can fit correctly in a regular seat belt.  
• Make sure that your child always wears a properly fitted safety helmet while riding a bicycle or scooter. A formal course in bicycle safety, if available, can be very helpful. 
• If your child plays sports, have him or her wear appropriate protective headgear that is fitted professionally. Helmets are essential in football, baseball, ice hockey, skiing, in-line skating, skateboarding, riding a scooter and snowboarding. 
• Do not allow your child to play on trampolines unless properly supervised. 
• When you go shopping, use a seat belt to secure your child safely in the seat of a shopping cart. Never leave your child unattended in the cart, and avoid placing the child inside the cart basket. 

Treatment

Children with mild head injuries usually don't need any treatment other than careful monitoring for 48 hours. For a child with a concussion careful monitoring also is important and the child may need to stay out of sports for an extended period. If your child's injury is more serious and he or she is being monitored in the emergency room or has been admitted to the hospital for observation, medical personnel will periodically assess your child's condition. Once your doctor is satisfied that your child can be sent home safely, he or she will allow you to leave with instructions. If your child complains of headaches, your doctor probably will suggest acetaminophen (Tylenol). You should avoid giving your child aspirin, ibuprofen (Advil, Motrin), naproxen (Naprosyn) or indomethacin (Indocin), because these drugs may increase the risk of bleeding inside the head. 

In children with more serious head injuries, treatment depends on the type of head injury, its severity and location. In some cases, the child may need to be treated in an intensive care unit (ICU). Depending on the severity of the brain injury, treatment may include a respirator machine to breathe for your child, and medications to control pain, limit body movement, decrease swelling inside the brain, maintain blood pressure and prevent seizures. Surgery may need to be done to drain an epidural or subdural hematoma, or to treat a depressed skull fracture, brain hemorrhage or contusion. 

When To Call a Professional

Call for emergency help immediately if your infant falls and does not respond to your voice or touch, or if he or she appears to have trouble moving any body part. In any other situation where a baby falls and hits his or her head, call your doctor for advice. This is the safest thing to do, even if the infant appears to have no serious injuries. 

Also, call for emergency help immediately if your older child hits his or her head and is unconscious (passes out). Call your doctor immediately if your child hurts his or her head and has any of the symptoms described in the Symptoms section.

Prognosis

The outlook depends on the location and severity of the injury, as well as the child's age. For example, most children with mild head injuries have an excellent prognosis with a very low risk of long-term complications. However, infants may be more likely to have complications because their brains have not finished growing.

Additional Info

National Institute of Neurological Disorders and Stroke
http://www.ninds.nih.gov/

National Institute of Child Health & Human Development
http://www.nichd.nih.gov/

American Academy of Neurology (AAN)
https://www.aan.com/

American Academy of Pediatrics (AAP)
http://www.aap.org/

Family Caregiver Alliance
http://www.caregiver.org/

National Rehabilitation Information Center (NARIC)
http://www.naric.com/

Brain Injury Association of America
http://www.biausa.org/

Brain Trauma Foundation
http://www.braintrauma.org/

National Highway Traffic Safety Administration
http://www.nhtsa.dot.gov/

U.S. Consumer Product Safety Commission (CPSC)
http://www.cpsc.gov/