Head Injury In Children
What Is It?
Head injury refers to a group of medical and surgical problems, ranging from mild to severe, caused by trauma to the head. Each year, childhood head injuries result in more than 500,000 emergency room visits in the United States, with more than 95,000 hospitalizations. Although 90 percent of all childhood head injuries are minor, about 7,000 children die each year of head trauma, and an additional 29,000 develop permanent disabilities. 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, more than 95 percent of serious head injuries are related to child abuse.
Children often accidentally bump their heads, resulting in minor bumps, bruises, or cuts in the scalp, but no damage to the brain inside. Sometimes, more serious injuries happen.
When injuries to the head cause a change in the ability to think clearly, it is called a concussion. Concussions are graded on a scale of I to III, depending on the severity of the symptoms. A grade I concussion is the mildest type, with only short-term confusion (less than 15 minutes) after the Head injury, while a grade III concussion is the most severe, with confusion, loss of memory (amnesia) and loss of consciousness (passing out) for a few seconds up to a few minutes. In most cases, X-rays or brain scans do not show any damage when someone has a concussion. Concussions usually do not cause long-term brain damage, unless the child suffers repeated concussions (for example, during high-risk activities such as boxing or football).
Childhood head trauma is rarely more serious than a concussion. However, when it is severe, the injury is usually the result of a direct blow to an area of the skull. In other cases, however, 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.
Types of the most 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 special surgery to fix.
- Epidural hematoma — This is generally the most serious form 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 resulting 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 produces an area of damage on the side of the brain opposite to the original 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 produce blood loss, breathing difficulties, very low blood pressure (hypotension), and other problems that can complicate the child’s treatment and make recovery more difficult.
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)
- Nausea and vomiting
- 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 a 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 (fontanel) in an infant
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, or bleeding from the ear?
- Your child’s immediate reaction to the injury, especially whether your child is aware of everything around him or has any loss of memory
- Any symptoms that occurred soon after 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, the initial evaluation will include the same questions. 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 as 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.
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 result in death.
To help prevent head injuries in children:
- Never leave your baby alone on a changing table, bed or chair. 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 also will help.
- 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, scootering 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.
Children with mild head injuries usually require no treatment other than careful monitoring for 48 hours. Treatment for concussions also involves careful monitoring and may include exclusion from 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. Depending on the severity of the brain injury, treatment may include a respirator 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 performed 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 experiences any of the symptoms described in the Symptoms section.
The prognosis 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.
by Arthur A. Poghosian, M.D.
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