Patient education: Head injury in children and adolescents (Beyond the Basics)

HEAD INJURY OVERVIEW — Head injuries occur commonly in childhood and adolescence. Most head injuries are mild and not associated with brain injury or long-term complications. Very rarely, children with more significant injuries may develop serious complications (eg, brain injury or bleeding around the brain).

The parent(s) of a child/adolescent with a head injury should work with their child's health care provider to determine if the child needs to be evaluated, how to monitor for signs or symptoms of worsening, and develop a plan for minimizing the risk of future injuries.

HEAD INJURY CAUSES — Falls are the most common cause of minor head injury in children and adolescents, followed by motor vehicle crashes, pedestrian and bicycle accidents, sports-related trauma, and child abuse. The risk of brain injury varies with the severity of the trauma.

Low force injuries (eg, short falls, hit by low speed or soft object such as toy or ball) have a low risk of brain injury.

In comparison, incidents that have a higher risk of brain injury include:

●High speed motor vehicle accidents

●Falls from great heights

●Being hit by a high speed, heavy, or sharp object (eg, baseball bat, golf club, bullet, knife)

●Inflicted injury (abuse), such as vigorous shaking, typically causes severe injury

HEAD INJURY SYMPTOMS — A child's behavior and symptoms after a head injury depend upon the type and extent of the injury. The most common signs and symptoms include:

●Scalp swelling – Scalp swelling is common because there are many blood vessels in the scalp. If the skin is not broken, it is common to develop a large lump from bleeding or swelling under the skin.

●Loss of consciousness – Only about 5 percent of children/adolescents with a mild head injury pass out (lose consciousness), usually just for a brief period (less than one minute).

●Headache – Headache occurs in about 45 percent of children/adolescents after head injury. In children who are too young to speak, irritability may be an indication of headache or other discomfort. (See "Patient education: Headache in children (Beyond the Basics)".)

●Vomiting – Approximately 10 percent of children/adolescents have at least one episode of vomiting after a head injury. Children who vomit after a head injury do not necessarily have a serious brain injury.

●Seizures – Less than one percent of children/adolescents have a seizure immediately after a head injury. A few of these children have a serious head injury. A CT scan of the head is usually recommended in this situation. (See 'Imaging tests' below.)

●Concussion – The term concussion is used to describe a mild form of traumatic brain injury. Common symptoms of a concussion include confusion, amnesia (not being able to remember events around the time of the injury), headache, vomiting, and dizziness. Loss of consciousness may occur but is uncommon, occurring in about 10 percent of young athletes with concussions.

HEAD INJURY TESTS — Many parents wonder if their child/adolescent needs medical attention after a head injury. The American Academy of Pediatrics recommends that parents contact their child's health care provider for advice for anything more than a light bump on the head.

Children with any of the following symptoms need to be evaluated by a health care provider since these symptoms may indicate a higher risk of complications. Depending upon the particular circumstances, this may be done at the pediatrician's office or in an emergency department:

●If the child has recurrent vomiting

●If the child has a seizure (convulsion)

●If the child loses consciousness after the injury

●If the child develops a headache that is severe or worsens with time

●If there are changes in the child's behavior (eg, lethargic, difficult to wake, extremely irritable, or exhibiting other abnormal behavior)

●If the child stumbles, or difficulty walking, clumsiness, or lack of coordination

●If the child is confused or has slurred speech

●If the child has dizziness that does not resolve or recurs repeatedly

●If blood or watery fluid oozes from the nose or ears

●If the child is younger than six months of age

●If a cut will not stop bleeding after applying pressure for 10 minutes

●If the child fell from a height greater than three to five feet, was hit with a high speed object, or was hit with great force

●If the parent/caregiver is concerned about how the child is acting

The goal of the evaluation is to determine if there is serious brain injury. The evaluation can also determine if the child needs immediate treatment, close follow up, or further testing (eg, computed tomography [CT] of the head).

Medical history and physical examination — Parents should try to describe how the injury occurred, if possible, including what the child was doing before the injury and how he/she responded after the injury. If there is any reason to suspect that another adult or child intentionally injured the child, this should be discussed with the health care provider.

Imaging tests — Many parents assume that their child will undergo imaging tests after a head injury. The purpose of imaging tests, such as a head CT, is to determine if there is bleeding inside or around the brain, if there is a skull fracture, or if there are other serious brain injuries. Most children with a minor head injury do not require an imaging test because the risk of a serious brain injury is small.

When is a head CT needed? — A head CT should be performed when there is concern about a serious brain injury. However, unnecessary use of CT exposes children to radiation and should be avoided.

A head CT may be recommended if there are concerning signs or symptoms of brain injury during the examination. These include the following:

●Prolonged loss of consciousness

●Persistent or severe memory loss, confusion

●Persistent vomiting

●Seizure

●Severe, persistent, or worsening headache

●Suspicion of intentional injury (abuse)

●Behavioral changes (eg, lethargy, decreased alertness, extreme irritability)

●Signs of a skull fracture or bulging fontanel (soft spot on an infant's head)

●Abnormal neurologic examination (eg, numbness, tingling, weakness, off balance)

●Significant scalp bruise or swelling in a very young infant

●Bloody or clear fluid oozing from the ears or nose

●Incident with a higher risk of brain injury (see 'Head injury causes' above)

Why is CT best? — Head CT is recommended to evaluate head injuries because it is fast, available in most hospitals, and is good at identifying recent, severe injuries. Young children may need to be sedated briefly (less than 15 minutes in most cases) to obtain the best results.

Magnetic resonance imaging (MRI) of the brain is not the test of choice in most settings for identifying recent brain injury. In most hospitals, it is not usually available quickly, which can delay identifying severe injuries; and compared with CT, it may require the child to remain completely still for much longer, which can require sedation or (in young children) general anesthesia.

Observation — In some cases, it is not clear initially if a head CT is needed. In studies, some children with vomiting, headache, or a brief loss of consciousness (without other symptoms) have a traumatic brain injury while others do not.

In these cases, one reasonable strategy is to observe the child closely for four to six hours after the injury, usually in the emergency department. If the child develops any other symptoms, a CT scan could be done at that time. If no further symptoms occur, the child does not usually need a CT scan. Children who are well more than 12 hours after a head injury have a very low risk of brain injury that requires surgical intervention, although there is always a very small chance. Observation has been shown to decrease the number of children undergoing CT scans without missing important injuries.

HEAD INJURY TREATMENT AT HOME — If the child/adolescent's injury is mild and there are no worrisome signs or symptoms, he or she can be treated and monitored at home. However, if there is any evidence that the injury is more serious, the child should be evaluated in their doctor's office or an emergency department. (See 'Head injury tests' above.)

Rest — Encourage the child to lie down or choose a quiet activity. Allow the child to sleep if desired. It is not dangerous to sleep after a minor head injury (especially if it is nap time), although the parent should monitor the child. (See 'Monitoring after a head injury' below.)

A mild headache, nausea, and dizziness are common, especially during the first few hours after the injury. If the child is nauseous or has vomited, try offering clear liquids (eg, soda, clear juice, gelatin).

Bleeding — If the head is bleeding, clean the area with soap and water and apply pressure to the area with a clean cloth (sterile gauze, if available). Bleeding should stop within 10 minutes. If bleeding does not stop or the cut is large, the child should be evaluated to determine if stitches are needed.

Swelling — Swelling (a large lump or "goose egg") is also common after a head injury. To reduce swelling, an ice or a cold pack can be applied to the area for 20 minutes. Swelling usually begins to improve within a few hours, but may take one week to completely resolve.

Pain — Acetaminophen (eg, Tylenol) may be given for a headache. If the child's headache is severe or worsens, the child should be evaluated by a health care provider.

MONITORING AFTER A HEAD INJURY — Parents of a child with a head injury are usually instructed to observe their child at home for signs of worsening injury. The parent(s) should call the pediatrician and/or take the child to the emergency department immediately if the child does any of the following:

●Vomits twice or continues to vomit four to six hours after the injury

●Develops a severe or worsening headache

●Becomes more and more drowsy or is hard to awaken

●Is confused or not acting normally

●Has a hard time walking, talking, or seeing

●Develops a stiff neck

●Has a seizure (convulsion) or any abnormal movements or behaviors that worry you

●Cannot stop crying or looks sicker

●Has weakness or numbness involving any part of the body

Waking from sleep — It is not usually necessary to wake the child/adolescent from sleep after a minor head injury. If the health care provider recommends waking the child, he or she should be able to wake up and recognize his or her surroundings and parent/caretaker.

Follow-up visit — Most health care providers recommend a follow up visit or phone call within 24 hours after the injury. This is to ensure that the child is behaving normally, feeling well, and that there are no signs of brain injury.

Return to play — Children and adolescents who have sustained a concussion are at risk for a serious or even fatal complication if they have a second head injury within a short time after the first injury. This is called second impact syndrome.

Any child/adolescent who is suspected of having a concussion should be removed from play (eg, if playing a team sport) and monitored for signs of brain injury (see 'Head injury symptoms' above). The child should follow up with a physician before returning to play.

HEAD INJURY OUTCOME — Children with a minor head trauma who do not have brain injury usually recover completely without any long term complications. Children with mild traumatic brain injury usually recover completely as well, but must be monitored closely and allowed to fully recover before returning to sports.

HEAD INJURY PREVENTION — Head injuries can often be prevented. The following tips can help to prevent head injuries, as well as other types of injuries.

Bicycle safety — The majority of bicycle-related deaths and hospital admissions are caused by head injuries. Bicycle helmets reduce the risk of head, and brain injuries for bicyclists of all ages. Thus, all bicycle riders and passengers of all ages should wear a helmet every time they ride a bicycle.

●Only bicycle helmets that meet US Consumer Product Safety Commission (CPSC) standards should be used; helmets that have been involved in a crash should be thrown away.

●Bicycle helmets should fit properly and be worn in the proper position (figure 1).

●Children younger than one year should not ride in bicycle-mounted carriers or trailers.

●When used, mounted carriers should be securely mounted, should have a spoke guard and seat with a high back, shoulder harness, and lap belt. Mounted carriers are not recommended once the child approaches four years of age since the weight of the child makes the bicycle unstable and difficult to handle.

●For child passengers, bicycle trailers are a safer alternative to bicycle mounted carriers. Children who ride in bicycle trailers should wear a helmet.

Bicycle skills — It is important for children to have the developmental skills needed to ride a bike.

●Children younger than three years often do not have the developmental skills necessary to ride a tricycle.

●Children aged four to five can typically ride a bicycle with training wheels and foot-operated brakes; they should not ride in traffic and must be supervised at all times.

●Children aged six and older can usually operate hand brakes and ride a bicycle without training wheels.

●Children should not be permitted to ride in traffic until they have demonstrated that they can control the bicycle, understand and follow the rules of the road, and exercise good judgment. The age at which a child has these skills is variable. Until this point, the child should be closely supervised by an adult and should not ride in the street.

General safety tips

●Install car seats and booster seats correctly, and use the seat every time the child rides in a car. A booster seat is needed until the shoulder belt can be worn across the shoulder (rather than the face or neck), when the child is at least 4 feet 9 inches (142.5 cm) tall. Individual states may have additional regulations regarding the need for booster seats.

Many fire and police departments in the United States can determine if the seat is installed correctly. More information is available online.

●Use gates on stairways and doors to prevent injuries in infants and young children. Install window guards on all windows above the first floor. Do not use wheeled baby walkers.

●Teach children to safely cross the street by stopping at the curb and looking both ways (left, right, left). Young children should never cross the street alone.

●Discuss sports safety with your child's health care provider. Be sure that the child or adolescent has the appropriate protective equipment for biking, skating, skateboarding, skiing, snowboarding, or contact sports. Protective equipment often includes a helmet, mouthguard, wrist guards, eye protection, and knee and shin pads.

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Head injury in children and teens (The Basics)
Patient education: Head injury in babies and children under 2 years (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Headache in children (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Child abuse: Eye findings in children with abusive head trauma (AHT)
Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children
Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children
Severe traumatic brain injury (TBI) in children: Initial evaluation and management
Minor blunt head trauma in infants and young children (<2 years): Clinical features and evaluation
Postconcussion syndrome
Bicycle injuries in children: Prevention
Prevention of falls and fall-related injuries in children
Skull fractures in children: Clinical manifestations, diagnosis, and management
Concussion in children and adolescents: Clinical manifestations and diagnosis
Concussion in children and adolescents: Management

The following organizations also provide reliable health information.

●Centers for Disease Control and Prevention

(www.cdc.gov/HeadsUp/index.html)

●Medline Plus

(https://medlineplus.gov/ency/article/000028.htm, available in Spanish)

●American Academy of Pediatrics

(www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/Head-Injury.aspx)

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