Patient information: Head injury in children and adolescents

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 healthcare 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 20 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 information: Headache in children".)

• 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 does not always occur.

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 healthcare 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 healthcare provider since these symptoms may indicate a higher risk of complications. Depending upon the particular circumstances, this may be done over the phone, 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 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, CT scanning).

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 healthcare 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 (computed tomography), 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 [1].

A head CT may be recommended if there are concerning signs or symptoms of brain injury during the examination. These include the following [2]:

• 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
• Significant scalp bruise or swelling in a very young infant
• 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.

MRI (Magnetic resonance imaging) of the brain is not the test of choice for recent brain injury. In addition, in most hospitals, it is not usually available quickly. MRI requires the child to remain completely still for at least 30 minutes, which often requires prolonged sedation or 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 low risk of brain injury that requires surgical intervention.

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 (table 1). If the child's headache is severe or worsens, the child should be evaluated by a healthcare 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 healthcare 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 healthcare 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 [3]. 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 [4]. (See 'Head injury symptoms' above.) The child should follow up with a physician before returning to play.

Postconcussion syndrome — A child/adolescent who has a concussion may develop a group of symptoms called "postconcussion syndrome" in the first few days after the injury. Symptoms can include headaches, personality changes (anxiety, irritability), dizziness, or impaired memory and concentration. In 85 to 90 percent of cases, these symptoms resolve within a few weeks to a few months after the injury. There is no specific treatment for postconcussion syndrome.

In a minority of cases, the symptoms may persist for one year or longer. Prolonged symptoms can affect the child or adolescent's school performance and may lead to depression. Thus, it is important that the child's medical team and teachers are aware of the injury and understand that changes in behavior or performance may occur.

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 [5].

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 (www.usa.safekids.org/skbu/cps/index.html).

• 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 healthcare 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 healthcare provider is the best source of information for questions and concerns related to your child's medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our Web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Headache in children

Professional Level Information:
Abusive head trauma in infants and young children: Ophthalmologic aspects
Approach to neuroimaging in children
Concussion and mild traumatic brain injury
Epidemiology, mechanisms, and types of abusive head injury in infants and children
Evaluation and diagnosis of abusive head injury in infants and children
Initial approach to severe traumatic brain injury in children
Minor head injury in infants and children
Postconcussion syndrome
Prevention of bicycle injuries in children
Prevention of falls in children
Skull fractures in children

A number of Web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• American Academy of Pediatrics Injury Prevention Program

      (www.aap.org/family/tippmain.htm)

• Medline Plus

      (www.nlm.nih.gov/medlineplus/ency/article/000028.htm, available in Spanish)

• American Academy of Pediatrics

      (www.aap.org/publiced/BR_HeadInjury.htm)

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