Minor Head Injuries in Children

Five little monkeys jumping on the bed.  One fell off and bumped his head.  Mama called the doctor and the doctor said, “No more monkeys jumping on the bed.”

Four little monkeys jumping on the bed.  One fell off and bumped her head.  Mama called the doctor and the doctor said, “No more monkeys jumping . . . hang on . . . didn’t I talk to you earlier?  For real, no more monkeys jumping on the bed.  OK?  OK.  Goodnight.”

Three little monkeys jumping on the bed.  One fell off and bumped his head.  Mama called the doctor and the doctor said, “Ma’am, I thought we already talked about this.  No more monkeys jumping on the bed.  How many kids do you HAVE?”

Two little monkeys jumping on the bed.  One fell off and bumped her head.  Mama called the doctor and the doctor said, “If you call me again, I am calling CPS.  No more monkeys jumping on the bed.  I mean it.”

One little monkey jumping on the bed.  He fell off and bumped his head.  Mama called the doctor and the doctor . . . the answering service says the doctor refuses to talk to you anymore . . . oh crap, someone’s knocking at the door . . . OH, um, hello, officer . . . you received a call about possible child endangerment? . . . Crap.

So your baby hit her head.  She was climbing up on the couch, lost her balance and fell backward, and clonked her little noggin on your hard wood floor.  The sound was enough to make a mommy throw up.  That horrible “thud” of a skull meeting a hard surface – it makes me queasy too, moms.  Maybe she was running down the cement driveway and tripped and face planted right on her forehead.  Maybe she was running full speed towards the yard only to discover that the open door was in fact a glass door.  Next comes the breath holding – that awful awful moment when your baby is so stunned they don’t even breathe for about 8 seconds (it feels like 78), and then, the SCREAMING.  All us moms who have a child old enough to walk have experienced the dreaded noggin bonk, and it scares parents half to death.  Immediately your brain calls up memories of celebrities who died in skiing accidents.  You try to determine if your child might have a concussion (whatever THAT is) or worse.  You hear the words of Grandma in your head.  You ask your local Facebook mommy group and the advice comes flooding at you. “Check his pupils, if they constrict, everything is OK!” “Don’t let her fall asleep, if she falls asleep she’ll definitely DIE!” “Does he have any swelling?  Because if you don’t see swelling on the outside it means the swelling is on the inside and he’s DOOMED!” “I knew a kid one time who fell down a flight of stairs and he seemed OK for the first couple of hours but then he suddenly fell down and had a seizure and he DIED!”

Great, now you’re REALLY scared and in full-on freak-out panic mode so you drive to your local emergency department and the doctors there are nice enough but they don’t even give your kid a CT scan.  They just tell you he’s fine and send you home.  So naturally you stay awake all night watching your toddler, waking him up every hour on the hour, certain he’s going to be dead by morning.

I have discovered in my 9 years of pediatric practice that parents are scared of head injury.  And you know what?  They should be.  Only very very recently has the medical community become more aware of the lasting consequences of repeated concussions and it turns out they can be devastating.  A serious head injury is one of those things that could actually take your beloved child from you.  Serious head injuries scare the crap out of me (also drowning, I’m ridiculously scared of drowning).  I am not going to talk to you about serious head injuries today, for that is a diatribe for another day (COULD WE NOT SACRIFICE OUR BEAUTIFUL BRIGHT YOUNG MEN ON THE ALTER OF FOOTBALL?  COULD WE NOT?)  Sorry, that just slipped out.  Anyway, today I’m going to write about how to tell if your kid has a serious head injury or a minor head injury.  I hate that mommies lose nights of sleep over minor head injuries, especially when they could have called me and I could have made them feel better.

As it happens, head injuries in children have been studied . . . A LOT.  We have a number of really high quality studies looking at features of head injury that do or do not raise concern for a brain injury.  As it turns out, your brain lives inside your skull, which is actually pretty darn tough.  It can take some serious impact before your brain is harmed in the slightest.  We also have decades of data that can help us determine which types of head injuries can result in traumatic brain injury (TBI) and which types can’t.  I’m going to share this information with you so that when your toddler falls down and bumps their head, you can decide whether you need to go the ED, come see your faithful pediatrician tomorrow, or just forget about it and go about your evening.

First, we need to talk about PECARN.  Not pecan, PECARN.  It stands for the Pediatric Emergency Care Applied Research Network.  It is, “the first federally-funded pediatric emergency medicine research network in the United States.” It is a network of seven really big, respected, important academic institutions working together to compile data and generate high-quality research publications that help doctors make decisions at points where the rubber meets the road.  These are some seriously smart people who are very good at interpreting the existing research and are dedicated to improving outcomes for our little patients.  They also conduct and publish rigorous original research and put together practice guidelines based on that research.

http://www.pecarn.org/index.html

As it happens, the folks at PECARN have looked at minor head injury in children and have come up with some handy guidelines to help us all determine how worried we should be about a kid who has hit his or her head on something.  We call these the Traumatic Brain Injury Prediction Rules: https://www.mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm Admittedly, this algorithm is written for doctors and involves a lot of concepts and terms that most lay people haven’t been educated about.  Here’s what you need to know – a child with a traumatic brain injury will show you they have a brain injury.  Here’s what to watch for:

  1. What was the mechanism of injury? In other words, what exactly happened?  How far did your child fall?  If the fall was less than about 5 or 6 feet and your baby didn’t hit anything on the way down, a significant traumatic brain injury is extremely unlikely.  Skull fracture and concussion are still possibilities though, so read on.
  2. What did your child do immediately after hitting their head? Did they lose consciousness?  Did they throw up?  Did they become suddenly sleepy (or extremely irritable or inconsolable)?  If the answers to these questions is “no”, that’s very reassuring.  If your child was immediately upset but could be consoled after a few minutes and immediately returned to normal AND the mechanism of injury was not serious (i.e. short fall, ran into a glass door, cousin whacked them in the head with a toy) it is all good.
  3. How does the injury site look? Is there a big open bleeding deep gash?  Yeah, you should go to the ED.  No laceration?    Is the site really swollen and squishy?  They should probably come see me tomorrow.  Not a mark to be seen?  Cool, no worries.  NOW, on the morning AFTER (or even three days later) is there a visible bruise with some swelling?  It’s probably fine but if it feels squishy you need to come see me.  An ice pack immediately after injury would be a good idea, by the way.
  4. What’s with the pupils? Most of us have heard that we should check the pupils in a child with a head injury.  We are told that the pupils should constrict in response to light.  This is true.  But here’s the thing, pupils that DON’T constrict briskly in response to light are a very ominous sign of serious intracranial bleeding and impending death.  There are other signs and symptoms that you should definitely pay attention to way before the pupils become dilated.  Just because the pupils are normal doesn’t mean a child doesn’t have a concussion or something more serious.  You should be REALLY ALARMED by pupils that are dilated, but don’t rely on normal pupils to tell you everything is fine.  You can have normal pupils and still be concussed.  A child’s mental status is much more important.  Know your kid.  If your kid is acting normal immediately after a head injury, everything is fine.  If they are not, everything is not fine.  Ignore the pupils.
  5. And how about letting them fall asleep? That’s another one of those medical truths that has been misinterpreted.  If a child has a blow to the head and becomes abnormally sleepy, that’s bad.  That’s a mental status change can be a sign of a brain injury.  If a child who has suffered a head injury is lethargic and difficult to keep awake, call 911.  BUT, that doesn’t mean that ALL children who have had a head injury need to be kept awake.  After a minor head injury, if you have observed the kid for a couple of hours and they have no mental status changes, they’re fine.  Let them sleep.

There have been a couple of really nice studies published over the years that help us feel confident that we can tell from the type of injury and symptoms if a child is at risk for a serious brain injury.  Sadly, a number of these came about as the medical community needed to know more about inflicted (i.e. abusive) head trauma.  When a baby has suffered an inflicted injury, the caregivers don’t come into the emergency department and tell the doctors what really happened.  Often they will report that their baby rolled off a couch or had some other trivial fall.  Over time, doctors began to be suspicious that the history given didn’t match up with the injuries they were seeing.  Thus, the research community has been paying pretty close attention to head injuries in small children.  While not the original intention, these studies give us some nice information for parents about when to be worried about a noggin bonk.

  • A 1991 study looking at risk of death from falls – http://journals.lww.com/jtrauma/abstract/1991/10000/deaths_from_falls_in_children__how_far_is_fatal_.6.aspx
  • So how far to they have to fall before we get worried? – http://www.medscape.com/viewarticle/405565_4
  • Falls under 1.5m are EXTREMELY unlikely to kill your baby – http://pediatrics.aappublications.org/content/121/6/1213

So what IS a concussion, anyway?  A concussion is a brain injury that does NOT involve significant bleeding (enough blood to see on a CT scan) but that does affect brain function.  It’s caused by stretching/compression of brain cells.  The pathophysiology is rather complicated but for lay person purposes, know that the mechanical insult to the brain cells releases different chemicals (neurotransmitters, inflammatory chemicals) that are damaging.  The insult also leads to disruption of metabolic processes.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC155411/ – pathophysiology of a concussion

By definition, any head injury that results in mental status changes (loss of consciousness, confusion, forgetfulness, immediate sleepiness, “brain fog”) is a concussion.  We also decide our management based on severity and there are criteria for that, but that’s a topic for another day.  Concussions are serious and repeat concussions are REALLY serious.  If your child has had a blow to the head followed by mental status changes I do not expect you to distinguish a concussion from a more immediate threat, so go get them checked out right away.  I want parents (and other adults) to be aware of the signs of a concussion so that we can stop telling our young athletes they need to “walk it off”.  I’ve seen far too many kids who have had a head injury during a sporting event, showed signs of a concussion, and were returned to play by the adults who are supposed to be looking out for their safety.  This is NOT OK and it will take informed, vocal parents to put a stop to this.

But back to your toddler who fell off the bed.  If they did not lose consciousness, did not throw up, did not become suddenly sleepy or irritable (basically returned to their normal self), and do not have a serious scalp injury, they’re fine.  For real.  Let them go to bed at their regular time.  Give them some Tylenol, check the injury in the morning, and don’t sweat it.  If they are acting weird or puking all over the place, go to the ED.  If you’re not sure or you just need some hand-holding, call me.

References and further readings:

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