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Head Injury in Children

What is a head injury?

Head injuries are one of the most common causes of disability and death in children. The injury can be as mild as a bump, bruise (contusion), or cut on the head. Or, it can be moderate to severe causing concussion, a deep cut or open wound, fractured skull bone(s), or internal bleeding and damage to the brain.

A head injury describes a vast array of injuries that occur to the scalp, skull, brain, and underlying tissue and blood vessels in the child's head. Head injuries are also commonly referred to as brain injury, or traumatic brain injury (TBI), depending on the extent of the head trauma.

What is a concussion?

A concussion is an injury to the head that may cause instant loss of awareness or alertness for a few minutes up to a few hours after the traumatic event. Some concussions are mild and brief, and the person or untrained observer may not recognize that a concussion has occurred.

What is a contusion?

A contusion is a bruise to the brain. A contusion causes bleeding and swelling inside of the brain around the area where the head was struck, or sometimes on the opposite side of the head due to the brain hitting the skull.

What is a skull fracture?

A skull fracture is a break in the skull bone. There are 4 major types of skull fractures:

  • Linear skull fractures. In a linear fracture, there is a break in the bone, but it does not move the bone. In many cases, these children can be observed in the emergency department or the hospital for a brief time, and can usually resume normal activities in a few days. No interventions are usually needed.

  • Depressed skull fractures. This type of fracture may be seen with or without a cut in the scalp. In this fracture, part of the skull is actually sunken in from the trauma. If the inner part of the skull is pressed against the brain, this type of skull fracture requires surgery to help correct it.

  • Diastatic skull fractures. These are fractures that  occur along the suture lines in the skull. The sutures are the areas between the bones in the head that fuse with the growth of the child. In this type of fracture, the normal suture lines are widened. These fractures are more often seen in newborns and infants.

  • Basilar skull fracture. This can be a serious type of skull fracture, and involves a break in the bone at the base of the skull. Children with this type of fracture often have bruises around their eyes and a bruise behind their ear. They may also have clear fluid draining from their nose or ears due to a tear in part of the covering of the brain. These children sometimes require close observation in the hospital.

What causes a head injury?

There are many causes of head injury in children. The more common injuries are sports injuries, falls, motor vehicle accidents (where the child is either riding as a passenger in the car or is struck as a pedestrian), or a result of child abuse.

The risk of head injury is high in teens. Head injuries are twice as frequent in males than in females. Studies show that head injuries are more common in the spring and summer months when children are very active in outdoor activities such as riding bikes, in-line skating, or skateboarding.  Although usually not life threatening, head injury that occurs in competitive sports such as football, soccer, hockey, and basketball can result in concussion.

What causes bruising and internal damage to the brain?

When there is a direct blow to the head, shaking of the child (as seen in many cases of child abuse), or a whiplash-type injury (as seen in motor vehicle accidents), there is bruising of the brain and the damage to the internal tissue and blood vessels. A bruise is directly related to trauma, at the site of impact. As the brain jolts backwards, it can hit the skull on the opposite side and cause a bruise. The jarring of the brain against the sides of the skull can cause tearing of the internal lining, tissues, and blood vessels that may cause internal bleeding, bruising, or swelling of the brain.

What are the symptoms of a head injury?

These are the most common symptoms of a head injury. The child may have varying degrees of symptoms associated with the severity of the head injury. The symptoms of a mild head injury may include:

  • Mild head injury:

    • Raised, swollen area from a bump or a bruise

    • Small, superficial (shallow) cut in the scalp

    • Headache

    • Sensitivity to noise and light

    • Irritability or abnormal behavior

    • Confusion

    • Lightheadedness or dizziness

    • Problems with balance

    • Nausea

    • Problems with memory or concentration

    • Change in sleep patterns

    • Blurred or double vision

    • "Tired" eyes

    • Ringing in the ears (tinnitus)

    • Changes in taste

    • Fatigue or lethargy

  • Moderate to severe head injury (that requires immediate medical attention)--symptoms may include any of the above plus: 

    • Loss of consciousness

    • Severe headache that does not go away

    • Repeated nausea and vomiting

    • Loss of short-term memory, such as trouble remembering the events that led right up to and through the traumatic event

    • Slurred speech

    • Trouble walking

    • Weakness in one side or area of the body

    • Sweating

    • Pale in color

    • Seizures or convulsions

    • Behavior changes including irritability or confusion

    • Blood or clear fluid draining from the ears or nose

    • One pupil (dark area in the center of the eye) looks larger than the other eye (unequal pupil size)

    • Deep cut or laceration in the scalp

    • Open wound in the head

    • Foreign object penetrating the head

    • Coma (a state of unconsciousness from which a person cannot be awakened; responds only minimally, if at all, to stimuli; and exhibits no voluntary activities)

    • Vegetative state (a condition of brain damage in which a person has lost his thinking abilities and awareness of his surroundings, but retains some basic functions, such as breathing and blood circulation)

    • Locked-in syndrome (a neurological condition in which a person is conscious and can think and reason, but cannot speak or move)

How are head injuries diagnosed?

The full extent of the problem may not be completely understood right after the injury, but may be revealed with a comprehensive medical evaluation and testing. The diagnosis of a head injury is made with a physical exam and tests. During the exam, the doctor takes a complete medical history of the child and asks how the injury occurred. Trauma to the head can cause neurological problems and may require further medical follow up.

Tests may include:

  • Blood tests

  • X-ray. This test uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

  • Magnetic resonance imaging (MRI). This procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.

  • Computed tomography scan (also called a CT or CAT scan).  This imaging procedure that uses a combination of X-rays and computer technology to produce horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general X-rays. Although an X-ray is useful when looking for a skull fracture, most skull fractures can also be detected by a CT scan, which also produces images of the brain. If a brain injury is suspected, a CT scan alone may be used to reduce the amount of radiation the person receives,

  • Electroencephalogram (EEG). This procedure records the brain's continuous, electrical activity by means of electrodes attached to the scalp.

Treatment of a head injury

Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.

Depending on the severity of the injury, treatment may include:

  • Ice

  • Rest

  • Topical antibiotic ointment and adhesive bandage

  • Observation

  • Immediate medical attention

  • Stitches

  • Hospitalization for observation

  • Moderate sedation or assistance with breathing that would require being placed on a breathing machine, also called a mechanical ventilator or mechanical respirator

  • Diagnostic tests

  • Surgery

  • Referral to a traumatic brain injury specialist

Treatment depends on the extent of the condition and the presence of other injuries. If your child has a head injury, he or she may need monitoring for increased pressure inside the skull (intracranial pressure). Head injury may cause the brain to swell. Since the brain is covered by the skull, there is only a small amount of room for it to swell. This causes pressure inside the skull to increase, which can lead to brain damage.

How is intracranial pressure (ICP) monitored?

Intracranial pressure is measured in two ways. One way is to place a small hollow tube (catheter) into the fluid-filled space in the brain (ventricle). Other times, a small hollow device (bolt) is placed through the skull into the space just between the skull and the brain. Both devices are inserted by the doctor either in the intensive care unit (ICU) or in the operating room. The ICP device is then attached to a monitor that gives a constant reading of the pressure inside the skull. If the pressure goes up, it can be treated right away. While the ICP device is in place your child will be given medicine to stay comfortable. When the swelling has gone down and there is little chance of more swelling, the device will be removed.

Lifelong considerations for a child with a head injury

The key is to promote a safe playing environment for children and to prevent head injuries from occurring. The use of seat belts when riding in the car and helmets (when worn properly) for activities, such as riding bikes, in-line skating, skateboarding, and skiing may protect the head from severe injuries.

Children who suffer a severe brain injury may lose part(s) of muscle, speech, vision, hearing, or taste function depending on the area of brain damage. Long- or short-term changes in personality or behavior may also occur. These children require lifelong medical and rehabilitative (physical, occupational, or speech therapy) management.

The extent of the child's recovery depends on the type of brain injury and other medical problems that may be present. It is important to focus on maximizing the child's capabilities at home and in the community. Positive reinforcement will encourage the child to strengthen his or her self-esteem and promote independence.