By Dr. B.J.C.Perera MBBS(Ceylon), DCH(Ceylon), DCH(England), MD(Paediatrics), FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, FCGP(Sri Lanka) Consultant Paediatrician
There is a great deal of concern and worry inherent in the minds of parents and caregivers with regard to head injuries in children. Many imagine even trivial knocks on the head to have the potential to produce long-lasting damage to the brain. In addition, there are a whole lot of myths surrounding the topic of head trauma. Although major injuries to the head can cause problems, these are not all that common. It is a common misconception that almost any head injury is likely to cause brain damage.
Very broadly, many head injuries fall into one of two categories:
1. External, usually scalp, injuries
2. Internal head injuries, which may involve the skull, the blood vessels within the skull or the brain substance itself.
Most fortunately, a large proportion of childhood falls or blows to the head result in injury to the scalp only. Although this type of injury is usually more frightening than threatening, the risks of internal damage are very small. On the other hand, an internal head injury could have more serious implications because it may result in bleeding into or bruising of the brain.The scalp is rich with blood vessels and as a consequence, even a minor cut there can bleed profusely. The "goose egg" or swelling that may appear after a head blow is the result of the scalp’s veins leaking fluid or blood into and under the scalp. It may take days or even a week to disappear. However, even apparently scalp injuries may require urgent medical attention under certain circumstances. If there is heavy and uncontrollable bleeding, persistent inconsolable crying, marked head and neck pain, repeated vomiting, drowsiness and sleepiness, problems with walking or some sort of weakness of a limb are some of the signs that indicate that urgent medical attention is needed.
If the child is not an infant, has not lost consciousness and is alert and behaving normally after the fall or blow, one could attempt to manage things at home. It is a very good idea to apply an ice pack or instant cold pack to the injured area for 20 minutes every 3 to 4 hours. If ice is used, one needs to always wrap it in a towel, washcloth or sock. The child needs to be observed carefully for the next 24 hours. If any of the signs of an internal injury, as elucidated below, develops, the child must be taken to an emergency medical facility at once. If the incident has occurred close to bedtime or naptime and the child falls asleep soon afterwards, one must check in once or twice to also check for disturbances in colour or breathing. If the colour and breathing are normal and one does not notice any abnormalities, the child may be allowed to sleep. There is no need to keep a child awake after a head injury. If one is not quite comfortable with the child’s appearance, one should try to rouse the child partially by sitting him or her up. It is most likely that the child would fuss a bit and attempt to resettle. If he or she does not protest, one should try to awaken the child fully. If the child cannot be awakened or shows any signs of internal injury, one needs to rush the child to an emergency medical facility. Different levels of injury require different levels of concern. It can be difficult to determine the level of injury and it is best to get a medical opinion if one is ever in doubt.
The brain is cushioned by a fluid medium known as the cerebrospinal fluid and it is encased in the hard, protective skull. The brain can move around inside the skull and even bang against it. A severe blow to the head may knock the brain into the side of the skull or tear blood vessels. If the brain does bang against the skull, perhaps due to a fall on a sidewalk, a sports injury or a whiplash-type of injury, it can be bruised, blood vessels can be torn and the nerves inside the brain can be injured. These injuries can lead to a concussion. Some internal head injuries such as complications of a fractured skull, torn blood vessels or damage to the brain itself, can be serious and sometimes even life-threatening.
It is necessary to immediately seek medical advice under certain circumstances when a child has sustained a head injury. Any of the following are warning signs :-
* unconsciousness for any length of time
* abnormal breathing
* obvious serious wound which is deep
* bleeding or clear fluid from the nose, ear, or mouth
* disturbance of speech or vision
* pupils of the eye showing some inequality in size
* weakness or paralysis of an arm or a leg or both
* neck pain or stiffness
* convulsion / seizure
Even if some of these features are present, one should not try to move the child immediately if there is any suggestion of a neck injury. One needs to call for help and some trained medical attendants would need to take over. If the child is vomiting or having a seizure, one needs to turn the child onto his or her side while trying to keep the head and neck straight. This will help prevent choking and provide protection in case of a neck and spine injury.
If the child is conscious, one needs to do one’s best to keep the child calm and still. Any bleeding should be controlled with a clean or sterile bandage. One should not attempt to cleanse the wound as such an effort may aggravate bleeding and even cause serious complications if the skull bones are fractured. One should also not try to apply direct pressure if there is any suspicion of a fracture of the skull.
Concussions are also a type of internal head injury. A concussion is the temporary loss of normal brain function due to an injury. Repeated concussions can result in permanent injury to the brain. However, it is possible to get a concussion that is mild and which does not result in long-term brain damage. One of the most common reasons children get concussions is through sports and the implication of this fact is the necessity for children to wear appropriate protective gear. It is also necessary to reiterate that children should not be allowed to continue to play if they have had a head injury.
If a child sustains an injury to the head, some of the signs that one should look out for in relationship to a possible concussion are :-
* "seeing stars" and feeling dazed, dizzy, or lightheaded
* memory loss, such as trouble remembering what happened right before and after the injury
* vomiting
* headaches
* blurred vision and sensitivity to light
* slurred speech or saying things that do not make sense
* difficulty concentrating, thinking or making decisions
* difficulty with coordination or balance such as being unable to catch a ball or other easy tasks.
* feeling anxious or irritable for no apparent reason
The term concussion conjures up the image of someone knocked unconscious while playing sports. But concussions with temporary loss of brain function can happen with any head injury, often without any loss of consciousness. A concussion is also known as a mild traumatic brain injury. Although we usually hear about head injuries in athletes, many of them occur off the playing field in car and bicycle accidents, in fights and even with minor falls.
Children who sustain concussions usually recover within a week or two without lasting health problems by following certain precautions and taking a breather from sports. However, a child with an undiagnosed concussion can be at risk for brain damage and even disability. Anyone who sustains a head injury should stop participating and be removed from the activity or sport. Even without significant loss of consciousness, it is important to watch for symptoms of a concussion.
Common initial symptoms of concussion also include the following :-
* a change in the level of alertness
* extreme sleepiness
* a bad headache
* confusion
* repeated vomiting
* seizure
Any child who develops these features following a head injury should be taken to a medical facility. It must also be pointed out that concussion symptoms may not appear initially and can develop over the first 24 to 72 hours.
Many different systems have been used to grade or describe concussions. The severity of a concussion is determined by how long signs and symptoms last and so can only realistically be known after someone has recovered. The longer the symptoms of changes in brain function, the more severe the concussion.
Though most children recover quickly from concussions, some symptoms, including memory loss, headaches and problems with concentration, may linger on for several weeks or months. Nearly 15 per cent of children aged 5 and older have symptoms and/or changes in functioning lasting 3 months or longer. It is important to watch for these symptoms and contact a doctor if they persist.
If a concussion is suspected, the doctor will ask about how the head injury happened, when it occurred and its symptoms. The doctor also may ask basic questions to gauge the child’s consciousness, memory and concentration ("Who are you?"/"Where are you?"/day is it?"). The diagnosis of a concussion is made by a doctor based on the history and physical examination findings. The doctor will perform a thorough examination of the nervous system, including testing balance, coordination, nerve function, and reflexes. Occasionally, specialised tests such as a CT or MRI of the brain may be necessary. These should be performed only when there is a real suspicion of possible brain injuries.
If the concussion is not serious enough to require hospitalization, the doctor will provide instructions on how to take care of the child at home. The doctor may give instructions to wake the child up at least once during the night to ensure that all is well. On observation, if the child cannot be easily awakened, becomes increasingly confused or has other symptoms such as continued vomiting, it may mean that there is a more serious problem that requires immediate hospitalisation. The primary treatment for a concussion include both physical and mental rest. While the child is having symptoms, he or she should not :-
* attend school or have a normal workload
* participate in physical activity including gym classes, recesses and sports
* participate in wheel activities such as biking, rollerblading, scootering or skateboarding
After a concussion, the brain needs time to heal. Recovery time will depend on how long the symptoms last. It is very important for kids to wait until all symptoms have subsided before resuming normal activities. Physical symptoms, balance and coordination, and thinking and personality all should return to the pre-injury level. Healthy children are usually able to resume their normal activities within a few weeks but each situation is different. Even mild concussions require a player to sit out for the remainder of the game. Individuals are much more likely to sustain a concussion if they have had one previously and evidence shows that repeated concussions can result in lasting brain damage, even when the injuries occur months or years apart. Children who have resumed normal activities and no longer have symptoms might be allowed to slowly return to sports. This is a gradual process that can take anywhere from a few days to weeks. A person should never return to play or other strenuous activities on the same day of the injury.
There is a generally held belief that a child should not be bathed even after minor knocks on the head. IT is also believed that hot fomentations are required if there is any swelling at the site of the injury to the head. Both these have no scientific basis. Some children are also not allowed to engage in the usual activities for a very prolonged period of time. This is not necessary and gradual transition to normal activities should be encouraged once the symptoms have settled down.
It is of course quite impossible to prevent children from ever being injured but there are ways to help prevent head blows. It is most desirable to make homes safe for children and take steps to prevent accidents. Certain areas in the home may need to be child-proofed. Children should be made to always wear appropriate headgear and safety equipment when biking or engaging in any activity or sport that has the potential to cause head trauma. Wearing an appropriately fitting bicycle helmet, for instance, reduces the risk of head injury by about 85 per cent. Children should always be made to use a child safety seat or, in the case of bigger children, made to wear appropriate seat belts. In the unfortunate event of a head injury occurring, one also needs to ensure that a child takes it easy after the injury, especially if there is an episode of concussion and that the child does not get back to rough play or playing sports until a doctor gives the all clear and approval. It is important to remember that if a child re-injures the brain while it is still healing, it will take even more time to completely heal.
The author would appreciate some feedback from the readers.
KEY POINTS
* Head injuries in children cause a great deal of anxiety among the parents and care-givers.
* Many such injuries are mild and trivial.
* Major injuries are associated with some damage to the brain.
* When there are some concerns, the situation has to be carefully evaluated by a doctor.
* When a more severe forms of injuries occur, a period of rest is mandatory.
* Many preventive strategies could be usefully employed to min imise the occurrence of head injuries in children.
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