Head Injury

From falling off the bed, to crashing the bicycle, to colliding on the sports field, head injuries are common in childhood. Head injuries range from minor to quite serious.  As a parent in a limited resource setting, it’s important to know how to prevent head injuries, what to look for, and when to go to the clinic. 

Prevention:

In an American Emergency Room one concerned mother of a toddler with a swollen forehead from a fall asked me, “Is there some kind of bubble we can put him in to protect him from injuries?”  

“No, no bubble.”  But there are some things we can do to help prevent head injuries.

Put your child in the proper car restraints every time you are in the car. This will prevent the most fatal head injuries.

Bicycle helmets protect kids should they crash their bikes and hit the hard ground or even a rock.  Be sure to buy a helmet when you buy the bike and insist they wear them every time.

Keep an eye on babies when they are on beds, couches, and changing tables. Even babies that aren’t old enough to roll over yet, somehow manage to roll off the bed. I see it often. Babies should only sleep in a crib, cot, or mat on the ground unless you are watching.  Once a toddler learns how to crawl out of his crib it’s near impossible to keep him safely in the crib or travel cot. You have no choice but to move him to a mattress that’s either low to the ground or on the ground.

Teach older babies and toddlers how to roll over onto their stomach and climb off of chairs, beds, and couches.  Babies’ heads are very heavy in proportion to their body. As they are learning to sit independently, crawl, and walk, they naturally fall head-first.  And they don’t understand that it’s a long way to the ground from a bed or couch.

Baby proof your house. When working in the emergency department, I saw more pediatric injuries on the holidays when kids were running around with their cousins in a non-childproof house.  Get down on your knees and see what hard surfaces your child could hit if she falls. Either remove them or pad them so they aren’t so sharp.

Questions to ask when evaluating a head injury: 

What is the mechanism of injury? – “How did the head injury happen?” “From how high did the child fall?”  The faster the child was going (car or bicycle vs. running or walking) or the higher up the fall (changing table vs. standing position) the more serious the injury could be. 

How did your child respond when the injury happened?– “Did the baby cry right away?”- crying is a healthy natural response with a head injury. If the child didn’t’ cry, you need to determine if he was unconscious. “Did your child black out?” “Was your child dazed or confused?”

What injuries has your child sustained? – The scalp is very vascular, so you can expect swelling almost immediately if the forehead gets hit with enough force (pictured above).  While it can look awful, it doesn’t necessarily mean it is a serious injury. The forehead is very thick and often can sustain more force than around the eye or the sides of the head. The back of the head is also thick, but the base of the skull can be a fragile area. The mechanism of action and loss of consciousness are more significant factors in the seriousness of the injury.  Make sure the breathing is even and regular. Feel along the clavicles and each of the arms and legs to find tender or swollen spots. 

How is your child acting after the injury?–  “Has it been 30 minutes and your baby is still screaming at the top of his lungs?”  “Is your child vomiting?”  “Is your child asking the same questions or repeating phrases again and again?”

When to be evaluated:

Any child that was unrestrained in a car accident 

Any child under one year of age that has fallen off a bed or high surface 

Any child that lost consciousness, no matter how brief

Any child with signs of confusion

Any child that has vomiting within 48 hours of head injury 

Injury to or around the eye (these bones are more delicate)

If you have any concerns. Mothers know their kids and if you don’t have a peace about watching your child from home, then you should bring him in to be professionally evaluated.

Only the most severe head injuries require a CT scan of the brain. CT’s have a lot of radiation that pose their own risk to a child. So, it’s only after careful evaluation by a healthcare provider that this test may be ordered. In Malawi, it’s difficult to find a place to sedate a baby for a proper scan, so often admitting the child for close observation is the preferred choice.

Home care:

If the fall was at a low speed, from a low distance, the child cried right away, was easily soothed, is acting fine, and no vomiting then you can watch your child from home. If your child has any confusion, repetition of phrases, vomiting, or you have any concerns then you should immediately take your child to the clinic. Wake your child every 4 hours in the night to make sure there is no change in condition.

For older children you can apply ice packs to the affected area. Toddlers and babies usually battle an ice pack, so it’s not worth the struggle.

You may give Panadol or paracetamol for pain if needed. I avoid Brufen for head injuries because it has blood thinning properties.

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