It helps to appreciate the difference between a skull injury and a brain injury. The skull acts as a protective helmet for the delicate
brain, and the skull is covered with a richly vascularized scalp. Most falls
involve injury to the scalp only, which bleeds profusely if cut or forms a large
swelling (goose egg) from broken blood vessels beneath the skin. Don't be
alarmed by how quickly these large bumps appear. They go down quickly with an
ice pack and pressure. These bumps and bleeds are usually limited to a scalp
injury and seldom indicate that the underlying brain has been injured.
The main concern after any blow to baby's head is injury to the underlying
brain, which occurs in two forms: bleeding and concussion. When
small blood vessels have been broken between the skull and the brain or within
the brain, bleeding occurs within this space and compresses the brain. A blow
to the head may also cause a concussion, meaning the brain has been "shaken up"
by the fall. Pressure on the brain from bleeding or from the swelling
associated with the concussion produces the outward signs of a brain injury.
WHAT TO LOOK FOR—WHEN TO WORRY
- If your child is unconscious, but breathing and pink (no blue lips), lay her
on a flat surface and call emergency medical services. If you have cause to
suspect a neck injury, don't move the child but let the trained experts in neck
injuries transport her. If she is not breathing, apply CPR, or if she's having
a convulsion, keep her airway clear.
- Sometimes, if baby is sensitive and prone to temper tantrums, she may be
pushed into a breath-holding spell, which could be mistaken for a
convulsion. This scene naturally pushes panic buttons and gets baby rushed to
the hospital. Even if this turns out to be unnecessary, it is better to be
safe. When in doubt, take baby and sit in the waiting room of the local
hospital emergency room.
- A period of observation. If your child is alert and conscious,
walking, talking, playing, and acting like she was before the fall, administer a
dose of parental sympathy, apply an ice pack to the cut or bump for twenty
minutes, and begin a period of observation before calling your doctor. The
reason for the period of observation is because doctors often rely more on how
the child behaves after the injury than what happened at the time of the injury.
If the brain has been injured, signs may show immediately, or they may appear
slowly during the next twenty-four hours.
After the period of observation, depending on your baby's condition, you may
or may not with to call the doctor. Besides any when-to-call-the-doctor list
there is an overriding inner voice. Trust this monitoring system as much as the
most sophisticated electronics. If it tells you something's not quite right,
call your doctor to report baby's condition, seek advice, and above all tell the
doctor why you are concerned.
SIGNS OF BRAIN INJURY
If your child shows any of the following signs after a head injury, call your
doctor or take her to the hospital.
- Disorientation, difficulty arousing
- Unusual breathing while sleeping
- Crossed eyes, unequal pupils
- Persistent vomiting
- Increasing paleness
- Oozing of blood or watery fluid from an ear canal
- Off balance while sitting, crawling, or walking
WHAT TO LOOK FOR OVER THE NEXT TWENTY-FOUR HOURS
1. Changes in baby's sleep behavior
Babies normally retreat into
sleep after trauma, which makes the usual admonition to "watch for a change in
consciousness" an anxiety-producing instruction for the parent. If a head
injury occurs near night or nap time in an already tired child, you may be
confused about whether the drowsiness is due to the injury or whether it's just
time for sleep to naturally overtake the child. And it may be impossible to
follow the advice "Don't let baby go to sleep." Let baby fall asleep, but
awaken yourself every two hours and do a baby check. This is what to look for:
- Change in color from pink to pale or, even more alarming, blue.
- Change in breathing: periods of very shallow breathing, ten-to
twenty-second periods of stop-breathing episodes followed by irregular
breathing, or gasping episodes (remember that newborns normally have irregular
- Twitches on one side of the body involving a whole limb.
If baby's color and breathing patterns are normal (no change from usual) and
your parental instincts sense nothing's wrong, there's no need to awaken baby
unless advised to do so by your doctor. The deep sleep from a head injury is
nearly always associated with shallow, irregular breathing patterns that
you are unlikely to have seen before.
If, however, you are uncertain or baby's appearance sets off a "not normal"
alarm, do a partial arousal. Sit or stand your child up and then put her back
down. Normally, a child will fuss a bit and thrash around in the bed to
resettle. If your child does not act like this, try to fully arouse her by
sitting or standing her up, opening her eyes, and calling her name. If she
awakens, looks at you, fusses or smiles, and struggles to be left undisturbed,
you can go back to sleep without worrying. If, on the other hand, she does not
protest, can't be awakened enough to begin fussing, is pale, shows irregular
breathing, and is drooling profusely, or shows any of the signs of brain injury
listed above, seek medical attention immediately.
2. Changes in balance and coordination
During the day signs of
head injury are easier to observe. Watch your child's normal play. Is he doing
everything the same after the fall: sitting straight, walking well, moving arms
and legs normally? Or is he off balance, wobbly, dragging a leg, or becoming
increasingly disoriented? In the prewalker, do you notice any change in sitting
or crawling skills or in manipulative hand skills?
Just as some children fall asleep after a head
injury, some children vomit, mostly from being upset at falling and hurting.
Don't worry. But persistent
vomiting over the next six to twenty-four
hours is an alarming sign. Call your doctor right away. As a precaution feed
the recovering faller clear liquids for a few hours. Breastfeeding is
4. Eye signs
The eyes mirror what's going on inside the body,
especially inside the brain. In fact, the back of the eye is so intimately
connected with the brain that your doctor looks at the backs of the eyes for
evidence of brain swelling while examining a child following a head injury. A
child's signs are more difficult to assess, but here are the call-doctor cues:
- Crossed eyes or rolling eyes
- One pupil larger than the other
- Behavior such as tripping or running into things that indicates baby's
vision is diminished
- In the older child, add complaints of seeing double and blurred vision to
the worry list
WHAT ABOUT SKULL X-RAYS?
Except for severe head injuries or obvious fractures, skull x-rays are seldom
helpful; nor is it necessary to rush a happily playing child to the hospital for
an x-ray. First, try a period of observation; next, call your doctor; then
comes the advice on whether or not to take baby to the hospital for x-rays. A
CAT scan, a series of cross-sectional x-rays of the brain, has nearly replaced
the plain skull x-ray. In most cases if a child warrants an x-ray at all, he
merits a CAT scan. This technological breakthrough reveals much more about an
injury, such as whether there is bleeding or swelling of the brain, than a
simple skull x-ray. On a softer note: In the life of a child, considering the
many times little heads meet hard floors, injuries to the brain are uncommon.