GP advice around toddlers and head injuries

Mama and urgent care doctor, Isabelle Duck talks us through what to do if your child has a head injury.

One of the most challenging aspects of parenting is seeing your child in pain. It's of particular concern when a child bangs their head. The good news is that the vast majority of head injuries in children are minor and do not require an admission into hospital (although some do require monitoring in the emergency department).  All children, however, need to be assessed by a doctor who will make this decision. Head injuries can range from small knocks to the head against a solid surface such as a wall, to knocks against a sharper surface such as the edge of a table, which may cause a wound. More serious head injuries are caused when a child falls from a height, such as a shopping trolley. In this article, I will discuss some of these injuries, and how they are assessed and managed.

It’s important that all children with a head injury are taken to the doctor without delay. If a child is unconscious after an accident, call an ambulance for an urgent assessment.  

In young children, there are several considerations which need to be addressed. Not only is a baby or toddler unable to fully articulate their symptoms, but their anatomy is very different from that of an adult's, meaning that the assessment of a head injury needs to be done by a fully trained medical professional who has had experience in assessing and managing children's injuries.

During this assessment, one of the first questions often asked is whether the accident was witnessed by an adult. If this is the case, it is important to explain the mechanism of injury. Specifically, did the child fall on a hard surface such as concrete? Approximately how far did they fall? Which part of the head was injured? Was there any loss of consciousness after the accident? And if so, for how long? How has the child been since? Are there any wounds, bruises or swellings? If there are wounds, it is important to apply gentle pressure to stop the bleeding. Even the smallest scalp wounds can bleed a lot, but often stop bleeding with adequate first aid. Swelling is common after a head injury but may occasionally indicate a fracture. Other findings which indicate a more serious head injury include bleeding from the nose or ears, vomiting, seizures, abnormal drowsiness, abnormal eye movements or pupil size, or agitation. Sometimes the accident is not witnessed by an adult – in these cases, clinical examination is of particular importance, as the severity of the accident is unknown. If there is the possibility of neck trauma, this information needs to be relayed to the doctor.

Remember to never shake a baby as it can cause severe brain trauma. If you suspect your baby has been shaken, it is important to tell the doctor. 

Wounds that are caused by head trauma are managed in different ways depending upon their size and depth. Small head or forehead wounds can be glued or steri-stripped. Larger ones need to be sutured (stitched), which in most young children requires some form of sedation. Suturing is best completed within the emergency department where sedation can be adequately administered.   

The decision of whether to scan a child's head is based on many factors, and is to be discussed with the treating doctor. The investigation of choice is a CT scan, which involves a significant amount of radiation and is not recommended for the majority of children with minor head injuries. Sometimes this decision is made after a period of observation for several hours in the hospital. There are certain guidelines that a doctor uses when making this decision, as well as the history and examination of the child.  Another consideration is whether the child has any relevant medical history such as a bleeding disorder. After your child has been discharged from hospital they will need to be closely monitored by a responsible adult. The 'red flag' signs will be discussed with you and it is very important that a child is brought back for a reassessment if there are any of these signs. 'Red flags' are signs which may become apparent after the child is sent home from the hospital and could indicate a more serious head injury than initially thought. Occasionally the clinical picture can change, this is sometimes the case in young children and babies.

Trust your instincts. If your child has been sent home from hospital and you feel they are not right and need a reassessment, then take them back to see a doctor.  

It's recommended that a child has a few days away from daycare or school as it is important that they rest their body and their brain. Rough sports should be avoided and screen time limited, as this can also slow down the recovery of the brain. 

To manage the pain after a head injury, paracetamol can be used, so long as there are no allergies or contraindications. Check the correct dosage with your doctor or pharmacist and if it doesn’t seem to be helping, your child may need to be reassessed by a doctor.

In general, after a minor head injury, your child should improve each day. They may be a bit more tired or grumpy than usual, but this is common. Your child should be reviewed by the doctor after ten days if you are concerned that their symptoms are not improving, or anytime if their condition deteriorates.        

CONCUSSION

A concussion is like a bruise to the brain which can change the way the brain functions for a period. In young children, a concussion can present with a number of symptoms including changes in sleep patterns, coordination challenges and poor attention. If your child is experiencing persistent symptoms, a doctor can refer them to a concussion clinic. These are specialist multidisciplinary clinics which are able to assess and support your child throughout the recovery process. 

HOW TO PROTECT CHILDREN FROM HEAD INJURIES

Accidents will always happen to children, and are an important part of a child's learning about the risks of the world around them. As much as we would like to, we cannot wrap our precious babies in cotton wool. As toddlers grow, they will learn the importance of protecting themselves and will become more careful. There are several things, however, that parents and caregivers can do in order to prevent serious head injuries.

Helmets are vital in protecting a child when they learn to ride a bike or scooter – make sure it’s the correct size and that the helmet is fitted appropriately.

Make sure your home is safe too; a stair gate for example can prevent a toddler from falling down the stairs and banging their head. Another common injury is a child who has banged their head on the edge of a coffee table. Foam protectors can be used on the sharp corners of furniture, and bookshelves need to be secured to the wall so that they cannot be pulled over. 

Toddlers need to be supervised in the home, outside, and in the playground particularly. Of course it’s very difficult to stop a toddler from getting the odd bump or scrape, but many head injuries can be avoided with adequate supervision from a responsible adult. It can be very tiring running after an active toddler, but this stage will pass and your toddler will gradually begin to learn the importance of being careful. 

When discussing head injuries, it is also important to consider car seats. New Zealand law requires all children under the age of seven to be seated in an appropriate car seat. This means it needs to be the correct car seat for a child's height, age and development. Rear facing seats are recommended for infants and toddlers under the age of two, this is because they are more at risk from head and spinal cord injuries at this age. Child restraint technicians are an excellent source of knowledge and advice on how to choose and install the correct car seat.     

The main take home message here is that early medical assessment is imperative. After review from a doctor, if you are still feeling concerned, or your child's condition deteriorates, you need to take your child back to be reassessed.

All children need a restful few days after a head injury in order to aid recovery, and concussion clinics are there to help those children with prolonged symptoms. As the saying goes, 'prevention is better than cure'.  Remember to monitor your toddler when they are on the move, and to use all appropriate methods to protect their precious wee heads.

References available on request. All medical advice given in this article is for informational purposes only. This information given is no substitute for a face-to-face examination by a trained medical professional.

Dr Isabelle Duck is a General Practitioner at Silverdale Medical  in Auckland. She lives in Hobsonville with her husband – a lecturer, and their daughter, Lauren.