Head and Brain Injury in Children
Recent news reports about long-term mental impairment among football and ice hockey professional athletes who sustain repeated head trauma have heightened awareness about the importance of concussions, a type of brain injury.
Fortunately most head injuries only involve the scalp and cause bleeding from a cut or the familiar "goose egg" swelling that is the result of the scalp's blood vessels leaking fluid or blood into and under the scalp.
Traumatic Brain Injury (TBI)
But the implications of a traumatic brain injury (TBI) from a blow to the head can be very serious and result in lifelong cognitive deficits. Head injuries include various combinations of concussion (a temporary loss of normal brain function), bruising of the brain tissue, bleeding into the brain from broken blood vessels, and skull fractures.
Traumatic brain injury is the leading cause of disability and death in children and adolescents in the United States. Head trauma represents about 80% of the traumatic injuries leading to death of children older than 1 year. Most pediatric head trauma occurs from motor vehicle crashes, falls, assaults, recreational activities, and child abuse.
The Center for Disease Control and Prevention notes that the two age groups at greatest risk for TBI are ages 0-4 and 15-19. Every year, children aged 0 to 14 years make almost half a million emergency department visits for TBI. Among children ages 0 to 19, each year an average of 62,000 children sustain brain injuries requiring hospitalization and about 2,700 die from TBIs as a result of motor vehicle crashes, falls, sports injuries, physical abuse and other causes. Child abuse causes severe or fatal brain injury among approximately 1,300 children every year.
The symptoms of a TBI may be physical (with headaches, fatigue, seizures, impairment of speech, vision, hearing, or coordination), cognitive (with impaired concentration, memory, attention span, communication or judgment) and emotional (with mood swings, anxiety, depression, lack of motivation or difficulty in controlling emotions). Symptoms can vary greatly depending on the extent and location of the brain injury. Impairments in one or more areas (such as cognitive functioning, physical abilities, communication, or social/behavioral disruption) are common.
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A Head Injury Can Be an Emergency
A head injury can be an emergency and it is time to call 911 for help if a child shows any of these symptoms after a head injury:
- unconsciousness for more than a few minutes (and an unconscious child should not be moved in case there is a neck or spine injury)
- abnormal breathing
- obvious serious wound
- bleeding or clear fluid from the nose, ear, or mouth
- disturbance of speech or vision
- pupils of unequal size
- weakness or paralysis or trouble waking
- neck pain or stiffness
- seizure (convulsion)
- vomiting more than 2 or 3 times
- difficulty in waking up or excessive drowsiness
- difficulty in recognizing familiar people
- symptoms that worsen over time
A concussion is a mild TBI that conjures up the image of someone knocked unconscious while playing sports, but many concussions are the result of car or bicycle crashes, fights, and even minor falls. Concussions are a type of brain injury that changes the way the brain normally works, and they can happen with any head injury, often without any loss of consciousness.
Children who sustain concussions usually recover within a week or two without lasting health problems if they get adequate rest from school and sports. But a child with an undiagnosed concussion can be at risk for brain damage and even disability. Even without a loss of consciousness, it's important to watch for symptoms of a concussion.
Common initial signs and symptoms include:
- a change in level of alertness
- extreme sleepiness
- a bad headache
- repeated vomiting
- crying and inability to be consoled
- restlessness or irritability
- difficulty in waking up
Someone with these symptoms should be taken to the emergency room or see a doctor right away.
Other signs of a concussion include:
- sleepiness or difficulty falling asleep
- feeling confused and dazed
- difficulty concentrating, thinking, or making decisions
- difficulty with coordination or balance (such as being able to catch a ball or other easy tasks)
- trouble remembering things, such as what happened right before or after the injury
- blurred vision
- slurred speech or saying things that don't make sense
- nausea and vomiting
- persistent headache
- feeling anxious or irritable for no apparent reason
Concussion symptoms may not appear initially and a child can seem fine at first but develop symptoms over the first 24-72 hours after an injury. Determining a concussion in a very young child who has been hit in the head by a ball, is in a car crash or has fallen can be difficult. Young children can have the same concussion symptoms as older children and adults, but changes in mood and behavior may be more subtle. Concussions can be especially difficult to recognize in infants and toddlers. They may not be able to describe a symptom like nausea or amnesia because they can't readily communicate how they feel.
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Nonverbal clues of a concussion may include:
- listlessness, tiring easily
- irritability, crankiness
- change in eating or sleeping patterns
- lack of interest in favorite toys
- loss of balance, unsteady walking
The rule is when in doubt, see a physician or emergency department for immediate evaluation.
Treatment and Recovery
Evaluation of brain injuries may require use of diagnostic tools including x-rays and magnetic resonance imaging (MRI) to rule out bleeding or other serious brain injury. Concussions change brain functioning, but usually imaging tests will be normal.
Depending on the severity of the injury, surgery, hypothermia (lowered body temperature) and various medicines to treat seizures, decrease brain swelling and to control blood pressure may be required.
The nature of the injury and its consequences can range from mild to severe, and the course of recovery is very difficult to predict for any given child. Brain injuries are different in children because the brain of a child is continuing to develop. Research has shown that a brain injury has a more devastating impact on a child than an injury of the same severity has on a mature adult.
The cognitive impairments of children may not be immediately obvious after the injury but may become apparent as the child gets older and faces increased cognitive and social expectations for new learning and more complex, socially appropriate behavior. These delayed effects can create lifetime challenges for living and learning for children, their families, schools and communities. Common deficits after brain injury include difficulty in processing information, impaired judgment and reasoning. When an adult is injured, these deficits can become apparent in the months following the injury. For a child, it may be years before the deficits from the injury become apparent.
The good news is that most concussions don’t cause any lasting effects, and most children make a complete recovery with physical and mental rest. Although most children recover quickly from concussions, some symptoms — including memory loss, headaches, and problems with concentration — may linger for several weeks or months. With early diagnosis and therapy, the severity of these symptoms will decrease in varying degrees.
After a concussion, nearly 15% of children age 5 and older have symptoms and/or changes in functioning lasting 3 months or longer. It's important to watch for these symptoms and get proper medical care if they persist.
The primary treatments for a concussion include both physical and mental rest. After a concussion, the brain needs time to heal. Recovery time will depend on how long the symptoms last. It's very important for children to rest until all symptoms have subsided. Physical symptoms, balance and coordination, thinking and personality all should return to the pre-injury level before resuming normal activities.
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Because the primary treatment for a concussion is both physical and mental rest, while a child has symptoms, he or she should not:
- attend school or have a normal workload
- take any high-stakes testing (for example, state testing, PSATs, SATs, etc.)
- participate in physical activity including gym class, recess, and sports
- participate in wheel activities (for example, biking, rollerblading, scootering, or skateboarding)
- drive or operate machinery
- return to work
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 and should see a doctor.
It is essential to get a medical clearance before a child resumes sports or other physical activities. Sometimes children feel better even though their thinking, behavior, and/or balance have not yet returned to normal. Even if a child pleads that he or she feels fine or a coach wants a child back on the field, it's essential to wait until the doctor has given the OK. Once a child has sustained a concussion, he or she is at a higher risk of sustaining another. The effects of multiple concussions over years can be cumulative.
Another blow to the head while the initial concussion is healing can occasionally result in fatal brain swelling — a condition known as second impact syndrome. Also, a young athlete who sustains a second concussion is at greater risk of developing postconcussion syndrome, which is characterized by persistent concussion symptoms such as headaches, dizziness, irritability and difficulty with thinking skills, such as memory and attention.
Remember, even mild concussions require a player to sit out for the remainder of the game and repeated concussions can result in lasting brain damage, even when the injuries occur months or years apart.
It is important to provide support to children and teens when they return to school after a concussion. A child’s teachers, school nurse, and coach, all need to know about a child’s concussion and symptoms. Extra parental support is often needed because a child may feel frustrated, sad, or angry because he or she cannot return to recreation and sports right away, or cannot keep up with schoolwork. They may also feel isolated from peers and social networks. Children and teens who return to school after a concussion may need to:
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- take rest breaks as needed
- spend fewer hours at school
- be given more time to take tests or complete assignments
- receive help with schoolwork, and/or
- reduce time spent reading, writing, or on the computer.
Preventing TBI and Concussions
- To reduce the risk of sustaining a TBI, children and their parents should:
- Wear a seat belt every time they drive or ride in a motor vehicle.
- Use a child safety seat, booster seat, or seat belt according to the child’s height, weight and age. Children should start using a booster seat when they outgrow their child safety seats, usually when they weigh about 40 pounds. Children should continue to ride in a booster seat until the lap/shoulder belts in the car fit properly, typically when they are approximately 4’9" tall.
- Children should wear properly fitted, appropriate headgear and safety equipment when biking, rollerblading, skateboarding, snowboarding or skiing, and playing contact sports. Some safety gear, such as bike helmets, has been shown to reduce the occurrence of severe head trauma.
- Parents should make sure playground surfaces are made of shock-absorbing materials, such as hardwood mulch or sand, and are maintained to an appropriate depth.
- Childproofing a home will go a long way toward keeping an infant or toddler safe from concussions and other injuries. Babies reach, grasp, roll, sit, and eventually crawl, pull up, and walk. All of these activities can result in a head injury that leads to a concussion. Be sure a child has a safe place to play and explore, and, most important never leave a baby or toddler unattended.
- Childproofing steps include:
- installing window guards to keep young children from falling out of open windows;
- using safety gates at the top and bottom of stairs when young children are around;
- keeping stairs clear of clutter;
- securing rugs and using rubber mats in bathtubs; and
- not allowing children to play on fire escapes or on other unsafe platforms.
Preventing traumatic brain injuries can avoid the mental deficits that present lifetime challenges for living and learning for children.Back to top
Resoucres and Links
Information and portions of text used in this essay have been derived from the following sources:
Graham R., Rivara F.P., Ford, M.A., Mason Spicer, C. Editors; Sports-Related Concussions in Youth: Improving the Science, Changing the Culture, Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families; Institute of Medicine; National Research Council, 2013
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