From mild Head Injury to traumatic Brain Injury/ when to you need attention?

Head Injuries/Traumatic Brain Injury Kids fall. I can safely say that not a week goes by at work when I don't get the ‘call’. The mom or dad is in tears as they recount in horror that their baby just fell. Sometimes the baby was left on an unprotected surface for a moment, not imagining that the infant could manage to roll off. That thud is an awful sound. Sometimes the caregiver is right there watching it happen, but can't move fast enough to catch them. Of course it isn't just babies who fall. Children and adults have accidents and sports injuries all the time.  If your baby just fell or you are the first responder at any kind of accident, take a deep breath. You need to remain calm. You can have a glass of wine later.  Medical personnel will want to know: How far do you think they fell? (rule of thumb, if it is a height taller than the child, they need to be seen) What kind of surface did they fall onto? What was the immediate reaction? How long did it take until they stopped crying? Of course, if there is a loss of consciousness, or any possible neck injury, don’t move them, CALL 911! Most of the time, after a moment or two of stunned silence, your child will be vigorously crying. Dr. Hurd adds that even if you were in the other room, if you heard the thud and then immediately hear the scream, there is probably no loss of consciousness. Do a quick head to toe assessment. Is there any obvious bleeding, bruising, sprains or fractures that need to be tended to? Put immediate pressure on any bleeding wounds. Check the mouth and make sure there are no loose teeth (this is the reason that you already have a relationship with a pediatric dentist.) If your child will cooperate, get a cold pack on any bruises. If you are out of the house, a cold can from a vending machine is a good option. If you are near a freezer, a bag of frozen peas makes a nice ice pack. For toddlers and preschoolers, playing doctor before anything happens can be very useful. “Uh oh, we have a boo boo, quick, let’s put the cold pack on there to help make it feel better.” There are some cute little pediatric friendly cold packs available that might elicit cooperation. I also have had good results with the use of Arnica. Arnica is a homeopathic treatment that comes as a topical ointment or little pellets that are taken by mouth. Many parents swear that it significantly decreases bruises (roll your eyes if you must, but I have seen it work.) It is worth having some around. Kids often like to have ‘cream’ applied to a little ‘owie’. Arnica is perfect for that. Be aware that head wounds can create a huge amount of blood if there is even a tiny little break in the skin. If the skin remains intact, all of that blood can rapidly collect into an enormous goose egg. These can look fairly alarming and can turn all sorts of lovely colors, but they do resolve. A big goose egg should be checked out to make sure there is no fracture. Mild bruises and bumps by themselves are not typically a concern if the child is acting fine otherwise. While I am not worried about some visible bleeding, any bleeding that is taking place underneath the skull is a different story. Any accumulation of fluid or swelling can cause potential pressure on the brain. If this is happening, your child will NOT be behaving as usual. Most of the time the kids are indeed fine following a mild to moderate fall or whack on the head, but we always need to be on the lookout to make sure there isn’t a concussion. A concussion is a type of traumatic brain injury that stems from an impact to the head that causes the head and the brain to move quickly back and forth. The brain may bounce or twist in the skull from this sudden movement. This in turn can cause stretching and damage to the brain cells as well as chemical changes in the brain. If your child is acting perfectly well after a fall, they are likely just fine. It is appropriate to call the doctor's office just to be on the safe side, but most of the time you will likely be told that you can just keep a close eye on them at home. All of the experts agree that once your child has calmed down and seems mostly okay, it is fine to let them take their normal nap. An overtired baby will be cranky and may be near impossible to assess. If they are nodding off, it is likely because they are tired, and not from the head injury. Do not let them take a nap that is significantly longer than the typical nap time. Depending on how far and hard they fell, I would also check on your child every couple of hours during the night. You can set your clock to make sure you get up to do this. With an infant you can offer them a dream feed. They don't need to be fully roused. With an older child, let them know you will be checking on them during the night. You can offer them a sip of water or just have them mumble “I love you”. You are simply establishing consciousness; you often don't need to wake them completely up. Keep in mind that if your child is in a deep sleep stage, a gentle whisper might not be enough to wake them up. For older kids, if they know ahead of time that you will be coming in, they are easier to wake up. If there is a TBI ( traumatic brain injury) you are going to have clues that something is not right. Physical symptoms would include dizziness or balance problems, headaches, vision problems, light sensitivity, sleepiness, and/or nausea and vomiting. I actually give the kids "one free vomit". Often they have cried hard enough that they might spit up a little. Let's not worry about that first emesis. If they vomit a second time, it’s time to call your doctor. Vomiting could simply be a sign that they are coming down with a tummy bug, but nonetheless, if they whacked their heads and are now vomiting, they need to be checked out. Traumatic Brain Injury symptoms are not only physical. We need to keep an eye out for social or emotional changes as well. If the head injury patient is having issues with anxiety, nervousness, irritability, or trouble with memory, that is worth bringing up to your medical team and having them seen. There is no downside to getting your child evaluated if you are even the least bit concerned. Most pediatric emergency rooms will do a thorough assessment without automatically jumping to a cat scan. Current practice does not usually do routine imaging unless there is loss of consciousness, there is suspicion for a skull fracture, or the patient is under the age of two. Doctors will use their clinical judgement and make a case by case decision. A basic neurological exam might include the following (of course some of these are age dependent): Can they answer simple questions? Is there any complaint of blurry vision Do the pupils react to light at the same speed (generally if a penlight is shined into the eyes, the pupil will get smaller) Pupil changes would be of immense concern but would happen only with a serious injury and would NOT be the only symptom. Some folks, as their baseline have pupils that are not exactly the same size. They were born this way but no one noticed. I would suggest checking your child's eyes before they fall so that you don't get freaked out if they seem off to you after a fall if you are noticing that for the first time.  Can they touch their finger to their nose? Do this with each hand. Is there any clear drainage from the nose or ears? Of course what toddler doesn't have a runny nose? If the patient is diagnosed with a concussion, high risk activities need to be avoided for several weeks  Aside from that provision, the newer protocols for concussion care are not as restrictive as they used to be. Right after the injury Rest right after the injury. Take it easy the first few days when symptoms are more severe. Avoid any activities that seem to be making symptoms worsen. Screen time, reading or anything that can cause eye strain is not a good idea. Find activities that are quiet and relaxing and don’t require a lot of mental stimulation. It is okay for you to read to them. Within a few days As your child starts to feel better he or she can gradually return to regular (non-strenuous) activities Return to school gradually. If symptoms do not worsen during an activity, then this activity is OK for your child. If symptoms worsen, cut back on that activity until it is tolerated. Encourage outside time, such as taking short walks if the weather cooperates. Make sure they are getting a good night's sleep. It is especially important to avoid screen time and loud music before bed. After a solid knock to the head you are not out of the woods right away. Any dizziness or headaches that occur within a week or two following the head trauma need to be paid attention to. Any time there is an increase in vomiting or confusion, get immediate medical attention! Discuss return to sports with your medical team. The large majority (70-80%) of people with Traumatic Brain Injuries are for the most part fully recovered by 3 months post-injury. Every child’s recovery period is unique. Misery loves company My husband came pretty close to dropping Lauren, our first born, when she was very young. He just barely caught her by grabbing the bottom of the sleep sack she was wearing; there she was, hanging upside down, her head a few inches from the ground. He had nightmares about that one for awhile. Last year I got the call about a Selfie accident! Mom was holding the phone way out for a photo op, She is the first to admit that she was more focused on posing than her grip on the baby. The poor baby’s head flopped back and gave a thump (he was fine.) I actually remember in my own case, what I describe as the definition of absolute ambivalence. My four year old Alana had a friend over and they were playing upstairs. I heard the unmistakable sound of someone tumbling down the steps. As I ran to the scene I recall thinking, "who do I want that to be? My child or the friend?" It turned out that it was my kid. They had been playing dress-up and she was wearing a pair of high heels (Satan's shoes.) She stood up with a giggle and brushed herself off, but it took me a moment before I could take a breath and then we made a new rule about dress up shoes and steps. Prevention Sometimes a parent falls when holding the baby and they both get injured. Beware of trying to manage a baby along with armloads of groceries. Never leave your baby on a surface that they can fall from; they will! I have had babies who are too young to roll, manage to wiggle themselves off edge of a king size bed, when they had started out in the middle. Watch out for wet squirmy babies right out of the tub. Using a towel or terry cloth robe can help give you traction. Skin to skin is especially slippery. Make sure your kids wear helmets when using bikes, scooters or skates. Model good behavior! Make sure your child is in the appropriate car seat. Make sure your house is childproofed with appropriate safety gates. Make sure that stairs are free from clutter. Choose playgrounds that have a safer ground to fall onto. Sand beats concrete anytime! Please exercise common sense precautions to avoid being the person who has to call about a fall, but remember that most of the time it is harder on the traumatized parent than it is for the patient. Accidents happen on the watch of even the most vigilant care giver. Stay safe! Thanks so much to my friend Amy who is the program manager at the UCSF TRACK-TBI/TED Research Network for helping make sure I had access to all the current research. https://www.cdc.gov/headsup/index.html If you are interested, their first two articles have now been published . These are articles written by doctors and TBI researchers, reviewed by kids/adolescents, and geared for kids https://www.frontiersin.org/research-topics/8603/understanding-traumatic-injury-to-the-human-brain