Kids fall. When I was working as the advice nurse at Noe Valley Pediatrics, not a week went by when I didn't get the ‘call’. The mom or dad would be in tears as they recounted in horror that their baby fell. With young babies, this can happen if you leave them on an unprotected surface for even a moment. More often than not, the caregiver was close by, watching it happen, but couldn't move fast enough. That thud is an awful sound.
Of course it isn't only babies who fall. Children and adults have accidents and sports injuries all the time.
If your child falls or you are the first responder at any kind of accident, take a deep breath. The most important thing is to remain calm. You can give yourself some great self care, later. (glass of wine, bubble bath, hug)
Medical personnel will want to know:
How far do you think they fell? The rule of thumb is, that if they fall from a height that is higher than they are tall, then they need to be evaluated. (Tripping from standing doesn’t count)
Were they in a moving vehicle where the airbags were deployed?
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!
A moment of stunned silence is common. If the fall is soon followed by crying it is unlikely that there was any loss of consciousness.
Do a quick head to toe assessment. Is there any obvious bleeding, bruising, sprains or fractures?
Put immediate pressure on any bleeding wounds.
Try to get a cold pack on any bruises. If you are out of the house, a cold drink from a vending machine is a good option. If you are near a freezer, a bag of frozen veggies makes a nice ice pack.
Kids might comply more easily if they know the routine. 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 also plenty of cute pediatric ice packs that might elicit cooperation.
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I also recommend Arnica. I imagine that some of you are asking, “what on earth is that?” Arnica is a homeopathic remedy. It comes as a topical ointment or little oral pellets. 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. I would keep it handy in your diaper bag or backpack. Kids often like to have ‘cream’ applied to a little ‘owie’. Arnica is perfect for that.
Check the mouth and make sure there are no loose teeth. While you are thinking about it, I suggest that you have an established relationship with a pediatric dentist. In the case of a mouth injury this will be very useful.
Before you completely flip out, it is important to know 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 that blood (that didn’t come out) can collect into an enormous goose egg. These can look alarming. Just to be on the safe side, a significant goose egg should be checked out to make sure there is no fracture.
Mild bruises and bumps by themselves are not a concern if the child is acting fine otherwise. The affected areas can turn all sorts of lovely colors as they resolve. Expect greens, purples and yellows.
Noticeable bruising around the eyes is worth reporting.
Simple bleeding doesn’t worry me as long as it stops within a reasonable amount of time. Hold pressure for at least 10 minutes. If it is still oozing at that point, you might need to go in to get the wound sutured or glued.
The potential bleeding that may be taking place internally is a different story. Any accumulation of fluid or swelling within the hard shell of the skull can cause pressure on the brain. A slow bleed might not show symptoms immediately, so I would be alert for at least a week or two after a significant impact. If there is anything going on in there, your child's behavior will not be normal.
Here is a gentle reminder that this post is NOT meant to freak you out. By far, most of the time kids are fine after a mild fall, but it is always wise to be on the lookout to make sure there isn’t a concussion.
Most of us have heard the term concussion, but might not actually know what it actually is. A concussion is a type of traumatic brain injury that stems from an impact 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 there is a TBI ( traumatic brain injury) you are going to have clues that something is not right. Physical symptoms would include
dizziness
balance problems,
headaches,
vision problems
light sensitivity
sleepiness
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.
Murphy's Law comes into play here. With children, vomiting could simply be a sign that they are coming down with a tummy bug. Nonetheless, if they whacked their heads and are now vomiting, they need to be checked out.
Regardless of symptoms, after any fall or accident, if you are worried, it is always appropriate to call the doctor's office to let them know what happened. It is reasonable to need a bit of reassurance! But more often than not, if your child is acting fine most of the time they will tell you to keep a close eye on your child at home.
What about sleep?
Assuming they are not showing any obvious worrisome symptoms, keeping someone awake after a head injury is not necessary:
If it is during the day, experts agree that once your child has calmed down 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. That being said, do not let them take a nap that is longer than the typical nap time.
If they are old enough that they no longer take naps, excessive sleepiness would be something to report.
Nights might feel a bit trickier. Research shows that if it has been more than 3 or 4 hours since the fall and there is no vomiting, you don’t actually need to wake them up.
Depending on how far and hard they fell, I would suggest checking on your child every couple of hours to make sure they haven’t thrown up and they seem to be peacefully sleeping. You can set an alarm to make sure you get up to do this.
The key is to monitor any status changes.
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 any of the following issues, bring that up with your medical team.
anxiety
nervousness
irritability
trouble with memory
New onset insomnia
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.
They may order a Cat scan if there is:
loss of consciousness
suspicion for a skull fracture
the patient is under the age of two and is showing any symptoms
Doctors will use their clinical judgement and make a case by case decision. A basic neurological exam might include the following
Can they answer simple questions?
Is there any complaint of blurry vision?
Do the pupils react to light at the same speed? (some people have pupils that are not quite equal and that is their norm. It is a good idea to check your kids pupils before an accident so that you have a baseline)
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?)
These little tests are obviously age dependent.
Newer protocols for concussion care are not as restrictive as they used to be.
Screen time has a big impact. Patients who abstained from it for the first 48 hours had a quicker recovery
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.
Anything that can cause eye strain is not a good idea. This includes screen time and reading
Find activities that are quiet and relaxing and don’t need a lot of mental stimulation.
It is okay for you to read to them.
Your child can return to non strenuous activities as soon as they start to feel better.
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 the first 48 hours it is appropriate to try to get back to normal. Let the teachers know what is going on so they can get a little leniency if needed
Remember, after a solid knock to the head you are not out of the woods right away. Pay attention to any dizziness or headaches. This is especially important within the first couple of weeks. Get immediate attention for any vomiting or confusion.
Discuss return to sports with your medical team. The research is constantly evolving
The large majority (70-80%) of people with Traumatic Brain Injuries recover within 3 months. Every child’s recovery period is unique.
There have been some new findings that females across all the age spans recover more slowly from a TBI than males. Studies are being done to look more closely into that.
Nurse Judy adds that a trusted and gentle chiropractor might help with healing
Prevention
Keep in mind that it is very unlikely that simply falling (toddlers learning to walk) will cause any actual damage.
Accidents happen on the watch of even the most vigilant care giver.
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.
I have seen “selfie” accidents. No photo op is worth it if your baby's head gets whacked in the process.
Never leave your baby on a surface that they can fall from; they will!
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 child-proofed with necessary safety gates.
Make sure that stairs are free from clutter.
If your child is sitting in a shopping cart, make sure to keep a hand on it. I had a little patient reach over to grab a box of cereal and she toppled the entire cart over!
Choose playgrounds that have a safer ground to fall onto. Sand beats concrete anytime!
Sometimes all of this feels more traumatic for the parent than the patient!
Dr. Ted tidbits:
You can’t keep your child on a leash. A bonk on the head at some point is inevitable. It is a question of when, not if.
If you haven’t done something egregiously careless, then don’t beat yourself up when these little accidents happen.
If there is something going on inside the brain, it is not silent or subtle.
Stay safe!
I have quite a few readers who swear that my posts are eerily timed. I hope this one is full of information that nobody is actually going to need any time soon. With the Super Bowl this weekend it felt timely.
Nurse Judy’s Substack is free. I have no current plans to add a payment option. But feel free to pass these along and share.
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