Although head injuries in childhood are usually minor and without consequence, head injury is responsible for the majority of accidental deaths in children beyond age one. These injuries are usually associated with motor vehicle accident or deliberate injury in child abuse cases. The degree of injury depends on the speed of the fall, the surface of impact, the use of protective head gear and in the case of auto accidents, the use of car seats and proper seat belt restraints.

One third of head injuries result in skull fracture but this fact alone is not sufficient to predict severity since most of these fractures are insignificant from a neurological point of view. In fact half of children who die as a result of head injury do not have a fracture at all. For this reason a skull xray is not always necessary in the assessment and management of a head injury and careful history and review of the exact details of the accident are the most vital pieces of decision making.

It is generally thought that head injury that does not result in a loss of consciousness, is harmless and does not require further evaluation. This is only partly true. History which includes impact from a significant height or of great force should be followed closely despite the child's apparent immediate cry. These children may warrant a scan of the brain as much as a child who has experienced a brief loss of consciousness and perhaps even more so. On examination of a child who has had a fall but is conscious and in no distress, several physical findings may lead the pediatrician to do further tests. First, it may be important to recall whether the child had a previous "runny nose" before the injury because cerebrospinal fluid may leak through the nose in a head injury and be easily confused with rhinnorhea. A bloody discharge form the ear may indicate a basal skull fracture as may "Battle signs" behind the ears a few days later in fracture cases. Swelling and bruising of the eyelids (raccoon's eye sign) may be evidence of another significant skull fracture. Other injuries may lead to cranial nerve deficits which may be noted as a child's apparent difficulty hearing or facial nerve paralysis. Any child with a soft or spongy feeling swelling on the skull needs a scan performed to rule out serious head injury, subdural or epidural hematoma.. If a child is otherwise well but has uneven pupils, abnormal fundoscopic findings (the examination the doctor does with a light shined into the eyes) or any signs of abnormal behavior, a scan of the brain is absolutely necessary.

A concussion is defined as a brief alteration in the consciousness with temporary amnesia sometimes associated with it that occurs with a head injury. The child may be irritable or somnolent, may vomit or be confused and all of these vents warrants an emergency call and visit to the doctor. Although the outcome of simple concussion in children is excellent some children need to be hospitalized for observation to be sure no further changes occur in the child's consciousness. Some of these children experience a period of seizures which usually are not permanent and only require temporary treatment with medication, but this event can be the herald of more significant damage that has gone undetected so far.

Any head trauma, no matter how minor, should be reviewed with the pediatrician in order to establish low risk and to be advised of signs to be alert for. Although it is not necessary to wake a child who has gone to sleep after a simple and mild head injury, it may be necessary for your child to be observed by professionals to be sure not to miss the unusual cases.