We all know toddlers have big heads. It’s no secret. I always used to get a good laugh from my kids as they were just learning to walk. As they leaned over, once the head started to fall, the body was sure to follow. Since I was a medical student and resident when my kids were that age, watching them weeble and wobble around the room provided hours of inexpensive entertainment in between studying for my board exams. But unfortunately, sometimes those falls result in more significant head injuries, with skull fractures, bleeding in the brain, and concussions.
The challenge for us as parents is determining when our children have sustained a “significant” head injury that we need to take them to see the doctor or when we can just observe them at home. For this reason parents often rush their kids to the ER after even a seemingly minor bump to the head.
This past weekend as I worked at Swedish’s newest ERs in Redmond and Mill Creek, I must have seen at least a half dozen kids who had fallen and hit their head. Fortunately all of them were fine, and after evaluation in the ER were discharged home to enjoy the rest of the weekend with their family.
But when should a kid be brought to the ER for a head injury? Like I said, it is often difficult to know, so if there is any doubt in a parent’s mind, it is never wrong to let us evaluate a kid after a head injury. There are several things that I am looking for when I evaluate a child with a head injury. But one of them is usually NOT the size of the “goose-egg” on their forehead.
We have all probably seen how a bruise to the head can swell up really fast, and create a fairly impressive black and blue lump. There are lots of small blood vessels on the face and scalp that can cause bleeding under the skin, resulting in what we call a hematoma. But the presence of a hematoma does not necessarily mean that there is a more serious injury such as a skull fracture lurking underneath.
The first thing that I ask about when talking to a parent is if the child lost consciousness after hitting their head. This is particularly worrisome if they have sustained periods of being more listless or lethargic, as these are signs of a possible concussion. Ongoing episodes of vomiting may indicate swelling of the to the brain or bleeding inside the skull. Persistent short-term memory loss or severe headaches, particularly if worsened by neck movement, can be signs of a more significant head injury. If your child is experiencing any of these symptoms, it would be best to have them evaluated by a physician.
But often a “mother’s instinct” is the most telling sign. If a mom tells me, “my kid is just not acting right” after a head injury, I am more often than not going to order a CT scan to check it out.
Which brings up one of the most common questions I get asked: “To CT or not to CT?” We are all trying to be cautious of how much x-ray radiation we expose kids to these days. Fortunately all of the new CT scanners we have installed in our Redmond and Mill Creek ERs along with the new hospital opening soon in Issaquah are the newest generation, which dramatically reduces the radiation exposure compared to older machines. But that being said, even an older CT scanner gives off a relatively limited dose of radiation.
According to the American College of Radiology, the average head CT exposes the patient to approximately 2 millisieverts of radiation. To put that in context we all are exposed to approximately 3 millisieverts per year of natural background radiation from the environment. So a head CT is about 8 months worth of background radiation. In comparison, our newest scanners approximately give off a 70% lower radiation dose than the prior generation of machines. While small, that exposure is not zero, and the long-term health risk is difficult to fully quantify.
Given this, we try to order CT scans only when the benefit clearly outweighs the risk. As a parent, if your doctor recommends getting a head CT, you should feel free to clarify exactly why s/he made that recommendation. You certainly don’t want to miss a serious brain bleed, but at the same time you want to avoid unnecessary radiation exposure.
Finally, the best way to avoid the need for a head CT is to prevent the head injury in the first place. Certainly easier said than done with active children. One key is a helmet. No, I am not advocating that all kids wear a helmet 24/7, although that might generate some fun smiles from the other parents at playgroup. It is important, however, to make sure that children riding on any sort of wheeled vehicle are wearing a helmet. This includes skateboards, scooters, trikes, bikes, and even ride-on toys. My kids all know that if I ever catch them riding their bikes without a helmet, the bike is going straight to Goodwill, no second chances. It is one of the few things as a parent that I am really a stickler about.
I hope this helps provide some perspective on head injuries in kids. The biggest thing to remember is that not all head injuries in kids need to be evaluated by a physician, but trust your instincts as a parent. If you are worried, it is never wrong to come and have us check it out. We are here if you need us.
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