Sit and watch children at play and you will quickly learn one thing: children are constantly hitting their heads! If your child hits his or her head, how do you know when it is serious enough to seek medical care and when you can relax and stay home?

As one of the St. Louis Children’s Hospital Pediatric Hospitalists, should you come to the emergency room at Missouri Baptist or Progress West Health Center, either I or one of my partners is likely to be your “official greeting party” there to calm your child and hopefully calm your worries by evaluating and caring for your child after a head injury.

But, how do you answer the line to that classic song, “Should I stay or should I go?” Hopefully with a little bit of information and a few tips, you will feel more equipped to do just that!

Every year millions of people have head injuries. The Center for disease Control and Prevention estimates that there are more than 435,000 visits to the emergency room each year for evaluation of head injury in children. Most of these injuries are minor because the skull and cerebrospinal fluid surrounding the brain provide considerable protection for the brain. However, more than half a million head injuries a year are severe enough to require hospitalization. Most of these are due to major head trauma such as high speed impacts from car and bike accidents, falls from great heights or gun shots.

Fortunately, serious injury to the brain from minor head trauma is very rare and most bumps to the head are safe. Symptoms of minor head injuries like bruises or mild headaches go away on their own.

Scalp Injuries

Before we talk about symptoms of serious head injury, let’s talk briefly about injuries to the scalp or external head injuries. Injuries to the scalp often look very scary. The scalp is rich in blood vessels and tightly adherent to the skull, so even minor injuries can bleed a great deal. The common “goose egg” children get after hitting their heads is the result of blood and fluid leaking into the scalp. While “goose eggs” and bleeding can look frightening, if the cut is small and bleeding stops with pressure after 5-10 minutes or the “goose egg” is not accompanied by neurologic changes noted below, you  do not need to seek immediate care. Call your doctor if in doubt.

When to Worry

Now let’s go over worries about the inside of the head. How do you know when to worry and when you can relax and observe at home? Here are some tips:

Seek Immediate Medical Attention if: Worry less if:
Your child losses consciousness or appears confused or drowsy. He does not lose consciousness or has a less than 5 second appearance of being stunned
Eye changes including: changes in pupil size, blurry or double vision, or eyes not moving correctly (one or both eyes do not move appropriately when the child look up down, or to the side Pupils appear normal, eyes move normally and your child doesn’t complain of visual difficulty (double vision, blurred vision, inability to see fully out of one or both eyes)
Weakness on inability to move one or both arms or legs, walks with difficulty or clumsiness Wants to play shortly after injury, no weakness or changes in gait or coordination
Severe headache Mild headache or only complains of headache when you ask
Vomiting more than twice or late onset vomiting Vomiting once or vomiting than begins 3 or more days after the head injury
Clear fluid or blood draining from the nose or ears, constant slow drip of fluid from the nose Runny nose associated with crying, resolves once crying subsides
Bleeding from the scalp that won’t stop Bleeding that stops after 5 to 10 minutes of pressure and a cut less than one centimeter.
Crying that lasts more than an hour, irritability or restlessness Child is able to be consoled, calmed and easily distracted. It is okay if your child wants to be held and or is less active much like when he or she has a minor cold
Something about child just doesn’t seem right Your child is interested in playing, talking and acting just as he or she did before the fall

In addition, seek immediate care if any of the following are present:

  • Convulsions
  • Changes in speech: slurred words or inability to come up with the right words
  • Changes in hearing, smell or taste
  • Breathing that becomes slow or very shallow
  • Neck pain
  • Changes in level of consciousness (from alert to very sleepy or confused)

Different levels of injury require different levels of concern. It can be difficult to determine the level of injury, so if in doubt, discuss the head injury with your doctor.

If your child is not an infant, has not lost consciousness and is alert and behaving normally after a fall or blow to the head:

  1. Apply an ice pack to the injured area. Be careful to cover the pack with cloth to avoid cold injury (frostbite) to the skin
  2. Watch your child carefully for the next 24 hours. If any symptoms described below occur, contact your doctor immediately.
  3. It is okay to let your child sleep if he or she is acting appropriately after an injury. Check on your child every 2 or 3 hours during nap or bed time. Does your child’s color and breathing appear normal? Is their anything else about the child’s appearance that worries you? If you aren’t comfortable with your child’s appearance, arouse your child partially by sitting him or her up. Your child should respond by attempting to resettle or being a bit fussy. If your child doesn’t arouse or responds abnormally, wake him or her up fully and check pupils, arm and leg strength and level of consciousness as described below.

Remember that, if a child begins to run or play immediately after a bump on the head, serious injury is unlikely.


While many minor head injuries are not preventable, most major head trauma and some minor head trauma is preventable. Follow these steps to protect your child and yourself from head injury:

  • Always use appropriate safety equipment. Use helmets for biking, skating, skiing, snow boarding, skate boarding, horse back riding and contact sports. Stick to strict rules with your kids on this. “No helmet, no bike.” In other words, if they are found doing an activity that requires a helmet and they don’t have one on, they lose the bike or skateboard for an extended period of time. Lead by example, kids won’t feel helmets are important if the adults in their life are not wearing them.
  • Wear seatbelts and use the appropriate car seat for your child.  Studies show greater than 80% of car seats are installed incorrectly.
  • Complete a home safety check and make changes as needed: cover sharp corners on furniture and fireplaces, when purchasing furniture consider round tables or furniture with rounded corners. Avoid purchasing furniture with glass. Anchor high bookshelves and TVs to the wall.
  • Don’t allow children to operate motorized vehicles like ATVs. Their inexperience and lack of coordination leave them at great risk when combined with speed.
  • Wear light reflective clothing when biking or being active outside after dark.