It is a call that pediatricians get all too often. “My child fell and hit his head on concrete. He is now getting a goose egg on his forehead. Should I take him to the emergency room?”

 

Talking to the distraught parent the first question would be how is he acting now? Does he seem stable and appropriate even though he may be understandably upset? What were the circumstances of the fall and what was he doing? Did he trip and fall forwards or backwards? Was he on a skateboard or did he fall from monkey bars? How far did he fall, and was it witnessed by anyone? Was there ANY loss of consciousness (LOC)? If there was even a second of LOC a trip to the ER for imaging such as a CT scan of the head would be necessary.

 

If there was no LOC and the child seems OK,

 

The parent should then get a bright light to make sure the pupils are equal in size. They should constrict briskly and equally when the light is shone directly in the eye. Any inequality would be concerning as would sluggishness of the pupils constricting in response to a bright light. This would also warrant a trip to the ER with probable imaging of the head.
 

If the pupils seem normal it is important to establish how the child is acting.

Does he seem appropriate in his actions? Are his responses to questions correct? After a bump on the head it can be normal for a child to seem quiet and a bit dazed. But he should NOT be somnolent or hard to arouse. He should be able to answer questions appropriately, especially after he has calmed down.
 

It is not uncommon for a child to vomit once shortly after a head trauma, particularly if he was upset and had been crying.

 

It would be worrisome if there was any persistent or forceful vomiting, or vomiting that occurred hours after the event.

 

After a bump on the head a younger child may want to take a nap. If there is no LOC and the pupils are equal, it is OK for him to take a nap provided he has calmed down and seems to be acting appropriately. The parent does not have to keep him awake. Make sure that he is breathing normally and sleeping comfortably. If the parent is concerned, make sure he is easily aroused and not hard to wake up. The same applies at bedtime for the night.

 

As for the bump on the forehead,

 

One can apply an ice pack or frozen vegetables to the area for around 10 minutes, two-to-three times a day to keep the swelling down. A toddler or young child is more likely to resist and put up a fight .If so, it is not worth the struggle or effort. If the child complains of a headache, it would be safe and appropriate to give Tylenol of Ibuprofen as this will not alter his level of consciousness.
 

In response to a goose egg bump on the forehead,

 

I alert the parents that over the next few days he may develop what looks like black eyes. As the blood from the forehead tracks downward by gravity it settles in the place of least resistance which would be around the orbits. In order to try to minimize this the head of the bed can be elevated around 20 degrees when the child naps or sleeps.

 

After going through this discussion with the parents, I always ask them to call the office in the morning with an update, even if the child seems fine. Obviously if there are ANY concerns or questions, the parents should call ASAP, no matter what time.

 

In summary, a child should be taken to the emergency room following a fall with head trauma

1. If there is ANY loss of consciousness.

2. If the pupils are not equal or do not respond equally to a bright light.

3. If there is any persistent or forceful vomiting.

4. If the child is somnolent or has a depressed level of consciousnes.

5. If he is sleeping soundly and is hard to arouse or awaken.

 

A good rule of thumb for parents when their child falls and hits his head is to call the doctor/pediatrician right away and discuss it with them to get further guidance no matter how insignificant the fall may seem.