From concussion to severe traumatic brain injury — what to expect
If your child has had a head injury, whether a small bump that is worrying you, a concussion from sport, or a serious injury that has brought them into hospital, this page explains what doctors look for, what the treatment involves, and what recovery can look like. The first point to know is that most paediatric head injuries are mild and the children recover well. The second is that serious injuries vary enormously in their course, your child's medical team is the best source of information for your child's specific situation.
A head injury is any blow to the head, and the term can mean very different things. The skin and scalp can be injured without the skull or the brain being affected at all. The skull itself can be fractured. And the brain inside can be injured in many ways, from a mild shaking (concussion) through to a serious bruise, bleeding, or tearing of the brain tissue. The combined term that doctors often use is "traumatic brain injury", or TBI.
Head injuries are usually grouped by their severity:
Mild TBI / concussion is the most common form, in particular from sport, falls, and minor accidents. The child may have been briefly stunned or knocked out, or may have had no loss of consciousness at all, but afterwards has symptoms such as headache, dizziness, confusion, or simply feeling "not quite right." Almost all children with concussion recover fully, although it can take days to weeks.
Moderate TBI involves a longer period of confusion or unconsciousness and usually requires a hospital admission for monitoring, often with a CT-scan. Most children improve with rest, careful watching, and time.
Severe TBI is the most serious form. The child may be deeply unconscious, may have bleeding or swelling inside the head, and is cared for in the paediatric intensive care unit (PICU). Some severe injuries need an emergency operation. Recovery is often a long journey involving many specialists.
Doctors also describe the type of injury when one is seen on the scan. Words you may hear include skull fracture (a break in the skull bone), contusion (a bruise of the brain), epidural or subdural haematoma (a collection of blood between the brain and the skull), subarachnoid haemorrhage (bleeding around the brain), and diffuse axonal injury (microscopic stretching damage seen in some severe injuries). Each of these has its own implications, which the team will explain.
After any head injury, some symptoms are expected and usually settle. Others are warning signs that the brain may be in trouble and need urgent attention. The list below is what to watch for in the first 24 to 48 hours following a mild head injury that did not require admission to hospital, and afterwards during recovery.
The most important assessment after a head injury is a careful examination by an experienced doctor or nurse. They will ask exactly how the injury happened, check your child's level of consciousness using a standard scale (the Glasgow Coma Scale, or GCS), examine the pupils and other reflexes, check strength and sensation in the arms and legs, and look at the scalp and skull for signs of injury. The examination tells the team far more than any scan can.
A CT-scan of the head is the main imaging test in the acute setting because it is fast and shows bleeding and fractures clearly. CT uses a small dose of X-ray radiation, so doctors do not order it for every head injury, they use careful decision rules to determine which children truly need a scan. If your child has had only a minor bump and is behaving completely normally, a scan is often not needed.
MRI is sometimes used later, particularly in moderate or severe injuries, because it shows finer detail of the brain tissue and is better than CT at picking up some kinds of damage that do not bleed. The MRI uses no radiation but takes longer.
In babies and toddlers, doctors are sometimes concerned about a form of injury called abusive (non-accidental) head trauma. When the story of how the injury happened does not match the findings, or when certain patterns of injury are present, the team is required to investigate further to protect the child. These questions are not directed at any one family in particular, they are standard practice when certain findings are present, and they are part of keeping children safe.
Treatment depends on the severity of the injury. Most children need only careful observation and time. A smaller number need hospital care, and a small number need an operation.
Helmets, for bicycles, scooters, skateboards, motorcycles, horse riding and contact sport, are one of the most effective ways of reducing serious head injuries in children. Car seats, seat belts, window guards and stair gates also matter. After a head injury, the team will often discuss prevention, not as a criticism but as part of looking forward.
Recovery from a head injury depends on how severe the injury was and on the individual child. For mild head injuries and most concussions, full recovery within a few days to a few weeks is the rule. Some children, in particular adolescents, have symptoms that last longer (this is sometimes called post-concussion syndrome), but most still recover fully with time, a gradual return to activity, and patience.
After a moderate or severe injury, the early days in hospital focus on stabilising the brain. As the child improves, the focus shifts to waking up, beginning to communicate and move again, and starting the rehabilitation process. The brains of children are remarkably good at adapting, but the recovery from a serious brain injury is usually slow, taking place over weeks, months and sometimes years. Different skills come back at different speeds, physical strength often returns earlier than speech, attention, and complex thinking.
Rehabilitation often involves a team, physiotherapy for movement, occupational therapy for daily-living skills, speech and language therapy, neuropsychology for thinking and memory, and sometimes mental-health support for the child and the family. Some children spend time in an inpatient rehabilitation unit before going home, others receive their rehabilitation as outpatients.
Return to school is usually gradual, partial days at first, with quiet breaks, a reduced workload, and adjustments for fatigue, light sensitivity, or attention difficulties. Many children look outwardly recovered before their brains are fully back to normal, this is sometimes called the "hidden disability" of TBI. Working closely with the school, with written plans agreed by the medical team, makes a real difference.
Long-term outcomes vary widely. Some children make a complete recovery and grow up with no lasting effects. Others have ongoing differences, in attention, learning, behaviour, mood, or physical ability, that they live with and adapt to. Honest, regular follow-up with the team is the best way to know what to plan for. And whatever the level of recovery, no family goes through this alone, brain injury organisations and other families who have travelled this path are an enormous source of practical and emotional support.
After any head injury, whether your child is at home after a minor bump, recovering on the ward, or back home after a more serious injury, certain signs can mean that the brain is in trouble. Do not wait, go to the nearest emergency department right away (or call the emergency services) if you notice any of the following:
If your child is unconscious, is having a seizure, or is having difficulty breathing, this is an emergency, call the emergency services immediately and do not attempt to move the child unless they are in immediate danger. If there is any suspicion of a neck injury, keep the head and neck still until help arrives.