Head Injury in a Child: When to Go to the Emergency Room

Most childhood head bumps are scalp injuries that need ice, comfort, and a few hours of watching at home. Go to the emergency room, or call 911, if your child lost consciousness, had a seizure, is vomiting repeatedly, is getting sleepier or more confused, has clear fluid draining from the nose or an ear, or was hurt in a high-force fall or crash. This guide walks through what to watch for hour by hour and what can safely wait for the pediatrician.

Three Different Injuries Get Called a Bump on the Head

The scalp itself. Scalp skin sits on bone and has a dense blood supply, so a modest knock swells fast into the classic goose egg and a small cut can soak a washcloth. The size of the lump shows how much the scalp bled, not how hard the brain was shaken. A big forehead lump on a child who is playing normally is the least worrying head injury there is.

A concussion. The brain shifts inside the skull and its function is briefly disrupted: headache, feeling dazed or slowed down, sensitivity to light and noise, nausea, trouble concentrating, or unusual weepiness. Most children with a concussion never black out, and it does not show on a CT scan, because the problem is how the brain is working rather than a visible break or a pool of blood.

Bleeding inside the skull. This is what the emergency room is looking for. Blood collects between the skull and the brain and takes up room the skull cannot give. The epidural hematoma comes from a torn artery under the thin bone at the temple, and it can bleed slowly enough that a child seems fine for one to several hours and then goes downhill fast. Doctors call that quiet stretch a lucid interval, and it is why "she was fine right after" never settles the question.

How the Injury Happened Changes the Answer

Emergency clinicians weigh the mechanism heavily, because force applied to a small head is the best clue available before symptoms appear.

• The height, and what they landed on. For a child under 2, a fall from higher than about 3 feet counts as significant, which covers a changing table, a counter, or an adult's arms on the stairs. For children 2 and older the threshold is about 5 feet. Landing on concrete or tile transmits far more force than carpet or grass.
• Speed and hard objects. Being struck by a car, a helmetless bike or scooter crash, a car crash with a rollover or ejection, or a baseball, bat, or falling tool hitting the head all count as high force.
• Age under 3 months. Very young infants have a thinner skull, open sutures, and no way to tell you their head hurts, so a real head injury at that age gets evaluated rather than watched at home.
• Anything affecting clotting. A child on a blood thinner, with hemophilia or von Willebrand disease, or with a shunt should be assessed after even a light head hit, because a small bleed may not stop on its own.

None of these means an injury has happened, only that the odds justify having a clinician look at your child even when they look and act normal.

The First 48 Hours at Home

If the mechanism was ordinary and your child is alert, talking or babbling normally, and moving all four limbs, watching at home is reasonable.

1. Press, do not peek. Hold a clean cloth firmly over any scalp cut for a full 10 minutes without lifting it. Scalp wounds bleed heavily and then stop. A cut that gapes, keeps bleeding, or is longer than about half an inch needs stitches or skin glue.
2. Ice the swelling. A cold pack wrapped in a thin towel, about 20 minutes at a time, limits the goose egg. Never press hard on a swollen area that feels soft or dented underneath.
3. Do not move a possible neck injury. If your child has neck or back pain, will not turn their head, or was thrown from a bike or a vehicle, leave them still and call 911 so the crew can protect the spine.
4. Let them sleep, and check that they rouse. Keeping a child awake all night is not required. Check on them twice the first night and make sure they stir, open their eyes, and respond the way they normally would.
5. Pick pain relief that does not blur the picture. Many pediatricians suggest acetaminophen rather than ibuprofen for the first day or two. Follow the product label for your child's age and weight and confirm with your pediatrician or pharmacist instead of estimating a dose at home. Skip anything sedating, which makes drowsiness impossible to read.

What you are watching for. One episode of vomiting shortly after impact is common and often means nothing. Vomiting three or more times, or vomiting that starts hours later after your child seemed settled, points toward rising pressure inside the skull. So does a headache that keeps building, drowsiness you cannot shake them out of, confusion, repeated questions, slurred speech, one pupil clearly larger than the other, vision that goes double or blurry, new one-sided weakness, or trouble walking in a child who walked fine an hour ago. A seizure after a head injury, meaning stiffening, jerking limbs, or a blank unresponsive stare, means calling 911 without waiting to see what happens next.

Signs the skull itself is broken. Clear watery fluid dripping from the nose or an ear is spinal fluid escaping through a fracture at the base of the skull, and bruising that appears behind an ear or around both eyes hours later comes from the same injury. Either one is an emergency even in a child who is talking to you.

In babies, the signs are behavioral. Watch for an infant who will not feed, cries in a way you cannot console, has a new high-pitched cry, has a soft spot that feels tense or bulging when upright and calm, will not track your face, or has a spongy swelling on the side or back of the head.

Concussion Recovery, School, and Getting Back to Play

If a concussion is diagnosed, the first 24 to 48 hours call for relative rest: quiet activity, less screen time, no sports. Days in a dark, silent room are no longer recommended and tend to slow recovery. After that, light walking and gentle activity that does not spike symptoms helps.

Return to learning comes before return to playing: a shorter school day, breaks in a quiet room, extra time on tests. Tell the school nurse, since a child who cannot focus is easily read as badly behaved rather than injured.

Return to sport is stepwise and supervised, because a second hit before the brain recovers does far more damage than the first. No child goes back to play the same day as a suspected concussion, a rule written into youth sports law in every state. The ladder runs light aerobic activity, sport-specific drills, non-contact training, then full-contact practice after medical clearance, moving up only when the last rung passed without symptoms. Most children are back to normal within one to four weeks.

When to Seek Medical Care