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The skull acts as a protective helmet for the delicate brain, and the skull is covered with a richly vascularized scalp. It is designed to withstand the hard bumps and bruises of childhood. It helps to appreciate the difference between a skull injury and a brain injury. Most falls involve injury to the scalp only, which bleeds profusely if cut or forms a large swelling (goose egg) from broken blood vessels beneath the skin. Don't be alarmed by how quickly these large bumps appear. They go down quickly with an ice pack and pressure. These bumps and bleeds are usually limited to a scalp injury and seldom indicate that the underlying brain has been injured. Here are some tips to help you get through this ordeal.

The main concern after any blow to baby's head is injury to the underlying brain, which occurs in two forms: bleeding and concussion. When small blood vessels have been broken between the skull and the brain or within the brain, bleeding occurs within this space and compresses the brain. A blow to the head may also cause a concussion, meaning the brain has been "shaken up" by the fall. Pressure on the brain from bleeding or from the swelling associated with the concussion produces the outward signs of a brain injury.

• Don't panic. Stay calm. If your child sees you remain relaxed, he is more likely to calm down.
• Ice, ice, ice! If your child will let you, gently hold an ice pack (a "boo-boo bunny") to the bump (bag of frozen vegetables works great!). This will decrease the eventual size of the bump. Apply the ice for 20 minutes and then take a 5-minute break, then 20 minutes again. Offer your child a treat to eat during the icing to consol him.
• Many children will kick and scream if you try to apply ice. You can decide if it is worth it. The main benefit from ice is cosmetic appearance. Rarely, a large bump will leave a tiny pea-sized residual hard calcium deposit felt under the skin. Applying ice may help prevent this.
• Stop the bleeding. The skin on the face and scalp is extremely rich in blood vessels. Cuts on the face and scalp will bleed much more than other areas of the body. Simply apply gentle pressure to the cut using a cloth (may have ice inside it). The bleeding will stop with time. Children virtually never lose too much blood from a cut or bump, even though it may seem like a lot.
• If there is a cut over the bump, wait for the bleeding to stop, then examine in closely. Click here on Cuts, Scrapes & Stitches to help you decide if it needs stitches.
• Acetaminophen. When your child has calmed down, you may want to give a dose to relieve the headache that might start. Click on Acetaminophen for dosing.
• You need to observe your child's mental status as explained below. Try to keep him awake for at least an hour. After that, you can allow him to take short naps, but no more than 20 minutes without observing him.
• Observe your child. If your child is alert and conscious, walking, talking, playing, and acting like she was before the fall, administer a dose of parental sympathy, apply an ice pack to the cut or bump for twenty minutes, and begin a period of observation before calling your doctor. The reason for the period of observation is because doctors often rely more on how the child behaves after the injury than what happened at the time of the injury. If the brain has been injured, signs may show immediately, or they may appear slowly during the next twenty-four hours. After the period of observation, depending on your baby's condition, you may or may not wish to call the doctor. Besides any when-to-call-the-doctor list there is an overriding inner voice. Trust this monitoring system as much as the most sophisticated electronics. If it tells you something's not quite right, call your doctor to report baby's condition, seek advice, and above all tell the doctor why you are concerned.

Bumps on the head, even large ones, don't always warrant a trip to the ER or even a call to your doctor. However a hard hit may shake up the brain – called a concussion, also blood can slowly leak out from a damaged blood vessel beneath the skull, called a hematoma that push into the brain tissue. A small hematoma is not dangerous, but larger ones can push into the brain tissue. This can either happen very quickly within an hour, or it can take two or three days. This is an emergency and requires a CAT scan of the head to diagnose. Remember, considering the many times children hit their head, injury to the brain is unusual. Most bumps on the head, even large ones, are not serious. Here are some signs to watch for that warrant a call to the doctor or the ER immediately:

• Loss of consciousness. If your child blacks out, even for a few seconds, this can mean that the force of the bump was strong enough to cause a hematoma. A reassuring sign is that you either hear or see your child start to cry immediately after the bump. This means he did not lose consciousness. If your child is unconscious, but breathing and pink (no blue lips), lay her on a flat surface and call emergency medical services. If you have cause to suspect a neck injury, don't move the child but let the trained experts in neck injuries transport her. If she is not breathing, apply CPR, or if she's having a convulsion, keep her airway clear. Sometimes, if baby is sensitive and prone to temper tantrums, she may be pushed into a breath-holding spell, which could be mistaken for a convulsion. This scene naturally pushes panic buttons and gets baby rushed to the hospital. Even if this turns out to be unnecessary, it is better to be safe. When in doubt, take baby and sit in the waiting room of the local hospital emergency room.
• Vomiting. Many children will vomit once or twice after a big bump on the head, either from crying, coughing and gagging, or just from the shock to the skull. This is expected. However, if your child vomits three or more times, he should be looked at in the ER. As a precaution feed the recovering faller clear liquids for a few hours. Breastfeeding is therapeutic.
• Altered mental status. This means that your child won't focus on you, look you in the eyes, or respond to questions or commands. Fighting you when you try to apply ice are actually goods signs that he is okay.
• Loss of balance while walking. Many children may complain of dizziness. This is expected. But if your child actually loses is balance and repeatedly falls over while walking, he needs to see a doctor. Watch your child's normal play. Is he doing everything the same after the fall: sitting straight, walking well, moving arms and legs normally? Or is he off balance, wobbly, dragging a leg, or becoming increasingly disoriented? In the pre- walker, do you notice any change in sitting or crawling skills or in manipulative hand skills
• Prolonged crying. If an infant continues to cry inconsolably for more than an hour after a good dose of acetaminophen, he should probably see a doctor.
• Severe headache. If a child continues to complain of a very severe headache you should consult a doctor immediately.
• Eye signs. The eyes mirror what's going on inside the body, especially inside the brain. In fact, the back of the eye is so intimately connected with the brain that your doctor looks at the backs of the eyes for evidence of brain swelling while examining a child following a head injury. A child's signs are more difficult to assess, but here are the call-doctor cues:
  • Crossed eyes or rolling eyes
  • One pupil larger than the other
  • Behavior such as tripping or running into things that indicates baby's vision is diminished
  • In the older child, add complaints of seeing double and blurred vision to the worry list
• When in doubt always seek medical attention.

Check your child frequently for any of the above signs. Also check for:

Changes in baby's sleep behavior. Babies normally retreat into sleep after trauma, which makes the usual admonition to "watch for a change in consciousness" an anxiety-producing instruction for the parent. If a head injury occurs near night or nap time in an already tired child, you may be confused about whether the drowsiness is due to the injury or whether it's just time for sleep to naturally overtake the child. And it may be impossible to follow the advice "Don't let baby go to sleep." Let baby fall asleep, but awaken yourself every two hours and do a baby check. This is what to look for:

• Change in color. From pink to pale or, even more alarming, blue.
• Change in breathing. Periods of very shallow breathing, ten-to twenty-second periods of stop-breathing episodes followed by irregular breathing, or gasping episodes (remember that newborns normally have irregular breathing).
• Twitches. On one side of the body involving a whole limb.

If baby's color and breathing patterns are normal (no change from usual) and your parental instincts sense nothing's wrong, there's no need to awaken baby unless advised to do so by you doctor. The deep sleep from a head injury is nearly always associated with shallow, irregular breathing patterns that you are unlikely to have seen before.

If, however, you are uncertain or child's appearance sets off a "not normal" alarm, do a partial arousal. Sit or stand your child up and then put her back down. Normally, a child will fuss a bit and thrash around in the bed to resettle. If your child does not act like this, try to fully arouse her by sitting or standing her up, opening her eyes, and calling her name. If she awakens, looks at you, fusses or smiles, and struggles to be left undisturbed, you can go back to sleep without worrying. If, on the other hand, she does not protest, can't be awakened enough to begin fussing, is pale, shows irregular breathing, and is drooling profusely, or shows any of the signs of brain injury listed above, seek medical attention immediately.

While it's standard advice to awaken the child frequently after a head injury, in practice this advice is confusing. Children normally retreat into sleep after any upset. In fact, because of new insights into the management of head injuries it is no longer standard practice for an ER physician to advise waking a child up, if the ER physician has thoroughly examined the child and found no evidence of internal injury. Studies of children seen in an ER for a head injury show that if a child has a normal neurological exam and normal CAT scan there is very low risk of that child deteriorating and therefore it is not necessary to wake that child up. A more practical approach is to observe a change in your child's color and breathing patterns. If your child looks pale and shows very irregular or very shallow breathing that is very different from his usual patterns awaken him for a more complete evaluation. Your doctor will advise you whether or not to awaken your child.

Except for severe head injuries or obvious fractures, skull x-rays are seldom helpful; nor is it necessary to rush a happily playing child to the hospital for an x-ray. First, try a period of observation; next, call your doctor; then comes the advice on whether or not to take baby to the hospital for x-rays. A CAT scan, a series of cross-sectional x-rays of the brain, has nearly replaced the plain skull x-ray. In most cases if a child warrants an x-ray at all, he merits a CAT scan. This technological breakthrough reveals much more about an injury, such as whether there is bleeding or swelling of the brain, than a simple skull x-ray. On a softer note: In the life of a child, considering the many times little heads meet hard floors, injuries to the brain are uncommon.