Falls are a common accident — they are, in fact, the most common reason for taking a child to the ER — that can make any parent anxious. Because most falls are not witnessed, they often can’t be understood or reconstructed for what really happened. Age-specific incidence increases at age 2 years (specifically 10-12 months, and 2 years of age), and again in adolescence (age 11-15 years) as risk-taking (and suicide) behaviors increase.
A multitude of injuries, in varying degrees of severity, can occur from falls. A 2000 study in Los Angeles found that most falls come from windows, balconies, stairs, furniture, tripping, walkers, and playground equipment. The majority of injuries in children occur at home (57%), with just a small number at school (6%). The same is true for head injuries. In this Doctor’s Note, we’ll focus on mild head injuries without loss of consciousness. A more extensive discussion of Concussion and Traumatic Brain Injury (moderate to severe head injury) is in our Doctor’s Note on Concussions.
Immediate reactions to help your child can often be random and confusing, given the nature of the accident and the fact that parents don’t want a child to be hurt or cry. So — in the case of a fall, what should a parent do? We’ll think of the care in three parts — Immediate (within 30 minutes), First 24 Hours, and Days to Weeks.
Immediate Care (Within 30 Minutes)
The first thing is to remain calm and allow the child to move or get up by his own power. In a soft voice, say his name and ask if anything hurts (you can find out what happened later). His movements will help you quickly assess if any body part is hurt or broken. Observe his natural movements, and note if he is limiting use of any body parts or “grabbing” at what hurts him.
If the child is unconscious, call 911.
A child who is crying is a reassuring thing – that means he is less likely to have suffered a concussion or serious traumatic brain injury. If the child refuses to get up, then let him lay there while you assess things.
Visualize the area(s) that hurt and quickly look over all exposed skin areas for any bleeding or scrapes. Control the bleeding with a damp cloth and moderate pressure. If any area of the face are bleeding, also look at the mouth and teeth (I will cover Injury to Teeth in an upcoming Doctor’s Note). One great concern and cause for alarming for parents is the ease with which the scalp or face can bleed. This is because the skin is the thinnest on these parts compared to the rest of the body, and will “show” blood more easily. That’s the bad news. The good news is that the bleeding can be controlled just the same as any other spot. Limiting the sight of blood will help calm your child more quickly (and you too if you are just as frightened).
If there is a cut or gash to the skin, it may need to be seen in the emergency room (preferably Childrens Hospital) to properly irrigate and close the wound. If the fall occurred on a gravel, sand, or dirt surface, small amounts of debris could be in the wound and can eventually cause an infection. When in doubt, get it checked out.
Calm your child to stop crying before moving on. He can help you figure out the severity of the injury if he is calm. If you have isolated the injury to one particular area, then quickly do a head-to-toe assessment for anything obvious like swelling, bruising, or any discoloration. It’s not necessary to remove all clothing to do this — rather, see what you can see and lightly touch what you can touch or squeeze. Note all the areas that hurt or have changes, and begin supportive care — rest, ice, and cool compress. Alert others to help you if needed, and call the doctor’s office for advice.
If there is no immediate injury apparent, then move on to…
First 24 Hours
Depending on the type of fall this level of assessment and care calls for patience and observation on your part.
The child has gone through a stressful event, and the natural tendency for the body is to compensate and go into an “excited” state to protect itself. As time passes after the injury, the physiological changes in the body begin to decrease and return to a passive status. This can lead to tiredness, fatigue, achiness, and behavior changes. There is nothing wrong with these changes, but the body needs time to readjust. So allow these changes to happen!
It’s not necessary to awaken a child in short periods to monitor her alertness. If she wants to sleep, let her sleep, especially if it is around a typical naptime or bedtime. Trying to assess behavior for anything wrong can be a challenge if children are also irritable from not being allowed to sleep at their usual time, or to sleep as long as they usually would.
The first 24 hours after the fall are important to allow the gradual return to normal function. Allow the child to play as she usually would. Allow her to go to school. Allow her to play as tolerated, except if she participate in a collision or contact sport. If the initial injury was significant or severe (in your opinion), then no physical activity should occur until cleared by a certified health professional in caring for concussions. Please review the Doctors Note on Concussions for more information regarding traumatic brain injuries.
Over time, you will be able to see if any regular daily activities — walking, running, jumping, climbing, resting, eating, playing, comprehending, remembering, change in behavior/personality — become affected. You will be able to see bruising more clearly and changes in swelling. If there are any changes, have your child evaluated by a doctor.
Red flags would be any nighttime awakenings from pain, 2 or more episodes of vomiting, back pain, neck pain, amnesia, or changes in vision or hearing.
If there are no concerns then move on to…
Days to Weeks
This period of time allows all minor injuries to heal and to make certain no undiagnosed injuries remain after the fall.
Again, if there you have any doubt get it checked out. Subtle fractures or dislocations can go undetected until the child has repeatedly tried to complete a function and has a hard time with it. In the case of any head injury, this extended period reaffirms a return to a normal status in all facets of everyday activity without any difficulties or hesitations.
At any point, if you have any questions or concerns after a fall and/or head injury, you should always call the doctor’s office immediately.
Dr. Lucas Godinez, a Kids Plus Doc since 2004, is an expert in head injuries and a certified ImPACT test clinician.