Every parent has watched a child fall and hit their head. A tumble from a bed, a collision in the playground, a fall from a cycle. In almost every case the child cries, is comforted, and within twenty minutes is playing again.
The difficulty is that a small number of head injuries do not follow that pattern â and in the first hour they can look exactly the same as the ones that do. What separates them is not how hard the fall looked or how loudly the child cried. It is what happens over the hours afterwards.
I have treated head injuries for over thirty years. This is what I tell parents in the OPD.
First: what actually matters
Parents usually judge severity by three things â the height of the fall, the size of the bump, and how much the child cried. None of these is reliable.
A large swelling on the scalp is often just a bruise in tissue with a rich blood supply. It looks alarming and means little. Meanwhile a child who took a modest knock and seemed fine can, uncommonly, develop bleeding inside the skull over the following hours.
What matters is how the child behaves afterwards. A child who is alert, recognises you, is walking normally and asking for food is giving you far more reassurance than any measurement of the bump.
Go to hospital immediately if any of these appear
These can develop hours after the injury, in a child who seemed completely normal at first. Do not wait for morning. Go to a hospital with a CT scanner.
- Increasing drowsiness, or difficulty waking the child
- Vomiting more than once or twice, particularly if it continues or worsens
- A headache that keeps getting worse rather than settling
- Confusion, not recognising you, or behaviour that is not normal for them
- Weakness or numbness of an arm or leg, or a change in walking
- A seizure â any jerking, stiffening or blank unresponsive spell
- Unequal pupils, squint, double vision or blurred vision
- Clear fluid or blood from the nose or ear
- Any loss of consciousness, however brief, or no memory of the fall
- Slurred or unclear speech
- In an infant â a bulging soft spot, a high-pitched persistent cry, refusing feeds, or unusual floppiness
Lower the threshold and go straight in if the child is under one year old, has a bleeding disorder, is on any blood-thinning medication, or if the fall was from a significant height, from a moving vehicle, or onto a hard edge.
If you are unsure, go. No doctor will criticise a parent for bringing a child in after a head injury. The mistake that costs is the one where a family waited to see.
When watching at home is appropriate
Most minor knocks do not need a hospital. If the child did not lose consciousness, is fully alert, is behaving normally, has not vomited repeatedly, and none of the warning signs above are present, home observation is reasonable.
For the first 24 hours:
- Someone should stay with the child and be able to rouse them
- Sleep is fine. You do not need to keep a child awake â that advice is outdated and simply exhausts everyone. What you do need is to check periodically that they wake normally when roused
- Quiet activity for a day or two; skip sport, cycling and rough play
- Simple pain relief for headache, at the dose your doctor advises
- Return to school and screens gradually over a few days
If at any point a warning sign appears, the plan changes and you go in.
Does my child need a CT scan?
Usually not, and this is worth understanding properly rather than pushing for a scan out of anxiety.
CT uses ionising radiation, and a child's brain is more sensitive to it than an adult's. Scanning every child who bumps their head would cause more harm across a population than it prevents. Doctors therefore use structured criteria â based on age, mechanism of injury, consciousness, vomiting, and examination findings â to decide who genuinely needs imaging.
Sometimes the right answer is a period of observation in hospital rather than a scan. That is not the doctor being casual. It is often a better test than an early image, because it watches for the thing that actually matters: change over time.
If a scan is advised, ask what it is looking for. If it is not, ask what to watch for at home. A doctor who cannot answer either question clearly is worth a second opinion.
Concussion: when the scan is normal but the child is not right
A concussion is a temporary disturbance of brain function. The scan is normal because the problem is functional, not structural â and telling a family "the scan is clear" without explaining this leaves them confused when symptoms continue.
After a concussion a child may have headache, dizziness, tiredness, poor concentration, irritability, sensitivity to light and noise, and disturbed sleep. These can last days to a few weeks. School performance often dips. Children who cannot yet describe how they feel may simply become clingy, tearful or badly behaved.
Recovery needs a graded return, not rest until symptoms vanish. Complete rest in a dark room for a week is no longer recommended and tends to prolong things. Light activity, then walking, then school in half days, then full days, then non-contact sport, then contact sport â progressing when each step is tolerated.
Return to contact sport only after full recovery. A second head injury while the brain is still recovering can cause harm out of proportion to the force involved. If your child plays cricket, football or any contact sport, this is the single most important paragraph on this page.
The injury that presents weeks later
Occasionally a child is brought in weeks after a fall the family has almost forgotten, with headaches, vomiting, unsteadiness or a change in behaviour. Slow bleeding around the brain can accumulate over that timescale.
This is uncommon, and I mention it not to alarm but for one practical reason: if your child develops persistent headaches, vomiting or behavioural change in the weeks after any head injury, mention the injury to the doctor. Families often do not connect the two, and the doctor cannot know unless you say so.
Preventing the ones that matter
Most serious paediatric head injuries in our practice come from three sources, and all three are preventable.
Road traffic. Helmets for cycles and two-wheelers, including for the pillion child and including for short distances. Rear seating and appropriate restraint in cars. In NCR this is where the most serious injuries come from, by a wide margin.
Falls from height. Balcony railings and window grilles in flats, stair gates for toddlers, and not leaving infants unattended on beds, sofas or changing tables â a rolling infant moves faster than most parents expect.
Playground and sport. Age-appropriate equipment, supervision, and helmets for skating and cycling. Also worth teaching children early that a knock to the head is something to report rather than hide because they want to keep playing.
What to bring if you do go in
Note the time of injury, how it happened, the height involved, and the surface landed on. Note whether there was any loss of consciousness and for how long, and how many times the child has vomited. If your child takes any regular medication, bring the list. If the fall was recorded on CCTV or a phone, that is genuinely useful.
These details shape the decision more than anything found on examination.
A closing note for anxious parents. The overwhelming majority of childhood head injuries are minor and recover completely. The purpose of this article is not to make you frightened of every fall. It is to give you a clear list of what to watch for, so you can stop watching for everything else.
If something feels wrong to you about how your child is behaving after a head injury â even if you cannot name it, and even if it is not on the list above â trust that. Parents notice change in their own child before any of us do.
Written by Dr. P. K. Jha, MBBS, MS, MNAMS, M.Ch (Neurosurgery, AIIMS New Delhi), DMC Reg 13809. Consultant Neurosurgeon with over 30 years treating brain and spine patients. Practising at Neuro Care India, Gaur City 1, Greater Noida.
This article is educational and is not a substitute for a clinical assessment. If any warning sign listed above is present, go to a hospital emergency department rather than seeking advice online.