What are the signs and symptoms of Closed Head Injury (CHI) in children?

Signs of Closed Head Injury (CHI) in Children

Children with closed head injury present with four main categories of signs and symptoms: physical, cognitive, emotional, and sleep-related, with headache being the most frequently reported symptom and loss of consciousness occurring in less than 10% of cases. 1

Physical Signs and Symptoms

The physical manifestations are often the most readily observable:

• Headache is the most common symptom across all age groups 1
• Vomiting occurs in approximately 39% of pediatric CHI cases 2
• Loss of consciousness is present in only 26% of cases, contrary to common belief that it must occur for significant injury 2
• Balance problems and dizziness are frequent complaints 1
• Light sensitivity (photophobia) and noise sensitivity (phonophobia) are characteristic features 1
• Fatigue and drowsiness are common physical complaints 1
• Scalp abnormalities (hematomas, lacerations) are present in 38% of cases 2
• Facial abnormalities are noted in 43% of ED presentations 2
• Neurologic deficits (focal weakness, coordination problems) occur in 9% of cases 2

A critical pitfall: Loss of consciousness occurs in less than 10% of concussions but when present may herald more serious injury requiring imaging 1. Do not dismiss a head injury simply because the child never lost consciousness.

Cognitive Signs and Symptoms

Cognitive impairments are typically the most disabling sequelae of CHI 3:

• Mental fogginess or feeling "slow" may predict slower recovery 1
• Difficulty concentrating is a hallmark feature 1
• Memory problems including both retrograde (before injury) and anterograde (after injury) amnesia 1
• Amnesia to the event is reported in 19% of cases 2
• Persistent amnesia occurs in 5% of presentations 2
• Confusion or disorientation 1
• Slowed reaction time 1

Important consideration: Memory and attention/information processing speed are typically the cognitive domains most severely affected by head injury, while intellectual, language, and perceptual skills tend to be relatively preserved 3.

Emotional and Behavioral Signs

Emotional symptoms may become relatively more common over time compared to cognitive/somatic symptoms 4:

• Irritability is a frequent complaint 1
• Sadness or depression 1
• Nervousness or anxiety 1
• Being more emotional than usual 1
• Altered mental status is present in 45% of ED presentations 2
• Behavior changes that parents describe as "not acting normally" 5

Critical temporal pattern: Cognitive/somatic symptoms tend to decline over the first year post-injury, whereas emotional/behavioral symptoms become relatively more common over time 4. This means emotional symptoms may emerge or worsen even as physical symptoms improve.

Sleep-Related Signs

Sleep disturbances are an important but often overlooked category 1:

• Trouble falling asleep 1
• Excessive sleep or drowsiness 1, 5
• Loss of sleep or insomnia 1
• Increased drowsiness or difficulty waking 5

Additional Important Clinical Signs

• Seizures occur in 4% of pediatric CHI cases 2
• Visual problems including blurred or double vision 1
• Numbness or tingling 1
• Unequal pupil size warrants immediate evaluation 5
• Unsteady walking or coordination problems 5

Age-Specific Considerations for Young Children

For toddlers and very young children, the presentation differs significantly 6:

• Cannot reliably report symptoms, requiring heavy reliance on parental observation of behavior changes 6
• Excessive irritability may be the primary manifestation 1
• Behavior changes are often the most reliable indicator in this age group 6, 5
• Maintain a higher index of suspicion in very young children due to ongoing brain development 6

Red Flag Signs Requiring Emergency Evaluation

The CDC guidelines specify these warning signs of more serious injury 1:

• Persistent or worsening vomiting 1, 5
• Increasing drowsiness or difficulty waking 1, 5
• Seizure activity 1, 5
• Worsening headache 1, 5
• Excessive irritability or significant behavior changes 1
• Unsteady walking or coordination problems 1
• Unequal pupil size 1
• Visual changes 6
• Scalp deformities 6

Symptom Assessment Tools

Use validated, age-appropriate symptom rating scales as part of the diagnostic evaluation 1:

• The Graded Symptom Checklist distinguishes children 6 years and older with mTBI from those without TBI within the first 2 days after injury 1
• The Post Concussion Symptom Scale distinguishes high school athletes with mTBI within the first 4 days after injury 1
• The Health and Behavior Inventory and Post-Concussion Symptom Inventory are validated for younger ages 1

Recovery Timeline and Symptom Evolution

Most children recover within 7-10 days, though some may take weeks to months 6:

• Approximately 80-90% recover within one month 6
• Pediatric patients generally have longer recovery than older athletes 6
• Symptoms experienced by most children resolve within 1 to 3 months after injury 1
• Following mild head injury, impairments typically resolve in 1 to 3 months, although chronic complaints persist in a minority 3