What are the home care instructions for a 6-year-old child who hit their head on a bookshelf 6 hours ago without loss of consciousness (LOC)?

Home Care Instructions for Minor Pediatric Head Injury

This 6-year-old child with no loss of consciousness meets PECARN criteria for very low risk and does not require imaging, but parents must monitor closely for the next 24-48 hours for any signs of neurological deterioration. 1

Risk Stratification

Based on validated PECARN criteria, this child falls into the very low risk category for clinically important traumatic brain injury (risk <0.05%) if ALL of the following are true: 1

• Glasgow Coma Scale of 15 with normal mental status
• No loss of consciousness occurred
• No vomiting episodes
• No severe mechanism of injury (bookshelf fall is not considered severe)
• No severe headache
• No clinical signs of basilar skull fracture (Battle sign, raccoon eyes, hemotympanum, CSF leak)

This risk stratification has been validated with 99% sensitivity and 100% negative predictive value in over 11,000 children, meaning imaging can be safely avoided. 1

Critical Warning Signs - Return to Emergency Department Immediately If:

Parents must bring the child back to the emergency department immediately if ANY of these develop: 1

• Vomiting (particularly if projectile or multiple episodes) - this is a validated predictor of intracranial pathology 2
• Worsening or severe headache that doesn't improve with acetaminophen
• Altered mental status - confusion, disorientation, difficulty recognizing people, unusual behavior, excessive drowsiness beyond normal sleep time
• Seizure or convulsion of any type
• Unequal pupil sizes or vision changes
• Slurred speech or difficulty speaking
• Weakness or numbness in arms or legs
• Loss of consciousness at any point after the initial injury
• Clear or bloody fluid draining from nose or ears
• Difficulty walking or loss of balance beyond initial injury period
• Persistent crying that cannot be consoled (in younger children)

Home Monitoring Protocol - First 24 Hours

Wake the child every 2-3 hours during the first night to assess responsiveness and check for warning signs: 1, 3

• Verify the child can be easily awakened
• Ask simple orientation questions (name, location, what happened)
• Check that pupils are equal and reactive to light
• Observe walking and balance if child gets up

Activity Restrictions

Complete cognitive and physical rest for the first 24-48 hours: 1

• No screen time (television, tablets, phones, video games)
• No reading or homework
• No sports or physical education
• No playground activities or rough play
• Quiet activities only (coloring, listening to music at low volume)
• Adequate sleep - encourage extra rest

Pain Management

Acetaminophen (NOT ibuprofen or aspirin) for headache: 1

• Dose: 10-15 mg/kg every 4-6 hours as needed
• Avoid NSAIDs (ibuprofen, aspirin) in the first 24 hours as they theoretically increase bleeding risk
• If headache persists despite acetaminophen or worsens, return to emergency department

Expected Recovery Timeline

Most children with minor head injury recover completely within 1-2 weeks: 1

• Mild headache for 24-48 hours is common and expected
• Brief irritability or emotional changes may occur
• Slight difficulty concentrating initially is normal
• Symptoms persisting beyond 2 weeks warrant medical follow-up

Follow-Up Care

Schedule follow-up with primary care provider within 3-5 days even if child appears well: 1

• To assess for any delayed symptoms
• To provide clearance for return to school and activities
• To discuss gradual return-to-play protocol if child participates in sports

Do not allow return to contact sports or high-risk activities until: 1

• Child is completely symptom-free at rest
• Medical provider has cleared the child
• Graduated return-to-play protocol has been completed

Common Pitfall to Avoid

Do not dismiss subtle cognitive or behavioral changes as unrelated to the head injury. Memory problems, difficulty concentrating, mood changes, noise sensitivity, or school performance decline can all be manifestations of mild TBI and should prompt medical evaluation. 1, 4 Up to 15% of children with "mild" TBI have compromised function one year later, so early identification and management of persistent symptoms is critical. 2