Concussion signs in toddlers

Your toddler just fell. Hit their head on the corner of the coffee table. There's a small lump but they cried for 30 seconds and then went back to playing. Now you're wondering: is this fine, or should we go to the ER?

Most toddler head bumps are fine. Their skulls are softer than adult skulls and their brains float in extra cerebrospinal fluid that protects them. But a real concussion can hide behind a "they seem fine" appearance because toddlers can't tell you their head hurts or their vision is blurry. The signs you're watching for are behavioral, not verbal.

What's a concussion?

A concussion is a traumatic brain injury caused by a bump, blow, or jolt to the head (or a hit to the body that causes the head to move rapidly). The brain bounces inside the skull, leading to temporary functional changes. Most concussions don't show up on imaging; the diagnosis is based on symptoms.

Concussions in toddlers are less common than in older kids (because they're moving slower and falling shorter distances), but they happen. Common causes:

• Falls from changing tables, beds, couches, or strollers.
• Tripping and falling face-first onto hard surfaces.
• Hitting head against furniture corners.
• Car accidents.
• Falls down stairs.
• Being dropped.
• Sibling collisions.

Red-flag signs: go to the ER immediately

After ANY head injury, these signs mean go to the ER right now:

• Loss of consciousness. Even for a few seconds. Even if they "came right out of it."
• Vomiting more than once. One small spit-up right after crying is common from emotion. Two or more episodes of real vomiting suggest brain injury.
• Seizure. Any abnormal jerking movements, blank stare with unresponsiveness, or convulsion.
• Unequal pupils. One pupil bigger than the other, or one not reacting to light.
• Lethargy that won't wake. Unusually drowsy. Hard to rouse. Doesn't respond to your voice or touch normally.
• Confused, disoriented, or weird behavior. Doesn't recognize you. Doesn't react like themselves. Slurred speech (for verbal toddlers).
• Blood or clear fluid from nose or ears. Could indicate a skull fracture.
• Bruising behind the ears or around the eyes ("raccoon eyes"). Also skull fracture signs.
• Soft or bulging fontanelle in babies under 18 months. The soft spot should be flat. A bulging one is a sign of pressure inside the skull.
• One-sided weakness. Arm or leg weakness, especially on one side. Drooping face.
• Trouble walking or major balance problems.
• Vision issues. Crossing eyes that wasn't there before, blank stare, can't focus.
• Inconsolable crying. Won't stop. Can't be soothed. Going on for over an hour.
• Falls of more than 3 feet for any baby under 12 months, even without obvious symptoms (their skulls are still flexible).
• Significant force of impact. High speed (car accident), falling from a height (more than your own height), or being struck by a heavy object.

Yellow-flag signs: call your pediatrician today

These don't require an ER visit but do need same-day phone consultation:

• One episode of vomiting.
• Headache that's more than mild (older toddlers).
• Sleepiness that's somewhat more than normal but they wake easily.
• Mild irritability lasting more than a few hours.
• Decreased appetite or fluid intake.
• A goose-egg lump that's growing bigger over hours.
• Sensitivity to light or loud noises.
• Crying when the head bump is touched.
• The injury happened on the front or side of the head with a clear impact (more concerning than top-of-head).

Your pediatrician will help you decide if observation at home is reasonable or if you need to be seen.

Green signs: home observation is fine

If your toddler:

• Cried right away (good sign of consciousness),
• Was calmed within 5 to 10 minutes,
• Is now back to playing or interacting normally,
• Has no vomiting,
• Has a small bump but no major swelling,
• Walks normally,
• Recognizes you,
• Has equal pupils,

...you're likely dealing with a routine bonk. Monitor at home.

Home observation protocol (next 24 hours)

For the first 24 hours after any head injury:

• Watch closely for the first 4 to 6 hours. Most concerning symptoms develop in this window.
• Keep them quiet. Low activity. No rough play. Reading, snuggles, calm screen time if necessary.
• Apply ice to the bump. 15 minutes at a time, with a cloth between the ice and skin. Reduces swelling.
• Give acetaminophen if needed for pain. See our Tylenol dose calculator. Avoid ibuprofen for the first 24 hours (some doctors prefer to keep ibuprofen off for head injury because it can affect bleeding, though current guidance is mixed).
• Allow sleep. The old advice to "keep them awake" is outdated. Sleep is fine.
• BUT: check on them periodically. Wake them once every 2 to 3 hours during the first 12 hours to confirm they wake easily, respond appropriately, and look the same.
• Hold off solid foods for 4 to 6 hours. If vomiting is going to happen, you'd rather not have a big meal in their stomach. Sips of water are fine.
• Re-introduce normal food slowly. Start with small bites, watch for vomiting, then resume normal eating.

The "wake them up" question

Current pediatric guidance is that you do NOT need to wake your toddler every hour to check on them after a head injury. Old advice from the 80s and 90s recommended this, but pediatric data shows that significant injuries declare themselves within the first 4 to 6 hours when the child is awake.

For the first overnight after a head injury, the modern approach is:

• Let them sleep normally (sleep is good for the brain).
• Check on them when YOU naturally wake (e.g., bathroom, baby's feeding).
• Confirm they look the same as usual (breathing normally, in a normal position).
• If you're truly worried, set a phone alarm for one check at 3 AM.

The exception: if the injury was significant and you're nervous, periodic checks (every 2 to 3 hours) for the first 12 hours is reasonable. Make sure they wake to your voice or touch, look at you, recognize you, and can move their limbs normally.

Watching for delayed concussion symptoms

Most concussion symptoms appear within the first 24 hours, but some can develop over days. For 5 to 7 days after a head injury, watch for:

• Persistent headache (older toddlers).
• Tiredness more than usual.
• Crankiness, mood swings.
• Sleep changes (more sleep, less sleep, harder to fall asleep).
• Sensitivity to bright lights or loud sounds.
• Vision changes.
• Trouble with balance.
• Vomiting that comes back.
• Personality changes.

Any of these developing after the immediate injury warrants a pediatrician call.

Recovery from a confirmed concussion

If your toddler has been diagnosed with a concussion, the treatment is rest. Specifically:

• Physical rest. No rough play, no climbing, no running for several days. Quiet activities only.
• Cognitive rest. Less stimulation. Less screen time. Quieter environment.
• Adequate sleep. The brain heals during sleep.
• Hydration and nutrition. Normal diet as tolerated.
• Gradual return to activity. When symptoms have been gone for 24 hours, slowly resume normal play. Stop if symptoms come back.

Most toddler concussions resolve in 1 to 3 weeks. A small percentage have longer-lasting symptoms (post-concussion syndrome).

Avoid head injury for at least 6 months after a concussion. A second concussion before the first one heals can cause much more serious damage (called second-impact syndrome).

Prevention

You can't prevent every toddler head bump (they're going to happen). But you can reduce the major-injury risk:

• Stair gates at top and bottom of every staircase.
• Window guards on any window above ground floor.
• Furniture anchored to walls (dressers and TVs tip over).
• Corner guards on coffee tables and other low sharp corners.
• Helmets for biking, scooting, skating (even with training wheels).
• Proper car seat use (most major head injuries in toddlers come from car accidents).
• Pool fences and water supervision (drowning incidents often involve head injury too).
• Don't shake. Shaking a baby/toddler in frustration causes severe brain injury.

When to fight to be seen

If you bring your toddler to the ER and you're told they're "fine to go home" but you don't agree:

• Ask specifically why they're not getting a CT scan (if you wanted one).
• Mention all symptoms again, even minor ones.
• Ask for the doctor's specific name and reasoning to be documented.
• If discharged and symptoms develop or worsen, return immediately.
• Trust your instincts. You know your child best.

That said: most ER doctors are very good at evaluating pediatric head injuries. A clinical assessment that doesn't include a CT scan is often the right call (CT involves radiation and the threshold for using it in toddlers is intentionally high). Your input matters, but so does theirs.