Assessment of Head Injury in a 12-Month-Old with Forehead Hematoma
Your child's current symptoms and behavior indicate a very low risk for serious head injury, and observation at home is appropriate as long as you monitor for any concerning changes in behavior or symptoms.
Initial Assessment
- The 12-month-old child with a 1cm forehead hematoma who is now laughing and playing with stable vitals and no loss of consciousness falls into the "very low risk" category according to the Pediatric Emergency Care Applied Research Network (PECARN) criteria 1.
- For children under 2 years of age, very low risk is defined as: Glasgow Coma Scale (GCS) = 15 with none of the following: palpable skull fracture, nonfrontal scalp hematoma, loss of consciousness ≥5 seconds, severe mechanism of injury, not acting normally per parents, or other signs of altered mental status 1.
- Your child's forehead (frontal) location of the hematoma is significant, as nonfrontal hematomas carry higher risk 1.
Signs to Monitor For
Concerning symptoms that would indicate possible intracranial injury:
- Vomiting (especially if persistent or worsening) 1
- Excessive sleepiness or difficulty waking 1
- Irritability that is unusual or persistent 1
- Changes in behavior or not acting normally 1
- Seizures 1
- Worsening headache (though difficult to assess in a 12-month-old) 1
- Unsteady walking (if the child is walking) 1
- Unequal pupil size 1
Reassuring signs (which your child currently shows):
- Return to baseline behavior (laughing, playing) 1
- No loss of consciousness 1
- Stable vital signs 1
- Frontal (rather than parietal or occipital) location of hematoma 2
- More than 10 minutes have passed with no deterioration 3
Time Course and Progression
- Most significant intracranial hemorrhages that require intervention will show symptoms within the first few hours after injury 3.
- Progressive hemorrhagic injury, when it occurs, is typically identified within the first 2-6 hours after trauma 3.
- The risk of delayed intracranial bleeding is extremely low in children who appear well and meet very low risk criteria 2.
Special Considerations
- The mechanism of injury (refrigerator door) is not considered a severe mechanism like high-speed motor vehicle accidents or falls from significant heights 1.
- Forehead hematomas are common in children and most resolve without complications 2.
- Children who present to emergency departments more than 24 hours after injury with isolated scalp hematomas and no concerning symptoms typically have good outcomes 2.
When to Seek Medical Attention
Seek immediate medical attention if any of the following develop:
- Persistent vomiting (more than 2-3 times) 1
- Increasing drowsiness or difficulty waking 1
- Seizure activity 1
- Worsening headache (child becoming increasingly irritable) 1
- Any new neurological symptoms (weakness, poor coordination) 1
- Significant increase in the size of the hematoma 4, 5
Conclusion
Based on the current presentation (stable, playing, no loss of consciousness, small frontal hematoma), your child falls into a very low-risk category for clinically important traumatic brain injury 1. Home observation is appropriate, but remain vigilant for any changes in behavior or new symptoms that would warrant immediate medical evaluation 1.