Observation at Home is Appropriate After Single Episode of Vomiting
If a baby falls from bed, vomits once, and then appears completely normal with no concerning signs, close observation at home for 24-48 hours is reasonable, but parents must monitor vigilantly for red flag symptoms that require immediate emergency evaluation. 1
Immediate Assessment Required
When evaluating the infant after the fall, look specifically for these concerning features that would mandate emergency department evaluation:
- Repeated or projectile vomiting (not just one episode) 1
- Bilious (green/yellow) vomiting, which indicates intestinal obstruction and is a surgical emergency 2, 3
- Bloody vomiting (hematemesis) 4
- Altered mental status or decreased responsiveness 4, 5
- Inconsolable crying or excessive irritability beyond normal 4
- Severe lethargy or difficulty arousing 4
- Seizure activity 4
- Bulging fontanelle (soft spot) 4
- Unequal pupils or abnormal eye movements 4
Why Single Vomiting Episode Can Be Normal
A single episode of non-bilious vomiting immediately after head trauma can represent a benign response to the stress of the fall and does not automatically indicate serious injury if the infant otherwise appears normal. 4 However, this requires the infant to be acting completely normal afterward—alert, interactive, feeding normally, and without any of the red flags listed above.
Observation Protocol at Home
If no red flags are present, parents should:
- Monitor continuously for the first 2 hours, checking alertness and behavior every 15-30 minutes 4
- Wake the infant every 2-3 hours overnight to ensure normal arousability 4
- Watch for delayed symptoms over 24-48 hours, as some complications can evolve 4
- Document any changes in behavior, feeding, or activity level 4
Return to Emergency Department If:
Parents must bring the infant back immediately if any of these develop:
- Any additional vomiting episodes, especially if becoming more frequent or forceful 1, 4
- Progression to bilious (green) vomiting, which suggests bowel obstruction requiring urgent surgical evaluation 2, 3
- Bloody or "currant jelly" stools, which may indicate intussusception 2
- Increasing irritability or inconsolable crying 4
- Refusal to feed or inability to keep fluids down 4
- Lethargy or decreased responsiveness 4
- Any neurological changes (abnormal movements, weakness, altered consciousness) 4
Critical Distinction: Bilious vs Non-Bilious Vomiting
The color of vomit is crucial. Bilious (green or yellow-green) vomiting in any infant is a surgical emergency until proven otherwise and requires immediate imaging to exclude midgut volvulus, which can cause intestinal necrosis within hours. 2, 3 Non-bilious vomiting (clear, white, or containing milk/formula) after a single fall with otherwise normal appearance carries much lower concern.
Prevention of Future Falls
To prevent recurrence, implement these safety measures immediately:
- Never leave the infant unattended on adult beds, changing tables, couches, or any elevated surface 1
- Place the crib on a firm, flat surface away from windows and cords 1
- Ensure proper crib safety: firm mattress with tight-fitting sheets, no gaps between mattress and crib sides, no soft bedding or pillows 6, 1
- Avoid using couches or armchairs for infant sleep, as these pose extremely high risk of injury or death 1
- Use appropriate sleep surfaces that meet current safety standards 1
Common Pitfall to Avoid
The most dangerous error is dismissing bilious vomiting as "just vomiting from the fall." Green or yellow-green vomit always requires emergency evaluation regardless of how well the infant otherwise appears, as conditions like malrotation with volvulus can rapidly progress to bowel necrosis. 2, 3 When in doubt about vomit color, seek immediate evaluation.