What are the next steps for a 9-month-old infant who fell from a counter, has stable vitals, and is exhibiting normal behavior, with Pupils Equal (PEERLA)?

Assessment and Management of 9-Month-Old After Fall from Counter

For a 9-month-old with stable vitals, normal behavior, and normal pupils after a counter fall, continue close observation for at least 4-6 hours while monitoring for red flag symptoms, but immediate emergency transport is not required if the infant remains neurologically intact.

Immediate Assessment Protocol

The initial evaluation should confirm the infant's current stability through systematic assessment 1:

• Verify scene safety and ensure the infant is in a safe environment for continued observation 1
• Assess responsiveness by observing the infant's interaction with caregivers and response to stimuli 1
• Evaluate breathing and circulation simultaneously - confirm normal respiratory effort and adequate perfusion 1
• Document vital signs including heart rate, respiratory rate, temperature, and oxygen saturation 1

Since your infant has stable vitals, normal behavior, and equal/reactive pupils (PEERLA), this indicates no immediate life-threatening injury requiring resuscitation 1.

Critical Red Flags Requiring Immediate Emergency Activation

You must call 911 or transport immediately if any of the following develop 1:

• Abnormal breathing or apnea (breathing stops or becomes irregular) 1
• Seizure activity (rhythmic jerking movements, staring spells, or loss of consciousness) 1
• Loss of consciousness or decreased responsiveness (infant becomes difficult to arouse or unresponsive) 1
• Persistent or worsening vomiting - particularly if it occurs more than 1-2 times or develops/continues beyond 3 hours post-injury 2
• Behavioral changes including extreme irritability, inconsolability, or lethargy 3

Observation Period and Symptom Monitoring

Physical symptoms to monitor over the next 24-48 hours 3:

• Headache indicators in infants include persistent crying, head holding, or refusal to lie down - this is the most common symptom and may persist for days 3
• Vomiting patterns - in children over 2 years, post-traumatic vomiting typically resolves within 3 hours if the injury occurred within an hour of eating, but may last 7.5 hours if injury occurred on an empty stomach 2
• Dizziness/balance problems - watch for unsteadiness when sitting or attempting to move 3
• Fatigue - more than 20% of children still experience this at one month post-injury 3

Cognitive and behavioral symptoms that may develop later 3:

• Sleep disturbances (difficulty falling asleep, frequent waking, or excessive sleepiness) - median duration 16 days 3
• Irritability and frustration - median duration 14-16 days 3
• Taking longer to respond or appearing "slower" than usual - median duration 14 days 3

Common Pitfalls and Caveats

The timing and nature of vomiting matters significantly 2:

• Vomiting is actually more common after minor head injuries than severe ones, so its presence alone doesn't indicate severity 2
• Post-traumatic vomiting is more common in children over 2 years old 2
• If vomiting occurs but the infant was injured within an hour of feeding, this typically resolves quickly and is less concerning 2
• Protracted vomiting (lasting >3 hours) or vomiting that begins hours after the injury warrants closer evaluation 2

Age-specific considerations for a 9-month-old 4:

• Infants have anatomic and developmental differences making them more vulnerable to rotational brain injuries 4
• The mechanism of injury (fall from counter height) can cause shearing forces even without visible external trauma 4
• Any suspicion of non-accidental trauma requires immediate evaluation - look for inconsistent history, multiple injuries, or retinal hemorrhages 4

Observation Location Decision

You can observe at home if 1:

• The infant remains alert and interactive
• Vital signs remain stable
• No red flag symptoms develop
• A responsible caregiver can perform continuous observation
• You can reach emergency services quickly if needed

Transport to emergency department if 1:

• Any red flag symptoms develop
• Caregiver is uncomfortable with home observation
• There are concerns about the mechanism of injury (very high fall, onto hard surface)
• The infant develops any change in behavior or responsiveness

Duration of Observation

Maintain close observation for at least 4-6 hours post-injury, as most serious complications manifest within this timeframe 5. Continue monitoring for subtle changes over the next 24-48 hours, as cognitive and emotional symptoms may develop later in the recovery period 3.

Most children recover from concussion within 48-72 hours, though symptoms can persist for 10 days or longer 6. Physical symptoms like headache predominate immediately after injury, while emotional symptoms tend to develop later 3.