What to do for a 4-month-old with a head injury?

Management of Head Bump in a 4-Month-Old Infant

For a 4-month-old with a head bump, immediately assess for high-risk features including altered mental status, palpable skull fracture, or loss of consciousness—if any are present, obtain emergent non-contrast CT imaging and consider transfer to a pediatric trauma center. 1

Immediate Risk Stratification

The first priority is determining whether this infant requires emergent imaging or can be safely observed at home. Apply the PECARN criteria to stratify risk 1:

High-Risk Features Requiring Immediate CT:

• Glasgow Coma Scale (GCS) score of 14 or less 1
• Any signs of altered mental status 1
• Any palpable skull fracture 1
• Loss of consciousness 1

If any high-risk feature is present, the risk of clinically important intracranial injury is 4.4%, mandating immediate non-contrast CT imaging. 1

Red Flags Requiring Emergency Evaluation:

• Severe or worsening headache (manifested as inconsolable crying in infants) 1
• Repeated vomiting 1
• Seizures 1
• Visual changes or unequal pupil size 1
• Scalp deformities 1
• Increasing drowsiness or difficulty waking 1
• Unsteady movements or coordination problems 1
• Excessive irritability or behavior changes 1

Imaging Decisions

CT is the first-line imaging modality for acute pediatric head trauma due to rapid acquisition, excellent sensitivity for acute hemorrhage and fractures, and no sedation requirement. 2, 1

• Non-contrast CT head should be obtained for any high-risk patient 1
• CT has excellent sensitivity for acute intracranial hemorrhage and skull fractures 2
• MRI is impractical in the emergent setting due to longer acquisition time, need for safety screening, and frequent sedation requirements in young children 2

Important caveat: The PECARN criteria specifically excluded children with concern for abuse, so maintain a higher index of suspicion in very young children and do not rely solely on these criteria if abuse is suspected 2, 1

Special Considerations for Infants Under 6 Months

Toddlers and infants cannot reliably report symptoms, requiring heavy reliance on parental observation of behavior changes. 1

• Maintain a higher index of suspicion in very young children due to ongoing brain development 1
• Consider the possibility of non-accidental trauma, particularly if the mechanism is unclear or inconsistent with the injury 2, 3
• Retinal hemorrhages are most commonly encountered in inflicted injury, though they can occur in serious accidental head injury 3
• Most household falls in children younger than 2 years are neurologically benign 3

Acute Management Protocol

First 24-48 Hours:

Complete physical and cognitive rest is recommended for the first 24-48 hours after concussion. 1

• Avoid strict prolonged rest beyond 48 hours as evidence shows this may be detrimental to recovery 1
• Monitor closely for development of concerning symptoms 1

Pain Management:

Avoid NSAIDs and aspirin in the immediate post-injury period due to theoretical risk of potentiating intracranial bleeding. 1

• Acetaminophen may be used cautiously for pain management if needed 1
• No studies have documented actual harm from NSAIDs in sport-related concussions, but caution is warranted in the immediate period 1

Observation and Monitoring

For infants without high-risk features who do not require imaging, close observation is essential:

• Watch for any of the red flag symptoms listed above 1
• Observe behavior changes including excessive irritability, poor feeding, or altered sleep patterns 1
• Most children recover within 7-10 days, though some may take weeks to months 1
• Pediatric patients generally have longer recovery than older athletes 1

Return to Normal Activities

For infants, gradual return to normal play activities should start with quiet play activities once asymptomatic at rest. 1

• Progress to light physical activity only when completely asymptomatic 1
• Never allow return to high-risk activities (being tossed in air, rough play) while any symptoms persist 1

When to Transfer to Pediatric Center

Consider transfer to a pediatric trauma center if:

• Advanced imaging is needed but not available at your facility 2
• Clinical suspicion for abuse is high and child abuse specialists are not available 2
• The infant requires specialized pediatric neurosurgical consultation 2

Critical Pitfall to Avoid

Do not apply routine clinical decision rules if there is any concern for non-accidental trauma—these children require comprehensive evaluation including skeletal survey and neuroimaging regardless of apparent injury severity. 2