What are the management and treatment options for a neonate with cephalohematoma or caput succedaneum?

Management of Neonatal Cephalohematoma and Caput Succedaneum

For uncomplicated cephalohematoma and caput succedaneum in neonates, observation with close monitoring is the primary management approach, as most resolve spontaneously within weeks to months without intervention. 1

Initial Assessment and Risk Stratification

Distinguish Between the Two Conditions

• Caput succedaneum presents as diffuse scalp edema that crosses suture lines, appears immediately at birth, and typically resolves within 48-72 hours without intervention 2, 3
• Cephalohematoma is a subperiosteal blood collection that does NOT cross suture lines, appears hours after birth (not immediately), and takes weeks to months to resolve 2, 3

Identify High-Risk Features Requiring Intervention

Monitor for these complications that necessitate escalation of care:

• Signs of infection: erythema (79% of infected cases), increasing size after initial stabilization (68%), fluctuant mass (46%), fever (64%), poor appetite (39%), or irritability (18%) 4
• Systemic illness: lethargy, poor feeding, loss of alertness, or sepsis 5, 6
• Large size: cephalohematoma with maximal projection >9-13mm on ultrasound or significant cosmetic deformity 7
• Associated hyperbilirubinemia: cephalohematoma is a recognized risk factor for severe hyperbilirubinemia requiring phototherapy 1

Management Based on Clinical Presentation

Uncomplicated Cases (Majority)

Observation alone is appropriate for small, uncomplicated lesions:

• No intervention required for caput succedaneum, which resolves spontaneously within days 2
• Small cephalohematomas (<9mm projection) resolve spontaneously over 2-12 weeks without treatment 8, 7
• Monitor bilirubin levels closely, as cephalohematoma increases risk of hyperbilirubinemia requiring phototherapy 1
• Assess risk using predischarge TSB or TcB measurement plotted on nomogram 1

Large Persistent Cephalohematoma (9-13mm+ projection)

For large cephalohematomas with high cosmetic concern, early needle aspiration between days 15-30 of life prevents calcification and deformity:

• Perform between day 15 and day 30 after birth, before spontaneous calcification occurs (after 4 weeks, calcification renders aspiration ineffective) 7
• Obtain coagulation studies and ultrasound of skull/scalp before procedure 7
• Use local anesthesia with oral sucrose for pain control 7
• Single puncture is sufficient in 83% of cases 8
• This approach is safe with no reported infections or complications in recent series 8, 7

Infected Cephalohematoma (Medical Emergency)

Any signs of infection require immediate diagnostic tap, blood cultures, and parenteral antibiotics:

• Perform diagnostic aspiration if erythema, fluctuance, increasing size, or systemic signs present 4
• Obtain blood cultures and consider lumbar puncture, as 36% have associated systemic infection (sepsis in 29%, meningitis in 11%, osteomyelitis in 4%) 4
• Start empiric IV antibiotics immediately: nafcillin or oxacillin 50 mg/kg/dose every 6 hours IV for suspected Staphylococcus aureus, or ampicillin 150 mg/kg/day divided every 8 hours PLUS gentamicin 4 mg/kg every 24 hours IV for broader coverage 5, 6
• Escherichia coli is the most common pathogen (57% of cases), followed by Staphylococcus aureus (18%) 4
• Mortality risk exists (11% in historical series), making prompt treatment critical 4

Ossified Cephalohematoma

For cephalohematomas that have calcified (typically after 4 weeks), early neurosurgical removal without cranioplasty is recommended:

• Ossification results from subperiosteal osteogenesis and progression of untreated cephalohematoma 8
• Early surgical intervention is technically less challenging and minimizes surgical trauma compared to delayed treatment 8
• 98 cases treated successfully with neurosurgery without need for cranioplasty 8

Critical Monitoring Parameters

Hyperbilirubinemia Surveillance

• Cephalohematoma is a major risk factor for severe hyperbilirubinemia 1
• Measure predischarge TSB or TcB and plot on nomogram (Figure 2 in AAP guidelines) 1
• Arrange follow-up within 24-48 hours for infants with cephalohematoma discharged before 72 hours of age 1
• Visual estimation of jaundice is unreliable; measure TSB/TcB if any doubt 1

Infection Surveillance

• Mean age at onset of infected cephalohematoma is 17.8 days (range varies widely) 4
• Check for leukocytosis (present in 82%) and elevated CRP (61%) if infection suspected 4
• Maintain high index of suspicion, as neonates under 2 weeks can deteriorate rapidly from localized infection to sepsis 5, 6

Common Pitfalls to Avoid

• Do not aspirate cephalohematoma before day 15 (too early increases rebleeding risk) or after day 30 (calcification makes aspiration ineffective) 7
• Never delay antibiotics for imaging or cultures in systemically ill neonates with suspected infected cephalohematoma 5, 4
• Do not dismiss increasing size of cephalohematoma after initial stabilization—this suggests infection requiring immediate evaluation 4
• Avoid cefalexin in neonates (birth to 28 days), as it is contraindicated in this age group 5, 6
• Do not rely on visual assessment of jaundice; measure bilirubin levels objectively in all neonates with cephalohematoma 1