What advice should be given to the parents of a 2-month-old baby with no visible signs of injury after a fall, prior to discharge from the emergency room (ER)?

Head Injury Discharge Instructions for a 2-Month-Old After a Fall

Parents should be instructed to monitor their 2-month-old infant closely at home for warning signs of serious head injury and return immediately to the emergency department if any concerning symptoms develop.

Critical Warning Signs Requiring Immediate Return to Emergency Department

Parents must bring their infant back immediately if any of the following occur:

• Persistent or repeated vomiting, especially if it becomes projectile or bilious 1
• Lethargy, difficulty waking, or decreased responsiveness 2
• Refusal to eat, poor feeding, or weak suck 2
• Seizure activity or abnormal movements 3
• Fever ≥38°C (100.4°F) or temperature <36.5°C (97.7°F) 2
• Rapid or labored breathing, grunting, or blue discoloration 2
• Increasing irritability or inconsolable crying 4
• Bulging fontanelle (soft spot on head) 4
• Clear or bloody fluid draining from nose or ears 4
• Unequal pupil size or abnormal eye movements 4
• Loss of consciousness or change in level of alertness 5

Observation Period and Monitoring

Parents should observe their infant closely for the next 24-48 hours, as serious complications from head injury can develop during this timeframe 6, 4. Infants under 3 months are at particularly high risk for traumatic brain injury even from seemingly minor falls 6.

• Check on the infant frequently, including waking them every 2-3 hours during sleep to ensure normal responsiveness 5
• Monitor feeding patterns and ensure the infant is feeding normally 2
• Watch for any behavioral changes or unusual fussiness 4

Context: Why This Age Group Requires Special Vigilance

Infants under 1 year, particularly those under 3 months, are at significantly higher risk for serious head injury from falls compared to older children 6. In one study, infants younger than 3 months had a 3.1 times higher risk of traumatic brain injury after falls 6. Another study found that 9.4% of infants under 1 year who fell from bed or furniture sustained significant injuries, with skull fractures occurring in 4.1% and traumatic brain injury in 2.1% 4.

The vulnerability of this age group stems from:

• Disproportionately large head size relative to body 7
• Thinner skull bones 6
• Limited ability to protect themselves during falls 5
• Higher risk that seemingly minor mechanisms can cause serious injury 8, 9

Safe Sleep and Fall Prevention

To prevent future falls, parents must implement strict safety measures 1:

• Always place the infant on their back to sleep on a firm, flat surface in a crib or bassinet that meets safety standards 7, 2
• Never leave the infant unattended on adult beds, couches, changing tables, or any elevated surface 1, 5
• Ensure the crib mattress fits snugly with no gaps between mattress and crib sides 7, 2
• Remove all soft bedding, pillows, toys, and bumper pads from the sleep area 7
• Avoid using sitting devices (car seats, bouncers, swings) for routine sleep, as these pose suffocation and fall risks 7, 8
• Place the infant's sleep area in the parents' room but not in their bed 7

Falls from furniture, particularly beds and couches, are the most common cause of injury in this age group and carry the highest clinical burden 5. One case report documented a fatal head injury in an infant who fell from a baby bouncer from only 2 feet height, demonstrating that serious injuries can occur from seemingly minor falls 8.

Follow-Up Care

• Schedule or confirm the newborn follow-up appointment within 3-5 days if not already arranged 2
• Contact the infant's pediatrician within 24 hours to report the fall and discuss any concerns 2
• Ensure parents know how to reach their healthcare provider for urgent questions 2

Common Pitfalls to Avoid

Do not assume the infant is fine simply because they appear normal immediately after the fall 6, 4. Serious intracranial injuries can present with delayed symptoms. While most falls result in minor or no injury (76% of infants in one study had no injury from short falls 9), the consequences of missing a serious injury in this vulnerable age group can be catastrophic 8.

Parents should not hesitate to return if they have any concerns, as clinical judgment in infants this young is challenging even for healthcare providers 6. The threshold for re-evaluation should be low given the age-specific vulnerability 6, 4.