What neurologic symptoms should be monitored in an infant who fell from a bed?

Neurologic Warning Signs After Infant Fall from Bed

Monitor for persistent or projectile vomiting, altered mental status, excessive sleepiness, seizures, worsening irritability, unequal pupils, and unsteady movements—these are critical warning signs requiring immediate emergency evaluation. 1

Immediate Red Flag Symptoms Requiring Emergency Care

The following neurologic symptoms mandate urgent medical attention:

• Altered mental status or decreased level of consciousness - Any change in the infant's responsiveness or awareness is concerning for intracranial injury 1
• Persistent or projectile vomiting - Especially if it becomes repeated, bilious, or worsens over time, as this may indicate increased intracranial pressure 2, 1
• Seizure activity - Any seizure following head trauma requires immediate evaluation 1
• Excessive drowsiness or difficulty arousing - Increasing sleepiness beyond normal sleep patterns is a critical sign 1
• Severe or worsening irritability - Changes in behavior or inconsolable crying that differs from the infant's baseline 1
• Unequal pupil size - Anisocoria may indicate serious intracranial pathology 1
• Unsteady or abnormal movements - New onset of motor dysfunction or asymmetry 1

Risk Stratification for Serious Injury

The risk of clinically important traumatic brain injury is extremely low (<0.02%) if the infant has normal mental status, no palpable skull fracture, no nonfrontal scalp hematoma, loss of consciousness ≤5 seconds, and is acting normally per parents. 1

However, certain findings increase risk substantially:

• High-risk factors (4.4% risk of serious injury): GCS ≤14, signs of altered mental status, or palpable skull fracture 1
• Intermediate-risk factors (0.9% risk): Loss of consciousness >5 seconds, not acting normally per parent, nonfrontal scalp hematoma, or severe mechanism of injury 1

Expected Injury Patterns from Bed Falls

Most injuries from bed falls are minor, but serious injuries can occur:

• Skull fractures occur in approximately 4% of infants who fall from beds, making them the most common significant injury 3
• Traumatic brain injury (intracranial hemorrhage or cerebral contusion) occurs in 2% of cases 3
• Long bone fractures occur in approximately 2%, most commonly proximal upper extremity fractures 3
• The majority (85-94%) of infants have minor or no injury including scalp hematomas, bruising, and lacerations 3, 4

Critical Caveat: Consider Non-Accidental Trauma

Severe injuries from simple bed falls should raise suspicion for child abuse, as intracranial hemorrhage from short vertical falls is extremely rare in accidental trauma. 5, 4

Red flags for non-accidental trauma include:

• Subdural hematoma - Highly specific for abuse, especially if bilateral or in multiple locations 6, 7
• Intracranial hemorrhage without adequate mechanism - Two studies found no true accidental intracranial hemorrhages from short falls; confirmed cases were ultimately abuse 4
• Multiple fractures or fractures in unusual locations without adequate explanation 7
• Femoral fractures in non-ambulatory infants - More likely abusive than accidental 7
• Retinal hemorrhages - Characteristic of abusive head trauma 7

If abuse is suspected, immediate actions include complete skeletal survey, funduscopic examination, and notification of child protective services. 7

Observation Period and Follow-Up

Infants with normal neurologic examination and no high-risk features can be safely observed at home with close parental monitoring for 24-48 hours. 1

Parents should be instructed to return immediately for:

• Persistent or worsening vomiting 2, 1
• Increasing drowsiness or difficulty waking 1
• Any seizure activity 1
• Worsening headache (manifested as inconsolable crying in infants) 1
• Changes in behavior or excessive irritability 1
• Unsteady movements or weakness 1
• Unequal pupil size 1

When Imaging Is Indicated

Immediate non-contrast head CT is indicated for infants with GCS ≤14, altered mental status, or palpable skull fracture. 1

The American Academy of Pediatrics recommends maintaining a low threshold for neuroimaging in infants <1 year due to their increased risk of significant intracranial injury without obvious signs—29% of abused children without clinical suspicion had positive neuroimaging. 1

CT is preferred over skull radiographs because radiographs have only 63% sensitivity for skull fractures and cannot detect intracranial injuries. 1

Rare but Documented: Delayed Deterioration

Although extremely rare, delayed death can occur after an apparently minor fall with an initial lucid interval of up to 72 hours. 8 This underscores the importance of providing clear discharge instructions and ensuring parents understand warning signs, even when the infant initially appears well.