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Hematomas in infants and young children have unique characteristics. The large subarachnoid spaces and the pliable calvarium in the infant and toddler enable the child to tolerate hematomas better than the older children and adults whom the bone has ossified dan the sutures have closed.

Still undergoing a process of maturation and development, the pediatric brain reacts differently to similar injuries depending upon the age of the child when the injury occurs. The skull is initially a one layered structure in infants and newborns with open sutures and small diploic spaces. However, by age 4, it has become a rigid closed system. As the child ages, his brain reaction to injuries becomes more like that of the adult.

Epidural hematoma

Prevalence & causes

Epidural hematomas are relatively uncommon in newborns. The dura of the newborn is unusually thick and attached tightly to the inner periosteum, preventing development of epidural fluid sacs. Also, the middle meningeal artery groove is shallow and the artery is not encased in bone, and therefore it is less susceptible to tearing during a fracture in the soft cranium, which in itself also acts as a shock absorber. The most common cause of epidural hematoma in newborns is bleeding due to birth trauma, most commonly is in the temporo-parietal and frontal regions.

In 50% of the cases of epidural hematomas in children, there is no underlying skull fracture although they usually result from trauma such as a severe fall onto a hard surface or child abuse. In children 6 years and older the most common event causing an epidural hematoma is a blow to the side of the head, such as a fall off a bicycle, a severe fall and motor vehicle accidents.

Symptoms

Children younger than 5 years with epidural hematomas rarely present with the classic pattern of a lucid interval followed by rapid deterioration. Many children at this age never become deeply unconscious but present within 48 hours of injury with papilledema, bradycardia, continued moderate lethargy and sometimes recurrent vomiting over several days.

Subdural hematoma

Prevalence & causes

Subdural hematomas tend to occur more in infants than in older children, typically newborns between the ages of 2 and 6 months. Infants are more prone to subdural hematoma than toddlers and older children because their brain has more room than that of older children to move around in the skull when shaken or hit. The neck muscles of infants are also less developed and unable to hold the head steady when shaken. Even if the head does not contact a solid surface, the shaking, whiplash movement of an accident can cause blood vessels in their brain to burst.

Infants rarely fall until they start learning to walk, so falls account for only a small number of subdural hematomas in infants. Most subdural hematomas in infants are non-accidental, such as the ensuing complications after troubling vaginal or forceps delivery. A large percentage of infants whose hematomas result from postnatal trauma are caused by parental abuse as typically indicated by tissue bruising and interhemispheric nature of the hematomas. Most subdural hematomas in toddlers, however, result from accidental falls, as they learn to walk and climb. Occasionally, an arachnoid cyst in the middle fossa can predispose to a chronic subdural hematoma in older children, especially during adolescence.

Symptoms

In infants, a subdural hematoma can cause the head to enlarge (as in hydrocephalus), because the skull is soft and pliable. Besides the enlarged head circumference, other common physical symptoms of a subdural hematoma in infants are a disproportionate and a swollen fontanel (the soft membrane-covered gap on an infant’s head) and disjointed sutures (the junction of bones in the skull). Clinical symptoms include:

• lethargy and seizures
• vommiting, fever and hyperirritability
• failure to gain weight
• refusal of feedings followed by frequent episodes of vomitting
• retinal hemorrhages