• Co-bedding/co-sleeping whilst breastfeeding
• Impaired awareness of mother e.g. fatigue, sedation, mobile phone use, dim lighting
• Immobility of mother e.g. epidural
• Primiparous mother
• Underlying maternal condition e.g. epilepsy, diabetes, disability, raised BMI
• Social issues e.g. young mother, single mother, language barrier
• Time of day 

• Place baby on warm, well-lit surface – ideally resuscitaire
• Assess:
  • airway, breathing, circulation 
  • level of consciousness, and pupil size and reaction to light 
  • local traumatic injuries 
  • full neurological examination and enhanced observations 

Immediate assessment and actions

*Enhanced observations = neonatal early warning score (NEWS) + modified paediatric Glasgow coma scale (GCS)

History

• Details of fall
  • time
  • detailed description of events
  • estimated height of fall (significant injury can occur after fall from a low height)
  • witnesses
• Most falls are accidental but be alert to possibility of non-accidental injury. Note: 
  • consistency of history
  • consistency between injury and proposed mechanism of injury
  • other injuries 
  • wider social situation (including safeguarding risks)
• Mode of delivery and any injuries attributed to birth 
• Administration of vitamin K – if not given or given orally, give IM (for dose see Vitamin K guideline)

Examination

• Full medical and neurological examination checking for signs of injury 
• Use body map to document any bruises, redness, swelling or skin marks 
• Perform neurological examination, and enhanced observations (NEWS + modified GCS) 
  Check https://hubble-live-assets.s3.amazonaws.com/bapm/attachment/file/244/Baby_Falls_-_FINAL_VERSION_19-03-20.pdf
  • anterior fontanelle and sutures 
  • pupil size, symmetry and response to light 
  • tone and power
  • primitive reflexes
• Measure occipital frontal circumference and plot 
• Review the need for analgesia (see Pain assessment and management guideline)

• NEWS and modified GCS for ≥12 hr 
  • half hourly for 2 hr
  • hourly for 4 hr
  • 2-hrly for 6 hr
• NEWS: 
  • heart rate
  • respiratory rate
  • SpO₂
  • temperature
• Modified GCS
  • eye opening
  • pupil reaction and size
  • best vocal response or grimace to stimulus
  • best motor response to stimulus
  • limb movement and tone 
• If all observations normal: discontinue after 12 hr 
• If any observations abnormal: request immediate middle grade review
  • baby may require return to half hourly observations or NNU admission and investigations 

Babies on postnatal ward/transitional care unit with stable enhanced observations

• No further investigations needed 

Babies admitted to NNU for clinical concerns

• FBC, U&E, group and save, clotting, blood gas, blood glucose
• If intracranial bleeds/fracture suspected, urgent CT head scan (see below)

Urgent CT head scan

• If indicated should be performed and reported within 1 hr of injury after stabilisation 
• Do not delay CT by performing cranial ultrasound scan as this has poor sensitivity for detecting extra-axial fluid collections
• If any of the following risk factors perform CT scan:
  • seizure 
  • focal neurological deficit including: 
    • asymmetrical pupils
    • ptosis
    • unilateral weakness
    • posturing 
    • loss of consciousness or unresponsive episodes 
  • modified GCS <14 on first assessment 
  • any soft tissue injury (bruise, swelling, laceration) not present before fall
  • suspicion of non-accidental injury
  • suspected open or depressed skull fracture 
  • any sign of basal skull fracture 
    • haemotympanum 
    • 'panda' eyes
    • cerebrospinal fluid leakage from ear or nose
    • Battle's sign (bruising over mastoid process)
• If ≥2 of the following risk factors, urgent review, and consideration of need for CT 
  
  • ≥3 episodes of forceful/projectile vomiting in 1 hr
  • abnormal drowsiness or irritability lasting >5 min
  • fall from height ≥90 cm
• If concerns of spinal injury, MRI head and spine after discussion with paediatric neurosurgical team 

• Complete incident form
• Consider possibility of non-accidental injury and document outcome of this 
• Ensure communication with mother includes provision of emotional support and information about immediate management plan
• Inform consultant

• If CT abnormal discuss with neurosurgical centre
• If CT normal/not indicated continue to monitor baby as described above for ≥12 hr 
• If enhanced observations become abnormal admit to NNU and investigate as detailed above 
• Baby with normal CT scan and no other clinical concerns may be monitored on postnatal ward or transitional care if staff are competent to perform enhanced observations 

• If observations normal for 12 hr and no significant extracranial injuries nor concerns about safeguarding, then middle grade/consultant may discharge baby
• Ensure community midwife/health visitor is aware of discharge and that the fall, assessment and investigations documented in discharge summary 
• If CT scan abnormal follow-up as advised by neurosurgical team