Patient Presentation
A 14-day-old female came to clinic for her routine infant followup. Her experienced parents had no questions other than when her small cephalohematoma should resolve. The past medical history showed a term infant at 3280 grams birthweight born by vaginal delivery, who was breastfeeding and had no significant jaundice.
The pertinent physical exam revealed a vigorous infant with a weight of 3340 grams, head circumference and length were 50%. She had an approximately 2 cm elevated firm mass on her right parietal skull that did not cross any suture line. The rest of her examination was normal.
The diagnosis of a healthy infant with a small cephalohematoma was made. The resident reassured the family that it should resolve in a few weeks, but when staffing said she didn’t know the exact answer. The attending said he didn’t know exactly either but in his experience it was just a few weeks but they could ossify which then takes longer to resolve. He said he had never seen any intervention done for them. The patient’s clinical course at followup at 2 months of age, showed the cephalohematoma to be resolved.
Discussion
Cephalomatomas occur relatively commonly in 0.2-3% of newborn infants. They are blood collections in the subperiosteal skull bones, usually in the parietal area. They are usually unilateral but can be bilateral. They do not transilluminate. They are felt to be caused by pressure or other trauma and occur in vaginal and cesarean deliveries, with presumed periosteal disruption leading to externally located bleeding (not on the brain side of the bone). The blood fills the space with some pressure building up and the blood acts to tamponade itself. The blood coagulates, slowly organizes and is reabsorbed. If reabsorption is delayed then ossification can occur but these also usually reabsorb but more slowly.
Increased risks include prolonged overall or second stage of labor, macrosomia, abnormal fetal position, multiple gestation, weak uterine contractions and instrumented delivery such as vacuum extractor or forceps. Larger cephalohematomas are more likely to have ossification. The differential diagnosis includes caput succedaneum, vacuum caput, subgaleal hematoma, congenital abnormalities such as leptomingeal cyst or meningocoeles. Persistent bleeding could also be an indication of a hemophilia. Underlying skull fracture can occur but is unlikely. If there is more significant bleeding, then hyperbilirubinemia may be accentuated.
Treatment is usually reassurance for families and watchful waiting. Compressive dressings can be applied around birth. Aspiration or other surgical techniques are usually not necessary and have risks of infection, anesthesia, potential surgical complications and necessary followup care. Usual indications for surgery include cosmetic deformities, craniosynostosis or confirmed restricted brain growth. Monitoring of infants is always recommended.
Learning Point
Reports of resolution timing usually say something like “a few weeks.” One case series of 94 infants with large (> 50 mm) cephalohematomas found 76.6% had resolved at 4 week examination and 12.7% more (total = 89.4%) had resolved by 8 week examination. The additional 9.6% became ossified but again resolved completely or partially by 1 year.
Another study of ossified cephalohematomas in their discussion state that “After ossification, cephalohematoma may still get absorbed slowly and most often disappears over 3-6 months.”
Questions for Further Discussion
1. What causes macrocephaly? A review can be found here
2. How is caput different than cephalohematoma?
3. What are indications for neonatology consultations?
Related Cases
- Disease: Cephalohematoma | Childbirth
- Symptom/Presentation: Mass or Swelling
- Specialty: General Pediatrics | Neonatology
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Child Birth Problems
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Guclu B, Yalcinkaya U, Kazanci B, Adilay U, Ekici MA. Diagnosis and treatment of ossified cephalohematoma. J Craniofac Surg. 2012;23(5):e505-507. doi:10.1097/SCS.0b013e318266893c
Ucer M, Tacyildiz AE, Aydin I, Akkoyun Kayran N, Isok S. Observational Case Analysis of Neonates With Large Cephalohematoma. Cureus. 13(4):e14415. doi:10.7759/cureus.14415
Raines DA, Krawiec C, Jain S. Cephalohematoma. In: StatPearls. StatPearls Publishing; 2022. Accessed June 27, 2022. http://www.ncbi.nlm.nih.gov/books/NBK470192/
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa
Pediatric Education 