Early Needle Aspiration of Large Infant Cephalohematoma: a Safe Procedure to Avoid Esthetic Complications

European Journal of Pediatrics https://doi.org/10.1007/s00431-019-03487-5 ORIGINAL ARTICLE Early needle aspiration of large infant cephalohematoma: a safe procedure to avoid esthetic complications Fabian Blanc1 & Michèle Bigorre2 & Audrey Lamouroux3 & Guillaume Captier4,5,6 Received: 12 August 2019 /Revised: 12 August 2019 /Accepted: 25 September 2019 # Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract Cephalohematoma is a common pathology in newborns. Observation is the primary treatment for most patients with small uncomplicated cephalohematoma. Conversely, a large cephalohematoma can lead to calcification with unesthetic local deformation or deformational plagiocephaly. The objective of the study was to evaluate the iatrogenic risk associated with early puncture under local anesthesia and oral sucrose. This is a retrospective study of 67 consecutive newborns followed at Montpellier University Hospital, France, between 2010 and 2017. Large cephalohematoma was defined on the basis of the bump projection. Due to the uncertainty of the spontaneous resorption and the risk of calcification after 4 weeks which render the needle aspiration ineffective, puncture was performed between 2 and 4 weeks of life after coagulation evaluation and ultrasound of the skull and scalp. Puncture was performed in 43 boys (64%) and 24 (36%) girls between day 15 and day 30 after birth. The cephalohematoma maximal projection measured by ultrasound ranged from 9 to 13 mm (Q1,Q4) with a median value of 12 mm. No puncture-related complication was recorded during the intervention and at the 1-month follow-up visit. Conclusion: In newborns with large and persistent unesthetic cephalohematoma, puncture under local anesthesia with oral sucrose can be safely proposed between day 15 and day 30 after birth. What is Known: • Infant cephalohematoma is a frequent pathology of newborns, consisting of a traumatic subperiosteal hematoma of the skull. Most cephalohematomas are small and require no treatment because they spontaneously disappear within the first month. • Large and non-resorptive cephalohematomas may have significant esthetic and functional consequences. What is New: • Early puncture under local anesthesia is a safe, effective, and rapid procedure, decreasing the risk of persistent skull deformities. • Puncture can be proposed for newborns with a large (high projection and/or high angle connection) persistent anesthetic cephalohematoma, between day 15 and day 30, before spontaneous calcification. Keywords Cephalohematoma; Infant . Newborn; Infant . Newborn . Diseases; Plagiocephaly . Nonsynostotic Communicated by Piet Leroy * Guillaume Captier 2 Pediatric Orthopedic Plastic Surgery Unit, Montpellier University [email protected] Hospital, University of Montpellier, Lapeyrone Hospital, 371 avenue du Doyen Gaston Giraud, 34090 Montpellier, France Fabian Blanc 3 [email protected] Gynecology and Obstetric District, Nîmes University Hospital, University of Montpellier, Montpellier, France Michèle Bigorre 4 Head of the Pediatric Orthopedic Plastic Surgery Unit, Montpellier [email protected] University Hospital, University of Montpellier, Lapeyronie Hospital, 371 avenue du Doyen Gaston Giraud, 34090 Montpellier, France Audrey Lamouroux [email protected] 5 EA2415, School of Medicine, University of Montpellier, 641 avenue du Doyen G. Giraud, 34093 Montpellier Cedex 5, France 1 Pediatric Orthopedic Plastic Surgery Unit, Montpellier University 6 Guillaume Captier, M.D. Ph.D, University Hospital Lapeyronie, Hospital, University of Montpellier, Lapeyronie Hospital, 371 University of Montpellier, 371 avenue du Doyen Gaston Giraud, avenue du Doyen Gaston Giraud, 34090 Montpellier, France 34090 Montpellier, France Eur J Pediatr Introduction puncture under local anesthesia to selected patients with large or non-resorptive cephalohematoma. The objective of this Infant cephalohematoma occurs in 0.5 to 2% of newborns [1–3]. study was to retrospectively evaluate the iatrogenic risk asso- It is a traumatic subperiosteal hematoma of the skull bone and ciated with this procedure under local anesthesia. must be differentiated from subgaleal hematoma and caput suc- cedaneum [4]. At physical examination, cephalohematoma is characterized by a bulge/swelling on the infant’s head due to blood accumulation between periosteum and skull, and is usually Materials and methods delimited by the suture lines due to the periosteum attachment to the bone’s edge. Cephalohematoma physiopathology is poorly This is a retrospective single-center observational study of understood, but it is considered to be caused by bleeding of the infants with cephalohematoma consecutively followed at the emissary or diploic veins after the detachment of the Pediatric Orthopedic Plastic Surgery Unit, Montpellier subperiosteal layer of the skull. This slow bleeding can lead to University Hospital, France, and who underwent puncture un- an increase in the size during the first days of life before it spon- der local anesthesia between 2010 and 2017. Patients with taneously stops limited by the sutures. The risk factors are com- cephalohematoma who did not undergo puncture as well as pression and shear strain to the scalp, in utero [5]orduringlabor infants with cephalohematoma associated with a neurosurgi- and delivery. Instrument-assisted delivery, prolonged labor, large cal pathology (n = 5) or with sepsis (n = 1; not linked to infants,anduncommonheadpresentation are classically associ- puncturing) were excluded from the study. ated with cephalohematoma [3]. For unknown reason is more The diagnosis of cephalohematoma was performed by two frequent in newborn boys. Cephalohematoma is mostly located senior plastic pediatric surgeons (G.C. and M.B.). Puncture over the parietal bone and on the right side, and is bilateral in was proposed to the parents in the case of large 10% of cases. It can be associated with linear skull fractures [6, cephalohematoma with a heavily projected bump or with a 7], and in this case, it requires specific pediatric neurosurgery very marked angle of connection between bump and scalp treatment. Infection is a rare complication, after systemic infec- (Fig. 1). Only infants without any clear sign of resorption after tion or focal skin lesion [8, 9]. Large cephalohematoma can 2 weeks of life underwent this intervention. induce hyperbilurubinemia in newborns [10, 11], or anemia [12]. When puncture was indicated, blood coagulation and com- Most cephalohematomas are small and require no treatment plete blood count were systematically determined before the because they spontaneously disappear within the first month for procedure. Trans-fontanel ultrasonography was carried out to most of them [13]. As cephalohematoma management is mainly exclude any endocranial complication, and scalp/skull ultra- observational, primary healthcare professionals play a significant sonography to exclude a fracture, confirm the diagnosis, and role in providing reassurance to the new parents who are often measure the height of the cephalohematoma between the skull very anxious [14]. On rare occasions, cephalohematomas persist and the periosteum. Cephalohematoma aspiration was per- beyond 4 weeks. Progressive calcification can be observed in formed after informing the parents about the risks associated these cephalohematomas, leadingtoasmallbumponthecalvaria with the procedure. that should disappear during the skull remodeling following its Puncture was carried out under not-fasting local anesthesia. rapidgrowthinthefirstyearoflife[15–17]. However, Topical lidocaine cream 5% was applied 2 h before the punc- cephalohematoma should be monitored until complete resorp- ture, followed by subcutaneous infiltration of lidocaine hydro- tion. Incomplete resorption of large cephalohematoma can lead chloride 5 mg/ml. Simultaneously, oral sucrose was also ad- to persistent unesthetic deformation of the calvaria. Indeed, the ministered by a nurse [20]. The puncture was made on a quiet bump on the side of the cephalhematoma may causes contro- child and the nurse remains on the side of the patient’sfaceto lateral occipital and frontal molding and cervical rotation leading assess if the procedure was comfortable the whole time. to deformational plagiocephaly [18]. Puncture was performed in the operating room using strict In the case of large and non-resorptive cephalhematoma, sterile techniques. The 20G spinal needle was introduced tan- needle aspiration may be an alternative to prevent progression gentially in the bump from the back side (Fig. 2), and blood of this molding [19]. was aspirated with a 20 cc syringe until there was no more Firlik and Adelson [18] proposed in 1999 needle puncture blood and the bump had disappeared. The total volume of the for persistent cephalohematoma. Although aspiration of a collected blood was noted. No drain was put in place, and cephalohematoma is technically uncomplicated, improper surgical dressing was left in place for 24 h. The infant was technique may predispose the patient to a scalp infection or discharged home the same day without any anesthetic moni- osteomyelitis [8, 9]. toring. Parent could wash their child’s head after 48 h. No study is available in the literature about the outcomes of Children were seen after 1 month to confirm the total this procedure. In our Pediatric Orthopedic Plastic Surgery cephalohematoma resorption and to provide preventive advice Unit, to avoid the risk of incomplete resorption, we propose

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