Bulging fontanelle: Difference between revisions

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==Pathophysiology==
==Background==
[[File:Sutures from top.png|thumb|Neonatal suture anatomy.]]
*Fontanelles are fibrous, membrane-covered gaps between cranial bones.
*A newborn has six fontanelles: anterior, posterior, two mastoid, and two sphenoid.
**Anterior and posterior are the most prominent
**The posterior fontanelle usually closes by 1-2 months of age.
**The anterior fontanelle usually closes between 7-19 months of age.
*A bulging fontanelle represents [[Management of Elevated Intracranial Pressure|increased intracranial pressure]], which may be transient and either benign or malignant.
*Meticulous history and physical is essential to guide management of these infants.


Fontanelles are fibrous membrane-covered gaps between cranial bones. A newborn has six fontanelles: anterior, posterior, two mastoid, and two sphenoid. The most prominent are the anterior and posterior fontanelles
==Clinical Features==
 
*Bulging fontanelle
A bulging fontanelle represents [[Management of Elevated Intracranial Pressure|increased intracranial pressure]], which may be transient, benign, or malignant. The most commonly considered etiologies include [[Meningitis]], space-occupying lesion, cerebral edema, and [[Intracranial Hemorrhage (Main)|hemorrhage]] (spontaneous, non-accidental, or traumatic). A meticulous history and physical is essential to guide management of these infants.
 
*The posterior fontanelle usually closes by 1-2 months of age.
 
*The anterior fontanelle usually closes between 7-19 months of age.


==Differential Diagnosis==
==Differential Diagnosis==
*[[Meningitis (Peds)|Meningitis]]
*[[Meningitis (Peds)|Meningitis]]
*[[Encephalitis]]
*[[Encephalitis]]
*Meningo-encephalitis
*Meningoencephalitis
*[[Congestive Heart Failure]]  
*[[Congestive Heart Failure]]  
*Space-occupying lesions  
*[[intracranial mass|Space-occupying lesions]]
*Thyroid disorders
*[[Thyroid]] disorders
*[[Intracranial Hemorrhage (Main)|Intracranial Hemorrhage]]
*[[Intracranial Hemorrhage (Main)|Intracranial Hemorrhage]]
*Parathyroid disorders  
*Parathyroid disorders  
*[[Brain Abscess]]
*[[Brain Abscess]]
*[[Diabetic Ketoacidosis]]   
*[[Diabetic Ketoacidosis]]   
*Hypervitaminosis A  
*[[vitamin A toxicity|Hypervitaminosis A]]
*Anemia  
*[[Anemia]]
*[[Lead Toxicity|Lead encephalopathy ]]
*[[Lead Toxicity|Lead encephalopathy]]
*[[Leukemia (Peds)|Leukemia]]
*[[Leukemia (Peds)|Leukemia]]
*Inborn errors of metabolism  
*[[Inborn errors of metabolism]]
*[[Uremia]]
*[[Uremia]]
*Trauma  
*[[trauma (peds)|Trauma]]
*[[Roseola Infantum]]
*[[Roseola Infantum]]
*[[Vaccination Schedule|Vaccinations]]
*[[Vaccination Schedule|Vaccinations]]
*Shigella  
*[[Shigella]]
*[[Idiopathic Intracranial Hypertension|Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)]]
*[[Idiopathic Intracranial Hypertension|Idiopathic Intracranial Hypertension (Pseudotumor Cerebri)]]
*Dural sinus thrombosis  
*Dural sinus thrombosis  
*Viral syndromes
*[[Viral syndrome]]s
*Hydrocephalus
*[[Hydrocephalus]]
 
==Evaluation==
*Clinical diagnosis
*Evaluate for underlying etiology
*Standard approach:
**[[Head CT]]
**[[LP]] (if not contraindicated by CT findings) with opening and closing pressures


==Management==
==Management==
Standard approach:
*Treat underlying pathology
 
*See [[elevated ICP]]
#[[Head CT]] followed by [[Lumbar Puncture]] if not contraindicated by CT findings
#Record opening and closing pressures in children is warranted
 
''for a well appearing, asymptomatic, afebrile child with bulging fontanelle, an observation period may be appropriate.  In these stable children, if a subacute condition such as an asymptomatic space-occupying lesion is likely, he may benefit from admission and MRI''
 
==Sources==
Baqui AH, de Francisco A, Arifeen SE, Siddique AK, Sack RB. Bulging fontanelle after supplementation with 25,000 IU of vitamin A in infancy using immunization contacts. Acta Paediatr. 1995 Aug;84(8):863-6.
 
Beri S, Hussain N. Bulging fontanelle in febrile infants: lumbar puncture is mandatory. [Letter]. Arch Dis Child. 2011; 96 (1):109.
 
Biswas AC, Molla MA, Al-Moslem K. A baby with bulging anterior fontanelle. Lancet. 2000; 356(9224):132.
 
Long SS. Transient bulging fontanelle after immunization. J Pediatr. 2005; 147(5):A3
 
Opfer K. The bulging fontanelle. Lancet. 1963 Jan 12;1(7272):116.
 
Silver W, Kuskin L, Goldenberg L. Bulging anterior fontanelle. Sign of congestive heart failure in infants. Clin Pediatr (Phila). 1970 Jan;9(1):42-3.


Shacham S, Kozer E, Bahat H, Mordish Y, Goldman M. Bulging fontanelle in febrile infants: is lumbar puncture mandatory? Arch Dis Child. 2009;94:690–692.
==Disposition==


==References==
<references/>


[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Symptoms]]

Latest revision as of 22:32, 1 February 2023

Background

Neonatal suture anatomy.
  • Fontanelles are fibrous, membrane-covered gaps between cranial bones.
  • A newborn has six fontanelles: anterior, posterior, two mastoid, and two sphenoid.
    • Anterior and posterior are the most prominent
    • The posterior fontanelle usually closes by 1-2 months of age.
    • The anterior fontanelle usually closes between 7-19 months of age.
  • A bulging fontanelle represents increased intracranial pressure, which may be transient and either benign or malignant.
  • Meticulous history and physical is essential to guide management of these infants.

Clinical Features

  • Bulging fontanelle

Differential Diagnosis

Evaluation

  • Clinical diagnosis
  • Evaluate for underlying etiology
  • Standard approach:
    • Head CT
    • LP (if not contraindicated by CT findings) with opening and closing pressures

Management

Disposition

References

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