Under Pressure
Answer: C
This girl presents with a condition that is distressful to parents and practitioners alike: the bulging
fontanelle.
A quick review:
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:
This girl presents with a condition that is distressful to parents and practitioners alike: the bulging
fontanelle.
A quick review:
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:
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, benign, or malignant. The most commonly considered etiologies include meningitis, space-occupying lesion, cerebral edema, and hemorrhage (spontaneous, non-accidental, or traumatic). A meticulous history and physical is
essential to guide management of these infants.
Causes of bulging fontanelle:
Meningo-encephalitis Congestive heart failure
Space-occupying lesions Thyroid disroders
Intracranial hemorrhage Parathyroid disorders
Brain abscess Diabetic ketoacidosis
Intracranial hemorrhage Hypervitaminosis A
Anemia Lead encephalopathy
Leukemia Inborn errors of metabolism
Uremia Trauma
Roseola Vaccinations
Shigella Benign Intracranial hypertension
Dural sinus thrombosis Viral syndromes
An Israeli retrospective study in 2009 contended that well appearing children (aged 3 to 18 months) with fever and bulging fontanelle were at low risk for bacterial meningitis (although they appropriately held that prospective work is necessary before implementing their findings). However, in this cohort of 153 children, 26.7% had viral meningitis and less than 1% had pneumococcal meningitis. The presentation of meningitis irrespective of etiology can be subtle in children, especially in non-verbal children and early in the course of the disease. To separate bacterial from viral meningitis clinically in children (especially in this age) is a failing prospect.
Interestingly as a counter-point, this cohort exhibited many less worrisome etiologies for bulging fontanelle, including upper respiratory tract infection (18.3%), viral syndrome (15.6%), and roseola (8.5%).
The key point here is that is a very difficult, perilous task to sort out the etiology in the ED without further
investigation.
After a thorough assessment, the cause may be simply benign intracranial hypertension, caused by viral syndrome, crying, vaccines, etc.
Bottom line:
● 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
● Barring the above, the typical approach is CT followed by lumbar puncture if not contraindicated by CT
findings (this is the occasion when measuring opening and closing pressures in children is warranted)
In other words, do a careful history and physical and have a very low threshold for CT and LP, but realize that a substantial proportion of well appearing children will have non-serious causes to the bulging fontanelle.
References
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;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;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.
The anterior fontanelle usually closes between 7-19 months of age.
A bulging fontanelle represents increased intracranial pressure, which may be transient, benign, or malignant. The most commonly considered etiologies include meningitis, space-occupying lesion, cerebral edema, and hemorrhage (spontaneous, non-accidental, or traumatic). A meticulous history and physical is
essential to guide management of these infants.
Causes of bulging fontanelle:
Meningo-encephalitis Congestive heart failure
Space-occupying lesions Thyroid disroders
Intracranial hemorrhage Parathyroid disorders
Brain abscess Diabetic ketoacidosis
Intracranial hemorrhage Hypervitaminosis A
Anemia Lead encephalopathy
Leukemia Inborn errors of metabolism
Uremia Trauma
Roseola Vaccinations
Shigella Benign Intracranial hypertension
Dural sinus thrombosis Viral syndromes
An Israeli retrospective study in 2009 contended that well appearing children (aged 3 to 18 months) with fever and bulging fontanelle were at low risk for bacterial meningitis (although they appropriately held that prospective work is necessary before implementing their findings). However, in this cohort of 153 children, 26.7% had viral meningitis and less than 1% had pneumococcal meningitis. The presentation of meningitis irrespective of etiology can be subtle in children, especially in non-verbal children and early in the course of the disease. To separate bacterial from viral meningitis clinically in children (especially in this age) is a failing prospect.
Interestingly as a counter-point, this cohort exhibited many less worrisome etiologies for bulging fontanelle, including upper respiratory tract infection (18.3%), viral syndrome (15.6%), and roseola (8.5%).
The key point here is that is a very difficult, perilous task to sort out the etiology in the ED without further
investigation.
After a thorough assessment, the cause may be simply benign intracranial hypertension, caused by viral syndrome, crying, vaccines, etc.
Bottom line:
● 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
● Barring the above, the typical approach is CT followed by lumbar puncture if not contraindicated by CT
findings (this is the occasion when measuring opening and closing pressures in children is warranted)
In other words, do a careful history and physical and have a very low threshold for CT and LP, but realize that a substantial proportion of well appearing children will have non-serious causes to the bulging fontanelle.
References
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;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;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.
