Answer to QOTW. (Caveat--if otitis media progresses to mastoiditis and abscess, ICP may elevate and cause a bulging fontanelle...expect fever in that situation). A 7-month-old baby girl born full term without complications is referred to the ED after she was seen at her pediatrician’s office for one day of a bulging fontanelle. The child has had some mild rhinorrhea this week, with tactile fever yesterday. The girl has had no vomiting or change in appetite, intake, or output. She has had no rash or inconsolability. Her mother brought her in to her pediatrician today because two days ago she was given DPT vaccine, and now with today’s events she is convinced that her doctor has made her baby “brain damaged”. On examination, T 37.9 HR 140 RR 28 BP 86/60 SpO2 100% RA The girl is interactive, smiling, comfortable, and taking PO well in the ED. She has a fairly tense, non-tender, bulging anterior fontanelle. Her neurologic, cardiopulmonary, abdominal, and skin examinations are normal. Which of the following is NOT a potential cause of this condition? A. Vaccination B. Congestive heart failure C. Otitis media D. Meningitis 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: 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 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.
Posted on: Tue, 23 Jul 2013 20:27:54 +0000
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