Pediatric emergency medicine trisk 2488 2488
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Shape, size, and symmetry are factors that must all be considered in the
evaluation of the neonate’s head. Macrocephaly, microcephaly, cranial
asymmetry, and bulging anterior fontanelle are signs of underlying pathology.
Goals of Treatment
Clinicians need to identify generally innocent etiologies from those that are life
threatening. The primary goals should be early recognition of hemorrhagic shock
from intracranial bleeding and increased intracranial pressure. All neonates with
disorders of size and shape of head need a thorough physical examination
including neurologic examination. Those with significant findings will require
head US, computed tomography (CT), or magnetic resonance imaging (MRI). In
any patient with significant findings, neonatology, neurology, and/or neurosurgery
consultation are warranted. Admission to the intensive care unit is necessary in
infants with cardiovascular instability.
Clinical Considerations
Clinical Recognition. The size, shape, and skin discoloration on the head can
first be noted by the clinician on inspection of the baby during physical
examination. Parents are often unaware of the problem unless the head size is
severely enlarged, has prominent skin changes, prominent asymmetry, or the baby
is presenting with other symptoms. Vague symptoms may be noted by the parent
including poor feeding, irritability, cyanotic episodes (apneic episodes), fever,
inability to maintain temperature, or the baby is “just not herself.” Measurement
of the head circumference should be routinely performed for infants presenting
within the first 2 weeks of life.
Triage Considerations. Neonates with bulging or sunken fontanelle associated
with poor feeding, irritability, or temperature instability should be evaluated
promptly for meningitis, sepsis, or shock. Associated hypothermia and ill
appearance imply neonatal sepsis and demands emergent treatment.
Clinical Assessment. Neonatal disorders of head shape, size, and symmetry are
detected by inspection, palpation, and measurement of head circumference. The
head should be examined in the midline position, then on each side. Benign
dermatologic lesions such as seborrheic dermatitis (cradle cap) ( Fig. 96.15 ),
capillary hemangioma, vesicles and ulcers from fetal scalp monitoring electrodes,
caput succedaneum ( Fig. 96.16 ), cephalohematoma ( Fig. 96.17 ) and significant
conditions such as giant congenital nevi, port-wine stain, and tumors may be
