A 4-month-old boy is brought to the office by his parents for a well-child visit. Their only concern is that the infant spits up a few times a day after breastfeeding. These episodes are occurring less frequently than before, and the emesis is not bilious or projectile. He is sometimes fussy after spitting up but is easily consolable. The patient was born at 37 weeks gestation by spontaneous vaginal delivery and has no chronic medical conditions. Vaccinations are up to date. His weight and length growth charts are shown in image 1, and the head circumference growth chart is shown in image 2. On physical examination, the patient is alert and smiling. The anterior fontanelle is soft and flat, and there are no craniofacial anomalies. Cardiac examination is normal. The abdomen is soft and nontender. He is able to roll from his stomach to his back and hold his head steady without support. Which of the following is the best next step in the management of this patient?

Question

A 4-month-old boy is brought to the office by his parents for a well-child visit.  Their only concern is that the infant spits up a few times a day after breastfeeding.  These episodes are occurring less frequently than before, and the emesis is not bilious or projectile.  He is sometimes fussy after spitting up but is easily consolable.  The patient was born at 37 weeks gestation by spontaneous vaginal delivery and has no chronic medical conditions.  Vaccinations are up to date.  His weight and length growth charts are shown in image 1, and the head circumference growth chart is shown in image 2.  On physical examination, the patient is alert and smiling.  The anterior fontanelle is soft and flat, and there are no craniofacial anomalies.  Cardiac examination is normal.  The abdomen is soft and nontender.  He is able to roll from his stomach to his back and hold his head steady without support.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfdf_5e3a_8f63_3b677864786a_MD0005_00 Head circumference (HC) is measured routinely from birth to age 2 or 3 years, the period of greatest brain growth. Macrocephaly, defined as HC ≥98th percentile for age, may be familial (eg, benign familial macrocephaly) or may signify an underlying genetic syndrome or life-threatening intracranial process. Neuroimaging is required to evaluate for a pathologic intracranial process in the following circumstances: Rapidly expanding HC (eg, >2 cm/month in infant <6 months) Neurologic abnormalities (eg, seizures) Developmental delay This infant with macrocephaly is feeding and growing normally; has a soft, flat fontanelle with no dysmorphic features to suggest an underlying genetic syndrome; and is meeting 4-month milestones (eg, holding head steady, rolling over). However, his HC is rapidly expanding (5 cm in 2 months), and he therefore requires imaging. A head ultrasound is the best study in infants with an open anterior fontanelle. It is fast, involves no radiation, and requires no sedation. If the ultrasound is normal, reassurance and observation are appropriate (Choice D). (Choices A and E) Evaluation with chromosomal analysis for syndromic macrocephaly (eg, Sotos syndrome) and a screen for metabolic macrocephaly (eg, organic acidurias) may be considered in a patient with developmental delay/regression and dysmorphic features, neither of which are seen in this patient. (Choice B) Plain radiographs of the head can detect skeletal dysplasias but have little use in the evaluation of macrocephaly. Educational objective: Infants with macrocephaly (head circumference ≥98th percentile) who have an open anterior fontanelle and rapidly expanding head circumference should have a head ultrasound to evaluate for pathologic intracranial processes. References: Fifteen-minute consultation on the infant with a large head. (http://www.ncbi.nlm.nih.gov/pubmed/23793045)

A 4-Month-Old Boy Is Brought to the Office by His