A previously healthy 6-month-old child is brought to the physician for a routine examination. The parents state that during the past month, the child has been feeding poorly and has been fussier than usual. On examination, the child has a bulging anterior fontanelle and widely spaced sutures. Her scalp veins are also noted to be prominent. The remainder of the physical examination is within normal limits. The infant's growth chart is shown below. Which of the following is the best next step in the management of this patient?

Question

A previously healthy 6-month-old child is brought to the physician for a routine examination.  The parents state that during the past month, the child has been feeding poorly and has been fussier than usual.  On examination, the child has a bulging anterior fontanelle and widely spaced sutures.  Her scalp veins are also noted to be prominent.  The remainder of the physical examination is within normal limits.  The infant's growth chart is shown below.  Which of the following is the best next step in the management of this patient?

Quizplus · Accepted Answer

On review of the growth charts, the head circumference is rapidly increasing in size to greater than the 97^th percentile. Infants with hydrocephalus may present with the following findings: The best diagnostic approach in symptomatic children with rapidly increasing head circumference is to perform diagnostic imaging. A CT scan of the brain is the best initial choice in an infant who is acutely symptomatic. A CT will reveal ventricular dilation as well as the infant's anatomy. In an otherwise stable and asymptomatic infant, a sedated MRI could be considered to spare the child radiation exposure. Both CT and MRI would provide much greater detail than ultrasound, which requires a widely open anterior fontanelle and is most useful in infants under 6 months of age. Treatment of hydrocephalus consists of a shunt that is placed from the ventricle to the peritoneum, pleura, or right atrium; which allows the excess CSF to drain rather than continue to collect in the ventricles. (Choice A) Having this child return in one month is inappropriate since she has a rapidly increasing head circumference and signs of increased intracranial pressure (i.e., poor feeding and irritability). (Choice B) Skull radiographs may be useful in evaluating an abnormal head shape if craniosynostosis is suspected. However, in infants with macrocephaly and signs of increased intracranial pressure, a CT scan is a better diagnostic study. (Choice C) A lumbar puncture (LP) may be useful in improving the symptoms of normal pressure hydrocephalus, which is seen in adults. Also, LP is helpful if meningitis is suspected. This patient has had symptoms for one month, which makes meningitis unlikely. CT would provide more diagnostic clues in this patient. (Choice E) An electroencephalogram is indicated for the evaluation of seizures, which this child does not have. Educational objective: Increasing head circumference and signs of increased intracranial pressure in children should be evaluated with an imaging study such as a CT scan of the brain.

A Previously Healthy 6-Month-Old Child Is Brought to the Physician