Increasing Head Circumference in a 4-Month-Old

Amy Terreros; Stephanie Zimmerman

Disclosures

J Pediatr Health Care. 2009;23(2):132-136. 

In This Article

Chief Complaint

L.M. is a 4-month, 3-week-old female infant who presented with lethargy to a local hospital via Emergency Medical Service (EMS).

History of Present Illness

L.M. was a previously healthy infant who had been active and playful when dropped off at the babysitter's house by her mother at 9:30 am. At noon, the babysitter called the mom and informed her that she was unable to arouse L.M. from her nap. L.M.'s mother instructed the babysitter to call 911. When EMS responded, they noted a lethargic infant. L.M. was transported to the closest emergency department (ED), where her level of consciousness improved with stimulation. No seizure activity was noted, and an ED physician diagnosed L.M. with bronchiolitis and arranged for a transfer to the local children's hospital.

Medical History

L.M. was the product of a term vaginal delivery without complications. Her mother received prenatal care throughout the pregnancy. L.M. had no prior hospitalizations or surgeries. She was not taking any medications at the time, and her immunizations were up to date. At her recent 4-month well-child visit (2 weeks prior to admission), her occipitofrontal circumference (OFC) was noted to be in the 95th percentile, increased from the 50th to 75th percentiles at birth and 2 month of age. Length and weight measurements were consistently at the 50th percentile. Her development was age on target: she smiled and cooed when talked to; she was able to hold up her chest and head when on her belly; and she reached for objects in near proximity. The babysitter reported a few episodes of vomiting 1 to 2 days prior to admission; otherwise, L.M. was in normal health prior to this incident.

Social History

L.M. resides at home with her biological mother and father. Both parents work full-time outside of the home. Her father is self-employed, and her mother is an administrative assistant at an automotive dealership. L.M. has been cared for by the same babysitter since 2 months of age.

Family History

The family denies any history of bruising easily, bleeding diathesis, or seizure disorders. As reported by her parents, the father and paternal uncle were macrocephalic as infants.

Physical Examination

Upon arrival at the Children's Hospital ED, L.M. was non-toxic appearing with appropriate level of consciousness but had intermittent episodes of crying. L.M. was afebrile with stable vital signs for her age. Her anterior fontanel was full and tense but non-bulging, the sutures were not overtly split, the scalp showed no signs of swelling or skull disruptions, and the OFC was 44 cm (>95th percentile). Her pupils were equal, round, and reactive to light; optic fundi could not be visualized. She was able to track laterally; however, upward gaze was limited. Oral mucosa was pink, moist, absent dentition, and free of lesions. Ear examination revealed intact tympanic membranes with normal landmarks. Her neck was soft and supple, and trachea was midline. Breath sounds were clear to auscultation, with no acute distress, and symmetrical chest excursion. Heart sounds were regular without murmur; peripheral pulses were palpable with good perfusion. Her abdomen was non-tender and non-distended, no masses were appreciated, and she had normal bowel sounds. The female genitalia was normal and without lesions or discharge. The skin examination was unremarkable; there were no abrasions, contusions, or ecchymosis. She had spontaneous movement of all extremities with full range of motion.

Diagnostic Testing

At the Children's Hospital ED, laboratory and radiographic studies were ordered and results were as follows: white blood cell count, 11.8 K/μL (6.0-14.0 K/μL); red blood cells, 3.58 M/uL (3.80-5.40 M/μL); hemoglobin, 10.1 gm/dL (10.5-14.0 gm/dL); hematocrit, 28.7% (32.0%-42.0%); platelet count, 442 K/μL (140-450 K/μL); prothrombin time (PT), 12.1 seconds (10.1-13.8 seconds); partial thromboplastin time (PTT), 25.3 seconds (22.2-39.5 seconds); alanine aminotransferase, 56 U/L (30-65 U/L); aspartate aminotransferase, 29 U/L (15-37 U/L); and her urine drug screen was negative. Findings from a computerized tomographic (CT) scan revealed subdural collections overlying the frontal convexities anteriorly and laterally and extending into the area of the anterior interhemisphere.

Patient Management

L.M. was admitted to the pediatric intensive care unit (PICU). After 2 days, she continued to be irritable and began vomiting after eating. Her anterior fontanel remained full and tense. Based on the clinical symptoms and lack of resolution of the subdural fluid collections, neurosurgery placed bilateral external subdural drains. Focal seizures developed on postoperative day 1. Upon consult by neurology, Fosphenytoin was prescribed every 8 hours. Seizure activity ceased after initiation of this drug. Bloody cerebral spinal fluid (greater than 800 mL) drained from the subdural collections over the course of 3 days. Subsequently, the external drains were clamped for 24 hours. L.M. remained stable and asymptomatic, and the drains were removed on postoperative day 4. At day 8, she was transferred out of the PICU to the general pediatric unit upon returning to her baseline activity level. She was discharged from the hospital on day 10.

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