Practice 10-Minute Consultation

Baby with an abnormal head

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.f7609 (Published 10 January 2014) Cite this as: BMJ 2014;348:f7609
  1. A Rashid Gatrad, consultant paediatrician and honorary professor1,
  2. Guirish A Solanki, consultant neurosurgeon and honorary senior clinical lecturer2,
  3. Aziz Sheikh, professor of primary care research and development, Harkness fellow in healthcare policy and practice34
  1. 1Manor Hospital, Walsall WS2 9PS, UK, and Universities Kentucky, Lexington, KY 40506, USA
  2. 2Birmingham Children’s Hospital, Edgbaston, Birmingham B4 6NH, UK, and University of Birmingham, Birmingham, UK
  3. 3Centre for Population Health Sciences, University of Edinburgh, Edinburgh EH8 9DX, UK
  4. 4Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA 02120-1613, USA
  1. Correspondence to: A R Gatrad abdul.gatrad{at}walsallhealthcare.nhs.uk
  • Accepted 27 August 2013

A young couple present to their general practitioner worried that their 4 month old baby’s head “doesn’t quite look right.”

What you should cover

What specifically is worrying the parents?—Parents sometimes get concerned that their baby’s head looks smaller or bigger than it should be, is flattened on one side, or is bumpy in places; they may also be worried about the presence or size of the “soft spot” (fontanelle).

Is it posture related?—Many babies have a postural asymmetry of the head (plagiocephaly). The main risk factor is the baby’s preferred resting head position, both in utero and in the first few months after birth, while the skull bones are still malleable.

Are other family members affected?—Microcephaly (head circumference <3rd centile) and macrocephaly (head circumference >97th centile) can run in families and are generally without consequence. Spontaneous microcephaly is often indicative of a serious underlying problem such as a neurodevelopmental disorder or craniosynostosis (premature fusion of sutures). Although spontaneous macrocephaly is seldom of clinical relevance, identifying secondary causes is important as this may be due to increased intracranial volume, such as in hydrocephalus or a subdural haematoma as a result of birth trauma, or more rarely congenital tumours. A wide fontanelle that is bulging or other sutures widely open can indicate clinically important macrocephaly, as would any evidence of neurodevelopmental issues such as altered tone or convulsions.

Do the parents have any concerns about the baby’s development?—If so, this may indicate a serious underlying cerebral problem.

Are parents consanguineous?—Metabolic disorders and syndromic disorders occur more commonly in children from …

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