EpistemisDomed fontanel
Specialty: Pediatrics.
Why it occurs
- Bacterial or viral meningitis (infection and edema of the meninges with increased pressure of the cerebrospinal fluid)
- Obstructive or communicating hydrocephalus (progressive accumulation of CSF due to alteration in its flow or reabsorption)
- Intracranial hemorrhage (intraventricular, subdural or epidural hemorrhage, common in premature infants or secondary to obstetric trauma/abuse)
- Hypoxic-ischemic encephalopathy or acute cerebral edema (sequela of perinatal asphyxia or severe metabolic disorders)
- Pediatric pseudotumor cerebri (idiopathic intracranial hypertension, induced by drugs such as tetracyclines or excess vitamin A)
Initial workup
Urgent transfontanelar ultrasound (initial method of choice, safe and can be performed at the bedside to assess ventricular size, presence of blood or deviations from the midline). Computed Tomography (CT) or Magnetic Resonance (MRI) of the brain if a mass or active bleeding is suspected. Lumbar puncture for biochemical and cytological analysis, Gram stain, multipathogen PCR and CSF culture (always after ruling out signs of imminent herniation by imaging or clinical examination). Complete blood analysis that includes a complete blood count, acute phase reactants (CRP, procalcitonin), paired blood cultures, ionogram, blood glucose (to correlate with CSF) and capillary blood gases.
red flags
Doubled and tense fontanel visible in a vertical position and in a state of absolute rest (without crying); presence of lethargy, deep drowsiness or extreme difficulty waking up; uncontrollable irritability with high-pitched crying ("meningeal cry"); asymmetric reactive pupils, mydriasis or acute strabismus (6th cranial nerve palsy); "setting sun" eye movements; projectile vomiting not preceded by nausea; focal or generalized clonic or tonic seizures.
Standard management
- Ceftriaxone — third generation cephalosporin for bacterial meningitis; dose of 100 mg/kg/day intravenously divided every 12 hours; contraindicated in hyperbilirubinemic neonates due to risk of kernicterus
- Ampicillin — added in children under 3 months of age to cover Listeria monocytogenes; dose of 150-200 mg/kg/day IV divided every 6 hours
- Mannitol 20% — osmotic diuretic for emergency intracranial pressure reduction; dose of 0.25 to 1 g/kg IV administered as a slow infusion over 20-30 minutes with hemodynamic monitoring
- Dexamethasone (adjuvant steroid anti-inflammatory in meningitis due to Haemophilus or Streptococcus pneumoniae; dose of 0.15 mg/kg IV every 6 hours for 2-4 days, administered before the first dose of antibiotic).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Pediatrics
- Listed causes
- 5
- Treatment options
- 4