Early closure of fontanelles

Craniosynostosis | Johns Hopkins Medicine

What You Need to Know

Craniosynostosis is common and occurs in one out of 2,200 live births.
The condition affects males slightly more often than females.
Craniosynostosis is most often sporadic (occurs by chance) but can be inherited in some families.

What is craniosynostosis?

In fetuses and newborns, the skull consists of several plates of bone that are separated by flexible, fibrous joints called sutures. As infants grow and develop, the sutures close, forming a solid piece of bone.

Craniosynostosis is a condition in which the sutures close too early, causing problems with normal brain and skull growth. Premature closure of the sutures may also cause pressure inside the head to increase and the skull or facial bones to change from a normal, symmetrical appearance.

What causes craniosynostosis?

Craniosynostosis is a feature of many different genetic syndromes that have a variety of inheritance patterns and chances for recurrence, depending on the specific syndrome present.

It is important for the child with craniosynostosis and his/her family members to be examined carefully for signs of an inherited genetic disorder, such as limb defects, ear abnormalities or heart defects.

Craniosynostosis Symptoms

In infants with this condition, the most common signs are changes in the shape of the head and face. One side of your child’s face may look markedly different from the other side. Other, much less common signs may include:

A full or bulging fontanelle (soft spot located on the top of the head)
Sleepiness (or less alert than usual)
Very noticeable scalp veins
Increased irritability
High-pitched cry
Poor feeding
Projectile vomiting
Increasing head circumference
Developmental delays

The symptoms of craniosynostosis may resemble other conditions or medical problems, so always work with your child’s physician to clarify a diagnosis.

Different Types of Craniosynostosis

Brachycephaly

Anterior brachycephaly involves fusion of either the right or left side of the coronal suture that runs across the top of the baby’s head from ear to ear.

This is called coronal synostosis, and it causes the normal forehead and brow to stop growing. The result is a flattening of the forehead and the brow on the affected side, with the forehead tending to be excessively prominent on the opposite side. The eye on the affected side may also have a different shape, and there may be flattening of the back of the head (occipital). When the suture fusion is all the way across the back of the child’s skull, the result is posterior plagiocephaly.

Trigonocephaly

Trigonocephaly is a fusion of the metopic (forehead) suture. This suture runs from the top of the head down the middle of the forehead, toward the nose.

Early closure of this suture may result in a prominent ridge running down the forehead. Sometimes, the forehead looks quite pointed, like a triangle, with closely placed eyes (hypotelorism).

Scaphocephaly

Scaphocephaly is an early closure or fusion of the sagittal suture. This suture runs front to back, down the middle of the top of the head. This fusion causes a long, narrow skull. The skull is long from front to back and narrow from ear to ear.

Craniosynostosis Diagnosis

Craniosynostosis may be congenital (present at birth) or observed later, often during a physical examination in the first year of life.

The diagnosis involves thorough physical examination and diagnostic testing. Your child’s doctor will start with a complete prenatal and birth history, asking about any family history of craniosynostosis or other head or face abnormalities.

The doctor may also ask about developmental milestones, since craniosynostosis can be associated with other neuromuscular disorders. Developmental delays may require further medical follow-up for underlying problems.

During the examination, the doctor will measure the circumference of your child’s head to identify normal and abnormal ranges. Craniosynostosis can be diagnosed by physical exam. If needed, your neurosurgeon may recommend imaging tests.

Craniosynostosis: Fitz’s Story

When Fitz was born, it was obvious that his skull was misshapen. By 5 weeks old, Fitz had been diagnosed with craniosynostosis. His skull had fused early and was constricting his brain growth.

See Fitz's story

Craniosynostosis Treatment

The key to treating craniosynostosis is early detection and treatment. Specific therapy for craniosynostosis will be determined by your child’s physician based on:

Your child’s age, overall health and medical history
Extent of the craniosynostosis
Type of craniosynostosis (which sutures are involved)
Your child’s tolerance for specific medications, procedures or therapies
Expectations for the course of the craniosynostosis
Your opinion or preference

Surgery is typically the recommended treatment, since it can reduce pressure in the head and correct the deformities of the face and skull bones.

Early diagnosis and consultation with a specialist are important. In general, the best time to operate is before the child is 1 year old, since the bones are still very soft and easy to work with. If your child’s condition is severe, the doctor may recommend surgery as early as 1 month of age.

Before surgery, your child’s physician will explain the operation and may review before-and-after photographs of children who have had a similar type of surgery.

Calvarial Vault Remodeling

In this procedure, the surgeon makes an incision in the infant’s scalp and corrects the shape of the head by moving the area of the skull that is abnormally or prematurely fused, and then reshapes the skull so it can take more of a round contour. Surgery can last up to six hours. Your baby will likely spend one night in the intensive care unit, plus an additional few days in the hospital for monitoring.

Even if your child’s deformity is seen early on, this surgery is best suited for babies 5-6 months of age or older to ensure the bone is thick enough to perform the needed reshaping. This surgery may commonly involve a blood transfusion.

After surgery, there may be temporary facial swelling. Unlike other surgical options, there are no additional steps post-surgery unless a recurrence of craniosynostosis is found. You can expect to follow up with your surgery team one month post-surgery to check on the surgery incision site, and again at six and 12 months after the procedure to ensure healing is progressing.

Endoscopic Craniosynostosis Surgery

Some hospitals may offer the option of this minimally invasive surgery, which may be performed when the baby is 2–3 months old, depending on the type and degree of craniosynostosis.

The procedure involves the use of an endoscope, a small tube that the surgeon can look through and see immediately inside and outside the skull through very small incisions in the scalp. The surgeon opens the prematurely fused suture to enable the baby’s brain to grow normally.

The surgery itself takes approximately one hour and involves less blood loss compared with cranial vault remodeling, so there is less chance of requiring a blood transfusion. Your baby will stay in the hospital overnight for monitoring before being released to go home.

This type of surgery is followed by the use of a molding helmet to reshape the skull. Additional appointments with the helmet provider (orthotist) will be necessary for fitting the helmet to your child. You can expect to follow up with your surgery team every three months for the first year post-surgery to check progress of the skull reshaping.

After Craniosynostosis Surgery

Following craniosynostosis surgery, your child will likely have a turbanlike dressing around his or her head, and may experience swelling in the face and eyelids. Your child will spend the period after surgery in an intensive care unit for close monitoring.

The care team will watch closely for any problems after surgery, such as:

Fever (greater than 101 degrees Fahrenheit)
Vomiting
Irritability
Redness and swelling along the incision areas
Decreased alertness

These complications require prompt evaluation by your child’s surgeon.

Follow-Up Care

The recovery process is different for each child. Your child’s health care team will work with your family, giving you instructions on how to care for your child at home and outlining specific problems that require immediate medical attention.

Craniosynostosis can affect a child’s brain and development. The degree of the problems depends on the severity of the craniosynostosis, the number of sutures that are fused, and the presence of brain or other organ system problems that could affect the child.

The physician may recommend genetic counseling to evaluate the child’s parents for any disorders that may run in families.

A child with craniosynostosis requires frequent medical evaluations to ensure that the skull, facial bones, jaw alignment and brain are developing normally. The medical team will provide education and guidance to help you make the most of your child’s health and well-being.

The Johns Hopkins Cleft and Craniofacial Center

Each year, the Johns Hopkins Cleft and Craniofacial Center treats approximately 650 babies and children with cleft lip and palate or other craniofacial conditions. Our goal is to help our patients achieve their full potential, without being defined or limited by facial differences.

Learn More about the Cleft and Craniofacial Center

Fontanelle Closures | Children's Hospital Colorado

Your baby has two places where their skull bones don’t fully fuse together in the first several months of life. These “soft spots” are fontanelles, a normal part of your baby’s development.

Issues with fontanelles, such as bulging or sinking, can be signs of other health concerns. Additionally, babies in the Neonatal Intensive Care Unit (NICU) or those with ongoing health conditions will have additional considerations related to their fontanelles.

Children’s Hospital Colorado neonatal experts explain how your baby’s fontanelles should feel and develop and when to seek care.

What are fontanelles?

Fontanelles are the soft spaces on your baby’s head where their skull bones have not yet fused together. These spaces allow for the skull bones to shift as needed during birth and for your baby’s brain to grow. They will close as your baby grows. You should keep your eye on two fontanelles:

Anterior fontanelle is located near the front, top of your baby’s head. This is the larger of the fontanelles.
Posterior fontanelle is located near the back of the head.

It’s OK to lightly touch your baby’s fontanelles. A healthy fontanelle should feel soft and flat. A bulging or sunken fontanelle may be a sign of a health issue.

When do fontanelles close?

Typically, fontanelles close by the time your baby is 18 months old. The posterior fontanelle usually closes first — within 2 months of birth. The anterior fontanelle closes between 7 and 18 months. If you feel your baby’s fontanelles are closing too soon or haven’t closed in 18 months, consult your pediatrician.

Fontanelle closure for babies with medical conditions

Premature babies or babies with ongoing medical conditions might have fontanelles close on a different schedule. Conditions like hydrocephalus and brain bleeds commonly affect when fontanelles close, although other conditions can have the same effect.

Your baby’s care team can tell you when to expect your baby’s fontanelles to close based on their condition.

Premature closure of the anterior fontanelle

Sometimes, the anterior fontanelle closes too early. This is known as craniosynostosis and can limit brain growth or create an abnormal head shape. If your baby’s doctor suspects craniosynostosis, they may recommend seeing pediatric craniofacial specialists or pediatric neurosurgeons. Contact your baby’s pediatrician if you feel their fontanelle has closed too early.

Delayed closure of the anterior fontanelle

Just as fontanelles can close too early, fontanelles that close late can also be a sign of medical issues. The most common causes of fontanelles closing outside the normal time range are:

Achondroplasia: A genetic disorder that affects cartilage and bone growth
Hypothyroidism: An issue in the thyroid gland that affects hormone production
Down syndrome
Increased pressure in the brain

What does a bulging fontanelle mean?

Sometimes when a baby cries or lies down, their fontanelle will bulge above the skull bone. This is normal, as long as the fontanelle returns to its regular position when the baby sits up or stops crying.

A bulging fontanelle when not crying or lying down, it may indicate a more serious medical issue, such as:

Hydrocephalus: A buildup of fluid in the brain
Encephalitis: Swelling of the brain usually caused by infection
Meningitis: Swelling of the membranes that cover the brain and spinal cord
Bleeding or pressure in the brain

A fontanelle that bulges when your baby is not crying, vomiting or lying down is a medical emergency. Call 911 or go to the nearest emergency room.

What does a sunken fontanelle mean?

A fontanelle that is sunken into the skull can also signal certain medical issues, including:

Dehydration: When your baby isn’t getting enough fluid; this is the most common cause of sunken fontanelles
Failure to thrive: Babies who are not gaining enough weight for their age
Malnutrition: Not getting enough food or having a very imbalanced diet

If your baby has a sunken fontanelle, contact their doctor immediately and seek care as soon as possible.

Fontanelle considerations for babies with medical conditions

Babies born early or with certain medical conditions may have different sized fontanelles than babies born at full term. A larger fontanelle can be a sign of various medical conditions. Your baby’s NICU care team will diagnose such a condition and arrange the right care. If you feel your baby’s fontanelle is larger than typical, talk to your care team.

Babies born prematurely also have a higher rate of bleeding in the brain, which can lead to hydrocephalus. If your baby had bleeding in their brain, pay close attention to their fontanelles and their head circumference. Talk to your baby’s care team if you have any concerns.

I want tips and advice about BehaviorHealthMental HealthParentingSafetyfor Before Birth (Prenatal)Babies (0-1) Toddlers (2-4)Kids (5-10)Pre-Teens & Teens (11+)

Fontanelle in a newborn

Fontanelles are non-ossified areas between the bones of the skull. By the time of birth, the baby has 6 fontanelles:

front (large) - has a diamond shape, its size is from 0.6 to 3.6 cm (average 2.1)
back (small) - its dimensions are about 0.5 cm
paired lateral: wedge and mastoid

The size of the fontanelles is determined by a large number of factors: gestational age, hereditary predisposition, metabolic state, the presence of diseases, and other components. nine0003

What are fontanelles for?

They allow the movement of the bones of the skull and the reshaping of the head for safe passage through the birth canal.

Mothers who have given birth naturally remember what a strange head shape the baby had after birth, and how it became normal after 3-5 days.

Nature designed it so that the bones of the skull during childbirth would not damage the brain, and the baby would not get stuck in the birth canal at birth. nine0003

What about skull growth?

It may be surprising, but the brain does not grow behind the bones of the skull, but the cranium increases due to the active growth of the brain. This process is especially active in the first two years of a child's life.

At the same time, the growth of the skull does not occur due to an increase in fontanelles, but due to the growth of each individual bone and the elongation of the sutures (the boundaries of the connection of the bones). If the suture between the frontal bones closes at an average of 2 years, then the remaining sutures remain open until the age of 18-20, until the end of brain growth. nine0003

Everything is individual, and the speed of closing the fontanelles depends on the characteristics of the baby. The norm is the closure of a large fontanel at 3 months. This fact must be compared with monthly increases in head circumference.

Normal indicators of fontanel closure:

large - 3 to 24 months (average 13.8)
small - up to 2 months
lateral in full-term babies at birth are mostly closed. nine0006

Important nuances:

Vitamin D supplementation and maternal diet have no effect on fontanel closure rate
the speed of closing the large fontanel is determined by the individual characteristics of the child
if the fontanelles close early, you need to monitor monthly increases in head circumference
early closure of fontanelles with a slowdown in the growth of head circumference requires careful examination by a pediatrician to rule out microcephaly

Fontanelles are an important indicator of the rate of brain growth. Therefore, the time of their closure requires supervision by a pediatrician or pediatric neurologist.

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"Myths" about fontanelles in children

There are great “myths” about fontanelles in newborns, which are often spread by the doctors themselves, in this article I will try to dispel them, but first a little about what this FELLOW actually is! nine0003

What are fontanelles and what do they consist of?

The skull of a newborn baby consists of a large number of individual and rapidly growing bones. The flat bones of the skull grow in the center and along the edges. A suture is formed at the meeting point of the two bones of the skull. Where three or more bones of the skull meet, a gap in the shape of a polygon is formed. Such gaps covered with strong connective tissue are commonly called fontanelles.

The basis of the fontanel is an extremely strong connective tissue, which gradually ossifies along the edges, which leads to a gradual decrease in the size of the fontanel and its complete closure. nine0003

Newborns have 6 fontanelles: anterior (largest), posterior (second largest), two mastoid and two wedge-shaped.
In most term babies, only the first two fontanelles are visible - the other four either close very quickly after birth, or are so small that they are very small.

The main role of the fontanelles is to ensure the elasticity of the child's skull during childbirth and during the first years of life. Thanks to the fontanelles, the bones of the skull of a newborn child remain very mobile, and the size of the child's skull easily adjusts to the size of the mother's small pelvis during childbirth. nine0003

What should be the fontanelles in the norm?

The large anterior fontanel is usually well visible and always arouses great interest. A large number of misconceptions are associated with the “normal size” and “terms for closing” a large fontanel, which often frighten inexperienced parents, and often frighten the doctors themselves or worried relatives, friends (whose children had “not so”).

Here are some of them:

nine0092 - At birth, the size of the large fontanel is the same for all children.
- In fact, the normal size of a large fontanelle varies greatly. The normal range of a large fontanel in newborns is 0.5 cm to 4 cm.

- After birth, the size of the fontanel should only decrease, and an increase in the fontanel is a sign of illness.
- In fact, due to the rapid development of the brain, the size of the large fontanel increases somewhat during the first months of a child's life. nine0003

- There is a certain period when the large fontanel should close
- In fact, the timing of the closure of the large fontanel is as individual as other parameters of a child's development (the beginning of walking, teething, the beginning of coherent speech).
Observations on healthy children showed that in 1% of cases the large fontanel closes at three months, in a year the large fontanel is closed in about 40% of children, and in two years in more than 95% of children. nine0003

But I repeat once again, even if the fontanel closed at 3 months or at 3 years, and there is no clinic and according to the study of the brain (NSG, TUS) everything is normal, then you should not worry !

-The smaller the fontanelle at birth, the faster it closes.
- In fact, there is no directly proportional relationship between the initial size of the fontanel and the proximity of the moment of its closure. nine0003

- Complete closure of the spring means a complete cessation of the growth of the skull and leads to an increase in intracranial pressure
- The bones of the skull grow mainly due to an increase in their central part and expansion of the edges in the suture area.

- The speed of fontanel closure depends on the intake of calcium and vitamin D in the child's body
this process is laid down at the genetic level, therefore, the recommendations of doctors that with a fast-growing fontanel, calcium-containing foods should be removed from the diet, or vice versa, they should be increased with a non-overgrowing fontanel, they have no basis. It is impossible to influence the speed of fontanel closure in healthy children. nine0003

Appearance of a large fontanel in a healthy child

Outwardly, a large fontanel in a healthy child looks like a pulsating or non-pulsating diamond-shaped, slightly sunken or slightly convex area of the scalp.