A surgeon should have three diverse properties in his person. That is to saie, a harte as the harte of a lyon. His eyes like the eyes of a hawke, and the handes of a woman. JOHN HALLE (1529–1568)
An imperative task for the GP is not only to diagnose surgical conditions in infancy and children as early as possible, but to be aware of the degree of urgency and the optimal times for intervention. In many instances the emphasis should be placed on a non-surgical solution using natural resolution with time and simple ‘tricks of the trade’.
The neonate’s head may become distorted because of the position in utero or after the passage through the birth canal. The head shape can recover to a normal shape within about 8 weeks following birth. If the abnormal shape persists consider deformational plagiocephaly or craniostenosis.
Plagiocephaly (flat head syndrome)
This is asymmetry of the skull with a normal head circumference. The shape can be likened to a tilted parallelogram (see FIG. 85.1); it is the most common cause of an abnormal head shape. On the side with the flat frontal area, the ear and the parietal eminence sit more posteriorly. It affects 1 in 5 infants and is either congenital or acquired and often results from the infant sleeping in one position, usually on their back. There is usually no impairment of cerebral development or intellect. If the sutures are ridged or the sleeping position causation is ruled out, a skull X-ray should be performed. Management involves initially changing the side to which the child usually faces for sleeping, then regularly changing sides and encouraging time in the prone position while awake. If not responsive, a cranial remodelling helmet can be tried—best from 4 to 8 months.1
Plagiocephaly, congenital or acquired. The long axis is deflected from the saggital plane. In this case the right ear is more posterior.
This is premature fusion of one or more sutures of the cranial vault and base, which act as lines of growth. The abnormality of head shape depends on the sutures involved. The diagnosis is confirmed by radiography. Prompt referral to a paediatric craniofacial surgeon is necessary as planning for possible complex surgery, best at 5 to 10 months, is required.
This condition, which is due to an imbalance between the production and absorption of CSF, usually caused by obstruction to circulation, requires early referral for diversion of ventricular fluid. Prognosis is generally good with early intervention and regular supervision.
Macrocephaly and microcephaly
Macrocephaly and microcephaly are defined ...