In a 10‑month‑old infant with a slightly indented coronal suture, normal fontanelles, and appropriate head growth, what is the appropriate next step in management?

Clinical Examination Alone is Sufficient – No Imaging Needed

In this 10-month-old infant with a slightly indented coronal suture, normal fontanelles, and appropriate head growth, continue clinical observation without imaging. The clinical examination findings are reassuring and do not warrant further workup at this time 1.

Rationale for Observation

The key clinical features that make this a low-risk presentation include:

• Normal fontanelles – indicating no increased intracranial pressure
• Appropriate head growth – the most important indicator that brain growth is not restricted
• Only slight indentation – not a rigid, palpable bony ridge

These findings strongly suggest either normal anatomical variation or positional changes rather than true craniosynostosis 1.

When Clinical Examination is Sufficient

The Congress of Neurological Surgeons guidelines explicitly state that clinical examination is most often sufficient to diagnose plagiocephaly and rule out craniosynostosis 1. Most infants with abnormal head shape can be adequately diagnosed through detailed clinical examination alone, without any imaging 1.

Red Flags That Would Change Management

Imaging should be reserved only for cases where the clinical examination is equivocal 1. Concerning features that would warrant imaging include:

• A palpable, rigid bony ridge along the suture (not just slight indentation)
• Abnormal head growth trajectory (crossing percentiles downward or accelerating inappropriately)
• Bulging or tense fontanelles suggesting increased intracranial pressure
• Compensatory skull deformities (frontal bossing, temporal hollowing)
• Inability to clearly distinguish between positional changes versus true synostosis on examination

If Imaging Were Needed (Not in This Case)

Should the clinical picture become equivocal, the appropriate imaging sequence would be 1:

1. First-line: Skull x-rays or ultrasound of the suture in question
2. Reserve CT only when absolutely necessary to definitively rule out craniosynostosis – always weighing radiation risk against diagnostic benefit
3. MRI has no role in this evaluation

Common Pitfall to Avoid

Do not order imaging based solely on parental anxiety or a subtle suture indentation. Many normal infants have palpable sutures or slight ridging, particularly benign metopic ridging 2. Overimaging exposes infants to unnecessary radiation without clinical benefit when examination findings are reassuring 1.

Ongoing Monitoring Plan

• Continue routine well-child visits with serial head circumference measurements
• Reassess head shape and suture palpation at each visit
• Educate parents about normal head growth patterns
• Refer to pediatric neurosurgery only if examination becomes concerning or head growth deviates from normal trajectory