What is the management approach for a newborn with a small anterior fontanelle (cranial fontanelle) due to overriding sutures, but is otherwise normal?

Management of Small Anterior Fontanelle with Overriding Sutures in an Otherwise Normal Newborn

Small anterior fontanelle with overriding sutures in an otherwise normal newborn requires observation and reassurance, as this is typically a benign finding that resolves spontaneously without intervention. 1

Assessment of the Anterior Fontanelle

Initial Evaluation

• Measure fontanelle size and assess tension
• Note presence of pulsations
• Measure head circumference and plot on growth chart
• Evaluate for overriding sutures

Key Differentiating Factors

• Benign finding: Small anterior fontanelle with overriding sutures in an otherwise normal newborn
• Concerning finding: Bulging fontanelle (suggests increased intracranial pressure) or sunken fontanelle (suggests dehydration)

Management Approach

For Small Anterior Fontanelle with Overriding Sutures

1. Reassurance to parents: This is a common finding in newborns, especially following vaginal delivery when molding of the head occurs 1, 2
2. Regular monitoring: Follow head circumference at routine well-child visits
3. Observe for normal development: Ensure normal neurological development and head growth

When to Consider Further Evaluation

• Abnormal head shape persisting beyond 6 weeks of age
• Failure of normal head growth
• Development of neurological symptoms
• Signs of increased intracranial pressure

Clinical Pearls and Pitfalls

Important Distinctions

• Overriding sutures vs. craniosynostosis: Overriding sutures are mobile and represent normal molding, while craniosynostosis involves premature fusion of sutures 2
• Timing matters: Most cases of overriding sutures resolve within the first few weeks of life

Reassuring Findings from Research

• Studies have shown that newborns with wide sutures and varying fontanelle sizes but normal head circumferences typically demonstrate normal head growth and development 3
• The anterior fontanelle has significant normal variation in size (average 2.1 cm) and closure timing (median 13.8 months) 4, 5

Warning Signs Requiring Urgent Evaluation

• Bulging fontanelle
• Rapidly increasing head circumference
• Neurological symptoms
• Failure to thrive

Follow-up Recommendations

• Monitor head circumference at routine well-child visits
• Reassess fontanelle size and suture status at each visit
• If normal head growth and development continue, no additional imaging or specialist referral is needed

When to Refer to Specialist

• If overriding sutures persist beyond 6 weeks
• If there is concern for true craniosynostosis
• If head growth deviates from normal curve
• If neurological concerns develop

Remember that recognizing the difference between benign variations and true craniosynostosis is critical, as early referral (before 6 months of age) to a craniofacial specialist allows for minimally invasive treatment options if needed 2.