Infant with a Large Head: Advice for Referrers

Red Flag Features suggestive of raised intracranial pressure include: drowsy or irritable child, vomiting, bulging fontanelle - refer urgently for assessment at the hospital.

Please refer:

A child whose OFC was on a lower centile and is now enlarging and crossing centiles in an upward direction.

Children with Red Flag Features suggestive of raised intracranial pressure (e.g. drowsy, irritable, vomiting, bulging fontanelle) should be referred urgently for assessment at the hospital

A child with an OFC that is crossing the centiles in an upward direction, but who is not acutely unwell should be referred to medical paediatrics via SCI gateway.

Please do not refer:

A child who has always had a large head, with an OFC tracking appropriately without deviating upwards away from previous measurements.

A well child with normal development, and a large OFC that is tracking appropriately, +/- a family history of macrocephaly, does not need further investigations.

• Is the child well and is development appropriate?
• Are the parents concerned about the child or has this been an incidental finding?
• Are there any signs of raised intracranial pressure – e.g. a child who is more irritable or drowsy than normal, who has poor feeding or vomiting?
• Do other members of the family have large heads?
• Has the child a past history of any serious illnesses, e.g. meningitis?

• OFC measurements (present and past)
• Weight and length (i.e. has the child’s weight and length also increased over the same time period)
• If possible include parents’ OFC measurements (Refer to head circumference chart – plot adult head circumference at age 18 years on the female/male chart as appropriate) 
• Assessment of child’s development and whether this is appropriate
• Approximate size of anterior and posterior fontanelles. The anterior fontanelle usually closes by 12-18 months and the posterior fontanelle by 2 months
• Is the anterior fontanelle tense suggesting raised intracranial pressure?

Nil specific

Nil specific

Seal A. Fifteen-minute consultation on the infant with a large head Arch Dis Child Educ Pract Ed 2013;98:122–125.