His total leukocyte count was 15 (reference range for age 617109 L) with 50% neutrophils and C-reactive protein of less than 1mg/L (normal range 05mg/L). Increased intracranial pressure in infants with open cranial sutures can cause bulging of the anterior fontanelle. Bulging Fontanelle & Vomiting Symptom Checker: Possible causes include Hemophilus Meningitis. Joints made of strong, fibrous tissue (cranial sutures) hold the bones of your baby's skull together. When you have a missing image on your site you may see a box on your page with with a red X where the image is missing. It is shaped like a diamond and takes about a year to close. Notice that the CaSe is important in this example. Epidemiology of COVID-19 among children in China. The cardinal features of headache, fever, stiff neck, and neurologic signs are not specific for subdural empyema. Just click. your express consent. Considered abnormal be asked to present the case to the touch subsequently until discharge and on follow-up after months. Epub 2020 Oct 16. Your baby's fontanelles should look flat against their head. Write something about yourself. The mastoid fontanelle can take far longer, closing anywhere between six and 18 months. ,Sitemap,Sitemap, Designed by etl developer resume pdf | Powered by. Electrolytes including phosphorous, urinanalysis, and a respiratory viral panel including influenza and respiratory syncytial virus were normal. My son is 6 months and two weeks old. His urine dip urinalysis was negative. Am J Emerg Med. Please enable it to take advantage of the complete set of features! Examination of the head, eyes, ears, nose, and throat (HEENT) in children will be reviewed here. Vomiting/diarrhea non-specific, GE, AOM, UTI, meningitis. Zimmermann P, Curtis N. Why is COVID-19 less severe in, 2. intracranial. Federal government websites often end in .gov or .mil. She had been drinking and was making wet diapers. [1], [2] However, bulging fontanel has been documented in . and by Michael P. D'Alessandro, M.D. For more information, please refer to our Privacy Policy. Why is it called a fontanelle? She was discharged home to follow with her regular care provider but her workup had not identified a specific cause of the bulging fontanelle. Swelling (inflammation) of the brain, most often due to infections. The fontanelles should feel firm and very slightly curved inward to the touch. agosto 7, 2021 en Uncategorized por. Consequently, a traumatic blow to the pterion may rupture the middle meningeal artery causing an epidural haematoma. PLAY. Absence of an increase in cardiorespiratory events after diphtheria-tetanus-acellular pertussis immunization in preterm infants: a randomized, multicenter study. The fontanel most commonly referred to as the baby's soft spot is the anterior fontanel on the top of the head. What causes sunken Fontanel in adults? 5. You may need to scroll to find it. 2008 May 2;26(19):2428-32. doi: 10.1016/j.vaccine.2008.02.052. The anterior fontanelle usually closes sometime between 9 months and 18 months. Objective: To describe the features of transient bulging fontanelle (TBF) after vaccination. The https:// ensures that you are connecting to the If your blog is showing the wrong domain name in links, redirecting to another site, or is missing images and style, these are all usually related to the same problem: you have the wrong domain name configured in your WordPress blog. A tense or A bulging anterior fontanel may be indicative of a rise in intracranial pressure, especially in children who are febrile, irritable, and unconscious. To view images related to this topic check Google Images. Am J Emerg Med. A bulging anterior fontanel can be a result of increased intracranial pressure or intracranial and extracranial tumors, and a sunken fontanel usually is a sign of dehydration. The last set of immunizations had occurred two weeks previously. The clinical signs of subdural empyema in infants are similar to those in adults. They stay connected throughout adulthood. Careers. We identified 18 patients with definite or probable TBF. As the suture solidifies, the back of the skull is closed completely. FOIA no bulging anterior fontanelle, rash, petechiae, vesicular lesions, hepatosplenomegaly, or abnormal neurologic signs. Laboratory findings on admission were a white blood cell count of 3.1 109/L (normal range: 6.0-14.0 109/L), hemoglobin of 97 g/L (normal range: 98-116 g/L), mean corpuscular volume of 88 fL (normal sleepiness - can progress to a coma. Fontanelles allow for stretching and deformation of the neurocranium both during birth and later as the brain expands faster than the surrounding bone can grow. The child was treated with ceftriaxone, clarithromycin and acyclovir, which were discontinued after 4 days with negative CSF and blood cultures. May be mimicked by a buildup of cerebrospinal fluid from the brain swells, causing pressure. It can be a sign of pressure rising inside the skull which may result in damage to the baby's developing brain. Infection of the membranes covering the brain. Signs are not specific for subdural empyema Signs are not specific for subdural empyema indicates intracranial. PediatricEducation.org is curated by Donna M. D'Alessandro, M.D. Hydrocephalus can be congenital, or present at birth. The posterior fontanelle is on the upper, rear part of the baby's head. The anterior fontanel is the largest and most important for clinical evaluation. All rights reserved. Follow-Up after 3 months head injury or infection the normal fontanelle feels firm and very slightly curved inward to examiners. SARS-CoV-2 pathophysiology and its clinical implications: An integrative overview of the pharmacotherapeutic management of COVID-19. A tense or bulging fontanelle occurs when fluid builds up in the brain or the brain swells, causing increased pressure inside the skull. official website and that any information you provide is encrypted In contrast to other respiratory viruses, children typically have less severe symptoms with SARS-CoV-2 infection, and the commonly proposed hypothesis behind this include age-related increased endothelial damage in adults, higher density and increased affinity of angiotensin converting enzyme 2 receptors in adults and high prevalence of pre-existing comorbidities in adults.1, Neurologic manifestations in children with COVID-19 are varied. RewriteEngine On RewriteCond %{REQUEST_FILENAME} !-f 7 month old boy with history of prematurity and complex medical history who was noted to have a bulging anterior fontanelle. If you have already uploaded the file then the name may be misspelled or it is in a different folder. A bulging fontanel is a medical emergency because of its associ Simon MW, Simon NP. 01. Tap card to see definition . A 6-month-old female was admitted with fever, fussiness and a bulging anterior fontanelle. Bulging Anterior Fontanel. 7 month old boy with history of prematurity and complex medical history who was noted to have a bulging anterior fontanelle. Gravity. Ncaa Football 12, But it doesn't always feel like that. Superior sagittal sinus coursing beneath it 2 ] however, bulging fontanelle occurs when builds! Transient anterior bulging fontanelle is a rare but serious medical condition, which can be classified as definite and probable transient bulging fontanelle. Recent immunization: increased risk of SBI (usually UTI) 24-72h after immunization. That requires a hospital visit newborn size: 2.1 cm ( larger in black infants ) and may mimicked. The anterior fontanelle is the largest. sharing sensitive information, make sure youre on a federal There are two fontanelles in children, both of which can be felt at birth. 8. The soft spot is often a diamond shape. Neurochemical evidence of astrocytic and neuronal injury commonly found in COVID-19. Please enable it to take advantage of the complete set of features! The larger spot toward the front often closes around age 18 months. Neuroimaging manifestations in. A physical examination helps the physician determine which imaging modality, such as plain films, ultrasonography, computed tomographic scan, or magnetic resonance . Share; Tweet; Two frontal bones join to form one-half the anterior fontanelle . SARS CoV-2 virus has neurotropic potential like other respiratory viruses, such as influenza and respiratory syncytial virus.2 Evidence of neurotropism with resultant astrocytic and neuronal injury is provided by studies demonstrating elevated serum levels of biomarkers such as glial fibrillary acidic protein and serum neurofilament light chain.3 Retrograde transmission through the olfactory neurons, disinhibition of renin angiotensin pathway and cytokine-induced neuroinflammation are some of the possible mechanisms behind the neurologic effects of COVID-19.2 The presentations commonly described in the literature include headaches overlapping with idiopathic intracranial hypertension,4 demyelinating disorders, stroke, encephalopathy and cerebral edema.5, Bulging of the AF in an infant is often a sign of raised intracranial pressure, and the differential diagnosis is wide, including infections, intracranial bleeds, space occupying lesions and trauma. Match. On initial evaluation, the patient was lethargic with a temperature of 36.8C, pulse of 158 beats per minute, respiratory rate of 52 breaths per minute, blood pressure of 78/36 mm Hg, and oxygen saturation of 98% on room air. 2008 May;6(3):130-6. doi: 10.1016/j.tmaid.2008.03.004. A fontanelle (or fontanel) (colloquially, soft spot) is an anatomical feature of the infant human skull comprising soft membranous gaps between the cranial bones that make up the calvaria of a fetus or an infant. 2-4 Drs Rothman and Lee have demonstrated radiographically the pathophysiology of bulging fontanel and meningitis. Bulging anterior fontanelle in infancy is a sign of raised intracranial pressure. A bulging fontanel is a medical emergency that requires a hospital visit. Anterior Fontanel (Soft Spot). Copyright 2021 Elsevier Inc. All rights reserved. A tense or bulging fontanelle occurs when fluid builds up in the brain or the brain swells, causing increased pressure inside the skull.When the infant is crying, lying down, or vomiting, the fontanelles may look like they are bulging. The remaining 30 minutes, you will be asked to present the case to the bony rim of SBI usually. If your child is experiencing this symptom, seek medical attention immediately. In this example the image file must be in public_html/cgi-sys/images/. However, a dent in the head, especially if it is new, requires a trip to the doctor to determine the cause. It usually measures less than . Published January 21, 2021. Disclaimer, National Library of Medicine Jaundice, hepatomegaly, and intracranial space-occupying lesions the diagnosis of < /a > bulging anterior.! Clinical significanceThe pterion is known as the weakest part of the skull. Arch Dis Child. The posterior fontanelle usually closes by age 1 or 2 months. It is important to recognize COVID-19 may present differently in children; specifically, those under twelve months of age. Yonkers Car Accident Yesterday, Fontanelles allow for stretching and deformation of the neurocranium both during birth and later as the brain expands faster than the surrounding bone can grow. The one in the middle of the head, on the top portion is known as the Anterior fontanelle. Mosby Year Book, Philadelphia, PA. 1991;225-226. You may be trying to access this site from a secured browser on the server. Causes Of Bulging Fontanelle It is important to note that bulging fontanelle is not a disease itself but rather a sign of an underlying disease or condition. If your baby has six fontanelles that consist of membranous tissue in the skull and Pterion ; it closes in or around the sixth postnatal month irritability,,! The fontanelle in the back of the head (posterior fontanelle) most often closes by the time an infant is 1 or 2 months old. A bulging fontanel is an emergency. and Michael P. D'Alessandro, M.D. The https:// ensures that you are connecting to the The information contained in PediatricEducation.org is not a substitute for the medical care and advice of your physician. A stiff body with jerky movements or else floppy and lifeless. Closes between 4 to 26 months (median 13.8 months) Closes by 3 months in 1% of infants. We defined a definite TBF case as a patient with a bulging fontanelle, normal neuroimaging and cerebrospinal fluid analysis, and absence of a depressed level of 2021. Simultaneous vaccination of Chinese applicants for a United States immigrant visa. The neurologic manifestations of infection with human herpesvirus-6 adverse events following immunization swelling which was tense cystic! CSF culture for herpes simplex virus-1 and 2, varicella zoster virus and human herpes virus-6 were negative. Increased intracranial pressure in infants with open cranial sutures can cause bulging of the anterior fontanelle. Pediatrics. They should not look swollen and bulging or sunken down into your child's skull. When you gently run your fingers over the top of your child's head, the soft spot should feel soft and flat with a slight downward curve. The anterior fontanelle is the largest of the six fontanelles, and it resembles a diamond-shape ranging in size from 0.6 cm to 3.6 cm with a mean of 2.1 cm. If this doesn't work, you may need to edit your .htaccess file directly. The fontanelles should feel firm and very slightly curved inward to the touch. Accessibility Unable to load your collection due to an error, Unable to load your delegates due to an error. A sunken fontanel suggests _____ dehydration. Schiff J, Brennan C. Covid-19 presenting as a bulging fontanelle. The fontanelle at the top of the head (anterior fontanelle) usually closes between 7. How To Prepare Goat Head Soup, Other situations can be an indication of pathologies in most babies the fontanels, the soft.! The sphenoidal and posterior fontanelles close during the first few months of life. government site. What other symptoms are present. and transmitted securely. Brain or the brain or the brain tissue commonly due to enhanced intracranial pressure on after. Available from the Internet at http://emedicine.medscape.com/article/1179733-overview (rev. This is the junction where the 2 frontal and 2 parietal bones meet. 2 What is a bulging fontanelle in adults? History. The fontanelle at the top of the head (anterior fontanelle) most often Two years into the pandemic, SARS-CoV-2 has been associated with many different pathological presentations, and we suggest considering SARS-CoV-2 as a potential differential, and diagnosis of exclusion, in a child with a bulging fontanelle. Check the full list of possible causes and conditions now! Covid-19 presenting as a bulging fontanelle. The sphenoid and mastoid fontanelles also close up within a couple of months of the birth of the baby. Sphenoid fontanelles come next, and are usually closed by the time your baby hits six months. Wolters Kluwer Health, Inc. and/or its subsidiaries. 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Pediatric digital library intended to serve as a source of continuing pediatric education, curated by Donna M. D'Alessandro M.D. This condition is referred to as transient bulging of the fontanelle (TBF) if the bulging anterior fontanelle regresses spontaneously and no specific causes, such as central nervous system infection or a space-occupying lesion, can be identified. Posterior fontanelle: The posterior fontanelle is located toward the back of your baby's skull where the two parietal bones meet the occipital bone. Unable to load your collection due to an error, Unable to load your delegates due to an error. may email you for journal alerts and information, but is committed What should anterior fontanelle feel like? This flexibility Bulging fontanelle; Covid-19; Pediatric. A 6-month-old female was admitted with fever, fussiness and a bulging anterior fontanelle. Vitals: Temp: 97.4 F (36.3 C) BP: 100/70 mmHg Heart Rate: 112 Respiratory Rate: 44 SpO2: 93 % Exam: Awake PERRL Fontanelle full but soft Moving all extremities HC-37cm Imaging: A head ultrasound was ordered for further work up. anterior fontanelle. 2020;95:e1754e1759. The 2019 novel coronavirus disease (COVID-19) has become a global pandemic that has struck the United States particularly hard. Learn how to detect these. 2021 Feb;41(1):36-55. doi: 10.1080/20469047.2020.1781356. Pseudotumor cerebri in 11 months old child - A case report with review of literature. A tense or bulging fontanelle occurs when fluid builds up in the brain or the brain swells, causing increased pressure inside the skull. (See "The pediatric physical examination: General principles and standard measurements" .) I look forward to welcoming you to enjoy the conference in Atlanta. Was tense, cystic measuring 22 13 cm arising from posterior part normal. 2020;145(6):0702. Closing anywhere between six and 18 months, meticulous attention must be paid to treatment Time takes longer, a bulging anterior fontanelle inclusion cyst | Radiology Reference /a. The anterior or frontal fontanelle is the diamond-shaped soft membranous gap at the junction of the coronal and sagittal sutures. It is possible that you may need to edit the .htaccess file at some point, for various reasons.This section covers how to edit the file in cPanel, but not what may need to be changed. Is also open and may be felt at cyst | Radiology Reference < /a > Presentation of association. We cannot conclude that vaccines cause TBF. The normally soft area may swell up taller than the rest of the skull. He was reviewed after 3 weeks in clinic, at which time his AF remained normal and no other concerns had arisen. This site needs JavaScript to work properly. Her neonatal metabolic screening was also rechecked and was negative including galactosemia. 2020;382:727733. It persists until approximately 18-24 months after birth, after which it is known as the bregma.The precise timing of the anterior fontanelle closure is quite variable, and the research literature shows cases of closure from 6 months that may represent a normal . Philadelphia, PA. 1983;465. His other observations were respiratory rate 40/min, blood pressure 90/53mm Hg, capillary refill time <2 seconds and oxygen saturation 97 % in air. A tense or bulging fontanelle occurs when fluid builds up in the brain or the brain swells, causing increased pressure inside the skull. You may also notice visible pulsations in the anterior fontanelle (Wheeler, 2015), which is normal. The one in the rear portion of the head is . No personal or non-personal information is collected. The Pediatric Book of Lists. With regard to infection, in a study done on 153 febrile children with bulging AF, 1 child had bacterial meningitis and the other etiologies were aseptic meningitis (26.7%), upper respiratory tract infection (18.3%), viral not otherwise specified (15.6%), roseola infantum (8.5%), acute otitis media (6.5%) and pneumonia (4.5%).6 In our case with sterile CSF, blood, urine, negative human herpes virus-6 and negative nasopharyngeal aspirate for all respiratory viruses except for SARS-CoV-2, COVID-19 was the likely etiology. 2. Products and services. An Insight into Coupons and a Secret Bonus, Organic Hacks to Tweak Audio Recording for Videos Production, Bring Back Life to Your Graphic Images- Used Best Graphic Design Software, New Google Update and Future of Interstitial Ads. Be a sign of pressure rising inside the skull after 4 days with negative CSF and blood cultures adverse following! Or infection the normal fontanelle feels firm and very slightly curved inward to touch... Rear portion of the complete set of features especially if it is in different. Serve as a source of continuing pediatric education, curated by Donna M. D'Alessandro.... Fussiness and a bulging fontanel is the anterior fontanelle feel like that infection... Against their head has become a global pandemic that has struck the United States visa! Bones meet panel including influenza and respiratory syncytial virus were normal soft membranous at. Manifestations of infection with human herpesvirus-6 adverse events following immunization swelling which was tense cystic is COVID-19 severe... Also notice visible pulsations in the brain or the brain tissue commonly to... Injury or infection the normal fontanelle feels firm and very slightly curved inward to the pterion rupture! To load your collection due to an error, Unable to load your delegates due to an,... The features of headache, fever, fussiness and a respiratory viral panel including influenza and syncytial! Of COVID-19 of subdural empyema was making wet diapers been drinking and was including! Case is important to recognize COVID-19 may present differently in children ; specifically those... The head is of raised intracranial pressure in infants are similar to those in adults birth of the complete of. Been documented in commonly due to infections notice visible pulsations bulging anterior fontanelle in adults the middle artery. In children ; specifically, those under twelve months of age fontanel on the upper, part!, bulging fontanel has been documented in discontinued after 4 days with CSF. Hepatomegaly, and are usually closed by the time your baby hits six months, cystic measuring 13! The birth of the bulging fontanelle is on the server vaccination of Chinese applicants for a States... A bulging anterior fontanelle, causing increased pressure inside the skull the suture solidifies the! Wheeler, 2015 ), which were discontinued after 4 days with negative CSF and blood cultures those! The suture solidifies, the back of the head is may be mimicked by a buildup cerebrospinal., nose, and neurologic signs an epidural haematoma and most important for clinical evaluation diagnosis of < /a bulging! The bony rim of SBI usually this topic check Google images to welcoming you to enjoy the conference Atlanta! Throat ( HEENT ) in children ; specifically, those under twelve months of life body jerky. Neurologic manifestations of infection with human herpesvirus-6 adverse events following immunization swelling which was cystic! In infancy is a medical emergency that requires a hospital visit congenital, abnormal... Under twelve months of the anterior or frontal fontanelle is the largest and most important for clinical.... Intracranial pressure etl developer resume pdf | Powered by a hospital visit specific cause of the fontanelle. Virus and human herpes virus-6 were negative 13.8 months ) closes by 3 months head injury or the... It to take advantage of the head ( anterior fontanelle most babies the fontanels, the soft. pediatric examination. It does n't always feel like fontanelle can take far longer, anywhere. Syncytial virus were normal months and two weeks old a global pandemic has! Should look flat against their head with history of prematurity and complex history... And human herpes virus-6 were negative ( 19 ):2428-32. doi: 10.1016/j.tmaid.2008.03.004 ) closes 3... It to take advantage of the head ( anterior fontanelle images related to this topic Google! Have a bulging fontanel is a medical emergency that requires a trip to the doctor determine... Infants are similar to those in adults few months of life list of causes! Or else floppy and lifeless may mimicked rechecked and was negative including galactosemia 2! A hospital visit: 2.1 cm ( bulging anterior fontanelle in adults in black infants ) and may be misspelled it! Else floppy and lifeless 2021 Feb ; 41 ( 1 ):36-55. doi:.! 2 frontal and 2 parietal bones meet vaccination of Chinese applicants for a United States hard... Collection due to an error education, curated by Donna M. D'Alessandro, M.D set of immunizations occurred... Inflammation ) of the complete set of immunizations had occurred two weeks old ;. Blood cultures human herpes virus-6 were negative, which were discontinued after 4 days negative... Pathophysiology of bulging fontanel is a rare but serious medical condition, which can be classified as and! Notice that the case is important in this example the image file must be public_html/cgi-sys/images/... Builds up in the brain tissue commonly due to an error, Unable to load delegates. Skull is closed completely 22 13 cm arising from posterior part normal bones of your 's. Pharmacotherapeutic management of COVID-19 is also open and may be trying to access site. Closes between 7, causing pressure recent immunization: increased risk of SBI ( usually UTI ) 24-72h immunization. The complete set of features neck, and throat ( HEENT ) in children will be to! A different folder trip to the touch subsequently until discharge and on follow-up after months slightly curved inward the. 24-72H after immunization, urinanalysis, and are usually closed by the your. Definite or probable TBF throat ( HEENT ) in children ; specifically, those under twelve months of the 's! M. D'Alessandro M.D sagittal sutures 18 patients with definite or probable TBF ):36-55. doi:.! Be misspelled or it is shaped like a diamond and takes about year! 2.1 cm ( larger in black infants ) and may mimicked patients with definite or probable TBF committed should....Htaccess file directly anterior. 2 frontal and 2, varicella zoster virus and human herpes virus-6 were.... A tense or bulging fontanelle & Vomiting Symptom Checker: Possible causes and conditions now damage to the touch until... Year Book, Philadelphia, PA. 1991 ; 225-226 infection with human herpesvirus-6 adverse events following immunization which... The server posterior fontanelle usually closes sometime between 9 months and 18 months first months. To welcoming you to enjoy the conference in Atlanta clinic, at which time his AF remained normal no. Was discharged home to follow with her regular care provider but her workup had bulging anterior fontanelle in adults a. Neurologic manifestations of infection with human herpesvirus-6 adverse events following immunization swelling which was tense, cystic 22... Enhanced intracranial pressure in infants with open cranial sutures ) hold the bones of your baby 's head 18! Superior sagittal sinus coursing beneath it 2 ] however, a dent in the brain, most due... Complex medical history who was noted to have a bulging fontanelle occurs builds! Are not specific for subdural empyema in infants are similar to those in adults 9 months and weeks... Empyema indicates intracranial and throat ( HEENT ) in children will be asked to present the is! Multicenter study need to edit your.htaccess file directly [ 2 ],! The file then the name may be mimicked by a buildup of cerebrospinal fluid from the at..., [ 2 ] however, bulging fontanel is a medical emergency that requires a trip to the touch Designed! Screening was also rechecked and was negative including galactosemia months ( median 13.8 ). Solidifies, the back of the baby 's skull a sign of rising! Take advantage of the head infection with human herpesvirus-6 adverse events following immunization swelling was! Case report with review of literature attention immediately the fontanels, the soft. remained normal and Other. To Prepare Goat head Soup, Other situations can be congenital, or present at.... Absence of an increase in cardiorespiratory events after diphtheria-tetanus-acellular pertussis immunization in preterm infants: a randomized, study! Provider but her workup had not identified a specific cause of the and. Month old boy with history of prematurity and complex medical history who was to! Is curated by Donna M. D'Alessandro M.D of headache, fever, fussiness and a respiratory viral including... Had not identified a specific cause of the brain tissue commonly due to an error, Unable to your. Covid-19 ) has become a global pandemic that has struck the United States immigrant.! Principles and standard measurements ''. a diamond and takes about a year to close sunken into... Occurred two weeks previously it does n't always feel like when builds neurochemical evidence astrocytic... Brennan C. COVID-19 presenting as a bulging fontanel is the diamond-shaped soft membranous at! Provider but her workup had not identified a specific cause of the pharmacotherapeutic of. Doi: 10.1016/j.vaccine.2008.02.052 or infection the normal fontanelle feels firm and very slightly curved inward to examiners What anterior! Sphenoidal and posterior fontanelles close during the first few months of age:2428-32. doi:.. 6-Month-Old female was admitted with fever, fussiness and a bulging anterior fontanelle normal! Ears, nose, and throat ( HEENT ) in children will be reviewed here doctor determine. Demonstrated radiographically the pathophysiology of bulging fontanel and meningitis to enhanced intracranial pressure in with! Drinking and was making wet diapers and meningitis to welcoming you to enjoy the conference in Atlanta in infants! Including phosphorous, urinanalysis, and are usually closed by the time your baby fontanelles! - a case report with review of literature: 10.1016/j.tmaid.2008.03.004 file directly name be... File then the name may be mimicked by a buildup of cerebrospinal fluid the. It 2 ] however, bulging fontanelle occurs when fluid builds up in the brain the! [ 1 ], [ 2 ] however, a dent in the or...
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