The all-important soft spot, and how doctors helped a baby get his

By John Kelly
Washington Post Staff Writer
Tuesday, December 28, 2010; 9:51 PM

When I was a brand-new parent, the human baby seemed to me the most poorly designed creature imaginable. Here is something that takes nine months to make - far longer than an automobile - and yet when it emerges from the end of the production line it's hardly suitable for anything. A baby is literally an accident waiting to happen: helpless, vulnerable, dependent on others for its every need.

Nothing illustrated a baby's fragility and poor design more than a little feature called the fontanel. It sounds like a French cheese, but in fact it's a soft spot. On the baby's skull. Above the baby's brain. Great idea!

For the first several months of our first child's life, I spent hours worrying about that soft spot, fearful that if I didn't drop something on the fontanel, I would drop the fontanel on something. Why, I wondered, couldn't we have gotten a baby without a soft spot?

Well, Matt and Amy Seabrook did, and believe me when I tell you that the soft spot serves a purpose, playing a role in how a baby is born and how a baby grows. Amy was in labor with Eric for 22 hours, and in the end she wound up having a Caesarean section. "I thought it was my fault," Amy , 24, told me. She'd been told as much by doctors, who said a problem with her hips had kept Eric bottled up. "Little did we know it was because of the craniosynostosis," she said.

Craniosynostosis. It means a cranium that is fused together. A newborn's skull is like the supercontinent Pangea: several plates that are unattached and can, relatively speaking, float. This helps the baby come out. There's some give in the plates. It isn't quite the same as the difference between trying to push an open umbrella through a mail slot and trying to do the same with a closed one, but you get the idea.

The soft spot also helps as the baby grows. "It allows the brain [and] the cranium to grow and get bigger," said Suresh Magge, a neurosurgeon at Children's Hospital. "That all depends on these bones being open. As you get older, the bones fuse together. If they fuse too soon, the skull's going to then be deformed."

That was the problem with Eric. He was born at Andrews Air Force Base, where dad Matt is stationed. At his 2-month, checkup doctors noticed Eric's head was enlarged. Even with a fused plate, the brain will continue to grow, pushing the skull in different directions. If left untreated, it can result in abnormally shaped heads: elongated, triangular, heavy-browed. In severe cases, the intercranial pressure can lead to cognitive difficulties.

Dr. Magge has several techniques at his disposal. All involve removing bits of the skull. Eric's problem was caught early enough that Dr. Magge could use a minimally invasive endoscopic method. Guided by a camera, he drilled two holes in the skull and removed the bone between them - the fused sagittal plate - in effect creating a soft spot.

For nine months Eric wore a specially fitted helmet 23 hours a day. It acted like a Jell-O mold, making sure his head grew to the right shape. He became accustomed to the helmet, maybe a little too accustomed. "He liked to head-butt people," Matt said. "Then he realized once the helmet came off that things are hard."

Eric is 17 months now and doing just fine.

As for the issue of fontanels, Dr. Magge said they're important windows into a baby's health.

"Some kids when they come in with a brain tumor, it can cause increased pressure," he said. "They come in with a fontanel bulging out. It's a nice little clue that there's a problem. As a pediatric neurosurgeon, I'm always feeling fontanel."

Better you than me, Doc.

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