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A fontanelle (or fontanel) (colloquially, soft spot) is an
anatomical Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having it ...
feature of the infant
human skull The skull is a bone protective cavity for the brain. The skull is composed of four types of bone i.e., cranial bones, facial bones, ear ossicles and hyoid bone. However two parts are more prominent: the cranium and the mandible. In humans, th ...
comprising soft
membranous A membrane is a selective barrier; it allows some things to pass through but stops others. Such things may be molecules, ions, or other small particles. Membranes can be generally classified into synthetic membranes and biological membranes. ...
gaps ( sutures) between the cranial bones that make up the calvaria of a
fetus A fetus or foetus (; plural fetuses, feti, foetuses, or foeti) is the unborn offspring that develops from an animal embryo. Following embryonic development the fetal stage of development takes place. In human prenatal development, fetal dev ...
or an
infant An infant or baby is the very young offspring of human beings. ''Infant'' (from the Latin word ''infans'', meaning 'unable to speak' or 'speechless') is a formal or specialised synonym for the common term ''baby''. The terms may also be used t ...
. Fontanelles allow for stretching and deformation of the
neurocranium In human anatomy, the neurocranium, also known as the braincase, brainpan, or brain-pan is the upper and back part of the skull, which forms a protective case around the brain. In the human skull, the neurocranium includes the calvaria or skul ...
both during birth and later as the brain expands faster than the surrounding bone can grow. Premature complete
ossification Ossification (also called osteogenesis or bone mineralization) in bone remodeling is the process of laying down new bone material by cells named osteoblasts. It is synonymous with bone tissue formation. There are two processes resulting in ...
of the sutures is called
craniosynostosis Craniosynostosis is a condition in which one or more of the fibrous sutures in a young infant's skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull. Because the skull cannot expand perpe ...
. After infancy, the anterior fontanelle is known as the bregma.


Structure

An infant's skull consists of five main bones: two
frontal bone The frontal bone is a bone in the human skull. The bone consists of two portions.'' Gray's Anatomy'' (1918) These are the vertically oriented squamous part, and the horizontally oriented orbital part, making up the bony part of the forehead, ...
s, two
parietal bone The parietal bones () are two bones in the skull which, when joined at a fibrous joint, form the sides and roof of the cranium. In humans, each bone is roughly quadrilateral in form, and has two surfaces, four borders, and four angles. It is n ...
s, and one
occipital bone The occipital bone () is a cranial dermal bone and the main bone of the occiput (back and lower part of the skull). It is trapezoidal in shape and curved on itself like a shallow dish. The occipital bone overlies the occipital lobes of the cer ...
. These are joined by fibrous sutures, which allow movement that facilitates
childbirth Childbirth, also known as labour and delivery, is the ending of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million births glob ...
and
brain A brain is an organ (biology), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It is located in the head, usually close to the sensory organs for senses such as Visual perception, vision. I ...
growth Growth may refer to: Biology * Auxology, the study of all aspects of human physical growth * Bacterial growth * Cell growth * Growth hormone, a peptide hormone that stimulates growth * Human development (biology) * Plant growth * Secondary grow ...
. * Posterior fontanelle is triangle-shaped. It lies at the junction between the sagittal suture and lambdoid suture. At birth, the skull features a small posterior fontanelle with an open area covered by a tough
membrane A membrane is a selective barrier; it allows some things to pass through but stops others. Such things may be molecules, ions, or other small particles. Membranes can be generally classified into synthetic membranes and biological membranes. ...
, where the two parietal bones adjoin the occipital bone (at the
lambda Lambda (}, ''lám(b)da'') is the 11th letter of the Greek alphabet, representing the voiced alveolar lateral approximant . In the system of Greek numerals, lambda has a value of 30. Lambda is derived from the Phoenician Lamed . Lambda gave ri ...
). The posterior fontanelles ossify within 6–8 weeks after birth. This is called intramembranous ossification. The mesenchymal connective tissue turns into bone tissue. * Anterior fontanelle is a diamond-shaped membrane-filled space located between the two frontal and two parietal bones of the developing fetal skull. It persists until approximately 18 months after birth. It is at the junction of the
coronal suture The coronal suture is a dense, fibrous connective tissue joint that separates the two parietal bones from the frontal bone of the skull. Structure The coronal suture lies between the paired parietal bones and the frontal bone of the skull ...
and sagittal suture. The fetal anterior fontanelle may be palpated until 18 months. In
cleidocranial dysostosis Cleidocranial dysostosis (CCD), also called cleidocranial dysplasia, is a birth defect that mostly affects the bones and teeth. The collarbones are typically either poorly developed or absent, which allows the shoulders to be brought close togeth ...
, however, it is often late in closing at 8–24 months or may never close. Examination of an infant includes palpating the anterior fontanelle. * Two smaller fontanelles are located on each side of the head, more anteriorly the sphenoidal or anterolateral fontanelle (between the sphenoid, parietal, temporal, and frontal bones) and more posteriorly the mastoid or posterolateral fontanelle (between the temporal, occipital, and parietal bones). During birth, fontanelles enable the bony plates of the skull to flex, allowing the child's head to pass through the birth canal. The
ossification Ossification (also called osteogenesis or bone mineralization) in bone remodeling is the process of laying down new bone material by cells named osteoblasts. It is synonymous with bone tissue formation. There are two processes resulting in ...
of the bones of the skull causes the anterior fontanelle to close over by 9 to 18 months. The sphenoidal and posterior fontanelles close during the first few months of life. The closures eventually form the sutures of the neurocranium. Other than the anterior and posterior fontanelles, the
mastoid fontanelle The asterion is a meeting point between three sutures between bones of the skull. It is an important surgical landmark. Structure In human anatomy, the asterion is a visible (craniometric) point on the exposed skull. It is just posterior to t ...
and the
sphenoidal fontanelle The pterion is the region where the frontal, parietal, temporal, and sphenoid bones join. It is located on the side of the skull, just behind the temple. Structure The pterion is located in the temporal fossa, approximately 2.6 cm be ...
are also significant.


Closure

In humans, the sequence of fontanelle closure is as follows: # The posterior fontanelle generally closes 2 to 3 months after birth; # The sphenoidal fontanelle is the next to close around 6 months after birth; # The mastoid fontanelle closes next from 6 to 18 months after birth; and # The anterior fontanelle is generally the last to close between 12 and 18 months.


Clinical significance

The fontanelle may pulsate, and although the precise cause of this is not known, it is normal and seems to echo the heartbeat, perhaps via the arterial pulse within the brain vasculature, or in the
meninges In anatomy, the meninges (, ''singular:'' meninx ( or ), ) are the three membranes that envelop the brain and spinal cord. In mammals, the meninges are the dura mater, the arachnoid mater, and the pia mater. Cerebrospinal fluid is located in ...
. This pulsating action is how the soft spot got its name – fontanelle is borrowed from the old French word fontenele, which is a diminutive of fontaine, meaning "spring". It is assumed that the term spring is used because of the analogy of the dent in a rock or earth where a spring arises. Parents may worry that their infant may be more prone to injury at the fontanelles. In fact, although they may colloquially be called "soft-spots", the membrane covering the fontanelles is extremely tough and difficult to penetrate. Fontanelles allow the infant brain to be imaged using ultrasonography. Once they are closed, most of the brain is inaccessible to ultrasound imaging, because the bony skull presents an acoustic barrier.


Disorders


Bulging

A very tense or bulging anterior fontanelle indicates raised
intracranial pressure Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury ( mmHg) and at rest, is normally 7–15 mmHg for a supine adul ...
. Increased cranial pressure in infants may cause the fontanelles to bulge or the head to begin to enlarge abnormally. It can occur due to: *
Craniosynostosis Craniosynostosis is a condition in which one or more of the fibrous sutures in a young infant's skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull. Because the skull cannot expand perpe ...
– premature fusion of the cranial sutures *
Encephalitis Encephalitis is inflammation of the brain. The severity can be variable with symptoms including reduction or alteration in consciousness, headache, fever, confusion, a stiff neck, and vomiting. Complications may include seizures, hallucinations ...
– swelling (inflammation) of the brain, most often due to infections *
Hydrocephalus Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. This typically causes increased pressure inside the skull. Older people may have headaches, double vision, poor balance, urinary i ...
– a buildup of fluid inside the skull *
Meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion or ...
– infection of the membranes covering the brain * Shaken baby syndrome


Sunken

A sunken (also called "depressed") fontanelle indicates
dehydration In physiology, dehydration is a lack of total body water, with an accompanying disruption of metabolic processes. It occurs when free water loss exceeds free water intake, usually due to exercise, disease, or high environmental temperature. Mil ...
or
malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues ...
.


Enlarged

The fontanelles may be enlarged, may be slow to close, or may never close, most commonly due to causes like: *
Down syndrome Down syndrome or Down's syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is usually associated with physical growth delays, mild to moderate intellectual d ...
*
Hydrocephalus Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. This typically causes increased pressure inside the skull. Older people may have headaches, double vision, poor balance, urinary i ...
* Intrauterine growth restriction (IUGR) *
Premature birth Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between ...
Rarer causes include: *
Achondroplasia Achondroplasia is a genetic disorder with an autosomal dominant pattern of inheritance whose primary feature is dwarfism. In those with the condition, the arms and legs are short, while the torso is typically of normal length. Those affected ha ...
* Apert syndrome *
Cleidocranial dysostosis Cleidocranial dysostosis (CCD), also called cleidocranial dysplasia, is a birth defect that mostly affects the bones and teeth. The collarbones are typically either poorly developed or absent, which allows the shoulders to be brought close togeth ...
* Congenital rubella * Neonatal hypothyroidism *
Osteogenesis imperfecta Osteogenesis imperfecta (; OI), colloquially known as brittle bone disease, is a group of genetic disorders that all result in bones that break easily. The range of symptoms—on the skeleton as well as on the body's other organs—may be ...
*
Rickets Rickets is a condition that results in weak or soft bones in children, and is caused by either dietary deficiency or genetic causes. Symptoms include bowed legs, stunted growth, bone pain, large forehead, and trouble sleeping. Complications ma ...


Third

Sometimes there is a third bigger fontanelle other than posterior and anterior ones in a newborn. In one study, the frequency of third fontanelles in an unselected population of newborn infants was 6.3%. It is very common in
Down syndrome Down syndrome or Down's syndrome, also known as trisomy 21, is a genetic disorder caused by the presence of all or part of a third copy of chromosome 21. It is usually associated with physical growth delays, mild to moderate intellectual d ...
and some congenital infections. If present, the physician should rule out serious conditions associated with the third fontanelle.


Other animals


Primates

In apes the fontanelles fuse soon after birth. In chimpanzees the anterior fontanelle is fully closed by 3 months of age.


Dogs

One of the more serious problems that can affect
canine Canine may refer to: Zoology and anatomy * a dog-like Canid animal in the subfamily Caninae ** ''Canis'', a genus including dogs, wolves, coyotes, and jackals ** Dog, the domestic dog * Canine tooth, in mammalian oral anatomy People with the surn ...
s is known as an "open fontanelle", which occurs when the skull bones at the top of the head fail to close. The problem is often found in conjunction with hydrocephalus, which is a condition in which too much fluid is found within and around the brain, placing pressure on the brain and surrounding tissues. Often the head will appear dome-shaped, and the open fontanelle is noticeable as a "soft spot" on the top of the dog's head. The fluid-filled spaces within the brain, known as ventricles, also become swollen. The increased pressure damages or prevents the development of brain tissue. Not all open fontanelles are connected with hydrocephalus. In many young dogs the skull bones are not fused at birth, but instead will close slowly over a three- to six-month period. Occasionally these bones fail to close, but the dog is still healthy. In these cases, however, the dog's owners need to be very careful, since any injury or bumps to the animal's head could cause significant brain damage, as well as conditions like epilepsy. An open fontanelle, known as a "molera", is a recognized feature of the
Chihuahua Chihuahua may refer to: Places * Chihuahua (state), a Mexican state **Chihuahua (dog), a breed of dog named after the state **Chihuahua cheese, a type of cheese originating in the state **Chihuahua City, the capital city of the state **Chihuahua Mu ...
breed. The
American Kennel Club The American Kennel Club (AKC) is a registry of purebred dog pedigrees in the United States. In addition to maintaining its pedigree registry, this kennel club also promotes and sanctions events for purebred dogs, including the Westminster Ke ...
breed standard states that the skull of the Chihuahua should be domed, with or without the molera being present. However, the
Fédération Cynologique Internationale The Fédération cynologique internationale (FCI) (English: International Canine Federation) is the largest international federation of national kennel clubs. It is based in Thuin, Belgium. History The FCI was founded in 1911 under the auspices ...
(FCI) standard for the Chihuahua lists an open fontanelle as a disqualification.


Additional images

File:Fontanelle.png, Fontanelle. File:Anterior fontanelle.jpg, Anterior fontanelle. File:Sutures from top.png, Cranial sutures shown from top of head. File:Cranium - baby, fontanel.jpg, infant skull.


References

{{Authority control Human anatomy Skull Neonatology