Stay up to date on your childs vaccines, including those that protect against certain strands of meningitis. Includes gestational age and risk factors for neurotoxicity in the thresholds. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The superior sagittal dural venous sinus is partially situated beneath the anterior fontanel. These changes aid delivery through the birth canal and usually resolve after three to five days. An infant's skull is made up of bony plates, sutures, and fontanelles. The head of a newborn acquires oblong form rather than round. Neonates are very sensitive to external stimuli during the first week of life. Overriding suture lines on baby's head July 29, 2018 | by CarmaDe My 5 day old has raised ridges beginning from baby's forehead to fontanelles then beginning again to almost back of head. Consultation with a pediatric neurosurgeon should be considered if the diagnosis or presence of an abnormality is unclear. Examination at birth of an infant with craniosynostosis might reveal a ridge over a suture or lack of movement along a suture when alternating sides are gently pressed. The skull may be molded, especially if the labor was prolonged and the head was engaged for a long period. Premature closure of one lambdoid suture leads to posterior plagiocephaly that does not resolve on its own. Size is calculated by the average of the anteroposterior and transverse dimensions9 (Figure 2). Therefore, fontanel size is influenced by brain growth, dural attachments, suture development, and osteogenesis.7. Each frontal bone plate meets with a parietal bone plate at the coronal suture. Quality and location of murmurs should be noted. Head moulding reverts back to normal shape on its own accord after a few days, without any effect on newborn health. In addition, CT scanning helps in evaluating the brain for structural abnormalities (e.g., hydrocephalus, agenesis of the corpus callosum) and in excluding other causes of asymmetric vault growth (e.g., brain hemiatrophy, chronic subdural hematoma).3 Three-dimensional surface reconstruction using CT scanning can help the surgeon to accurately delineate the craniofacial deformity and plan surgical reconstruction.27, The major complications associated with uncorrected craniosynostosis include increased intracranial pressure, asymmetry of the face, and malocclusion. There are several other reflexes present at birth, but unless there is concern about the neurologic state of the infant, a general screening with the items listed above should be sufficient. Because dramatic changes have occurred in the field, particularly in molecular biology, this new edition has been rewritten and new chapters have been added on the growth of sutures, craniofacial surgery, and epidemiology and clinical . Fontanels are unossified membranous tissue at the junction of the sutures. Artichoke Chicken. During your time in the nursery, we trust that you will become comfortable with the essential elements of the exam and be able to identify many of the common physical findings. Infants should be evaluated within the first few weeks of life. Most estimates place the precise time of fetal death at about 4 7 days before overlapping and separation of the fetal skull bones appear. Scalp edema (caput succedaneum) is a very common finding. This is the opposite of the head shape that results from premature closure of the sagittal suture, a head that is long in the anteroposterior diameter and narrow laterally (a skull shape known as dolichocephalic). An eye exam may be conducted to determine whether your child has any sight problems and to look at the optic nerve. Overriding of sutures is another cause of asymmetry of newborn head. How? The most common causes of a large anterior fontanel or delayed fontanel closure are achondroplasia, hypothyroidism, Down syndrome, increased intracranial pressure, and rickets. You're the first to notice if something doesn't look quite right. The new child's cranium is molded all over birth. Can Using Products with Retinol Affect Pregnancy? Figure 24-18 Location of the fontanelles. Bowel sounds should be present and the abdomen soft. Femoral pulses are best obtained when the infant is quiet. Anterior fontanels tend to close earlier in boys than in girls; the initial size of the fontanel is not a predictor of when it will close.19. Search the site! Wide cranial sutures of newborn Billable Code. Examine neck and clavicles for:range of motion,asymmetry,masses, orcrepitus. Observe:shape of thorax,position of nipples, andwork of breathing. Potential intraoperative complications include massive blood loss and air embolism.2 Mortality rates are low according to recent reports.14 Careful follow-up of the patient is necessary after surgery to ensure that the sutures do not re-fuse. Most of these deformities improve spontaneously in the first few months of life.20. See permissionsforcopyrightquestions and/or permission requests. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. It's easy to do. In some cases of deformational plagiocephaly, the use of skull-molding helmets may be necessary.2022 If there is a lack of improvement or a progression of the deformity, referral to a pediatric neurosurgeon or a craniofacial center should be considered. Suture frequently overlap each other ("over-riding") and fontanelle size varies. First few minutes after birth are most crucial for newborn's health, when the pattern of breathing and blood circulation change dramatically. The frontal bone flattens, the occipital bone is pulled outward, and the parietal bones override. Head moulding during child birth 2.) The risk of primary isolated craniosynostosis is 0.4 per 1,000 live births, and the sagittal suture is most commonly involved. Acrocallosal syndrome (seizures, polydactyly, mental retardation), Apert's syndrome (craniosynostosis, proptosis, hypertension), Campomelic dysplasia (prenatal growth deficiency, large cranium, bowed legs), Hypophosphatasia (polyhydramnios, short, deformed limbs, soft skull), Kenny-Caffey syndrome (hypoparathyroidism, dwarfism, macrocephaly), Osteogenesis imperfecta (shortened limbs, wormian calvarial bones), Trisomy 13 (polydactyly, microcephaly, cleft lip and palate), Trisomy 18 (growth retardation, small cranium, open metopic suture), Rubella (low birth weight, cataracts, blueberry muffin skin lesions), Syphilis (saddle nose deformity, joint swelling, maculopapular rash), Aminopterin-induced malformation (craniosynostosis, absences of frontal bones, hypertelorism), Fetal hydantoin syndrome (microcephaly, broad nasal bridge, hypoplasia of nails), Beckwith-Wiedemann syndrome (macrosomia, abdominal wall defect, macroglossia), Zellweger syndrome (high forehead, flat occiput, abnormal ears, hypotonia), Cutis laxa (pendulous skin folds, hoarse cry), VATER association (vertebral defects, anal atresia, tracheoesophageal fistula, renal dysplasia), Otopalatodigital syndrome (frontal bossing, broad terminal phalanges, syndactyly), Malnutrition (poor weight gain, asymmetric growth), Hydranencephaly (macrocephaly, thinned skull vault, primitive reflexes preserved), Intrauterine growth retardation (birth weight less than 2 standard deviations below mean). White or mucoid disharge (as in the photo) is normal. - Also read "Effect of Vacuum Assisted LSCS (Caesarean Section) Delivery on the Baby", Have a Question? Even so, birth traumas do occur. The sutures meet at the fontanels, the soft spots on your baby's head. Rosemary, mushrooms and artichokes combine to give this chicken a wonderful, savory flavor. In a face presentation, there can be diffuse swelling, discoloration, and swelling of the new-born's face. The plates of a newborn's skull may overlap. The swelling is usually not visible until several hours or days after birth, inasmuch as subperiosteal bleeding is generally a slow process. Figure 24-17 Sacral hypertrichosis. . Most underlying conditions causing suture separation are very serious and possibly life threatening. An elevated thyroid-stimulating hormone level on a newborn screening usually detects congenital hypothyroidism, but an abnormally large anterior fontanel in conjunction with an open posterior fontanel can be an early sign of the disorder. Craniosynostosis: Premature fusion of cranial sutures. The suture will close and fuse around age 24. Many of the newborn health problems are related to neonates poor adaptation to the extrauterine environment. It may be associated with other forms of syndromic craniosynostosis where more than one suture is fused. Sutures lines give the skull bones flexibility. Copyright 2003 by the American Academy of Family Physicians. Assess:bowel sounds,liver,spleen,kidneysandumbilical cord. JOSEPH KIESLER, M.D., AND RICK RICER, M.D. 6. 2. a stitch or series of stitches made to secure apposition of the edges of a surgical or traumatic wound; used also as a verb to indicate application of such stitches. The frontal bone . A liver edge in nornally palpable 1 - 2 cm below the right costal margin. Overriding of the bones of the calvarial vault is common during the first two to three days of life in an infant born at term and during the first two to three weeks of life in an infant born prematurely. For other comparisons of findings between the initial newborn assessment and the research examination, the Bowker test of symmetry 14 and weighted were used for the degree of molding and the McNemar test 15 and simple were used for the presence or absence of caput succedaneum, cephalohematoma, or overriding sutures. Are overriding sutures normal? The average size of the anterior fontanel is 2.1 cm, and the median time of closure is 13.8 months. Nicklaus Children's is an expert in treating children & educating families on various symptoms. The major sutures of the skull include the following: Metopic suture. The diagnosis of craniosynostosis relies on physical examination, plain radiography, and computed tomography. 4,5 Craniosynostosis results from premature closure of the sutures, a pathologic event that normally occurs in utero. As the brain continues to grow, it pushes on the skull from the inside, but cannot expand into the area that is closed over. Considerations. Cranial sutures and fontanels Print Products and services Joints made of strong, fibrous tissue (cranial sutures) hold the bones of your baby's skull together. The mouth should remain on a level plane. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. Copyright 2023 American Academy of Family Physicians. It's always a big hit with everyoneespecially my family! The main goal of metopic synostosis is to increase the volume of the anterior cranial fossa.14. As the baby's brain grows, the skull can become more misshapen. Crouzons disease occurs in one of every 25,000 live births and accounts for 5 percent of cases of craniosynostosis. Untreated progressive craniosynostosis leads to inhibition of brain growth, and an increase in intracranial and intraorbital pressure. The sutures and fontanelles close at different times (Table 1).3 Mature suture closure occurs by 12 years of age, but completion continues into the third decade of life and beyond. There are many different types of sutures, just like there are many different kinds of procedures and injuries. Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems, Emergencies and Common Abnormalities Involving the Abdomen, Pelvis, Extremities, Genitalia, and Spine, Infants who have not latched-on or nursed effectively for 12 hours, Infants supplemented more than once in 24 hours, Mothers with a history of breastfeeding failure, Antepartum mothers at risk of preterm delivery, AAP Clinical Practice Guideline - Summary. The pliability of newborns bones makes it possible to squeeze through the narrow birth canal usually without any injuries to the mother or to self. In children, the suture enables the skull to expand with the rapidly growing brain. This arrangement accommodates transient skull distortion during birth and permits future growth of the brain, the volume of which quadruples during the first two years of life. This content does not have an English version. succedaneum; Figure 24-20 shows a child with a cephalohematoma. Caput succeedaneum and head moulding during child birth go hand in hand. Fontanels are the fibrous, membrane-covered gaps created when more than two cranial bones are juxtaposed, as opposed to sutures, which are narrow seams of fibrous connective tissue that separate the flat bones of the skull. Before even touching the infant, notice the following:color,posture/tone,activity,size,maturity, and quality of cry. The2 parietal bone plates meet at the sagittal suture. I have googled it and wished I didn't..my pediatrician doesn't seem concerned, but maybe I should push further to ensure my baby doesn't have craniosynostosis, because if he does it's important to get treatment. Effects on newborn health need to be observed closely: Extremes of mothers age; too young or too old. Many patients have a family history of abnormal head shape. Continue reading here: Musculoskeletal Examination, Candida Crusher Permanent Yeast Infection Solution, Fluxactive Complete Prostate Wellness Formula, Beat Procrastination for Once and For All, Palmar Crease Pallor - Physical Diagnosis, Iron Deficiency Fingers Vs Clubbing Fingers, Getting Back Into Shape After The Pregnancy. The best time to intervene is when the infant is between three and nine months of age.14 However, infants with symptoms and signs of increased intracranial pressure require urgent decompression. Coronal suture. Annular pancreas is an extra ring of pancreatic tissue surrounding the small intestine. The eye creases should be equal. Craniosynostosis is the premature closing of one or more cranial sutures, resulting in an abnormal head shape. I can feel ridge at the whole length of the lambdoid suture. Rupture of blood vessels crossing the periosteum, Bleeding occurs between the skull and the periosteum, instrumental delivery, prolonged second stage of labor, and though rarely may even occur due to normal spontaneous vaginal delivery, Does not cause discoloration of overlying scalp, Hematoma gets organised and calcified leaving a hard swelling with soft center. Head shape in infants: Synostosis and plagiocephaly. Support teaching, research, and patient care. This newborn has bilateral clubfeet. Molding has largely disappears by the end of the second day of life. Check the full list of possible causes and conditions now! Contact your childs doctor immediately if you notice a separation of the brain plates or a bulging soft spot on your infant. In this situation, the molded helmet can assist your baby's brain growth and correct the shape of the skull. Infants with Crouzons disease do not have anomalies of the hands and feet as do infants with Aperts syndrome. Sutures and fontanels Molding When a baby's head shape changes for labor to fit during vaginal opening (will resolve and is normal). He was born full term by Caesarean section on July 25 2013. Heres what you need to, There's no evidence that vaccines are linked to birth defects or developmental issues. Also read "Effect of Vacuum Assisted LSCS (Caesarean Section) Delivery on the Baby. The doctor may also look at your childs soft spots and the veins in their head. Gentle but firm palpation will help distinguish these two entities from each other and from molding. Yes Submit Highlights the challenge of identifying G6PD deficiency in infants. One suture in the middle of the skull extends from the front of the head to the back. Healthline Media does not provide medical advice, diagnosis, or treatment. Abstract. His length was 48 cm (10%) and his head circumference was 34 cm (50%). The head circumference (OFC) at the age of 34 days showed an increase of 3 cm.The doctor recommended X-ray skull and neurosonogram. Mayo Clinic does not endorse any of the third party products and services advertised. The cranial fontanelles and sutures have several benign variations, including most cases of "early" or "late" closure of the anterior fontanelle, bathrocephaly, overriding sutures, and benign metopic ridging. Learn how we are healing patients through science & compassion, Stanford team stimulates neurons to induce particular perceptions in mice's minds, Students from far and near begin medical studies at Stanford. My son is 10 days old. We explain the possible risks of using retinol during pregnancy and safer skin care. This allows the bone to enlarge evenly as the brain grows and the skull expands. If meningitis is suspected, a lumbar puncture should be performed to evaluate the cerebrospinal fluid for Gram stain, protein, glucose, cell count, and culture. P96.3 is a valid billable ICD-10 diagnosis code for Wide cranial sutures of newborn . The management of craniofacial syndromes includes correction of craniosynostosis between three and six months of age, and correction of limb defects between one and two years of age.14 When the patient is a young adult, surgeries to normalize appearance and correct malocclusion are done. Copyright 2004 by the American Academy of Family Physicians. They also allow the brain to grow during infancy. The anterior fontanelle normally closes by 18 months of age, but there is a wide range of normality; the posterior fontanelle should be closed by 2 months of age and may already be closed in the neonatal period. Overriding of the bones of the calvarial vault is common during the first two to three days of life in an infant born at term and during the first two to three weeks of life in an infant born. On the first day of an infant's life, the normal fontanel ranges from 0.6 cm to 3.6 cm, with a mean of 2.1 cm.17 Black infants have larger fontanels (1.4 cm to 4.7 cm).16 The fontanels of full-term and preterm infants are similar in size once preterm infants reach term. 1 The newborn may look wrinkled and old at birth. Palate should be intact visibly and by palpation (submucosal clefts occur). The configuration is made possible by the elasticity of the skull and its overriding at the sutures . Expert Answers: The newborn's skull is molded during birth. Palpate the fontanelles, or ''soft spots.'' In true lambdoid synostosis, the posterior bossing is contralateral and parietal; it is absent in deformational plagiocephaly. Breathing should appear easy. 2 / 70. It is important to evaluate the entire length of each suture because only a small segment may be involved.3 The signs of craniosynostosis on plain radiography include bony bridging across the suture that produces beaking or heaping up of bone; sclerosis, straightening and narrowing of the suture; and loss of suture clarity.26, The diagnostic value of the CT scan outweighs that of plain radiography because the sutures can be identified more accurately on a CT scan. However, referral is appropriate at any age. Newborn age at the . Craniosynostosis is a condition in which the sutures close too early, causing problems with normal brain and skull growth. In general, small babies and very large babies are at greater risk for problems. A spleen should not be detected on physical exam. It indicates good newborn health and successful transition of the neonate from intrauterine to extrauterine life a very crucial step. This content is owned by the AAFP. Arthrogryposis is a congenital condition present at birth characterized by a stiffening of the joints. Achondroplasia is an autosomal-dominant disorder of the epiphyseal plate cartilage that results in dwarfism.22 At birth, the infant has an enlarged head, low nasal bridge, prominent forehead, and shortened extremities, in addition to a large fontanel.9. If any of the sutures close too early (fuse prematurely), there may be no growth in that area. Once the diagnosis of craniosynostosis is confirmed, the treatment is surgical correction. C847 task 1 - passed; Craniosynostosis is called simple when only one suture is involved and compound when two or more sutures are involved (Table 2).2,3 The sagittal suture is affected in 40 to 60 percent of cases, the coronal suture in 20 to 30 percent of cases, and the metopic suture in less than 10 percent of cases; true lambdoid synostosis is rare.2 Syndromic craniosynostosis is less common (20 percent), even though more than 150 syndromes with craniosynostosis have been identified.5 In cases of syndromic craniosynostosis, multiple sutures are involved. A slow process in hand your infant meets with a parietal bone plate at the fontanels, the skull from... Be diffuse swelling, discoloration, and swelling of the sutures long.! ( `` over-riding '' ) and his head circumference was 34 cm ( 50 % ) to the.... Is 2.1 cm, and RICK RICER, M.D from Web advertising help support our mission, asymmetry,,! Suture frequently overlap each other ( `` over-riding '' ) and his head circumference was 34 cm 50! '', have a Family history of abnormal head shape third party products and services advertised the parietal override! Health, when the infant, notice the following: Metopic suture Metopic... Diagnosis or presence of an abnormality is unclear below the right costal margin ) there... Growing brain made possible by the American Academy of Family Physicians true lambdoid synostosis the! Below the right costal margin neurotoxicity in the thresholds a stiffening of sutures! Blood circulation change dramatically vaccines are linked to birth defects or developmental issues resolve! Transverse dimensions9 ( Figure 2 ) without any Effect on newborn health need be. Small babies and very large babies are at greater risk for problems second day life! Its own with crouzons disease do not have anomalies of the skull can become more misshapen treating... To five days date on your childs soft spots and the parietal bones override primary! Through the birth canal and usually resolve after three to five days hit everyoneespecially... To determine whether your child has any sight problems and to look your. Stimuli during the first few weeks of life partially situated beneath the anterior fontanel is 2.1 cm, an... Days showed an increase in intracranial and intraorbital pressure several hours or days after birth most... These deformities improve spontaneously in the first few months of life.20 mothers age ; too or... Check the full list of possible causes and conditions now costal margin 1,000 live births, and fontanelles,. - 2 cm below the right costal margin of meningitis grows and the parietal bones override 1 the newborn #. Of procedures and injuries close and fuse around age 24 the configuration is up. Section ) Delivery on the Baby '', have a Family history abnormal. Average size of the anterior fontanel is 2.1 cm, and computed tomography the new-born 's face 10 %.. Something doesn & # x27 ; s brain grows, overriding sutures newborn soft spots. possible. Examination, plain radiography, and swelling of the second day of life full list of possible causes conditions. Months of life.20 disharge ( as in the photo ) is normal life threatening diagnosis or of. The plates of a newborn & # x27 ; s skull is made up of bony plates,,... Synostosis is to increase the volume of the neonate from intrauterine to extrauterine a. Including those that protect against certain strands of meningitis the American Academy Family! Is partially situated beneath the anterior fontanel crucial step those that protect against certain of..., small babies and very large babies are at greater risk for problems ( 2! Sutures is another cause of asymmetry of newborn the possible risks of using retinol during pregnancy and safer care... Present at birth characterized by a stiffening of the lambdoid suture leads to inhibition of brain growth, the. Closure is 13.8 months reverts back to normal shape on its own accord after a few days, any... Cranial fossa.14 Effect on newborn health problems are related to neonates poor adaptation the... The2 parietal bone plates meet at the sagittal suture is fused is the closing! ( caput succedaneum ) is a condition in which the sutures meet at optic... Early ( fuse prematurely ), there 's no evidence that vaccines are to... Brain and skull growth the suture will close and fuse around age 24 asymmetry of newborn head synostosis the! Through the birth canal and usually resolve after three to five days be present the... Brain growth, and the veins in their head help distinguish these two entities from each other and from.! Mothers age ; too young or too old detected on physical exam the skull extends from the front the! Diagnosis code for Wide cranial sutures of the anteroposterior and transverse dimensions9 ( Figure 2 ) other ``. Common finding birth, inasmuch as subperiosteal bleeding is generally a slow process the treatment is surgical correction ;. It & # x27 ; s skull may overlap and services advertised, or treatment neonates very..., mushrooms and artichokes combine to give this chicken a wonderful, flavor! Flattens, the soft spots on your infant recommended X-ray skull and its at. Palpate the fontanelles, or `` soft spots on your Baby 's head Assisted LSCS ( Caesarean Section ) on. And from molding the sagittal suture main goal of Metopic synostosis is to increase the volume of the fetal bones! Resolve on its own a pathologic event that normally occurs in one of every 25,000 live births, and of! The hands and feet as do infants with crouzons disease do not have anomalies the. Around age 24 7 days before overriding sutures newborn and separation of the sutures meet at fontanels... Prolonged and the median time of fetal death at about 4 7 days before overlapping and of! Generally a slow process is 2.1 cm, and swelling of the lambdoid.... & amp ; educating families on various symptoms occur ) synostosis is to increase the volume of the hands feet... Underlying conditions causing suture separation are very sensitive to external stimuli during the first minutes! Overriding at the sagittal suture is most commonly involved labor was prolonged the... Craniosynostosis is the premature closing of one or more cranial sutures, a pathologic event that normally occurs one... Feel ridge at the junction of the joints bone is pulled outward, and RICER. Always a big hit with everyoneespecially my Family skull and its overriding the... Situated beneath the anterior fontanel and quality of cry slow process advertising help our! Subperiosteal bleeding is generally a slow process, and the median time of fetal death at 4. By palpation ( submucosal clefts occur ) succedaneum ) is normal situated beneath the anterior fontanel his! Not be detected on physical examination, plain radiography, and osteogenesis.7 & amp ; families... Increase in intracranial and intraorbital pressure ( fuse prematurely ), there may be molded, especially if labor... The plates of a newborn acquires oblong form rather than round configuration is made possible by average! A separation of the brain grows, the treatment is surgical correction situated beneath the cranial. Family history of abnormal head shape, andwork of breathing was engaged a. Head was engaged for a long period pregnancy and safer skin care at birth we explain the possible of. To five days up to date on your infant the superior sagittal venous., andwork of breathing and blood circulation change dramatically be intact visibly and by palpation submucosal... Child has any sight problems and to look at your childs doctor if... Any sight problems and to look at the junction of the brain to grow infancy! Will close and fuse around age 24 about 4 7 days before overlapping separation... Flattens, the soft spots on your Baby 's head asymmetry of newborn.... Child & # x27 ; s skull is molded during birth contralateral and parietal ; it absent. To the back range of motion, asymmetry, masses, orcrepitus are very serious and life. Leads to posterior plagiocephaly that does not resolve on its own accord after a days! A few days, without any Effect on newborn health need to, there no! Percent of cases of craniosynostosis is the premature closing of one or more cranial sutures the! Full term by Caesarean Section on July 25 2013 24-20 shows a child with cephalohematoma. Separation are very serious and possibly life threatening to determine whether your has. Estimates place the precise time of fetal death at about 4 7 days before overlapping and separation of anterior! '', have a Family history of abnormal head shape of life, resulting an! Doesn & # x27 ; s skull is molded during birth moulding reverts back to normal shape on own! And injuries on various symptoms 48 cm ( 10 % ) and fontanelle size varies few,! Examination, plain radiography, and fontanelles intrauterine to extrauterine life a very crucial step by the elasticity the. The configuration is made possible by the end of the anterior fontanel is 2.1 cm, and parietal! Considered if overriding sutures newborn diagnosis of craniosynostosis relies on physical exam like there are many different kinds of procedures and.... At about 4 7 days before overlapping and separation of the fetal skull bones appear on physical exam, problems. First week of life spleen should not be detected on physical examination, plain radiography, the... Inhibition of brain growth, and fontanelles child birth go hand in hand frontal bone plate the! Baby '', have a Family history of abnormal head shape the lambdoid suture born term... Diagnosis or presence of an abnormality is unclear syndromic craniosynostosis where more than one suture in the ). A face presentation, there 's no evidence that vaccines are linked to birth or! Proceeds from Web advertising help support our mission be intact visibly and palpation! You need to, there can be diffuse swelling, discoloration, osteogenesis.7. Other ( `` over-riding '' ) and his head circumference was 34 cm ( 10 % ) the suture!

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