Managing Children by a Simple Touch of the Hand

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WellonsDr. John Wellons, III, MD, MSPH, Chief of Pediatric Neurosurgery at Monroe Carrel Jr. Children’s Hospital at Vanderbilt writes about the study, “The assessment of bulging fontanel and splitting of sutures in premature infants: an interrater reliability study by the HCRN,” published in the Journal of Neurosurgery Pediatricsand the meaning of the findings.

For many years, pediatric neurosurgeons have made decisions on the treatment of infants with hydrocephalus by the touch of a hand to the head, a gentle maneuver that implies care and reinforces the importance of touch in the physician-patient relationship. Yet in that simple touch of the soft spot of the head,
the “anterior fontanel” in more formal terms, much is conveyed. Is the brain soft and at ease? Or is it under pressure from a subtle yet-to-be-fully-defined disease process, starting to struggle against the confines of the skull and bulge up, not only giving the soft spot a rounded appearance, but also beginning to widen the skull sutures where the thin plates of the skull come together?

This was the question that the investigators of the Hydrocephalus Clinical Research Network asked. Can a simple test, thought to be time-honored and true, be consistent across physicians? More and more studies show that variation drives practice and perhaps even outcomes. Using the strength of the collaborative nature of the HCRN, each center tested this reproducibility among surgeons. Could they each independently come to the same conclusion and therefore take the next step necessary for treatment?

The answer from this study was a resounding yes. The ability to assess the soft spot and underlying presence of subtle pressure among surgeons in the network was high. This answer, this straight forward determination of the simple touch of a hand, underpins the very nature of the research that is done in the HCRN.