🧠 Hydrocephalus & Spina Bifida
Two neural problems of infancy. One is about pressure and a shunt; the other is about protecting a sac and avoiding latex.
🧬 Hydrocephalus
CSF accumulates because it cannot drain or be absorbed. In an infant the skull can expand, so the head grows instead of the pressure spiking immediately.
| Infant signs | Older child signs | |
|---|---|---|
| Head | Rapidly increasing head circumference, bulging fontanelle, separated sutures | Normal size — skull is fused |
| Eyes | “Sunset eyes” — sclera visible above the iris | Papilledema, double vision |
| Behavior | High-pitched cry, irritable, poor feeding, vomiting | Headache worse on waking, vomiting, confusion |
| Scalp | Shiny with distended veins | — |
Measure head circumference at every well-child visit up to 2 years. A crossing of percentile lines is the earliest objective sign.
🚨 VP shunt — what to watch
A ventriculoperitoneal shunt drains CSF from the ventricles into the abdomen.
Signs of malfunction or infection are the signs of raised ICP returning:
- Irritability, lethargy, poor feeding, vomiting
- Bulging fontanelle; increasing head circumference
- Fever — suspect shunt infection
- Redness or swelling along the shunt tract
After shunt insertion, position the infant FLAT or as prescribed on the UNOPERATED side. Raising the head too fast drains CSF too quickly and can collapse the ventricles.
Teach parents that the shunt must be revised as the child grows, and that any of those signs means coming straight in. Shunt malfunction is common and treatable if caught.
🦴 Spina bifida
| Type | What it is |
|---|---|
| Occulta | Hidden defect; sometimes a dimple, tuft of hair or birthmark over the spine. Often no symptoms |
| Meningocele | Sac containing meninges and CSF; usually no nerve tissue, so function is often preserved |
| Myelomeningocele | Sac contains spinal cord and nerves. Motor and sensory loss below the level; bladder and bowel involvement |
🚨 Before surgical repair
- Position PRONE - never on the back. Pressure on the sac can rupture it.
- Keep the sac covered with a STERILE, MOIST, non-adherent dressing. It must not dry out.
- Latex-free environment — these children have a very high rate of latex allergy from repeated exposure. Flag it from birth
- Measure head circumference — hydrocephalus develops in most cases
- Meticulous perineal care; keep urine and stool away from the sac
- Assess movement and sensation in the legs; note the level
✅ Long-term
- Clean intermittent catheterisation for neurogenic bladder — taught to family, later to the child
- Bowel program
- Skin care — they cannot feel pressure injuries developing
- Mobility aids; orthopedic follow-up
- Intelligence is often normal — never assume otherwise
💉 Prevention
Folic acid 400 mcg daily for all women of childbearing age, and 4 mg if there has been a previous affected pregnancy.
The neural tube closes by about week 4 - often before pregnancy is known. That is why it must be taken BEFORE conception.
🎯 NCLEX traps
- Prone position, sterile moist dressing, latex-free
- Sunset eyes and a high-pitched cry = hydrocephalus in an infant
- Shunt malfunction looks like rising ICP returning
- Folic acid before conception
- Head circumference at every visit