Common Newborn Findings Monica Riojas, MD November 18, 2010

Common Skin Rashes

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Match the Description to the Rash Picture 1 Picture 2 Picture 3 Appears at 2 weeks of age, resolves within 3 months, localized to scalp and face. Appears within 2-3 days of life, fades within 5-7 days, lesions contain eosinophils. Present at birth, lesions in different stages, widespread, lesions contain neutrophils. L 4

1 3 2 Transient Neonatal Pustular Melanosis Erythema Toxicum Neonatorum 2 Neonatal Acne 5

Milia, Miliaria, and Sebaceous Gland Hyperplasia…?

Milia Small keratin filled cysts. Common on face and scalp, but seen everywhere. Resolve within a few months.

Dew Drops

Miliaria Obstruction of eccrine sweat ducts. Associated with increased temperature. Scalp, forehead, neck, intertriginous and occluded areas. Resolves with cooling. Crystallina → dew drops, fades within several hours. Rubra → “prickly heat”, disappears in days.

Sebaceous Gland Hyperplasia Tiny yellow macules or papules, present at the opening of each pilosebaceous follicle. Localized to nose and cheeks. Resolves by 4-6 months of age. Caused by maternal androgens.

Mongolian Spots Congenital, benign macular blue-gray pigmentation. Usually fade during the first or second year of life. Not to confuse with bruises of child abuse (fade into surrounding skin and have different colors).

Case 1 FT female born to a 33yo G1P0, (+) PNC, all maternal labs (-), MBT B(-)/BBT A(+), mom exclusively breastfeeding. What is this patient at risk for?

On DOL #3, Indirect Bili 10.4

Jaundice Clinically apparent at serum bili levels of >5 mg/dl. Cephalo-caudal progression. Peaks between days 2-4, usually resolves spontaneously. On exam, pressing lightly on the skin with a finger will result in a yellow color blanch compared with the surrounding skin. Useful to determine whether the jaundice is progressing or improving over time. Exam not accurate after phototherapy due to “bleaching effect”. 14

Salmon Patches (Nevus Simplex) 40 – 70% of newborns. Capillary malformations. Darken with crying and exertion. Nape of the neck (stork bite), glabella, forehead (angel kiss), upper eyelids, scrotum, lumbosacral. Usually fade in first year (may persist, especially if nuchal or lumbosacral). No further evaluation. 16

Common HEENT Findings

Case 2 FT male born via NSVD, prolonged labor and uncomplicated delivery. You are called to the nursery to examine the baby…

Should you be worried?

Molding Temporary asymmetry of the skull. Caused by birth. Mainly seen with vaginal deliveries and prolonged labor. Normal head shape is usually regained within 1 week.

Case 3 FT male born via vaginal delivery, complicated by maternal fatigue. Vacuum extraction was used. On PE, the newborn is noted to have swelling of the head that crosses suture lines. What is the most likely diagnosis?

Caput Succedaneum vs Cephalhematoma Crosses suture lines. Involves scalp only (soft tissue swelling). Seen at birth. Resolves spontaneously within 24-48 hours. Common cause of jaundice. Does NOT cross suture lines. Involves bone (subperiosteal hemorrhage). Fluctuant on palpation. Not seen at birth, but can increase in size over first few days. Slow resolution (3 wks-3mo). Can be seen with nondepressed skull fx.

Caput Succedaneum 24

Cephalhematoma

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Subconjunctival Hemorrhage Frequent finding in normal newborns. Caused by the breakage of small vessels during the pressure of delivery. Always confined to the limits of the sclera. Asymptomatic, does not affect vision, and spontaneously resolves in several days to a few weeks. 27

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Leukocoria Causes: Congenital cataracts (18% unilateral and 42% bilateral). Retinoblastoma (11% unilateral and 7% bilateral) Retinal detachment (2.8% unilateral and 1.4% bilateral) Uveitis: TORCH ROP Persistent hyperplastic primary vitreous (90% unilateral) Vitreous hemorrhage Coat’s disease (retinal telangectasia), presents 8-10yrs. 29

Case 4 An infant in the newborn nursery is normally grown and normally formed, except for a preauricular pit (preauricular sinus) bilaterally. He has passed his newborn hearing screening. When you meet the baby's mother, you learn that she has progressive, bilateral sensorineural hearing loss for which she uses hearing aids. Of the following, the MOST helpful test to aid in diagnosis and management of this baby's condition is chromosome analysis head ultrasonography ophthalmology consultation radiographic skeletal survey renal ultrasonography

Preauricular Pit/Sinus Uni or bilateral. Malformed external and middle ears may be associated with renal anomalies, craniofacial malformations, and inner ear malformations. Screening for associated renal anomalies if: Associated malformations FHx of deafness, renal or auricular malformations Mother with gestational diabetes Branchio-oto-renal syndrome: audiologic testing, renal evaluation 32

Preauricular Skin Tag 33

Preauricular Skin Tag Often a familial trait. Most often benign and isolated. Can be associated with cleft lip and palate. If associated to abnormal pinna, other malformations, or risk factors for hearing loss: further evaluation recommended. 34

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Microtia Rare. Grade I – IV, grade III most common. Often unilateral (4:1), right side. Hearing evaluation and ENT referral. 50% have an associated genetic syndrome. Goldenhar, Treacher Collins, hemifacial microsomia 37

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Low Set Ears If an imaginary line is drawn from the outer canthus of the eye straight back to the occiput, a low set ear will fall completely below the line. An ear with normal set will cross or touch the same line. This infant had trisomy 18 as an underlying etiology. 39

Case 5 You are assessing a FT newborn for the first time in the mother’s room. As you are examining the patient, the mother asks you what the bumps are on the baby’s upper and lower gums. What do you respond?

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Bohn's Nodules Unknown etiology. Different type of inclusion cysts, thought to be remnants of salivary glands. Present either on the lateral aspect of the gum or on the periphery of the palate. When large can be mistaken by congenital teeth (but located in the external surface of the gum vs. alveolar ridge). Benign finding and disappear within 3 months. 43

Salivary Glands 44

Epstein’s Pearls Keratin containing cysts. Normal variant. Seen only in newborns. Located on the raphe of hard and soft palates. Resolve within several weeks.

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Natal Teeth 1 in 2,000 - 4,000 newborns Usually lower incisors. Can present visible or as eruption cysts completely covering the teeth. They are usually part of the primary dentition, so they should not be removed unless they are mobile, presenting an aspiration risk, or causing secondary tongue ulceration or problem feeding. Dental X-ray and consultation is indicated. 50