Well-Newborn Care
Andria Barnes Ruth
Kathleen Wholey Zsolway
INTRODUCTION
The birth of a new baby is a marvelous time for a family, full of excitement as well as some uncertainty as the amazing journey of child-rearing begins. The wellnewborn visits are an opportunity for parents to ask questions regarding the health and development of their baby. These visits enable the physician to assess the baby’s health, growth, and development and offer guidance to parents throughout their baby’s early years. It is also an important time for the pediatrician to assess the infant’s temperament, to evaluate the adequacy of maternal and paternal bonding with their infant, and to be sensitive to any family stressors. The physician’s role may involve encouraging parents to be sensitive to the cues that their normal newborn will give them regarding their need to feed, sleep, be changed, be held, or even to cry. Parents are often given reassurance about many aspects of normal newborn physical findings and development. This chapter describes the concerns most frequently encountered during the well-newborn visits.
SKIN
Generalized Rashes
Neonatal rashes are a common cause of concern for parents. A full discussion of rashes occurring in infancy is provided in Chapter 64, “Rashes.”
Diaper Dermatitis (Diaper Rash)
Diaper dermatitis is a common problem presenting in infancy. Multiple conditions can predispose an infant to diaper rash, including sensitive skin, moisture trapped by a diaper, and the acid-base balance of stool and urine. Parents should be advised that prevention is the best cure. The diaper area should be kept as dry as possible; frequent diaper changes decrease the occurrence of diaper dermatitis.
Parents should also be instructed to leave the perineal area open to air as much as possible and apply a barrier cream to protect against local irritation. Physical examination allows for the diagnosis of some of the more common skin irritations in the diaper area:
Irritant contact dermatitis appears as erythema with shallow ulcerations predominantly located on the buttocks, thighs, abdomen, and perianal area, sparing the creases. The diagnosis is made clinically, and treatment involves elimination
of the irritant, use of a barrier cream, and exposure of the area to air as much as possible.
Candida diaper dermatitis can appear at any age and is characterized by beefy red, scaly plaques with satellite lesions, papules, and pustules. Diagnosis is most often made clinically on the basis of the characteristic appearance of the skin; however, a potassium hydroxide preparation would demonstrate the presence of yeast. Treatment involves application of a topical antifungal agent (e.g., nystatin or clotrimazole ointment) and exposure of the perineal area to air.
HINT: Candida diaper dermatitis can be easily differentiated from irritant diaper dermatitis by its involvement of the creases (which are spared in irritant diaper dermatitis) and by the presence of satellite lesions.Mongolian Spots (Congenital Dermal Melanocytosis)
Mongolian spots are blue-gray macules that are most commonly seen in Asian, Hispanic, and African American infants. They are typically a few centimeters in diameter and located on the buttocks and lumbosacral area; less commonly, they may be much larger or located on the face or extremities. They typically disappear by 7 to 13 years of age, but some lesions (particularly the larger ones) persist into adulthood.
Salmon Patch (Nevus Simplex and Telangiectatic Nevus)
A salmon patch is a congenital capillary malformation that involves the eyelids, glabella, forehead, or occiput. It consists of smooth pink or red macular lesions, often accompanied by telangiectasia. Salmon patches on the glabellar region or upper eyelids usually disappear by 1 year of age, whereas those on the nape of the neck persist ˜ 50% of the time.
Port Wine Stain
A port wine stain or nevus flammeus is present in 0.1% to 0.3% of newborns. They are low flow capillary malformations which are pink or red and generally are unilateral. They persist in 40% to 60% of affected patients. Sturge-Weber syndrome is a rare syndrome in which infants with a facial capillary malformation involving the first or second division of the trigeminal nerve have associated ocular and neurologic abnormalities, including glaucoma and seizures.
Café-au-Lait Macules
Café-au-lait macules are pale brown macules with irregular margins that range in size from 2 mm to 2 cm. They may appear at birth or in early childhood. Isolated café-au-lait macules occur in 10% to 20% of the normal population. The presence of six or more café-au-lait macules >5 mm prior to puberty in combination with one of the following additional criteria are diagnostic of neurofibromatosis: two or more neurofibromas, axillary or inguinal freckling, optic glioma, Lisch nodules (iris hamartoma), osseous lesions, or a first-degree relative with neurofibromatosis.
CRANIUM
Fontanelles
There are commonly two palpable fontanelles: the anterior fontanelle and the posterior fontanelle. The anterior fontanelle may minimally increase in size immediately after birth but then gradually decreases in size and is generally closed by 6 to 18 months of age. The posterior fontanelle is generally smaller than the anterior fontanelle and usually closed to palpation by 4 months of age.
Caput Succedaneum
A caput succedaneum is a diffuse swelling of the soft tissue of the scalp, usually involving the presenting portion of the head during a vertex delivery. The edema, which is evident during the first few hours of life, crosses suture lines and may cross the midline. In uncomplicated cases of caput succedaneum, no specific treatment is needed; the swelling resolves during the first few days of life. In rare instances, a hemorrhagic caput may occur and cause shock secondary to loss of circulating blood volume. In this instance, blood transfusion and circulatory support are needed. Extensive ecchymoses may result in hyperbilirubinemia, necessitating phototherapy. Molding of the head and overriding of the parietal bones is often associated with a caput succedaneum; however, these conditions resolve during the first few weeks of life.
Cephalohematoma
A cephalohematoma is a subperiosteal hemorrhage that results in swelling limited in distribution to one cranial bone (i.e., the swelling does not cross suture lines). Subperiosteal bleeding is a slow process; therefore, the cephalohematoma may not be evident until several hours after birth. A skull fracture, usually linear, may be an associated finding. Most cephalohematomas are resorbed between the ages of 2 weeks and 3 months. In some cases, a bony protuberance remains. Despite this residual calcification, no specific treatment is recommended.
HINT: Cephalohematoma may be differentiated from caput succedaneum by the fact that the swelling in cephalohematoma does not cross suture lines.Molding
Asymmetry in the appearance of the cranium, known as molding or positional plagiocephaly, results from the gentle application of asymmetric pressure on the cranial bones, which occurs when an infant spends a significant portion of time in the same position. The incidence of this condition has increased markedly since implementation of the recommendation to place infants to sleep in a supine position. Infants with asymmetric plagiocephaly should be examined carefully for the presence of torticollis, which manifests as decreased range of motion of the neck and head tilt to one side. Affected infants may have a characteristic mass in
the affected sternocleidomastoid muscle. Positional plagiocephaly can be managed by environmental manipulation and repositioning the infant to eliminate asymmetric pressure. In cases where torticollis is present, passive stretching is also recommended. In severe cases, cranial molding helmet therapy may be prescribed to diminish the asymmetry.
the affected sternocleidomastoid muscle. Positional plagiocephaly can be managed by environmental manipulation and repositioning the infant to eliminate asymmetric pressure. In cases where torticollis is present, passive stretching is also recommended. In severe cases, cranial molding helmet therapy may be prescribed to diminish the asymmetry.
Craniosynostosis (premature closure of a suture) is another cause of progressive cranial asymmetry. Positional plagiocephaly can generally be differentiated from craniosynostosis by clinical features. When the diagnosis is not apparent clinically, radiographic studies may be performed. Computed tomography (including three-dimensional surface reconstruction) can be used to delineate the extent of craniosynostosis as well as to evaluate intracranial structures. In the event of craniosynostosis, neurosurgical intervention is indicated because of the possibility of asymmetric brain growth and compression of intracranial structures.
HINT: It is important to differentiate craniosynostosis from positional plagiocephaly early to improve clinical outcome.EYES
Eye Color
Eye color is a frequent question posed by parents. Eye color is usually established by 3 to 6 months of age; however, additional iris pigmentation continues throughout the first year of life. Depth of eye color may not be evident until the first birthday.
Strabismus
During the newborn period, the eyes frequently wander. However, the wandering should diminish (until it eventually disappears) within the first 2 to 3 months of life. Intermittent or persistent esotropia or exotropia after the age of 3 months warrants an evaluation by an ophthalmologist.
HINT: True strabismus must be differentiated from pseudostrabismus with the use of the corneal light reflex and the cover/uncover test.Nasolacrimal Duct Obstruction
The lacrimal system develops fully over the first 3 to 4 years of life. The lacrimal glands begin to produce tears by week 3 or 4 of life. In ˜ 6% of
newborns, one or both of the lacrimal ducts is blocked, preventing drainage of tears.
Affected children appear to have excessive tearing. Therapy entails gentle massage of the lacrimal duct in a downward direction and the use of a warm wet cloth to wipe the collection of tears and mucus from the eye. Most (˜ 90%) blocked lacrimal ducts open spontaneously by 6 months of age. Of those that are still blocked at 1 year of age, <1% open spontaneously. Thus, children with persistent
lacrimal duct obstruction beyond 6 to 12 months of age should be evaluated by an ophthalmologist. Parents should be cautioned to call the pediatrician if the conjunctiva becomes red, if the eye discharge becomes purulent, or if the area surrounding the eye or the medial aspect of the nose becomes swollen. These physical findings may indicate conjunctivitis, ophthalmia neonatorum, or dacryocystitis (see Chapter 65, “Red Eye”).
lacrimal duct obstruction beyond 6 to 12 months of age should be evaluated by an ophthalmologist. Parents should be cautioned to call the pediatrician if the conjunctiva becomes red, if the eye discharge becomes purulent, or if the area surrounding the eye or the medial aspect of the nose becomes swollen. These physical findings may indicate conjunctivitis, ophthalmia neonatorum, or dacryocystitis (see Chapter 65, “Red Eye”).
EARS
Hearing
Significant bilateral hearing loss (>35 dB) is present in 1 to 3 per 1,000 wellnewborns, and in 2 to 4 per 1,000 infants in the intensive care unit. Because auditory stimulation during the first 6 months of life is very important for the development of speech and language skills, significant hearing loss that goes undetected can impede speech, language, and cognitive development. Universal hearing screening should occur prior to discharge from the hospital, with appropriate rescreening for those who do not pass the initial test. For infants with significant hearing loss, audiologic and medical evaluations should be performed before 3 months of age, and intensive interventions should be implemented before 6 months of age.
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