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Physical examination of Newborn

By

Dr behzad barekatain MD

Assistant professor of pediatrics, neonatologist

Academic member of isfahan university of medical sciences

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Immediately after a baby is born, all parents want to know, “Is my baby all right?” Answer to this guestion dependents to your knowledge about fetal circulation and transition to neonatal circulation as well as your proficiency about physical examination

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Fetal Physiology

In the fetus

• Alveoli filled with lung fluid

• In utero, fetus dependent on placenta for

gas exchange

Fetal

circulation

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Fetal Physiology

Click on the image to play video

In the fetus

• Pulmonary arterioles constricted

• Pulmonary blood flow diminished

• Blood flow diverted across ductus arteriosus

Shunting of blood

through the ductus

arteriosus before birth

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Lungs and Circulation

After Delivery

• Lungs expand

with air

• Fetal lung fluid

leaves alveoli

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Lungs and Circulation

After Delivery

Click on the image to play video

• Pulmonary

arterioles dilate

• Pulmonary blood

flow increases

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Normal Transition

• Fluid in alveoli absorbed

• Umbilical arteries and vein constrict thus

increasing blood pressure

• Blood vessels in lung relax

The following major changes take place within seconds after birth:

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Lungs and Circulation

Click on the image to play video

• Blood flows through lungs to pick up oxygen

• Blood oxygen levels rise

• O2 Ductus

arteriosus constricts

Cessation of shunt

through ductus arteriosus after

birth, as blood preferentially

flows to the lungs

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Although the initial steps in a normal transition occur

within a few minutes of birth, the entire process may

not be completed until hours or even several days after

delivery.

For example, studies have shown that, in normal

newborns born at term, it may take up to 10 minutes to

achieve an oxygen saturation of 90% or greater.

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Functional closure of the ductus arteriosus may not

occur until 12 to 24 hours after birth, and complete

relaxation of the lung vessels does not occur for

several months.

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What Can Go Wrong During Transition

• The lungs may not fill with air even when

spontaneous respirations are present

(inadequate ventilation)

• The expected increase in blood pressure may

not occur (systemic hypotension)

• The pulmonary arterioles may remain

constricted after birth

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Signs of a Compromised Newborn

• Poor muscle tone

• Depressed

respiratory drive

• Bradycardia

• Low blood pressure

• Tachypnea

• Cyanosis

Good tone

with

cyanosis

Bad tone

with

cyanosis

Many of these same findings also may occur in other

conditions, such as infection or hypoglycemia, or if

the baby's respiratory efforts have been depressed by

medications, such as narcotics or general anesthetic

agents, given to the mother before birth

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• Control of vital sign should done after birth every 1

hours until two consecutive evaluation is normal then

every 6 hours at least 24 hours

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A quick initial physical examination of all newborns should

be performed in the delivery room to ensure that there are no

major anomalies or birth injuries, that the newborn’s tongue

and body appear pink, and that breathing is normal.

The entire body must be checked.

This usually allows the clinician to reassure the parents that

their infant looks well and appears normal.

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Every newborn infant should undergo a “routine examination of the newborn. This is a detailed examination performed by a trained health care provider within 24 to 72 hours of birth.

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The examination should include checking the baby’s:

• appearance including colour, breathing, behaviour, activity and posture

• head (including fontanelles), face, nose, mouth (including palate), ears, neck and

general symmetry of head and facial features; measure and plot head circumference

• eyes; check opacities and red reflex

• neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry

• heart; check position, heart rate, rhythm and sounds, murmurs and femoral pulse

volume

• lungs; check effort, rate and lung sounds

• abdomen; check shape and palpate to identify any organomegaly; also check

condition of umbilical cord

• genitalia and anus; check for completeness and patency and undescended testes in

males

• spine; inspect and palpate bony structures and check integrity of the skin

• skin; note colour and texture as well as any birthmarks or rashes

• central nervous system; observe tone, behaviour, movements and posture; elicit

newborn reflexes only if concerned

• hips; check symmetry of the limbs and skin folds (perform Barlow’s and

Ortolani’s manoeuvres)

• cry; note sound

• weight; measure and plot

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PREPARATION Before approaching the mother and infant, the mother’s and infant’s

medical and nursing records should be checked.

Determines the relationship between antenatal (before birth) and

intrapartum (occurring during labour and delivery) events that may

impact on the newborn’s health status, and subsequent events that may

impact on the 6- to 8-week infant

Ensures that the environment is conducive to effective and safe

examination

Utilises a holistic, systematic approach, to comprehensively examine

the neonate/infant effectively and sensitively

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INTRODUCTION TO THE MOTHER The health care provider should introduce himself or herself to the mother or, preferably, to both parents and explain the purpose of the examination. It is usually best at this stage to inquire whether there are any problems with feeding or any other worries about the infant. Before starting the examination the health care professional must observe hand hygiene and ensure that the newborn can be examined in a warm, private area with good lighting.

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ORDER OF THE EXAMINATION The exact sequence in which the newborn is examined is not important. What is important is that the entire body is examined at some stage. If the newborn is quiet, one may well take the opportunity to listen to the heart and examine the eyes directly. It is often convenient to make general observations of the newborn’s appearance, posture, and movements while undressing him or her, then to conduct the examination from head to foot, to then remove the diaper to examine the genital region, femoral pulses and hips, and finally to pick the newborn up and turn him or her over to be prone and examine the back and spine and assess tone in the prone position

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A checklist is helpful to record the findings of the examination and to ensure that nothing has been omitted. For example, in the United Kingdom, the Newborn and Infant Physical Examination Program requires a specific checklist to be completed and inserted in the infant’s personal child health record.

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MEASUREMENTS The infant’s birth weight, gender, and gestational age should be noted. The 10th to 90th percentile for weight at 40 weeks’ gestation for a male infant is 2.8 to 4.0 kg (mean, 3.3 kg) and for a female infant is 2.7 to 3.9 kg (mean, 3.2 kg). The birth weight percentile should be ascertained from the gestation-specific growth chart. If the infant’s gestational age is uncertain, it can be determined (±2 weeks’ gestational age)using

a standardized scoring scheme.

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Infants often lose weight over the first 5 days of life up to a maximum of 10% of birth weight. The head circumference should be measured with a disposable tape measure at its maximal occipital frontal circumference and plotted on a gestation-specific growth chart to identify microcephaly or macrocephaly and to serve as a reference for future measurements. However, the measurement can change markedly in the first few days because of molding of the head during delivery. The 10th to 90th percentile is 33 to 36 cm (boys) and 32 to 35 cm (girls) at 40 weeks.

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The infant’s length (47 to 52 cm at 40 weeks) is measured routinely in the United States. Because the hips and lower legs need to be held extended by an assistant, the length is rarely measured accurately enough to identify short stature or serve as a reliable reference value when measured routinely. The length of the arms and legs relative to that of the trunk is observed, although short limbs from skeletal dysplasias can be difficult to appreciate in the immediate newborn period.

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One of the earliest observations an examiner can make when evaluating a newborn is that of size. Because small term babies and large preterm babies may be the same weight but have very different problems, the categorization of size should always be made in relationship to the gestational age. Babies who are large or small for their age need special consideration. Typically, term babies are appropriate for gestational age (AGA) when their weights fall between 2.5kg and 4kg. This baby, at about 7 pounds is AGA.

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GENERAL OBSERVATION OF APPEARANCE, POSTURE, AND MOVEMENTS Much valuable information can be gleaned by simply observing the newborn. Central cyanosis is best observed on the tongue. If present, it requires urgent investigation.

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If there is any doubt, the newborn’s oxygen saturation should be checked with a pulse oximeter. Polycythemic infants (central hematocrit >65%) sometimes appear cyanotic because they have more than 5 g of reduced hemoglobin per 100 mL of blood, even though they are adequately oxygenated. Peripheral cyanosis confined to the hands and feet is common during the first day of life and is of no clinical significance.

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The assessment of tone can be made both from observing the posture

and activity of the infant when undisturbed and also by handling the

baby.

Infants with normal tone will not feel "floppy" when held by the

examiner.

The infant in the photo is hypotonic. When this baby was lifted, the

examiner had to give much more support to the head and shoulders than

is usual to keep the infant from sliding our of her hands.

Notice how the both arms fall back

(instead of being held in flexion),

and the baby's chest seems to drape over the

physician's hand.

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Here is the same infant held in ventral suspension.

Normally newborns do have a convex curvature of the spine in this

position, but not to this degree. Here the head drops much lower than

one would expect, and the examiner has the sense that the infant could

easily slip out of her hand without extra support.

In this case, the hypotonia was caused by trisomy 21.

ERYTHEMA TOXICUM

Erythema toxicum is a benign and self-limited eruption that usually

develops between 24 and 72 hours of age, but new lesions may

appear until 2 to 3 weeks of age.

found in up to70% of newborn.

The disorder is more common in term infants than in premature

infants, which suggests that it may represent an inflammatory

reaction requiring mature skin.

This condition may be exacerbated by handling or chafing from linen.

skin

These lesions may vary considerably in character and number; they

may be firm, 1- to 3-mm, pale yellow-to-white papules or pustules on

an erythematous base resembling flea bites or erythematous

macules as large as 3 cm in diameter.

Individual lesions are evanescent, often lasting only a matter of

hours.

They may be found on any area of the body but occur only rarely on

the palms and soles.

They are asymptomatic with no related systemic involvement, and

their cause is unknown, although a variety of specific cytokines have

been implicated in the pathogenesis.

A microscopic examination of a Wright-stained or Giemsa-stained

smear of the pustule contents demonstrates numerous eosinophils;

Gram stains are negative for bacteria, and cultures are sterile.

No treatment is necessary, because spontaneous resolution occurs

in 6 days to 2 weeks.lotion or creams may exacerbate condition

TRANSIENT NEONATAL PUSTULAR MELANOSIS

Transient neonatal pustular melanosis is a distinctive eruption that

consists of three types of lesions.

First-stage lesions are small, superficial

vesiculopustules with little or

no surrounding erythema.

These rapidly progress to the second stage, which

consists of collarettes of scale or

scale crust surrounding a hyperpigmented

macule (third stage)

All three types of lesions may be present at birth, but the macules

are observed more frequently.

The lesions may be profuse or sparse and occur on any body

surface, including the palms, soles, and scalp.

Sites of predilection are the forehead, submental area and anterior

neck, and lower back.

When intact pustules rupture, a pigmented macule often is

discernible central to the collarette of scale, which represents the

margin of the unroofed pustule.

Presumably, the macules result from postinflammatory

hyperpigmentation, and those present at birth may be the sequelae of

in utero pustular lesions.

Pustular melanosis may be confused with erythema toxicum,

congenital cutaneous candidiasis, or staphylococcal pyoderma.

Cultures and Gram stains of smears prepared from intact pustules

are devoid of organisms; Wright stains of intralesional contents

demonstrate cellular debris, polymorphonuclear leukocytes, and a

few or no eosinophils, in contrast to those of erythema toxicum.

Although the pustules disappear in 48 hours, the hyperpigmented

macules may persist for as long as 3 months.

Occur in black infant(5%) mora than white infant (0/2%).

Neither type of lesion requires therapy, and although the cause is

unknown, parents may be reassured that the disorder is benign and

transient.

The most frequently encountered pigmented lesion is the mongolian

spot (cutaneous melanosis or hyperpigmented macules ), which

occurs frequently (80%) in African-American, Asian, and Native

American infants and, infrequently, in white infants.

Although most of these lesions are found in the lumbosacral area,

occurrence at other sites is not uncommon.

The pigmentation is macular and gray-blue, lacks a sharp border,

and may cover an area 10 cm or larger in diameter.

Pigmented skin lesion

Pigmentary lesions result from delayed disappearance of dermal

melanocytes.

Most of these lesions gradually disappear during the first few years of

life, but aberrant lesions in unusual sites are more likely to persist.

It is important to document size and location to avoid question of

nonaccidental trauma

SALMON PATCHES

Salmon patches or transient macular stains or nevus simplex or

stork bite are present in up to 70% of normal newborns.(in some

reference 30-50%0

They are usually found on the nape, the eyelids, and the glabella.

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Vascular lesion

They have diffuse border,blanched with pressure ,and become pinker

with crying

In a prospective study of affected infants, most of the facial lesions had

faded by 1 year of age, but those on the neck were more persistent.

Surveys of adult populations confirm the persistence of the nuchal

lesions in approximately one fourth of the population

MILIA

Approximately 40% of infants have multiple, white, 1-mm cysts (i.e.,

milia) scattered over the cheeks, forehead, nose, and nasolabial

folds.

These milia may be few or numerous, but they frequently occur in

clusters.

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Histologically, milia are keratogenous cysts similar to Epstein pearls,

which are distributed along the midpalatal raphe

Bohn nodules are cysts that occur on the palate and the buccal and

lingual aspects of the dental ridges and represent remnants of

mucous gland tissue.

Intraoral lesions are found in 75% to 80% of newborns. Because all

these cysts exfoliate or involute spontaneously within the first few

weeks of life, no treatment is required.

Epstein pearls

Oral counterpart of facial milia

They can seen in the midline of palate or on the alveolar ridges in

60% of neonates

SEBACEOUS GLAND HYPERPLASIA

Milia are often confused with the smaller(./5 mm), flatter, more yellow

dots of sebaceous gland hyperplasia seen on the midface as well

MILIARIA

Miliaria is an eruption resulting from eccrine sweat duct obstruction

leading to sweat retention.

The three types of lesions are

superficial thin-walled vesicles

without inflammation

(i.e., miliaria crystallina)

small, erythematous grouped papules

(i.e., miliaria rubra)

and nonerythematous pustules

(i.e., miliaria pustulosis or profunda).

The eruption most frequently develops in the intertriginous areas and

over the face and scalp.

It is exacerbated by exposure to a warm and humid environment.

Miliaria sometimes can be confused with erythema toxicum; rapid

resolution of the lesions when the infant is placed in a cooler

environment differentiates them from pyoderma.

A Wright-stained smear of vesicular lesions demonstrates only sparse

squamous cells or lymphocytes, permitting exclusion of infectious

vesicular eruptions. No topical therapy is indicated.

Port-wine stain

A flat vascular nevus is present at birth

It is usually pink but can be red or purple

May be small or cover almost half of the body

It is flat ,sharply delineated and blanched minimally

Facial lesions are the most common

This lesion consist of mature capillaries that are dilated and congested

directly below the epiderm.the cause is unknown.

The nevus dose not grow in area or size.

It will not resolve and should be considered permanent

The lesion may become darker and thicker with age.

Sturge-weber syndrome

Port-wine stains are confined to a pattern similar to that of the

branches of the trigeminal nerve

It is associated with atrophic changes in the cerebral cortex and

calcium deposits in the wall of small vessels and area of affected

cortex

Manifested by glucoma,focal siezures, hemiparesis, and mental

retardation

Cutis marmorata

Bluish mottling or marbling effect of the skin

*physiologic response to chilling because of dilation of capillaries and

venules and disappeare with warming

*sign of stress or overstimulation of newborns

*common in infant with trisomy of 18 and 21

*if persist for 6 month or later,it may be a symptom of hypothyroidism

or a vascular abnormality such as cutis marmorata telangiectasia

Diaper dermatitis

May be caused by chafing from diapers,by prolonged contact with

urine and feces , or by sensitivity to chemicals in disposable diapers

or in detergent used in laundering cloth diaper or by candida

The best treatment is prevention by frequent diaper changes and by

protection of the skin with a barrier product containing zinc oxide

The skin should be cleansed with warm water after voiding and stooling

Avoid diaper wipes that contain alchol

Cornstarch and baby powder shoud noy be used.they provide a

medium for growth of bacteria and yeast and inhaled particles are

irritating to the respiratory tract

Subcutaneous fat necrosis and sclerema neonatorum

Subcutaneous fat necrosis and sclerema neonatorum occur within

the first 3 months of life.

They may be variants of the same basic disorder of fat metabolism.'

Sclerema neonatorum usually affects the preterm or debilitated

newborn.

It manifests by diffuse hardening of the subcutaneous tissue,

resulting in a tight, smooth skin that feels bound to the underlying

structures.

The skin is cold and stony hard.

The joints become immobile and the face masklike.

The affected infant also may have multiple congenital anomalies or

may develop sepsis, pneumonia, or severe gastroenteritis.

CNS abnormalities, autonomic dysfunction, and respiratory distress

frequently complicate the course of the disease.

The mortality rate is high, but the cutaneous changes rarely last

longer than 2 weeks if the infant survives.

For infants who are severely ill, exchange transfusion and systemic

administration of steroids have been used, but their efficacy has not

been confirmed.

The lesions of subcutaneous fat necrosis are localized and

sharply circumscribed

They appear 1 to 4 weeks after delivery as small nodules or large

plaques and are found on the cheeks, buttocks, back, arms, and

thighs.

The affected fat is firm, and the overlying skin may appear reddish or

violaceous and occasionally has the texture of orange peel.

Histologically, there is a granulomatous reaction in the fat, with

formation of needle-shaped crystals, foreign body giant cells,

fibroblasts, lymphocytes, and histiocytes.

Resolution of the lesion results in fibrosis.

Possible precipitating causes of fat necrosis include cold exposure,

trauma, asphyxia, and peripheral circulatory collapse.

The lesion is caused by crystallization of the subcutaneous fat cells

The lesions usually resolve in several weeks or months without

complications.

Serum calcium levels should be monitored since subcutaneous fat

necrosis has been associated with hypercalcemia and its

complications.

Hypocalcemia has also been reported.

congenital pigmented melanocytic nevi

Dark brown or black macules that may or may not be hairy

May occur anywhere on the body,with the” bathing trunk” area

being the most common site

Caused by collection of melanocytes under the skin

Can be small size(more common),less than 2 cm.

Large nevi (> 10 cm ) is rare.

Pigmented nevi are generally benign.

Malignant changes may occur but is rare before puberity

Close observation of changes in size or shape is indicated,with

possible surgical excision

Large unusually shaped nevi may be difficult to assess for change and

should be followed closely

A hairy nevus present over the spine may be associated withspina

bifida or meningocele

Pigmented nevi may also be associated with neurofibromatosis or

tuberous sclerosis

Disorders of Cornification: The Scaly Baby

The most common causes of excessive scaling in the neonate are

physiologic desquamation and dysmaturity, neither of which is of

long-term significance.

Less common causes include the congenital ichthyoses and the ectodermal dysplasias (particularly hypohidrotic ectodermal

dysplasia), all of which are chronic, heritable disorders.

physiologic desquamation

The gestational age of a newborn with accentuated physiologic

desquamation usually is 40 to 42 weeks; peak shedding occurs near

the eighth day of life.

These infants are otherwise normal in physical appearance and

behavior.

In contrast, the dysmature infant has distinctive characteristics.

The body is lean, with thin extremities and decreased subcutaneous

fat.

The ponderal index is low and indicates diminished body weight in

relation to length.

The skin is often scaly with

parchment-like desquamation,

especially of the distal extremities.

There is often meconium staining of the skin

as well as the nails and umbilical cord.

The hair is abundant, and the nails are abnormally long.

In the normal infant with accentuated physiologic scaling and the

dysmature infant, desquamation is a transient phenomenon, and the

integument continues to serve its intended protective function.

In contrast, the infant with congenital ichthyosis may have serious

difficulties early in life because of impaired barrier function and

subsequent risks of secondary infection.

Collodion babies often are born prematurely.

The infant is covered with a cellophane-like membrane, which by its

tautness may distort the facial features and the digits.

Less commonly, only part of the integument is involved.

The membrane is shiny and brownish-yellow, resembling an

envelope of collodion or oiled parchment, and may be perforated by

hair.

The presence of ectropion, eclabium, and crumpled ears causes

these infants to resemble one another for the first few days of life.

HARLEQUIN COLOR CHANGE

Harlequin color change is a phenomenon observed in the immediate

neonatal period and is more common in the infant with low

birthweight

The dependent side of the body becomes intensely red, and the

upper side pales, with a sharp midline demarcation. When the infant

position is reversed,the color change to the oder side

This condition may also be seen when the infant is lying flat

It is most often seen in the trunk

The peak frequency of attacks in one series occurred on the second,

third, and fourth days, but episodes were observed during the first 3

weeks of life.

These episodes are of no pathologic significance.

They have been attributed to a temporary imbalance in the autonomic

regulatory mechanism of the cutaneous vessels; there are no

accompanying changes in the respiratory rate, muscle tone, or

response to external stimuli.

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Incontinentia pigmenti

In this X-linked dominant condition, the lesions go through three

distinct phases, commencing as an erythematous widespread linear rash,

replaced within weeks by a verrucous phase and finally developing into

the classical hyperpigmented streaky rash shown, which is said to follow

the cleavage lines of Blashkow.

The risk of intra-cranial pathology is high and the condition is usually

fatal in boys in utero.

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Epidermal naevus

This naevus is usually present at birth and is a raised plaque-like lesion

that becomes papillomatous.

It is significant in its association with other system abnormalities, e.g.

central nervous system (seizures, learning disability, tumours), spinal

and cardiac.

When such an association occurs, the condition is called epidermal

naevus syndrome.

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Skull The shape of the head should be noted.

It may be asymmetric from the infant’s intrauterine position or molded

from having to squeeze through the birth canal during

delivery.

After elective cesarean birth the infant’s head shape is round and

symmetric.

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The fontanelle and sutures are palpated.

The size of the anterior fontanelle is variable.

If the fontanelle is tense when the newborn is not crying, this may be

from elevated intracranial pressure, and cranial ultrasonography should

be performed. A tense fontanelle is also a late sign of meningitis.

HEAD The size of the head, measured by the maximal head circumference, and

the sizes of the anterior and other fontanelles should be compared with

those of appropriate standards.

Head size varies with age, sex, and racial group and correlates with body

size.

Macrocephaly as an isolated anomaly often is familial and inherited in an

autosomal dominant fashion; therefore,determining the head

circumferences of the parents is helpful.

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However, macrocephaly may be a manifestation of several

disorders, including hydrocephaly and various conditions

affecting the skeletal system, such as achondroplasia, or

overgrowth syndromes, such as the PTEN and hamartoma

tumor syndrome and PHVD

Microcephaly can also be familial, either autosomal dominant or

recessive, but it is more commonly a manifestation of many

syndromes that result in mental retardation

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Microcephaly

The skull grows to accommodate the growing brain.

If the brain is severely injured in any way, for example, infection

such as maternal rubella, severe asphyxia or cerebral dysplasia, the

final result will be microcephaly.

This infant had congenital rubella and was later found to have severe

mental retardation.

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Anencephaly

This is the most severe neural tube defect with absent cerebral

hemispheres incompatible with life.

Rarely seen now due to antenatal detection and termination.

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Encephalocoele

An extensive encephalocoele is seen, with the sac arising from the

occiput containing brain tissue, thus differentiating the lesion from a

cranial meningocoele in which the sac contains only cerebrospinal

fiuid.

Frontal encephalocoeles are more common but when small, they may

cause diagnostic confusion.

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Posthaemorrhagic hydrocephalus

Twins who were born preterm are shown with one suffering from

hydrocephalus caused by intraventricular haemorrhage.

The setting sun sign is visible.

Other causes include congenital aqueduct stenosis

Large fontanelles occur in hypothyroidism; in trisomies 21, 18,

and 13; in peroxisomal disorders like Zellweger syndrome, and

in many bone disorders, such as hypophosphatasia and

cleidocranial dysostosis.

A small anterior fontanelle may be a sign of failure of normal

brain growth.

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Premature infants and those with trisomy 18 characteristically

have dolichocephaly and hypotonic infants often develop

dolichocephaly over time, but either type of head shape may be

of familial or racial origin.

Many Asian and American Indian infants, for example, have

strikingly brachycephalic heads.

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Premature fusion of cranial sutures (craniosynostosis) results in

an abnormal configuration in head shape.

Torticollis or abnormal mechanical forces in utero can cause

asymmetric head shape (plagiocephaly).

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Posterior plagiocephaly is almost always deformational and rarely

related to premature fusion of the lambdoid suture.

Anterior plagiocephaly, on the other hand, is most commonly caused by

unilateral coronal synostosis

The incidence of true lambdoid synostosis is very low, estimated to

occur in only approximately 3% of patients with craniosynostosis.

The prevalence of deformational plagiocephaly has increased

dramatically since 1992, when the American Academy of Pediatrics

instituted the “back to sleep” program.

The prone position has been linked with the sudden infant death

syndrome, and placing infants on their backs has led to a significant

reduction in the frequency of this syndrome. The tradeoff has been an

increase in the diagnosis of deformational plagiocephaly, with one

institution reporting a sixfold annual increase in referrals to their center

beginning in 1992, compared with the previous 13 years

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The diagnosis of deformational plagiocephaly is usually made on the history and

confirmed by the physical examination.

Typically, the infant has a normal, rounded head at birth. After several weeks or

months, the head assumes the shape of a parallelogram. Usually, the child has been

lying on his or her back with the head favoring one direction.

The parallelogram shape is best appreciated by examining the head from above. There

is unilateral flattening of the occiput with an ipsilateral frontal prominence, creating a

characteristic “windswept” appearance.

The ipsilateral ear is displaced forward, but both ears are in the same horizontal plane

Radiographic confirmation is unnecessary in typical cases.

When skull films are obtained, they usually show patent lambdoid sutures,

sometimes with associated perisutural sclerosis. Perisutural sclerosis has no

diagnostic value because in true lambdoid synostosis the suture is obliterated

radiographically.

A common CT finding in deformational plagiocephaly is prominent extra-axial

CSF collections (widening of the subarachnoid spaces).

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Deformational plagiocephaly may be associated with multiple forces

acting on the skull.

Prenatal factors include uterine abnormalities such as a bicornuate

uterus, uterine crowding caused by a large fetus, twinning, or a pelvic

lie.

Postnatal factors include behavioral perseverance (child favors a

particular position), torticollis with shortening or contracture of the

sternocleidomastoid or trapezius muscles, head tilt from trochlear

nerve palsy, and congenital vertebral disorders such as hemivertebrae

or Klippel-Feil syndrome

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Deformational plagiocephaly is differentiated from true lambdoid synostosis by several

features.

Statistically true lambdoid synostosis occurs much more infrequently.

Lambdoid synostosis is more likely to cause occipital flattening at the time of birth.

Lambdoid synostosis, like deformational plagiocephaly, causes ipsilateral occipital

flattening, but in lambdoid synostosis the ipsilateral ear is drawn posteriorly and

inferiorly compared with the contralateral ear, and the skull shape is that of a rhomboid

rather than a parallelogram.

The degree of frontal asymmetry in lambdoid synostosis is less than in deformational

plagiocephaly, and the frontal bossing tends to be contralateral rather than ipsilateral.

The foramen magnum is drawn toward the fused suture in lambdoid synostosis and

appears normal in deformational plagiocephaly.

A ridge is sometimes, but not always, palpable along

the fused suture in lambdoid synostosis.

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Unilateral right coronal synostosis (anterior plagiocephaly , Greek plagio, “oblique,” kephale, “head”) with flattening of the ipsilateral forehead and compensatory bossing of the contralateralforehead. Note the facial asymmetry, ipsilateral frontal flattening, and vertical orbital dystopia with inferior displacement of the contralateral orbit. A, Front view. B, Top view.

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A common anomaly in head shape is frontal bossing, which is

frequent in some skeletal dysplasias such as achondroplasia

and in some cases of hydrocephaly.

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Different type of skull swelling A caput succedaneum is bruising and edema of the presenting part of the head. It extends beyond the margins of the skull bones.

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A cephalhematoma is caused by bleeding between the periosteum and the skull bone. It is confined within the margins of the skull sutures and usually affects the parietal bone. These conditions may take several weeks to resolve.

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In subgaleal hemorrhage, there is bleeding between the galea aponeurosis and periosteum. Vacuum extraction and coagulopathy are risk factors. The head may have a boggy appearance with pitting edema of the scalp and anterior displacement of the ears. Early recognition and treatment is paramount because it may progress to hypovolemic shock.

Lesion resulting from trauma Forceps or vaccum marks

Red or bruised area seen over the cheek , scalp , or face after forceps

delivery

The infant should be examined for underlying tissue damage or pther sign

of birth trauma like scalp abrasion , fractured clavicles or facial palsy

Scalp laceration

May be caused by trauma , scalp electrods , or fetal PH monitoring

Treatment consist of keeping the area clean and dry and assessing for

infection

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Foetal scalp electrode burn

Note the scalp lacerations caused by numerous attempts to place a foetal

Electrode

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Thank you