Newborn And Early Infancy

The newborn infant's skin has a unique characteristic texture and appearance. The texture is soft and smooth because it is thinner than the skin of older children. Within the first 10 minutes after birth, a normal newborn progresses from generalized cyanosis to pinkness. In lighter-skinned infants, an erythematous flush, giving the skin the appearance of a "boiled lobster," is common during the first 8 to 24 hours, then the normal pale pink coloring predominates.

Cutis marmorata is prominent in premature infants, and in infants with congenital hypothyroidism and Down syndrome.

Vasomotor changes in the dermis and subcutaneous tissue—a response to cooling or chronic exposure to radiant heat—can produce a latticelike, bluish mottled appearance (cutis marmorata), particularly on the trunk, arms, and legs. This response to cold may last for months in normal infants. Acrocyanosis, a blue cast to the hands and feet when exposed to cold (see the photo on the next page), is very common in newborns for the first few days, and may recur throughout early infancy. Occasionally in newborns, a striking color change (harlequin dyschromia) appears with transient cyanosis of one half of the body or one extremity, presumably due to temporary vascular instability.

If acrocyanosis does not disappear within 8 hours or with warming, cyanotic congenital heart disease should be considered.

The amount of melanin in the skin of newborns varies, affecting pigmentation. Black newborns may have a lighter skin color initially than later on, except in the nail beds and genitalia, which are dark at birth. A dark or bluish pigmentation over the buttocks and lower lumbar regions is common in newborns of African, Asian, and Mediterranean descent. These areas, formerly called Mongolian spots, are due to the presence of pigmented cells in the deep layers of the skin; they become less noticeable with age and usually disappear during childhood. It is important to document these pigmented areas to avoid later concern about bruising.

Acrocyanosis in the first half hour of life in a 32-week infant. (From Fletcher M: Physical Diagnosis in Neonatology, Philadelphia, Lippincott-Raven Publishers, 1998.)

Central cyanosis in a baby or child of any age should raise suspicion of congenital heart disease. The best area to look for central cyanosis is the tongue and oral mucosa, not the nail beds or the extremities.

Pigmented light-brown lesions (<1-2 cm at birth) are cafe-au-lait spots. Isolated lesions have no significance, but multiple lesions with smooth borders may suggest neurofibromatosis (see Table 17-6, p. 761).

At birth there is a fine, downy growth of hair called lanugo over the entire body, but especially the shoulders and back. This hair is shed within the first few weeks. Lanugo is prominent in premature infants. Hair thickness on the head varies considerably among newborns, and fortunately is not predictive of later hair growth. All of the original hair is shed within months, replaced with a new crop, sometimes of a different color.

Inspect the newborn closely for a series of common skin conditions. At birth, a cheesy white material called vernix caseosa, composed of sebum and desquamated epithelial cells, covers the body. Some newborns have edema over their hands, feet, lower legs, pubis, and sacrum; this disappears within a few days. Superficial desquamation of the skin is often noticeable 24 to 36 hours after birth.

Skin desquamation at birth occurs in some normal babies, and frequently in post-term babies (>40 wks gestation). Rarely, it is a sign of placental circulatory insufficiency or congenital ichthyosis.

You should be able to identify four common dermatologic conditions in newborns. None is clinically significant. Milia, pinhead-sized smooth, white raised areas without surrounding erythema on the nose, chin, and forehead, are caused by retention of sebum in the openings of the sebaceous glands. While occasionally present at birth, milia usually appear within the first few weeks and disappear over several weeks. Miliaria rubra consists of scattered vesicles on an erythematous base, usually on the face and trunk, caused by sweat gland duct obstruction; it also disappears spontaneously within weeks. Erythema toxicum, which usually appears on the 2nd or 3rd day of life, consists of erythematous macules with central pinpoint vesicles scattered diffusely over the entire body, appearing much like flea bites. These lesions are of unknown etiology, but disappear within a week after birth. Pustular melanosis, seen more commonly in black infants, is present at birth as small vesiculopustules over a brown macular base and can last for several months.

Midline hair tufts over the lum-bosacral spine region suggest a spinal cord defect.

Both erythema toxicum and pustular melanosis may appear similar to the pathologic vesicular rash of herpes simplex or staphylococcus aureus skin infection, which are serious infections requiring rapid treatment.

Note any signs of trauma from the birth process and the use of forceps or suction; these signs disappear but should prompt a careful neurologic examination.

Normal "physiologic" jaundice, which occurs in half of all newborns, appears on the 2nd or 3rd day, peaks at about the 5th day, and usually disappears within a week. Jaundice can best be appreciated in natural daylight rather than artificial light. Newborn jaundice seems to progress from head to toe, with more intense jaundice on the upper body and less intense yellow color in the lower extremities. To detect jaundice, apply pressure to the skin as shown below to press the normal pink or brown color out. Look for the presence of a yellowish "blanching," which indicates jaundice. Another technique is to press a glass slide against the skin to empty the capillary bed and observe for color contrast. Also see Table 17-7, p. 762.

Jaundice that appears within the first 24 hours of birth is likely to be pathologic jaundice due to hemolytic disease of the newborn.

Jaundice that persists beyond 2-3 weeks should raise suspicions of biliary obstruction or liver disease.

Pressing the red color from the skin allows better recognition of the yellow of jaundice. Infant with no appreciable jaundice at chest level. (From Fletcher M: Physical Diagnosis in Neonatology, Philadelphia, Lippincott-Raven Publishers, 1998.)
Infant with bilirubin level of 13 mg/d (222 iJmol/L). (From Fletcher M: Physical Diagnosis in Neonatology, Philadelphia, Lippincott-Raven Publishers, 1998.)

A common vascular marking, found in 40% of newborns, is the "salmon patch" (also known as nevus simplex, telangiectatic nevus, or capillary heman-gioma). These flat, irregular, light pink patches are most often seen on the nape of the neck ("stork bite"), upper eyelids, forehead, or upper lip ("angel kisses"). They are not true nevi, but are due to distended dermal capillaries; they almost all disappear by 1 year of age. Darker, purplish lesions on the face or extremities are "port wine stains" and do not fade.

Does Angel Kiss Baby Eyelids Fade
Nuchal salmon patch at hairline. (From Fletcher M: Physical Diagnosis in Neonatology, Philadelphia, Lippincott-Raven Publishers, 1998.)

A unilateral port wine stain over the distribution of the ophthalmic branch of the trigeminal nerve may be a sign of Sturge-Weber syndrome, which is associated with seizures, hemiparesis, glaucoma, and mental retardation.

The examination of the skin should include palpation to assess the degree of hydration or turgor. Roll a fold of loosely adherent skin on the abdominal wall between your thumb and forefinger to determine its consistency. The skin in well-hydrated infants and children returns to its normal position immediately upon release.

Significant edema of the hands and feet of a newborn girl may be suggestive of Turner's syndrome.

Delay in return to normal skin position as shown on the left, a phenomenon called "tenting," usually occurs in children with significant dehydration.

From Zitelli BJ and Davis HW: Atlas of Pediatric Diagnosis, ed. 3, St. Louis, 1997, Mosby-Year Book.

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