Congenital melanocytic nevi are pigmented lesions of varying size noted in 1% of neonates. Giant pigmented nevi are uncommon but have malignant potential. Capillary hemangiomas are raised, red lesions, whereas cavernous hemangiomas are deeper, blue masses. Both lesions increase in size after birth, then resolve when the child is 1 to 4 years of age. When enlarged, these hemangiomas may produce high-output heart failure or platelet trapping and hemorrhage. Erythema toxicum is an erythematous, papular-vesicular rash common in neonates that develops after birth and involves eosinophils in the vesicular fluid. Pustular melanosis, more common in African American infants, may be seen at birth and consists of a small, dry vesicle on a pigmented brown macular base. Erythema toxicum and pustular melanosis are benign lesions but may mimic more serious conditions, such as the vesicular rash of disseminated herpes simplex or the bullous eruption of S. aureus impetigo. Tzanck smear, Gram stain, Wright stain, direct fluorescent antibody stain, polymerase chain reaction for herpes DNA, and appropriate cultures may be needed to distinguish these rashes. Other common characteristic rashes are milia (yellow-white epidermal cysts of the pilosebaceous follicles that are noted on the nose) and miliaria (prickly heat), which is caused by obstructed sweat glands. Edema maybe present in preterm infants, but also suggests hydrops fetalis, sepsis, hypoalbuminemia, or lymphatic disorders.
Figure 58-5 Maturity rating as calculated by adding the physical and neurologic scores, calculating the gestational age. (From Ballard JL, Khoury JC, Wedig K, et al: New Ballard Score, expanded to include extremely premature infants, J Pediatr 119:417-423, 1991.).
The skull may be elongated and molded after a prolonged labor; this resolves 2 to 3 days after birth. The sutures should be palpated to determine the width and the presence of premature fusion or cranial synostosis. The anterior and posterior 4.5 3.5 2.5 1.5 0.5 0 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41
Figure 58-6 Birth weight–specific and estimated gestational age–specific mortality rates. The dashed lines of the figure represent the 10th and 90th percentile weights. The grid lines are plotted by each gestational age and in 250-g weight increments. Each number in the box is the percent mortality rate for the grid defined by gestational age and birth weight range. (From Thomas P, Peabody J, Turnier V, et al: A new look at intrauterine growth and impact of race, attitude, and gender, Pediatrics 106:E21, 2000.) fontanelles should be soft and nonbulging, with the anterior larger than the posterior. A large fontanelle is associated with hydrocephalus, hypothyroidism, rickets, and other disorders. Soft areas away from the fontanelle are craniotabes; these lesions feel like a Ping-Pong ball when they are palpated. They may be a result of in utero compression. The skull should be examined carefully for signs of trauma or lacerations from internal fetal electrode sites or fetal scalp pH sampling; abscesses may develop in these areas.
Face, Eyes, and Mouth
The face should be inspected for dysmorphic features, such as epicanthal folds, hypertelorism, preauricular tags or sinuses, low-set ears, long philtrum, and cleft lip or palate. Facial asymmetry may be a result of seventh nerve palsy; head tilt may be caused by torticollis.