Newborn Exam: Birth Injuries & Skin Findings
Separate the reassuring from the red flags, head to navel
Scalp swellings
| Feature | Caput succedaneum | Cephalohematoma | Subgaleal hemorrhage |
|---|---|---|---|
| Layer | Subcutaneous edema over the presenting part | Subperiosteal blood | Blood beneath the galea aponeurosis |
| Sutures | Crosses | Confined to one bone (usually parietal) | Crosses; extends from orbital ridges to nape |
| Onset and feel | At birth; soft, pitting | Hours after birth; firm, well defined | Hours after birth; boggy, fluctuant, shifts with position |
| Course | Resolves in 2–3 days | Weeks to months; may calcify; jaundice | Hypovolemic shock, consumptive coagulopathy |
| Management | Reassurance | Observation; monitor bilirubin; do not aspirate | Serial head circumference, hematocrit, coagulation; volume, RBCs, plasma |
Cephalohematoma. The periosteum is anchored at the sutures, so the collection cannot cross them. Resorption of the blood adds to the bilirubin load and can cause hyperbilirubinemia; a minority overlie a linear skull fracture. Aspiration is avoided because it risks infection.
Subgaleal hemorrhage follows vacuum extraction, which tears emissary veins into the large, loose subaponeurotic space. Each 1-cm increase in head circumference represents roughly 40 mL of blood, a large share of a newborn's blood volume. Pallor, tachycardia, and a falling hematocrit in the first hours demand immediate volume, packed red cells, and plasma.
Nerve injuries and birth fractures
Erb-Duchenne palsy (C5–C6). The most common brachial plexus injury, caused by stretching the upper trunk during shoulder dystocia or delivery of a macrosomic infant. The arm lies adducted and internally rotated with the elbow extended, forearm pronated, and wrist flexed (the "waiter's tip"). The Moro and biceps reflexes are absent on that side, but the grasp is preserved. An ipsilateral phrenic nerve palsy (C3–C5) can accompany it, causing respiratory distress and an elevated hemidiaphragm.
Klumpke palsy (C8–T1). A rarer lower-trunk injury from traction on an abducted arm, as in breech arm delivery. Weak intrinsic hand muscles and wrist flexors produce a claw hand with an absent grasp. Involvement of the T1 sympathetic fibers causes an ipsilateral Horner syndrome (ptosis, miosis, anhidrosis, later iris heterochromia), which suggests root avulsion and a poorer prognosis.
Managing plexus palsies. Most recover over weeks to months. The sleeve is pinned across the chest for about a week, then gentle passive range-of-motion exercises prevent contractures. Infants without returning biceps function by about 3 months are referred to a brachial plexus specialist for possible nerve surgery. Radiographs exclude an associated clavicle or humerus fracture.
Clavicle fracture. The most common bone broken during birth. Signs are crepitus or a bony step-off, reduced arm movement, and an asymmetric Moro with a normal grasp. A radiograph confirms it, and a firm callus becomes palpable within 1–2 weeks. Treatment is gentle handling with optional sleeve pinning and analgesia; healing is complete within weeks, and a fracture explained by the delivery does not require an abuse evaluation.
Facial nerve palsy. Compression of the peripheral facial nerve by a forceps blade or by the maternal sacral promontory. On crying, the mouth is pulled toward the normal side, while the affected side has a flat nasolabial fold, incomplete eye closure, and a smooth forehead. Most recover within weeks; eye lubrication prevents corneal injury.
Asymmetric crying facies with normal eye closure and forehead wrinkling points instead to congenital hypoplasia of the depressor anguli oris muscle, which can accompany cardiac defects such as those of 22q11 deletion.
Benign newborn skin findings
Erythema toxicum neonatorum. The most common newborn rash in term infants: blotchy erythematous macules with central yellow-white papules or pustules on the trunk and face, appearing at 24–72 hours and sparing the palms and soles. A Wright-stained smear shows eosinophils. It resolves within 1–2 weeks.
Transient neonatal pustular melanosis. Present at birth and more common in darker-skinned infants. Fragile pustules without surrounding erythema (sometimes on the palms and soles) rupture to leave collarettes of scale and hyperpigmented macules that fade over months. The smear shows neutrophils without organisms.
Milia and oral cysts. Milia are pearly white keratin-filled papules on the nose, cheeks, and chin; Epstein pearls are the palatal equivalent and Bohn nodules sit on the gum ridges. All resolve spontaneously.
Congenital dermal melanocytosis. Flat blue-gray patches over the sacrum, buttocks, or back, caused by melanocytes arrested in the dermis. They are most common in Asian, Black, Hispanic, and Native American infants and usually fade during early childhood. Their location and size are recorded at birth so they are not later mistaken for abuse: bruises are tender, change color over days, and appear in new places, whereas melanocytosis is painless and unchanged for months.
Vascular birthmarks
| Feature | Salmon patch (nevus simplex) | Port-wine stain | Infantile hemangioma |
|---|---|---|---|
| Nature | Capillary stain, midline | Capillary malformation (somatic GNAQ), unilateral | Benign endothelial tumor, GLUT-1 positive |
| At birth | Present: nape, glabella, eyelids | Present | Absent or faint precursor |
| Course | Darkens with crying; most fade (nape may persist) | Grows with the child; darkens and thickens | Rapid growth, mostly by 3–5 months; involutes over years |
| Key concern | None | V1 location → Sturge-Weber | Periocular, airway, ulceration, PHACE, lumbosacral |
| Treatment | None | Pulsed-dye laser | Oral propranolol if high risk; topical timolol if small |
Sturge-Weber syndrome. A port-wine stain involving the forehead and upper eyelid (V1) signals risk of ipsilateral leptomeningeal angiomatosis, which causes seizures, hemiparesis, intellectual disability, and "tram-track" gyriform calcifications, and of glaucoma. These infants need ophthalmology with intraocular pressure checks and a contrast-enhanced brain MRI.
Infantile hemangioma. The most common tumor of infancy, more frequent in girls, preterm and low-birth-weight infants, white infants, and multiple gestations. Superficial lesions are bright red "strawberry" plaques; deep lesions are bluish subcutaneous masses. Involution often leaves fibrofatty residue.
When to treat. High-risk hemangiomas are referred early, ideally by 1 month of age: periocular lesions (amblyopia), "beard-distribution" lesions (subglottic hemangioma with stridor), ulcerated lesions, and large lesions of the face, nasal tip, or lip. Oral propranolol is first-line and is given with feeds because it can cause hypoglycemia, bradycardia, and bronchospasm.
Large segmental facial hemangioma → PHACE (posterior fossa malformations, hemangioma, arterial anomalies, cardiac defects such as coarctation, eye anomalies): obtain MRI/MRA of the head and neck, echocardiogram, and eye exam before propranolol. Midline lumbosacral hemangioma → spinal ultrasound or MRI for tethered cord; five or more skin hemangiomas → liver ultrasound.
The umbilicus
Vessels. The normal cord has two arteries and one vein. A single umbilical artery is associated with renal and genitourinary anomalies, cardiac defects, and aneuploidy such as trisomy 18; if the infant is otherwise normal, a renal ultrasound is obtained.
Delayed separation. The stump usually falls off within 1–2 weeks. A cord still attached after about 3 weeks raises concern for leukocyte adhesion deficiency (defective CD18/β2 integrin), with marked neutrophilia, omphalitis, and infections that do not form pus.
Granuloma vs remnant. An umbilical granuloma is moist, pink, friable granulation tissue at the base after separation and responds to topical silver nitrate; one that fails may be an umbilical polyp of ectopic intestinal or gastric mucosa, which is excised. Persistent drainage signals an embryologic tract: clear urine that increases with crying or straining means a patent urachus (allantois remnant to the bladder), evaluated with ultrasound and often a voiding cystourethrogram; stool or mucus means a patent omphalomesenteric (vitelline) duct to the ileum, whose partial persistence is a Meckel diverticulum. Both tracts are surgically excised.