II. Exam: Head

  1. Molding
    1. Over-riding of cranial bones
    2. Normal finding at delivery
    3. Resolves spontaneously over first 5 days of life
  2. Scalp Swelling
    1. Caput Succedaneum
      1. Skin or soft tissue scalp edema not limited by Suture lines
      2. Resolves within 48 hours of delivery
    2. Cephalohematoma
      1. Scalp Hematoma limited by Suture lines
      2. Subperiosteal blood vessel injury typically associated with vacuum or Forceps Assisted Delivery
      3. May worsen over the first 48 hours and require months to resolve completely
      4. Increases risk for Neonatal Hyperbilirubinemia and Neonatal Sepsis
      5. Rarely associated with Skull Fracture
    3. Vacuum Caput
      1. Associated with vacuum extractor usage
    4. Subgaleal Hemorrhage
      1. Deep scalp Hematoma that crosses midline and Suture lines and may grow to encompass the entire scalp
      2. Associated with repeated Vacuum Assisted Delivery attempts or Coagulopathy
      3. Distinguish from Cephalohematoma as Subgaleal Hemorrhage requires close observation for Hemorrhagic Shock
    5. Encephalocele or Meningocele
      1. Midline swelling
  3. Fontanelles
    1. See Fontanelle
    2. Fontanelle should be soft, not sunken (e.g. Dehydration), and not bulging (e.g. Increased Intracranial Pressure)
    3. Anterior Fontanelle is 2.1 cm on average at birth, up to 3 to 6 cm in diameter
    4. Posterior Fontanelle is 0.5 to 0.7 cm on average at birth, up to 1 to 1.5 cm in diameter
  4. Head Circumference
    1. Head Circumference normally 33 to 38 cm
    2. See Microcephaly
    3. See Macrocephaly
    4. See craniocynostosis
  5. Facial Asymmetry
    1. See Facial Nerve Injury from Birth Trauma
    2. Birth Trauma (e.g. difficult forceps delivery) may be associated with Facial Nerve injury
    3. May present with persistantly open eye, unilateral loss of nasolabial fold or drooping at corner of mouth
    4. Resolves over first few weeks of life in most cases

III. Exam: Ears

  1. Newborn Hearing Screening (performed before discharge after delivery)
    1. Automated Auditory Brainstem Response (ABR) or
    2. Transient Evoked Otoacoustic Emissions (OAE or TEOAE)
  2. Congenital Ear Anomaly
    1. Low Set Ears
      1. Pinna falls below the horizontal level of the medial canthus of the eye (or line drawn from the lateral canthus to the occipital protuberance)
      2. Caused by several congenital disorders (e.g. Trisomy 21, Trisomy 18)
      3. Associated with Hearing Deficits (obtain Newborn Hearing Screening) and genitourinary anomalies (obtain renal Ultrasound)
    2. Microtia
      1. Small, undeveloped pinna or absent pinna in the case of anotia
      2. May occur in isolation or due to underlying condition (e.g. CHARGE Syndrome, Goldenhar Syndrome, Treacher-Collins Syndrome)
      3. May be associated with Hearing Deficit
    3. Pre-auricular Skin Tags, ear pits, fissures or sinuses
      1. Growths or defects at the anterior Ear Pinna
      2. Associated with Hearing Deficits (obtain Newborn Hearing Screening)
      3. Renal Ultrasound not indicated unless other dysmorphic features, Teratogen Exposure, deafness Family History or maternal diabetes

IV. Exam: Nose

  1. Physiology
    1. Infants are obligate nose breathers until 4 months old
  2. Exam
    1. Check patency with stethoscope (listen over nares)
    2. Nasal Saline can reduce nasal stuffiness
  3. Choanal Atresia
    1. Fixed obstruction of nares (narrowed or completely obstructed)
    2. Attempt to pass a small-caliber catheter
    3. Bilateral Choanal Atresia in the newborn is an airway emergency
  4. Asymmetry of the nasal septum
    1. Most often due to in utero positioning
    2. Correction of asymmetry by depressing the nasal tip predicts spontaneous resolution (refer non-correcting cases to otolaryngology)

V. Exam: Mouth

  1. Cleft Lip and Cleft Palate
    1. Most common significant head and neck anomalies
    2. Midline clefts require evaluation for midline defects involving the brain and other central structures
  2. Micrognathia (Mandibular Hypoplasia)
    1. Small Mandible undersized for the associated Maxilla associated with many congenital disorders (e.g. Pierre Robin Syndrome)
  3. Ankyloglossia (short frenulum)
    1. Short frenulum tethers the Tongue to the mouth floor and may inhibit feeding
  4. Bifid Uvula
    1. Often associated with a submucosal cleft
  5. Lip Suction Blisters
  6. Neonatal Teeth
    1. Lower gum teeth that (usually require extraction, especially if loose due to risk of aspiration)
  7. Epstein's Pearls
    1. Small (1-2 mm) white palatal Vesicles (analogous to milia on skin)
    2. Localized to the midline palatal raphe near the boundary between the hard and Soft Palates
    3. Resolve spontaneously
  8. Bohn Nodules (Epithelial Pearls)
    1. Small (1-3 mm), shiny white keratin-filled nodular lesions on the Buccal mucosa that resolve spontaneously
  9. Ranula
    1. Benign mucus retention cysts in the floor of the mouth (often require surgical removal)

VI. Exam: Neck

  1. Congenital Torticollis
    1. Reduced neck range of motion typically due to Birth Trauma to sternocleidomastoid Muscle
    2. Typically referred to physical therapy
    3. Risk of Positional Plagiocephaly if not corrected
  2. Webbed Neck (Pterygium Colli Deformity)
    1. May appear as loose folds of skin at the neck
    2. Seen in Turner's Syndrome, Noonan Syndrome and Klippel-Feil Syndrome
  3. Cystic Hygroma
    1. Congenital lymphocytic malformation at the neck
  4. Thyroglossal Duct Cyst
    1. Congenital midline neck lesion moves with the Tongue
  5. Branchial Cleft Cyst
    1. Congenital lateral Neck Mass
  6. Thyroid Goiters
    1. Rare in developed countries
  7. Clavicle Fracture from Birth Trauma
    1. Most common newborn orthopedic injury (associated with Shoulder Dystocia)

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