General examination initial and subsequent assessments

FIGURE 44-1. Examination: First hours of life. (Source: Adapted from Kempe C, Silver H, O’Brien D, eds. Current Pediatric Diagnosis and Treatment. 3rd ed. Los Altos, CA: Lange; 1974.)
SKIN
Gestational Changes
Fine, soft, lanugo hair covers the entire body in very preterm infants and disappears from the face and lower back between 32 and 37 weeks. The term infant has lanugo hair on the upper back and dorsal aspects of the limbs. Vernix caseosa, a thick white material with the consistency of soft cheese, covers the skin of the entire body until 35 to 37 weeks. By term, the amount of vernix has decreased so that it is present mainly in the flexor creases. Also by term, the subcutaneous tissue is relatively thick, and the fingernails and toenails are fully formed and extend slightly beyond the ends of the digits. If fetal hypoxia occurs at term, meconium may be passed into the amniotic fluid. If meconium has been in the amniotic fluid for several hours, it will also stain the skin, fingernails, toenails, and umbilical cord with a greenish hue. Fetuses at less than 34 weeks of gestation rarely pass meconium in response to hypoxia. The postmature infant (beyond 42 weeks) may have a somewhat wasted appearance with dry, peeling skin, a decreased amount of subcutaneous tissue, long fingernails, and an alert appearance.
Skin Abnormalities
A neonatal rash may also indicate a serious systemic infection. Intrauterine infections may present with thrombocytopenic purpura. A red maculopapular rash may occur with toxoplasmosis. Congenital rubella often produces macular or slightly raised purple lesions, called a “blueberry muffin” rash. Herpes simplex can cause a few vesicles or a generalized vesicobullous eruption with an erythematous base; these cutaneous lesions may precede disseminated disease or may appear following the onset of disease in other organs. Congenital syphilis may cause a pink, maculopapular rash that later turns brown or becomes vesicobullous and hemorrhagic. Syphilitic rashes commonly involve the palms or soles. Staphylococcal infection may appear as pustules, generalized erythema, or extensive bullous eruptions (termed scalded skin syndrome, toxic epidermal necrolysis, or Ritter disease). Listeria monocytogenes can produce purple, miliary granulomas of the skin. Cutaneous moniliasis often produces macerated, erythematous skin, usually in the diaper area, and often occurs in infants treated with antibiotics. Many of these skin lesions contain viable organisms (eg, syphilis, herpes, Staphylococcus) and are highly infectious. Some generalized viral infections are characterized by small red papules that contain infiltrations of erythroid cells.
The normal newborn often has some form of benign skin lesion. These neonatal skin abnormalities include congenital absence of skin (aplasia cutis), rashes, erythroderma, vesicles, pustules, bullae, purpura, and petechiae are discussed in Chapter 357. Pigmented skin lesions and nevi are discussed in Chapter 361, vascular lesions in Chapter 364 and other genetic skin disorders in Chapter 360.
Color
Pallor may result from anemia or poor perfusion. With poor perfusion from vasoconstriction or low cardiac output, capillary filling after blanching of the skin over the tibia is delayed (> 3 sec). In pigmented babies, poor perfusion is more readily detected by delayed capillary filling after blanching of the toes or fingers. Pallor of mucous membranes in these infants suggests anemia. A generalized gray hue may indicate acidosis. Pale, mottled skin occurs with sepsis or hypothermia. There may be cyanosis of the hands and feet (acrocyanosis), which is normal immediately after birth or if the infant has been exposed to a cold environment. Generalized cyanosis occurs with significant arterial hypoxemia as well as with methemoglobinemia. Plethora may indicate polycythemia. Harlequin skin describes a transient change in the skin color: one side of the body turns pale while the other side remains pink with a sharp line of demarcation in the midline. Harlequin change can last for seconds or a few minutes and may recur but is of no known pathologic significance.