Assessment of the new born

DR AJIT GADEKARDEPARTMENT OF PEDIATRICS

Aims ……………………………• To review anticipated problem

• To ascertain family worries

• To screen for specific target conditions

• To diagnose congenital malformation

• To collect baseline information

• To identify mother with substance abuse

• To initiate appropriate treatment

Assessment of fetal well being• ANTEPARTUM TEST…………………………………………• Fetal movement monitoring.. 30-40mts ..inacitvity > 1hr.• non stress test – quick non invasive no discomfort fatal activity accelerate FHR required maturity > 32 wks

Fetal well being• Non stress test result..reactive ..non reactive ..inadequate• Reactive .. FHR 120-160 .. normal beat to beat variabilty .. 2 acceleration 15 bpm not less than 15 seconds each in 20 mts period.

Fetal well being

• Contraction stress test ……………………… .. Uterine contraction compromise unhealthy fetus. .. Under hypoxic condition FHR show characteristic pattern relative to contraction

Fetal well being

• Contraction stress test is completed Spontaneous contraction within 3o mts lasted for 40-60 seconds frequency of 3 within 1o mts• late deceleration type II FHR decelerate 15-30 seconds after contraction does not return to baseline until end of

contraction deceleration of uteroplacental insufficiency

Fetal well beingCST NEGATIVE.. 3 contraction/10mts for 40 sec no late declaration

CST POSITIVE.. Consistent late deceleration

CST SUSPICIOUS.. Inconsistent late declaration

CST HYPERSTIMULATED.. No interpretation

Fetal well being

• Reactive NST Chance of fetal demise.. 3/1000

• Negative CST chance of fetal demise 0.4/1000

• Positive CST following Non reactive NSTRisk of still birth , NMR 88/1000

Biophysical profile• NST with real time ultrasonic parameters reactive NST

Adequate amniotic fluid volume

Fetal breathing movement

Fetal activity

Normal musculoskeletal tone

Biophysical profile

• Reassuring test ( 8-10 )Repeat weekly , fetal demise 0.6/1000

• Less reassuring test ( 4-6 )Repeat later the same day

• Very low score ( 0-2 )Prompt delivery

Umbilical artery blood flow• Non invasive technique

• To assess placental resistance

• Increased resistance is noticeable in fetal diastole

• Systolic frequency shift (S) , end diastolic frequency shift (D) ,S : D , S-D/S (resistance index),puslatility index ( PI )

Intrapartum assessment of fetal well being

fetal heart rate monitoring - tachycardia

Uterine activity

Beat to Beat variability … 5-10beats/mts

FHR acceleration - reassuring

Intrapartum assessment

• Decelerations early type I ( head compression deceleration )Symmetric in shape , mirror of uterine

contraction , good beat to beat variability

Late type II ( uteroplacental insufficiency )

Variable type III ( cord pattern deceleration )

Ultrasound assessment

• Fetal abdominal circumference < 10 th centile

• Fetal head circumference

• Estimation of fetal weight accuracy +/-10 %

• Cerebral circulation – MCA

Assessment in the delivery room

• First interview

• Maternal history is history of new born

Normal values for umbilical cord blood

• UApH• UApCO2 (mmHg)• UApO2 (mmHg)• UA-BE• UVpH• UVpCO2 (mmHg)• UVpO2 (mmHg)• UV-BE (meq/l)

• 7.26• 53• 17• -4• 7.34• 41• 29• -3

Gestational age assessment

• Early obstetrics ultrasound + menstrual dates

• Direct ophthalmoscopy to visualize lens can be applied after 27th wk to vessels of lens cover entire anterior surface of lens 27-28wkReach to middle of the lens 31-32wkReach periphery at 33-35wk

Gestational age assessment

• Physical maturation

• Development of the nervous system

Physical maturation

• The physical assessment part of the Dubowitz/Ballard Examination examines physical characteristics that look different at various stages of a baby's gestational maturity.

• Points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as high as 4 or 5 for post maturity.

Physical assessment

• Farr et al 11 criteria 34 points

• Dubowitz et al 35 points for same criteria

• Parkin et al 4 criteria 13 points

• New Ballard score is valid for preterm

Physical assessment • skin textures (i.e., sticky, smooth, peeling).

• lanugo (the soft downy hair on a baby's body) - is absent in immature babies, then appears with maturity, and then disappears again with postmaturity.

• plantar creases - these creases on the soles of the feet range from absent to covering the entire foot, depending on the maturity.

Physical assessment • breast - the thickness and size of breast tissue and areola (the

darkened ring around each nipple) are assessed.

• eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue.

• genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled.

• genitals, female - appearance and size of the clitoris and the labia.

How is neuromuscular maturity is assessed

• posture - how does the baby hold his/her arms and legs.

• square window - how far the baby's hands can be flexed toward the wrist.

• arm recoil - how far the baby's arms "spring back" to a flexed position.

How is neuromuscular maturity is assessed

• popliteal angle - how far the baby's knees extend.

• scarf sign - how far the elbows can be moved across the baby's chest.

• heel to ear - how close the baby's feet can be moved to the ears.

Examination of new born

• Answer any question mother may arise

• Introduce yourself to mother explain what you are doing

• Fully examine the baby

• Give advise , information , arrange follow up , and provide reassurance where appropriate

Examination of new born

• Observe mothers attitude to her baby whether she is happy , tense , withdrawn

• Observe the colour , fascies , breathing pattern , posture , movement

Order of examination

• Remove the baby's clothes except nappy

• Feel the AF for tension

• Look at the face for colour or any peculiarities

• Estimate RR , HR, listen to heart

Order of examination

• Palpate the abdomen

• Return to head examine scalp , skull , OFC

• Examine the eyes , ears , nose , mouth

• Examine the neck , clavicles

Order of examination

• Examine arms , hands , legs , feet.

• Remove the nappy

• Feel the femoral pulse

• exaamine the genitalia and anus

Order of examination

• Turn the baby to the prone position and examine the back , spine , assess tone

• Return infant to supine position evaluate CNS

• Examine the hips

• Make sure u have not omitted anything.

Systematic review

• SKIN

colour , texture , cyanosis , icteurs , pallor

skin rashes erythema toxicum , transient neonatal pustular melanosis , Miliaria rubra

Systematic review – skin erythema toxicum

Systematic review – skin normal peeling

Icthyosis – avoid fluid loss involve dermatologist , geneticist

Mongolian spot slate gray no evaluation

Acrocynosis

Salmon patch (angel kisses), one over forehead resolves late

Port wine stain• congenital pink patches more intense and

purple-red in colour than salmon patches. • The discoloration is not, of itself, a problem,

but it may be a clue to an underlying condition.

• Port wine stains on the face may be associated with sturge weber syndrome,

• extremities may be associated with klippel trenaunay-weber syndrome, in which overgrowth of an extremity may occur.

Port wine stain

Milia

Milia are keratin filled epithethial cysts which occur in up to 40% of newborns.

Spontaneous exfoliation and resolution is expected within a few weeks.

Parents will occasionally mistake these lesion for neonatal acne, but Milia are present at birth and have no inflammatory component. .

Milia

sebaceous hyperplasia

• The lesions are more yellow than Milia and are the result of maternal androgen exposure in utero.

• Sometimes referred to as "the miniature puberty of the newborn"

• Sebaceous hyperplasia is a benign finding and spontaneously resolves with time. No evaluation is needed.

sebaceous hyperplasia

subcutaneous fat necrosis• This red lesion is subcutaneous fat necrosis. On

palpation, there is a firm nodule in the subcutaneous tissue under the area of redness that is freely mobile with respect to the bony structures underneath it.

• Subcutaneous fat necrosis is more common in infants who have had difficult deliveries, cold stress, or perinatal asphyxia.

• Lesions are typically asymptomatic and resolve spontaneously within several weeks, usually without scarring or atrophy.

• Hypercalcemia associated with subcutaneous fat necrosis is rare, but is a potentially lethal complication.

subcutaneous fat necrosis

Transient neonatal pustular melanosis• The hallmark of this rash is the hyperpigmented

spots that remain (seen here on the chest) after the fragile pustules (seen on the scrotum and thigh) have resolved.

• Because the rash starts in utero, lesions may be in any stage at birth.

• Despite the anxiety-provoking appearance of a newborn covered in pustules in the delivery room, no evaluation is needed.

Transient neonatal pustular melanosis

Petechiae

• Blanching the abdomen reveals more petechiae than were appreciated on casual examination.

Petechiae

Congenital melanocytic nevus

• Here is a typical appearance of a junctional melanocytic nevus.

• The lesion is completely flat and is medium to dark brown in colour.

• It may be present at birth. It may become slightly raised as the infant grows and may become a compound nevus if intradermal melanocytes develop. It is considered a benign lesion.

Congenital melanocytic nevus

Cafe au lait spots

• Cafe au lait spots are lighter in colour than melanocytic nevi, but they also may be congenital macules.

• They are caused by an increased amount of melanin in both melanocytes and epidermal cells, and may increase in number with age

• Most children with cafe au lait spots do not have neurofibromatosis, but the presence of six or more of these spots that are larger than 0.5cm diameter is considered to be a major clue to the diagnosis.

Cafe au lait spots

Cutis aplasia• The red "excoriated" area and the hairless,

circular lesion anterior to the ear.

• Cutis aplasia is often thought of in association with trisomy 13, but it can also be an isolated finding in an otherwise well newborn

Cutis aplasia

Forceps mark

• The semi-circular red mark on this infant's right cheek is a forceps mark.

• These marks have no consequence and will spontaneously resolve. In rare cases when the skin is abraded, antibiotic ointment may facilitate healing.

Forceps mark

Head and skull overriding of sutures • This picture shows what is usually noted

primarily on palpation: the ridges that develop when one bone slightly overlaps the adjacent one during delivery.

• These over-riding sutures are part of molding. Complete resolution is expected with time.

Head and skull overriding of sutures

Breech moulding • With breech positioning in utero, the head is in a

position against the uterine fundus.

• This gives the newborn head molding that is flat on the top and elongated in AP diameter.

• As with any molding, this appearance will be improved significantly over the next few days

Breech moulding

Cephalohematoma • Cephalohematoma is a collection of blood under

the periosteum of a skull bone. Because of its location, it is impossible for Cephalohematoma to cross suture lines.

• If more than one bone is affected, there will be a separation between the two areas at the suture line as seen in this photo -- the sagittal suture separates the bilateral parietal Cephalohematoma.

• On palpation, these areas feel fluctuent.

Cephalohematoma

Cephalohematoma

Firm, constant pressure in one spot is the easiest way to elicit the characteristic pitting edema of caput.

subgaleal bleed• The subgaleal area (between the scalp and the skull) is

a large potential space, so when bleeding occurs there, it easily moves to the dependent part of the skull.

• As pressure is placed on that area, a fluid wave can be seen that radiates from the occiptal area all the way to the space over the anterior fontanelle .

• Because of the size of the space, exsanguination of the baby's entire circulating blood volume into the subglaeal space is a possiblity if active bleeding continues.

Subgaleal bleed

Eye examination- dysconjugate eye movements

During the first few months of life, newborns will frequently have dysconjugate eye movements, where the eyes appear to move independently. Eyes may transiently appear crossed or divergent. This phenomena is particularly noticeable when the infant is falling asleep or being woken from sleep. If the dysconjugate movement is fixed (one eye is always out, or always in, relative to the other), a paediatric ophthalmologist should be consulted. But if the movements are transient, it is a normal finding and will spontaneously resolve.

dysconjugate eye movements (roving eye)

Dacrocystoceles bluish nodules inferior to the medial canthi of

both eyes, widely spaced eyes (hypertelorism), and a flat nasal bridge.

They are caused by obstructions at both superior and inferior ends of the nasolacrimal duct. Though relatively small externally, these lesions can obstruct the nasal passages.

internal nasal evaluation is recommended when the dacrocystoceles are bilateral, even when the patient is otherwise asymptomatic .

Dacrocystoceles

Subconjunctival haemorrhage• Subconjunctival haemorrhage is a frequent

finding in normal newborns. • It results from the breakage of small vessels

during the pressure of delivery. • The red area may be large or small but is always

confined to the limits of the sclera.• It is asymptomatic, does not affect vision, and

spontaneously resolves in several days.

Subconjunctival haemorrhage

gonococcal conjunctivitis When gonococcal conjunctivitis occurs, it typically

presents in the first few days of life with copius, purulent discharge in the eyes.

In this infant, the marked edema of the eyelids was the first symptom noted, but with just slight pressure on the lids, purulent material oozed out .

Gonococcal conjunctivitis is an ophthalmologic emergency. Because the bacteria can erode through an intact cornea.

Treatment is very aggressive and includes systemic intravenous antibiotics, frequent eye washes, and monitoring in a neonatal intensive care unit.

gonococcal conjunctivitis

Congenital glaucoma

Congenital cataract• the opacities here

occur behind the pupil, as the pupil is easily and clearly seen along its entire circumference.

• Red light reflexes could not be obtained from either eye

Peters anomaly

• the opacity is central and could be mistaken for opacity of the lens, a view from a more oblique angle shows the cloudiness extends over parts of the iris as well.

• With the use of a flash, a red reflex should have been prominent in this photo, but wasn't.

Normal ear • the normal ear is

one is which all the structures (helix, antiehelix, tragus, antitragus, scaphoid/triangular fossa, and external auditory canal) are all present and well formed.

Ear tag• A single, small ear tag is

an occasional finding on physical examination.

• It is often inherited as a familial trait.

Ear pit• They are located at the

superior attachment of the pinna to the face and may be unilateral or bilateral.

• There is a rare association between ear pits and Brachio-Oto-Renal Syndrome .

• audiologic testing of these infants is recommended, but otherwise this is considered a benign finding.

Stahl's ear

• Also known as Satyr ear, Spock ear, or Vulcan ear, this deformity of the pinna is characterized by a flat helix at the superior pole, a third crus extending into the helix, and a flattened scaphoid fossa.

• When this deformity is severe enough to be of cosmetic concern, molding and splinting can be initiated by a plastic surgeon

• As an isolated finding, cosmesis is the only concern, but the appearance will not improve with time. Exact etiology is unknown.

lop ear• This pinna deformity,

where the superior edge of the helix is folded down, is known as lop ear.

• Again, it is typically an isolated finding.

• This is another deformity that may be improved with splinting.

Prominent ear or cup ear• Cup ear refers to an

auricle shape that stands away from the head at the superior, posterior, and inferior aspects.

• In the past, this ear morphology was thought to be an indicator of underlying neuromuscular pathology, but more recent experience does not seem to support this theory.

• This finding is only of cosmetic concern.

Microtia • In contrast to the

previous photos, this pinna is not well-formed and is smaller than a normal ear.

• This is microtia. Hearing evaluation is mandatory in these infants and referral to a pediatric ENT specialist is recommended.

Hypoplastic ear• The ear is hypoplastic and

low set. Again, because genetic syndromes are frequently associated with abnormal ear shapes, a careful physical examination should be performed.

• Even in the absence of other findings, referral to a pediatric ENT specialist may be indicated, as an abnormal pinna may be an indicator of internal ear abnormalities

Low set ear • Here, the low set

position of the ear (also hypoplastic) can be appreciated.

• If an imaginary line is drawn from the outer canthus of the eye straight back to the occiput a low set ear will fall completely below the line.

Dislocated nasal septum• The septum is not

straight and the whole bottom segment of the nose appears to be shifted to the baby's left .

• Compressing the tip of the nose gently can also help distinguish this condition from a positional problem, as the next photo demonstrates.

Dislocated nasal septum • When the tip of the nose

is compressed gently in the presence of a dislocated septum, the deformity appears to worsen. With positional deformity, the septum would stay straight, even if the nares appear uneven. recognition of this condition and timely referral is important to prevent permanent deformity.

Positional deformation of jaw

• the angle between the upper and lower jaws can be better appreciated with the gums closer together.

Epstein pearl• The small white papule

seen in the midline of the palate of this infant is an Epstein pearl.

• It represents epithelial tissue that becomes trapped during the palatal fusion. It is a very common and benign finding.

Bifid uvula• The uvula is almost twice the

normal width, and although it is not clearly bifid, there is a suggestion of two halves. This finding is known to be associated with submucous cleft ,

• Submucous cleft may be noted on palpation, but it is important to note that when a newborn is comfortably sucking on the examiner's finger, one is palpating only the hard palate. Direct palpation of the soft palate is necessary to evaluate for submucous cleft.

Cleft lip • unilateral cleft on the

left side of the lip. It is important to distinguish unilateral (or bilateral) cleft lip from the more unusual and concerning midline clefts that can occur.

• Midline clefts are often associated with underlying midline defects in the brain or other structures.

Bohn's nodules• The white bumps present

on the upper gum in this infant are Bohn's nodules.

• The exact etiology is unknown, but they are thought to arise from remnants of the dental lamina or from heterotrophic salivary glands.

• these nodules are a benign finding and will disappear with time.

Ankyloglossia • Tongue-tie occurs in

approximately 4% of newborns. Many babies with this condition can breastfeed without difficulty, but in some cases, a tight frenulum makes latching on difficult. In those cases, frenotomy may be indicated

Natal teeth• Natal teeth usually occur in this

location in the mandibular gum. In this case, eruption cysts are still completely covering the teeth, but with palpation, 2 firm teeth can be appreciated. They are also partially visible as faint white streaks within the cysts. Natal teeth occur in 1:2000 - 1:3500 newborns. They are usually part of the primary dentition of the child, so they should not be removed unless they are mobile, presenting an aspiration risk,

Micrognathia• Micrognathia, or "small

jaw", can often be best appreciated when looking at the profile of the infant. While many infants may appear to have a slightly recessed chin, the appearance above is clearly abnormal. Underlying genetic conditions should be considered in cases such as this.

Neck - clavicle

• Clavicle fracture

• Notice asymmetry

Supernummerary nipple• The brown macule

below the left nipple in this infant is a supernummerary nipple. Found along the "milk lines" they may be single or multiple, unilateral or bilateral. It is an insignificant finding.

Prominent xiphoid• This visible, firm lump in

the midline of the chest is a frequently observed finding in newborns. It is simply a prominence of the xiphoid process and does not represent an abnormality. With time, this becomes less noticeable.

Pectus excavatum • With deep inspiration,

the sternum appears to almost collapse into the chest cavity. While connective tissue disorders, such as Marfan's, may be associated with this finding, pectus excavatum is more commonly a benign, isolated entity.

Diastasis recti• A vertical bulge down the

midline of the abdomen can be seen in many newborns when intra-abdominal pressure increases. In this photo, a shadow lateral to the bulge can be seen going up the left side of the abdomen, starting near the umbilical clamp. Diastasis recti is caused by a relative weakness of the fascia between the two rectus abdominus muscles. It is not a herniation and is not pathologic. With time, this will disappear.

Normal umbilical cord• Looking at the cut edge

more clearly shows the normal vessels of the umbilical cord. The two arteries are to the left and the vein, with a spot of blood in its large lumen, is on the right.

Meconium stained umbilical cord

omphalitis• this is the appearance of a

full-blown case of omphalitis. The progression of erythema over time can be clearly seen from the circles marked on the abdomen. The first circle was drawn less than 12 hours after redness was initially seen, and the second circle was drawn several hours after that. Omphalitis of this degree can be fatal, even with aggressive antibiotic therapy, so infection in this area should always be taken seriously.

Wharton's jelly cyst• Also known as a "false

cyst" of the cord, a Wharton's jelly cyst is an area where liquefaction of the jelly has occured. Up to 20% of infants with this condition have associated anomalies.

Typical breech position• When an infant has been in

breech position in utero, the legs have a tendency to remain in this position for the first few days. As with any positional deformity, spontaneous resolution is anticipated.

• This leg position does not, of itself, indicate any problems with the hips.

galeazzi sign A positive galeazzi sign

(unequal knee heights) suggests a unilaterally dislocated hip.

It is important to remember that bilateral dislocations will likely appear symmetric, so this assessment should only be used in combination with the Ortolani and Barlow manuevers. The infant in this photo has a negative galeazzi -- the hips are normal.

Positive galeazzi sign

pavlik harness

pavlik harness

Abnormal hip abduction• Limited abduction can be

a sign of DDH, so it is a useful tool in assessment, especially for older infants when Ortolani and Barlow manuevers are not helpful.

Penile pearl The tip of the foreskin is

another relatively common location. The pearl is a small, firm, white nodule that contains keratin. It will spontaneously exfoliate and resolve with time. It is a normal finding and is not a contraindication to circumcision, if desired

Hypospadias• opening of the urethra on

the distal penile shaft. A hooded foreskin, which allows the glans to be readily visible, is present. Hypospadias affects 1:250 boys, but most have a milder form than that shown here.

Hypospadias

epispadias• With epispadias, the

urethral meatus is dorsally displaced. This condition is much less common than hypospadias, but also presents a contraindication to routine circumcision. In it's severe forms, epispadias is often associated with exstrophy of the bladder.

This is an example of severe epispadias and bladder exstrophy

Chordee• Chordee exists when there is

a ventral curvature of the penis. It can occur in the setting of hypospadias, but can also be isolated, as in this case. In this baby, the curvature is most visible from this view from the side. Chordee is a contraindication to circumcision in the newborn period, but if desired, circumcision can be done at the time of surgical correction

Hydroceles• Hydroceles are a

frequent finding in newborns. It is important on palpation to identify the normally small testicles (approximately 1 cm) as separate entities from the large, smooth-walled fluid collections of hydroceles.

Acute testicular torsion• Because of the pathology

that is occuring in the right testicle, the right scrotum does not transilluminate equally with the left.

Ambiguous genitalia

• under-virilized male with hypospadias, micropenis, and bifid scrotum (testes were present bilaterally).

Ambiguous genitalia• This infant is a male with

micropenis and a cleft scrotum, but on initial evaluation the gender cannot readily be determined. Genetic, metabolic, and urologic evaluation is necessary.

Hymenal tag• In many girls, a small tag of

mucosal tissue can be seen protruding from the vaginal area at birth. This is a hymenal tag, a benign physical finding. With time, this tissue will recede into the vagina and decrease in size. No further evaluation is necessary.

Vaginal cyst

Paraurethral cyst• This mass, present at

birth, was a paraurethral cyst. The fact that the hymen can still be seen inferior to the mass helps differentiate this from imperforate hymen, which could have a similar appearance.

Extremeties • Most newborns have

two major creases on the palm, neither of which completely extend from one side of the palm to the other.

Transverse palmar crease • A common variant, found in

approximately 5% of newborns, a transverse palmar crease is frequently inherited as a familial trait. Although single palmar creases are also associated with Down's syndrome and other genetic disorders, the absence of other abnormalities on physical exam should reassure the examiner that no further evaluation is necessary.

polydactyly • Post-axial polydactyly is

the most common variety. The extra digit may seem almost fully formed or may be attached only by a thin fleshy stalk. This is typically an isolated finding. A positive family history is often obtained.

polydactyly • In cases where the

attachment of the extra digit is very thin, the appendage can be successfully tied off with a silk suture. After allowing some time for hemostasis to occur under the ligature, we usually snip off the appendage with a sterile scissors

Preaxial polydactyly

syndactyly• This type of mild

syndactyly is found occasionally on the physical examination. Again, this is a subtle finding. If the exam is not a careful one, this can easily be missed since both digits are otherwise normally formed. This is usually an isolated finding, and in this location, has no impact on function

severe syndactyly.• In this case, the

syndactyly is severe. All four of the digits on the right were completely fused together (notice the four fused nail beds). The thumb was normally formed and can be seen to the right of the abnormal area. This was a unilateral, isolated finding in an otherwise well newborn; amniotic bands were thought to have caused this problem.

polysyndactyly• When the digits are fused

in addition to being too numerous, the term polysyndactyly is used. Careful examination is important to identify conditions such as this. If the socks (or mittens) are not removed, this finding can be easily missed. While this is not expected to cause a significant functional problem, cosmesis can be of concern as the child gets older

clinodactyly• A slight medial incurvation

of the fifth finger is a frequent finding on the newborn exam. It is often inherited as a familial trait. Although it can be associated with several genetic disorders, including Down's syndrome, the absence of other physical findings will confirm that it is a benign, isolated finding. In this case, no further evaluation is necessary.

Finger hypoplasia• On first inspection, this

infant's hands may appear normal, but on closer inspection, the fifth fingers bilaterally appear hypoplastic, and there is a complete absence of the nail on the infant's left side

Toe hypoplasia

Overlapping toes

• it is a positional deformity of no significance

Edema of the feet • Here is another baby

with edematous feet as a result of Turner's syndrome. From this angle, the excessive puffiness behind the toes can be easily seen.

Club foot • With an attempt to bring

the foot to neutral position, the rigidity of the ankle is apparent. Although the skin is sliding and wrinkling, the actual position of the foot is not changed. The dark discoloration around the ankles are slate grey patches (mongolian spots), not bruises.

Bilateral club foot The feet are plantar-flexed and inverted. Because this is a bony

deformity, this position is rigid.

Sacral hair• Many newborns,

especially those with increased skin pigmentation, will have an increased amount of hair over the lower back and sacrum. This appearance is entirely within normal limits and is not a marker for underlying spinal dysraphism

Neural tube defects

Sacral dimple• Most of these dimples are

"simple dimples" and require no further evaluation.

• A simple dimple is one that is located within 2.5 cm of the anus, has a base that can be visualized and is not associated with other abnormality on exam.

Sacral skin tag• Skin tags in the sacral

area are also potential indicators of spinal dysraphism. In some cases, the "tag" may in actuality be a residual tail.

Dysmorphology

Sandal gap deformity

Loose nuchal skin• Abnormal skin folds over

the back of the neck can be a marker for genetic abnormality. Increased nuchal thickness can be seen on prenatal ultrasound in some infants with Down's syndrome, and increased nuchal lucency (thought to be related to lymphedema) has been noted in fetuses with Turner's syndrome.

Facial palsy in forceps delivery

Brachial plexus injury• This photo shows how the

posture of the arms is asymmetric: the left arm is at the side and the hand is medially rotated at a time when the other arm is flexed with crying. Most brachial plexus injuries of this type resolve spontaneously. Improvement in movement can often be noted within the first 24 hours. If improvement does not occur, referral to a pediatric neurologist, and possibly a physical therapist, is warranted.