Abstract
The newborn period is an exciting time for families but can be anxiety producing for parents and providers. Newborns have limited communication skills and are at high risk for infection as well as presentation for congenital anomalies. History and physical examination are incredibly important in the early infant period as they will often provide clues for further diagnostic evaluation.
Keywords
bronchiolitis, cough, fever, infant, jaundice, newborn, pneumonia, vomiting
Central Cyanosis Versus Acrocyanosis in Infants
1
What is the difference between central cyanosis and acrocyanosis?
Cyanosis is a common clinical finding in newborn infants. Central cyanosis is caused by reduced arterial oxygen saturation. Central cyanosis can be associated with life-threatening illnesses such as cardiac, metabolic, neurologic, infectious, and parenchymal and nonparenchymal pulmonary disorders. Normal infants have central cyanosis until up to 5 to 10 minutes after birth as the oxygen saturation rises to 85% to 95% by 10 minutes of age. Persistent cyanosis is always abnormal and should be evaluated and treated promptly. By contrast, acrocyanosis is seen in healthy newborns and it refers to the peripheral cyanosis around the mouth and the extremities including hands and feet. It is caused by benign vasomotor changes that cause peripheral vasoconstriction and increased tissue oxygen extraction. As opposed to in central cyanosis, in acrocyanosis the mucous membranes of the neonate remain pink. This may persist for 24 to 48 hours, and it is usually not pathologic.
2
In a cyanotic newborn, how could pulmonary disease be distinguished from cyanotic congenital heart disease?
The hyperoxia test is used to differentiate cyanosis secondary to pulmonary versus congenital heart disease. The infant is placed in 100% oxygen, and arterial blood gases are obtained. P co 2 >100 mm Hg is seen with primary lung disease, whereas with heart disease the Pa0 2 is <100 mm Hg.
3
Which congenital heart lesions present with cyanosis on day 1 of life?
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Transposition of great arteries with an intact ventricular septum
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Tricuspid valve atresia
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Pulmonary valve atresia with intact ventricular septum
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Tetralogy of Fallot
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Ebstein anomaly of the tricuspid valve
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Total anomalous pulmonary venous return
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Hypoplastic left heart syndrome
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Truncus arteriosus
Oral Candidiasis
4
How do newborns acquire oropharyngeal candidiasis?
Transmission of fungi from maternal vaginal candidal colonization is the primary means of infection in newborns. It can also be transmitted during breastfeeding. It affects up to 3% to 5% of healthy newborns. Median age of onset is reported to be 9 to 10 days of life. On examination, the thrush presents as white plaques with or without an erythematous base on the buccal or lingual mucosal surface of the mouth. Infants are usually asymptomatic; however, it may interfere with feeding due to discomfort. Mild punctate areas of bleeding confirm the diagnosis during scraping. Nystatin 100,000 U/mL as a dose of 0.5 mL to each side of the mouth given four times daily is the treatment of choice for oral candidiasis.
Newborn Rashes
A 4-week-old presents with rash limited to the cheeks and forehead. She is otherwise feeding and growing well. She is afebrile.
5
Is there a difference between neonatal acne and infantile acne?
Neonatal acne is a variant of acne vulgaris that presents at birth or in the first weeks of life ( Fig. 24.1 ). This occurs in about 20% of newborns. It is due to androgenic hormones, both maternally derived and endogenous. The lesions resolve within 1 to 3 months as the androgenic levels drop. A small percentage of infants develop acne at about 3 to 6 months of age with a greater degree of inflammation. The infantile acne may persist for years, and the cause is unknown. Usually there is no evidence of precocious puberty or increased hormonal levels.
6
How is cradle cap treated at home?
Seborrheic dermatitis presents as a yellow scaly rash on the scalp and may involve the head, eyes, ears, eyebrows, nose, and back of head. Treatment is mineral oil followed by shampooing with a mild anti-dandruff shampoo containing selenium. If lesions are inflamed, a mild topical steroid may be applied.
7
What are the differences between erythema toxicum neonatorum (ETN) and transient neonatal pustular melanosis?
Erythema toxicum is noted in 31% to 72% of full-term infants. Etiology is not known. It presents as multiple erythematous macules and papules that rapidly progress to pustules on an erythematous base. On examination they are noted over the trunk and proximal extremities, sparing palms and soles. They may be present at birth but can be seen at 24 to 48 hours of life and usually resolve within 7 days. Peripheral eosinophilia may be present in 7% to 18% of patients. Transient neonatal pustular melanosis ( Fig. 24.2 ) is less common than ETN. On examination small pustules are seen on a nonerythematous base, and they are usually present at birth. As the pustules rupture erythematous macules with surrounding scale may develop and can persist for weeks to months. These pustules contain neutrophils.
8
What is the difference between milia and miliaria?
Milia are white papules caused by retention of keratin. They are firm and, unlike pustules, are not easily denuded by pressure. Milia consist of epithelial lined cysts arising from hair follicles. On examination the rash is found on the nose and cheeks, and it resolves within the first weeks of life. Miliaria is caused by accumulation of sweat beneath the eccrine sweat ducts at the level of stratum corneum resulting in the formation of 2- to 3-mm sweat retention vesicles. In infants, the lesions are noted over the head, neck, and upper trunk.
9
What are the different types of miliaria?
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Miliaria crystallina ( Fig. 24.3 ) presents as small thin-walled vesicles without inflammation.
Fig. 24.3
Miliaria crystallina.
From Dermatoses Resulting from Physical Factors. Andrews’ Diseases of the Skin , Philadelphia, 2011, Saunders, pp 18–44. Fig. 3.3.
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Miliaria rubra ( Fig. 24.4 ) occurs when the obstructed sweat leaks into the dermis and causes an inflammatory response that results in erythematous papules and pustules.
Fig. 24.4
Miliaria rubra.
From Dermatoses Resulting from Physical Factors. Andrews’ Diseases of the Skin , 2011, Saunders, pp 18–44. Fig. 3.4.
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Miliaria pustulosa results from localized inflammation consisting of pustules over an erythematous base.
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Miliaria profunda is papular or papulopustular and skin colored.
10
What is the differential diagnosis of sucking blisters?
Herpes simplex virus infection, bullous impetigo, congenital syphilis or candidiasis, neonatal lupus erythematous, and hereditary bullous diseases. Other clinical signs and symptoms along with positive maternal history usually accompany these disorders.
11
What is the difference between cutis marmorata and harlequin color change?
Cutis marmorata ( Fig. 24.5 ) is asymmetric reticular mottling of the skin of the extremities and trunk. It is a vascular response to cold and usually resolves with warming. Harlequin color change is noted when an infant is lying on one side of the body. There is an intense reddening of the dependent side and blanching of the nondependent side with a demarcated line at midline. It can range from a few seconds to 20 minutes. It is benign and self-limited, and it can be seen up to 3 weeks after birth.
Oral Candidiasis
4
How do newborns acquire oropharyngeal candidiasis?
Transmission of fungi from maternal vaginal candidal colonization is the primary means of infection in newborns. It can also be transmitted during breastfeeding. It affects up to 3% to 5% of healthy newborns. Median age of onset is reported to be 9 to 10 days of life. On examination, the thrush presents as white plaques with or without an erythematous base on the buccal or lingual mucosal surface of the mouth. Infants are usually asymptomatic; however, it may interfere with feeding due to discomfort. Mild punctate areas of bleeding confirm the diagnosis during scraping. Nystatin 100,000 U/mL as a dose of 0.5 mL to each side of the mouth given four times daily is the treatment of choice for oral candidiasis.
Newborn Rashes
A 4-week-old presents with rash limited to the cheeks and forehead. She is otherwise feeding and growing well. She is afebrile.
5
Is there a difference between neonatal acne and infantile acne?
Neonatal acne is a variant of acne vulgaris that presents at birth or in the first weeks of life ( Fig. 24.1 ). This occurs in about 20% of newborns. It is due to androgenic hormones, both maternally derived and endogenous. The lesions resolve within 1 to 3 months as the androgenic levels drop. A small percentage of infants develop acne at about 3 to 6 months of age with a greater degree of inflammation. The infantile acne may persist for years, and the cause is unknown. Usually there is no evidence of precocious puberty or increased hormonal levels.
6
How is cradle cap treated at home?
Seborrheic dermatitis presents as a yellow scaly rash on the scalp and may involve the head, eyes, ears, eyebrows, nose, and back of head. Treatment is mineral oil followed by shampooing with a mild anti-dandruff shampoo containing selenium. If lesions are inflamed, a mild topical steroid may be applied.
7
What are the differences between erythema toxicum neonatorum (ETN) and transient neonatal pustular melanosis?
Erythema toxicum is noted in 31% to 72% of full-term infants. Etiology is not known. It presents as multiple erythematous macules and papules that rapidly progress to pustules on an erythematous base. On examination they are noted over the trunk and proximal extremities, sparing palms and soles. They may be present at birth but can be seen at 24 to 48 hours of life and usually resolve within 7 days. Peripheral eosinophilia may be present in 7% to 18% of patients. Transient neonatal pustular melanosis ( Fig. 24.2 ) is less common than ETN. On examination small pustules are seen on a nonerythematous base, and they are usually present at birth. As the pustules rupture erythematous macules with surrounding scale may develop and can persist for weeks to months. These pustules contain neutrophils.
