Initial Newborn Assessment: APGAR, Screening, Skin Findings, Birthmarks, and Birth Injuries

APGAR assigns 0–2 points to each of five indexes. For appearance, pink all over earns 2; blue all over earns 0. For pulse, 120–160 beats/min earns 2; less than 60 beats/min or asystole earns 0. For grimace, a sneeze or cough earns 2; no response earns 0.

Erythema toxicum, or urticaria neonatorum, is described as an autoimmune newborn rash. Small red, white, or yellow papules or pustules sit on an erythematous base, usually appearing after the first day of life and resolving within 2 weeks. The infant generally looks well. Scraped pustules are benign and filled with eosinophils.

Congenital dermal melanocytosis is a benign, flat, gray-blue congenital birthmark with wavy borders and an irregular shape. It is more common in dark-skinned races, usually lies over the presacral area or near the buttocks at birth, and disappears during the first few years. Dermal melanocytes cause it. Unlike this lesion, an abuse bruise usually fades into surrounding skin with different colors and carries other evidence.

Birth injuries include avoidable and unavoidable injuries during labor and delivery. Cephalhematoma is a subperiosteal bleed, usually limited to one bone, that does not cross sutures; an edge rim is palpable. It may accompany a nondepressed skull fracture and can enlarge over the first few days. Two formulations differ: it may not be present at birth versus it is not present at birth.

Facial palsy after difficult delivery is usually a peripheral, flaccid paralysis; the affected side fails to move when the infant cries. Brachial palsy usually occurs in large infants after traction on the head during delivery. Its prognosis depends on the extent of nerve damage. Separate its two common presentations by roots and limb posture.

Clavicular fracture is the most common bone fracture during delivery and is associated with large-for-gestational-age infants and shoulder dystocia. Look for fussiness, an asymmetric Moro reflex, and crepitus. A palpable healing callus usually forms in less than 1 week without treatment. Subconjunctival hemorrhage is a temporary, self-limited lesion caused by increased pressure during passage through the birth canal.

For activity, active movement earns 2 points and no movement earns 0. For respiration, a strong rate of 40–60 breaths/min earns 2; absent respiration earns 0. Rapid APGAR scoring helps determine resuscitation need: 8–10 means good cardiopulmonary adaptation; 4–7 may require resuscitation, monitoring, stimulation, and possible ventilation support; 0–3 requires immediate resuscitation.

Distinguish erythema toxicum from staphylococcal scalded skin syndrome: in the latter, the infant looks very ill, lesions contain neutrophils, and skin culture reveals Staphylococcus aureus. Other listed differential diagnoses are pyoderma and candidiasis. The infant’s overall appearance and the eosinophil-versus-neutrophil distinction organize the comparison.

A salmon patch is a flat, salmon-colored vascular lesion, commonly over the eyelids, glabella, or nuchal area. It usually disappears, although nuchal lesions may persist; port-wine stains are usually unilateral and permanent. A capillary, or strawberry, hemangioma begins as bright-red, strawberry-like macular lesion(s) in the first few months, grows quickly during the first year, then regresses spontaneously without treatment.

Caput succedaneum is soft, boggy swelling over the presenting scalp part, mostly from pressure during labor and delivery. It can and usually does cross suture lines, resolves early over several days without treatment, and is a common cause of jaundice. Cephalhematoma resolves later: one formulation says mostly over months; another specifies 2 weeks–3 months.

Erb-Duchenne palsy involves C5–C6. The affected arm is adducted and pronated, with wrist flexion and finger flexion—the “waiter’s tip” posture. C4 is occasionally involved; when it is, ipsilateral diaphragmatic paralysis can occur. Preserve the combination of root level, arm position, and possible diaphragmatic finding when identifying this presentation.

All infants must be screened before discharge for phenylketonuria and congenital adrenal hyperplasia. Phenylketonuria reflects phenylalanine hydroxylase deficiency, which leads to intellectual disability; treatment is a low-phenylalanine diet for at least the first 16 years. Congenital adrenal hyperplasia may cause errors in steroidogenesis and sexual development; treatment replaces mineralocorticoids and glucocorticoids, with possible genital reconstruction.

Sebaceous hyperplasia produces small yellow-white, oily, shiny facial papules or bumps in infants and adults; acne can occur with it but is more frequent in teenagers. Milia are small, pearly-white, keratin-filled inclusion cysts on skin or mucous membrane. Oral milia are Epstein pearls. They often disappear within 2–4 weeks; differentiate them from sexually transmitted disease and, in adults, whiteheads.

Nevus sebaceous appears as yellow-orange, hairless scalp plaques resembling flat warts. Because of malignant potential, these plaques are usually removed by adolescence. Café-au-lait spots are superficial, light-brown, flat birthmarks with sharply demarcated borders and varied shapes. They may occur anywhere on the skin in normal people or with neurofibromatosis type 1 and other conditions.

After difficult delivery, especially forceps or vacuum extraction, subcutaneous fat necrosis causes palpable, rubbery, firm nodules on the cheeks, buttocks, back, or extremities. Most resolve spontaneously, although occasional calcium deposits remain. Listed causes of macrocephaly are caput, cephalhematoma, subgaleal hematoma, hydranencephaly, subdural collections, Sotos syndrome, Canavan disease, and Alexander disease.

Klumpke paralysis involves C7–T1. It produces elbow flexion and supination, wrist extension, finger flexion forming a “claw hand,” and numbness along the ulnar nerve distribution. If injury includes the T1-root sympathetic fibers, ipsilateral Horner syndrome appears. This associated sympathetic finding belongs specifically to the stated T1 injury pattern.

Mandatory pre-discharge screening also includes galactosemia, in which GALT deficiencies can cause feeding problems, failure to thrive, cataracts, and sepsis; treatment removes all galactose-containing products. Congenital hypothyroidism can lead to cretinism. Other recommended screens include homocystinuria, mainly causing thromboembolic complications; biotinidase deficiencies, causing developmental delays; and beta thalassemia, a serious anemia.

Cutis marmorata is a vasomotor response to cold stress that creates a lacy, cobblestone-like skin pattern. A persistent form is seen in trisomy 21, trisomy 18, and cutis marmorata telangiectasia congenita. Neonatal acne may have open and closed comedones, possibly from increased androgen levels; it is self-limited and needs no treatment.

Nonpathological neonatal entities include erythema toxicum, Epstein pearls, stork bites, vaginal bleeding from maternal hormones, phimosis, and breast engorgement. A premature neonate is described by widely separated sutures, shiny skin, abundant lanugo, reduced subcutaneous fat, sluggish neonatal reflexes, and a small face. Recognize these grouped findings during the initial examination.