Short Atlas in Pediatrics Mohammed El-Naggar
Chapter Notes

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  • Skin color variations
  • Neonatal jaundice
  • Common skin lesions
  • Common superficial infections
  • Common umbilical lesions
  • Vascular disorders
  • Congenital anomalies
  • Birth injuries
  • Abnormal birth weight
  • Chromosomal syndromes
Normal Pinkish Appearance
The color of the normal newborn is reddish at birth and it changes to pink within a day or two.
However, the pink color at rest may be transformed to a deep red on crying.
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Fig. 1.1: Normal pinkish appearance of the newborn
Reddish Color of Premature Baby
The color of the premature baby is deep pink to red. In severe prematurity, the color is deep red. Note also the small size (compared to the examiner's hand) and the relatively large head.
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Fig. 1.2: Reddish color of premature baby
Cutis Marmorata
Cutis marmorata is a violaceous or blue mottling of the skin that occurs when the infant is exposed to low temperature (as during bathing or changing). This lacy reticulated pattern appears over most of the body surface. It is an accentuated vasomotor response that disappears with age.
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Fig. 1.3: Violaceous or blue mottling of the skin
Physiological Jaundice
Physiological jaundice is a very common condition that occurs in up to 40 percent of normal newborns. It usually appears on the third day and remains for less than a week. In most cases, the bilirubin level is quite below the critical level.
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Fig. 1.4: Yellowish coloration of the skin
When jaundice is more severe and bilirubin level is near to critical value (i.e. above 15 mg/dl), phototherapy for a few or several days is useful in lowering bilirubin level. Note the eye cover to protect the eyes.
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Fig. 1.5: Phototherapy of physiological jaundice
Neonatal Cholestasis
Neonatal cholestasis is a condition characterized by persistent jaundice, hepatomegaly and pale clay colored stool.
Neonatal hepatitis and extrahepatic biliary atresia are the two main causes. Early differentiation between these two conditions (by HIDA scan and liver biopsy) is important because in biliary atresia, early surgical correction is indicated (Kasai operation).
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Fig. 1.6: Jaundice and hepatomegaly
Milia are tiny sebaceous retention cysts scattered over the face, mainly on the nose and around it. They appear as whitish opalescent pinhead-sized spots that can be felt with the finger. They usually disappear within a few weeks and no treatment is required.
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Fig. 1.7: Tiny sebaceous cysts on the nose
Infantile Eczema
Infantile eczema is a form of atopic dermatitis that mostly starts in infancy. It mainly involves the face (cheeks) but scalp and extensor surface of extremities may be also affected. The lesions are intensely pruritic erythematous papules with scaling and roughening of the skin. It responds to topical steroids but the lesion has a recurrent nature.
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Fig. 1.8: Erythematous scaly papules on the cheeks
Cradle Cap
Cradle cap is a form of seborrheic dermatitis that may start during the neonatal period. The scalp is the mainly involved site where diffuse or focal scaling and crusting occur (cradle cap). The lesions may involve the face, retroauricular area and diaper area. The condition responds to topical steroids.
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Fig. 1.9: Diffuse scaling and crusting on the scalp
Erythema Toxicum
Erythema toxicum is a very common lesion that occurs in 50 percent of newborns during the first few days after birth. The lesions are firm yellow white papules or pustules (1–2 mm) with surrounding erythematous flare. The condition is benign and usually disappears over a few days. The cause is unknown.
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Fig. 1.10: Yellow white papules with surrounding erythema
Diaper (Napkin) Dermatitis
Erythematous diaper area due to prolonged contact with urine and stool. The lesion involves mainly the convex surfaces of buttocks, medial side of thighs and genital area but groin creases are usually spared. Secondary fungal infection (monilial) is common (see also monilial napkin dermatitis).
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Fig. 1.11: Erythematous diaper area
Mongolian Spots
Mongolian spots are blue macular lesions that occur most commonly in the presacral area. They may be solitary or multiple and usually involve large areas. These lesions usually fade during the first two years.
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Fig. 1.12: Blue macular lesions in presacral area
Bullous Impetigo
Bullous impetigo is a common superficial infection in infants and young children caused by Staphylococcus aureus. It causes flaccid transparent bullae that mainly occur in diaper area and trunk. The bullae can easily rupture leaving a narrow rim at the edge of the moist lesion. Oral antibiotic therapy may be needed in extensive lesions.
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Fig. 1.13: Superficial easily ruptured bullae
Oral Moniliasis
Oral moniliasis is an acute infection of oral cavity caused by Candida albicans. It is most common in neonatal period and early infancy. It is characterized by white flaky plaques covering all or part of the tongue, gingiva and oral mucosa. These plaques when removed leave a bright inflamed base. The condition usually subsides within one week of effective therapy with oral nystatin or miconazole.
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Fig. 1.14: White flaky plaques on tongue and oral mucosa
Monilial Napkin Dermatitis
Monilial napkin dermatitis usually follows contact dermatitis. It is characterized by intense fiery red erythema with sharp edge, which may extend to involve the whole napkin area and rises on the trunk. Small satellite lesions outside the sharp edge are characteristic of monilial napkin dermatitis. Treatment is by local antifungal cream.
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Fig. 1.15: Intense erythema of napkin area with sharp edge
Umbilical Sepsis (Omphalitis)
The necrotic tissue of umbilical cord is an excellent medium for bacterial growth. Omphalitis may remain localized or may spread causing abdominal wall cellulitis and bacteremia. Portal vein phlebitis may occur and lead later to extrahepatic portal hypertension. Antibiotic therapy effective against Staph. aureus and E. coli is important.
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Fig. 1.16: Umbilical sepsis with surrounding abdominal wall cellulitis
Umbilical Granuloma
Umbilical granuloma is a moist granulation tissue at the base of the cord. The granuloma is soft, vascular and pinkish in color with mucoid or mucopurulent discharge. Cleaning with alcohol several times a day may be effective. Cauterization with silver nitrate (2%) may be necessary in persistent cases.
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Fig. 1.17: Soft pinkish umbilical granuloma
Umbilical Hernia
Umbilical hernia is a common anomaly that appear as a soft swelling covered by skin. It protrudes during crying, coughing or straining and it can be reduced easily through the fibrous ring of the umbilicus. Obstruction is unusual because of the wide ring. Most hernias that appear in the first 6 months disappear spontaneously before the age of one year.
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Fig. 1.18: Protruded umbilical hernia
Salmon Patch
Salmon patches (nevus simplex) are small ill-defined pink vascular macules that occur in 30–40 percent of normal newborn infants. The most common sites are glabella eyelids and back of the neck. Most lesions persist for several months but eventually fade and disappear.
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Fig. 1.19: Salmon patch on the back of the neck
Port-wine Stain
Port-wine stains (nevus flammeus) are large sharply circumscribed pink to purple macular lesions. The head and neck are the most common involved sites. Most lesions are unilateral and usually end along the midline. Unlike salmon patches, port-wine stains are permanent lesions that do not disappear with time but in contrary they may become darker with time. When port-wine stain is localized to the trigeminal area of the face, especially around the eye, the diagnosis of ‘Sturge-Weber syndrome’ should be considered. However, it is important to note that port-wine stains are commoner as isolated lesions.
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Fig. 1.20: Port-wine stain on the face
Hemangioma of the Back of the Neck and Trunk
Hemangiomas are sharply demarcated bright red lesions that are protuberant and compressible. They may be present at birth or appear during the first two months. They may occur at any area of the body and may be small or large and single or multiple.
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Fig. 1.21: Sharply demarcated red hemangioma on the back of the neck
Multiple Hemangiomas of the Face
Most hemangiomas undergo a phase of rapid expansion, followed by stationary period and finally by spontaneous involution. Most lesions involute completely before the age of nine years. Treatment is not required and reassurance of parents is important.
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Fig. 1.22: Multiple hemangiomas of the face
Large Lobulated Hemangioma of the Face
Large hemangiomas may interfere with vision or feeding and may lead to ulceration and bleeding. Treatment includes dilute bicarbonate soaks, gel foam and compression therapy. Oral corticosteroid therapy for four weeks is effective in some patients.
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Fig. 1.23: Large lobulated hemangioma
Cleft Lip and Palate
The incidence of cleft lip with or without cleft palate is about 1 in 750 births. It can be just a small notch on the upper lip or it may cause complete separation and extension into the floor of the nose. It can be also unilateral (to one side) or bilateral. Surgical closure of cleft lip is made at the age of three months while closure of the palate is made before the age of one year to enhance normal speech.
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Fig. 1.24: Cleft lip
Meningomyelocele is a fluctuant midline mass mostly in the lumbosacral region. It is a sac-like cystic structure covered by a thin layer of epithelialized tissue (meningocele is covered by normal skin). It causes neurological manifestations as bowel and bladder incontinence and may be flaccid paralysis of lower extremities (these problems are usually absent with meningocele). Surgical repair can be made in the first week but bowel and bladder incontinence persist.
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Fig. 1.25: Cystic lesion of meningomyelocele on the back
Ambiguous Genitalia
Ambiguous genitalia is a genitalia in which sex cannot be identified. It is either due to virilized female (labial fusion and clitoral hypertrophy) or due to undervirilized male (bifid scrotum and micropenis). It is a medical emergency and birth certificate should not be filled before identification of the sex (See endocrinal disorders).
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Fig. 1.26: Ambiguous genitalia
Talipes Equinovarus
Talipes equinovarus is a common malformation that occurs due to intrauterine molding and fetal crowding. The foot is turned downwards and inwards so that the sole is directed medially. Orthopedic treatment should be started as early as possible in the first few days after birth.
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Fig. 1.27: Talipes equinovarus
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Fig. 1.28: Orthopedic treatment of talipes
Congenital Hip Dislocation
Congenital hip dislocation is another common malformation that occurs due to intrauterine molding and fetal crowding. Limitation of abduction is the cardinal sign of hip dislocation. Examination for hip dislocation is made by ‘Ortolani maneuver’. With the hips and knees flexed at right angles, the thighs are abducted; a dislocated femoral head will clunk back into the acetabulum. This palpable clunk can be felt by the middle finger of each hand placed over each great 16trochanter. Both hips should be examined independently. Suspicion is confirmed by an X-ray or ultrasound. Orthopedic treatment should be started as early as possible.
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Fig. 1.29: Ortolani maneuver
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Fig. 1.30: Orthopedic treatment of congenital dislocation of the hip
Undescended Testes
Undescended testes is the common disorder that occurs in 4 percent of boys at birth. In 90 percent of cases, the testes can be palpated in the inguinal canal and in 10 percent of cases it is bilateral. In the majority of cases, the testis descends spontaneously during the first 6 months. If not, it will remain undescended and needs operation at 1 year old (orchipexy).
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Fig. 1.31: Palpated right undescended testis
Congenital Hydrocele
Congenital hydrocele is a common disorder that occurs in 1–2 percent of boys at birth. It is an accumulation of fluid in the tunica vaginalis. It is a smooth and nontender swelling and transillumiation of the scrotum confirms the fluid-filled nature of the mass. Most cases resolve at the age of one year.
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Fig. 1.32: Congenital hydrocele
Inguinal Hernia
Inguinal hernia is a common disorder that occur in 4 percent of newborns and it is six times more common in boys. It can be unilateral or bilateral and it appears as a bulge in the inguinal region. The bulge is more visible during crying or coughing. The hernia may descend to the scrotal sac but it can be reduced by gentle pressure. Once diagnosed, surgical repair is indicated.
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Fig. 1.33: Bilateral inguinal hernia
Caput Succedaneum
Caput succedaneum is a diffuse edematous swelling of the soft tissue of the scalp over the presenting part of the head. It may extend over the middle line and may be associated with ecchymotic patches. The edema subsides spontaneously within the first few days.
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Fig. 1.34: Caput succedaneum
Cephalohematoma is a subperiosteal hemorrhage that presents as a firm swelling limited to the surface of one cranial bone usually the parietal. The swelling does not appear except after several hours after birth. Anemia and jaundice are the main complications and phototherapy may be needed. It usually subsides gradually over 4–6 weeks.
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Fig. 1.35: Right parietal cephalohematoma
Erb's Palsy
Injury of brachial plexus is common and it occurs following traction on the head and neck. The affected arm is flaccid with forearm pronation and wrist flexion (waiter's tip position).
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Fig. 1.36: Erb's palsy of the right arm
Premature Baby
Low birth weight (below 2.5 kg) is due to either premature delivery or intrauterine growth retardation (50% of cases for each). Premature baby has incomplete flexion of limbs and signs of prematurity are evident (incomplete sole creases, underdeveloped genitalia, small breast nodule, underdeveloped ear lobule and fine wooly scalp hair).
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Fig. 1.37: Incubator care of premature baby
Intrauterine Growth Retardation
Fetal malnutrition due to placental insufficiency leads to intrauterine growth retardation (IUGR) and low birth weight. The head is relatively large and features of prematurity are absent. The skin is pale and looks dry with cracking and peeling.
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Fig. 1.38: Relatively large head of IUGR
Infant of Diabetic Mother
The baby is overweight, large, plump and plethoric. The face resembles that of patients receiving steroids. Hypoglycemia and hypocalcemia are common and the baby tends to be tremulous and hyperexcitable. Cardiomegaly occurs in 30 percent of cases. The incidence of congenital anomalies is three times higher. Also, the subsequent incidence of diabetes is higher than that of general population.
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Fig. 1.39: Plump plethoric face of infant of diabetic mother
Trisomy 21
Trisomy 21 (Down's syndrome) is the most common autosomal trisomy (1/700 live birth). Recognition at birth is not difficult due to its characteristic features (upward slanting palpebral fissure, epicanthal folds, flat nasal bridge, simian crease and big space between first and second toes). Associated congenital heart disease occurs in 40 percent of cases. Delayed motor and mental development appears in infancy. In absence of congenital heart disease, long-term survival is usual.
Mongoloid Features
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Fig. 1.40: Mongoloid face of trisomy 21
Simian Crease and Clinodactyly
Simian crease (single transverse palmar crease) is present in only 50 percent of cases. Clinodactyly (incurved little finger) is commonly present. It is important to note that simian crease is present in 4 percent of normal individuals.
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Fig. 1.41: Simian crease and clinodactyly
Big Space between First and Second Toes
Big space between first and second toes is one of the most constant findings in Down's syndrome (in 97% of cases). Also, upward slanting palpebral fissure is present in 97 percent of cases.
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Fig. 1.42: Big space between first and second toes
Trisomy 18
Trisomy 18 (Edward's syndrome) is the second most common autosomal trisomy (1/4000 live birth).
Characteristic Features
The main characteristic features are low birth weight, microcephaly, micrognathia (receding mandible), low set malformed ears, prominent occiput, clenched fist, syndactyly and rokerbottom feet.
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Fig. 1.43: Prominent occiput and low set malformed ears
Clinched fist, syndactyly (fused digits or toes) and rokerbottom feet are commonly present limb anomalies. However, these anomalies are not peculiar to trisomy 18 and may be present in other morphological syndromes.
Associated congenital heart disease occurs in 60 percent of cases. Severe CNS malformations as hydranencephaly are common. Prognosis is poor as 30 percent of cases die in neonatal period and 90 percent die in infancy.
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Fig. 1.44: Clinched fist
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Fig. 1.45: Syndactyly (fused second and third toes)
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Fig. 1.46: Rokerbottom feet
Trisomy 13
Trisomy 13 (Patau syndrome) is the third most common autosomal trisomy (1/6000 livebirth).24
Coarse Features
The main characteristic features are low birth weight, microcephaly and coarse features (low anterior hair line, microphthalmia, micrognathia, hypotelorism, median cleft lip and palate and low set malformed ears). Associated congenital heart disease occurs in 80 percent of cases. Severe CNS malformations are common. Prognosis is poor as 50 percent of cases die in neonatal period and 90 percent die in infancy.
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Fig. 1.47: Coarse features and median cleft lip and palate
Low Set Malformed Ears
Low set malformed ears is usually present, but this finding is common with many other chromosomal diseases.
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Fig. 1.48: Low set malformed ears
Polydactyly (extradigit) is common in trisomy 13, but again this finding is not peculiar and present in many other syndromes.
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Fig. 1.49: Polydactyly (6 toes)
Turner's Syndrome
Webbed Neck and Low Posterior Hair Line
Turner's syndrome (45, X female) is a common chromosomal disorder of females (1/10.000). It can be recognized at birth by the presence of webbed neck, low posterior hair line, widely separated nipples and edema of the dorsum of hands and feet. Later in childhood, it presents with short stature and gonadal dysgenesis (primary amenorrhea).
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Fig. 1.50: Webbed neck and low posterior hair line
Widely Separated Nipples
Associated renal anomalies (40% of cases) and cardiac anomalies especially coarctation of aorta (20% of cases) may be present.
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Fig. 1.51: Widely separated nipples
Edema of Hands and Feet
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Fig. 1.52: Edema of the foot
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Fig. 1.53: Edema of the hand