Head Circumference
One of the first things to assess when evaluating the head of the newborn is the Occipital Frontal Circumference (OFC). This simple measurement may be the first clue to an underlying problem. The 50th percentile for OFC of a term newborn is 34 cm, so if an infant has a normal weight and length for a term infant (near 50th %ile for age), a measurement of <31 cm is disproportionately small (<< 10th %ile for age). Further evaluation is indicated; head imaging, screening for TORCH infection, and assessment for chromosomal abnormalities should all be considered.
photo by Janelle Aby, MD
Molding
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.
photo by Janelle Aby, MD
Breech Molding
With breech positioning in utero, the head is often in a position against the uterine fundus. This causes newborn head molding that is flat on the top and elongated in the anterioposterior diameter. As with any molding, this appearance is expected to improve significantly within the first week.
photo by Janelle Aby, MD
Bruising
Bruising of the vertex of the head is a fairly common finding in newborns. The affected area may be rather large (6-8cm is not unusual) and may be various shades of red and blue. In some cases, traumatic blisters or bullae may be present. If a scalp electrode was used during delivery, a small scab is often visible is this area as well. No treatment is required. This photograph was taken a few days after delivery; the bruising was improving by this time.
photo by Janelle Aby, MD
Caput Succedaneum
This photo was taken on the first day of life. Caput (scalp edema) is not visibly obvious here, but it could be appreciated on exam. In the following photos, the extent of the edema is easily seen.
photo by Janelle Aby, MD
Caput Succedaneum
Firm, constant pressure in one spot is the easiest way to elicit the characteristic pitting edema of caput. In this patient, the extent of the caput is already becoming visible.
photo by Janelle Aby, MD
Caput Succedaneum
After the pressure is released, the pitting indentation is clearly seen. Although caput can cross over suture lines (since it affects the scalp), it is often predominently or entirely unilateral. Evaluating for pitting edema is a much more useful diagnostic tool than location. By the next morning, the edema had completely resolved.
photo by Janelle Aby, MD
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 cephalohematomas. On palpation, these areas feel fluctuent.
photo by Janelle Aby, MD
Subgaleal Bleed
From this angle, the subgaleal bleed is not visible. 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 head (in this photo the fluid is posterior and is causing the scalp to bulge loosely onto the mattress). 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 (see following photos). 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 beeding continues.
photo by Janelle Aby, MD
Subgaleal Bleed
The baby's head and camera are in the same position as in the previous photo, but here pressure is being applied with the palm and fingers to squeeze the blood that was in a dependent location into a more visible, anterior location. The sensation is similar to that of handling a water balloon. It is a very fluctuent, shifting mass without discernable limitations.
photo by Janelle Aby, MD
Small subgaleal fluid wave
Whenever a fluctuant collection of fluid on a newborn's head freely crosses suture lines, subgaleal hemorrhage is a possibility. In this case, the fluid crosses the sagittal suture. Pressure on one side of the head results in a fluid wave that readily crosses the midline.
video by Janelle Aby, MD
Moderate subgaleal fluid wave
Blood or fluid in the subgaleal space can be identified on examination as a freely moving fluctuance. Notice how pressure applied posteriorly to this infant's head causes a fluid wave which crosses several suture lines and the anterior fontanelle. This is a concerning finding. Not all subgaleal hemorrhages lead to rapid, life-threatening clinical decompensation, but some do. An escalation of care appropriate to the situation is warranted.
video by Janelle Aby, MD
Unusual Hair Whorls
Normally, because the growth of the brain occurs in a predictable fashion, there is one primary hair whorl over the vertex of the head. When hair whorls are multiple or in unusual locations, abnormal brain growth may be a causative factor. In this infant, a hair whorl can be seen behind the right ear, and the rest of the hair appears unruly, with a variety of directions of growth. Trisomy 13 was the underlying diagnosis.
photo by David Clark, MD
