CEPHALOHEMATOMA

Definition: A swelling of the scalp caused by a hemorrhage under the outer layer of bone in one area of the skull.

1. What caused this condition?

The swelling associated with this condition is a result of the scalp tissues being injured during the delivery process. There are several types of swelling of the scalp that can occur, based on the depth of the swelling and/or the amount of bleeding involved.  The  different  types  of  swelling  are  caput  succedaneum, cephalohematoma,  and  subgaleal  hematoma.  Most  types  are  more common with vaginal deliveries than cesarean sections. Caput succedaneum: Superficial layers of the scalp with swelling and bruising that generally improves significantly prior to discharge from the hospital. Cephalohematoma: Bleeding between the outer layer of the scalp bone and the lining of the bone. It is more contained and does not spread past the edge of the bone. It is often present along with caput

succedaneum. When the superficial swelling goes away, it is more iden-
tifiable. The affected areas are soft and may be on one or both sides of
the scalp. They may take several months to completely dissolve. As
they go away, they may have a crunchy or crackly feeling to them. Subgaleal hematoma: Bleeding that occurs deeper under the skin layers, but above the outer layer of the bones. This swelling can be seen all around the scalp and may push the ears forward slightly. Due to the amount of bleeding that can occur, it requires close monitoring and occasionally blood transfusions.

2. Is it potentially dangerous?

Cephalohematomas  and  subgaleal  hemorrhages  can  be  potentially dangerous depending on the amount of bleeding that occurs. Some cephalohematomas can also include fractures of the skull and bleeding inside the bones of the skull.

3. Does this condition represent any possible injury to the brain?

The majority of the time, there is no injury to the brain, as all the
bleeding is small and outside of the skull. Rarely, when there is bleeding
that occurs inside the skull, the brain may be at risk for injury.

4. What tests are needed to further define the condition?

The majority of the time, nothing needs to be done except a physical examination  and  observation.  When  there  are  concerns  for  larger amounts  of  bleeding,  a  blood  count  may  be  performed.  In  rare instances of concern for a skull fracture or bleeding on the inside of the skull, X rays of the skull and/or a CT scan of the skull and brain may be performed.

5. Are there any other potential problems that can occur in the future?

In the first week of life, the baby may have to be watched more closely for jaundice that needs treatment. The risk for significant jaundice increases with the amount of bleeding and the destruction of the red blood cells within the swollen area. If there are fractures of the skull, most do not need treatment. Also, bleeding inside the skull generally does not need surgery unless it is progressive and causes excessive pres-sure on the brain.

6. Over what period of time can we expect this condition to improve?

Caputs  generally  improve  within  several  days.  Cephalohematomas may take up to six months to resolve.

7. How often will you need to see my baby for follow-up after discharge from the hospital?

In most cases there is no needed special follow-up for this swelling. If there are concerns about jaundice, a daily blood test may be needed for several days after discharge from the hospital. In severe cases where there are skull fractures or bleeding inside the skull, follow up with a neurosurgeon (surgeon of the brain) may be necessary.

BLOOD INFECTION (Bacterial Sepsis)

Definition: A serious condition caused by multi-plying bacteria in the bloodstream.

1. What caused this condition?

Infections due to bacteria in the bloodstream may occur during the birthing  process  when  bacteria  from  the  birth  canal  get  onto  the newborn’s skin, nose, mouth, and eyes. These bacteria can then get into the lungs and/or bloodstream to cause the infection. Another way that the newborn may become infected is by bacteria infecting  the  placenta  and  getting  into  the  infant’s  bloodstream through the placenta and umbilical cord. The most common bacteria that cause neonatal infections are Group B streptococcus, Listeria mono-cytogenes, and Escherichia coli  (E. coli). Occasionally, viruses such as herpes or cytomegalovirus may also cause infections in the newborn.

2. What problems does it pose?

Infections in newborns can be relatively minor, causing problems such
as mild breathing issues, decreased temperature, or low blood sugar. They  can  also  be  life-threatening  or  fatal,  resulting  in  severe breathing concerns, decreased heart function, and/or seizures.

3. What tests are needed to further define the condition?

The growing of the bacteria or virus on a culture, which is a test performed
by applying samples of the baby’s blood onto a plate with nutrients,
confirms the presence of an infection in the blood. In addition to blood,
samples of the airway secretions; swabs of the eyes, nose, and skin; urine;
and spinal fluid (spinal tap) may also be collected and tested in this manner.

4. How is blood infection treated?

Antibiotics are used to kill the bacteria causing the infection. Some viral infections can be treated with antiviral medications. The laboratory tests (culture) will confirm which medications are most effective in treating the infection. In serious infections, other medications and treatments may be necessary to assist with breathing, to help the heart function properly, and to control seizures.

5. Do we need to consult with a neonatologist (newborn specialist) or an infectious disease specialist?

Very minor or “suspected” infections can be treated by the pediatrician. If the infection is significant or other support is needed, then referral to a neonatologist and/or an infectious disease specialist should occur.

6. How long will it take for my baby to recover from this illness?

Infections  that  are  confirmed  in  the  bloodstream  will  require  a
minimum of seven to fourteen days treatment with intravenous (IV)
antibiotics. If the infection is in the spinal fluid, the antibiotics may be required for up to twenty-one days or more. Depending on the seriousness of the infection, the time for recovery may extend beyond the end of taking antibiotics.

7. Will this condition weaken my baby in any way in the future, and will there be any long-term ill effects caused by it?

In serious infections or infections that involve the spinal fluid or the
brain, there can be long-term effects, such as movement abnormalities,
mental retardation, cerebral palsy, or hearing loss. There may be some
continuing lung abnormalities due to the use of a breathing machine.
Occasionally, the blood infection also infects a joint or bone. This could
result in an injury to that joint or a limitation of the growth of the bone.

8. How long will my baby have to stay in the hospital as a result of this disorder?

At least seven to fourteen days will be required, as the antibiotics to treat the infection have to be given through an IV. In serious infections with complications it may be a month or longer.

9. After discharge from the hospital, what kind of follow-up will be needed?

Infections that did not require significant levels of support other than antibiotics may be monitored under routine care by the pediatrician. If there are complications, especially of the brain and nervous system, developmentalists or neurologists (specialists that monitor the development of the brain) may be recommended.

BIRTH DEFECT

Definition: Any structural difference in the baby’s body. Also called congenital anomaly or congenital malformation.

1. What are birth defects?

Birth defects are changes in the normal structure of the body that are present when the baby is born. They may be minor problems, like a small extra finger or a large birthmark, or significant problems, such as a missing limb or an abnormal heart.

2. What causes birth defects?

Some birth defects are caused by genetic problems such as chromosome
abnormalities or mutations (changes) in a particular gene. Other defects are
caused by exposure to a toxin during pregnancy. Alcohol, the acne medicine
isotretinoin (Accutane), and methyl mercury are recognized as causing birth
defects if the fetus is exposed to these substances early in the pregnancy.
Some birth defects are multifactorial; they have many factors that cause
them, some of which are genetic and some of which are environmental.

3. What sort of tests should be done on my child?

The specific tests that your physician may perform will depend on what part of the body is affected. Typical tests include ultrasounds of the head and abdomen, X rays, CT or MRI scans, and echocardiograms (ultrasounds of the heart). These tests are done to determine how serious the problem is and whether there are other problems. Your child may get some or all of these tests. Genetic testing is done to try to determine the cause of the birth defect. These may include an analysis of the baby’s chromosomes, tests for specific mutations, or tests of the baby’s metabolism.

4. What is the treatment for birth defects?

The treatment depends on the birth defect. Some do not need treatment. Some can be treated easily while the baby is in the nursery or soon after birth. Many require monitoring by a specialist, and some can only be fixed using surgery.

5. No one else in the family has this problem; why did it happen to my child?

About one out of every twenty babies  (5 percent) are born with
some sort of birth defect. There are many things that have to go
right in order for babies to be born normal. Sometimes this just
doesn’t  happen.  Much  of  the  time  it  is  impossible  to  say  why  a
particular baby has a birth defect. Sometimes a problem can run in
a family without causing difficulty until a baby is born with a serious
version of it.

6. Do we need to consult with a geneticist or any other specialist?

Yes. All babies with birth defects can benefit from seeing a doctor who
specializes in genetics. The geneticist will help determine whether the
problem is isolated or whether there is a larger “syndrome.” It is always
helpful to have the input of a geneticist before undergoing genetic
testing. He or she can also help find out whether the problem runs in
the family and what your chances are of having another affected child.

7. Will my next child have birth defects?

Whether birth defects will happen in another child depends on what the
defects are and what caused them. All pregnancies have a risk of about 5
percent (one in twenty) that the baby will have a birth defect. Having one
child with a birth defect increases your chances of having another. The first
step is to have a firm diagnosis of the problem in your affected child.

8. How early can birth defects be diagnosed?

Large birth defects, such as spina bifida, can be detected in the late first trimester of pregnancy. As pregnancy progresses and the fetus gets larger, other birth defects can become apparent. If your doctor knows you have one child with a particular problem, then the doctor can specifically look for that problem. Some birth defects, such as cleft palate, are very difficult to diagnose before birth. All birth defects can be diagnosed after birth, but some are not found until the child is older, or unless they cause a problem.

9. Is there a way to prevent birth defects?

Every pregnancy is at risk for birth defects. There is no guaranteed way
to eliminate all of them, but you can reduce the risk. Here are some ways to reduce your risk of having a child with birth defects:

• Be  as  healthy  as  possible  before  you  get  pregnant.  Control chronic illnesses and start taking prenatal vitamins or at least folic acid supplements.

• Plan and space out your pregnancies and get good care during your pregnancy.

• Do not smoke or drink alcohol while pregnant. Do not use any medications  without  talking  to  your  doctor.  Remember  that everything that you put in your body also is going into the baby’s body.

• Seek out information about your personal risk from a geneticist if anyone in your family has a birth defect or has had a child who died or required surgery before one year of age. The same applies to someone who comes from a culture in which people marry within the extended family or someone who has had two or more pregnancy losses.

10. Will in vitro fertilization prevent birth defects?

No. There are some fertility treatments that can be used to avoid a particular birth defect or genetic condition, but there is never a guar-antee that a child will be normal. It has also been found that artificial reproductive techniques have a higher than normal incidence of certain problems in the baby. One of these problems is hypospadias, which is an abnormality of the penis. Another problem is called an imprinting defect. This is an abnormality in the way the early embryo manages the genetic material that can lead to some specific genetic syndromes.

ARM PARALYSIS (Brachial Plexus Palsy)

Definition: Paralysis or weakness of the arm muscles.

1. How did this condition occur in my baby?

Brachial  plexus  palsy  is  caused  by  a  stretch  injury  of  the  nerves supplying the muscles of the upper extremity (brachial plexus) during delivery. Recognized risk factors include large birth weight, breech position, prolonged labor, difficult delivery, shoulder dystocia, and neonatal distress.The causes of this stretch are due to the forces of labor, especially in  cases  of  shoulder  dystocia,  and  extraction  maneuvers.  Greater trauma occurs with forceful arm extraction maneuvers during a breech delivery. Exactly how much stretch is needed to produce permanent injury in any infant is not known.

2. Is my baby experiencing any discomfort?

No. This condition is caused by injury to the nerves supplying strength
and  sensation  to  the  arm.  Typical  symptoms  include  asymmetric
infantile reflexes and decreased spontaneous movement of the affected arm. If the child appears to be in pain, other conditions such as fractures of the clavicle (collarbone), humerus (upper arm bone), and shoulder should be ruled out with an X ray. Bone and/or joint infections should also be ruled out by blood tests, if pain is present.

3. What tests are needed to further define the condition?

X rays and blood tests may be required to rule out other conditions that  can  cause  your  child  to  have  decreased  movement  of  one extremity. Usually, no further tests are needed once the diagnosis has been made.

4. What is the treatment, and will physical therapy be needed?

Initial treatment includes protecting the involved limb by pinning the
sleeve to the shirt or wrapping it to the body for the first several weeks.
As soon as your child can tolerate it, gentle range of motion exercises
should be started. These can typically be performed at home by the
parents. Many infants will recover spontaneously on their own in the
first six to eight weeks of life, and many will progress to a normal result.
Those infants who do not initiate recovery until after three months of
age may require future surgery to optimize the function of the arm.

5. How long will it take for the condition to be corrected, and will there be any residual weakness or decreased function of the arm?

If recovery is to occur on its own, it most commonly begins in the first six to eight weeks of life. If little or no active motion of the affected arm begins before three months of age, surgical procedures are commonly necessary to maintain motion of the shoulder, elbow, and wrist. Even after surgery, some residual decrease in function is very likely.

6. Should a neurologist or an orthopedist be consulted?

Consultation with an orthopedist should be initiated as soon as the diagnosis is made. Often, an orthopedist will assist in ruling out other conditions  and  in  establishing  the  diagnosis  in  a  newborn  with decreased spontaneous movement of an arm.

7. When do you wish to see my baby again for this condition?

Your orthopedist will need to reassess the child every few weeks to ensure that the parents are performing the range of motion exercises properly and for signs of recovery. The decision whether to perform surgery or continue nonoperative treatment is usually made at three months of age.