 Integumentary System

 All structures of the IS are present at birth but skin’s function is immature
 Smooth and elastic with fair amount of subcutaneous tissues
 Preterm infants have lesser subcutaneous tissues so skin appears almost transparent
 subQ tissues are important for insulation
 Brown fats - responsible for additionally, providing with insulation : located in perineum, chest
areas, intrascapular areas
 Post-term infants have paler, dry, peeling skin
 Skin Color
 Ruddy complexion- ruddiness fades slightly over the first month
 Bright red at the first day
 Twin transfusion phenomenon
 Acrocyanosis is normal for the first 24-48 hours; central cyanosis is not
 central cyanosis, or cyanosis of the trunk, is always a cause for concern. Central cyanosis
indicates decreased oxygenation. It may be the result of a temporary respiratory obstruction or an
underlying disease state.
 Mucus obstructing a newborn’s respiratory tract causes sudden cyanosis and apnea. Suctioning of
the mucus relieves this. Always suction the mouth of a newborn before the nose, because
suctioning the nose first may trigger a reflex gasp, possibly leading to aspiration if there is
mucus in the posterior throat. Follow mouth suctioning with suction to the nose, because the
nose is the chief conduit for air in a newborn.

 Mottling
 Irregular discoloration of the skin due to cold exposure, lack of fat, or hypoxia
 Cutis marmorata—transient mottling when infant is exposed to decreased temperature
 Hyperbilirubinemia
 leads to jaundice, or yellowing of the skin (Beachy, 2007)
 Globin is a protein component that is reused by the body and is not a
factor in the developing jaundice.
 Heme is further broken down into iron (which is also reused and not
involved in the jaundice) and protoporphyrin.
 Protoporphyrin is further broken down into indirect bilirubin.
 Indirect bilirubin is fat soluble and cannot be excreted by the
kidneys in this state. For removal from the body, it is converted by
the liver enzyme glucuronyl transferase into direct bilirubin, which
is water soluble. This is incorporated into stool and then excreted in feces. Many newborns have such
immature liver function that indirect bilirubin cannot be converted to the direct form; it therefore
remains indirect.
 As long as the buildup of indirect bilirubin remains in the circulatory system, the red coloring of the
blood cells covers the yellow tint of the bilirubin. After the level of this indirect bilirubin has risen to
more than 7 mg/100 mL, however, bilirubin permeates the tissue outside the circulatory system and
causes the infant to appear jaundiced.
 If the level rises to more than 10 to 12 mg/100 mL, treatment is usually considered. Phototherapy
(exposure of the infant to light to initiate maturation of liver enzymes) is a common therapy. If this is
necessary, the incubator and light source can be moved to the mother’s room so that the mother is not
separated from her baby. Some infants need continued therapy after discharge and receive
phototherapy at home (Mills & Tudehope, 2009).

 Physiologic jaundice (90 days -- lifespan of RBC in NB)

 Occur after 24 hours of life (2-3 days); infant’s skin and the sclera of the eyes appear noticeably yellow
 Due to destruction of high fetal RBC built up in utero
 Pathologic bilirubinemia
 Pregnanediol - a component of hormone progesterone that interferes with the action of glucoronyl
transferase
 Occur within 24 hours after birth
 Jaundice lasts for more than 10 days
 May lead to kernicterus
 Above-normal indirect bilirubin levels are potentially dangerous because, if enough indirect
bilirubin (about 20 mg/100 mL) leaves the bloodstream, it can interfere with the chemical
synthesis of brain cells, resulting in permanent cell damage, a condition termed kernicterus. If this
occurs, permanent neurologic damage, including cognitive challenge, may result.

Protoporphyrin indirect bilirubin glucuronyl transferase (liver enzyme) direct bilirubin

 Harlequin’s sign
 clear color division of the skin with lower half of the body
pinkish in color and the upper half pale when the infant is on
side lying position
 Fair complexion
 Pallor—d/t anemia
 Pallor (pinkish) - reddish pink because of pulling of blood
 Anemia -- poor nutrition of mother; destruction of fetal RBC
 Excessive blood loss when the cord was cut
 Inadequate flow of blood from the cord into the infant at birth
 Fetal–maternal transfusion
 Low iron stores caused by poor maternal nutrition during pregnancy
 Blood incompatibility in which a large number of red blood cells were hemolyzed in utero. It also
may be the result of internal bleeding.

Birthmarks
Hemangioma- vascular tumors of the skin
TYPES:
Stork bite — a macular purple or dark-red lesion present over the eyelids,
above the bridge of the nose, face and thighs; does not blanch with pressure;
does not fade with age.
 A.k.a. port - wine strain
 they can be covered by a cosmetic preparation later in life or removed
by laser therapy, although lesions may reappear after treatment
(Berger, 2009).

Stork’s Beak marks or Telangiectasia

 lighter, pink patches at the nape of the neck
 Mostly in females
 Does not fade w/ age

Strawberry hemangioma/nevus vasculosus

 dark-red, raised, and strawberry-like in appearance found at the head
d/t dilated immature capillaries occupying the dermal and subdermal
layers of the skin; also associated with connective tissue hypertrophy
  Most are present at birth in the term neonate or may appear up to 2 weeks or months after birth.
 may continue to enlarge from their original size up to 1 year of age.
 Completely disappears by school age
 Typically, they are not present in the preterm infant because of the immaturity of the epidermis.
Formation is associated with the high estrogen levels of pregnancy. They may continue to enlarge from
their original size up to 1 year of age. After the first year, they tend to be absorbed and shrink in size.
By the time the child is 7 years old, 50% to 75% of these lesions have disappeared. A child may be
10 years old before the absorption is complete. Application of hydrocortisone ointment may speed the
disappearance of these lesions by interfering with the binding of estrogen to its receptor sites.
 Surgery to remove strawberry hemangiomas is rarely recommended because it can lead to secondary
infection, resulting in scarring and permanent disfigurement. Large lesions that are disfiguring can be
removed by laser therapy.
 MNGT: Application of hydrocortisone ointment may speed the disappearance of these lesions

Cavernous hemangioma
 appears like strawberry hemangioma but primarily d/t dilated vascular spaces
 consist of a communicating network of venules in subcutaneous tissue and do not fade with age
 Present at birth or appear several months after
 does not disappear with time

Mongolian Spots
 are collections of pigment cells (melanocytes) that appear as slate-gray patches across the sacrum or
buttocks and possibly on the arms and legs.
 They tend to occur in children of Asian, southern European, or African ethnicity.
 They disappear by school age without treatment.
 Be sure to inform parents that these are not bruises; otherwise, they may worry their baby sustained a
birth injury.
 Bluish - to black; bluish to blue
 Abused child - varying degrees of healing

Vernix Caseosa
 is a white, cream cheese–like substance that serves as a skin lubricant in utero.
 Formed from old cutaneous cells and secretions of sebaceous glands while in utero
 Document the color of vernix, because it takes on the color of the amniotic fluid. For example, a yellow
vernix implies that the amniotic fluid was yellow from bilirubin; green vernix indicates that
meconium was present in the amniotic fluid.

Lanugo
 is the fine, downy hair that covers a newborn’s shoulders, back and upper
arms, on the forehead and ears.
 1 st appearance: 19 weeks of fetal life
 Most obvious at 27- 28 weeks of fetal life
 Babies born between 37 to 39 weeks of gestation: more lanugo than a
newborn of 40 weeks’ gestational age.
 Disappears: 2 weeks post life
 Rubbed away by: friction of bedding and clothes against the newborn’s skin

Desquamation
 areas of peeling similar to those caused by sunburn.
 Caused by drying of the NB skin within 24H of life
 Particularly evident on the palms of the hands and soles of the feet.
 Mngt: hand lotion to prevent excessive dryness if they wish.
Milia
 All newborn sebaceous glands are immature. At least one pinpoint white papule (a plugged or unopened
sebaceous gland) can be found on the cheek or across the bridge of the nose disappear by 2 to 4 weeks of
age, as the sebaceous
 Teach parents to avoid scratching or squeezing the papules, to prevent secondary infections

Erythema Toxicum
 Appears in the first to fourth day of life but may appear up to 2 weeks of age.
 Begins as papules that develop in a hive like elevations with a center containing clear fluid as a
reaction of the skin to the clothes and sheets; become erythema by the second
day, and then disappears by the third day.
 Caused by a NB’s eosinophils reacting to the environment as the immune system
matures.
 Requires no treatment
 It is sometimes called a flea-bite rash because the lesions are so minuscule.
 It is caused by a newborn’s eosinophils reacting to the environment as the
immune system matures. It requires no treatment.

Skin Turgor
 An indicator of the hydration status of the NB
 Well hydrated: feel resilient
 Elastic and immediately returns back to normal contour when grasped b/n the thumb and fingers

EYES
 Absence of tears (tear glands matures at about 3 months of age)
 Corneal and blink reflexes in response to touch
 Pupillary reflex in response to light
 (+) strabismus and nystagmus until 4 months the sclera may be blue because of its thinness.
 Infant eyes assume their permanent color between 3 and 12 months of age.

**Subconjunctival hemorrhage - red spots on the sclera d/t rupture of

subconjunctival capillaries appears as a red spot on the sclera, usually on the
inner aspect of the eye, or as a red ring around the cornea.
 The bleeding is slight, requires no treatment, and is completely absorbed
within 2 or 3 weeks.
 Usually edematous (periorbital, eyelids)
 This remains for the first 2 or 3 days, until the newborn’s kidneys are
capable of evacuating fluid more efficiently.
 Optimal visual field: 9-12 inches away

EARS
 pinna, cartilage present
 Position: top of pinna in line with outer canthus of the eye
 Flat against head = premature
 Skin tags may be present

Mouth
 opens evenly when crying
 Presence of sucking, rooting, gagging, and extrusion reflexes
 Absent or minimal salivation; tongue appears large and prominent in the mouth
** Epstein’s pearls
 small round, glistening, wellcircumscribed cysts on the hard palate; d/t deposition of extra load of
calcium in utero
 disappears within 1 week
 It is highly unusual for a newborn to have teeth, but sometimes one or two (called natal teeth) will
have erupted. Any teeth that are present must be evaluated for stability. If loose, they are usually
extracted (they remove easily) to prevent possible aspiration during feeding.
 a parent may mistake them for thrush, a Candida infection, which usually appears on the tongue and
sides of the cheeks as white or gray patches and needs therapy with an antifungal drug

ABDOMEN
 Normal contour: Slightly protuberant
 Scaphoid (sunken appearance) > diaphragmatic hernia
 + barrel chest, wherein intestines are positioned going to the chest; bowel goes to the chest
 Bowel sound should be present within 1 hour after birth
 Edge of liver palpable 1-2 cm below right costal margin
 Edge of spleen palpable 1-2 cm below left costal margin
 Cord stump 1st Hr: white, gelatinous structure marked with the blue and red streaks of the umbilical
vein and arteries
 1 artery in cord = CHD or renal abnormality
 Brown (after 2-3 hours)
 black (2-3 days)
 breaks free by day 7 - 10

Anogenital Area
 Male genitalia
 penis of newborns: appears small, approximately 2 cm
long
 Scrotum: rugae present; deep pigmented; with 2 testicles
 Cryptorchidism—absence of testicle or both
 Causes of cryptorchidism:
 Agenesis - absence of organ
 Undescended testicles
 Ectopic testis - scrutal sac is closed
 Positive cremasteric reflex maybe absent until 10 days old

**Penis—2 cm or more
 Epithelial pearls—small, firm, white lesions at the tip of prepuce
 Erection or priapism
 Chordee—lateral curvature of the penis

**Urethral opening
 Hypospadias—urethral opening on the ventral surface of the penis
 Epispadias—urethral opening on the dorsal surface of the penis

 Female genitalia
 Labia and clitoris usually edematous
 Urethral meatus below clitoris
 Vernix caseosa maybe found between labia
 Pseudomenstruation—blood-tinged or mucoidal discharge d/t maternal hormone
 Hymenal tag maybe present

Anus/rectum
 Patent
 Imperforate
 (+) anal reflex

Back
 surface; no dimpling, opening, or masses
 dermal sinus or spinal bifida occulta.
 Tuft of hair along the spine
 (+) trunk incurvation reflex

Extremities
 Symmetrical
 10 fingers and toes
 Polydactyly - is the presence of one or more additional fingers or toes. These extra fingers are
often just cartilage or skin tags, and removal is simple and cosmetically sound.
 Syndactyly - (two fingers or toes are fused), the fusion is usually caused by a
simple webbing; separation of the digits into two sound and cosmetically
appealing ones is usually successful.
 Phocomelia - a rare birth defect characterized, in most instances, by severe
malformation of the extremities.
 Hemimelia - born with a short or missing fibula (one of the two bones in the lower leg).
 Fingertips should reach over the proximal thigh
 Unusually short arms: achondroplastic dwarfism
 Full ROM
 Soft and smooth nails; Nailbeds pink, with transient cyanosis
immediately after birth
 Simian crease—Down syndrome
 Creases on anterior 2/3 of sole
 Sole usually flat
 Clonus—rapid alternating contraction and relaxation of the foot
after dorsiflexion; may indicate neurologic involvement
 Hallux - hallux valgus (HV), also known as a bunion, is one of the most common forefoot deformities.
 Ortolani’s sign—clicking sound upon upward rotation of the thigh
Neck
 short and chubby, with creased skin folds
 Head should rotate freely
 Present tonic neck reflex
 Torticollis (wry neck)—head held to one side with chin pointing to opposite
side as a result of injury to the sternocleidomastoid muscle
 Nuchal rigidity