Newborn assessment: fontanelles// cephalohematoma/ caput// NCLEX 4

Obviously, a good exam of the head is super important, so make sure that you assess and then document the head well. Remember that the bones of the skull in a newborn baby are not fused, so often you can feel the lines between the skull plates, and these are called the suture lines. So it's just the connective tissue between the two skull plates. Often, as the head is going through the vaginal canal during delivery, the head gets really, really squashed and kind of starts looking like a cone head. This is called molding, and molding normally goes away over the first kind of 72 hours of life, and it all relaxes again, and the head becomes more circular. But sometimes when you feel the skull immediately after delivery, you can't really feel those suture lines at all because the bones were all kind of pushed together, and because of the molding, some of those skull plates are like overriding each other. So you have kind of like overriding sutures where you can't really feel the gaps between the plates. Again, this goes away after the first couple of days of life. Newborn babies generally have two fontanelles, and a fontanelle is just the meeting place between all the different skull plates. So before those skull plates are fused, then babies can have like missing bone in that area. The anterior fontanelle, or like the soft spot, is right at the top of the baby's head, and it's normally diamond-shaped, kind of two to three centimeters in each direction. Always feel for this on an exam. Honestly, it's almost like I'm addicted to it now. Every time I'm holding a baby, even if it's a friend's, I can't help feeling for the fontanelle. But generally, if it's really full and bulging, then you're worried that there's increased pressure in the brain. If it's like really sunken down, it like dips down underneath the bones, then you're more worried that the baby could be dehydrated. Generally, the anterior fontanelle closes between 12 and 18 months of life. The posterior fontanelle, which is kind of like right at the back of the baby's head, isn't always open when the baby is born. It might already be closed. If it is open, then generally the posterior fontanelle closes much sooner than the anterior fontanelle. Normally, it closes by two to three months of life. The posterior fontanelle is also much smaller. It's triangular shape, and it's about one centimeter, and it lies right between the occipital and the parietal bones. There are two common lesions that we see all the time on baby's heads, which are generally associated with just the normal trauma of being delivered. Obviously, if forceps or a vacuum was used, in addition to kind of trying to get the baby out, then the baby is much more likely to have these two lesions. The first is called a caput succidanium, or we call it a caput, I never say that word, which is basically a soft tissue swelling. Normally, it's right at the back on top of the head, and it's very superficial. So because it's superficial, it is way above the bone, and it crosses all the suture lines. Remember this, a cap would also cross suture lines. So a caput does cross the suture lines. Generally, because it's just soft tissue swelling, then this goes down over the first two to three days of life. The second lesion that a baby can have is something called a cephalohematoma. This is a little deeper, and also can signify that the baby has other issues going on. This happens when there is bleeding between the bone and its sheath, or what's called the periosteum. Generally, these can continue to get bigger after birth, and they feel a lot harder than the caput. Because it's basically under the bone, it doesn't cross the suture lines. It's trapped within that sheath. So basically, you'll only see a bump on one side of the head, or the baby could have two cephalohematomas, and you'd have two separate bumps on either side of the head. These cephalohematomas can take weeks for them to resolve by themselves. Sometimes they kind of harden, and the baby ends up with a hard lump on the baby's head. Sometimes, very rarely, rarely, cephalohematomas can be associated with skull fractures, which are right under the area of the cephalohematoma. Right, the last thing I'll say about heads, probably not the last thing, but babies are born floppy. So remember, babies aren't able to keep their heads up, whichever position they're in. So for example, if they are being pulled up by the shoulders, their heads will lag a little bit behind. If they're lying prone, then a baby can lift its head up a little bit, and kind of maybe turn its head from side to side, but can't lift its head up all the way off the bed. Obviously, that strength should improve over the first few months of life, so that if by six months old, the baby still has a head lag, then at that point, you would be worried about neurological and muscle function. Right, now go watch the video on the examination of the neonatal face.