A 1-day-old girl is being evaluated in the newborn nursery. She was born at 39 weeks gestation. Vital signs are normal. Examination shows a vigorous newborn with a firm, nonfluctuant swelling confined to the right side of the skull, as seen in the image below: In addition to monitoring bilirubin levels, which of the following is the best next step in management of this patient?

Question

A 1-day-old girl is being evaluated in the newborn nursery.  She was born at 39 weeks gestation.  Vital signs are normal.  Examination shows a vigorous newborn with a firm, nonfluctuant swelling confined to the right side of the skull, as seen in the image below:  In addition to monitoring bilirubin levels, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d6fc_c7ac_bc81_a16085cb1cd8_MD0003_00 Cephalohematoma is a collection of blood between the skull and periosteum (ie, subperiosteal space) caused by rupture of subperiosteal blood vessels due to birth trauma. Infants delivered with assistance by forceps or vacuum are at increased risk. Due to the slow nature of the bleed, cephalohematomas present hours after birth with a firm, nontender, nonfluctuant scalp swelling. The swelling is well demarcated and confined to the surface of a single bone because the hematoma does not cross suture lines. Diagnosis is clinical, and management is with observation. As blood from the cephalohematoma breaks down, the patient is at increased risk for hyperbilirubinemia and may require phototherapy. Families should be reassured that cephalohematomas typically resorb spontaneously within a month, during which time the affected area may feel firmer due to clotting or calcification. (Choice A) Infection (eg, abscess, osteomyelitis) is a rare complication of cephalohematoma that may require MRI for diagnosis and management. Patients may be ill-appearing or febrile and have overlying erythema of the cephalohematoma. This patient is vigorous with no signs of infection. (Choice B) Cranial molding helmets are occasionally recommended for positional plagiocephaly (ie, abnormal skull flattening), which is most commonly caused by supine positioning of young infants (not newborns). Congenital plagiocephaly may be due to abnormal closure of sutures (ie, craniosynostosis). Neither condition presents with scalp swelling. (Choice C) Intracranial hemorrhage (eg, epidural, subdural) is a rare neonatal injury that typically presents with hemodynamic instability or neurologic symptoms (eg, seizure), often warranting hematoma evacuation. This patient is otherwise asymptomatic, and cephalohematomas typically resolve without intervention. (Choice E) Subgaleal hemorrhage (ie, blood between the periosteum and gala aponeurotica) is a life-threatening injury due to potential massive blood loss and warrants serial hemoglobin monitoring. Newborns have diffuse, fluctuant scalp swelling that expands after delivery. In contrast, cephalohematomas are localized and not associated with significant blood loss. Subgaleal hemorrhage Educational objective: A cephalohematoma is a collection of blood between the skull and periosteum caused by the rupture of subperiosteal vessels during delivery. Examination reveals a firm, nonfluctuant scalp swelling that does not cross suture lines. Management is with reassurance and observation because most cephalohematomas resolve without intervention. References: Cephalohematoma. (http://www.ncbi.nlm.nih.gov/pubmed/29262234)

A 1-Day-Old Girl Is Being Evaluated in the Newborn Nursery