Sheila Fallon Friedlander, MD Staff, Scripps Clinic San Diego, Professor Emeritus, Dermatology Department, UCSD Medical Center, San Diego, California
“Ted, the pediatric dermatology staff are all away at a meeting, and I have a newborn with a funny rash. Can I send him over to you?”
“Sheila, we have a funny looking baby in the neonatal intensive care unit with an odd rash. Could you please come over and weigh in?”
Why Are We So Afraid of the Littlest Ones?
Why do we all get so anxious when we receive such a call? I am triple boarded (pediatrics, dermatology, pediatric dermatology), but I still shudder when the NICU calls.
There are several reasons why we are so anxious.
First, we know a baby’s skin, particularly associated with prematurity, is less likely to optimally protect the “little one” from the outside world, with suboptimal barrier function integrity and more risk for erosions and infection. This could then obscure the true nature of any underlying disorder.
Second, neonates can develop or manifest weird disorders, including genodermatoses not usually seen in adults.
Third, we often cannot perform an optimal physical examination.
Finally, distraught parents often prove too emotional to provide a meaningful complete history, including a family history.
How do we face these little tykes with more equanimity and less anxiety? Here are a few rules that I have found helpful and would like to share:
Most important, determine if the child is really sick or is at risk for severe illness:
Make friends with the neonatal nurses and ask them how the child is doing. Limp? Unstable? Temperature? Not feeding? A good neonatal nurse can usually more efficiently update you than hours of chart reviews.
Get a good maternal/antenatal history. If Baby has a facial rash and Mom has a history of dry mouth/eyes or autoimmune disease, you need to think about neonatal lupus. If there was prolonged rupture of membranes you need to worry more about infection, particularly due to streptococci and yeast. If Mom had a first episode of genital herpes during her pregnancy, you need to rule out herpes simplex virus (HSV).
You do not know every possible skin condition that could affect a “little one.” It is better to develop an approach that can help identify the child at-risk for severe consequences from his illness, rule out serious possibilities, and counsel the pediatric staff to evaluate rapidly when appropriate. No one is likely to fault you if you recommend a herpes work-up that ends up negative, but it would be really bad if you did not mention the possibility of viral, bacterial, or fungal infection when they are reasonable possibilities. Mortality is significant with some of these infections, particularly in preemies.
Significant erosions raise the issue of blistering disorders, as well as infection, and such children need a good evaluation and special handling of the skin if epidermolysis bullosa is a consideration. DEBRA is a research foundation that provides clinical support for clinicians and families; their nurse educators are available to speak with you regarding skin care while awaiting confirmation of the diagnosis. The phone number is 833-332-7287 or email nurse@debra.org.
Do not be afraid to biopsy a small baby (other than midline lesions!), or at least get someone involved who can help with one when needed. On the other hand, there are now so many relatively non-invasive ways to make diagnoses ([polymerase chain reaction] PCR viral panels, mutational analysis via buccal swab, or blood sampling) that you often can do something other than a biopsy to arrive at the right diagnosis.
Beware the lump or bump that presents early, grows fast, and is fixed to underlying tissue. While most of the time it will be a hemangioma, other more serious considerations exist. Beware of any midline bump and recommend further assessment before even considering biopsy. Doppler ultrasound will let you know whether you are dealing with a solid or vascular lesion. MRI/MRA is crucial for most solid midline lesions, but an ultrasound is an often useful, easily obtained first-line option.
In general, it is better not to hastily diagnose a syndrome in a newborn FLK (funny looking kid). Most vaginally delivered newborns are funny looking! Abnormally shaped skulls and significant facial edema with “squashed faces” are not unusual. Give such babies time to “settle” before deciding on a serious disorder or syndromes. In general, there is not a major rush to make those diagnoses, whereas missing HSV or a tumor is a more urgent issue.
One can derive a significant amount of joy by evaluating (and most often reassuring) families of neonates. I hope that this discussion has increased your comfort zone for this activity!
