Summary of findings
I examined Baby Okafor, a 1-day-old boy born at term by vaginal delivery with a birth weight of 3.2 kg, which is appropriate for gestational age. He is pink, active, with a lusty cry and normal tone. Temperature 36.8 °C, respiratory rate 48, heart rate 136, saturation 98% in the right hand and the foot. There is a 3 cm fluctuant swelling over the right parietal bone that does not cross the suture line — a cephalhaematoma. The red reflex is present in both eyes, the palate is intact and the femoral pulses are palpable. The hips are stable, the spine is normal and the primitive reflexes are symmetrical. The rest of the examination is normal.
Differential diagnoses
| Finding | What it means |
|---|---|
| Caput succedaneum | Soft oedema that crosses sutures; resolves in days |
| Cephalhaematoma | Subperiosteal blood limited by sutures; can worsen jaundice |
| Subgaleal haemorrhage | Boggy swelling across sutures with pallor and shock — an emergency |
| Absent red reflex | Cataract, retinoblastoma, glaucoma — same-week ophthalmology review |
| Weak or absent femoral pulses | Coarctation or interrupted aortic arch — echocardiography now |
| Pre- and post-ductal saturation difference above 3% | Duct-dependent heart disease or persistent pulmonary hypertension |
| Single umbilical artery | Associated renal anomalies — consider renal ultrasound |
| Sacral dimple above the natal cleft, or with a hair tuft | Possible spinal dysraphism — ultrasound of the spine |
| Limp arm held in internal rotation (waiter's tip) | Erb palsy — also check the clavicle |
| Positive Ortolani or Barlow | Developmental dysplasia of the hip — ultrasound and orthopaedic referral |
Investigations
- Blood glucose in babies at risk: small or large for gestational age, preterm, infant of a diabetic mother, hypothermic
- Serum bilirubin if jaundiced in the first 24 hours
- Hepatitis B and HIV exposure status and the related prophylaxis
- Hearing screening by otoacoustic emissions
- Hip ultrasound for breech presentation, family history or abnormal hip tests
Treatment
- BCG, oral polio and hepatitis B birth doses
- Vitamin K 1 mg intramuscularly (0.5 mg below 1.5 kg)
- Chlorhexidine 7.1% gel to the cord stump once daily for 7 days, as recommended in Nigeria
- Tetracycline eye ointment
- Early and exclusive breastfeeding, warmth and skin-to-skin contact
Warning signs to teach the mother: poor feeding, yellow soles or jaundice in the first day, fever or cold body, fast or difficult breathing, convulsions, reduced movement, a red or smelly cord.
Examiner questions
References
- Kliegman RM, St Geme JW, Blum NJ, Tasker RC, Wilson KM, et al., eds. Nelson Textbook of Pediatrics. 22nd ed. Philadelphia: Elsevier; 2025.