ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﻴﻢ Cutaneous Manifestations of Newborns in Omdurman Maternity Hospital A thesis submitted in the partial fulfillment of the degree of clinical MD in pediatrics and child health University of Khartoum By DR. AMNA ABDEL KHALIG MOHAMED ATTAR MBBS University of Khartoum Supervisor PROF. SALAH AHMED IBRAHIM MD, FRCP, FRCPCH Department of Pediatrics and Child Health University of Khartoum University of Khartoum The Graduate College Medical and Health Studies Board 2008 Dedication I dedicate my study to the Department of Pediatrics University of Khartoum hoping to be a true addition to neonatal care practice in Sudan. i Acknowledgment I would like to express my gratitude to my supervisor Prof. Salah Ahmed Ibrahim, Professor of Peadiatric and Child Health, who encouraged me throughout the study and provided me with advice and support. I am also grateful to Dr. Osman Suleiman Al-Khalifa, the Dermatologist for his support at the start of the study. Special thanks to the staff at Omdurman Maternity Hospital for their support. I am also grateful to all mothers and newborns without their participation and cooperation this study could not be possible. Love and appreciation to my family for their support, drive and kindness. ii Table of contents Dedication i Acknowledgement ii Table of contents iii English Abstract vii Arabic abstract ix List of abbreviations xi List of tables xiii List of figures xiv Chapter One: Introduction & Literature Review 1.1 The skin of NB 1 1.2 Traumatic lesions 5 1.3 Desquamation 8 1.4 Lanugo hair 9 1.5 Sucking Blisters 9 1.6 Skin Nodules in Newborns 10 1.7 Vesiculobullous and pustular lesions in the newborn 14 1.7.1 Erythema toxicum neonatorum 15 1.7.2 Transient neonatal pustular melanosis 16 1.7.3 Miliaria 17 1.7.4 Bacterial Infections 19 1.7.5 Viral infections 23 1.7.6 Fungal Infections 25 1.8 Color Changes 25 iii 1.9 Vascular birthmarks 28 1.10 Congenital Melanocytic Nevi 32 1.11 Café-au-lait spot 33 1.12 Supernumerary nipple 34 1.13 Adnexal polyp of neonatal skin 35 1.14 Puberty in Miniature 35 1.15 Accessory Tragus (Preauricular tag) 36 1.16 The Genodermatoses 37 1.17 Statistical Survey of Skin Changes In Neonates 45 Justifications 50 Objective 51 Chapter Two: Materials And Methods 2.1 Study design 52 2.2 Study area 52 2.3 Study duration 52 2.4 Study population 54 2.5 Sample Size and sampling techniques 54 2.6 Research Technique 55 2.7 Research team 58 2.8 Data Management 58 2.9 Limitation of the study 59 Chapter Three: RESULTS 3.1 Newborns’ specific data 60 3.1.1 The age distribution of the newborns 60 3.1.2 The gender distribution of the newborns 60 iv 3.1.3 The number of birth distribution of the newborns 63 3.1.4 The gestational age distribution of the newborns 63 3.1.5 The birth weight distribution of the newborns 63 3.1.6 The appropriation for gestational age distribution of the newborns 63 3.2 The deliveries; mode and complications 67 3.2.1 The distribution of the newborns according to mode of delivery 67 3.2.2 The distribution of the complicated vaginal delivery 67 3.2.3 The distribution of the neonatal complications after delivery 67 3.3 The distribution of the skin lesions possibly related to delivery events 69 3.4 The distribution of skin lesions according to the most frequent 69 detected types 3.5 73 The distribution of lesions according to the less frequent detected types: 3.6 73 The distribution of skin lesions in newborns according to the rare frequent detected types: 3.7 Infections and culture results 76 3.7.1 The distribution of NBs according to prevalence and type of infections 76 3.7.2 The distribution of NBs according to laboratory culture results 76 3.8 Skin lesions in relation to certain newborns’ characteristics 79 3.8.1 Frequency of neonatal skin lesions in relation to neonatal age 79 3.8.2 Frequency of neonatal skin lesions in relation to neonatal gender 81 3.8.3 Frequency of neonatal skin lesions in relation to number of gestation 81 3.8.5 Frequency of neonatal skin lesions in relation to gestational age 85 3.8.6 Frequency of neonatal skin lesions in relation to appropriateness for 85 gestational age 3.8.7 Frequency of neonatal skin lesions in relation to mode of delivery 85 3.9 Skin lesions analysis 89 v Chapter four :Discussion , Conclusion and Recommendations 4.1 Discussion 114 4.2 Conclusion 124 4.3 Recommendations 126 References 129 Appendices vi Abstract The neonatal skin lesions in Sudan had not been studied before. This is a cross – sectional descriptive hospital based study. A total of 602 Newborns (NB) delivered at Omdurman Maternity Hospital were examined for the presence of skin and oral lesions within 96 hours of birth to study the clinical spectrum of neonatal cutaneous lesions, from August 2007 to January 2008. Precoded questionnaire regarding perinatal, maternal, and family medical history was administered to the mother of each child, clinical examinations were recorded and laboratory investigations were used to confirm the diagnoses of certain lesions. The data were collected, stored and analyzed using x2 and Fishers exact test for statistical association. The commonest types of skin lesions in NBs were: Mongolian spots in 471 (79.5%) NBs, linea nigra in 421 (70%), epithelial pearls in 285 (47%), sebaceous hyperplasia in 197 (32.7%), milia in 107 (17.7%), salmon patch in 106 (17.6%), desquamation in 98 (16.3%), café-au-lait spots in 91 (15%), erythema toxicum neonatorum in 82 (13.6%), Lanugo in 63 (10.5%), lcterus in 42 (7%), congenital melanocytic nevi in 37 (6%), transient vii neonatal pustular melanosis in 30 (5%), supernumerary nipple in 28 (4.6%) and miliaria in 22 (3.6%) newborns. Pigmentary lesions comprised mainly birthmarks; melanocytic brown lesions (MS, CMN, CALS and LN) were the most frequently encountered clinically, this is influenced by the racial background of the study population. Desquamation was more frequent among those less than 24 hours age and post term neonates. Salmon patch was more frequent in female (24%). Pustular eruptions in the neonate can have many clinical presentations and significance. Erythema toxicum and transient neonatal pustular melanosis (18.6%) were among the frequent, benign and temporary dermatoses of NBs. Both lesions were more frequent among full term babies who were appropriate for gestational age. Skin infections were seen in 15 (2.5%) newborns, omphalitis in 11 of NBs, impetigo bullosa manifested in 2 NBs, and skin abscess in 2 newborns. One of the newborns had the severe manifestations of the harlequin fetus. viii Almost all newborns seen in their first 96 hours would show some sort of cutaneous manifestation. The majority of which are benign and transient needing reassurance. ix ﻣﺴﺘﺨﻠﺺ ﺍﻻﻃﺮﻭﺣﺔ ﺍﻟﻤﻅﺎﻫﺭ ﺍﻟﺠﻠﺩﻴﺔ ﻟﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﻓﻲ ﺍﻟﺴﻭﺩﺍﻥ ﻟﻡ ﻴﺘﻡ ﺩﺭﺍﺴﺘﻬﺎ ﻤﻥ ﻗﺒل. ﻫﺫﻩ ﺍﻟﺩﺭﺍﺴﺔ ﻭﺼﻔﻴﺔ ﻤﻘﻁﻌﻴﺔ ﻤﺒﻨﻴﺔ ﻋﻠﻰ ﺩﺭﺍﺴﺔ ﺒﺎﻟﻤﺴﺘﺸﻔﻰ. ﺘﻡ ﺍﻟﻔﺤﺹ ﻋﻠﻰ ﺘﻤﺎﻡ ﺍﻟـ 602 ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﻓﻲ ﻤﺴﺘﺸﻔﻰ ﺍﻡ ﺩﺭﻤﺎﻥ ﻟﻠﻭﻻﺩﺓ ﺒﻬﺩﻑ ﺍﻟﺒﺤﺙ ﻋﻥ ﻭﺠﻭﺩ ﺍﺼﺎﺒﺎﺕ ﺍﻟﺠﻠﺩ ﻭﺍﻟﻔﻡ ﺨﻼل 96 ﺴﺎﻋﺔ ﻤﻥ ﻋﻤﺭ ﻭﻻﺩﺓ ﺍﻟﻁﻔل ﻟﺘﺤﺩﻴﺩ ﺍﻟﻨﻁﺎﻕ ﺍﻻﻜﻠﻴﻨﻴﻜﻲ ﻻﺼﺎﺒﺎﺕ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﺍﻟﺠﻠﺩﻴﺔ ﻓﻲ ﺍﻟﻔﺘﺭﺓ ﻤﻥ ﺃﻏﺴﻁﺱ 2007ﻡ ﺤﺘﻰ ﻴﻨﺎﻴﺭ 2008ﻡ. ﺸﻤل ﺍﻻﺴﺘﺒﻴﺎﻥ ﺍﻟﺘﺎﺭﻴﺦ ﺍﻟﻁﺒﻲ ﻟﻸﻡ ﻭﺍﻷﺴﺭﺓ ﻭﻓﺘﺭﺓ ﺍﻟﻭﻻﺩﺓ. ﺘﻡ ﺘﺴﺠﻴل ﺍﻟﻔﺤﺹ ﺍﻟﺴﺭﻴﺭﻱ ﻭ ﺍﻟﻔﺤﺹ ﺍﻟﻤﻌﻤﻠﻲ ﺍﺴﺘﺨﺩﻡ ﻟﺘﺄﻜﻴﺩ ﺍﻟﺘﺸﺨﻴﺹ ﻓﻲ ﺇﺼﺎﺒﺎﺕ ﻤﺤﺩﺩﺓ. ﺘﻡ ﺠﻤﻊ ﻭﺘﺨﺯﻴﻥ ﻭﺘﺤﻠﻴل ﺍﻟﻤﻌﻠﻭﻤﺎﺕ ﺒﺎﺴﺘﺨﺩﺍﻡ ﻤﻌﺎﻤل ﻜﺎﻱ ﺍﻟﺘﺭﺒﻴﻌﻲ ﻭﻤﻌﺎﻤل ﻓﺸﺭ ﻟﻼﺭﺘﺒﺎﻁ ﺍﻹﺤﺼﺎﺌﻲ. ﺍﻟﺤﺎﻻﺕ ﺍﻟﺠﻠﺩﻴﺔ ﺍﻷﻜﺜﺭ ﺸ ﻴ ﻭ ﻋ ﺎﹰ ﻓﻲ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﻫﻲ: • ﺍﻟﺒﻘﻊ ﺍﻟﻤﻨﻘﻭﻟﻴﺔ ﻤﺘﻭﺍﺠﺩﺓ ﻓﻲ 471 (79%) ﻁﻔل ﻤﻥ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﻭﺍﻟﺨﻁ ﺍﻷﺴﻭﺩ ﺍﻟﻭﻻﺩﻱ ﻓﻲ 421 (70%) ﻭﺍﻟﻶﻟﻲﺀ ﺍﻟﻁﻼﺌﻴﺔ ،265 (%47)، ﻭﺍﻟﻔﺭﻁ ﺍﻟﺯﻫﻤﻲ 197 (32%)، ﺍﻟﺩﺨﻴﻨﺎﺕ 71 (17.7%) ﻭﺒﻘﻊ ﺴﺎﻟﻤﻭﻥ 106 (17.6%)، ﺍﻟﺘﻘﺸﻴﺭ ﻓﻲ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ 98 (16.3%) ﻭﺒﻘﻊ ﺍﻟﻘﻬﻭﺓ ﺒﺎﻟﺤﻠﻴﺏ 91 (15%)، ﺍﻷﺤﻤﺭﺍﺭ ﺍﻟﻭﻻﺩﻱ ﺍﻟﺴﻤﻰ 82 (13.6%) ﻭﻓﺭﻁ ﺍﻟﺸﻌﺭ ﺍﻟﻭﻻﺩﻱ 63 (10.5%)، ﺍﻷﺼﻔﺭﺍﺭ ﺍﻟﻭﻻﺩﻱ 42 (7%)، ﺍﻟﺸﺎﻤﺔ ﺍﻟﺴﻭﺩﺍﺀ ﺍﻟﺨﹸﻠﻘﻴﺔ 37 (6%)، ﺍﻟﺘﺴﻤﺭ ﺍﻟﺨﻤﺠﻲ ﺍﻟﻤﺅﻗﺕ ﺍﻟﻭﻻﺩﻱ 30 (5%)، ﺍﻟﺤﻠﻤﺔ ﺍﻟﺯﺍﺌﺩﺓ 28 (4.6%)، ﻭﺍﻟﺤﻤﻭ 22 (3.6%) ﺒﺎﻟﺘﺭﺘﻴﺏ. x • ﺤﺎﻟﺔ ﺍﻟﺘﻠﻭﻥ ﺘﻌﺘﺒﺭ ﺃﻜﺜﺭ ﺍﻟﻌﻼﻤﺎﺕ ﺍﻟﻭﻻﺩﻴﺔ ﻜﺎﻻﺼﺎﺒﺎﺕ ﺒﺎﻟﺘﺴﻤﺭ ﺍﻟﺒﻨﻲ (ﺍﻟﺒﻘﻊ ﺍﻟﻤﻨﻘﻭﻟﻴﺔ ﻭﺍﻟﺸﺎﻤﺔ ﺍﻟﺴﻭﺩﺍﺀ ﺍﻟﺨﹸﻠﻘﻴﺔ ﻭﺒﻘﻊ ﺍﻟﻘﻬﻭﺓ ﺒﺎﻟﺤﻠﻴﺏ ﻭﺍﻟﺨﻁ ﺍﻷﺴﻭﺩ ﺍﻟﻭﻻﺩﻱ) ﻜﻠﻬﺎ ﻤﻥ ﺍﻟﺤﺎﻻﺕ ﺍﻟﻤﺘﻌﺩﺩﺓ ﺍﻟﺤﺩﻭﺙ ﺘ ﺄ ﺜ ﺭ ﺍﹰ ﺒﺨﻠﻔﻴﺔ ﺍﻷﺠﻨﺎﺱ ﺍﻟﺴﻜﺎﻨﻴﺔ ﻓﻲ ﺍﻟﺒﺤﺙ. • ﺍﻟﺘﻘﺸﺭ ﺍﻟﻭﻻﺩﻱ ﺃﻜﺜﺭ ﺤ ﺩ ﻭ ﺜ ﺎﹰ ﻓﻲ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﺍﻟﺫﻴﻥ ﻫﻡ ﺃﻗل ﻤﻥ 24 ﺴﺎﻋﺔ ﻋ ﻤ ﺭ ﺍﹰ ﻭﺘﻌﺩﻱ ﻓﺘﺭﺓ ﺍﻻﻜﺘﻤﺎل. • ﺒﻘﻊ ﺍﻟﺴﺎﻟﻤﻭﻥ ﺃﻜﺜﺭ ﺤ ﺩ ﻭ ﺜ ﺎﹰ ﻋﻨﺩ ﺍﻹﻨﺎﺙ. • ﺍﻟﻔﻘﻊ ﺍﻟﺨﻤﺠﻴﺔ ﻓﻲ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﻤﺘﻌﺩﺩﺓ ﺍﻟﺩﻻﻟﺔ ﻭﺍﻟﺘﻭﺍﺠﺩ ﺍﻻﻜﻠﻴﻨﻴﻜﻲ. • ﺍﻷﺤﻤﺭﺍﺭ ﺍﻟﻭﻻﺩﻱ ﺍﻟﺴﻤﻲ ﻭﺍﻻﺴﻤﺭﺍﺭ ﺍﻟﺨﻤﺠﻲ ﺍﻟﻤﺅﻗﺕ ﺍﻟﻭﻻﺩﻱ ﻤﻥ ﺍﻟﺒﺜﻭﺭ ﺍﻟﺤﻤﻴﺩﺓ ﺍﻟﻤﺅﻗﺘﺔ ﺍﻟﻤﺘﻜﺭﺭﺓ ﺍﻟﺤﺩﻭﺙ ﻓﻲ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ (18.6%). ﻭﺍﻟﻨﻭﻋﻴﻥ ﺃﻜﺜﺭ ﺸ ﻴ ﻭ ﻋ ﺎﹰ ﻓﻲ ﺍﻷﻁﻔﺎل ﻤﻜﺘﻤﻠﻲ ﺍﻟﻨﻤﻭ ﻭﻤﺘﻨﺎﺴﺒﻲ ﺍﻟﻭﺯﻥ ﻤﻊ ﺍﻟﻌﻤﺭ ﺍﻟﺤﻤﻠﻲ ﻟﻠﻁﻔل. • ﺍﻷﻟﺘﻬﺎﺒﺎﺕ ﺸﻭﻫﺩﺕ ﻓﻲ 15 ﻁﻔل ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﻤﻨﻬﺎ ﺍﻟﺘﻬﺎﺏ ﺍﻟﺴﺭﺓ ﻓﻲ 11 ﻁﻔل، ﺍﻻﻨﺘﻔﺎﺨﺎﺕ ﺍﻟﺨﻤﺠﻴﺔ ﻓﻲ ﻁﻔﻠﻴﻥ ﻭﺍﻟﺘﻘﻴﺢ ﺍﻟﺠﻠﺩﻱ ﻓﻲ ﻁﻔﻠﻴﻥ. • ﻁﻔل ﺍﻟﻬﺎﺭﻟﻜﻭﻴﻥ ﻅﻬﺭ ﻓﻲ ﺤﺎﻟﺔ ﻭﺍﺤﺩﻩ ﺒﻜل ﻋﻼﻤﺎﺘﻪ ﺍﻟﻤﺭﻀﻴﺔ. • ﺃﻏﻠﺒﻴﺔ ﺤﺩﻴﺜﻲ ﺍﻟﻭﻻﺩﺓ ﺨﻼل ﺍﻟـ 96 ﺴﺎﻋﺔ ﺍﻷﻭﻟﻰ ﻤﻥ ﺍﻟﻌﻤﺭ ﺘﻅﻬﺭ ﻋﻠﻴﻬﻡ ﺍﻟﻤﻅﺎﻫﺭ ﺍﻟﺠﻠﺩﻴﺔ ﺍﻟﺘﻲ ﻓﻲ ﺍﻟﻐﺎﻟﺏ ﻤﺎ ﺘﻜﻭﻥ ﺤﻤﻴﺩﺓ ﻭﻤﺅﻗﺘﺔ . xi List of Abbreviations AGA : Appropriate for Gestational age CALS : Café-Au-Lait Spots CMN : Congenital Melanosis Nevus CMTC : Cutis Marmorata Telangictasia Congenita DESQU : Desquamation EB : Epidermolysis Bullosa EP : Epithelial Pearls ETN : Erythema Toxicum Neonatorum GAS : Group A Streptococci GBS : Group B Streptococci HSV : Herpes Simplex Virus LGA : Large for Gestational Age LN : Linea Nigra MS : Mongolian Spots NB : Newborn NVD : Normal Vaginal Delivery P : Probability S. nipple : Supernumerary nipple S. aureus : Staphylococcal aureus S. epidermis : Staphylococcal epidermis xii SGA : Small for Gestational Age SH : Sebaceous Hyperplasia SP : Salmon Patch SPSS : Statistical Package for the Social Sciences SSSS : Staphylococcal Scalded Skin Syndrome TEWL : Transepidermal Water Loss TNPM : Transient Neonatal Pustular Melanosis