Skin Texture Review -Infant

Summary of Recommendation and Evidence

Population	Recommendation	Grade (What's This?)
Screening of both Genders	This screening is recommended a best practice.	B

A newborn infant's skin goes through many changes both in appearance and texture.

The skin of a healthy newborn at birth has:

Deep red or purple skin and bluish hands and feet. The skin darkens before the infant takes his or her first breath (when they make that first vigorous cry).
A thick, waxy substance called vernix covering the skin. This substance protects the fetus's skin from the amniotic fluid in the womb. Vernix should wash off during the baby's first bath.
Fine, soft hair (lanugo) that may cover the scalp, forehead, cheeks, shoulders, and back. This is more common when an infant is born before the due date. The hair should disappear within the first few weeks of the baby's life.

Newborn skin will vary, depending on the length of the pregnancy. Premature infants have thin, transparent skin. The skin of a full-term infant is thicker.

Changes in Infant Skin

By the baby's second or third day, the skin lightens somewhat and may become dry and flaky. The skin still often turns red when the infant cries. The lips, hands, and feet may turn bluish or spotted (mottled) when the baby is cold.

Other changes may include:

Milia, (tiny, pearly-white, firm raised bumps on the face) which disappear on their own.
Mild acne that most often clears in a few weeks. This is caused by some of the mother's hormones that stay in the baby's blood.
Erythema toxicum- This is a common, harmless rash that looks like little pustules on a red base. It tends to appear on the face, trunk, legs, and arms about 1 to 3 days after delivery. It disappears by 1 week.

Colored birthmarks or skin markings may include:

Congenital nevi are moles (darkly pigmented skin markings) that may be present at birth. They range in size from as small as a pea to large enough to cover an entire arm or leg, or a large portion of the back or trunk. Larger nevi carry a greater risk of becoming skin cancer. The health care provider should follow all nevi.
Mongolian spots are blue-gray or brown spots. They can emerge on the skin of the buttocks or back, mainly in dark-skinned babies. They should fade within a year.
Café-au-lait spots are light tan, the color of coffee with milk. They often appear at birth, or may develop within the first few years. Children who have many of these spots, or large spots, may be more likely to have a condition called neurofibromatosis.

Red birthmarks may include:

Port-wine stains are growths that contain blood vessels (vascular growths). They are red to purplish in color. They are frequently seen on the face, but may occur on any area of the body.
Hemangiomas are a collection of capillaries (small blood vessels) that may appear at birth or a few months later.
Stork bites are small red patches on the baby's forehead, eyelids, back of the neck, or upper lip. They are caused by stretching of the blood vessels. They usually go away within 18 months.

Inspection

Starting with the patient’s head and scalp, inspect the skin for color, hair distribution, and any lesions. Be sure to inspect for the presence of any infestations such as lice or nits. After inspecting the head and scalp, systematically inspect all of the child’s skin, uncovering one body part at a time. Use a measuring device to document any wounds or lesions. If you note bruising on several parts of the body, in various stages of healing, or in places where bruises are not normally found, inquire about how the child got them. It is also important to be aware of any cultural practices (such as coining) that might cause skin alterations. Some culturally acceptable “lesions” could be mistaken for burns or non-accidental, trauma-inflicted lesions.

For light-skinned infants, the overall color of the skin should be pink. Skin folds may appear red or irritated, though, since these areas are often moist. Infants might have tiny white papules called milia on the cheeks, forehead, nose, and chin. Let the parents know that milia will go away on their own, and encourage them not to rub vigorously or break the intact skin. Another irregularity you might note on the forehead or the back of the neck is a “stork bite,” a type of nevus that is irregularly shaped and red or pink. This type of lesion typically fades during the first year.

Inspect the nails of the infant’s feet and hands, looking at color and shape. The nails should be firmly attached. To assess capillary blood flow, raise the child’s extremity above the heart, press gently over a finger’s nailbed (or the heel of the foot) to cause blanching of the skin and occlusion of blood flow, release the pressure, and count the time it takes for a full return of blood to the blanched tissue. Normal capillary refill time is less than 2 seconds. Delayed capillary refill indicates poor blood flow.

For dark-skinned infants, assess for Mongolian spots. These are bluish-gray macular areas on the sacrum or buttocks. These spots usually fade over the first year. It is important to recognize Mongolian spots as such and not mistake them for bruises. Café au lait spots are another skin color variation common in infants. They are usually large round or oval patches that are light brown in color and are a normal finding unless each one is larger than 1.5 cm in diameter.

Palpation

Palpate the skin for temperature, texture, moistness, and resilience. Use your fingertips to assess the texture and moisture of the skin and the back of your hand to feel temperature. A normal finding is for the skin to be smooth, warm, and dry with no tenting of the skin when you test turgor, or resilience.

Because an infant has difficulty controlling body temperature and can become cold rather quickly, be sure to uncover only one area at a time. The infant’s skin should feel soft, smooth, dry, and warm. If the infant has been crying, the skin may feel slightly damp.

Over the infant’s abdomen, gently pinch a skin fold to check skin turgor, which reflects hydration status. Well-hydrated skin in this area is resilient and returns quickly to its original position, while poorly hydrated skin retains the “tent” shape of the pinched skin. If the infant is dehydrated, estimate the degree of dehydration based on the time it takes the skin to return to its normal position.