A Clinical and Statistical Survey of Cutaneous Changes in the First 120 Hours of Life

Abstract

Background:

The spectrum of dermatological manifestations during neonatal period varies from transient self-limiting conditions to serious dermatoses; the latter, fortunately few, are disproportionately stressful to the parents, who due to lack of specialized pediatric dermatology clinics frequently get tossed between a dermatologist and a pediatrician.

Objectives:

This study was formulated to record cutaneous changes over the first five postnatal days of life and to statistically correlate those changes occurring in ≥ 11 neonates with three (parity, associated illnesses, and mode of delivery) maternal and three (sex, birth weight, and gestational age) neonatal factors.

Methods:

This descriptive, cross-sectional study at a tertiary care hospital entailed recording detailed dermatological examination of 300 neonates having some (physiological and/or pathological) cutaneous changes and their statistical evaluation using the Chi-square test and significance (P < 0.05) as above.

Results:

Superficial cutaneous desquamation (SCD), Mongolian spots (MS), and erythema toxicum neonatorum (ETN) were the first three common changes among a total of 15 conditions observed overall; these three, as also milia and icterus, revealed statistical significance with both maternal as well as neonatal factors. Lanugo and napkin dermatitis (ND) were statistically significant with respect to two neonatal factors and cradle cap (CC), a single maternal factor. Gestational age was of statistical significance regarding five cutaneous changes, associated maternal illness during pregnancy regarding four, birth weight as well as parity regarding three each, and sex of the neonate as well as mode of delivery regarding two each.

Conclusion:

Despite observing a statistically significant correlation of eight cutaneous changes with three maternal and/or three neonatal factors, more extensive studies in neonatal dermatology are required for validation of these unique statistical correlations.

Introduction

What was known?

Cutaneous lesions are common in neonates; a wide majority, fortunately, are transient benign/physiological conditions. However, many lesions, namely, birthmarks, malformations, blisters, scaling, skin sclerosis, and so forth, may be harbingers of aberrations having prognostic implications and, thereby, need appropriate work up, management, and, occasionally, even genetic consultation.

The skin of a neonate (first 4 weeks of extrauterine life)[1] plays a pivotal role in transition from an aqueous to an air-dominant environment by providing mechanical protection and assisting thermoregulation, immune-surveillance, and fluid balance.[2]

Skin, oral mucosa, genitals, hair, and nails have been found to be affected nearly universally, upto in 99.3% neonates,[3] in dermatoses ranging from transient self-limiting conditions rarely examined by a dermatologist[4] to serious afflictions requiring specific therapies, genetic counseling, and family planning.[5] Hence, their correct identification not only helps allay anxiety and stress of the parents but also prevent their tossing between dermatologists and pediatricians/neonatologists.[5,6] Herein, we report our study of skin changes over first 5 days of neonatal life classified into six etiological groups, and the statistical analysis of those conditions recorded in ≥ 11 neonates with respect to three maternal (parity, associated illnesses, and mode of delivery) and three neonatal (sex, birth weight, and gestational age) factors.

Materials and Methods

This descriptive cross-sectional study conducted at a tertiary care hospital included 300 neonates with some cutaneous changes-physiological or pathological. Their initial examination (general physical, systemic, and dermatological) was done within 24 h of birth and thereafter daily for the next 4 days. The data recorded on a predesigned proforma only with respect to those conditions seen in ≥ 11 neonates, i.e. 10 most common conditions in our study, were then statistically correlated with the above-mentioned maternal and neonatal factors by the computerized program Epi Info version 3.4.3 using the Chi-square test and significance defined as P < 0.05. Permission from ethics committee/institutional review board was obtained.

Results

Maternal

Majority (78.6%) of mothers of neonates in our study group belonged to the age group of 18-25 years, the remaining 20.4% being 25-40 years of age. The ratio of homemakers/working mothers was approximately 3:1. As regards their literacy status, postgraduates, graduates, postprimary, preprimary, and illiterate were 13, 30, 27, 17 and 13%, respectively. Multipara and primipara were 171 and 129, respectively. Some illness during pregnancy was recorded in 140 mothers of neonates (46.6%): Common ones being fever (54, 38.5%), hypertension (32, 22.8%), and diabetes mellitus (29, 20.7%). Vaginal and cesarian section deliveries were carried out in 160 and 140 mothers of neonates, respectively.

Neonatal

Males comprised 59.3% of the neonates. The normal birth weight (NBW) to low birth weight (LBW) ratio was 2.94:1. Full term to preterm ratio was 1:0.13.

Cutaneous changes

The distribution of the 15 skin changes individually as well as their classification into six etiological groups comprising physiological changes (280; 93.3%), nevi (213; 71%), transient non-infective disorders (79; 26.3%), infantile eczema (26; 8.6%), genodermatoses (two; 0.6%), and infections (one; 0.3%) is given in Table 1. Analysis regarding statistical significance of neonatal cutaneous changes vis-à-vis gender, maturity, birth weight, parity, maternal illness, and mode of delivery [Tables 2 and 3] revealed eight, excepting cyanosis and salmon patch, of the 10 skin changes recorded in ≥ 11 neonates in our study to be of statistical significance.

Table 1.

Incidence of cutaneous changes individually (15) and groupwise (6)

Table 2.

Analysis regarding statistical significance of neonatal cutaneous changes vis-à-vis gender, maturity, birth weight, parity, maternal illness, and mode of delivery

Table 3.

Incidence of cutaneous changes in the group vis-à-vis gestational age

The salient features with respect to five conditions seen in 10 or less of our study neonates that were neither analyzed statistically due to their low incidence nor tabulated are presented below.

Port-wine stain

This vascular malformation was recorded in 10 (3.3%) of our study neonates, eight (80%) of them were males. All the neonates were born at term to five multiparas and five primiparas. Six were delivered vaginally. Eight neonates (six; 75% males) weighed more than 2.5 kg. Mothers of seven (87.5%) out of the eight NBW neonates gave history of having had some illness during pregnancy.

Congenital melanocytic nevi (CMN)

These nevi seen in six (2%) neonates were more frequent in female (five; 83.4%) neonates born at term (six; 100%) having NBW (five; 83.4%) via normal vaginal deliveries (four; 66.6%) to multipara mothers (four; 66.6%) without any maternal illness (five; 83.4%).

Out of the numerous possible causes of neonatal erythroderma,[7] the solitary case in our study was due to nonbullous ichthyosiform erythroderma in a male collodion baby, weighing 2.7 kg at term, born vaginally to primipara without any history of illness during pregnancy.

Another solitary case of epidermolysis bullosa simplex was seen in a male neonate, weighing 2.6 kg at term, delivered via cesarian section to a primipara without any history of illness during pregnancy.

Candidal intertrigo

This condition, only one of the infectious etiologies in our study, occurred in a preterm, LBW, male neonate born via cesarian section. His mother was primigravida and did not give history of any illness during pregnancy.

Discussion

The study of prevalence and statistical analysis of dermatoses, recorded in ≥11 neonates in our study, vis-à-vis three neonatal-gender, maturity, birth weight-and three maternal-parity, maternal illness, mode of delivery-parameters revealed eight of the conditions to be statistically significant with respect to one or more aspects. The same are discussed and compared with previous studies below.

Superficial cutaneous desquamation

The occurrence of Superficial cutaneous desquamation (SCD) [Figure 1] has varied from 13.3 to 83%.[3,5,8,9,10,11,12] In the present study as also in those by Dash et al.,[10] and Nobby et al.,[9] SCD was found to be more common in neonates born at term, whereas another study[11] found it to be more common in post term neonates. The highly significant (P = 0.001) statistical correlation noted with respect to SCD among neonates (78; 33.4%) whose mothers had any illness during pregnancy (fever 37 cases; hypertension 17 cases; diabetes 15 cases; asthma six cases; anemia three cases, and a single case of antepartum hemorrhage) in our study was not found existing in similar previous Indian studies.

Figure 1.

Superficial cutaneous desquamation

Mongolian spots

Incidence of Mongolian spots (MS) [Figure 2a and b] has been recorded ranging from 11.7 to 89% in previous Indian studies.[3,5,8,9,10,11,12,13] Wide variation exists in its reported incidence among Asian (95-100%), east African (90-95%), Native American (85-90%), Hispanic (50-70%), and Caucasian (1-10%) neonates.[14] Its incidence of 94.4% term neonates in another Indian study[10] is akin to that of ours (89.1%). Though a more frequent occurrence of MS in neonates of multipara mothers was recorded in our as well as a previous Brazilian study,[3] its statistically higher incidence (P = 0.004) among neonates in our study whose mothers had an associated illness during pregnancy was not found elsewhere.

Figure 2.

(a) Atypical location of Mongolian spot over the hand (b) Mongolian spots

Erythema toxicum neonatorum

Incidence of Erythema toxicum neonatorum (ETN) [Figure 3] has ranged from 1.3 to 40.8%.[3,5,8,9,10,11,12,13,15] Statistically significant female preponderance (P < 0.05) of ETN as noted in our study was also observed by Zagne et al.,[3] Another study[13] reported it equally among sexes. Its statistically significant frequency (P < 0.05) in NBW (50; 63.3%) neonates in our study is also found recorded in an Egyptian[8] and a Japanese[13] study. Though our study did not find any statistically significant correlation between associated maternal illness and ETN, correlation of ETN with mode of delivery was statistically significantly higher (P < 0.05) in neonates (51; 64.5%) delivered vaginally. However, Gokdemir et al.,[11] and Zagne et al.,[3] reported ETN to be more common in neonates delivered by cesarian section.

Figure 3.

Severe erythema toxicum neonatorum

Milia

Occurrence of milia [Figure 4] in the previous similar studies has ranged from 1.4 to 93.1%.[3,5,8,9,10,11,12,15] There was a statistically significant greater proportion (P = 0.001) of milia in neonates born at term (47; 70.2%) and having an NBW (40; 59.7%) in our study as also in two previous studies.[8,10] More (51; 76.2%) frequent (P = 0.001) occurrence of milia, as recorded in our study, in neonates born to multipara mothers was also observed in 67.9% of their study neonates by Zagne et al.[3] However, a statistically significant higher incidence (P < 0.05) of milia observed in our study (39; 58.2%) neonates whose mothers had some illness (fever 13 cases; hypertension 12 cases; diabetes four cases; anemia five cases; antepartum hemorrhage two cases; epilepsy two cases, and a single case of asthma) during pregnancy was not found reported previously.

Figure 4.

Milia

Icterus

Reported incidence of icterus has ranged from 3.5 to 20.6%[5,9,10] and was statistically significantly frequent (P = 0.001) in our LBW (40; 68.9%) neonates of mothers with some associated illness (38; 65.5%) during pregnancy. It was also significantly frequent (P = 0.002) in neonates (28; 65.6%) delivered via cesarian section in the present study. However, none of these three correlations were found reported elsewhere.

Lanugo

Previously reported incidence of lanugo has ranged from 7 to 14.6%.[3,5,9,10,11] In our study, incidence of lanugo was statistically highly significant (P = 0.001) in term (24; 70.6%) neonates with NBW (18; 52.9%). Lanugo was observed in 55.4% of NBW in their study neonates by El-Moneim et al.[8]

Napkin dermatitis

Incidence of Napkin dermatitis (ND) [Figure 5] has ranged from 0.3 to 18.9%.[3,5,9,10,12,13] The gestational age of neonates in our study who developed ND was observed to be statistically highly significant (P = 0.001) in term (nine; 60%) neonates and significantly more frequent (P < 0.05) in LBW (10; 66.6%) neonates; the former was previously also observed by Dash et al.,[10] and the latter by El-Moneim et al.[8]

Figure 5.

Napkin dermatitis

Cradle cap

Previous reported incidence of Cradle cap (CC) has ranged from 0.3 to 4.4%.[3,5,9,10,12] In our study, CC was common in males (eight; 72.7%) born at term (10; 91%), whereas Dash et al.,[10] reported its occurrence equally among full term and preterm neonates. Eight (72.7%) of the NBW neonates in our study had CC, an incidence nearly identical to that of 70.8% recorded by El-Moneim et al.,[8] in NBW neonates in their study. A statistically highly significant (P = 0.007) occurrence of maternal illness during pregnancy in 10 cases (fever six cases; hypertension two cases; asthma two cases), i.e. 91% mothers of our study neonates with CC was not found commented upon elsewhere.

The three cutaneous changes of cyanosis, salmon patch, and port-wine stain [Figure 6] seen in ≥ 10 of our study patients did not prove to be of statistical significance with respect to any of the above-mentioned neonatal or maternal parameters. The cases of CMN (six) and one each of EBS and collodion baby [Figure 7] due to nonbullous ichthyosiform erythroderma, which is an important cause of neonatal erythroderma and candidal intertrigo [Figure 8] could not be subjected to statistical analysis due to their numerical paucity.

Figure 6.

Port-wine stain

Figure 7.

Collodion baby

Figure 8.

Candidal intertrigo in the groin

Statistical correlation with respect to 10 out of the 15 cutaneous changes, belonging to six etiological groups, that occurred in ≥ 11 neonates during 120 postnatal hours of their life vis-à-vis three maternal and three neonatal factors revealed a total of 21 statistically significant correlations with respect to eight cutaneous changes. However, larger and variously designed studies of neonatal changes are necessitated to validate these correlations unique to our study.

What is new?

Our small prospective study found 15 highly significant and six significant correlations with respect to eight neonatal conditions vis-à-vis six (three neonatal and three maternal) parameters; this quantum of 21 correlations was unprecedented despite a diligent literature search regarding the same in previous similar studies.