My 7 day old granddaughter and her parents just returned from the emergency room. Her mother noticed a small lump right after she was born and inquired, they said it was her soft spot. In the past couple of days we noticed that it has more than doubled. This morning I looked closer and it was inflamed, warm to the touch, approx. 2 " in length and white in the center. They did not determine what it was and sent her home. She is not displaying any other symptoms, eating and sleeping well, contented. She did have some jaundice and did spend some time under the lights in the hospital.
Person's Gender: female
Person's Age: infant
trip to ER
I'd love to help with your question. I'll never give you advice that I wouldn't give to my own patients or do for my own child.
Are you available to chat?
I'd like to get a little bit more information if I could...
So this lump is on her head, yes?
my son said it's more like 21/2 cm by 11/2 cm
yes, it's on the back, right, off center
Do you happen to have a picture?
If not, I can ask you a few questions to get a better idea about what we're talking about...
I do have a suspicion about what it may be.
I don't have a picture of it
Let me ask just a few questions, then.
let me try to get a photo for you
Is there a scab or anything like that anywhere in the area?
no scab on or around
Okay. Is the area soft to the touch? Does it squish in when you push on it?
yes to both
And tell me just a little bit about your granddaughter's birth...
Was she born vaginally, or by C-section?
her delivery was fast
my dtr in law thinks she remembers seeing blood come out of it when she was born
she pointed it out to the medical staff, but they told her it was her soft spot
Well, what we normally call the 'soft spot' is what's technically termed the anterior fontanelle.
It's the gap between the skull bones toward the front of the head.
It sounds like what you're describing is in a different area, really.
yes, it's on the back of her head
at first I thought it was that pointy part that is near our spine, but today realized that it was off center
That's not really the soft spot, then! Or at least not what I call the soft spot.
I felt like they weren't listening to her
So the baby was born vaginally?
Hannah had some jaundice and had to be readmitted at day 3. She stayed under the lights, then was discharged the next day
tough pregnancy, but very fast delivery
And you said she was born quickly... By chance, did she have a fetal monitor in place on the baby?
She probably didn't if she was born that quickly...
water broke at 6:30am, admitted at 8:00am, fully dialted at 10:00am
39 weeks and 2 days gestation
But often, OB's will place a fetal scalp electrode to monitor the baby during labor.
no internal fetal monitor
Well, let me tell you what I think...
If you have a photo, feel free to upload it... but I'll go ahead and start "talking" about what I think the most likely possibility is.
the location starts just above the posterior fontanelle (my dtr in law is a nursing student and just got her text book to describe the location)
ok, downloading photo
Sometimes it takes a few minutes to show up for me.
Initially the ER MDs thought it might be an infection
we were just concerned because it seems to grow exponentially from yesterday to today
That is the unusual part of this - I agree.
but she doesn't seem to be bothered, no fever, no crying
That is all reassuring.
Babies only have a few ways to "tell us" that something is wrong - so the fact that she's acting normally is a good sign.
Did you upload the photo?
No rush - just wondering if you need to try again. Nothing has shown up on my end so far.
Take your time.
Just let me know once you've posted it.
ok hope you can see it ok
It came through.
First and foremost - Hannah has a beautiful head of hair!
Especially for a newborn.
So let me tell you what I think... and what I think we should do.
I thank you for noticing
She truly is the most beautiful baby I have ever seen....
Her hair is striking. And I see a lot of babies, believe me.
So let me tell you what I think we need to do.
Feel free to stop me at any point with questions - otherwise, I'll just keep typing.
I think that the most likely thing is a small cephalohematoma.
Basically, that's an area of bleeding underneath the scalp.
It happens commonly in babies...
And will get reabsorbed and go down on its own.
Cephalohematomas are soft and squishy because they're full of blood.
That will eventually get reabsorbed.
I would suggest trying not to touch it a whole lot...
they were speculating that the fluid in there was clear, but they didn't run tests so they said a dr. would call in the am and they could take her in
Well, that's where I'm going next with this.
If this is a cephalohematoma - there's nothing to do for it. It will get better on its own in a matter of days.
The thing that makes me think it may NOT be a cephalohematoma is the delayed appearance.
Typically, with a cephalohematoma, the bleeding is caused by stretching of the scalp at birth.
So it's surprising to me that it would swell up so late.
That makes me think that we need to do a bit more workup, because there are a few other possibilities.
My dtr in law noticed it at birth and believed it was bleeding. When she pointed it out to the nurses they didn't seem concerned
You mentioned one of them.
Well, some amount of "birth trauma" isn't too unusual...
...so the nurses may not have been alarmed.
It's tough getting born, you know!
The major problem that comes with a cephalohematoma is one that your granddaughter already had - jaundice.
As the blood gets reabsorbed, it increases the bilirubin - sometimes to the degree that phototherapy is required.
Still, like I was saying, the late appearance of this thing concerns me.
Because this area could be filled with something other than blood...
One other possibility is that it could be filled with spinal fluid.
This is much rarer - but it does happen.
It is usually because there is a tiny "leak" between the fluid that bathes the brain and the skull... so fluid can get out and underneath the scalp
Typically, as children grow, that hole or leak seals itself.
they didn't test the fluid, but they told my son that it was not purilant ? it was clear
If not, surgery could be required.
So they actually drew off fluid???
no, so we're not sure how they can be sure
Okay. That's good.
They may say that it's clear because they shone a light through it.
If there's coagulated blood in there - the light won't pass.
If there's clear fluid, it will.
So that may be how they made that determination.
I'm glad that they didn't put a needle in it or anything.
I'll explain why.
Like I said, rarely babies will have a leak of cerebrospinal fluid - the fluid that bathes the brain and spinal cord.
If there is a small hole in the skull, for instance, that cerebrospinal fluid (or CSF) can get underneath the scalp.
When that happens, you get a little bit of swelling.
It's not usually a big problem.
Because typically, as kids grow older, that leak or hole seals itself up.
Can you suggest some questions they could ask tomorrow?
The #1 thing to request, I think, is a head ultrasound.
That will let us see if this fluid collection communicates with the deeper areas in the skull.
Also, can she be bathed normally? She just had a serious diaper deposit
I was told to ask that question, sorry
Yes, I think so. So long as the skin is intact over the area on her scalp - I wouldn't worry about that.
You should wait to give her a bath until her cord has come off, though.
Till then, you just want to give her a sponge bath of washcloth bath.
yes, we have been doing little shallow soaks for her bottom, keeping her cord above the water
So let me tell you about what to do when you see her pediatrician.
I will just say to avoid washing her hair
to be safe
Have the pediatrician try to transilluminate the scalp (shine a bright light through it).
That will help us know if it's blood in there - or something else.
If it's blood - if the light doesn't pass through all that well - I don't think you have to do anything.
That would be a cephalohematoma, and we can just watch and make sure it starts shrinking down.
If, however, the light passes through well...
Then I think you need to have an imaging study done.
That will give us more information about the anatomy underneath the swelling.
There are two choices for what study to obtain...
I would do an ultrasound first.
You could also do a CT.
The CT will give you better pictures - but involves a significant amount of radiation.
So if we can see what we need to with the ultrasound, that is the best test, I think.
Let me try to give you a picture of this other thing that I'm talking about...
Give me just a sec...
Try clicking on that link. Are you able to see the images?
Did that work?
we looked at the photos, Hannah's is much different
it's more red around it with a white looking center
That's probably good.
The picture I just sent was of a child with a cerebrospinal fluid "leak" into the scalp.
The final possibility is that this could be an infection - or abscess.
This a smaller, more isolated area.
and has gotten more pointed
That would be a bigger deal.
And the white center does concern me for that possibility.
the cerebralspinal leak would be a bigger deal?
No... an infection would.
The CSF leak will require monitoring - but will seal up.
A blood leak - cephalohematoma - won't require anything other than observation.
But if the fluid in there is pus...
That's a problem.
It's very reassuring to me that your granddaughter is acting normally.
But if that changes -
If she doesn't want to eat, or has a fever - you need to get her seen ASAP.
An abscess is basically an area of infection where the bacteria build a "wall" around themselves.
it has become more prominant, in dimention
Within that wall, they grow and multiply.
At her age, she would need to be hospitalized with IV antibiotics if she has an infection of any kind, really.
Little babies don't have very good immune systems.
So if they have an infection - of any kind - we want to treat it in a monitored environment.
I am sending a photo of her profile, so you can see how much it is protruding
you can see that it is protuding significantly from the back of her head
That really is significant.
Okay, let me ask just a couple of other questions.
How long ago were you in the ER?
they were there from 2-6pm
And you have an appointment with her pediatrician tomorrow?
they were told to take her home and wait to hear from a pediatrician tomorrow and that she would probably have to go in.
The ER MD was puzzled, sent for a Pediatrician
who was also puzzled, so they sent her home
I guess this was at a regular hospital - not a children's hospital, then?
Do you have a children's hospital in your area?
My son is a SF Army Medic, stationed at Ft. Bragg
let me ask them
they said they need a referral to go anywhere but the hospital on base
Well, then let me tell you what I think you should do.
The more I look at the photos, the more concerned I get.
So long as your granddaughter is acting normally and has no fever...
I think it's fine to wait till tomorrow.
But I really do want her to be seen again tomorrow.
And I really do think we need to prove what this swelling is.
Like I said, the three main possibilities are:
a) blood (cephalohematoma) - not a big deal;
b) spinal fluid (CSF leak) - would require monitoring, but usually gets better without surgery;
c) pus (abscess) - would require drainage and IV antibiotics in the hospital.
I think if there is any question about what this is, we should do either an imaging study (ultrasound) or have someone drain some of the fluid in a carefully controlled, sterile environment.
Does that all make sense?
Yes it does, I am writing all this down, although I am hopeful that I could print out this conversation for them.
what would cause an infection?
You should be able to...
You can at least cut-and-paste into an e-mail or Word document.
For what the cause might be...
The usual suspects are the kind of germs that live in the birth canal.
like I said, her mother said she noticed it right after she was born
E.coli is the most common, probably.
But most anything could do it.
Like I said - babies don't have very good immune systems.
you said that the cephalohematoma is linked to the jaundice?
is that right
Yes. Or at least, the breakdown of a cephalohematoma is.
but then it shouldn't get worse?
As the body breaks down the blood inside a cephalohematoma, it increases the bilirubin.
As babies get older, they get better at clearing bilirubin.
A 7 day old can get rid of more bilirubin than a 3 day old can.
What concerns me is that the thing is getting bigger.
That doesn't really fit with a cephalohematoma.
It suggest to me one of the other possibilities.
Either there is fluid that's leaking (CSF), which is why it's getting bigger...
Or there are bacteria that are multiplying, which is why it's getting bigger.
The first one is not so big of a deal - the second one is.
we will request a referral tomorrow if we are able
So that's why I think it's so important that she get seen tomorrow.
They should at least try to answer this tomorrow, I think.
That is their plan
I expect that they'll be as impressed in person as I am by the pictures!
Please let me know how things turn out.
they were certainly puzzled today in the ER
Feel free to share any of my thoughts with the doctors that see her tomorrow.
I think we were all dissapointed when they sent her home without an answer and a suggestion to call the dr. tomorrow
I think that an imaging study could be helpful...
I will, this has been very helpful
...although if they're concerned about an abscess, they need to aspirate some of the fluid.
I usually avoid looking on the internet, but when they came home, I felt helpful
I mean helpless
I'm so glad I could help!
What other questions do you have for me?
Are there any questions you think they should ask?
Well, I think that the most important thing is advocating for Hannah. We need to understand what this thing is.
That may take a little bit of additional workup if they're concerned about some of the possibilities that I am.
If they think it's just a cephalohematoma - that will go away on its own, and just watching it would be fine.
So I'd push the doctors to explain what they think, and why. That's always a fair question, you know!
I am hoping that is what it is, but honestly, my first impression when I got a closer look this morning was that it was an abscess
it's warm to the touch
Then she absolutely needs to be seen tomorrow.
And if it should start to drain nasty fluid - she needs to go back to the ER.
I was reassured by the fact that they thought the fluid was clear, but still have no understand how they came to that conclusion
since they didn't run any of the tests you mentioned
If she's acting fine - you can wait till tomorrow. But if she has other symptoms - we need to rethink all of this sooner.
I think that is all we have
if this was your child, what would you ask?
besides what we discussed
I think the most important thing is to ask what the doctors think is going on, and why. If they don't think it's an abscess, why? If they don't think she needs an imaging study, why?
so basically "why" is the word of the day tomorrow
They may have good reasons - but it's important for them to communicate to you what their thought process is.
we can do that
I think so!
That's fair game with any doctor, you know.
You should leave with an understanding of what they're thinking.
Yes, it's an intimidating task for a young parents
And if the answer is "I don't know" - that's okay, as long as there are reasons for why we are (or are not) choosing the plan that we are choosing.
my son is trained to save the lives of injured soldiers, but this is a whole different story for him
If I can help you with anything more as you and your family work through this - please just let me know.
I have 4 children of my own and I thought I have seen almost everything, this is a new one for me
This is unusual... that's why I want you to let me know how things turn out!
Do you want us to let you know how it goes, or do you guys do that?
You should be able to message me once the chat is over...
I will be anxious to hear what comes of this.
If I have answered your question, please click accept.
And if I can help with anything more - at any point - please do not hesitate to ask.
Best wishes to you and your family...
Thank you for your help, this gives us some support in our concern and some valuable information to use tomorrow.
I'm so glad I could help.
Board Certified; Graduated from top 20 medical school
I wanted to follow up with our discussion last night. Today my grand daughter, Hannah, had an appt. with a pediatrician. They did a sonogram of her head and the growth and determined that it was a hemangioma. They are going to check it again at her two week appt. (next week)
Your information was helpful and we used it today to guide conversation with the dr.
Thank you so much for the update! I think this is wonderful news - certainly compared to an abscess.
As I'm sure they told you, hemangiomas are common in infants. A hemangioma is basically a proliferation of tiny blood vessels - that's the reason it's soft and squishy. They tend to grow larger initially, then involute and regress - and they usually go away altogether by the time the baby is 12 months old or so.
Occasionally, hemangiomas can cause problems if the skin overlying them cracks open (ulcerates) - in that case, the hemangiomas can bleed. If that ever happens, the hemangioma can bleed for a while (since it's made up of blood vessels, after all). So get your granddaughter to a doctor right away if she ever has significant bleeding from the hemangioma that doesn't stop promptly.
If hemangiomas become too large, cause problems with bleeding, or don't completely regress, there are things we can do. The two best therapies are usually a medication called propranolol (which is often used for high blood pressure or heart failure in adults, but at the appropriate dose is safe and effective for hemangiomas in infants) or steroids (which can be taken by mouth or injected into the hemangioma). There are also dermatologists and plastic surgeons who operate on hemangiomas with lasers for cases that don't respond to medications.
Thanks again for the update - I was a little bit worried about you all!
Well they had to take her to the ER yesterday. Hannahs "hemangioma" ruptured, leaking pus. They gave her a shot of anti biotics and sent her home again. Today at her recheck they decided to admit her and give her IV antibiotics. They tolhem she
Oh my.So I suppose the good news here is that we finally have a diagnosis... so for the first time, it's absolutely clear what we need to do. First and foremost, it's absolutely critical that the physicians caring for your granddaughter obtain a sample or swab of the pus to send to the lab for culture. We need the lab to grow the germs that are inside the abscess so that we can determine a) what they are, and b) what antibiotic to kill them with. This should be pretty straightforward - if the lab can grow the germs, they can also test them against various antibiotics to see what will kill them the quickest. Like we discussed before, the typical germs that cause abscesses in newborns are ones that live in the female birth canal. For the most part, they tend to be wimpier germs than the kind of germs that cause abscesses in adults. But now is not the time for guesswork - we need to know exactly what kind of germ we're fighting. Second, we need to drain the pus. An abscess, as you probably know, is essentially an area where bacteria get under the skin and make a wall around themselves. It's sort of like an orange with the rind on it - the rind is the wall, and the bacteria are inside. What this means is that antibiotics alone won't work: they go into the bloodstream, but don't penetrate the rind and get into the inner cavity of the abscess very well. (As a sidenote, this is the very reason that I'm so surprised that we initially thought your granddaughter had a hemangioma... You mentioned that they did an ultrasound - but a hemangioma should have lots of blood flow - since it's made of blood vessels - while an abscess should have essentially none.)My point here is that the cure for an abscess is NOT antibiotics - it's draining the pus. If the abscess is draining on its own, that may be adequate - but sometimes, abscesses will be made of lots of little abscesses (called loculations) and getting them all to drain may require a minor surgical procedure. I don't mean that your granddaughter should not get antibiotics - because she absolutely should. But the main thing that the antibiotics will do is prevent the infection from spreading elsewhere. They probably won't help so much with the area of infection that is present. Finally, although I'm sorry that your granddaughter is in the hospital, I'm at the same time glad that she's in the hospital, if that makes sense. I say that because she needs to be in a monitored environment right now. The immune system of a newborn is not mature enough to localize infections well - so things can spread rapidly. We have to take any infection in a newborn seriously - and I'm so glad to hear that her doctors are. Thank you for the update... although I wish it were better news. And of course, if there is anything I can do to help at any point, don't hesitate to ask.
I struggled with typing the message on my phone so I didnt menyion that she also got a spinal tap. The abscess did rupture but they also drained it. She has an all over body rash now as well. Shes eating well, no fever, no gaining weight fast enough but not losong. Very frustrated with the myriad of thought. You were right and its been a struggle to feel heard. Finally on the rifht track. Culture is being done also. Thanks again for your help
I'm glad that she did get the spinal tap - I think it was the right thing to do. That's because of what I said about how babies don't localize infections well.
For example, if a 5 year old gets an ear infection, his immune system will corral the infection there and keep it from spreading anywhere else. Young infants can't do that so well... so an infection that begins in one place has a tendency to spread to other areas. In fact, when I looked up a case series of infants like Hannah with scalp abscesses, a good number of the babies who were reported in the medical literature had both an abscess and bacteria in their bloodstream (even if they were acting well).
Like I mentioned, it's important that we know exactly what we're treating. If the infection is trying to spread (i.e., she had bacteria in her bloodstream) or if we found evidence that it had already spread (i.e., she had bacteria in her spinal fluid) then we would need to deal with those problems aggressively.
It's hard to know what to make of the rash... There are a variety of common newborn baby rashes, so it may be that the rash was something that was going to come up regardless of the scalp abscess. However, it may also be a side effect of her antibiotics. If I were treating Hannah, I would use a combination of two antibiotics until we got results from the culture and knew exactly what to choose. (I imagine her doctors are doing something similar.)
The standard regimen for covering the usual suspects in young babies is ampicillin and gentamicin, although in some places they'll use cefotaxime (or something similar) in place of the gentamicin. And in patients with abscesses, we may want to swap the ampicillin for vancomycin (a different antibiotic that's better at killing staph bacteria). Any of those antibiotics can cause a rash. The vancomycin causes a rash particularly frequently - but it's not harmful. (And often, we can prevent patients from getting the rash if we infuse the medication more slowly.)
I am so glad that it sounds like things are finally headed in the right direction. You do have a beautiful granddaughter, and although I'm sure it breaks your heart to have her in the hospital now, you'll soon forget all of these bad times once we get this infection stomped out and get her back home!
Thought I'd give you the latest: After 2 1/2 days in the hospital on antibiotics, they determined that Hannah has an Epidermal Inclusion Cyst. The infection is drained and appears to be healing. They said they want to remove the cyst, surgically, but want to wait until she gets a little older and wouldn't want to do it while it was inflamed. The surgeon said he'd never seen one in an infant, especially a newborn. So they will need to watch and make sure that they stay on top of any potential infection brewing. Thanks again for your help
Wow... I agree - that is unusual!
Thanks again for the update. Please do let me know if I can help you with anything more in the future with Hannah - and best wishes to you!