Head and scalp assessment

In a head to toe assessment, it makes sense to begin with an examination of the baby’s skull. Let’s explore what to note during your examination.

Our first step is to look and take note of the size of the skull. Keep in mind, the baby’s genetics, ethnic group, gestational age and growth in the womb will all play a factor in determining skull size (Kain & Mannix, 2018). The normal range for head circumference in a term baby is between 31 and 38cms.

The next area to assess is the scalp and fontanelles. The fontanelles are small spaces in between the ‘plates’ of the skull. These spaces are joined by cranial sutures and make it possible for the soft bones of the baby’s skull to move slightly, allowing easier passage through the birth canal.

The four fontanelles

The posterior fontanelle usually closes by around two to four months of age, however the anterior fontanelle may still be felt up until 18 months to 2 years of age (Forster & Marron, 2018). The sphenoid fontanelle is found on the side of the baby’s head a short distance behind the eye and the mastoid fontanelle is located behind the baby’s ear.

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When assessing the fontanelles, use the flat pads of your fingers to palpate (gently feel) the surface of the head. Ensure you make note of any retraction or bulging, as the normal fontanelle feels firm and flat (not sunken or bulging). You may also notice visible pulsations in the anterior fontanelle (Wheeler, 2015), which is normal.

Pressure on the baby’s head during vaginal delivery can change the shape of the newborn’s head. This process is known as moulding and may result in oedema (some collection of fluid) on the scalp (Kain & Mannix, 2018). Caput succedaneum is the medical term for this swelling. It normally resolves within a few days after birth (Kain & Mannix, 2018).

If you note a collection of blood on the baby’s scalp, this is known as cephalhaematoma and if the scalp has a ‘boggy’ consistency with mobile fluid moving across the suture lines of the skull, this may indicate a more serious problem, known as subgaleal haemorrhage (Kain & Mannix, 2018). This requires urgent medical intervention.

Measuring head circumference

The initial measurement of the head circumference after birth provides a baseline to work from, as comparison measurements will continue throughout infancy and toddlerhood up until around 3 years of age. Head circumference is one of the indicators of brain growth and is plotted on standard growth charts.

If the head circumference is too small or too large this may indicate a congenital or developmental disorder (Harris, 2015). To measure the newborn’s head circumference, it’s best to use a paper tape measure. Place it in a line above the eyebrows, and the pinna of the ears and around to the occipital prominence of the skull, which is the widest part of the back of the baby’s skull (Forster & Marron, 2018).

Inspecting the baby’s hair

Note the amount of hair and coverage. Some newborns will have very little head hair whereas others will have abundant, thick locks. Again, genetics and ethnic origin will play a hand in this.

Ensure you make a note of the hairline. If the hairline is low and the muscle tone of the baby is also low, it may indicate a condition known as neonatal hypothyroidism. This occurs when the thyroid gland is not producing sufficient hormones (Kain & Mannix, 2018).

Your task

Watch the video and post your comments and questions about assessment of the newborn’s head, using the link below. We look forward to hearing from you.

References

Forster, E. & Marron, C. (2018). Paediatric Assessment Skills. In E.Forster & J.Fraser. Paediatric Nursing Skills for Australian Nurses. Port Melbourne, Victoria: Cambridge.

Harris, S.R. (2015). Measuring head circumference: Update on Infant Microcephaly. Canadian Family Physician, 61 (8) 680-684.

Kain, V. & Mannix, T. (2018). Neonatal Nursing in Australia and New Zealand, 1st Edition. Australia: Elsevier