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Head and scalp assessment

In this demonstration video, Dr Elizabeth Forster explains what to be aware of when assessing the head and scalp of the newborn.

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Normally, your baby will be well wrapped and that’s because they have not very good thermoregulation, or maintenance of a good core body temperature. So, it’s a good idea to perform that assessment in a place where the baby’s going to be well wrapped and warm, because you want them to be comfortable and relaxed during the assessment. But for the examination of the head, you’ll need to of course, remove their little cap that they have. And then you’re wanting to actually inspect the baby’s head and just look at the shape of the baby’s head. During delivery, there can be some moulding of the baby’s head because of delivery. And that will normally normalise over the next few days after birth.

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But you need to, as well as inspecting the scalp, you need to actually palpate the scalp, or feel the scalp, just to make sure that there’s no areas of bogginess, or oedema, or fluid collection. There are some abnormalities that are quite serious. If there’s bleeding in the scalp, so if it feels boggy and that fluid that you can feel is moving across the cranial sutures, then that needs to be reported to the paediatrician and some intervention may be needed very quickly to avoid any complications there. So in terms of the scalp, you’ll be looking at the fontanelles. And there are four fontanelles.

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The main two are the anterior fontanelle, which you can palpate, or feel, at the top of the baby’s head, and that is diamond shaped. And then there’s a posterior fontanelle at the rear of the baby’s head, which is triangular shaped. Sometimes, the posterior fontanelle will be closed at birth. The anterior fontanelle will normally stay palpable and open, sometimes up to 12 to 18 months of age. So the fontanelle will normally be flat and it can be pulsatile, so you can actually see some pulsations in the normal fontanelle. It shouldn’t be sunken. If it’s sunken, that might indicate a hydration issue with the baby.

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And it shouldn’t be bulging either, because that might indicate a raised intra cranial pressure or some issue that’s causing fluid in the cranial cavity. So it should be, as I said, flat and pulsatile. There are two other ones, a mastoid suture fontanelle and also the sphenoid fontanelle. But the main two that we look at are the anterior and the posterior fontanelle. The next area that you’ll be looking at is the hair of the baby. And you just need to check that the hair may be– there may be plentiful hair in some babies, there may be only slight amounts of hair.

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One thing you do look for is a low hairline, because that can be associated with some syndromes in the neonate. So if a baby, for example, has a low hairline, and then doesn’t have very good tone in their body, that might indicate a problem that needs to be looked at. So now we’re going to assess the baby’s head circumference. And this is important as head circumference gives us an indication of brain growth. And so we need a baseline to start with with the neonate. And then the baby’s head circumference, as well as weight and length will be regularly measured as they grow in that first year of life.

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So, to measure the baby’s head circumference, what we want to do is actually make sure that the tape measure is above the baby’s eyebrows, over the pinna of the ear, and then round to the occiput, which is the broadest part of the base of the skull. And that’s the correct spot to actually do your measure. Usually, you’ll use a paper tape measure. It gives you much more flexibility than some of the plastic tape measures. And the normal head circumference for a term baby is 31 to 38 centimetres in length. So if you were to find that a baby’s head circumference was particularly large, or particularly small, those would be things that you would need to report on.

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And it may not indicate an issue. For example, genetics has a part to play in head size, et cetera. But if there was a particularly small head circumference, that might indicate an underlying problem and so would a large one, as well. So we just need to note that and then monitor. So it’s one part of your assessment. You’re looking at the overall baby, as well.

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

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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.

An illustration shows the location of the four fontanelles, along with the sutures in the skull ©Shutterstock

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

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