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Difficulty: EasyPediatric Infectious Diseases

A 2-day-old male newborn is evaluated in the nursery for a newly developed skin rash. He was born at 39 weeks gestation via uncomplicated spontaneous vaginal delivery to a 28-year-old primigravid mother. Maternal prenatal laboratory testing, including group B Streptococcus screening, was negative. The infant has been breastfeeding well and stooling normally. Vital signs are temperature 36.8°C (98.2°F), heart rate 140/min, and respiratory rate 40/min. Physical examination reveals multiple erythematous macules and papules with small central pustules scattered across the trunk and proximal extremities. The palms and soles are spared. The infant is vigorous and in no apparent distress. Which of the following is the most appropriate next step in management?

  1. Reassurance and routine newborn careAnswer
  2. B
    Initiation of intravenous acyclovir therapy
  3. C
    Collection of blood cultures and administration of ampicillin and gentamicin
  4. D
    Application of topical mupirocin to the affected areas
  5. E
    Isolation of the infant and application of contact precautions

Answer

Reassurance and routine newborn care
The correct action is to provide reassurance and routine newborn care. The clinical presentation of a healthy, vigorous, well-feeding newborn with scattered erythematous macules, papules, and pustules on the trunk and proximal extremities (sparing the palms and soles) is characteristic of erythema toxicum neonatorum (ETN). ETN is a benign, self-limited eruption that typically appears within the first few days of life and resolves spontaneously over a week without any specific therapy.

Step-by-Step Solution

1
Evaluate the clinical presentation of the neonatal rash
The newborn has scattered erythematous macules, papules, and central pustules on the trunk and proximal extremities, with sparing of the palms and soles.
Identifying the distribution and morphology of the rash is essential for distinguishing benign neonatal skin conditions from serious infectious etiologies.
2
Assess the infant's overall clinical status
The infant is vigorous, breastfeeding well, and has normal vital signs without any evidence of systemic illness.
The absence of systemic signs (e.g., fever, lethargy, poor feeding) strongly points away from neonatal sepsis or a severe systemic infection.
3
Determine the most likely diagnosis and management
The clinical picture is classic for erythema toxicum neonatorum. The best management is reassurance.
Erythema toxicum neonatorum is a common, benign, self-limited rash in healthy newborns that resolves without treatment within one to two weeks.

Key Concept

Erythema toxicum neonatorum is a benign, asymptomatic rash in healthy newborns characterized by erythematous macules and papules with central pustules, typically sparing the palms and soles. It requires only reassurance and routine care.
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Pediatric Infectious Diseases

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