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Difficulty: MediumPediatric Infectious Diseases

During a routine morning nursery round, a physician evaluates a newborn male at 48 hours of life. The infant was delivered vaginally at 39 weeks gestation to a 22-year-old primigravida who received limited prenatal care. Maternal admission laboratory screening for HIV, hepatitis B, and syphilis were negative, but her Group B Streptococcus status was unknown. The newborn is breastfeeding vigorously and has had appropriate wet diapers and meconium passage. Vital signs show a temperature of 37.1 °C (98.8 °F), heart rate of 142/min, and respiratory rate of 42/min. Physical examination reveals an alert, well-appearing infant. There is a diffuse cutaneous eruption consisting of multiple 2- to 3-mm firm, yellowish pustules, each surrounded by a prominent erythematous macular base. The lesions are scattered across the chest, abdomen, and proximal thighs, but the palms and soles are completely clear. Mucous membranes are moist without lesions. Which of the following is the most appropriate next step in the management of this patient?

  1. Reassurance and continued routine newborn careAnswer
  2. B
    Initiation of intravenous acyclovir therapy
  3. C
    Administration of intravenous ampicillin and gentamicin
  4. D
    Application of topical mupirocin to the affected skin areas
  5. E
    Gram stain and bacterial culture of the pustule contents

Answer

Reassurance and continued routine newborn care
The correct answer is reassurance and continued routine newborn care. This patient's presentation is classic for erythema toxicum neonatorum (ETN), a common, benign, asymptomatic rash that typically appears within the first few days of life in full-term infants. The rash is characterized by firm, pale yellow or white papules and pustules on a broad erythematous base, often described as 'flea-bitten' in appearance. The lesions are predominantly found on the trunk and proximal extremities, characteristically sparing the palms and soles. Because the infant is afebrile, feeding well, and shows no signs of systemic illness, the diagnosis is purely clinical. No diagnostic testing or medical intervention is required; the rash will spontaneously resolve within a few days to weeks.

Step-by-Step Solution

1
Analyze the patient's clinical presentation and vital signs.
The newborn is full-term, afebrile, feeding vigorously, and has normal vital signs, indicating a stable, non-toxic state.
To distinguish between a well infant with a benign condition and one with a severe systemic infection like neonatal sepsis.
2
Evaluate the characteristics and distribution of the rash.
The rash consists of yellowish pustules on a broad erythematous base located on the trunk and proximal extremities, distinctly sparing the palms and soles.
To identify the specific etiology of the skin findings based on classic dermatologic patterns.
3
Synthesize the findings to establish a diagnosis and treatment plan.
The presentation is classic for erythema toxicum neonatorum, a benign physiologic condition requiring no medical intervention.
Determines the most appropriate, evidence-based next step in management.

Key Concept

Erythema toxicum neonatorum is a benign, self-limited rash in healthy newborns characterized by erythematous macules and pustules that typically spare the palms and soles, requiring clinical diagnosis and reassurance rather than infectious workup or treatment.
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Topics

Pediatric Infectious Diseases

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