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Difficulty: MediumNeonatal Disorders

A 48-hour-old female newborn is evaluated in the nursery prior to discharge. She was born at 39 weeks and 2 days of gestation via uncomplicated vaginal delivery to a 26-year-old primigravid woman. Birth weight was 3,450 g (7 lb 10 oz). Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. The mother received adequate prenatal care, and her prenatal laboratory results were unremarkable, including a negative screening for group B Streptococcus. Vital signs show a temperature of 36.9°C (98.4°F), heart rate of 135/min, and respiratory rate of 40/min. Physical examination reveals a vigorous, well-appearing infant who is breastfeeding well. Skin examination shows scattered 2- to 3-cm erythematous macules on the chest, back, and proximal extremities. Several of these lesions contain central 1- to 2-mm yellowish-white pustules. The palms and soles are completely spared. The remainder of the physical examination is unremarkable. Which of the following is the most appropriate next step in management?

  1. Reassurance and continued routine careAnswer
  2. B
    Comprehensive diagnostic workup including blood and cerebrospinal fluid cultures
  3. C
    Empiric administration of intravenous ampicillin and gentamicin
  4. D
    Application of topical mupirocin to the affected areas
  5. E
    Viral swab of the lesions and initiation of intravenous acyclovir

Answer

Reassurance and continued routine care
The correct answer is reassurance and continued routine care. This patient's presentation is classic for erythema toxicum neonatorum (ETN), a benign, self-limited rash that occurs in up to half of all full-term neonates. It typically appears within the first 24 to 72 hours of life and is characterized by erythematous macules and papules that often develop central yellowish-white pustules. A key pathognomonic feature is the sparing of the palms and soles. Because the infant is vigorous, afebrile, and well-appearing, no further diagnostic evaluation or treatment is required. The rash will spontaneously resolve within a week.

Step-by-Step Solution

1
Analyze the patient's presentation and vital signs.
The patient is a full-term, 48-hour-old newborn with normal vital signs, a reassuring physical exam, and appropriate feeding behaviors.
Establishing that the infant is hemodynamically stable and not systemically ill is critical to rule out early-onset neonatal sepsis.
2
Evaluate the morphological characteristics of the skin rash.
The rash consists of scattered erythematous macules with central pustules that strictly spare the palms and soles.
Specific lesion morphology and anatomic distribution help differentiate between benign neonatal rashes and infectious etiologies.
3
Synthesize the findings to formulate the most likely diagnosis.
The clinical picture is diagnostic of erythema toxicum neonatorum (ETN).
ETN classically presents at 24-72 hours of life in healthy term infants with this exact distinctive rash pattern.
4
Determine the appropriate management for the condition.
Observation and reassurance are indicated.
ETN is a transient, physiologic process that resolves spontaneously within a week without any treatment.

Key Concept

Erythema toxicum neonatorum is a benign, self-limited rash in healthy newborns characterized by erythematous macules with central pustules that requires no medical intervention.
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Topics

Neonatal Disorders

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