053 Ped Erythema Toxicum Neonatorum

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A 2-day-old girl in the newborn nursery develops a rash on her face, abdomen, chest, and extremities. She was born at 40 weeks gestation to a 30-year-old woman by vaginal delivery. The mother is very concerned about the rash as she occasionally develops "cold sores" during stressful events, most recently a year ago. She also had "chickenpox" as a child. The neonate has been breastfeeding every 2-3 hours. Her temperature is 36.7 C (98 F), pulse is 132/min, and respirations are 42/min. She appears comfortable in her mother's arms. Small blanching, erythematous papules and pustules are seen throughout the body, except for the palms and soles. The rash is shown in the images below. Which of the following is the most appropriate next step in management of this patient?

0 A. Bacterial blood culture and intravenous antibiotics 0 B. Contact isolation and cessation of breastfeeding 0 C. Reassurance 0 D. Skin biopsy 0 E. Topical corticosteroids 0 F. Viral DNA testing and intravenous antiviral therapy

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A 2-day-old girl in the newborn nursery develops a rash on her face, abdomen, chest, and extremities. She was born at 40 weeks gestation to a 30-year-old woman by vaginal delivery. The mother is very concerned about the rash as she occasionally develops "cold sores" during stressful events, most recently a year ago. She also had "chickenpox" as a child. The neonate has been breastfeeding every 2-3 hours. Her temperature is 36.7 C (98 F), pulse is 132/min, and respirations are 42/min. She appears comfortable in her mother's arms. Small blanching, erythematous papules and pustules are seen throughout the body, except for the palms and soles. The rash is shown in the images below. Item: ~'?Mark ~ f> 6t ~ ~ , GJIIA) a. ld : 3122 PreVIOUS Next lab Values Notes Calculator Reverse Color Text Zoom

Which of the following is the most appropriate next step in management of this patient?

A. Bacterial blood culture and intravenous antibiotics [3%] B. Contact isolation and cessation of breastfeeding [3%) C. Reassurance [77%] D. Skin biopsy [0%) E. Topical corticosteroids [2%] F. Viral DNA testing and intravenous antiviral therapy [1 6%]

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Neonatal rashes

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Neonatal rashes

Diagnosis Clinical presentation Treatment

Erythema Asymptomatic, scattered toxicum erythematous macules, papules None neonatorum & pustules throughout the body

Three patterns • Vesicular clusters on skin, eyes Neonatal HSV & mucous membranes Acyclovir • Central nervous system infection • Fulminant, disseminated multi-organ disease

Fever; ranges from vesicular Neonatal clusters on skin to fulminant, Acyclovir varicella disseminated disease

Staphy lococcal Fever, irritability & diffuse erythema Oxacillin, nafcillin, followed by blistering & exfoliation, scalded skin or vancomycin syndrome positive N ikolsky's sign

The healthy appearance of the neonate and the asymptomatic blotchy, erythematous papules and pustules support the diagnosis of erythema tox icum neonatorum (ETN). "Toxicum" is a misnomer as the rash is benign and evanescent. It is common in full-term neonates. The rash can change appearance and can occur on any part of the body (sparing the palms and soles) in the first 2 weeks of life. The etiology is unknown. Parents should be reassured that treatment is unnecessary as the rash resolves spontaneously without sequelae.

(Choice A) Neonates with staphylococcal scalded skin syndrome. are ill-appearing and febrile. Prompt anti-staphylococcal therapy is necessary due to the risk of septic shock. "Toxicum" is a misnomer as the rash is benign and evanescent. It is common in full-term neonates. The rash can change appearance and can occur on any part of the body (sparing the palms and soles) in the first 2 weeks of life. The etiology is unknown. Parents should be reassured that treatment is unnecessary as the rash resolves spontaneously without sequelae. (Choice A) Neonates with staphylococcal scalded skin syndrome are ill-appearing and febrile. Prompt anti-staphylococcal therapy is necessary due to the risk of septic shock. In contrast, neonates with ETN are well-appearing and afebrile, making bacterial cultures and antibiotics unnecessary. (Choice B) This mother has no contraindications to breastfeeding (eg, herpetic breast lesions, peripartum varicella infection) and should be encouraged to breastfeed exclusively. Breast milk contains secretory lgA, which protects against infections and provides other benefits that cannot be attained from formula. "Kangaroo care" (placing the infant and mother skin-to-skin) should also be encouraged to stimulate breast milk production. (Choice 0) Further workup is rarely necessary. If the presentation is atypical, skin biopsy with a sterile pustule and numerous eosinophils would support the diagnosis of ETN. (Choice E) Topical steroids are indicated for inflammatory dermatoses (eg, eczema) and not ETN. (Choice F) Neonatal exposure to herpes simplex and varicella-zoster viruses is extremely dangerous. Infection can disseminate rapidly to vital organs, and acyclovir should be given immediately to decrease morbidity and mortality. The lack of vesicular clusters or exposure to active maternal lesions makes these infections very unlikely. Educational objective: Erythema toxicum neonatorum is a benign neonatal rash characterized by blanching erythematous papules and/or pustules. It resolves spontaneously within 2 weeks after birth.

Reference.s: 1. Breastfeeding and the use of human milk. 2. Prospective study of erythema toxicum neonatorum: epidemiology and predisposing factors.

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na toxicum neonatorium

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· varicella infection

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