Clinical assessment and risk stratification

1) Erythema Toxicum Neonatorum

Typically the rash presents as a maculo-papular or vesiculo-pustular eruption over the face, trunk and limbs. Each lesion is surrounded by an area of erythema.

The palms and soles remain unaffected.

The child remains systemically well.

If the child is sick other differentials for vesiculo-pustular rashes in the neonate should be considered (i.e. HSV, candida, Staphylococcus)⁴.

2) Transient Pustular Melanosis

Typically the rash presents as a vesiculo-pustular eruption that can occur anywhere on the body, including the palms and soles.

Unlike Erythema Toxicum the lesions have no surrounding erythema and rupture to leave a characteristic pigmented macule.

The child remains systemically well

3) Milia

Milia presents as 1-2mm pearly white or yellow papules that typically occur on the face (especially the forehead, cheeks, nose and chin).

However, they may appear on any part of the body include the mucous membranes, palate or penis.

The child remains systemically well

4) Harlequin colour change

Harlequin colour change occurs when the newborn lies on their side. The dependant side develops erythema whereas the contralateral side blanches.

The colour change can last between 30 seconds to 20 minutes and resolves with crying or increased activity

5) Seborrhoeic Dermatitis

The condition typically presents with erythema to the face, neck and flexural folds and greasy scales to the scalp (i.e. cradle cap). The napkin area can also be affected.

Unlike atopic eczema (which tends not to present in the neonatal period) pruritus is uncommon⁹.

The child is systemically well and, although often distressing for the parents, unaffected.

Generalized seborrhoeic dermatitis accompanied by failure to thrive and diarrhoea should prompt an evaluation for immunodeficiency¹¹

6) Mongolian Blue Spot

They present as dark blue-grey lesions typically involving the lumbosacral region.

They are present from birth.

The child remains systemically well

What is physiological jaundice?

Jaundice developing after the first 24 hours.

Jaundice resolving by 14 days of life in term (37-42 weeks) or 21 days in preterm neonates (<37 weeks).

The child is systemically well and thriving.

The total serum bilirubin is less than the treatment threshold (see below).

Otherwise, pathological causes should be considered.

1) Jaundice developing within the first 24 hours

Jaundice developing within the first 24 hours of life is likely to be related to a haemolytic process (i.e. ABO incompatibility) and thus, always pathological.

In young babies indirect bilirubin can pass the blood brain barrier and high levels can lead to long-term damage to the CNS (kernicterus).

Hence, such patients should have urgent serum levels taken and referred urgently to paediatrics.

2) Jaundice not resolving by 14 days of life in term (37-42 weeks) or 21 days in preterm neonates (<37 weeks)

Symptoms continuing beyond this period are termed prolonged jaundice and can be a clue to serious underlying liver disease such as biliary atresia.

As such infants require investigation they should be referred to paediatrics.

NB: such patients are often referred from the community and investigated in a specific prolonged jaundice clinics. We would recommend following local guidelines.

3) If the child is unwell or failing to thrive

If the child is unwell alternative diagnoses such as sepsis, dehydration or inborn errors of metabolism should be considered. The management of these conditions is beyond the scope of this module.

As a general rule of thumb:

• It is normal for a newborn baby to lose up to 10% of their birth weight.
• This should be regained by 2 weeks of life.
• If jaundice is diagnosed in the context of a baby who has lost excessive weight, dehydration should be considered.

4) The total serum bilirubin is greater than the treatment line

The NICE guidelines have published treatment thresholds based upon gestation at birth and hours of life¹³.

Serum levels should be compared to these graphs and treatment started as appropriate.

Patients who exceed these thresholds should be referred for treatment and investigation to determine the underlying cause.