10.4 Specific care when the mother has a transmissible infection

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10.4.1 Syphilis

Look for signs of syphilis in all neonates of mothers in case of positive syphilis test and/or suspected maternal syphilis infection:
- mucocutaneous rash, grey patches, papules and bullae followed by desquamation of the skin on the palms and soles of the feet;
- sepsis, jaundice, anaemia, enlarged lymph nodes and abdominal distension with hepatosplenomegaly.
Verify that the mother received an adequate treatment for syphilis at least one month before delivery (see Chapter 4, Section 4.2.1).
Based on the findings, administer one of the following treatments:

Criteria	Treatment
Neonate has clinical signs of syphilis or Mother did not receive adequate treatment during pregnancy	benzylpenicillin IV: D1 to D7: 50 000 IU/kg (= 30 mg/kg) every 12 hours D8 to D10: 50 000 IU/kg (= 30 mg/kg) every 8 hours or benzylpenicillin procaine IM: D1 to D10: 50 000 IU/kg (= 50 mg/kg) every 24 hours
Neonate has no clinical signs of syphilis and Mother received adequate treatment during pregnancy	benzathine benzylpenicillin IM: 50 000 IU/kg (= 37.5 mg/kg) single dose

In addition to "standard" precautions, use "contact" precautions (gloves and protective gown) at each contact with the neonate during the first 24 hours after starting the treatment.

10.4.2 Genital gonococcal and/or chlamydial infection

Neonates of mothers with purulent cervical discharge at the time of delivery may be asymptomatic or may present with symptomatic conjunctivitis.

For neonates with symptomatic conjunctivitis (whether the mother is symptomatic or not) or born to mothers who were symptomatic at the time of delivery (even if they are asymptomatic):
- Clean each eye with 0.9% sodium chloride at least 4 times daily until discharge disappears.
- Administer at birth a single dose of ceftriaxone IM: 50 mg/kg; max. 125 mg (or cefotaxime IM: 100 mg/kg if ceftriaxone is contraindicated).

If the conjunctivitis persists 48 hours after the ceftriaxone injection, administer :

azithromycin PO: 20 mg/kg once daily for 3 days (or, if azithromycin is not available, erythromycin PO: 12.5 mg/kg 4 times daily for 14 days)

If the symptoms appear after 7 days of life, administer simultaneously ceftriaxone IM + azithromycin or erythromycin PO, as above.

10.4.3 Genital herpes

Neonates of mothers who have active genital herpes lesions at the time of delivery may present with neonatal herpes.
The neonate is usually asymptomatic at birth. The symptoms appear sometime within the first 4 weeks of life (usually between 7 and 14 days of life).

Look for signs of neonatal herpes:
- Vesicular lesions on skin, mouth and/or eyes (only in 45% of neonates).
- Cerebral involvement: encephalitis and seizures.
- Non-specific signs of disseminated infection (irritability, lethargy, fever, poor feeding).
Management depends on the neonate’s risk at birth:

Criteria for risk of herpes infection	Treatment [1] Citation 1. Neonatal herpes simplex virus infection: Management and prevention, Gail J Demmler-Harrison, UpToDate, Literature review current through: Oct 2013, last update: Mar 7, 2013.
High Neonate with signs of herpes OR Mother has primary genital herpes lesions at the moment of delivery OR Mother has genital herpes lesions at the moment of delivery and it is unknown whether it is a primary or recurrent infection OR Mother with recurrent genital herpes lesions at the moment of delivery WITH at least one of the following risk factors: rupture of membranes ≥ 6 hours before delivery (even if caesarean section) birth weight < 2000 g or preterm ≤ 37 weeks neonatal skin laceration or maternal HIV infection	Immediately apply one dose of 3% aciclovir eye ointment in each eye at birth. (a) Citation a. In this case, wait 12 hours before applying tetracycline eye ointment (Section 10.1.1, Preventive treatments). Refer to neonatal care unit for IV aciclovir treatment.
Low Neonate is asymptomatic AND Mother has recurrent genital herpes lesions at the moment of delivery AND Absence of risk factors in previous column.	Immediately apply one dose of 3% aciclovir eye ointment in each eye at birth. (a) Citation a. In this case, wait 12 hours before applying tetracycline eye ointment (Section 10.1.1, Preventive treatments). Observe for 5 days: If the neonate becomes symptomatic: refer to neonatal care unit for IV aciclovir treatment. If the neonate remains asymptomatic: discharge; ask parents to seek urgent attention if symptoms appear.

Criteria for risk of herpes infection

Treatment [1] Citation 1. Neonatal herpes simplex virus infection: Management and prevention, Gail J Demmler-Harrison, UpToDate, Literature review current through: Oct 2013, last update: Mar 7, 2013.

High

Neonate with signs of herpes
OR
Mother has primary genital herpes lesions at the moment of delivery
OR
Mother has genital herpes lesions at the moment of delivery and it is unknown whether it is a primary or recurrent infection
OR
Mother with recurrent genital herpes lesions at the moment of delivery
WITH
at least one of the following risk factors:

rupture of membranes ≥ 6 hours before delivery (even if caesarean section)
birth weight < 2000 g or preterm ≤ 37 weeks
neonatal skin laceration or maternal HIV infection

Immediately apply one dose of 3% aciclovir eye ointment in each eye at birth. (a) Citation a. In this case, wait 12 hours before applying tetracycline eye ointment (Section 10.1.1, Preventive treatments).
Refer to neonatal care unit for IV aciclovir treatment.

Low

Neonate is asymptomatic
AND
Mother has recurrent genital herpes lesions at the moment of delivery
AND
Absence of risk factors in previous column.

Observe for 5 days:

If the neonate becomes symptomatic: refer to neonatal care unit for IV aciclovir treatment.
If the neonate remains asymptomatic: discharge; ask parents to seek urgent attention if symptoms appear.

In addition to "standard" precautions, use "contact" precautions (gloves and protective gown) at each contact with the neonate for 24 hours after the start of treatment.

10.4.4 Hepatitis B infection

The neonate is asymptomatic.
Hepatitis B vaccine should be given to the neonate at birth, regardless of the mother’s serological status (Section 10.1.1, Vaccinations).

10.4.5 HIV infection

The neonate is asymptomatic.
Antiretroviral prophylaxis should be started immediately after birth: refer to the PMTCT guides.
For breastfeeding: see Appendix 3, Section 3.7.

10.4.6 Active tuberculosis

For all neonates born to mothers with active tuberculosis at birth:

Do not administer BCG.
Administer preventive therapy with isoniazid PO: 10 mg/kg once daily for 6 months.
Administer the BCG vaccine after completion of isoniazid therapy.
Do not separate the mother from the neonate (breastfeeding, etc.), but observe the rules for transmission prevention.

For more information, refer to the guide Tuberculosis, MSF.

(a) In this case, wait 12 hours before applying tetracycline eye ointment (Section 10.1.1, Preventive treatments).

References

1.Neonatal herpes simplex virus infection: Management and prevention, Gail J Demmler-Harrison, UpToDate, Literature review current through: Oct 2013, last update: Mar 7, 2013.