10.4 Specific care when the mother has a transmissible infection

10.4.1 Syphilis

Look for signs of syphilis in all infants of mothers with a positive syphilis test:
– 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.

If the infant has no signs of syphilis and the mother received appropriate treatment during the pregnancy (at least one dose of penicillin1 administered at least one month before delivery), give the infant: benzathine benzylpenicillin IM, 50 000 IU/kg as a single dose.

If the infant has signs of syphilis or the mother did not receive appropriate treatment (see above):
– Administer to the infant:
benzylpenicillin IV for 10 days: 100 000 IU/kg/day in 2 divided doses given 12 hours apart from Day 0 to Day 7, and then 150 000 IU/kg/day in 3 divided doses given 8 hours apart from Day 8 to Day 10
– In addition to “standard” precautions, use “contact” precautions2 during care for 24 hours after starting the treatment.

10.4.2 Genital gonococcal and/or chlamydial infection

Newborns of mothers with purulent cervical discharge at the time of delivery may be asymptomatic or present purulent conjunctivitis, usually within the first 7 days for gonorrhoea and after 7 days for chlamydia. Chlamydial pneumonia is possible.

Administer ceftriaxone IM: 50 mg/kg as a single dose (maximum 125 mg) to:
– All infants with purulent conjunctivitis, whether the mother is symptomatic or not;
– All infants born to mothers who were symptomatic at the time of delivery, even if the infants are asymptomatic.

In case of symptomatic conjunctivitis (purulent discharge): clean each eye with 0.9% sodium chloride at least 4 times a day.

If the conjunctivitis persists 48 hours after the ceftriaxone injection, administer :
erythromycin PO: 25 to 50 mg/kg/day in 4 divided doses for 14 days
or azithromycin PO: 20 mg/kg once daily for 3 days
If the symptoms appear after 7 days of life, administer ceftriaxone IM + erythromycin or azithromycin PO, as above.

10.4.3 Genital herpes4

Infants of mothers who have active genital herpes lesions at the time of delivery may present with neonatal herpes.

The infant is usually asymptomatic at birth. The symptoms appear sometime within the first 4 weeks of life (usually between 3 and 10 days of life).

Symptoms of neonatal herpes may include:
– Local, external involvement: skin, mouth (vesicles) and/or eyes (conjunctivitis);
– Cerebral involvement: encephalitis (with seizures in 60% of cases), accompanied in 60% of cases by local external involvement;
– Disseminated infection: primarily brain, lungs and liver. The infant may present danger signs suggesting septicaemia (fever, lethargy, respiratory distress or seizure). Local external involvement is associated in 60% of cases.

Management depends on the infant’s risk at birth:

High risk of herpes infection

– Infant with symptoms of neonatal herpes, or
– Active primary or unknown maternal genital herpes at the time of delivery, or
– Active recurrent maternal genital herpes at the time of delivery, with at least one of the following risk factors: rupture of membranes ≥ 6 hours before delivery (vaginal delivery or caesarean section) or birth weight < 2000 g or premature ≤ 37 weeks or skin laceration or maternal HIV infection.

In these cases, 3% aciclovir eye ointment: a single application in each eye at birth (in this case, wait 12 hours before applying tetracycline eye ointment, Section 10.1.7) and refer to neonatal care unit for aciclovir IV therapy, with isolation of mother and infant.

Low risk of herpes infection

Recurrent active genital herpes with none of the risk factors listed above.

In these cases, observe for 5 days, with isolation of the mother and infant.
Apply 3% aciclovir eye ointment, as above.
If the infant becomes symptomatic, refer to neonatal care unit for aciclovir IV therapy.
Discharge at 5 days of life if the infant has not developed symptoms; ask parents to seek urgent attention if symptoms appear.

10.4.4 Hepatitis B infection

The infant is asymptomatic.
Administer Hepatitis B vaccine to the infant at birth, regardless of the mother’s serological status (Section 10.1.8).

10.4.5 HIV infection

The infant is asymptomatic.
Administer antiretroviral prophylaxis immediately after birth: refer to the PMTCT-specific guides.
For breastfeeding: see Appendix 3, Section 3.7.

10.4.6 Active pulmonary tuberculosis

Congenital tuberculosis is rare, and the infant is usually asymptomatic at birth.

After birth, the mother can transmit tuberculosis to the infant as long as she is contagious, i.e. sputum smear positive or culture positive.
In that case:
– Do not administer BCG.
– Administer preventive therapy to the infant, 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 infant (breastfeeding, etc.), but observe the rules for transmission prevention. For more information, refer to the MSF handbook, Tuberculosis.

Ref Notes
1 Erythromycin is not an appropriate treatment.
2 Contact precautions include: isolation of the infant, use of gloves and protective gown at each contact with the infant.