Serious maternal and neonatal infections in the local context
Doug Simkiss
Associate Professor of Child Health
Warwick Medical School

Key issues
• What do you think are the important neonatal infections?
• How does neonatal and maternal care interact in prevention of infection?

Important neonatal infections
• Neonatal tetanus
• Congenital gonorrhoea
• Congenital Syphilis
• Baby of mother with TB
• Baby of mother with HIV and PMTCT HIV

Neonatal infections
• ‘ rapid reductions in mortality are possible ’
• ‘ prevention of infection is mainly dependent on maternal health packages and programs such as antenatal care, hygienic care during childbirth and the postnatal period and early and exclusive breast feeding ’

Prevention of neonatal infections
• Many early neonatal infections can be prevented by:
– Good basic hygiene and cleanliness during delivery of the baby
– Special attention to cord care
– Eye care

Prevention of neonatal infections
• Many late neonatal infections are acquired from the health care facility. These can be prevented by:
– Exclusive breast feeding
– Strict procedures for hand washing for all staff and for families before and after handling babies
– Strict sterility for all procedures

Prevention of neonatal infections
– Avoiding incubators (using
Kangaroo mother care instead) or not using water for humidification in incubators
(Pseudomonas often colonises in these devices)
– Clean injection procedures
– Removing intravenous drips when no longer needed
– Avoiding unnecessary blood transfusions

Serious bacterial infections
• Risk factors are:
– Maternal fever (temperature >37.9°C before delivery or during labour)
– Membranes ruptured more than 24 hours before delivery
– Foul smelling amniotic fluid

Danger signs in newborns
• Neonates and young infants often present with non-specific symptoms and signs which can indicate serious bacterial infection. Signs include:
– Unable to breast feed
– Convulsions
– Drowsy or unconscious
– Respiratory rate < 20/minute

Danger signs in newborns
– Bleeding
– Central cyanosis (blueness)
– Hypothermia
– Hyperthermia
– Hypoglycaemia
– Dehydration

Danger signs in newborns
• APLS video clips
– Neonate gasping
– Acidotic breathing
– Testing dehydration

Neonatal tetanus
• What is the Malawi protocol to prevent neonatal tetanus?
– All pregnant women to receive at least 2 doses of tetanus toxoid vaccine. But they and infants are also considered protected if they received
– 2 doses, the last in the last 3 years
– 3 doses, the last in the last 5 years
– 4 doses, the last in the last 10 years
– 5 doses or more in her lifetime

Neonatal tetanus

Neonatal tetanus
• What else is important?
• Good cord care
• Video clips tetanus and tetanus with commentary

Babies of mothers with infections

Eye care
• Apply antimicrobial to eyes, either
– 1% silver nitrate solution
– 2.5 % povidone - iodine solution
– 1% tetracycline ointment
• Povidone – iodine should not be confused with tincture of iodine which could cause blindness if used

Babies of mothers with infections
• Gonorrhoea ( K12 )
– Severe conjunctivitis (pus++ +/- eyelid swelling)
– Treat in hospital as risk of blindness and needs twice daily review
– Wash eyes to remove as much pus as possible
– Ceftriaxone 50mg/kg up to 150mg im ONCE
– Tetracycline / Chloramphenicol eye ointment
– Treat mother and partner for STI

Babies of mothers with infections

Babies of mothers with infections
• Signs of congenital syphilis
– Often low birth weight
– Red rash, grey patches, blisters or peeling skin on palms and soles
– ‘snuffles’, rhinitis with nasal obstruction, highly infectious
– Abdominal distension from large liver/spleen
– Jaundice

Babies of mothers with infections
– Anaemia
– Some very low birth weight babies with syphilis have signs of severe sepsis with lethargy, respiratory distress, skin petechiae or other bleeding
• If you suspect syphilis, do
VDRL test if available

Babies of mothers with infections
• Treatment of congenital syphilis ( K12 )
– Asymptomatic neonate born to VDRL or RPR
+ve mother, treat with 50,000 units/kg of benzathine benzyl penicillin i.m. ONCE.
– Symptomatic infants require treatment with
– Procaine benzyl penicillin 50,000 units/kg daily for 10 days or

Babies of mothers with infections
– benzyl penicillin 50,000 units/kg every 12 hours i.m. or i.v. for first 7 days of life and then every 8 hours for a further 3 days
• Treat the mother and partner for syphilis and check for other sexually transmitted infections.

Babies of mothers with infections
• If the mother has active lung tuberculosis and was treated for less than 2 months before birth or was diagnosed with TB after birth:
– Reassure that it is safe to breast feed
– Do not give BCG vaccine at birth
– Give prophylactic isoniazid 5mg/kg p.o. daily
– ( K13 )

Babies of mothers with infections
• Re-evaluate baby at 6 weeks of age, checking weight and a chest X ray.
– Any findings suggestive of active disease, start full ant-tuberculosis treatment
– If baby is well and tests are –ve, continue prophylactic isoniazid to complete 6 months of treatment
– Delay BCG until 2 weeks after treatment finished. If it was given earlier, repeat.

Babies of mothers with infections
• Prevention of mother to child transmission of HIV – Malawi National Reproductive
Health Service Delivery Guidelines, 2007.
– Short course Nevirapine 2mg / kg po stat or within 72 hours of delivery
– Passive and active immunisation – 2 drops of polio and 0.05 ml BCG
– Vitamin A 100,000 IU po stat at 6 weeks
– Cotrimoxazole prophylaxis at 6 weeks

Prevention of mother to child transmission of HIV
• Breastfeeding – 1/3 of vertical transmission
– ‘ HIV positive mothers should be given adequate information about advantages and disadvantages of breastfeeding and replacement feeding to enable them to make an informed choice about infant feeding’
– Malawi NRHSDG, 2007

Prevention of mother to child transmission of HIV
• Breast feeding options
– Exclusive breast feeding for 6 months and stop
– (all women who choose to breast feed should
be counselled to breast feed exclusively)
– Heat treated breast milk
– Wet nursing
– Milk banks

Prevention of mother to child transmission of HIV
• Replacement feeding options ( J12 )
– When replacement feedig is acceptable, feasible, affordable, sustainable and safe, avoidance of all breast feeding by HIV infected mothers is recommended
– Commercial infant formula
– Home prepared infant formula

Prevention of mother to child transmission of HIV
• HIV + mothers should be counselled on continued risks of HIV transmission with mixed feeding and early breast feeding cessation
• HIV – or unknown status mothers should practice safe sex to avoid HIV infection while breast feeding

Prevention of mother to child transmission of HIV
• HIV + mothers who choose breast feeding should have information on
– Breast care to avoid nipple cracks or breast infections ( J9 )
– Seeking early treatment of infections
– Need for good maternal nutrition
– Avoiding breastfeeding is infant has oral thrush, stomatitis or pharyngitis