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

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

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

4. 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’

5. 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

6. 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

7. 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

8. 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

9. 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

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

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

12. 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

13. Neonatal tetanus

14. What else is important? Good cord care Video clips tetanus and tetanus with commentary

15. Babies of mothers with infections

16. 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

17. 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

18. Babies of mothers with infections

19. 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

20. 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

21. 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

22. 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.

23. 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)

24. 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.

25. 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

26. 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

29. 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

30. 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

32. 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

33. 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