neonatal infections.

3. INTRODUCTION
Infections of neonates during neonatal period are called as
Neonatal infections. Neonatal infections, are the most
common cause of neonatal mortality in India. Infections
can occur in intrauterine life or during delivery or in
neonatal period. The neonates are more susceptible to
infections because they lack natural immunity and take
some time for development of acquired immunity.

4. TERMINOLOGY
ANTENATAL: Period between the conception to child
birth.
POSTNATAL: Period after birth
CONJUNCTIVA: The clear mucous membrane that
lines the inner surface of eye lids and the exposed surface
of eye ball and sclera.
CONGENITAL: Present since birth
HIV: Human Immuno Virus
AIDS: Acquired Immuno Deficiency Syndrome

5. DEFINITION OF NEONATAL INFECTIONS:
Invasion and uncontrollable growth of pathogenic
microorganisms in the body of neonate is known as
neonatal infections.
SOURCES OF INFECTIONS: Infections can occur
in antenatal, intranatal and postnatal period due to
various conditions.

6. ANTENATAL PERIOD
Antenatal infections may occur due to various micro
organism and described with an acronym of STORCH
where in:
S  syphilis
T  toxoplasmosis.
O  Other (Gonococci Infections , Tubercular Infections,
Malaria, Varicella, Hepatitis B, HIV Etc)
R Rubella
C Cytomegalovirus And
H Herpes Simplex Virus.
These infections can develop due to direct transplacental
transfer or following placental infections.

7. INTRANATAL PERIOD
Aspiration of infected liquor in prolonged labour
following early rupture of membrane which may lead to
neonatal aspiration pneumonia.
Infection may occur due to related vaginal examination
by the delivery assistant especially when the membrane is
ruptured
Infected birth passage may infect the eyes and mouth of
the neonate leading to Opthalmia neonatorum and oral
thrush.
Improper aseptic technique during care of umbilical cord
may cause umbilical sepsis.
Ascending Infections with contaminated liquor amnii
and amnionitis related to infected birth passage and
premature rapture of membrane may also lead to
intrauterine infections of the fetus.

8. POSTNATAL PERIOD
The following are important cause of neonatal infections in
postnatal period:
Transmission of infection from human contact or care
givers especially from infected hands of mother or family
members and health care providers
Cross infection from other baby who is infected and no
barrier nursing is practiced and universal precautions are not
followed
Infected articles for baby care and contaminated clothing
Invasive procedures without aseptic technique
Infected environment around the neonates at hospital or
home

9. PREDISPOSING FACTORS RESPONSIBLE
FOR NEONATAL INFECTIONS
The Predisposing Factors Of Neonatal Infections Are:
Low birth weight infant.
Contaminated intrauterine environment like
prolonged rapture of membrane , unhygienic and
multiple vaginal examination, meconium-stained
liquor etc.

10. Infected birth canal and infection at birth in delivery room
or neonatal care units.
Birth asphyxia and resuscitations
Congenital anomalies
Various procedures with inadequate asepsis during iv
infusion , parenteral medication, endo tracheal intubation,
assisted ventilation, exchange blood transfusion etc.
Artificial feeding other than human milk

11. CLASSIFICATION OF NEWBORN
INFECTIONS.
ON THE BASES OF SOURCE:- the various
types are
1. Intrauterine infections: it refers to infection
acquired in utero. The STORCH a group of
infections (syphilis, toxoplasmosis, rubella,
cytomegalovirus, herpes simplex virus) belonging
to this category. Viral infections in utero may lead
to fetal death, congenital malformations or severe
systemic manifestations of disease.

12. The presence of any three of the following
features should make alert to the possibility of
intrauterine infections.
i. Maternal history of infection.
ii. Intrauterine growth retardation
iii. Hepatospleenomegaly.
iv. Jaundice.
v. Meningo-encephalitis.
vi. Raised IgM in cord blood

13. 2. Perinatal infections: it refers to infection that is
acquired just before pregnancy and during delivery from
the mother. Such an infection occurs from the organisms
colonizing the birth passage.
3. Early neonatal infection: should be limited to
perinatal infection with manifestations occurring within
72 hours of birth.

14. 4.Late–onset neonatal infection: it is sepsis
occurring after 8th day of birth.
5.Post neonatal infection: it refers to
infections occur after 28 days of delivery. The
organisms responsible for post neonatal
infections are Staphylococcus areus, Klebsialle
Proteus, E.coli, salmonella pseudomonas,
Candida Albicans

15. ON THE BASIS OF LOCATION:- The
infection can be superficial or systemic
1.Superficial infections: the infection occurs on the
outer side of body. The common sites of superficial
infections are eyes, skin, umbilicus and oral cavity.
2.Systemic infections: It includes septicaemia,
meningitis, pneumonia, necrotising enterocolitis,
tetanus neonatorum, systemic candidiasis,
DIC(Disseminated intravenous coagulopathy),
pyelonephritis etc

16. BASED ON THE CAUSATIVE ORGANISMS
1. Bacterial infections
2. Viral infections
3. Protozoa infections
4. Fungal infections

17. NEONATAL CONJUNCTIVITIS
(OPTHALMIA NEONATORUM)
INTRODUCTION
Inflammation of conjunctiva during first 3 weeks of life is
termed as ophthalmic Neonatorum. Sticky eyes without
purulent discharge are common during first 2-3 days after
birth. Unilateral conjunctivitis after 5 days of life is often
due to Chlamydia trachomatis.
Purulent conjunctivitis with profuse discharge is usually
due to gonococcus which affects one or both eyes within 48
hours of age.
Other microorganisms causing neonatal conjunctivitis are
streptococcus, staphylococcus, pneumococcal, E.coli, herpes
simplex virus etc.
Chemical conjunctivitis may occur due to irritation of
silver nitrate, soap and local antibiotic drops.

18. DEFINITION
Ophthalmic neonatorum was the term used to describe a
hyper acute purulent conjunctivitis, usually caused by
gonococcus, in the first 10 days of life. –WHO.
Ophthalmic neonatrum was the term used that any hyper
acute purulent conjunctivitis occurring during the first 10
days of life, usually contracted during birth from infected
vaginal discharge of the mother.
-Medical Dictionary
Neonatal conjunctivitis is swelling (inflammation) or
infection of the tissue lining the eyelids in a newborn.
Pub Med

19. MODE OF INFECTIONS
It includes infected hands of care givers, infected birth
canal and cross-infection from other infected infants.
Infection can occur directly from other sites of
infections like skin and umbilicus.

20. CLINICAL FEATURES
Varies with mode of infection and causative organism.
The neonate may present with sticky eyes with or
without discharge ranging from watery or purulent or
muco purulent in one or both eyes. The eyelids may be
markedly swollen and stuck together with redness of
eyes. Closed eyelids may present due to spasm of
orbicularis oculi muscle.

21. PATHOPHYSIOLOGY
Inflammation of
conjunctiva
Blood vessel dilation
& chemosis
Absence of tears at
birth

22. DIAGNOSTIC STUDIES
Culture of the drainage from the eye to look for
bacteria or viruses .
Slit-lamp examination to look for damage to the
surface of the eyeball

23. MANAGEMENT
is done with specific antibiotic therapy, after identification
of causative organism.
The baby should be isolated to prevent cross infection.
Sulfacetamide or gentamycin or cholramphenicol drops or
erythromycin ointment can be used.
For Gonococcal infection penicillin therapy should be
initiated promptly.
If organism are resistant to Pencillin then cefotaxime or
ceftrioxone (50mg/kg IM or IV) are used.
Cleaning of the infected eye with sterile cotton swabs
soaked in saline should be done after hand washing.
Instillation of eye drops be done with proper aseptic
techniques.

24. NURSING MANAGEMENT
All infants should receive ocular prophylaxis at birth to
prevent Gonococcal Opthalmia. Neonates presenting with
signs of conjunctivitis should have a conjunctival swab sent
for Gram stain and culture. If Gram-negative diplococci are
present on the Gram stain results, the infants and their
parents should be treated immediately for presumed
gonorrhoea.
Infants with chlamydial infection should be treated with
oral antibiotics. Most of all other forms of bacterial
conjunctivitis can be treated with topical antibiotics, with the
exception of Pseudomonas infection.

25.  Infants should be followed during their treatment and
upon completion of therapy to ensure resolution of
symptoms. For cases in which sexually transmitted
bacteria are implicated, the mothers and their sexual
partners should be treated.
Five clean practices should be followed during
delivery; clean hands, clean tie, clean blade and clean
cord stump. Sixth clean practice include clean clothing
for mother & baby
Hand washing before and after handling the babies.
Maintenance of cleanliness of the environment i:e
delivery room , neonatal care unit , postnatal area and
separate area for mother and baby at home

26. CONGENITAL SYPHILIS
Syphilis is caused by Treponema pallidum.
Congenital syphilis occurs when the spirochete
Treponema palladium is transmitted from a
pregnant woman to her fetus. Infection can result
in stillbirth, prematurity, or a wide spectrum of
clinical manifestations; only severe cases are
clinically apparent at birth.
WHO

27. RISK FACTORS
Baby has an increased risk of developing congenital
syphilis in following conditions:
Lack of inadequate prenatal care of mother.
Maternal substance abuse.
Failure to repeat a serological test for syphilis in the third
trimester.
Treatment failure.
Inadequate access to Sexually Transmitted Diseases
(STD) clinics and STD outreach activities.

28. MODES OF TRANSMISSION
Sexual contact.
Trans-placental passage from infected mother.
Contact with lesion at the time of delivery.
The risk of developing syphilis after exposure is
about 40%.

29. TYPES
1.Acquired syphilis is transmitted almost exclusively
by sexual contact, including oral sexual exposure.
Less common modes of transmission include
transfusion of contaminated blood or direct contact
with infected tissues

30. 2. Congenital syphilis results from transplacental transmission of
spirochetes. Women with primary and secondary syphilis and
spirochetemia are more likely to transmit infection to the fetus
than are women with latent infection. Transmission can occur at
any stage of pregnancy. The incidence of congenital infection in
offspring of untreated or poorly treated infected women remains
highest during the first 4 yr after acquisition of primary infection,
secondary infection and early latent disease. Risk factors most
commonly associated with congenital syphilis are lack of prenatal
care and cocaine drug abuse, unprotected sexual contact, trading
of sex for drugs, and poor treatment of syphilis during pregnancy.

31. CLASSIFICATION
1. EARLY: It occurs in children between 0 and 2 years
old.
2. LATE: Late congenital syphilis is a subset of cases
of congenital syphilis

32. PATHOPHYSIOLOGY
Initial invasion through mucous membranes or skin
The organism rapidly multiplies and widely
disseminates
Organism spreads through the perivascular
lymphatics
Primary clinical manifestations

33. CLINICAL MANIFESTATIONS AND
LABORATORY FINDINGS
Many persons infected with syphilis are asymptomatic for
years or do not recognize the early signs of disease.
Hutchinson's trait
Scarring skin around the mouth & nasal discharge
Secondary lesions on feet
Lesions on face
Hutchinson's teeth (Abnormal notched and peg-shaped,
blunted upper incisor teeth)
Saddle nose(collapse of the bony part of nose)
Clutton's joints(swelling of joints)
Sabre shins (malformation of tibia)
Osteochondritis of distal radius and ulna
Papulosquamous Plaques
Osteochondritis of femur and tibia metaphysis

34. MANAGEMENT
Infected baby with positive serological reactions requires:
Isolation from the mother
Intramuscular administration of aqueous procaine Pencillin G
50,000units per kg body weight each day for 10 days OR
Aqueous crystalline Penicillin G 100,000-150,000U/kg/ day
(given q8-q12hrs) IV for 10 days
If >1 day of therapy missed, entire course should be restarted
Positive serological reaction without clinical evidences of
disease- the baby is treated with a single intramuscular dose of
penicillin G 50000 Units Per Kg Body Weight
An Apparently Healthy Child Of A Known Syphilitic Mother-
Serological Reaction Should Be Tested Weekly For The First
Month And Then Monthly For 6 Months.

35. Follow up
 Baby must have careful follow-up examination at
1, 2, 4, 6, and 12 months of age.
 Serologic non-treponemal tests: 3, 6, 12 months
and end of treatment (or until non-reactive)
 Non-treponemal Ab titers decline by 3 months of
age, and should be Non-reactive by 6 months, if
infant was not infected.(transplacentally acquires
antibodies.)
 If persistent, stable titers, consider retreatment.
 Congenital neurosyphilis- CSF exam at 6 month
intervals until normal

36. HIV AND AIDS
 In 2009, the World Health Organization (WHO)
estimated that there are 33.4 million people worldwide
living with HIV/AIDS, with 2.7 million new HIV
infections per year and 2.0 million annual deaths due
to AIDS. At the end of 2010, there were 3.4 million
children living with HIV around the world. An
estimated 3,90,000 children became newly infected
with HIV in 2010. HIV is primary cause of AIDS.
There are different strains of HIV. HIV -2 is prevalent
in Africa, where as HIV-1 is more common form in the
United States. The majority of children with HIV
infection are younger than 7 years of age.

37. DEFINITION
 An infectious disease of the immune system
caused by a human immuno deficiency virus
(HIV). AIDS is characterized by a decrease in the
number of helper T cells, which causes a severe
immune deficiency that leaves the body
susceptible to a variety of potentially fatal
infections.
OR
 A disease of the immune system characterized by
increased susceptibility to opportunistic
infections, as pneumocystis carinii pneumonia and
candidiasis, to certain cancers, as Kaposi's
sarcoma, and to neurological disorders caused by
a retrovirus.

38. ROUTES OF
TRANSMISSION
Blood
Semen
Vaginal fluidPre-ejeculate
Breast milk

39. MATERNAL INFANT TRANSMISSION
 Intrauterine: 25-40%
 Intrapartum: 60-75%.
 Added risk of breast -feeding: 12-14%.

40. RISK FACTORS OF PEDIATRIC AIDS
 Mothers who addicted with intravenous drugs.
 Mothers who indulge in prostitution.
 Mothers who are heterosexual with bisexual
husbands.
 A history of blood transfusion with blood or its
products including factor-8 concentrates with
in preceding 5 years.
 A history of residence in certain geographical
areas that are inhabited considerably with aids
patients.

41. ETIOLOGY
 HIV is primary cause of AIDS. There are different strains of HIV. HIV
-2 is prevalent in Africa, where as HIV-1 is more common form in the
United States.
 Horizontal transmission of HIV occurs through intimate sexual
contact or paternal exposure to blood or body fluids containing visible
blood
 Vertical –perinatal transmission occurs when an HIV infected
pregnant women passes the infection to her infant.
 There is no evidence that the casual contact between the infected and
uninfected individual can spread the virus. The majority of children
with HIV infection are younger than 7 years of age.
 Children with HIV fall into two subpopulations: infants born to HIV-
infected women and adolescents infected as a result of high-risk
behaviours.
 The transmission of HIV can occur in utero, intrapartum, or after
delivery through breastfeeding.

42.  Nevirapine administered to the mother at labor and to the
infant within 48 to 72 hours of life is the most popular
regimen in the developing world because of its ease of
administration and low cost
 The World Health Organization has recommended that
pregnant women be treated with an antiretroviral regimen
appropriate for their own health if possible Since
breastfeeding is essential for infant survival in developing
countries,
 HIV mothers on antiretroviral treatment who exclusively
breastfed for a duration of their own choosing had lower
HIV-1 breast milk concentrations than mothers who
abruptly weaned the infant at approximately 4 months of
age

43.  Transfusion of infected blood or blood products
has accounted for 3% to 6% of all pediatric
AIDS cases to date Sexual contact is the leading
source of exposure to HIV in the United States.
 In the young pediatric population this is an
infrequent route of transmission; a small number
of children have been infected through sexual
abuse. In contrast, sexual activity is a major
cause of HIV infection in adolescents. Given
that the average time from HIV infection to the
development of AIDS in adults is 10 years.

44. Clinical manifestations
 Clinical manifestations found more commonly in
children than adults with HIV infection include
 Recurrent bacterial infections, chronic parotid swelling,
lymphocytic interstitial pneumonitis (LIP) and early
onset of progressive neurologic deterioration.
 Overall progression of disease is more rapid in children.
 Immune system is more immature than adults.
 Recurrent invasive bacterial infections are more
common in children.
 Disseminated CMV, Candida, Herpes Simplex and
Varicella Zoster are more common.
 CNS infections are common.
 Peripheral neuropathy, Myopathy is rare in children.

45. Categories
 The HIV classification system is used to categorize the stage of
pediatric disease by using 2 parameters: clinical status and degree of
immunologic impairment Among the clinical categories,
 category A (mild symptoms) includes children with at least 2 mild
symptoms such as lymphadenopathy, parotitis, Hepatomegaly,
Spleenomegaly, dermatitis, and recurrent or persistent sinusitis or
otitis media
 Category B (moderate symptoms) includes children with LIP,
oropharyngeal thrush persisting for >2 mo, recurrent or chronic
diarrhea, persistent fever for >1 mo, hepatitis, recurrent (HSV)
stomatitis,
 HSV esophagitis, HSV pneumonitis, disseminated varicella (i.e., with
visceral involvement), cardiomegaly, or nephropathy
 Category C (severe symptoms) includes children with opportunistic
infections (e.g. oesophageal or lower respiratory tract candidiasis,
cryptosporidiosis (>1 mo), disseminated mycobacterial or
cytomegalovirus infection, Pneumocystis pneumonia, or cerebral
toxoplasmosis [onset >1 mo of age]), recurrent bacterial infections
(sepsis, meningitis, pneumonia), encephalopathy, malignancies, and
severe weight loss.

46. WHO CLINICAL STAGING SYSTEM
 CLINICAL STAGE I
 Asymptomatic
 General Lymphadenopathy
 CLINICAL STAGE II
 Diarrhea >30 days
 Sever persistent or recurrent diarrhea outside neonatal
period. Weight loss
 failure to thrive
 Persistent fever >30 days
 Recurrent sever bacterial infection other than
Septicemia or Meningitis. (e.g. Osteomylitis, Abscess,
Bacterial Pneumonia-non tubercular)

47. CLINICAL STAGE III
 AIDS defining opportunistic infections.
 Sever failure to thrive.
 Progressive Encephalopathy.
 Malignancy.
 Recurrent Septicemia or Meningitis.

48. DIAGNOSTIC EVALUATION
 For children 18 months of age and older, the
HIV enzyme linked immunosorbent assay
(ELISA) and Western blot immunoassay are
performed to determine HIV infection.
 In infants born to HIV-infected mothers, other
diagnostic tests are used, most commonly the
HIV polymerase chain reaction for detection of
proviral DNA. With this technique, almost all
infected infants can be diagnosed between 1 to
6 months of age

49. MANAGMENT
 The goals of therapy for HIV infection include slowing
the growth of the virus, preventing and treating
opportunistic infections, and providing nutritional
support and symptomatic treatment.
 Antiretroviral drugs work at various stages of the HIV
life cycle to prevent reproduction of functional new
virus particles. Antiretroviral therapy regimens are
continually evolving.

50.  Although antiretroviral drugs are not a cure, they can
delay progression of the disease. Classes of
antiretroviral agents include nucleoside reverse
transcriptase inhibitors (e.g., zidovudine, didanosine,
stavudine, lamivudine, abacavir); nonnucleoside
reverse transcriptase inhibitors (e.g., nevirapine,
delavirdine, efavirenz); and protease inhibitors (e.g.,
indinavir, saquinavir, ritonavir, nelfinavir, amprenavir,
lopinavir, ritonavir).
 Combinations of antiretroviral drugs are used to stall
the emergence of drug resistance, which has been
observed historically in some children who received a
single drug

51. IMMUNIZATION
 HIV-exposed children should be immunized
according to the routine national immunization
schedule with the following notes:
 BCG should not be given in symptomatic HIV-
infected children.
 HiB vaccine should be given to all who are
confirmed HIV-infected
 Additional vaccines such as Pneumcoccal,
Varicella, Hepatitis A, Influenza Virus etc. may
be given as necessary.
 Vitamin A supplementation should be as per the
UIP schedule.

52. NURSING CARE MANAGEMENT
 Education concerning the transmission and
control of infectious diseases, including HIV
infection, is essential for children with HIV
infection and anyone involved in their care.
 The basic tenets of standard precautions should
be presented in an age appropriate manner, with
careful consideration of the educational level of
the individual Safety issues, including
appropriate storage of special medications and
equipment (e.g., needles and syringes) are
emphasized.

53.  Unfortunately, relatives, friends, and others in the general
public may be fearful of contracting HIV infection, and
criticism and ostracism of the child and family may occur.
In an effort to protect the child and deal with the
community’s fear, the family may limit the child’s activities
outside the home.
 Although certain precautions are justified in limiting
exposure to sources of infections, they must be tempered
with concern for the child’s normal developmental needs.
 Both the family and the community need ongoing
education about HIV to dispel many of the myths that have
been perpetuated by uninformed persons.

54.  Prevention is a key component of HIV
education. Educating adolescents about
HIV is essential in preventing HIV
infection in this age-group.
 Education should include information on
the routes of transmission, the hazards of
IV and other recreational drug use, and the
value of sexual abstinence and safe sex
practices