Neonatal Infections

NEONATAL INFECTIONS Infections in the newborn infant can be divided into: ❖ Minor acute infections ❖ Major acute infections ❖ Chronic intra-uterine infections where the fetus has been infected across the placenta.

❖ MINOR INFECTIONS The common minor acute infections in the newborn infant are: 1. Conjunctivitis 2. Infection of the umbilical cord(Omphalitis) 3. Tetanus 4. Skin infection 5. Oral thrush CONJUNCTIVITIS Conjunctivitis presents in one or both eyes with: → An exudate (discharge) from the eyes → Redness of the conjunctivae → Edema of the eyelids Causes In the newborn infant conjunctivitis is usually caused by: 1. Chlamydia trachomatis: It is sexually transmitted and causes infection of the cervix. During vaginal delivery the eyes of the infant may be colonized with Chlamydia as it passes through the cervix. Chlamydial conjunctivitis, usually mild, develops in one or both eyes a few days after delivery. The infection lasts a few weeks and then resolves spontaneously if not treated. Chlamydia is the commonest cause of conjunctivitis in the newborn infant. 2. Gonococcus (Neisseria gonorrhoeae): It causes mild, moderate or severe conjunctivitis. Most cases of severe infection are caused by the Gonococcus and can result in blindness. Like Chlamydia, the Gonococcus is sexually transmitted and causes a cervicitis. 3. Staphylococcus: acquired in the nursery after delivery, can also cause conjunctivitis. Degree of conjunctivitis It can be divided into mild, moderate and severe: ✓ Mild conjunctivitis consists of a slight muco-purulent discharge causing a dry exudate on the eyelashes. The eyelids tend to stick together. ✓ Moderate conjunctivitis presents with redness of the conjunctivae with an obvious purulent discharge. Pus is present in the eye when the lids are separated.

✓ Severe conjunctivitis has a marked purulent discharge with edema of the eyelids. Pus spurts from the eye and runs down the cheeks when the eyelids are opened. In the most severe cases, it is not possible to separate the eyelids due to the edema. Diagnostic evaluation 1. Gram’s stain: Gonococci and Staphylococci can be seen on a Gram stain of pus wiped from the eye. 2. Immunofluorescent test: Chlamydial infection can be confirmed by pus swabbed from the eye. Management ✓ The choice of treatment depends on the severity of the conjunctivitis and the causative organism. ✓ Mild conjunctivitis is treated by cleaning the eye with saline if the lashes become sticky. If the infection does not recover in a few days, tetracycline or chloromycetin ointment should be used 6hrly for 5 days. Tetracycline, chloromycetin and erythromycin ointment will kill Gonococcus but only erythromycin and tetracycline will treat Chlamydia. ✓ Moderate conjunctivitis should be treated by cleaning the eye and then instilling tetracycline or chloromycetin ointment 3hrly or more frequently if needed, for 5 days. ✓ Severe conjunctivitis is a medical emergency as it can lead to blindness if not promptly and efficiently treated. The infection is usually due to the Gonococcus and treatment consists of irrigating the eye and giving intramuscular ceftriaxone. ✓ The pus must be washed out of the eye with saline or warm water. This must be started immediately and repeated frequently enough to keep the eye clear of pus ✓ Only when this treatment has been started should the infant be referred urgently to hospital for further management. ✓ If possible a pus swab should be taken before treatment is started to confirm the diagnosis of Gonococcal conjunctivitis. When positive, the mother and her partner must be checked for sexually transmitted diseases such as syphilis and treated.

INFECTION OF THE UMBILICAL CORD

Definition Infection of the umbilical cord (omphalitis) is characterized by:

1. An offensive (smelly) discharge over the surface of the cord. 2. Failure of the cord to become dehydrated (i.e. the cord remains wet and soft). 3. Erythema of the skin around the base of the cord, where the cord meets the skin. Causes Infection of the umbilical cord usually is caused by: • Escherichia coli • Staphylococcus • Clostridium tetani Pathophysiology ➢ In uncomplicated cord infection, there is no edema of the skin around the base of the cord. ➢ The infection may spread to the anterior abdominal wall (cellulitis) from where it may cause a peritonitis or septicemia, manifested by: ▪ Redness and edema of the skin around the base of the cord. ▪ Abdominal distension often with decreased bowel sounds and vomiting (peritonitis). ▪ The infant is generally unwell with the features of septicemia. ➢ Infection of the umbilical cord may also cause tetanus in the newborn infant if the mother has not been fully immunized. ➢ The infant may die if not treated immediately. Management → When infection is localized to the umbilical cord (with no signs of cellulitis, peritonitis, septicemia or tetanus) then treatment consists of: • Cleaning the cord frequently with surgical spirit swab every 3 hours to clear the infection and hasten dehydration. • Special attention must be paid to the folds around the base of the cord which often remain moist. • Within 24 hours the infection should have resolved. → Cellulitis of the abdominal wall around the base of the cord (redness and edema of the skin), peritonitis or septicemia must be treated with parenteral antibiotics. Prevention ✓ Prevention consists of routine applications of alcohol (surgical spirits) to the cord every 6 hours until it is dehydrated. ✓ Antibiotic powder is not used. ✓ Never cover the cord as this keeps it moist.

TETANUS

Tetanus in the newborn infant (tetanus neonatorum) is caused by the bacterium, Clostridium tetani, which infects dead tissues such as the umbilical cord. It produces a powerful toxin that affects the nervous system. Clinical features • Increased muscle tone, especially of the jaw muscles and abdomen. • Generalized muscle spasms and convulsions, often precipitated by stimulation such as handling or loud noises. • Respiratory failure and death in untreated infants, due to spasm of the respiratory muscles. Management The emergency treatment of tetanus consists of: ✓ Keeping the airway clear and giving oxygen. ✓ Not stimulating the infant. ✓ Stopping spasms with 1 mg diazepam (Valium) intravenously or rectally, repeatedly until the spasms stop. ✓ Transferring the infant urgently to the nearest level 2 or 3 hospital. ✓ Hospital management of tetanus includes penicillin, human anti-tetanus immunoglobulin, tracheotomy, paralysis and ventilation. Prevention Tetanus can be prevented by: ✓ Good cord care ✓ Immunizing all pregnant women with tetanus toxoid.

SKIN INFECTION The 2 commonest forms of skin infection in the newborn infant are: 1. Bullous impetigo caused by the Staphylococcus which presents as pus-filled blisters usually seen around the umbilicus or in the nappy area. 2. A rash caused by the fungus Candida albicans. This almost always occurs in the nappy area and presents as a red, slightly raised, ‘velvety’ rash which is most marked in the skin creases. Rashes that frequently mimic skin infections are:  Erythema toxicum: usually appears on day 2 or 3 after delivery as red blotches with small yellow pustules in the centre. The rash is marked on the face and chest and

disappears after about a week. It may look like a Staphylococcal infection. No treatment is needed.  Nappy rash is due to irritation of the skin by stool and urine and, unlike a Candida rash, usually spares the creases.  Sweat rash may present as small, clear blisters on the forehead or a fine red rash on the neck and trunk. Both are due to excessive sweating when an infant is kept too warm. Blisters are caused by the droplets of sweat that are not able to get through the upper layer of the skin while the red rash is due to the irritant effect of the salty sweat on the skin. Treat both rashes by washing the infant, to remove the sweat, and prevent overheating.  Pustular melanosis is usually present at birth as small blisters that soon burst to leave a small, peeling, pigmented area of skin. Sometimes the blisters have already burst before delivery. The infants are well and the rash slowly disappears without treatment. Management Bullous impetigo is treated by: ✓ Washing the infant in chlorhexidine twice a day for 5 days. ✓ Do not cover the infected area with a nappy. ✓ Treat any cord infection. ✓ Wash hands well after handling the infant to prevent the spread of infection to other infants. ✓ If the infant remains generally well, local or systemic antibiotics are not needed. However, if the infant shows any signs of septicemia, then urgent treatment with parenteral antibiotics is indicated. Candida rash should be treated with: ✓ Topical mycostatin (Nystatin) cream and the area should not be covered. ✓ Allow the infant to sleep prone on a nappy to keep the infected area of skin exposed to the air. ✓ Exposing to little sunshine is helpful but do not let the infant get too hot or sunburned. ✓ If the rash does not improve in 48 hours, give oral mycostatin drops also.

ORAL THRUSH Oral thrush (candidiasis or moniliasis) is caused by the fungus Candida albicans, which may also cause skin infections. Oral thrush presents as patches of white coating on the tongue and mucous membrane of the mouth. Types The degree of infection varies from mild to severe: 1. With mild infection there are only scattered areas of thrush with the remainder of the mucous membrane appearing healthy. The infant also sucks well. Mild thrush is very common, especially in breastfed infants. 2. With severe infection there are extensive areas of thrush. The tongue and mucous membrane are red and the infant feeds poorly due to a painful mouth. The infant appears miserable and may lose weight or even become dehydrated. Repeated, severe oral thrush in a young infant is suggestive of AIDS. Management The treatment of oral thrush depends on the degree of infection: ➢ Mild thrush: The infection usually clears spontaneously. ➢ Severe thrush requires treatment as it interferes with feeding. The treatment of choice is 1 ml mycostatin drops (Nystatin) into the mouth after each feed. Mycostatin ointment can also be used and should be wiped onto the oral mucous membrane with a swab or clean finger. Treatment should be continued for a week. Gentian violet can be used if mycostatin is not available. ➢ In a breastfed infant the source usually is Candida colonization of the mother’s nipples. Mycostatin ointment should be smeared on the nipple and areolae after each feed. ➢ In bottle-fed infants, the bottles and teats must be boiled after the feed. Disinfectant solutions are useful to prevent bacterial contamination of bottles but may not kill Candida. Rather use a cup than a bottle for feeding as it is easier to clean. ➢ If the mother has a monilial vaginal discharge, this should be treated with mycostatin vaginal cream to reduce skin colonization with Candida.

MAJOR INFECTIONS The most frequent major acute infections in newborn infants are: i. Septicemia ii. Pneumonia iii. Meningitis iv. Necrotizing enterocolitis v. Chorioamnionitis SEPTICEMIA Septicemia is infection of the blood stream with bacteria which may have colonized the infant before, during or after birth. Septicemia is often a complication of a local infection, e.g. pneumonia, umbilical cord or skin infection. Causes Septicemia is caused by either ➢ Gram-positive bacteria (Eg. Staphylococcus and Group B Streptococcus) or ➢ Gram-negative bacteria (e.g. Escherichia coli, Klebsiella and Pseudomonas). Clinical features The common clinical signs are ➢ Lethargy: It is the earliest sign of septicemia. ➢ Poor feeding or poor sucking. ➢ Abdominal distension ➢ Vomiting and decreased bowel sounds (ileus) ➢ Pallor ➢ Jaundice: due to raised concentration of both unconjugated and conjugated bilirubin in the blood. ➢ Purpura (petechiae): due to too low platelet level. There can also be bleeding from puncture sites (due to DIC). This indicates that the infant is severely ill. ➢ Recurrent apnea. ➢ Hypothermia ➢ Edema or sclerema (a woody feel to the skin). ➢ Infant may also have signs of a local infection, e.g. umbilical cord infection, pneumonia or meningitis. Diagnostic evaluation 1. TLC: A total leucocyte count of less than 5000 or an immature to total neutrophil ratio of more than 20%is highly suggestive of septicemia. 2. Blood culture: The diagnosis of septicemia is confirmed by blood culture. 3. CRP (C-reactive protein):positive.

Management Management of septicemia consists of: → General supportive care of a sick infant. Transfer to a level 3 unit NICU is needed. → Antibiotics: When culture and sensitivity results are available, the most appropriate antibiotic is chosen. The antibiotics most commonly used are either: o Benzyl penicillin: 50,000units/kg/dose + gentamicin 5mg/kg/dose or cloxacillin 50mg/kg/dose + amikacin 5 mg/kg/dose. Gentamicin and amikacin are given intravenously daily These are usually the first drug combinations of choice. o Cefotaxime 50 mg/kg/dose or ceftriaxone 50 mg/kg/dose, given once a day intravenously or intramuscularly. They are usually the second choice of antibiotic. o Penicillin, cloxacillin and cefotaxime are given in divided doses either intravenously or intramuscularly every 12 hours for infants under one week and every 8 hours after one week of age. Antibiotics should be continued for 10 days. PNEUMONIA Pneumonia in the newborn infant is acquired as the result of colonization of the upper airways before, during or after delivery: ✓ Before delivery, the fetus may be infected by inhaling liquor that is colonized by bacteria due to chorioamnionitis. ✓ The lungs may be infected by organisms that colonize the infant’s upper airways during delivery. ✓ Most pneumonia in the nursery is due to bacteria that are spread to the infant on the hands of the mother and staff. Causes → Anaerobic bacteria, E. coli and the group B Streptococcus are the commonest organisms infecting the fetus before delivery → The group B Streptococcus and Chlamydia colonize the infant during delivery. → In the nursery, Staphylococcus aureus and bowel organisms are responsible. Diagnostic evaluation ▪ The diagnosis is made by observing typical clinical signs. The infant develops signs of respiratory distress (tachypnoea, cyanosis, recession and grunting). ▪ A chest X-ray shows typical features of pneumonia with areas of consolidation. ▪ There are usually also signs of septicemia. Management ✓ General supportive care is important. Transfer to a level 3 NICU is needed. ✓ Oxygen therapy. ✓ Administer intravenous or intramuscular antibiotics. Usually cefotaxime or ceftriaxone, or penicillin and gentamicin are given.

BACTERIAL MENINGITIS Bacterial meningitis in the newborn infant is caused by Gram-negative bacilli (e.g. E. coli or Klebsiella) or the Group B Streptococcus. Clinical features The newborn infant does not present with the signs of neck stiffness, full fontanelle, photophobia, vomiting and headache - common in older children with meningitis. The infant is usually generally ill and may have signs of septicemia. In addition the infant may: 1. Be irritable with a high-pitched cry. 2. Have abnormal movements or convulsions. 3. Tend to stare and keep the fists clenched. 4. Have recurrent apnea or cyanotic spells. Diagnosis If meningitis is suspected, ▪ lumbar puncture must be done to confirm or exclude the diagnosis. ▪ cerebrospinal fluid (CSF) must be examined for chemistry and cells, and it must be cultured for bacteria. Management ✓ Good supportive care and transfer to a level 3 unit. ✓ The choice of antibiotics must be based on type of bacteria and also entry into CSF ✓ The drugs used are either cefotaxime 50 mg/kg/dose IV or IM every 12 hours or ceftriaxone 100 mg/kg/dose as a daily dose. ✓ The antibiotic should be given for 14 days. ✓ To prevent or treat convulsions give phenobarbitone 20 mg/kg intravenously or intramuscularly, followed with 5 mg/kg orally daily until the infant is clinically well. Complication Deafness, convulsions and cerebral palsy are common complications. Prognosis The condition is fatal despite treatment and half the infants have permanent brain damage.

NECROTISING ENTEROCOLITIS Necrotizing enterocolitis (NEC) is necrosis or death of part or all of the small and large intestine. It is usually seen in 2 groups of newborn infants: → Term infants who had severe intrapartum hypoxia which has caused ischemia and damage to the gut. → Preterm infants who have been infected in the nursery. Clinical features Ischemia or infection is the main cause of NEC, and the infant presents with:  Signs of septicemia and shock.  Abdominal distension and ileus.  The abdomen is tender when palpated.  Vomiting which is often bile stained.  Blood in stool: Detected when the stool is tested for occult blood.  An X-ray of the abdomen shows air in the bowel wall. This finding will confirm the clinical diagnosis of necrotizing enterocolitis. Management Infants with NEC must be referred to a level 2 or 3 hospital. The following management is needed: ✓ A nasogastric tube must be passed to relieve the bowel distension. ✓ Keep nil per mouth and start an intravenous infusion. Stabilized human serum or fresh frozen plasma may be needed to treat shock. ✓ Give general supportive care. ✓ Give penicillin, gentamicin and metronidazole intravenously. ✓ Parenteral nutrition is needed for1-2 weeks while the damaged gut recovers. ✓ Bowel resection may be needed for extensive necrosis or perforation. Mortality following surgery is high. Metronidazole (Flagyl) 25 mg/kg/day is given orally or intravenously 8 hourly. Complications Complications that can lead to death: ➢ Bowel perforation ➢ Massive hemorrhage from the gut ➢ Septicemia ➢ Malabsorption and multiple stricture

CHORIOAMNIONITIS Chorioamnionitis is an acute inflammation of the chorion, amnion and placenta. Etiology: Bacteria, such as E. coli and the group B Streptococcus, infect the fetus causing pneumonia and septicemia. Pathophysiology: Normally the intra-uterine cavity is sterile during pregnancy. However, bacteria from the vagina sometime spread through the cervical canal and infect the chorion, amnion and placenta resulting in chorioamnionitis The infection may then spread to the amniotic fluid (amniotic fluid infection syndrome) and colonize the fetus. Diagnostic evaluation ➢ Usually asymptomatic in the mother and, therefore not diagnosed before delivery. Only if the infection is severe, the mother develops fever, abdominal tenderness and an offensive vaginal discharge. ➢ When the infection has spread to the amniotic fluid, the infant smells offensive at delivery. Infants will be clinically well but will develop signs of infection soon after delivery. ➢ Gastric aspirate examination: It is diagnosed at birth by examining a sample of gastric aspirate, collected within 30 min of delivery. The presence of pus cells indicates chorioamnionitis. Management Usually the infant appears well and does not need to be treated. However, parenteral antibiotics should be given if: • The infant is clinically ill with signs of pneumonia or septicemia. • The infant weighs less than 1500 g. Infection with group B Streptococcus should be treated with parenteral ampicillin for 48 hours if the infant appears well, and for a full 5-day course if clinically ill.

CHRONICINTRA-UTERINE INFECTION A chronic intra-uterine infection is an infection of the fetus that is present for weeks or months before delivery and is caused by organisms that cross the placenta from the mother to the fetus during pregnancy. The infection may result in either: • Miscarriage • Stillbirth • An ill infant that may die after delivery. • Ill infants that survive may have permanent damage. Causes The important causes of chronic intra-uterine infection are: 1. Syphilis 2. Rubella (German measles): it causes congenital malformations if the infection takes place during the first 16 weeks of pregnancy (e.g. heart defects, deafness and blindness). Thereafter it causes fetal infection with damage to many organs. As there is no treatment for congenital rubella, it must be prevented by immunization. 3. Cytomegalovirus (CMV) infection is usually asymptomatic. However, it may cause severe damage to the fetal brain resulting in mental retardation and cerebral palsy. Congenital CMV infection is more common if the mother has AIDS. 4. Toxoplasmosis, which is rare and causes the same problems as CMV infection. SYPHILIS

Congenital syphilis is a chronic intra-uterine infection caused by Treponema pallidum. Syphilis causes infection and damage to many organs but, unlike rubella infection, does not cause congenital malformations. Stillbirth and neonatal death are common. Clinical features  Low birth weight  Blisters and peeling of the hands and feet  Enlarged liver and spleen  Pallor due to anemia  Petechiae due to too few platelets  Jaundice due to hepatitis  Respiratory distress due to pneumonia  A heavy, pale placenta weighing more than a fifth of the weight of the infant  Osteitis of the bones around the knee

Diagnostic evaluation: An X-ray of the legs showing osteitis of the bones around the knee, useful diagnostic sign in congenital syphilis. A positive VDRL (or RPR or syphilis rapid test) plus TPHA (or FTA) in the mother or infant confirms that the mother has syphilis. Tests for specific IgM antibodies: If positive in the infant then infection of the infant is confirmed. Management ✓ Maternal treatment for syphilis consists of 2.4 million units of benzathine penicillin given IM weekly for 3 weeks. ✓ If the infant has clinical signs of syphilis give 50,000 units/kg of procaine penicillin daily by IM inj for 10 days. Benzathine penicillin is not adequate to treat infants with clinical signs of congenital syphilis. ✓ Good general supportive care in a level 2 hospital.

NEONATAL SEPSIS Introduction Newborn infants are at much higher risk for developing sepsis than children and adults because of their immature immune system. Especially premature infants, where 1 out of every 250 will be diagnosed with sepsis. Sepsis is one of the major leading causes of death in the first few months of a newborn’s life. Risk factors Source Maternal (Intrauterine)

Intrapartum

Neonatal(Postnatal)

Risk Factors Poor prenatal care Poor nutrition Recurrent abortions Substance abuse Premature rupture of membranes Maternal fever Prolonged labor Maternal UTI Male Birth asphyxia Low birth weight

Causes The causative organisms are: • Cytomegalovirus (CMV) • Group B Streptococcus (GBS), • Nosocomial infection

Types Neonatal bacterial infections are classified into two different categories depending on the time of their presentation. 1. Congenital infections or early onset infection: occurs when an infant presents with signs and symptoms of the illness within the first week of life. 2. Acquired or late onset infection: occur after the infant is greater than a week old. Characteristics of Congenital vs. Acquired Sepsis Characteristics Congenital Acquired Time of Onset Birth - 4 Days > 7 Days OB Complications Frequent Unusual Source Mother’s Genital Tract Postnatal Environment Clinical Presentation Multisystem Focal Mortality Rate(%) 5-50 2-6 Usual Organisms Group B Strep Staph Epi E. Coli Candida

Clinical features The clinical signs of sepsis are: − Pallor − Poor temperature control − Grunting − Flaring − Apnea & Bradycardia − Lethargy − Hypoglycemia − Poor feeding − Abdominal distention Diagnostic evaluation 1. Cultures: Positive CSF, urine, and bacterial blood cultures are lab results that confirm the infant has an infection and which pathogen is the causative organism. 2. Other abnormal results of sepsis are hypoglycemia, hyperglycemia, metabolic acidosis, thrombocytopenia, or hyperbilirubinemia. 3. CBC: an elevated or decreased white blood count (WBC), a low platelet count indicates sepsis 4. I:T ratio: it is ratio of immature to total white blood cells. When the I:T ratio is greater than 0.2, this indicates that there is a “left shift”, it means there are more immature neutrophils than mature neutrophils circulating around in the bloodstream. High ratio indicates sepsis. I:T Ratio Calculation I:T ratio =Immature cells Total (mature + immature) 5. Chest x-ray TYPES OF PATHOGENS Group B Strep (GBS): GBS infections can either be an early or late onset infection. In early onset infection, initially the symptoms are subtle and nonspecific like pallor, tachypnoea, tachycardia, or decreased activity. Later it would result in temperature instability, respiratory distress with grunting, nasal flaring, retractions, and apnea. The infant can deteriorate to septic shock and death. Late onset infection is less severe than early onset form but still carries a mortality rate of 25%. In this, infants often present with meningitis as their main symptom. In infants who acquire GBS infection, treatment includes antibiotics, such as ampicillin and gentamicin, fluid and volume support, and respiratory (ventilator)support. Staphylococcus: Staphylococcal pathogens can cause mild to severe infections like osteomyelitis, sepsis. The major source of this infection is due to improper hand washing by the hospital staff, infections arising from umbilical catheters, endotracheal tubes, and central lines. It is most often treated with vancomycin Escherichia Coli: It is the most common cause of gram-negative neonatal infection. The pathogen can

cause severe infections that may lead to respiratory distress, cardiovascular collapse, meningitis, multiorgan failure, and even death. It is treated with gentamicin. Management Management consists of antibiotic treatment and circulatory, respiratory, nutritional, and developmental support. The treatment includes: ➢ Careful monitoring of the infant’s vital signs and regulation of the thermal environment. ➢ Supportive therapy for a septic infant starts with the administration of oxygen when respiratory distress or hypoxia becomes present. ➢ The infant may also need invasive respiratory support such as continuous positive airway pressure (CPAP) or to be placed on a ventilator if they are suffering from apneic episodes. ➢ Careful, ongoing monitoring and adjustment of the fluid and electrolyte balance, especially when the infants are NPO. ➢ Antibiotic therapy for 7-21 days if the cultures are positive, or discontinued in 3 days if cultures are negative. Nursing Considerations Nursing care for the infant with sepsis involves skilled observation and ongoing assessments. ➢ It involves constant assessment and documentation of changes in the infant’s vital signs, physical assessments, feeding tolerance, responsiveness, and general behavior. ➢ Nurses must be aware of the side effects of the specific antibiotics and the proper administration guidelines. ➢ Prolonged antibiotic therapy poses additional hazards for affected infants. Antibiotics predispose the infant to growth of resistant organisms and superinfections from fungal agents such as candida. The nurse must be alert for signs of such complications. ➢ Decreasing any additional physiologic and environmental stress. This includes providing an optimum thermoregulated environment and anticipating potential problems, such as dehydration or hypoxia.

HIVINFECTION AIDS (Acquired Immune Deficiency Syndrome) is a severe illness caused by the Human Immunodeficiency Virus (HIV). When a woman with HIV infection falls pregnant, or gets infected with HIV during pregnancy or while breastfeeding, the fetus or newborn infant also become infected. Clinical features Common clinical signs of HIV infection in pregnant women include: Weight loss and general lethargy

Chronic fever Generalized lymphadenopathy (enlarged lymph nodes) Persistent diarrhea Repeated acute bacterial infections (e.g. pneumonia), tuberculosis or unusual (opportunistic) infections Recurrent oral thrush Dementia (loss of memory and changes in behaviour) Diagnosis ✓ An infant with HIV infection usually appears normal and healthy at delivery. ✓ However, between 2mnths-2yrs after birth, most infants infected with HIV will present with failure to thrive and repeated infections. ✓ Most of the infants die before 3 years of age if they are not correctly managed with antiretroviral treatment. ✓ Infants exposed to HIV infection (born of mothers with HIV) will have a positive HIV screening test up to 18 months of age. Therefore a positive PCR (polymerase chain reaction) test at 6 weeks is used to identify infants infected with HIV. ✓ Fortunately most HIV-exposed infants are not HIV infected. Prevention of mother-to-child transmission of HIV The risk of mother-to-child transmission (MTCT) can be reduced with antiretroviral prophylaxis and formula feeding. Usually two antiretroviral drugs are used: ➢ AZT (zidovudine) to the mother daily from 28 weeks gestation and also during labor. ➢ AZT daily to the infants for the first week of life. ➢ A single dose of nevirapine to the mother when labor starts and a single dose to the infant after delivery. ➢ Antiretroviral treatment (HAART) from early pregnancy gives the fetus almost complete protection. Management of an HIV-exposed infant 1. Early identification of HIV-exposed infants by screening all women early in pregnancy. Antiretroviral prophylaxis must be given to such infants after delivery. 2. If the mother has not received antiretroviral prophylaxis, AZT should be given to the infant daily for a month in addition to the single dose of nevirapine after delivery. 3. The mother must decide, after counselling, whether to breastfeed or formula feed. 4. The PCR test should be used to identify HIV-infected infants. Infants who are HIV exposed but not infected can be followed at a well baby clinic. 5. HIV-infected infants must be started on co-trimoxazole prophylaxis and be referred to an HIV clinic for further management.

Feeding infants with HIV 1. Formula milk feeds: A cup rather than a bottle for feeding is advantageous due to increased risk for infections. 2. Exclusive breastfeeding: The benefits of exclusive breastfeeding for 6 months are greater than the risk of HIV infection. Therefore exclusive breastfeeding is recommended in HIV-positive women, especially in rural areas with inadequate health-care services. 3. Each mother should be individually counselled so that she can choose the most appropriate method of feeding her infant. Infection to the staff ✓ The maternal blood and vaginal secretions are infectious if the woman has HIV infection. ✓ Proper infectious precautions must be taken for vaginal examinations and deliveries. ✓ Gloves should be worn when handling both the infant and placenta at birth. ✓ The blood of an infant who has HIV infection, even if there are no clinical signs of illness, is infectious. Staff can, therefore, become infected with HIV if they prick themselves with a needle or lancet that has been used to obtain a blood sample from an infected infant. ✓ Special care is needed when blood is sampled from either an HIV-infected mother or infant. Immediately after the needle or lancet has been withdrawn from the skin, it must be placed in a sharps container. ✓ Never leave the needle or lancet lying next to the patient as the nurse or doctor may prick themselves when cleaning up after the procedure. ✓ Always have a sharps container at the bedside when collecting a blood sample. ✓ While the wearing of gloves for procedures is advised, this will not always protect the person from needle pricks. Conclusion HIV infection cannot be cured but this chronic illness can be successfully controlled for many years with antiretroviral treatment while many of the complicating infections can be treated. Every effort must be made to prevent the sexual spread of HIV. Education, safer sex practices and the use of condoms are important