International perspective on looked after children
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 >37.9C 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
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