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Some Infections in Newborns

By Robert L. Stavis, PhD, MD, Clinical Director, Neonatal ICUs;Associate Professor, Department of Pediatrics, Main Line Health, Bryn Mawr, PA; Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children;Thomas Jefferson University Hospital

Some infections that can affect people of all ages cause particular problems when they occur in a fetus or newborn. (See also Zika Virus Infection.)

Candidiasis

Candidiasis is infection by Candida, a type of yeast or fungus.

Transmission

Infection by the fungus Candida can occur during or after delivery.

Symptoms

White spots or patches caused by Candida develop in the mouth (thrush). Thrush sometimes causes pain and might make it difficult for the newborn to feed.

Sometimes, newborns develop a diaper rash caused by Candida, which may be painful.

Rarely, newborns develop Candida infections in their blood, spinal fluid, or organs. These infections occur especially in premature newborns or very sick newborns in the hospital.

Treatment and prevention

Mouth or diaper area: Drugs that are applied directly to these areas (called topical drugs) are given when needed.

Blood infections: Infants are hospitalized for intensive treatment.

Conjunctivitis

Conjunctivitis is inflammation of the conjunctiva, the membrane that lines the eyelid and covers the white of the eye. Conjunctivitis in newborns can be caused by an infection or by a reaction to drugs put into their eyes.

Transmission

The bacteria Chlamydia or Neisseria gonorrhoeae, if present in the vagina, infect the fetus during delivery.

Symptoms

Chlamydia: Conjunctivitis usually begins 5 to 14 days after delivery but sometimes 6 weeks after.

Newborns have swollen eyelids and a watery discharge from the eyes that contains increasing amounts of pus.

Neisseria gonorrhoeae: Conjunctivitis usually begins 2 to 5 days after delivery.

Newborns have severe inflammation of the eyelids and discharge of pus from the eyes.

Without treatment, blindness may occur.

Treatment and prevention

Chlamydia: Erythromycin ointment is used for prevention and by mouth for treatment.

Neisseria gonorrhoeae: Erythromycin ointment is used for prevention, and the antibiotic ceftriaxone is given by vein for treatment.

Cytomegalovirus (CMV)

Cytomegalovirus is a common virus that usually causes few or no problems but can cause serious illness in infants who are infected before birth.

Transmission

The virus is thought to cross the placenta from the mother during pregnancy or during delivery.

After birth, newborns may become infected if breast milk contains the virus or if they are given a contaminated blood transfusion.

Symptoms

Most newborns who have CMV do not have symptoms, but about 10% have problems at birth that may include prematurity, a low birth weight, a small head, growth delay, jaundice, bruises, inflammation of the lungs or eyes, an enlarged liver and spleen, anemia, a low platelet count, and a high or low number of white blood cells.

CMV may cause death, and the outcome for survivors is highly variable. Hearing loss develops in about 10% of children as they grow older and may occur up to 6 years of age. Neurodevelopmental delays and intellectual disability are frequent long-term problems.

Treatment

Treatment of cytomegalovirus infection involves the use of antiviral drugs such as ganciclovir or valganciclovir. However, these drugs can be toxic to the newborn because they may lower the white blood cell count and possibly damage the liver and kidneys. Because of these complications, these drugs are not recommended for infants who have no signs of problems caused by CMV and who pass the newborn hearing test.

Doctors are not sure whether drug treatment decreases the risk of further hearing loss in infants who have no symptoms but who fail the newborn hearing test.

Research is showing that treatment of symptomatic infants improves outcomes in terms of hearing loss and neurodevelopment.

Periodic hearing evaluations are recommended for CMV-infected children in infancy and early childhood.

Hepatitis B virus (HBV)

Of the 5 types of hepatitis virus, hepatitis B is the one of concern in newborns. This infection rarely causes severe illness in newborns but it is highly likely to progress to a chronic infection. About 90% of newborns with HBV develop chronic infection, compared to a 5% rate of chronic infection in adults. Chronic hepatitis B infection in newborns progresses to liver cirrhosis and/or liver cancer in about 25% of cases, so it is very important to prevent hepatitis B infection in newborns.

Transmission

Newborns most commonly acquire HBV from their infected mother during delivery. However, newborns may become infected from other sources as well. In some cases, the source of the infection is never identified.

Symptoms

HBV rarely causes symptoms in newborns. However, chronic liver disease (such as chronic hepatitis or cirrhosis) may eventually develop but usually does not cause symptoms until young adulthood.

Treatment and prevention

All newborns are given hepatitis B vaccine at birth. The vaccine is highly effective in reducing the chances of a hepatitis B infection. If the mother's blood tests indicate the potential to infect the baby at birth, newborns are also given hepatitis B immune globulin, a preparation of antibodies against hepatitis B. The vaccine and the immune globulin are given within 12 hours of birth.

Herpes simplex virus

The herpes simplex virus usually causes only annoying, recurring sores in healthy adults but can cause life-threatening infection in newborns.

Transmission

Usually, the virus (herpes simplex) is transmitted during delivery through the mother’s infected genital tract, but, in a small number of cases, the infection occurs before delivery or after the baby is born. Mothers frequently do not know they have herpes.

Symptoms

Usually, a rash of small fluid-filled blisters appears between the first and third weeks of life.

Some newborns do not have a rash but are severely ill with a widespread infection that affects many organs, such as the eyes, lungs, liver, brain, and skin.

Other symptoms include sluggishness, diminished muscle tone, respiratory distress, pauses in breathing (apnea), and seizures.

Treatment and prevention

Mothers who have herpes have a low risk of transmitting herpes to their newborn. This risk is further decreased if mothers are given the antiviral drugs acyclovir or valacyclovir beginning at 36 weeks gestation. If mothers have an active herpes infection at the time of delivery, a cesarean delivery (C-section) may be done to decrease the risk of infection of the newborn. Newborns at high risk of herpes infection are tested for herpes when they are 24 to 48 hours old and may be treated with antiviral drugs depending on the results of the tests. Newborns who have a rash or who have symptoms that suggest a herpes infection are typically treated with acyclovir.

Eye infections are treated with trifluridine, iododeoxyuridine, or vidarabine drops as well.

Human immunodeficiency virus (HIV)

HIV infection is a viral infection that progressively destroys certain white blood cells and causes acquired immunodeficiency syndrome (AIDS).

Transmission

The virus is transmitted from mother to fetus during pregnancy or to the newborn during labor and delivery or after birth through breastfeeding. With appropriate management of the delivery and treatment of the newborn, the risk of transmission can be reduced to 1% or less.

Symptoms

Symptoms range from none during the first few months of life to very severe (AIDS) if not treated.

When untreated, the lymph nodes may swell.

Infection can affect many organs such as the liver, spleen, heart, kidneys, brain, and spinal cord.

Symptoms can also include developmental delays, pneumonia, recurring diarrhea, poor weight gain, invasive bacterial infections, and viral and fungal infections.

Treatment and prevention

Antiretroviral drugs are used beginning within a few hours after delivery. Newborns at risk of HIV infection should be managed by a pediatric HIV specialist at a children's hospital.

Human papillomavirus (HPV)

There are over 100 types of HPV, some of which cause common skin warts and some of which cause genital warts. Some of the types that cause genital warts can cause cancer.

Transmission

Usually, newborns become infected during delivery.

Symptoms

Warts caused by HPV may grow in the windpipe and can alter the newborn’s cry and sometimes cause difficulty breathing or even block the airways.

The lungs may become infected.

Treatment and prevention

Warts are removed surgically.

The drug interferon can reduce the risk of recurring infections. However, the most effective approach is to prevent infection by giving the HPV vaccine, which is given to boys and girls 11 to 12 years of age. Adolescents and young adults who were never vaccinated or who did not receive all the doses can be vaccinated up to age 26.

Rubella

Rubella is a typically mild childhood viral infection that may, however, have devastating consequences for infants infected before birth.

Transmission

The virus may cross the placenta during pregnancy. Infection of pregnant women is now rare because vaccination is routine.

Risk of severe abnormalities is higher if the fetus is infected early in pregnancy.

Symptoms

Effects on the newborn range from death before birth to birth defects or to hearing loss without other symptoms.

Newborns may have a low birth weight, brain inflammation, cataracts, damage to the retina, heart defects, an enlarged liver and spleen, bruising, bluish red spots, enlarged lymph nodes, and pneumonia.

Treatment and prevention

No specific treatment is available.

Vaccinating all girls in infancy and women of childbearing age before pregnancy can prevent infection in the fetus.

If an expectant mother who has not been immunized comes into close contact with an infected person early in pregnancy, she may be given an injection of immune globulin.

Syphilis

Syphilis is a sexually transmitted disease caused by the bacteria Treponema pallidum. It causes a variety of problems in adults and has serious consequences for infants infected before birth.

Transmission

Treponema pallidum can cross the placenta during pregnancy if the mother acquires syphilis during pregnancy or if she has been inadequately treated for syphilis in the past.

Symptoms

Stillbirth or premature birth may occur.

Newborns may have no symptoms.

During the first 3 months of life, large blisters or a flat copper-colored rash may develop on palms and soles. Raised bumps may develop around the nose and mouth and in the diaper area. Newborns may not grow well. They may have cracks around the mouth, or mucus, pus, or blood may run from the nose.

Usually, the lymph nodes, liver, and spleen are enlarged.

Rarely, inflammation of the eye or brain, seizures, meningitis, or intellectual disability occurs, but these symptoms may not appear until the child is age 2 years or older.

Treatment and prevention

Before birth, the mother is treated with penicillin.

After birth, the mother, if still infected, and newborn are treated with penicillin.

Corticosteroid and atropine drops are given for eye inflammation.

Toxoplasmosis

Toxoplasmosis is an infection with the parasite Toxoplasma gondii. It usually does not cause problems in healthy adults, but can cause serious illness in newborns and people with a weakened immune system. If a woman becomes infected with the parasite during pregnancy, it may cross the placenta and infect the fetus.

Transmission

Cats are the main reservoir of Toxoplasma gondii, and cat feces contaminate soil and water. Humans and animals become infected by ingesting material contaminated with cat feces or undercooked meat from infected animals. Touching contaminated material, particularly cat feces or soil contaminated by cat feces, can allow the parasite to be transferred to food. Thus, common sources of infection include eating raw vegetables or undercooked meat (particularly beef, lamb, pork, or game meats) or meat products (such as raw sausages, salami, and cured meats).

Infection of the fetus is more severe if the infection occurs early in pregnancy.

Symptoms

Pregnant women who become infected with Toxoplasma gondii may have a flu-like illness with fever, headache, fatigue, and swelling of the lymph nodes, but, in most cases, there are no noticeable symptoms.

Most infected fetuses have no symptoms at the time of birth, but about 10% have signs of infection that include low birthweight, prematurity, a rash, a small head (microcephaly) or a very large head with fluid (hydrocephalus), brain inflammation, anemia, jaundice, an enlarged liver and spleen, and inflammation of the heart, lungs, and eyes.

Unfortunately, even newborns without signs of infection at birth may still have long-term complications including eye problems (which may progress to blindness), hearing loss, poor overall growth related to hormonal disturbances, reduced growth of the head, intellectual disability, and seizures.

Diagnosis

Toxoplasma gondii antibody levels in blood early in pregnancy can determine whether a women is susceptible to toxoplasmosis. Women who have had such an infection in the past are not at risk of another infection. Repeat blood tests later in pregnancy can be used to determine whether the mother has become infected, and additional tests for Toxoplasma gondii DNA in amniotic fluid (obtained by amniocentesis) can determine whether there is infection in the fetus.

Newborns may be suspected of having toxoplasmosis based on the mother's history and the examination of the baby. Infection is confirmed by testing for antibodies in the newborn's blood and finding Toxoplasma gondii DNA in the newborn's blood and/or body fluids.

Treatment and prevention

Pregnant women should avoid handling cat litter and should not eat raw vegetables or undercooked meat or meat products. The processes used to cure meat do not kill the Toxoplasma gondii parasite.

If a mother becomes infected early in pregnancy and the fetus is not infected, she may be given spiramycin to reduce the risk of transmitting the infection to the fetus. Infections in the fetus or newborn (with or without symptoms) are treated with pyrimethamine and sulfadiazine.

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