INTRODUCTION

Infections are common in the new born period. The newborns poor resistance
results in septicemia from localized lesions. The viruses of herpes simplex or cytomegalic
inclusion disease, and toxoplasmosis which hardly affect the adult, can damage the new born
seriously. The delicate skin of the new born and the umbilicus serve as easy portals of entry
for the organisms, in addition to the respiratory tract and the oral route. Attendants and others
caring for the new born often harbour staphylococci in their nares or nails. Droplet infections
from attendants is another source. However in certain diseases like poliomyelitis and
diphtheria , the immunoglobulin IgG is passively transmitted from mother to baby affording
protection. However ,the IgM fraction is not transmitted from the mother to the fetus and
probably the reason why E-coli and other Gram negative organisms cause generalized and
over whelming infection.
INCIDENCE
The World Health Organization estimates that more than 4 million neonates die each year and
98% of these deaths occur in developing countries. Infections are among the main causes of
neonatal mortality. The neonatal health is intrinsically linked to the mother's health and the
care she receives before, during and immediately after delivery. If in resource-rich countries
improvements in perinatal conditions, prevention and management of fetal-neonatal infections
have reduced the burden of neonatal morbidity and mortality, in resource-limited areas they
have only just improved and many barriers remain still to be overcome. Prematurity is often
due to fetal infections and represents a significant risk factor for nosocomial infections.
PREDISPOSING FACTORS

low birth weight

Preterm babies are more susceptible to develop infection due to deficient humoral and cellular
immune mechanisms. Their exposure to warm and humid atmosphere ,respirators,resuisitors
and catheters is conductive to the development of infections.

contaminated in utero environment

Prolonged rupture of membranes, unhygienic and multiple vaginal examinations, prolonged

labor, and poor personal hygiene lead to asending infection of the amniotic fluid which is
good culture medium for bacterial growth especially when it is contaminated with meconium

infected birth passages

A number of bacterial and non bacterial infections are contracted by the baby during its
passage through the birth canal eg:Gonococci,Listeria monocytogenase,E coli,Streptococcus
hemolyticus, Candida albicans,Herpis virus hominis,etc. Nearly 90% of pregnant women

harbor potentially pathogenic organisms in their genital tract. Chorioamnionitis is

characterized by maternal fever , pain, tenderness, in the uterus, foul smelling
liquor.leucocytosis and positive CRP

infection at birth

The neonates not only have enhanced vulnerability to infections but they also have greater
opportunities to get infected in the labor room and NICU. Hands of personnel are a potent
source of microbes unless due precausions are taken. The high risk neonates are exposed to a
variety of formites which are potential source of pathogen such as incubators, cots, linen,
suction and oxygen catheters, thermometers, endotracheal tubes, resuscitation equipment etc.
The congestion and overcrowding in the nursery are associated with increased risk of
nosochomial infections. The lack of enough disposibles(small vein infusion sets, catheters)
TYPES OF INFECTIONS
The infections may remain superficial and localized or the baby may develop fulminant and
disseminated systemic infection. Due to inability on the part of the neonate to develop
sufficient inflammatory response to localize the infection,it gets rapidly disseminated
especially in the low birth weight babies

superficial infections

Superficial infections are common and their incidence is related to the standard of hygiene
and attitude of the personnel working in the maternity units. Majority of these infections are
caused by Gram positive organisms, Staphylococcus aureus and albus. The infection is
conveyed to the baby through contaminated hands of the nurses ,doctors, and relatives who
may be nasal carriers of Staphylococci

pyoderma

Pustules are commonly seen on scalp,neck,groin,and axillae. These are more common during
the summer months. Their frequency can be reduced considerably by routine application of
triple dye to the umbilical cord and hexachlorophene skin prophylaxis during epidemics. The
spread of infection may lead to formation of abscess ,parotitis osteomyelitis and septisemia.
Life threatening staphylococcal infection may lead to manifestations of pemphigus
neonatorum which is characterized by marked erythema,bullous lesions,and exfoliation giving
an appearance of scalded skin syndrome

OTHER TYPES

Early onset infection.

Prematurity has got special challenge for clinicians and also other medical staff, such as
microbiologists. Immature host defense mechanisms support early-onset sepsis, which can be
very serious with very high mortality. While the past decade has been marked by a significant
decline in early-onset group B streptococcal (GBS) sepsis in both term and preterm neonates,
the overall incidence of early-onset sepsis has not decreased in many centers, and several
studies have found an increase in sepsis due to gram-negative organisms. With increasing
survival of these more fastidious preterm infants.

late onset infections

Nosocomial bloodstream infection (BSI) will continue to be a challenging complication that

affects other morbidities, length of hospitalization, cost of care, and mortality rates. Especially
the very low birthweight (VLBW) infants sensitive to serious systemic infection during their
initial hospital stay. Sepsis caused by multiresistant organisms and Candida are also increasing
in incidence, has become the most common cause of death among preterm infants. This
review focuses on the clinical microbiology of neonatal sepsis, particularly among preterm
babies, summarizing the most frequent bacterial and fungal organisms causing perinatally
acquired and also nosocomial sepsis.
CLINICAL FEATURES
1 )History
The predisposing factor may include active infection of the mother active infection of the
mother during pregnancy, prolonged rupture of membrane , pre mature or difficult delivery
and asphyxia at birth. It should be stressed that negative history does not preclude congenital
infection.
2)Symptoms and signs
Infections in the new born are different from those encountered in older infants and
adults. Fever is not always present, being found only in half the cases. Poor feeding, poor
activity, jaundice and poor weight may be the only symptoms drawing attention to the
generalized infection ,especially in the pre matures .Vomiting and diarrhea are sometimes due
to a generalized infection apart from gastro intestinal infection .Pallor accompanies the
infections while it lasts. Rapid breathing and even slight cyanosis may be found in some of the
infants with septicemia. Meningitis occurs in a quarter off all septicemic babies but, the
specific signs are often lacking( stiffness of the neck being very rare and the bulging
fontanelle in only a third of proved meningitis cases ). Convulsions are variable , and lumbar
puncture must be performed in every baby suspected of generalized sepsis to exclude
meningitis

3) Investigations and diagnostic findings

Whenever infection is suspected, the following investigations have to be carried out.
a. Blood cultures- at least two specimens are taken where such facilities are available
b. Culture swabs should be taken from umbilical cord base, throat, stools and urine when
infection is suspected and before antibiotics are used
c. The CSF is obtained and send for both bacteriological and biochemical examination
d. Routine blood counts chest x-ray and urine analysis
e. Gastric smear examination appear to be a simple , quick and reliable method for screening
babies who are candidates for neonatal infection. The gastric contents are aspirated an hour
after birth using a sterile rubber catheter and a sterile glass syringe. A drop of the gastric juice
is placed on a clean glass slide while the reminder is send for culture and sensitivity tests. A
smear is made and stained with fresh leishmans stain . the number of cells per High Power
Field are counted and a count more than 5 cells (HPF) is considered diagnostically
significant . it is a very simple bed side clinical test which can be performed with out extra
equipment or specially trained staffs.
f. Micro ESR by collecting capillary blood
g. Acute phase proteins C reactive protein , alpha acid glyco protein ,hapto globin, alpha
antitrypsin and fibrinogen increased with inflammation where as pre albumin and transferrin
decrease with inflammation .
h.
Band neutrophil to total neutrophil count ratio sensitivity of 82-90 percent of detecting
septisemia and
i. Limulus lysate assay detects the endotoxin released by gram negative bacteria .
Expect culture and Gram stain ,other tests are indirect markers. This investigational exercise is
known as the SEPSIS SCREEN.

BACTEREMIC SHOCK (GRAM NEGATIVE SEPTICEMIA)

Bacteremic shock sometimes goes unrecognized in the neonatal period.

The clinical pattern is similar to shock like states in later life (pallor, low temperature,
collapse).only autopsy studies have revealed the correct diagnosis in these infants. Hence
routine blood studies should be carried out in all infections.
Septicemia is the commonest infection in the newborn, closely followed by pneumonia,
diarrhea and meningitis. The clinical picture is extremely variable, the striking feature being
lack of specific signs and symptoms, some of which are lethargy, abdominal distension,
vomiting, spells of cyanosis and irritability in addition to poor feeding and jaundice ,the latter
often ushered in by the second or third day. Fever is variable ,with severe infections showing
sub normal temperatures.
The common etiologic agent of the serious infections (pneumonia, meningitis, diarrhoea,
septisemia) in the newborn is E coli. Second in the frequency to E coli is Staphylococcus
aureus of which some strains are resistant to the popular antibiotics. Severe staphylococcal

infections like pustules or bolis which may assume epidemic proportions in a nursery.
Another important feature is that the serious forms of staphylococcal infections may occur
after discharge from the nursery. Some strain of Staphylococcus aureus appear to have
unusual pathogenicity and once the organism has been introduced into the nursery by an
adult,the spread is rapid.
Group B streptococcal sepsis is particularly common in prematures. The respiratory picture in
this infection may be difficult to differtiate from hyaline membrane disease.
Pseudomonas pyocyaneus is an important pathogen which affect prematures in particular.
The organism can produce symptoms ranging from vague undefined ill health to serious
conditions like septisemia accompanied by jaundice,purpura,high temperature and death.
Treatment : maintenance of optimum temperature,oxygenation and fluid electrolyte balance is
of prime importance. A continuous intravenous drip of dopamine is ideal for combating
septicemic shock.
In the hypovolemic stage ,hydrocortisone should be started and replaced later by
dexamethasone.
The selection of antibiotics ideally should depand on the prevailing pattern of entiological
agents and their sensitivity pattern. By and large ,the trend even today is to start with a
combination of ampicillin and gentamycin.in a recent review of literature on sensitivity
patterns,in the last 10 years in India,it was conclusively stated that gentimycin is still effective
against most Gram negative and many Gram positive organisms.
In suspected group B streptococcal infection,crystalline penicillin is the alternative to this
combination. Intravenous metronidazole is given in anaerobic infections for 5-7 days. In
general , in proved sepsis ,antibiotics have to be given for 7-10 days,except in meningitis
where the treatment has to be continued for three weeks.
Newer aminoglycosides do not offer much advantages over gentamycin. Among
cephalosporins,the third generation has just been introduced in India. Imipenam and
aztreonam are still in the investigational stage.
Immunotherapy
Exchange blood transfusion in infected babies can help achieve improved oxygen
delivery,the correction of coagulation abnormalities and the removal of toxins and other
bacterical products. It may also provide specific antibodies,complement and phagocytic
cells.simple plasma or whole blood transfusion has been reported to the useful in cases of
streptococcal sepsis. Polymorphonuclear leukocyte transfusion is being tried in advanced
centres to replace the depleted neutrophil storage pool

UMBILICAL INFECTIONS

The manifestations are ,

1. Redness around the base progressing in the worst case to cellulitis
2. Serous ,purulent or sanguineous discharge from the umbilicus severa;l days after the cord has
dropped is sticky and moist

3. A moist granulating base after the cord had dropped is common. Such a granuloma has to be
distinguished from an umbilical polyp with a fistulous tract to the bowel(and so fecal
discharge) or to the bladder(urine like discharge) due to dermanants of the omphalo
mensenteric ducts ,respectively
4. Clinically silent omphalitis and umbilical phlebitis occurring in the first few days,before the
umbilical vessels have thrombosed firmly,carry the risk of general systemic infection.
Minimal infection to the umbilicus may not affect babys health. Tetanus neonatorum often
has its origin in contamination of the cord stump,through evidences of local infection are not
always present
Treatment
Simple omphalitis without evidence of peri umbilical spread respond to local applications
of antibiotic compresses or oilments (bacitracin and neomycin oilments).
Parenteral antibiotic medication is indicated if the discharge is obviously purulent or if there
is peri umbilical redness
The healing of a discharging granuloma can be hastened by cautious cauterization with silver
nitrate
Prevention is by scrupulous attention to the cleanliness of the surgical scissors and ligatures,
etc used for cutting the umbilical cord and taking care that the babys feces and urine do not
contaminate the cord. Neosporine powder can be used initially for the cord stump, and
painting with triple dye around the umbilicus daily may reduce the incidence of colonization
by pathogens

SKIN INFECTIONS

A . Impetigo neonatorum
Impetigo neonatorum is the commonest skin infection in the newborn. A few,
loosely filled vesicles 0.5-1 cm in diameter ,appear over the lower part of the abdomen or
upper part of the thigh. The epidermis lies wrinkled on the skin. After rupture there is a round
,bright red ,moist, denuded area which does not crust. In advanced cases there are many
lesions in all stages, namely full vesicles ,broken vesicles covered with wrinkled skin, freshly
denuded areas which are bright red and also dry healing spots.
Treatment
1) 1-2 percent aquous gentian violet solution painted on the lesions twice a day often controls
them effectively
2) Alternatively ,bacitracin and neomycin oilments are used
3) Systemic antibiotics against staphylococci are indicated only if new vesicles continue to
appear frequently ,in order to prevent systemic spread
Prevention

Infants with Impetigo must be strictly isolated. Appearance of more than one case in a nursery
demands examination of the staff to detect the source of infection.
B . Pemphigus neonatorum
This appears to represent an exaggerated form of impetigo neonatorum in that the vesicles
are considerably large, becoming bullous and continuing to grow peripherally. This bullous
variety of impetigo (pyosis mansoni) involving the whole body is especially common in the
tropics. The disease which occurs soon after birth is termed pemphigus neonatorum. If left
untreated ,fatal septicemia may supervene. Constitutional symptoms like fever, vomiting, etc.
accompany it unlike in impetigo
Differtial diagonosis is form syphilitic pemphigus, in which the bullae occur mainly on the
palms and soles with other associated manifestations. Cutaneous candidiasis appear
maceration of the anal mucosa,peri anal skin and the groin. Raw areas redden outwards and
are fringed with pseudo membranes,often together with oral thrush. Two percent nystatin
oilment can be used for the skin
Treatment
Penicillin in large doses is indicated since the organism responsible is streptococcus rather
than staphylococcus. Oilments containing bacitracin, neomycin, gentamycin, nitrofurantoin
and hydroxyquinoline can all be used topically. Supportive treatment with fluids and
electrolytes as well as replacement of lost proteins are indicated.
EYE INFECTIONS
A . Acute conjunctivitis
In descending order of frequency, the organisms are staphylococcus, Pneumococcus, non
hemolytic Streptococcus, H influenze and E coli. Mild infections are treated with oilments
containing bacitracin or neomycin or both or chloramphenicol. In addition , in severe cases,
appropriate antibiotics have to be identified by a conjunctival smear. The TRIC virus may also
produce acute inflammation and responds well to tetracycline oilment.
B .Gonorrheal ophthalmia
The discharge from the eye appear on the second or third day, the infection progresses
rapidly and the conjunctiva may become so oedematous that they even bulge out through the
closed lids. The discharge may run constantly down the cheeks. If not promptly treated ,
corneal ulceration may follow.
Treatment

It consists of instilling solutions containing 2500 units of penicillin per ml every half hour for
three hours and then every hour for 24 hours and thereafter every two hours until the eyes are
clear. In addition penicillin has to be given parenterally
RESPIRATORY INFECTIONS
A . Rhinitis
A stuffy nose may be the first and only indication of a cold passed on by an attendant.
Other causes of a stuffy nose are chemical rhinitis,hypothyroidism,choanal atresia and side
effects from drugs used by the mother eg:reserpine
B . Pneumonia
Pneumonia is one of the important causes of perinatal death. The so called congenital
pneumonia due to intra uterine infection may be present soon after birth. In acquired
pneumonia infection occurs after the first few days of life. E coli ,non hemolytic streptococcus
and Staphylococcus aureus are the most common causative organisms of both types of
pneumonia, while Pneumococcus , H influenza and hemolytic streptococcus are infrequent
causes of pneumonia in the newborn period.
Clinical manifestations
It first usually unspecific such as a sudden rise or fall in body temperature ,refusal
to feed, poor colour, abdominal distension and a general impression of ill health and
discomfort. Cough, through not constant when present cannot pneumonia. Soon rapid
breathing accompanies a flaring of the nostril. Signs of respiratory distress and noisy grunts
become apparent in the later stages. Physical signs in the chest are not always present. It is
important to auscultate the chest both when the baby is crying and when quiet since fine
crackling rales are the commonest finding, they may be heard only during deep inspiration.
Pneumonia often complicates diarrhoea in the newborn.
Aspiration pneumonia is a third variety present in a number of conditions .
eg: difficult deliveries with fetal distress(and consequently attempts to breathe in utero) and
trachea-oesophageal fistula. The lungs are partially athelectatic with a hilar flare on x ray
Lipoid pneumonia results from aspiration of oil owing to the custom of instillation of oil drops
in the nose. The clinical spectrum ranges from acute segmental collapse of the lung,which
clears in a few days to a chronic picture mimicking pulmonary tuberculosis or
mucoviscidosis
Empyema is frequently encountered in the newborn period, the incidence being about three
percent of all empyemas among children. septic foci such as abscesses, pustules, umbilical
sepsis and cellulitis may be associated. The right pleural cavity is affected more than the left.

There is slight preponderance of the male sex. The symptoms include general debility, refusal
of feeds, tachypneoa, abdominal distension, febrile cry ,fever. vomitting etc. Pyo
pneumothorax appears to be the most common mode of clinical presentation. Broncho
pneumonia and pneumatoceoles are found to be the nextin order of frequency. Among the
causative organisms staphylococcus aureus accounts for most of the cases followed by
pseudomonas. The antibiotic of choice appears to be a combination of Gentamycin and
Cloxacillin or Ampicillin
Treatment
Administration of oxygen and suitable antibiotics against the causative organisms are
indicated. Since staphylococcus and E coli are the common organisms,it may be necessary to
use kanamycin.
For Psedomonas infection ,Gentamycin and Carbenicillin(100 Mg/Kg/tds) are currently used.
For Klebsiella pneumonia , Kanamycin or Gentamycin can be used successfully. For the rare
Pneumocystis carinii pneumonia ,pentamidine isothionate and gammaglobulin are indicated.
GASTRO INTESTINAL TRACT INFECTIONS

Oral Thrush

In the newborn period ,healthy infants can be infected from maternal vaginal moniliasis and
contaminated supplies. Thrush must be suspected whenever a baby refuses to suck. The
white elevated patches of coalescent foci can be seen on the gingiva, tongue, and other parts
of the buccal mucosa. They are tenacious and resistant to tongue blade scraping , a point of
differtiation from milk curds remaining in the mouth. Oesophago- gastritis may occur by
extension in neglected cases, making swallowing difficult. Aspiration into lungs produces
pneumonitis
Treatment
One percent acquous solution of Genitian violet solution or Nystatin 200,000 units/ml is
applied locally with a soft cotton swab allowing the infant to swallow whatever portions
remains

diarrhoea

Diarrhea in newborn posses a serious problem of management as well as cross infection in the
nursery. Most of the known as intestinal pathogens(Shigella,Salmonella,Enteropathogenic
Ecoli,etc) have been incriminated or suspected in individual epidemics. In addition , normal,
normal bacterial inhabitants of the intestinal tract (Staphylococcus,Streptococcus, Proteus,
Pseudomonas,and Paracolon) may act as pathogens under certain circumstances in the
newborn period, eg oral antibiotics that suppress Streptococci may allow Staphylococci to

flourish unduly. Enteropathogenic Ecoli types 026,055,0125 and 0126 are particularly liable
to cause diarrhoed in the nursery. There is also some evidence of viral causative organisms
( Echo virus) in some epidemics. The so called epidemic diarrhoea of the newborn is nothing
but diarrhea caused by pathogenic strains of E coli. The epidemic can be checked only by
constant supervision, early diagnosis, and prompt treatment. The stools tent to be watery,
yellowish and later greenish and acidic enough to produce irritation to skin around the anus.
Dehydration and circulatory failure can supervene rapidly. Even though acidosis is common ,
hyperpnea is frequently absent in newborn period especially in low birth infants. However the
severity varies greatly from case to case. Exacerbations and complications (otitis,
Pneumonia,etc) are common . In the diagnosis of mild diarrhea ,it must be remembered that
the transitional stools are often normally loose;moreover frequent over feeding , the high
carbohydrate content of formula feeds and intolerance to cows milk may all be responsible
for loose stools in bottle fed infants.

Necrotizing enterocolitis

This is a serious disorder among newborns and pre mature infants, its danger being recognized
more in recent years. The etiology is obscure, but the disease is in some way associated with
pulmonary hemorrhage, hyaline membrane disease, gastroenteritis, selective circulatory
ischemia of the gut after exchange transfusions and umbilical catheterization. The clinical
features are ushered in abruptly with abdominal distension, bilious vomiting ,initial bloody
diarrhea followed by later shock and signs of peritonitis. X rays of the abdomen may show
multiple fluid levels, air under the diaphragm(indicating a perforation) and pneumatosis( intra
mural gas)
Treatment
It consists of avoiding oral feeds. A nasogastric tube is placed and low intermittent suction is
applied. I V fluids, oxygen, maintenance of hematocrit, fresh frozen plasma, platlets
transfusion,etc.are supportive measures. Oral gentamycin may be used to maintain the blood
pressure. The current trend is to give a combination of ampicillin, gentamycin, and
metronidazole intravenously for at least 10 days. Surgery is usually reserved for cases with
intestinal perforation. Complications in the survivours include strictures, areas of stenosis and
mal absorption.
CENTRAL NERVOUS SYSTEM INFECTIONS

meningitis

Meningitis accompanies a quarter of cases of septisemia,there being no specific signs or

symptoms referable to the nervous system in small infants. A bulging fontanelle,high pitched
cry,vomiting, convulsions are late signs. The diagnosis must be made before these signs

appear in order to institute early treatment and avoid chronic and residual damage. In the
newborn period ,meningitis is often caused by E coli infection. Listeria monocytogenes is a
rare cause of purulent meningitis in this period. Other offenders are Klebiella, Proteus,
Hemophilus, Pseudomonas, Meningococccus, Pneumococcus and Staphylococcus. In a small
proportion of cases mixed infection occur while in a significant number of babies , no
organism is detected.
Treatment
Besides supportive management symptomatic management of convulsions with pareneral
diazepam or phenol barbitone may be needed. In clinically suspected bacterial meningitis a
combination of ambicillin (200 mg/kg/day) and Gentamycin (5 mg/kg/day) is started till
culture and sensitivity results are available. In babies more than 7 days old I V cotrimaxole or
chloramphenicol have been also tried. In ant case I V therapy has to be continued for 3
weeks. Ventriculitis is frequent and even difficult to treat even with intra thecal antibiotic
instillation. Subdural effusion is common immediate complication whereas late complication
include hydrocephalus,mental retardation and cerebral palsy
BONE INFECTIONS

Osteomyelitis

Staphylococcus aureus hemolytics is the organism found in babies with osteomylitis.

Infection( which may be through the skin, umbilicus, respiratory tract, blood stream, etc)
localizes at the ends of the long bones and because the cortex and epiphyseal plate are thin ,
the pus ruptures into the joints and surrounding tissues. The symptoms may be mild,
characterized by swelling around a joint, commonly the hip, with few constitutional
symptoms or may be severe with fever , anorexia, and vomiting. The other sites may be
involved are the maxilla , the knee, the long bones and the vertebral column. X ray films
show only joint swelling, the destructive bone changes, and periosteal thickening make their
appearance only two or more weeks after the onset. The condition has to be differentiated
from syphilitic osteochondritis
Treatment
Besides administering antibiotics against staphylococci, the swelling should be aspirated and
if pus is found , incised and drained. Traction and immobilization are then indicated.
INTRA UTERINE INFECTIONS
An acronym TORCH is used to describe serious infections like Toxoplasmosis,
others(syphilis, T B, Malaria, Varicella, Hepatitis B,),Rubella, Cytomegalovirus, and Herpes
simplex hominis. Besides these transplacental infections, ascending bacterial infections with

contamination of liquor amni and amnionitis may also occur in case of premature rupture of
membrane, repeated vaginal examination and instrumentation

Toxoplasmosis

The disease is due to infection by Toxoplasma gondii, a delicate ,oval protozoan measured
about 4-7 microns in length. While acquired toxoplasmosis in older infants and adults may be
either asymptomatic or mild, congenital toxoplasmosis due to transmission of infection from
mother inutero is a serious disease resulting in either stillbirths or severe illness with
constitutional symptoms. The survivors may show varying degrees of disability(hydrocephaly,
microcephaly, choreoretinitis, mental retardation, convulsions, ocularpalsies);cerebral
calcification ,single or multiple may be visualized in X rays of the skull. The protozoan can be
demonstrated in strained films made from the sediment of the C S F during the acute phase of
the disease; while the antibodies are positive early in the disease, the compliment- fixation
test become positive more slowly. The demonstration of IgM antibodies in the baby provides
an additional clue to the diagnosis
Treatment
During the acute stage is by combination of sulphadiazine and pyrimethamine . A
combination of supranol and sulphamerazine has been found very effective . in spite of
adequate treatment there is residual neurological damage leading to severe mental retardation.

Cytomegalic inclusion disease

This may be transplacentally transmitted from the mother or postnataly acquired. The
virus may be excreted in the urine for months or years by the infected infants who are often
pre mature or of low birth weight. The disease is a serious one in the newborn period. The
symptoms are referable to the hemopoietic system( micro or hydrocephaly due to poor
development of the cerebral convolutions and dilations of the ventricles) Hepatosplenomegali
often present
Diagnosis may be often confirmed by serological studies and finding the characteristic intra
uterine inclusion body(owls eye cells) in the strained smear of the centrifuged urine. Such
inclusion bodies can also be found in the salivary glands. An abnormally large
placenta,sometimes with cell inclusions may also give a clue to the diagnosis
There is no specific therapy. Transfusions for anemia and in selected cases exchange
transfusion are indicated

Herpes simplex infection

This is the infection of the newborn infant is often severe, and generalized vesicles may be
present on the skin, buccal mucosa,conjunctiva and over the larynx. There is also severe

constitutional
symptoms
(fever,
poor
feeding,
vomiting,
jaundice,purpura,petechiae,etc),hepatosplenomegali,congestive heart failure and CNS
manifestations. Recurrent herpetic lesions impair cerebral function in the long run

Coxsackie virus infection

This infection in the newborn may take the form of an acute fulminating febrile illness with
myocarditis may prove fatal. In some infants the disease may take the form of meningo
encephalitis with vomiting, lethargy, and convulsions. Hepatomegaly, respiratory signs and
hemorrhagic skin manifestations indicate severe involvement. From the diagnostic standpoint
a combination of myocarditis and meningo-encephalitis should suggest the possibility of
coxsackie virus infection

Tetanus neonatorum

This is unfortunately still prevalent in many tropical countries and high in mortality.

Congenital neonatal malaria

In the epidemic areas, it is difficult to differtiate between congenitally acquired malaria and
post natal infection. The placenta act as a barrier to the malarial parasite and the transmission
is further blocked if the mother is immune.fetal infection may occur due to the direct
penetration of paracites through the chorionic villi,premature separation of placenta and
materno fetal transfusion at delivery. RBCs containing fetal Hb are relatively resistant to
malaria. Thus the incidence is very low and placental malaria is symptomless except for silent
fetal death. This disease may manifest 4-6 weeks of age and treated with chloroquin
OTHER COMMON DISORDERS OF THE NEWBORN

pulmonary disorders

Respiratory difficulties constitute the commonest cause of morbidity in the

newborns ,and pulmonary pathology is the most frequent autopsy finding. The clinical
diagnosis is based on recordings of a respiratory rate of more than 60 b/mt. in a baby who is
quiet and who has an inspiratory indrawing and/or expiratory grunt. Cyanosis is variable.

Congenital toxoplasmosis

In cases of overt congenital toxoplasmosis,treatment is given for one year. Give oral
pyrimethamine(1 mg/kg/day) and sulfadiazine (75 mg/kg/day in 2 divided doses). For 6
months .Sulfadiazine should not be used during the first week of life due to danger of
displacement of bilirubin from protein binding sites. Subsequently, pyrimethamine and
sulfadiazine therapy for one month is alternated with spiramycin(100mg/kg/day in 2 divided
doses) for one month.

Cytomegalovirus disease

Indications for specific antiviral therapy are not well defined. Apart from chorioretinitis which forms a definitive indication for specific therapy,other relative indications
include colitis, esophagitis, hepatitis, pneumonitis, meningoencephalitis. Therapeutic utility is
doubtful in acquired CMV pneumonia in recepients of blood transfusion or bone marrow.
Ganciclovir (9-1,3 dihydroxy-2-propoxy methyl guanine or DHPG ) is given IV 5
mg/kg/dose twice daily for 2-3 weeks of induction phase. Maintenance therapy is continued
with 2 mg/kg/d IV single dose for 5-7 days in a week for8-12 weeks. The drug is very toxic
and demands daily or every other day blood counts, platlet and weekly assessment of renal
function tests. Therapy should be stopped if neutrophil count falls below 500/mm3 or platlet
count drops to 25,000/mm3. The hematological side effects are reversible within 5-7 days an
cessation of therapy. Testicular atropy is another recognized serious side effect
Be delivered by elective cesarian section preferably within 4 hours of rupture of membranes.
Acyclovir is now preferred over vidarabine due to ease of administration and minimal side
effects. In infants with localized skin,eyr,and mouth disease,give acyclovir 10-15 mg/kg/dose
IV every 8 hr for 10 to 14 days. Infant with disseminated or CNS infection with HSV
should receive 10-15 mg/kg/dose IV every 8 hr for 21 days. There are no serious side effects.

congenital malaria

Malaria during neonatal period most commonly occurs due to administration of

infected blood. In endemic areas it is difficult to differentiate between congenitally acquired
malaria from post natal infection acquired through mosquito bites or blood transfusion. It
appears that placenta acts as a barrier to the malarial parasite and its transplacental
transmission is further blocked if mother is immune. The incidence of placental malaria in
endemic areas may be high as 30% while incidence of congenital malaria in infants of
immune mothers is estimated to be as low as 0.3%(upto 10%in the non-immune mothers).
Placental malaria is asymptomatic and it silently causes fetal wasting. Among firstborn ,it can
significantly affect the birth weight ,the differences between the birth weight of an infant born
with a negative and a positive placenta for malarial parasites is usually around 150-300g. The
blood film of the mother is often negative. It is recommended that in endemic areas routine
administration of chloroquine to all mothers during 3rd trimester of pregnancy is desirable and
is associated with improvement in the birth weight of the offspring.

congenital tuberculosis

Despite adoption of several national strategies , tuberculosis continues to be a disease of public

health relevance in India. It has assumed more sinister severity due to increasing incidence of
HIV infection and emergence of multi drug resistant strains of M.tuberculosis due to non
compliance in therapy. Fortunately, congenital tuberculosis is relatively uncommon. Women
with pulmonary tuberculosis may occur if placenta is infected by TB bacilli. The infection may
be transmitted to the fetus through umbilical vein or infant may aspirate infected secretions at
the time of birth. Post natal exposure from an infected mother or other family member and an
infected health care worker is far more common

HIV infection

Asymptomatic HIV positive mother can transmit infection to her offspring. In view of the
increasing prevalence of AIDS infection due to the raging epidemic of HIV Infection
,obstetrician and Pediatricians must take all the necessary precausions and wear gloves while
conducting deliveries and resuscitating newborns. The infection in the newborn babies can be
suspected by high risk behavior and confirmed by positive serological test during ante natal
visit.
There is 15 to 35 % transmission of infection of HIV mother to her offspring. Majority of
infection is transmitted during late third trimester or during delivery. In multiple pregnancy
the highest risk is for the first of the twin. The infection can occur in utero, intrapartum or
through breast milk. Maternal antibodies against HIV are passively transmitted through
placenta. Therefore positive ELISA and Western blot test for HIV antibodies in the cord blood
or infant are not indicative of infection unless these antibodies persist beyond 15 months age.
When facilities are available it is desirable to identify HIV p24 antigen or virus by PCR and
culture HIV from babys blood to confirm the diagnosis during neonatal period. Specific IgM
and IgA antibodies against HIV can be identified by ELISA . most laboratories do not have
facilities for direct identification of antigen or isolation of virus,necessitating periodic ELISA
and Western blot test every 3 months until it become negative or remains positive beyond 15
months thus confirming the diadnosis of HIV infection.

congenital syphilis

Syphilis is common in many developing countries and venereal disease research

laboratory(VDRL) test routinely performed in all mothers during antenatal visits. In high risk
populations a second VDRL test should be done at 28 weeks gestation. Contrary to
convensional opinion transplacental infection by Treponema pallidum can occur during first
trimester of pregnancy. If mother has untreated primary or secondary syphilis ,the risk of fetal
infection is almost 100 percent ,whereas in late maternal syphilis (of more than 2 years
duration) risk of infection is minimal. When one of the non treponemal tests(VDRL or RPR)
is positive during pregnancy,the expectant mother should be interviewed by taking a detailed
history and examined thoroughly for any clinical evidences of the disease or its stigmata. The

diagnosis should be confirmed by triponema pallidum hemagglutination assay or by

fluorescent treponemal antiboby absorption test. The treatment of syphilis during pregnancy
,at all trimesters,is similar to the drug schedule used in non pregnant patients.
If spinal fluid count is still elevated at 6 months or VDRL in the CSF is positive ,the infant
should be retreated.

chlamydial infections

During the last decade genital venereal infection with Chlamydia trachomatis has come to be
recognized as a significant pathogen with a high infectivity to the newborn baby. Chlamydial
cervicitis has been implicated to cause premature rupture of membranes, pre mature labor,
high incidence of LBW babies and increased perinatal mortality rate. Several population
surveys have reported 5 to 20 %genital colonization rate with Chlamydia trachomatis in
pregnant women with extremely high rate of vertical transmission of the infection to the
newborn baby during delivery. Conjunctiva and respiratory passages are the most vulnerable
to infection by this organism. The usual incubation period varies between 5 to 14 days.
NURSES RESPONSIBILITY IN PREVENTION AND TREATMENT OF NEONATAL
INFECTIONS.
1. NICU nurses monitor the PIV site with vigilance to aid in early identification of infiltration and
extravasation and prevent this type of injury whenever possible. Identifying an infiltration may be
difficult, even for the most experienced nurse.
2.The NICU nurse is aware of the subtle changes in heart rate, oxygen saturations, apnea, and the
more obvious change in behavior such crying and agitation that may indicate problems with the
chid.
3. Neonatal nursing entails not only basic knowledge of the anatomy and physiology of neonatal
organ system and how to prevent iatrogenic injury from routine nursing care .
4. These evidence-based guidelines and grading scales for care of child can aid with standardizing
documentation and protocols that guide nursing care and improve patient outcomes
Cardiopulmonary support and intravenous (IV) nutrition may be required during the acute phase
of the illness until the infants condition stabilizes.
5. Monitoring of blood pressure, vital signs, hematocrit, platelets, and coagulation studies .
6. An infant with temperature instability needs thermoregulatory support with a radiant warmer or
incubator. Once the infant is stable from a cardiopulmonary standpoint, parental contact is
important.

7. Examine client for possible source of infection, such as sore throat, sinus pain, burning with
urination, localized abdominal pain, burns, open wounds or cellulitis, presence of invasive
catheters, or lines , because the Respiratory tract and urinary tract infection are the most frequent
causes of infections, followed by abdominal and soft tissue infections.

8. Maintain sterile technique when changing dressings, suctioning, and providing site care, such
as an invasive line or a urinary catheter because medical asepsis prevents or limits introduction of
bacteria and reduces the risk of nosocomial infection.
9. Wash hands with antibacterial soap before and after each care activity, even when gloves are
used because Hand washing and hand hygiene reduce the risk of cross contamination. Methicillinresistant Staphylococcus aureus (MRSA) is most commonly transmitted via direct contact with
healthcare workers who fail to wash hands between client contacts.
10.Encourage client to cover mouth and nose with tissue when coughing or sneezing. Place in
private room if indicated. Wear mask when providing direct care as appropriate because
appropriate behaviors, personal protective equipment, and isolation prevent spread of infection
via airborne droplets.
11. Encourage or provide frequent position changes, deep-breathing, and coughing exercises
because good pulmonary toilet may reduce respiratory compromise.
12.Provide isolation and monitor visitors, as indicated because wound and linen isolation and
hand washing may be all that is required for draining wounds. Clients with diseases transmitted
through air may also need airborne and droplet precautions. Reverse isolation and restriction of
visitors may be needed to protect the immunosuppressed client.
13. Limit use of invasive devices and procedures when possible. Remove lines and devices when
infection is present and replace if necessary ,because it reduces number of possible entry sites for
opportunistic organisms.
14. For umbilical infections prevention is by scrupulous attention to the cleanliness of the surgical
scissors and ligatures, etc used for cutting the umbilical cord and taking care that the babys feces
and urine do not contaminate the cord. Neosporine powder can be used initially for the cord
stump, and painting with triple dye around the umbilicus daily may reduce the incidence of
colonization by pathogens.
15. Supportive treatment with fluids and electrolytes as well as replacement of lost proteins are
indicated for infection treatment.

CONCLUSION

Neonatal infections may be acquired prenatally, perinatally or postnatally. Development

of intensive anti-infection measures has greatly reduced both mortality and morbidity from
neonatal infections un developed countries during recent years . nonetheless there are still
significant numbers of deaths and handicaps resulting from such infections. Antibiotic
resistance has assumed major importance and a more critical approach to their use is
necessary.