Immunological complications in newborn

Group 6 names AND STUDENT NO.

OMPHILE MABASO 34293574

BRILLIANT MADODA 34829393
AMOGELANG MAPOGO 34714359
MAXINE DERBYSHIRE 34902317
TADIWA MASHIRI 34564225
Sample Footer Text

Study Unit 6.6.1: NEONATE OF THE HIV POSITIVE MOTHER

Learning Outcomes
• Discuss the prevention of mother-to-child transmission

• Discuss the risk of mother-to-child transmission

• Discuss the management of a seemingly healthy baby of an HIV-positive mother

• Discuss the diagnosis of HIV-infected baby

• Discuss the nursing care in the hospital of a baby of an HIV-positive mother and apply it to the case study

• Utilize the latest evidence and policies on infant feeding and apply this knowledge when designing a
feeding plan for the HIV exposed infant

• Discuss the education to parents in respect of the home care of such neonate

• Critically discuss the ethical, human rights and other issues regarding mother-to-child HIV transmission
Prevention of MTCT and prophylaxis treatment
• The risk of mother to child transmission can be b prevented or be reduced to less
than 5% with antiretroviral prophylaxis. Usually, two antiretroviral drugs are used
it depends on the viral load of the mother before delivery.
• AZT(zidovudine) to the mother daily from 28 weeks gestation and during labour.
• AZT daily to the infant for the first week of life.
• A single dose of nevirapine to the infant after delivery and then for 6 weeks. The
mother’s ART history and viral load is essential to determine if the infant needs
additional prophylaxis. Antiretroviral treatment (HAARR) gives the fetus almost
complete protection when taken from early pregnancy (Woods, 2010:237)
Risks of MOTHER TO CHILD TRANSMISSION

• A woman with HIV infection that’s pregnant may transmit the virus to her baby or
when breastfeeding if the correct management is not given.
• The risk of HIV crossing the placenta from the mother to her fetus during
pregnancy is 5%.
• The risk that the infant will be infected by contact with the virus in maternal blood
and secretions during vaginal delivery is 15%
• The risk of MTCT when exclusively breastfeeding is much less than when mix
feeding (Woods, 2010:237).
Management of an exposed infant
• It is important to screen all women for HIV early in pregnancy to be able to identify HIV
exposed infants.
• Antiretroviral prophylaxis must be given to these infants after delivery. If the mother has not
received correct antiretroviral prophylaxis, AZT should be given to the infant daily for a month
in addition to the single dose of nevirapine after delivery.
• The mother must decide, after counselling, whether to breastfeed or formula feed. But
breastfeeding is most preferred.
• The birth PCR should be used to identify HIV infected infants
• HIV infected infants must be started on co-trimoxazole prophylaxis. Many of these infants are
now being started on antiretroviral treatment while still clinically well (Woods, 2010:237)
 Diagnosis of HIV
infected baby
• An infant with HIV infection usually appears normal
and healthy at delivery. However, between 2 months
and 2 years after birth, most infants infected with HIV
will present with failure to thrive and repeated
infections.
• Most of these infants will die before 3 years of age if
they are not correctly managed with antiretroviral
treatment.
• All HIV-exposed infants (infants born to a mother with
HIV infection) will have a positive HIV screening test
up to 18 months of age.
• Positive PCR (polymerase chain reaction) test at 6
weeks (or 6 weeks after the last breastfeed is given) is
used to identify infants infected with HIV. Fortunately,
most HIV-exposed infants are not HIV infected
 • Antiretroviral prophylaxis must be given to
the infant after delivery. If the mother’s VL
was <1000copies/ml during labour period,
the infant should be given NVP prophylaxis
and if the VL was > 1000copie/ml the
infant should be given both the NVP and
AZT prophylaxis.
• The PCR test should be used to identify if
the infant is HIV infected or not. If the
infant is HIV exposed but not infected. The
infant can be followed at a well baby clinic.
• If the infant is HIV infected, he/she should
be started on co-trimoxazole prophylaxis.
ART should be initiated even if the infant
Nursing care in the hospital of a baby of an weighs less than 2.5kg.
HIV positive mother • Routine growth monitoring by weighing
the infant daily (Department of Health,
2020:73).
Feeding Plan for the HIV exposed infants
• HIV exposed infants should be exclusively breastfed for the first six months, with
complementary food being introduced from six months and to continue
breastfeeding for up to twelve months.
• In order to make breastfeeding safer, all HIV-exposed infants should receive NVP
from birth for six weeks.
• The only exception is infants of mothers on second- or third-line ART and VL
>1000 copies/ml, these infants should not be breastfed, formula feeds will be
available on prescription by an appropriate health care practitioner.
• It is most important that HIV- infected mothers do not give mixed breastfeeds
( breast milk as well of formula or solid feeds) as this carries the highest risk of
HIV transmission from mother to infant (Department of Health, 2018: 84).
When is it best to formula feed HIV-exposed infants.
The World Health Organisation recommends that HIV-positive women exclusively formula feed their
infants only if all the following criteria can be met:
• It should be feasible to formula feed. The mother must have the knowledge and skills to make up
formula milk correctly .
• It must be affordable to formula feed. Formula is expensive. Free formula may be provided in some
areas.
• It should be sustainable. Formula must be always available.
• It should be safe. Clean water must be available. The mother should be able to prepare feeds
hygienically and be able to clean the bottles, teats and the cups. Access to primary health care is
particularly important if infants are formula fed.
If any of the above criteria cannot be met, it would be better for mothers to exclusively breastfeed as
the risk of HIV transmission in breastmilk is probably less than the dangers of formula feeding.
Mothers who decide to formula feed must be taught how to prepare and give formula correctly. A cup
Education to parents in respect of the home care of
such a neonate
• Risk of HIV infection in the infant from mixed breastfeeding is high. Hence mothers
living with HIV are advised against mixed feeding. Reason being that the lining of the
gastrointestinal tract which facilitates the entry of the HI virus into the baby’s system may
be disturbed
• Ensure the adherence of medication so the viral load is low in the mother’s system, this
will help lower the chances of HIV transmission.
• Keep the neonate away from mother’s body fluids e.g., blood.
• Mother is advised not to substitute no additional water, other fluids, or dietary items for
3-6 months when breastfeeding.
• Make sure the infant latches correctly in order to prevent cracked nipples as this may lead
to bleeding and the transmission of the HIV virus (Marshall 2015, 260)
the ethical, human rights and other issues regarding mother-to-
child HIV transmission
• Ethical-legal concerns that are encountered regarding HIV/AIDS include duty to treat, confidentiality and
the right to privacy, informed consent, duty to warn, and duty to know.
• Ethical issues around infants and HIV/AIDS include prenatal screening for HIV, HIV screening of
newborns , HIV status at birth, and infants who develop AIDS
• National human rights institutions are well positioned to make a unique contribution to a comprehensive
and rights based national response to HIV. As the independent, national body with a specific mandate to
promote and protect human rights, a national human rights institution can advocate the inclusion of a
strong human rights component in the national AIDS plan, including various specific rights-based
programmatic strategies.
• The national institution can assist rights holders such as people living with HIV and those vulnerable to
infection to claim their rights to nondiscrimination, to HIV prevention information, education, modalities
and services; to freedom from sexual coercion and violence; and to HIV treatment.
• It can also assist efforts to monitor progress towards universal access to HIV prevention, treatment, care
and support—a part of the right to health and non-discrimination (United Nations, 2007).
Study unit 6.6.2: Infections
Learning Outcomes
• Discuss the predisposing effects with regards to infection in
neonates
• Discuss the source of infection in neonates
• Discuss the diagnosis of infection
• Discuss the principles of treatment with regards to infection in
neonates
• Discuss the causes and management of conjunctivitis, infection of
the umbilical stump, skin infections, septicaemia, pneumonia, &
congenital septicaemia in neonates
Predisposing effects regarding to infections in
neonates
• Prematurity and very low birth weight causes the neonate to be prone to getting
infections as their immune system and internal organs are not fully developed
Maternal
• Use of substance and alcohol consumption during pregnancy can increase the
risk of the neonate being prone to infections as the neonate was exposed to the
toxicity during pregnancy, this can also lead to complications after birth
• Multiple PV examinations on the mother during labour and prolonged rupture
of membranes, can lead to risk pf mother developing chorioamnionitis which is
an intra-amniotic infection that affects two surrounding the fetus during
pregnancy.
Source of infection
Before delivery
• Can be caused by infection crossing the placenta from the mother’s
bloodstream to cause intra-uterine infection in the fetus e.g., HIV, syphilis
(non-bacterial) or due to (bacterial) spreading from vagina into the membranes
and liquor.
During delivery
• The infant is infected as it passes through the cervix and vagina and may be
present with infection hours/days after delivery.
After delivery
• The infant later becomes infected in the nursery or at home ( e.g., infection of
the umbilical stump).
Diagnosis of infection
Skin infection
• Bullous impetigo caused by the staphylococcus which present as pus/fluid filled
blisters usually seen around the umbilicus or the nappy area.
• A rash caused by the fungus candida Albicans. This almost always occurs in the
nappy area ad presents as a red, slightly raised, “velvety ”rash which is most
marked in the skin creases.
Umbilical Cord infection
• Reddish skin around the umbilical stump.
• An offensive (smelly) discharge over the surface of the cord .
• Failure of the cord to become dehydrated ( i.e., the cord remains wet and soft).
Continue………
Pneumonia
• Infant develops signs of respiratory distress (tachypnoea, cyanosis, recession and grunting)
• Chest X-ray will show the typical features of pneumonia ( white spots in the lungs called infiltrates.)
Septicaemia
• Non-specific signs and difficult to make an early diagnosis
• Common signs:
• Lethargy, infant appears less active and generally unwell
• Poor feeding or poor sucking. Infant may also fail to gain weight or lose weight
• Abdominal distention, vomiting and decreased bowel sounds.
• Pallor ( anaemia)
• Jaundice
• Recurrent apnoea
• Hypothermia
• Oedema ( Woods, D 2017).
the principles of treatment with regard to infection in
neonates (reduce and kill the causes of infection in neonates)
Ventilation and Temperature :
• Ideally all the neonatal units should be ventilated. This ventilation system should be separate from the main
hospital ventilation system.
• Filters with an efficiency of at least 90% must be used.
• Minimum of 6 air changes per hour.
• The nursery should be maintained at a temperature of 24-26◦C with a humidity of 30-60%.
Hand hygiene has been shown to reduce infection rates
• There should be adequate clinical basins with liquid soup, paper towel and water to allow for hand washing.
• Use liquid soap to thoroughly wash hands under running water on entry and exiting the nursery and when
hands are visibly soiled.
• Long nails are difficult to clean, can pierce gloves and harbour more microorganisms than short nails.
Therefore, nails should be kept natural and clean.
 Continue……….
Perform five moments for hand hygiene
• Before contact with the Immediate Care Environment.
• Before contact with the neonate or the Neonate Environment.
• Before performing an aseptic procedure.
• After care involving body fluid exposure risk.
• After contact with the Immediate Care Environment.
Environmental hygiene
• Cleaning methods that minimise dust dispersal should be used.
• Clean neonatal unit at least twice daily and additionally as required. Particular attention should be paid to peak
traffic areas and times(around hand basins and after feeding or visiting times) Horizontal surfaces must be dust and
soil free.
• Immediately clean up spills of blood or body fluid with disinfectant solution( chlorine-based disinfectant).
• Walls to be cleaned monthly and pest control inspection should be undertaken monthly.
• There should be no posters on the walls, except for a laminated poster to demonstrate the clinical hand wash.
 Continue………
Incubators/radiant warmers
• Clean incubators every day with a disposable cloth soaked in detergent and water, don’t use
chemicals or spirits.
• Strip and clean incubators and clean environment thoroughly with chlorine based disinfectant
500ppm after use by a neonate(discharge) and after 7 days. Phenolic solutions should not be used
as absorption through the skin may cause hyperbilirubinaemia.
Umbilical cord care
• Ensure umbilicus is always kept dry and clean
• Clean cord with 0.5% alcohol solution(spirits) immediately after birth and at every nappy change
• Ensure diaper is folded below the umbilicus to ensure cord remains dry and is not contaminated
with urine and stools.
Continue……..
Maintain skin Integrity as a major barrier to infection
• Apply hydrocolloid/semi permeable dressing beneath all adhesives.
• Bath babies with warm water and/or PH neutral cleanser or aqueous
cream.
• Apply barrier cream e.g., Zinc and castor oil at each nappy change.
• Use of aqueous disinfectant agents for skin cleaning products.
 CAUSES OF •

•
In the newborn infant conjunctivitis is usually caused by:
Chlamydia trachomatis. It is sexually transmitted and causes
CONJUNCTIVITIS infection of the cervix. During vaginal delivery, the eyes of the
infant may be colonised with Chlamydia as the infant passes
through the cervix. Chlamydial conjunctivitis, which is 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 probably the
commonest cause of conjunctivitis in the newborn infant.
• Gonococcus (Neisseria gonorrhoeae). This bacteria causes
mild, moderate, or severe conjunctivitis. Severe conjunctivitis
is most important as it can result in blindness. Like Chlamydia,
the Gonococcus is sexually transmitted and causes a cervicitis.
The eyes of the infant are colonised during vaginal delivery
and conjunctivitis develops hours or days thereafter.
• Staphylococcus. This, and other bacteria acquired in the
nursery after delivery, can also cause conjunctivitis (Woods,
2017).
MANAGEMENT OF Conjunctivitis
• The choice of treatment depends on the severity of the conjunctivitis
as the causative organism is often not known at the time of diagnosis.
• Mild conjunctivitis can usually be treated by cleaning the eye with
saline or warm water if the lashes become sticky. A local antibiotic is
frequently not needed. However, if the infection does not recover in a
few days, tetracycline or chloromycetin ointment should be used 6
hourly 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 3 hourly or
more frequently if needed. Usually, 5 days treatment is needed.
• 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. The simplest way of irrigating the eye is to
use a vacolitre of normal saline via an administration set.
Management of Conjunctivitis continue…..
• Intramuscular Ceftriaxone daily for 3 days must be given. Many strains of
Gonococcus are now resistant to penicillin. Therefore, intramuscular, or intravenous
penicillin should only be used if ceftriaxone is not available. Local antibiotic drops
alone are inadequate for treating a severe conjunctivitis as the infection may have
already spread to involve the whole eye.
• 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 treated. Also look for other sexually transmitted diseases such as syphilis
(Woods, 2017).
 Causes of umbilical cord/stump infection
• Infection of the umbilical cord/ stump usually is caused by:
• Bacteria that colonise the infant’s bowel such as
INFECTION OF THE UMBILICAL STUMP
OR CORD Escherichia coli
• Staphylococcus
• Clostridium tetani that causes tetanus
Management of umbilical cord/stump infection
• With good preventative cord care, infection of the umbilical
cord should not occur. 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.
• If the infection is localised to the umbilical cord or stump,
and there are no signs of cellulitis, peritonitis, septicaemia,
or tetanus, then treatment consists simply of cleaning the
cord frequently with surgical spirits. Neither local nor
systemic antibiotics (Woods, 2017).
 Management of the umbilical stump
infection.
• The cord or stump should be carefully cleaned with a
swab and adequate amounts of spirits 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. Keep a careful
watch for signs that the infection may have spread
beyond the umbilicus.
• Cellulitis of the abdominal wall around the base of
the cord (redness and oedema of the skin), peritonitis
or septicaemia must be treated with parenteral
antibiotics (Woods, 2017).
Causes of Skin infections

• The 2 commonest forms of skin infection in the

newborn infant are:
• Bullous impetigo caused by the Staphylococcus
which presents as pus-filled blisters usually
seen around the umbilicus or in the nappy area.
• 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
(Woods, 2017).
Rashes that frequently mimic skin infections are:
• Erythema toxicum which usually appears on day 2 or 3 after delivery as red blotches which
develop small yellow pustules in the centre. The rash is most marked on the face and chest and
disappears after about a week. The cause is not known, the infants remain generally well, and no
treatment is needed. This rash is important as it may look like a Staphylococcal infection.
• 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 (Woods, 2017).
 • If vernix is not routinely washed off immediately after
birth and if strict attention is paid to hand washing and
spraying, skin infection should not be a problem in a
nursery.
• Bullous impetigo is treated by washing the infant in
chlorhexidine (e.g., Bio scrub) twice a day for 5 days. Do
not cover the infected area with a diaper. 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 should
Management of become unwell and show any signs of septicaemia, then
urgent treatment with parenteral antibiotics is indicated.
Skin infections • 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. A little sunshine
will also help 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 to decrease the number of
Candida spores in the stool (Woods, 2017).
 • Septicaemia is infection of the blood stream with bacteria
which may have colonised the infant before, during or after
birth. Septicaemia is often a complication of a local

Causes Septicaemia infection, e.g., pneumonia, umbilical cord, or skin infection.

• Septicaemia can be caused by either Gram-positive bacteria
(e.g., Staphylococcus and Group B Streptococcus) or Gram-
negative bacteria (e.g., Escherichia coli, Klebsiella and
Pseudomonas) (Woods, 2017).
Management of Septicaemia
• General supportive care of a sick infant. Often transfer to a level 3 unit is needed.
• Antibiotics. When culture and sensitivity results are available, the most appropriate antibiotic
is chosen. While awaiting these results, however, the antibiotics most used are either:
• Benzyl penicillin 50 000 units/kg/dose plus gentamicin (Garamycin) 5 mg/kg/dose; or
cloxacillin 50 mg/kg/dose plus amikacin (Amikin) 5 mg/kg/dose. These are usually the first
drug combinations of choice.
• Cefotaxime (Claforan) 50 mg/kg/dose or ceftriaxone (Rocephin) 50 mg/kg/dose. They are
usually the second choice of antibiotic.
• 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. Ceftriaxone has the advantage of being given once a day intravenously or
intramuscularly. Gentamicin and amikacin are given also intravenously daily. Antibiotics
should be continued for 10 days (Woods, 2017).
Causes Pneumonia • Pneumonia may be acquired as the
result of colonisation of the upper
airways before, during or after
delivery:
• Before delivery, the foetus may be
infected by inhaling liquor that is
colonised by bacteria that have
spread from a chorioamnionitis.
• The lungs may be infected by
organisms that colonise 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
34
mother and staff (Woods, 2017).
 • General supportive care is important.
Transfer to a level 3 unit may be
needed.
• Usually, oxygen is needed.
• Give intravenous or intramuscular
antibiotics. Usually cefotaxime or
ceftriaxone, or penicillin and
Management of Pneumonia gentamicin are given (Woods, 2017).
Causes of Congenital
septicaemia OR • Caused by bacteria such as Escherichia coli (E coli), listeria

Neonatal sepsis and some strains of streptococcus. Group B streptococcus is

a major cause of congenital septicaemia. The problem has
become less common because women are screened during
pregnancy (Kaneshiro et al., 2021).
Management of Congenital septicaemia

• Babies younger than 4 weeks old who have fever or other signs of infection are started on intravenous
antibiotics right away. It may take 24 to 72 hours to get lab results. Newborns whose mothers had
chorioamnionitis or who may be at high risk for other reasons will also get IV antibiotics at first, even if
they have no symptoms.
• The baby will get antibiotics for up to 3 weeks if bacteria are found in the blood or spinal fluid.
Treatment will be shorter if no bacteria found.
• An antiviral medicine called acyclovir will be used for infections that may be caused by HSV.
• Babies who need treatment and have already gone home after birth will most often be admitted to the
hospital for monitoring (Kaneshiro et al., 2021).
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