Definition and Severity

Neonatal infections are those acquired by newborns during the earliest stage of life. These infections tend to be severe as the baby’s immune system is not yet fully developed to combat them effectively. Infection refers to the invasion of the body by harmful organisms such as bacteria, protozoa, and viruses.

Categorization

These infections can occur during intrauterine life, delivery, and the neonatal period. They are categorized into:

1. Congenital infections
2. Acquired infections.

Sources of Infections Workflow

Antenatal Period Sources

• Intrauterine infections can arise from various microorganisms, described by the acronym “STORCH” (Syphilis, Toxoplasmosis, Others including Gonococcal infections, Tuberculosis, Malaria, Varicella, Hepatitis B, HIV, Rubella, Cytomegalovirus (CMV), and Herpes Simplex). These infections may develop due to direct transplacental transfer or placental infections.
• Ascending infections can contaminate amniotic fluid and cause amnionitis, leading to intrauterine fetal infection.

Intranatal Period Sources

• Neonates can get infected during delivery through:
  
  1. Aspiration of infected liquor during prolonged labor or early rupture of membranes, leading to neonatal aspirated pneumonia.
  2. Repeated vaginal examinations by the delivery assistant, particularly after membrane rupture.
  3. Infection from the birth passage (vagina) may affect the eyes and mouth, causing ophthalmia neonatorum and oral thrush.
  4. Improper umbilical cord care techniques may result in umbilical sepsis.

Postnatal Period Sources

• Transmission of infections can occur from human contact or caregivers, including infected hands of mothers, family members, and health workers.
• Cross infections from other infected babies due to lack of barrier nursing and universal precaution measures.
• Infections can spread through contaminated articles, equipment, clothing, invasive procedures without aseptic techniques, and the surrounding environment in hospitals, health centers, or homes.
• Other sources include infected clinical waste, contaminated food and water, infected insects or animals, and dust.
• Additionally, babies born before arrival may be exposed to infections during transit.

Routes of Infection Workflow

Entry Sites

1. Respiratory tract: Infections can enter the baby’s body through the air they breathe, causing issues in the lungs and respiratory system.
2. Cord stump: The area where the umbilical cord was attached is susceptible to infection until it fully heals, providing a route for bacteria to enter the body.
3. Broken skin (cuts and bruises): Any breaks in the skin, like cuts or bruises, can allow bacteria to enter the body and cause infection.
4. Alimentary tract: Infections can occur through the digestive system, affecting organs like the stomach and intestines, often through contaminated food or water.
5. Eyes, orifices like vagina and anus: Infections can enter through the eyes or openings in the body, such as the vagina and anus, leading to conditions like conjunctivitis or diaper rash.

Factors Responsible for Neonatal Infections Workflow

Contributing Factors

1. Low birth weight infants: Babies born with low birth weight may have weaker immune systems, making them more susceptible to infections.
2. Birth asphyxia and resuscitation: Difficulties during birth, like lack of oxygen, can weaken the baby’s immune system and increase the risk of infection.
3. Congenital anomalies: Structural abnormalities present at birth can make it easier for infections to occur.
4. Sex of the baby: Boys may be more susceptible to infections due to genetic factors related to immune function.
5. Lack of natural immunity in newborns: Newborns have not yet developed their own immune defenses, relying on antibodies passed from their mothers to protect them.
6. Delay in acquiring acquired immunity: It takes time for newborns to develop their own immune responses, leaving them vulnerable to infections in the meantime.
7. Placental barrier: While the placenta protects the baby during pregnancy, certain infections can still pass through to the fetus.
8. Maternal mucus at the cervix: Mucus in the mother’s cervix helps protect against infections, but it’s not always effective in preventing all types of pathogens from reaching the baby.
9. Liquor amnii: The amniotic fluid surrounding the baby in the womb can become contaminated with bacteria, potentially causing infections.
10. Artificial feeding other than breastfeeding: Breast milk provides important antibodies that help protect babies from infections, so babies who are not breastfed may be more vulnerable.
11. Infections from the birth canal or delivery room: Babies can be exposed to bacteria during birth, especially if there are complications like prolonged labor or ruptured membranes.
12. Inadequate asepsis during neonatal procedures: Procedures like IV insertion or intubation can introduce bacteria into the baby’s body if proper sterile techniques are not followed.
13. Contaminated intrauterine environment: Factors like prolonged rupture of membranes or repeated vaginal examinations can increase the risk of infections for the baby before birth.
14. Risk of infections spreading to other babies: Infections can easily spread in healthcare settings if proper infection control measures are not followed.
15. Contribution to high percentages of neonatal morbidity and mortality: Infections can lead to serious complications and even death in newborns if not promptly diagnosed and treated.

Babies at Risk of Infections Workflow

High-Risk Groups

• Premature babies: Babies born prematurely may have underdeveloped immune systems, increasing their susceptibility to infections.
• Babies born following early rupture of membranes: Babies exposed to amniotic fluid for a prolonged period before birth may be at higher risk of infections.
• Babies born after prolonged and difficult labor: Complications during labor can weaken the baby’s immune system and increase the risk of infections.
• Babies born with severe asphyxia and undergo prolonged resuscitation at birth: Lack of oxygen during birth can compromise the baby’s immune defenses, making them more susceptible to infections.
• Babies born to mothers with diabetes mellitus, pre-eclampsia, eclampsia, chronic anemia, active tuberculosis, bottle-fed babies, and babies born before arrival: These babies may have weakened immune systems or other risk factors that make them more susceptible to infections.

Diagnosis Workflow

Suspicion and General Signs

Sometimes, a midwife may not see obvious signs of infection, but suspicion should rise if the baby fails to thrive despite adequate feeding (breastfeeding). The presence of one or more of the following signs suggests infection:

• Refusal of feeds
• Vomiting
• Diarrhea with or without blood
• Weak or high-pitched cry
• Restlessness or lethargy and loss of interest in surroundings
• Twitching or generalized convulsions
• Diminished or absent reflexes, especially Moro and sucking reflexes
• Bulging fontanelle
• Alterations in rate and rhythm of respiration, which may be labored or grunting
• Nasal discharge
• Bleeding from the rectum or mouth
• Presence of rash, especially pustules
• Jaundice
• Cyanotic attacks Note: Temperature may be elevated, but the midwife must be aware that a low temperature in the presence of infection is common in newborn babies.

Site-Specific Signs

• Heat: The affected area may feel warm to the touch due to increased blood flow and inflammation caused by the body’s immune response to the infection.
• Redness: Inflammation can cause the skin to appear red or flushed around the infected area.
• Swelling: Swelling occurs as a result of fluid accumulation in the tissues as part of the body’s defense mechanism against infection.
• Tenderness: The infected area may be sensitive to touch or pressure, causing discomfort or pain.
• Loss of function: In severe cases, the infected area may lose its normal function due to pain, swelling, or tissue damage caused by the infection.

Investigations Workflow

Core Tests

• Estimation of hemoglobin: This test measures the amount of hemoglobin, a protein in red blood cells that carries oxygen. Low levels of hemoglobin may indicate anemia, which can be a sign of infection or other health issues.
• White blood cell count: White blood cells are a key part of the body’s immune system and are responsible for fighting infections. An elevated white blood cell count may indicate an active infection.
• Urine testing: Urine analysis can detect the presence of bacteria, white blood cells, and other substances that may indicate a urinary tract infection or other systemic infection.
• Blood culture: This test involves taking a sample of blood and culturing it in a laboratory to detect the presence of bacteria or other pathogens. A positive blood culture indicates the presence of an infection in the bloodstream.
• Lumbar puncture: Also known as a spinal tap, this procedure involves inserting a needle into the spinal canal to collect cerebrospinal fluid for analysis. It is commonly used to diagnose infections of the central nervous system, such as meningitis.

Additional Tests

• Chest X-ray: This imaging test may be performed to assess the lungs for signs of infection, such as pneumonia.
• CRP (C-reactive protein) levels: Elevated levels of CRP in the blood indicate inflammation and can be a marker of infection.
• Procalcitonin levels: Procalcitonin is a marker of bacterial infection, and elevated levels in the blood may indicate a bacterial infection rather than a viral one.
• Throat swab: A swab of the throat may be taken to test for bacterial infections such as strep throat.
• Stool culture: This test may be performed to detect the presence of bacteria, parasites, or viruses in the stool, which can indicate gastrointestinal infections.
• Imaging studies: Depending on the suspected site of infection, imaging studies such as ultrasound, MRI, or CT scans may be ordered to visualize internal structures and identify signs of infection or inflammation.

Prevention and Control Workflow

During Antenatal Care

1. Proper antenatal care (ANC)
2. Encourage all expectant mothers to attend ANC
3. Immunize mothers and administer tetanus toxoid (TT)
4. Screen mothers for infections like syphilis, gonorrhea, and candidiasis, and treat them
5. Provide health education on personal hygiene and the importance of a clean, safe delivery environment
6. Teach mothers how to care for umbilical stumps
7. Encourage mothers to use clean materials for cord cutting and tying, avoiding banana fibers, and prepare mamakit in case of home or roadside deliveries

During Labor

1. Avoid premature and prolonged labor
2. Perform vaginal examinations only when necessary and under strict aseptic techniques
3. Try to keep membranes intact as long as possible

During Delivery

1. Conduct delivery in an environment with trained personnel knowledgeable about sterility
2. Supervise delivery by trained individuals
3. Minimize excessive interference and trauma
4. Use sterile equipment for procedures like suction and cord cutting

During Postnatal Period

1. Emphasize cleanliness, both domestic and personal
2. Wash hands frequently and thoroughly before and after handling baby equipment or the baby
3. Keep hair clean and short, and maintain uniform, clean, and tidy attire
4. Ensure an adequate supply of clean linen for both baby and mother
5. Disassemble and clean incubators with antiseptic solution
6. Dust and mop nursery floors with disinfectant
7. Do not exchange baby cots or individual equipment between infants
8. Maintain cleanliness during feeding; clean hands and breasts before breastfeeding
9. Encourage breastfeeding to take advantage of its many anti-infective properties
10. Use aseptic techniques when preparing feeds; have a designated area for boiling and preparation, and ensure cleanliness of feeding utensils
11. Teach mothers proper breast care and hygiene
12. Conduct regular observations of both baby and mother to detect deviations from normal early
13. Inspect babies daily for signs of infection
14. Observe mothers for signs of infection, particularly in the breasts; isolate infected mothers if necessary
15. Strictly isolate all infected babies
16. Monitor for early signs of infection like thrush or ophthalmia neonatorum and report promptly for treatment
17. Avoid overcrowding in the nursery
18. Disinfect articles, utensils, and linen or isolate as necessary
19. Only allow nursery staff to enter the nursery
20. Wear gowns while in the nursery
21. Do not allow midwives or mothers with sore throats, colds, or other infections to enter the nursery or care for newborns
22. Care for the umbilical cord by keeping it dry and clean with normal saline or sterile swabs
23. Consider prophylactic antibiotics for babies at higher risk of infection, but avoid overuse to maintain effectiveness