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Referral and warning signs
When to refer
Refer Urgently to Hospital if: Signs of Very Severe Disease develop (See PED002). Local infection not improving after 2 days of home treatment. Eyes still discharging pus after 2 days of treatment. Umbilical redness extending to surrounding skin. >=10 skin pustules or any bullae/hardness.
Red flags
- Any Newborn Danger Sign.
- Umbilical redness spreading to abdominal wall.
- Large blisters (bullae) or hardened skin swelling.
- Severe eye swelling or corneal clouding.
- Signs suggesting congenital syphilis (rash, snuffles, hepatosplenomegaly) or TB.
Signs and symptoms
- Local Infections:
- - Umbilical Infection: Redness and/or pus discharge from umbilicus (without redness extending to skin - otherwise PSBI).
- - Skin Infection: <10 skin pustules.
- - Eye Infection (Ophthalmia Neonatorum): Eyes swollen and/or draining pus.
- Risk Factors (Increased risk of systemic infection):
- - Maternal fever (>38°C) or antibiotic treatment within 2 days of delivery.
- - Rupture of membranes >18 hours before delivery.
- - Mother RPR positive (Syphilis risk).
- - Mother started TB treatment <2 months before delivery (TB risk).
Risk factors
- Poor hygiene during delivery or postnatal care.
- Application of substances to umbilical cord.
- Maternal infections (GBS, Gonorrhoea, Chlamydia, Syphilis, TB).
- Prolonged rupture of membranes.
Diagnosis
Clinical assessment
Direct examination of eyes, umbilicus, and skin. History taking regarding maternal infections, duration of membrane rupture, cord care practices.
Investigations
- Clinical examination is primary.
- Swab for Gram stain/culture (eye discharge, umbilical pus) - rarely done at primary level.
- Maternal RPR status check.
- Maternal TB/HIV status check.
Diagnostic criteria
Based on clinical findings (pus, redness, pustules) or presence of specific risk factors.
Management
Non-pharmacological management
- Local Umbilical Infection: Teach mother home care: Wash crust/pus with cooled boiled water, dry, apply Gentian Violet 0.5% TID. Follow up in 2 days.
- Local Skin Infection (<10 pustules): Teach mother home care: Wash crust/pus with cooled boiled water, dry, apply Gentian Violet 0.5% TID. Follow up in 2 days.
- Eye Infection: Teach mother home care: Clean eyes with clean wet cloth (separate part for each eye, wipe outwards) TID. Apply Tetracycline eye ointment 1% TID after cleaning. Follow up in 2 days.
Pharmacological treatment
- Local Umbilical / Skin Infection: No systemic antibiotics if truly localized (no danger signs, no surrounding skin redness for umbilicus, <10 pustules).
- Gonococcal Eye Infection (Ophthalmia Neonatorum):
- - Ceftriaxone 125 mg IM single dose
- - PLUS Azithromycin syrup 20 mg/kg PO once daily for 3 days.
- - Treat mother and partner for GC/Chlamydia (See STI chapter).
- Risk of Bacterial Infection (PROM >18h or Maternal Fever/Antibiotics):
- - Prophylactic Antibiotics: Ampicillin 50 mg/kg IM Q12H PLUS Gentamicin 5 mg/kg (4 mg if preterm) IM OD for 5 days. Assess baby daily.
- Risk of Congenital Syphilis (Mother RPR Positive):
- - Benzathine Penicillin G 50,000 IU/kg IM single dose.
- - Ensure mother/partner treated. Follow up baby every 2 weeks.
- Risk of TB (Mother started ATT <2m pre-delivery):
- - Isoniazid (INH) prophylaxis 5 mg/kg PO daily for 6 months.
- - Delay BCG vaccination until INH prophylaxis complete.
- - Reassure mother breastfeeding is safe. Follow up baby every 2 weeks.
Monitoring
Follow up local infections in 2 days - assess for improvement or signs of worsening/systemic spread. Follow up infants on prophylaxis as per schedule.
Complications
- Progression from local to systemic infection (sepsis, meningitis).
- Corneal scarring/blindness (from untreated ophthalmia neonatorum).
- Complications of congenital syphilis or TB if prophylaxis fails/not given.
- Umbilical hernia (if infection severe).
Prevention
- Clean delivery practices.
- Clean cord care (dry care recommended).
- Antenatal screening and treatment of maternal infections (Syphilis, Gonorrhoea, Chlamydia).
- Tetracycline eye ointment prophylaxis at birth.
- Prompt management of prolonged rupture of membranes.
- Appropriate management of maternal TB.
Patient education
- How to perform home care for local infections (umbilicus, skin, eyes) including hygiene.
- How to administer prescribed medications (e.g., Azithromycin syrup, INH).
- Signs of worsening infection or danger signs requiring immediate return.
- Importance of follow-up appointments.
- Importance of maternal/partner treatment for STIs.
- Rationale for prophylactic treatment based on risk factors.
Uganda-specific notes
Umbilical infections due to unhygienic practices are common. Ophthalmia neonatorum often gonococcal. Gentian violet is widely used for local infections. Prophylaxis based on maternal RPR/TB status is important. Partner treatment for STIs is crucial but challenging.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 17, Section 17.1.2
- Uganda Clinical Guidelines (UCG) 2023
Chapter 3 (STI sections 3.2.1, 3.2.2, 3.2.7, 3.2.9.1)
- Uganda Clinical Guidelines (UCG) 2023
Chapter 5 (TB section on prophylaxis)