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Spotlight on Neonatal Herpes

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The American Academy of Pediatrics has updated its guidelines for management of babies born to women who have active (or suspected) genital herpes lesions at delivery.

Women with genital herpes typically have normal pregnancies and deliver healthy babies, especially if the infection is long-standing: the mother’s antibody response to the virus is shared with the fetus, thus offering protection. The risk of neonatal herpes is highest among women who are infected with genital HSV close to the time of delivery. The lack of an immune response to share with the baby – and the large amounts of virus shed during first outbreaks- combine to put the baby at risk.

Symptoms of neonatal herpes, which are rarely present at birth, may take a few weeks to develop. This can be trouble, because prompt diagnosis and treatment (with the antiviral drug acyclovir) is critical in neonatal HSV infections.

Mother’s HSV History Guides Baby’s Treatment
When the mother has both a history of genital herpes and active lesions at delivery, Academy guidelines call for:

  • obtaining samples from the baby of areas vulnerable to HSV infection: eyes, mouth, nasal passages, and rectum
  • blood sample of the infant for HSV PCR testing
  • refraining from treatment if the baby has no symptoms.

If tests are all negative, then educate the family on signs of HSV and follow-up visits are scheduled for close monitoring of the baby. If any tests are positive, though, begin acyclovir treatment and do more advanced testing (such as cerebral spinal fluid (CSF) tests). If baby remains without  symptoms and CSF tests are negative, then continue with the preemptive treatment for 10 days. If baby develops symptoms or any of the tests indicate infection, then treat for 14 days. With disseminated infections, treatment should be extended to 21 days.

If the mother has lesions but no prior history of HSV, more aggressive management is recommended: this includes starting acyclovir even if the baby has no symptoms. The guidelines in this case also call for:

  • type-specific tests for maternal HSV-1 and HSV-2 antibodies
  • obtaining skin and blood samples from baby and also test CSF for HSV
  • If mother is determined to have a newly acquired genital herpes, course of treatment depends on symptoms and results of baby’s tests: 10 days with negative tests; 14 days with infections of the skin, eyes, or mouth; 21 days with disseminated infection
  • If mother is determined to have recurrent episode, however, then stop acyclovir if baby’s tests are negative.

For more on HSV and pregnancy, visit the Herpes Resource Center.

Kimberlin D, Baley J, and the Committee on Infectious Diseases and Committee on Fetus and Newborn. Guidance on Management of Asymptomatic Neonates Born to Women with Active Genital Herpes Lesions. Pediatrics, 2013. Accessed February 13, 2013 online.


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