Approach to evaluation and management of newborns born to a birthing parent who tested positive for syphilis during pregnancy or at delivery

ABR: auditory brainstem response; CBC: complete blood count; CDC: Centers for Disease Control and Prevention; CSF: cerebrospinal fluid; DFA: direct fluorescent antibody; IM: intramuscular; IV: intravascular; LP: lumbar puncture; PCR: polymerase chain reaction; RPR: rapid plasma regain; VDRL: venereal disease research laboratory.

* Findings of congenital syphilis may include hepatosplenomegaly, rash, condyloma lata, snuffles, jaundice (nonviral hepatitis), pseudoparalysis, pallor (anemia), or edema (nephrotic syndrome and/or malnutrition). Refer to UpToDate topic on congenital syphilis for additional details.

¶ A 4-fold titer is equivalent to two dilutions (eg, infant's titer 1:32 when the birthing parent's titer is 1:8).

Δ These tests are not available in most clinical settings.

◊ Additional testing may include neuroimaging if there are concerning neurologic findings, chest radiograph if there are pulmonary findings, or abdominal imaging if there is significant organomegaly.

§ Adequate treatment is defined as completion of a penicillin-based regimen, in accordance with CDC treatment guidelines, appropriate for stage of infection and initiated ≥4 weeks before delivery. Relapse or reinfection after treatment is suggested by a 4-fold increase in the birthing parent's VDRL or RPR titers after treatment. Inadequate/suboptimal therapy includes any of the following:

• Treatment with a nonpenicillin antibiotic
• Treatment given <4 weeks before delivery
• Inappropriate dose for stage of disease
• Inadequate documentation of maternal treatment
• Inadequate response to therapy (ie, birthing parent's VDRL or RPR titers did not decline at least 4-fold after treatment)

¥ The CDC guidelines include a caveat that additional evaluation may not be necessary for neonates in the "possible" category if a 10-day treatment course is planned. Nevertheless, we suggest performing the evaluation in higher-risk neonates (as defined above) since the evaluation may inform decisions regarding treatment and follow-up.

‡ Follow-up evaluations are warranted for all infants who have undergone testing for congenital syphilis. The approach is as follows:

• If the infant was seropositive at birth, they should be monitored with follow-up examinations and serial serologic testing with VDRL or RPR (use same test as for initial testing) every 2 to 3 months until nonreactive. If serology is still positive at 6 months, the infant should be re-evaluated (including LP) and treated with an extended course of parenteral penicillin.
• If the infant was seronegative at birth, they should be retested at 3 months to confirm that they remain seronegative.

† For infants in the "less likely" category, some specialists opt not to treat and instead provide close (ie, monthly) serologic follow-up. If this approach is chosen, treatment should be provided if the infant's titers do not decline as expected over the first few months after birth.

** If follow-up is uncertain, some specialists would provide a single dose of IM penicillin G benzathine (long-acting IM penicillin) to protect the infant in the unlikely event that the birthing parent was reinfected.