Should I refer an 18-month-old with herpes simplex virus (HSV) infection acquired from the mother to a specialist?

Referral for 18-Month-Old with Herpes on Scalp

Yes, an 18-month-old with herpes simplex virus (HSV) infection on the scalp acquired from the mother should be referred to a pediatric specialist, specifically a pediatric ophthalmologist or infectious disease specialist. 1, 2

Rationale for Referral

The American Academy of Pediatrics guidelines specifically state that infants and children with "ocular or periocular inflammation not responding to initial topical and/or systemic antibiotic therapy or not clearing within 3 weeks of treatment and children with suspected herpes simplex or zoster infections involving the eye or a history of these infections involving the eye" should be referred to a pediatric ophthalmologist 1.

Even though the current infection is on the scalp, HSV infections in young children warrant specialist evaluation for several reasons:

1. Risk of complications: HSV infections in young children can spread and potentially involve:

   • Eyes (keratoconjunctivitis)
   • Central nervous system
   • Multiple organ systems

2. Need for appropriate treatment: While the infection appears localized to the scalp now, specialist evaluation ensures:

   • Proper diagnosis confirmation
   • Appropriate treatment regimen
   • Monitoring for complications

Management Considerations

Immediate Assessment

• Evaluate extent of lesions on scalp
• Check for any signs of eye involvement
• Assess for systemic symptoms (fever, irritability, lethargy)
• Determine if this is a primary infection or recurrence

Treatment Options

• For localized skin infections in children, treatment options include:
  • Oral acyclovir at 20 mg/kg every 8 hours for children under 12 years 3
  • For more severe cases, intravenous acyclovir may be required

Follow-up Care

• Regular monitoring for recurrences, especially during the first 6 months
• Long-term follow-up to assess for any developmental concerns

Special Considerations

Maternal History

• Determine if the mother has a history of HSV-1 or HSV-2
• Assess if transmission occurred during pregnancy, delivery, or postpartum
• If the mother has active lesions, advise on preventing further transmission

Breastfeeding Considerations

• Breastfeeding can generally continue unless the mother has herpetic lesions on the breasts 4
• If the mother has cracked nipples with detectable HSV DNA, temporary interruption of direct breastfeeding may be necessary 2

Prevention of Further Spread

• Proper hand hygiene for all caregivers
• Avoid direct contact with lesions
• Keep lesions covered when possible
• Avoid sharing personal items (towels, clothing)

Pitfalls to Avoid

• Delayed referral: HSV infections can progress rapidly in young children
• Inadequate treatment: Insufficient dosing or duration of antiviral therapy can lead to treatment failure
• Missing eye involvement: Always check for ocular manifestations, even when primary lesions are elsewhere
• Failure to consider systemic spread: Be vigilant for signs of disseminated disease

Early specialist referral ensures optimal management of this potentially serious infection and helps prevent complications that could affect the child's long-term health and development.