(Step-by-Step Clinical Algorithm)
1️⃣ When to Suspect Congenital Syphilis
Maternal Clues
Mother untreated or inadequately treated for syphilis
Treatment given <30 days before delivery
No documentation of falling titers
Maternal RPR/VDRL positive
High-risk pregnancy (HIV+, multiple partners)
Neonatal Clues
Early CS (<2 years):
Snuffles (bloody nasal discharge)
Skin rash on palms/soles
Hepatosplenomegaly
Jaundice, anemia, thrombocytopenia
Pseudoparalysis of Parrot
Osteochondritis
Mucocutaneous lesions
Late CS (>2 years):
Hutchinson triad (teeth, deafness, interstitial keratitis)
Saber shins
Saddle nose
Frontal bossing
2️⃣ Initial Workup (Screening & Confirmation)
Maternal RPR/VDRL & Treponemal test
Check treatment status
Compare maternal & infant titers
Infant Evaluation Checklist
✔ Non-treponemal test (RPR/VDRL) — must compare infant vs mother
✔ Treponemal test (FTA-ABS/TPPA)
✔ CBC — anemia, thrombocytopenia
✔ LFTs
✔ LP (CSF VDRL, protein, cells)
✔ Long bone X-ray (metaphyseal changes)
✔ Placental/cord tests (dark-field if available)
✔ HIV testing (co-infection risk)
3️⃣ Diagnosis
Infant is considered infected if:
Infant RPR/VDRL ≥ 4× maternal titer
Clinical signs of congenital syphilis
Maternal treatment inadequate or undocumented
Positive CSF VDRL
4️⃣ Treatment Algorithm (VERY IMPORTANT)
A. Proven or Highly Probable Congenital Syphilis
(Symptomatic OR ≥4× titer OR abnormal CSF OR abnormal XR)
→ Aqueous Crystalline Penicillin G
50,000 units/kg/dose IV
Every 12 h for first 7 days
Every 8 h for next days to complete 10 days
OR
→ Procaine Penicillin G
50,000 units/kg IM daily × 10 days
B. Possible Congenital Syphilis
(Asymptomatic, normal CSF, but maternal treatment inadequate or unknown)
Two acceptable regimens:
→ Aqueous Crystalline Penicillin G × 10 days
OR
→ Benzathine Penicillin G single dose
50,000 units/kg IM
(Only if full evaluation is normal & reliable follow-up possible)
C. Less Likely Congenital Syphilis
(Normal baby, maternal treatment adequate, no reinfection)
→ No treatment OR single dose Benzathine Penicillin G
50,000 units/kg IM
If follow-up uncertain → give single dose.
D. Proven Congenital Syphilis With Neurosyphilis
(CSF VDRL positive / high protein / high cells)
→ Aqueous Crystalline Penicillin G × 10–14 days
At meningitis dosing (every 8–12 hrs)
5️⃣ Follow-up Schedule
Non-treponemal titers (RPR/VDRL)
At 1, 3, 6, 12 months
Should decline by 3 months
Should be nonreactive by 6–12 months
If persistent titers → Evaluate for treatment failure or reinfection
Treponemal tests remain positive for life → Not useful for follow-up
CSF repeat
Only if initial CSF abnormal
Repeat at 6 months
6️⃣ Complications to Monitor
Hearing impairment
Ophthalmologic problems
Dental abnormalities
Developmental delay
Bone deformities
Approach to Congenital Syphilis (Pediatrics)
