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id.hsv-neonatal.core.v1PRODUCTION
id.hsv-neonatal.core.v1

Neonatal HSV (SEM, CNS, disseminated forms) — empiric acyclovir + form-specific duration

pediatricsacuteneonatal
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Neonatal HSV (≤ 28 d, late-onset variants out to ~ 42 d). Three biologic forms: SEM (skin/eye/mouth — 14 d acyclovir), CNS (encephalitis — 21 d + 6 mo PO suppression), disseminated (21 d + ICU + bacterial co-empirics). Untreated mortality > 50% disseminated, > 80% CNS. Recognition + empiric IV acyclovir BEFORE PCR is the index intervention.

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Neonatal HSV suspected (clinical features OR maternal HSV OR PCR positive)

Patient inputs (29)

Preterm < 35 wk drives reduced acyclovir interval (q12h not q8h) for adequate exposure without nephrotoxicity (Kimberlin 2013; AAP Red Book 2024)

Weight-based acyclovir dosing (mg/kg, mL/kg); ECMO eligibility threshold ≥ 2 kg + ≥ 34 wk per institutional protocol

Tachycardia > 180 OR bradycardia < 100 (terminal sign) per age-appropriate thresholds

Tachypnoea > 60 OR apnoea — disseminated HSV pneumonitis or CNS HSV brainstem involvement

Hypoxaemia in disseminated HSV pneumonitis; drives O2 + intubation decision

Maternal primary HSV near delivery → 30-50% transmission risk; recurrent → 2-5%; no known history does NOT lower pretest because primary infection often asymptomatic (ACOG Practice Bulletin 220 2020)

Active maternal genital lesions at delivery → highest-pretest cohort; C-section reduces but does NOT eliminate transmission (ACOG 220 2020)

Vaginal with active lesions = highest risk; scalp electrode / vacuum / forceps trauma sites can be HSV reactivation foci (Kimberlin 2013)

Vesicles on skin / mucous membrane → LR+ ~ 8 for HSV in neonate (Kimberlin 2013); vesicle-base PCR has highest yield

≤ 28 d defines neonatal HSV; late-onset variants out to ~ 42 d; partitioning age-band drives source (maternal vs caregiver) hypothesis (Kimberlin 2013 PMID 23359576)

CSF HSV PCR sensitivity ≥ 95% for CNS HSV; specificity ~ 100%; repeat at 48-72 h if clinical suspicion remains + initial negative (Kimberlin NEJM 2011)

Blood HSV PCR positivity supports disseminated form; pairs with CSF and surface PCR (Kimberlin 2013)

Surface swabs: mouth, nasopharynx, conjunctivae, anus, vesicle base. Timing > 24 h of life for true infant infection (avoid maternal-flora contamination from < 12 h swabs) (AAP Red Book 2024)

CSF: lymphocytic pleocytosis (vs neutrophilic in bacterial), elevated protein (often 100-500 mg/dL), normal-low glucose — CNS HSV pattern

ALT/AST > 100 supports disseminated HSV (Kimberlin Pediatrics 2013 PMID 23359576); baseline for acyclovir hepatic monitoring

Thrombocytopenia common in disseminated HSV; baseline for acyclovir neutropenia monitoring (Kimberlin NEJM 2011 — neutropenia ~ 20% on 60 mg/kg/d)

DIC pattern in disseminated HSV: PT/PTT prolonged, fibrinogen low, D-dimer high; transfuse cryoprecipitate + FFP + platelets per shortfall

Baseline + serial during IV acyclovir for crystalline nephropathy monitoring; dose-adjust if AKI (FDA label + Kimberlin 2013)

Bacterial co-empirics until alternative source identified; rule out bacterial coinfection in sepsis-like disseminated HSV

Hypothermia < 36 °C in neonate is a sepsis / disseminated-HSV criterion; fever ≥ 38 °C also relevant

New-onset seizures in ≤ 28 d neonate + no other cause → CNS HSV until excluded; AED + EEG monitoring (Kimberlin NEJM 2011)

Encephalopathy / abnormal tone / lethargy / poor feeding — CNS HSV marker; bulging fontanelle in infant

Hypotension in disseminated HSV septic-shock physiology by gestational-age threshold; drives vasoactive

Conjunctival injection + corneal involvement — SEM eye form; ophthalmology consult mandatory + topical antiviral (trifluridine)

EEG for CNS HSV: focal sharp waves, periodic patterns, especially temporal lobe; baseline for seizure monitoring + recurrence detection

MRI: temporal lobe + insular T2 hyperintensity classic for HSV encephalitis; baseline for severity + sequelae

CXR if respiratory distress; disseminated HSV pneumonitis = diffuse infiltrates; differentiate RDS, TTN, bacterial pneumonia

Cranial US for ventriculomegaly + IVH baseline; serial × 7 d in preterm with CNS HSV

Late-onset (> 21 d) often HSV-1 from caregiver oral source; check caregiver active lesions / cold sores (Kimberlin 2013)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateningvesicles_in_neonate_under_28d
    Vesicular skin or mucous-membrane lesions (mouth / conjunctivae / scalp) in a neonate ≤ 28 d — empiric IV acyclovir 60 mg/kg/d divided q8h within 1 h + HSV PCR (CSF + blood + surface swabs) + admit + close monitor (Kimberlin Pediatrics 2013 PMID 23359576; AAP Red Book 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningseizure_in_neonate_under_28d_with_no_other_cause
    New-onset neonatal seizures (often subtle — lip smacking, eye deviation, bicycling) in a ≤ 28 d neonate with no clear bacterial / metabolic / structural cause — empiric acyclovir + LP for CSF + HSV PCR + EEG; routes to peds.status_epilepticus.v1 if status epilepticus evolves (Kimberlin Pediatrics 2001 PMID 11483782)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghypothermia_or_unexplained_encephalopathy_in_neonate
    Hypothermia (T < 36 °C) OR unexplained encephalopathy / abnormal tone / lethargy / poor feeding in a neonate ≤ 28 d — empiric acyclovir + sepsis workup + bacterial co-empirics; do NOT defer for culture results (AAP Red Book 2024; HSV mimics sepsis)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdisseminated_hsv_with_dic
    Disseminated HSV features in neonate ≤ 28 d — sepsis-like + DIC (prolonged PT/PTT, low fibrinogen, high D-dimer, low platelets) + hepatic (AST/ALT 2-10× ULN) + hypothermia + multi-organ failure → ICU + acyclovir + bacterial co-empirics + supportive (cryoprecipitate + FFP + platelets); mortality ~ 30% even with treatment; routes to id.sepsis.peds.v1 + id.neonatal-sepsis.early-late.v1 with dual coverage (AAP Red Book 2024; Kimberlin NEJM 2011)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcns_hsv_with_csf_pleocytosis
    CSF lymphocytic pleocytosis ≥ 5 WBC/µL + elevated protein (often 100-500 mg/dL) + normal-low glucose + HSV PCR positive OR strong clinical suspicion in neonate ≤ 28 d → 21 d acyclovir IV + 6 mo oral suppression per Kimberlin 2011 PMID 21991950 (Kimberlin Pediatrics 2001 PMID 11483782)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransaminitis_in_neonate_under_28d
    AST/ALT 2-10× ULN in a neonate ≤ 28 d — suspect disseminated HSV; full HSV workup + empiric acyclovir + serial AST/ALT + consider hepatic ultrasound; differential includes ischemic hepatopathy and metabolic disease (Kimberlin Pediatrics 2013 PMID 23359576)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverematernal_active_genital_hsv_at_delivery
    Maternal active genital HSV lesions at delivery — primary infection (30-50% transmission) OR recurrent infection (2-5% transmission); C-section indicated if active lesions; consider neonatal prophylactic acyclovir × 10 d for maternal primary HSV with delivery within 4 wk of seroconversion per local protocol (ACOG Practice Bulletin 220 2020; Kimberlin Pediatrics 2013 PMID 23359576)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_completion_oral_suppression_x_6mo
    Neonate completed 21 d IV acyclovir for CNS or disseminated form → transition to oral acyclovir suppression 300 mg/m² PO TID × 6 months per Kimberlin NEJM 2011 PMID 21991950 (neurodev outcome benefit at 12 mo + recurrence reduction ~ 50%)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehsv_recurrence_postnatal
    Recurrent SEM disease after completed acute treatment course — ~ 50% of treated infants by 12 mo (especially HSV-2) → re-treat acute (14 d IV acyclovir) + extend suppression duration per ID consult; ocular recurrence → topical trifluridine + systemic acyclovir; do not skip systemic for ocular-only (Kimberlin Pediatrics 2013 PMID 23359576)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateacyclovir_nephrotoxicity_monitoring_required
    Neonate on IV acyclovir 60 mg/kg/d requiring serial renal monitoring + IV hydration 1.5-2× maintenance + dose-adjust for AKI; foscarnet alternative only if persistent HSV PCR positive on adequate acyclovir dose + adequate hydration + adequate duration (Kimberlin 2013 PMID 23359576; FDA label)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Neonatal HSV acyclovir regimen — by form (SEM / CNS / disseminated) + duration + suppression
axis: neonatal_hsv_acyclovir_by_formstep sem_form_14d - SEM (skin / eye / mouth) form — 14 days IV acyclovir
Selected step "SEM (skin / eye / mouth) form — 14 days IV acyclovir" — HSV PCR positive surface (vesicle / mouth / conjunctivae) OR clinical SEM presentation in neonate ≤ 28 d WITHOUT CSF pleocytosis AND WITHOUT disseminated features (normal LFT, no DIC, no shock)
  • acyclovir
    first line
    antiviral_nucleoside_analog
    60 mg/kg/day divided q8h IV (20 mg/kg/dose) for term ≥ 35 wk; q12h if preterm < 35 wk • IV • q8h (q12h preterm)
    triggers: sem_form_recognition, hsv_pcr_positive_surface
    Kimberlin Pediatrics 2001 PMID 11483782 — high-dose 60 mg/kg/d superior to historical 45 mg/kg/d for outcome; 14 d duration for SEM form (no CSF pleocytosis + no disseminated features)
    rxcui 281

outpatient playbook — drug actions (6)

  1. 1. oral acyclovir suppression × 6 months (CNS / disseminated)
    300 mg/m² PO TID × 6 months • PO • TID
    trigger: Completed 21 d IV course for CNS or disseminated form
    Kimberlin NEJM 2011 PMID 21991950 — neurodev outcome benefit at 12 mo; reduces skin recurrence ~ 50%; monthly CBC for neutropenia monitoring
  2. 2. oral acyclovir suppression case-by-case (SEM)
    300 mg/m² PO TID × 6 months (some centres) • PO • TID
    trigger: SEM form with high recurrence-risk profile per local protocol (not universal practice)
    Recurrence prevention; case-by-case per ID input; not all centres do this for SEM
  3. 3. recurrent SEM re-treatment
    Acyclovir 60 mg/kg/d IV × 14 d for each recurrence • IV • q8h
    trigger: Skin recurrence (~ 50% by 12 mo; especially HSV-2) — confirm with PCR
    Re-treat acute + extend suppression duration per ID consult (Kimberlin 2013)
  4. 4. topical trifluridine for eye involvement
    1 drop to affected eye q2h up to 9 drops/d × 7-14 d • ophthalmic • q2h × 7-14 d
    trigger: HSV keratitis / conjunctivitis recurrence
    Topical antiviral; ophthalmology consult mandatory; do not skip systemic acyclovir for ocular recurrence
  5. 5. AED management for persistent neonatal-onset seizures
    Per neurology — wean phenobarbital / levetiracetam per EEG normalisation + seizure-free 6-12 mo • PO • per AED
    trigger: Persistent CNS HSV-related seizures
    Neurology-led management; some neonatal-onset seizures resolve, others require chronic AED
  6. 6. standard immunization schedule
    Per ACIP age-based schedule • IM / PO • per ACIP
    trigger: Age 2 months (after neonatal period ends)
    AAP Red Book + ACIP; HSV history does not modify immunization schedule (live virus vaccines acceptable per standard contraindication criteria)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Vesicular skin / mucous-membrane lesions in a neonate ≤ 28 d (Kimberlin Pediatrics 2013 PMID 23359576; AAP Red Book 2024); Seizures (often subtle — lip smacking, eye deviation, bicycling) in a neonate ≤ 28 d with no other clear cause (Kimberlin Pediatrics 2001 PMID 11483782); Hypothermia (T < 36 °C) or unexplained encephalopathy / abnormal tone / lethargy / poor feeding in a neonate ≤ 28 d (AAP Red Book 2024; HSV mimics sepsis).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Neonatal HSV (SEM, CNS, disseminated forms) — empiric acyclovir + form-specific duration** (id.hsv-neonatal.core.v1).
Phenotype framing: Look-alikes: neonatal bacterial sepsis (pivot: AST/ALT trajectory + HSV PCR + vesicles), neonatal bacterial meningitis (pivot: CSF profile + HSV PCR + Gram stain), enterovirus meningitis (pivot: lymphocytic CSF + enterovirus PCR + HSV PCR negative), congenital varicella (pivot: maternal varicella history + dermatomal distribution), erythema toxicum / miliaria (pivot: PCR + clinical course), neonatal candidiasis with vesiculo-pustular rash (pivot: KOH + fungal culture + HSV PCR). Coexistence: HSV + bacterial sepsis can co-occur — continue both empirics until both excluded.
Scope: Neonatal HSV (≤ 28 d, late-onset variants out to ~ 42 d). Three biologic forms: SEM (skin/eye/mouth — 14 d acyclovir), CNS (encephalitis — 21 d + 6 mo PO suppression), disseminated (21 d + ICU + bacterial co-empirics). Untreated mortality > 50% disseminated, > 80% CNS. Recognition + empiric IV acyclovir BEFORE PCR is the index intervention.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Neonatal HSV acyclovir regimen — by form (SEM / CNS / disseminated) + duration + suppression** — step "SEM (skin / eye / mouth) form — 14 days IV acyclovir".
1. acyclovir 60 mg/kg/day divided q8h IV (20 mg/kg/dose) for term ≥ 35 wk; q12h if preterm < 35 wk IV q8h (q12h preterm) (antiviral_nucleoside_analog, first line) — Kimberlin Pediatrics 2001 PMID 11483782 — high-dose 60 mg/kg/d superior to historical 45 mg/kg/d for outcome; 14 d duration for SEM form (no CSF pleocytosis + no disseminated features)

Setting playbook (outpatient) — Post-discharge primary-care + peds-ID + neurology + ophthalmology + audiology + developmental follow-up; oral suppression × 6 months for CNS / disseminated forms; recurrence surveillance; family education + lifelong-suppression-decision counseling; high-risk neonatal HSV survivors need close neurodevelopmental surveillance
2. oral acyclovir suppression × 6 months (CNS / disseminated) 300 mg/m² PO TID × 6 months PO TID — Completed 21 d IV course for CNS or disseminated form (Kimberlin NEJM 2011 PMID 21991950 — neurodev outcome benefit at 12 mo; reduces skin recurrence ~ 50%; monthly CBC for neutropenia monitoring)
3. oral acyclovir suppression case-by-case (SEM) 300 mg/m² PO TID × 6 months (some centres) PO TID — SEM form with high recurrence-risk profile per local protocol (not universal practice) (Recurrence prevention; case-by-case per ID input; not all centres do this for SEM)
4. recurrent SEM re-treatment Acyclovir 60 mg/kg/d IV × 14 d for each recurrence IV q8h — Skin recurrence (~ 50% by 12 mo; especially HSV-2) — confirm with PCR (Re-treat acute + extend suppression duration per ID consult (Kimberlin 2013))
5. topical trifluridine for eye involvement 1 drop to affected eye q2h up to 9 drops/d × 7-14 d ophthalmic q2h × 7-14 d — HSV keratitis / conjunctivitis recurrence (Topical antiviral; ophthalmology consult mandatory; do not skip systemic acyclovir for ocular recurrence)
6. AED management for persistent neonatal-onset seizures Per neurology — wean phenobarbital / levetiracetam per EEG normalisation + seizure-free 6-12 mo PO per AED — Persistent CNS HSV-related seizures (Neurology-led management; some neonatal-onset seizures resolve, others require chronic AED)
7. standard immunization schedule Per ACIP age-based schedule IM / PO per ACIP — Age 2 months (after neonatal period ends) (AAP Red Book + ACIP; HSV history does not modify immunization schedule (live virus vaccines acceptable per standard contraindication criteria))

Non-pharmacologic actions:
- Physical therapy if functional decline / muscle tone abnormalities (especially CNS form)
- Occupational therapy if fine-motor / ADL development concerns
- Speech / language therapy if speech delay post-CNS HSV
- Developmental peds referral if Bayley / ASQ delays > 1 SD below mean
- Audiology + ENT if hearing loss confirmed (early intervention essential)
- Ophthalmology long-term if eye involvement (recurrent HSV keratitis risk)
- Lactation continued support if breastfeeding
- Family adherence support + psychosocial barrier identification + social work if resource gaps
- Family CPR / infant safety + return precautions reinforcement
- Maternal HSV counseling + future-pregnancy management (acyclovir suppression from 36 wk for recurrent; C-section criteria)
- Caregiver oral HSV counseling (especially for late-onset cases — caregiver cold-sore avoidance + hand hygiene)

AVOID / contraindication checks:
- Acyclovir IV hydration prevent crystal nephropathy (Kimberlin 2013 PMID 23359576; AAP Red Book 2024; FDA label)
- Acyclovir cbc q1w monitor neutropenia (Kimberlin Pediatrics 2001 PMID 11483782 — neutropenia ~ 20% at 60 mg/kg/d, reversible on dose hold)
- Acyclovir dose adjust AKI (Cr × 1.5 2 → q12h; Cr × 2 3 → q24h per FDA label)
- Oral acyclovir suppression cbc monthly monitor neutropenia (Kimberlin NEJM 2011 PMID 21991950 — ~ 5 10% reversible neutropenia on suppression)
- Foscarnet nephrotoxicity electrolyte monitoring (FDA label; reserve for documented acyclovir resistance)
- Hsv pcr csf timing coupling repeat if clinical suspicion remains (Kimberlin 2013 — CSF PCR may be falsely negative early; repeat at 48 72 h)
- Ceftriaxone avoid under 28 days bilirubin displacement calcium ivf (AAP Puopolo 2018; FDA 2009 — applies to bacterial co empirics in disseminated form)
- Phenobarbital respiratory depression monitor neonate (FDA label; neonatal AED first line but monitor sedation + respiratory depression)

Monitoring

Regimen monitoring:
- Serial CBC q1w during IV acyclovir (neutropenia ~ 20% at 60 mg/kg/d — Kimberlin NEJM 2011)
- Serial creatinine + UOP q24h during IV acyclovir (crystalline nephropathy prevention; IV hydration 1.5-2× maintenance)
- Serial LFT q24-48h (disseminated form; resolution tracks treatment response)
- Serial CSF HSV PCR at end-of-IV-course for CNS form (some centres at d 21) — persistent positivity → extend acyclovir + ID consult
- Monthly CBC during PO suppression × 6 months (Kimberlin NEJM 2011 PMID 21991950)
- Audiology (AABR + audiology at discharge then 3-6 mo)
- Developmental peds + neurology + ophthalmology assessment at 6, 12, 24 mo (especially CNS / disseminated)
- Bacterial culture follow-up at 24 + 48 h; de-escalate bacterial empirics by 48-72 h if cultures negative

Setting (outpatient) monitoring:
- Peds visit at 1 wk, 1 mo, 3 mo, 6 mo, 12 mo, 24 mo, then per standard schedule
- Neurodevelopmental re-assessment at 6 mo + 12 mo + 24 mo for CNS / disseminated forms
- Family mental health re-screen at 3 mo + 6 mo + 12 mo
- Immunization status audit at every visit until catch-up complete
- Suppression monthly CBC × 6 mo + LFT q3 mo + creatinine q3 mo
- Recurrence surveillance at every visit through 24 mo (peak recurrence-risk window)

Follow-up plan: Oral acyclovir suppression 300 mg/m² PO TID × 6 months for CNS or disseminated forms (Kimberlin NEJM 2011 PMID 21991950 — neurodev outcome benefit). Monthly CBC on suppression (neutropenia ~ 5-10%). Developmental peds + neurology + ophthalmology + audiology at 6, 12, 24 mo. Recurrence surveillance — ~ 50% of treated infants have skin recurrence by 12 mo; re-treat acute (14 d IV) + extend suppression. Family education for return precautions (new vesicles, neuro signs, hypothermia). Lifelong suppression-decision counseling.
- Close-out criterion: Suppression initiated (CNS / disseminated); developmental + sub-specialty follow-up scheduled; family education delivered

Monitoring phase: Daily neuro exam (CNS form); serial CBC (acyclovir neutropenia ~ 20% at 60 mg/kg/d — Kimberlin NEJM 2011); serial creatinine + UOP (crystalline nephropathy); LFT trend (disseminated form); EEG monitoring if seizures; serial CSF HSV PCR at end of IV course (some centres at d 21) — persistent positivity → extend acyclovir + ID consult. Bacterial culture follow-up; de-escalate bacterial empirics by 48-72 h if cultures negative + alternative diagnosis identified.

Disposition

Current setting: outpatient — Post-discharge primary-care + peds-ID + neurology + ophthalmology + audiology + developmental follow-up; oral suppression × 6 months for CNS / disseminated forms; recurrence surveillance; family education + lifelong-suppression-decision counseling; high-risk neonatal HSV survivors need close neurodevelopmental surveillance

Disposition criteria:
- Sustained recovery — growth at age-appropriate baseline, neurodevelopmental assessments within age-appropriate range, suppression course complete (6 mo), immunization catch-up complete, family demonstrating return-precaution knowledge, no recurrent severe disease in 12 mo, family + caregiver HSV-prevention education delivered

Escalation triggers (move to higher acuity):
- New vesicles / seizures / encephalopathy / hypothermia → urgent peds / ED + acute re-treatment
- New focal neurological signs OR new seizures → urgent neuro + neuroimaging + EEG
- Hearing loss confirmed on audiology → ENT + audiology + speech + early intervention
- Family caregiver PHQ-9 ≥ 15 OR EPDS elevated → mental-health urgent referral
- Suspected immunodeficiency (≥ 2 serious infections in 12 mo OR unusual pathogen recurrence) → clinical immunology referral
- Suppression neutropenia (ANC < 500) → hold suppression + ID consult; resume after recovery (Kimberlin NEJM 2011 PMID 21991950)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Vesicular skin or mucous-membrane lesions (mouth / conjunctivae / scalp) in a neonate ≤ 28 d — empiric IV acyclovir 60 mg/kg/d divided q8h within 1 h + HSV PCR (CSF + blood + surface swabs) + admit + close monitor (Kimberlin Pediatrics 2013 PMID 23359576; AAP Red Book 2024)
- [LIFE_THREATENING] New-onset neonatal seizures (often subtle — lip smacking, eye deviation, bicycling) in a ≤ 28 d neonate with no clear bacterial / metabolic / structural cause — empiric acyclovir + LP for CSF + HSV PCR + EEG; routes to peds.status_epilepticus.v1 if status epilepticus evolves (Kimberlin Pediatrics 2001 PMID 11483782)
- [LIFE_THREATENING] Hypothermia (T < 36 °C) OR unexplained encephalopathy / abnormal tone / lethargy / poor feeding in a neonate ≤ 28 d — empiric acyclovir + sepsis workup + bacterial co-empirics; do NOT defer for culture results (AAP Red Book 2024; HSV mimics sepsis)

Citations

- AAP Red Book current edition (2024 + 2026 floor) — Neonatal HSV chapter + Kimberlin NEJM 2011 high-dose acyclovir PMID 11483782 + Kimberlin NEJM 2011 suppression companion PMID 21991950 + Kimberlin Pediatrics 2013 management overview PMID 23359576 + ACOG Practice Bulletin 220 (2020) Management of Genital Herpes in Pregnancy + NICE NG195 (2021) + NIAID Collaborative Antiviral Study Group (CASG) historical RCTs [PMID:11483782](https://pubmed.ncbi.nlm.nih.gov/11483782/)
- Cited evidence (PMID 21991950) [PMID:21991950](https://pubmed.ncbi.nlm.nih.gov/21991950/)
- Cited evidence (PMID 23359576) [PMID:23359576](https://pubmed.ncbi.nlm.nih.gov/23359576/)
- Cited evidence (PMID 30455342) [PMID:30455342](https://pubmed.ncbi.nlm.nih.gov/30455342/)
- Cited evidence (PMID 30455344) [PMID:30455344](https://pubmed.ncbi.nlm.nih.gov/30455344/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AAP Red Book current edition (2024 + 2026 floor) — Neonatal HSV chapter + Kimberlin NEJM 2011 high-dose acyclovir PMID 11483782 + Kimberlin NEJM 2011 suppression companion PMID 21991950 + Kimberlin Pediatrics 2013 management overview PMID 23359576 + ACOG Practice Bulletin 220 (2020) Management of Genital Herpes in Pregnancy + NICE NG195 (2021) + NIAID Collaborative Antiviral Study Group (CASG) historical RCTs — PMID:11483782
  • Cited evidence (PMID 21991950) — PMID:21991950
  • Cited evidence (PMID 23359576) — PMID:23359576
  • Cited evidence (PMID 30455342) — PMID:30455342
  • Cited evidence (PMID 30455344) — PMID:30455344