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(See also Mycobacteria: Tuberculosis (TB).)
Tuberculosis can be acquired during the perinatal period. Symptoms and signs are nonspecific. Diagnosis is by culture and sometimes x-ray and biopsy. Treatment is with isoniazid and other antituberculous drugs.
Infants may acquire tuberculosis (TB) by the following means:
About 50% of children born to mothers with active pulmonary TB develop the disease during the first year of life if chemoprophylaxis or BCG vaccine is not given.
Symptoms and Signs
The clinical presentation of neonatal TB is nonspecific but is usually marked by multiple organ involvement. The neonate may look acutely or chronically ill and may have fever, lethargy, respiratory distress, hepatosplenomegaly, or failure to thrive.
Diagnosis
All neonates with suspected congenital TB and infants born to mothers who have active TB should have a chest x-ray and culture of tracheal aspirates, gastric washings, urine, and CSF for acid-fast bacilli; the placenta should be examined and cultured as well. Skin testing is not extremely sensitive, particularly initially, but should be done. Biopsy of the liver, lymph nodes, lungs, or pleurae may be needed to confirm the diagnosis.
Well-appearing neonates whose mothers have a positive skin test but a negative chest x-ray and no evidence of active disease should have close follow-up and evaluation of all household members. If there is no exposure to a case of active TB, the neonate does not need treatment or testing. If significant exposure to a case of active TB is found in the neonate's environment after birth, the neonate should be evaluated for suspected congenital TB as described previously. If the neonate is well and active and disease is reasonably excluded by the chest x-ray and physical examination, the neonate should begin treatment with isoniazid (INH) 10 mg/kg po once/day. Further follow-up and management is then identical to that for an asymptomatic neonate born to a woman with active TB (see Infections in Neonates: Asymptomatic neonates of women with active TB), including a skin test at age 3 or 4 mo.
Treatment
Management depends on the whether there is active TB or only a positive skin test (in mother, infant, or both).
Pregnant women with a positive tuberculin test:
Women are evaluated for active TB. Because the hepatotoxicity of INH is increased in pregnancy, and because the risk of contracting TB from a mother with a positive tuberculin test is greater for the neonate than for the fetus, INH use may be deferred until after the postpartum period unless the woman has active TB or recent contact with a person with contagious TB (in which case the benefit outweighs the risk). Treatment is given for 9 mo, along with supplemental pyridoxine. Treatment for a pregnant woman exposed to contagious TB should be deferred until the 1st trimester is complete.
Neonates with a positive tuberculin test:
If there is no clinical or x-ray evidence of disease, the infant should receive INH 10 mg/kg po once/day for 9 mo and should be closely monitored.
Pregnant women with active TB:
INH, ethambutol, and rifampin use in recommended doses during pregnancy has not been shown to be teratogenic to the human fetus. The recommended initial treatment regimen in the US includes INH 300 mg po, ethambutol 15 to 25 mg/kg po, and rifampin 600 mg po. All pregnant and breastfeeding women receiving INH should also receive pyridoxine 25 mg po. All these drugs can be given once/day. The recommended duration of therapy is at least 9 mo; if the organism is drug-resistant, an infectious disease consultation is recommended, and therapy may need to be extended to 18 mo. Streptomycin is potentially ototoxic to the developing fetus and should not be used early in pregnancy unless rifampin is contraindicated. If possible, other antituberculous drugs should be avoided because of teratogenicity (eg, ethionamide) or lack of clinical experience during pregnancy. Breastfeeding is not contraindicated for mothers receiving therapy who are not infective.
Patients with active TB should be reported to the local health department. Mothers with active TB should be tested for HIV.
Asymptomatic neonates of women with active TB:
The neonate usually is separated from the mother only until effective treatment of both mother and neonate is under way. Once the neonate is receiving INH, separation is not necessary unless the mother (or a household contact) has possible multidrug-resistant organisms or poorly adheres to treatment (including not wearing a mask if TB is active) and directly observed therapy is not possible. Family contacts should be investigated for undiagnosed TB before the infant goes home.
If adherence can be reasonably assured and the family is nontuberculous (ie, the mother is being treated and no other transmission risks are present), the neonate is started on a regimen of INH 10 mg/kg po once/day and sent home at the usual time. Skin testing should be done at age 3 or 4 mo. If the neonate is tuberculin-negative, INH is stopped. If the skin test is positive, chest x-ray and cultures for acid-fast bacilli are done as described previously and, if active disease is excluded, treatment with INH is continued for a total of 9 mo. If cultures become positive for TB at any time, the neonate should be treated for TB.
If adherence in a nontuberculous environment cannot be ensured, BCG vaccine may be considered for the neonate, and INH therapy should be started as soon as possible. (Although INH inhibits the multiplication of BCG organisms, the combination of BCG vaccine and INH is supported by clinical trials and anecdotal reports.) BCG vaccination does not ensure against exposure to and development of TB, but offers significant protection against serious and widespread invasion (eg, tuberculous meningitis). BCG should only be given if skin testing of the neonate is negative. Neonates should be monitored for development of TB, particularly during the first year. (Caution: BCG vaccine is contraindicated in immunosuppressed patients and those suspected of being infected with HIV. However, in high-risk populations, the WHO recommends that asymptomatic HIV-infected neonates receive BCG vaccine at birth or shortly thereafter.)
Neonates with active TB:
For congenital TB, the American Academy of Pediatrics recommends treatment once/day with INH 10 to 15 mg/kg po, rifampin (0 to 20 mg/kg po, pyrazinamide 30 to 40 mg/kg po, and an aminoglycoside (eg, amikacin or streptomycin). This regimen should be modified as indicated based on results of testing for resistance.
For TB acquired after birth, the suggested regimen is treatment once/day with INH 10 to 15 mg/kg po, rifampin 10 to 20 mg/kg po, and pyrazinamide 30 to 40 mg/kg. A fourth drug such as ethambutol 20 to 25 mg/kg once/day or an aminoglycoside should be added if drug resistance or tuberculous meningitis is suspected. After the first 2 mo of treatment, INH and rifampin are continued to complete a 6- to 12-mo course (depending on disease category) and other drugs are stopped. Breastfed infants should also receive pyridoxine supplementation.
When the CNS is involved, initial therapy also includes corticosteroids (prednisone 2 mg/kg po once/day for 4 to 6 wk, then gradually tapered). Other therapy continues until all signs of meningitis have disappeared and cultures are negative on 2 successive lumbar punctures at least 1 wk apart. Therapy can then be continued with INH and rifampin once/day or twice/wk for another 10 mo. Corticosteroids may also be considered for infants and children with severe miliary disease, pleural or pericardial effusions, endobronchial disease, or those with abdominal TB.
TB in infants and children that is not congenitally acquired or disseminated; does not involve the CNS, bones, or joints; and results from drug-susceptible organisms can be treated effectively with a 6- to 9-mo (total) course of therapy. Organisms recovered from the child or mother should be tested for drug sensitivity. Hematologic, hepatic, and otologic symptoms should be monitored frequently to determine response to therapy and drug toxicity. Frequent laboratory analysis is not usually necessary.
Directly observed therapy is used whenever possible to improve adherence and the success of therapy. Many anti-TB drugs are not available in pediatric dosages. When possible, experienced personnel should give these drugs to children.
Prevention
Routine neonatal BCG vaccination is not routinely indicated in developed countries but may curb the incidence of childhood TB or decrease its severity in populations at increased risk of infection.
Last full review/revision October 2009 by Mary T. Caserta, MD
Content last modified February 2012
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