Tuberculosis in mother
Management of the newborn whose mother has tuberculosis is based on
categorization of the maternal infection. Although protecting the infant from
infection is of paramount importance, separation from the mother should be
avoided when possible. Recommendations of the American Academy of Pediatrics’
Committee on Infectious Diseases are determined by the type of maternal
infection and include:
• If the mother has a positive skin test, normal findings on chest
radiography, and is asymptomatic, no separation is required. The newborn
needs no special evaluation or therapy. Because a positive skin test result
could be a marker of an unrecognized case of contagious tuberculosis within the
household, other household members should have a skin tests and further
evaluation.
• If the mother’s radiograph is abnormal, the mother and infant should
be separated until the mother has been evaluated and, if tuberculosis is
found, until the mother is receiving appropriate antituberculosis therapy.
Other household members should have skin testing and further evaluation.
• If the mother’s chest radiograph is abnormal but not typical of
tuberculosis and the history, physical examination findings, and sputum
smear indicate no evidence of tuberculosis, the infant can be assumed to
be at low risk for Mycobacterium tuberculosis infection and need not be
separated from the mother. The mother and infant should receive follow-up care.
Other household members should have skin testing and further evaluation.
• If the mother has clinical or radiographic evidence of possibly contagious
tuberculosis, the case should be reported immediately to the local health
department so that all household members can be investigated within several
days. All contacts should have skin testing, a chest radiograph, and a
physical examination. Women who have only pulmonary tuberculosis are not
likely to infect the fetus, but they may infect their infant after delivery.
Congenital tuberculosis is rare, but in utero infections can follow maternal
M tuberculosis bacillemia. The infant should be evaluated for congenital
tuberculosis and tested for human immunodeficiency virus infection. If a
newborn is suspected of having congenital tuberculosis, a skin test, chest
radiograph, lumbar puncture, and appropriate cultures should be obtained
promptly. The skin test result usually is negative in
newborns who have congenital or perinatally acquired infection. Hence,
regardless of the skin test results, the infant should be treated promptly with
isoniazid, rifampin, pyrazinamide, and streptomycin or kanamycin. The
placenta should be examined histologically and cultured for M
tuberculosis. The mother should be evaluated for the presence of pulmonary
or extrapulmonary (including uterine) tuberculosis. If findings on the maternal
physical examination or chest radiograph support the diagnosis of tuberculosis,
the newborn should be treated with regimens recommended for tuberculous
meningitis, excluding corticosteroids. If meningitis is confirmed,
corticosteroids should be administered. Drug susceptibilities of the
organism recovered from the mother, infant, or both should be determined. If
the infant is receiving isoniazid, separation is not necessary. Other
household members should have skin testing and further evaluation.
• If congenital tuberculosis is excluded, isoniazid is administered until the
infant is 3 or 4 months of age, at which time the skin test should be repeated.
If the skin test result is positive, the infant should be reassessed for
tuberculosis. If disease is not present, isoniazid should be continued for at
least 9 months. If the purified protein derivative test is negative and the
mother and other household contacts who have tuberculosis have good adherence
and response to treatment and are no longer contagious, isoniazid may be
discontinued. The infant should be evaluated at monthly intervals during
treatment.
• If the mother has disease due to multiple drug-resistant M tuberculosis
or adheres poorly to treatment and directly observed therapy is not possible,
the infant should be separated from the ill mother and bacillus Calmette-Guérin
(BCG) immunization considered for the infant. Because the response to BCG
in infants may be delayed and inadequate for prevention of tuberculosis,
directly observed therapy for the mother and infant is preferred.
M tuberculosis usually is spread via airborne transmission, with
inhalation of droplet nuclei produced by an adult or adolescent who has
contagious, cavitary, pulmonary tuberculosis. The duration of contagiousness of
an adult receiving effective treatment depends on drug susceptibilities of the
organism, the number of organisms in sputum, and the frequency of cough.
Although contagiousness usually lasts only a few weeks after initiation of
effective drug therapy, it may extend further, especially when the patient does
not adhere to medical therapy or is infected with a resistant strain. If the
sputum is negative for organisms on three smears and coughing has ceased,
the person is considered noncontagious. Children younger
than 12 years of age who have primary pulmonary tuberculosis usually are not
contagious because their pulmonary lesions are small, cough is minimal or
nonexistent, and there is little or no expulsion of bacilli.
References:
American Academy of Pediatrics. Tuberculosis. In: Pickering LK, ed. 2000 Red
Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove
Village, Ill: American Academy of Pediatrics; 2000:593-613
Centers for Disease Control and Prevention. The role of
BCG vaccine in the prevention and control of tuberculosis in the United States.
A joint statement by the Advisory Council for the Elimination of Tuberculosis
and the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly
Rep. 1996;45(RR-4):1-18
Starke JR, Munoz F. Tuberculosis. In: Behrman RE, Kliegman RM, Jenson HB, eds.
Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders Co;
2000:885-897