Treatment of the Infant exposed to Maternal Tuberculosis

Flowchart

• Aim
• Maternal TB
• Infection Control
• Pulmonary TB
• Treatment
• Screening Contacts
• Follow Up
• Appendix

AIM

To streamline the treatment of infants born to mothers with known tuberculosis (TB) in accordance to current guidelines.

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MATERNAL TB

Identification and treatment of maternal TB is the best prevention for congenital TB.

Standard treatment of TB in pregnancy (with Rifampicin, Isoniazid, Pyazinamide, and Ethambutol) is not known to increase fetal malformation. In drug resistant TB, some second line drugs may cause problems and early consultation between the obstetric team and the TB specialist is essential.

Breastfeeding should be allowed. If the mother is on isoniazid, this may be transmitted in milk. There is a small risk of isoniazid induced peripheral neuropathy in the infant. To prevent this, supplementation with 5mg/day pyridoxine is recommended. The mother should take pyridoxine 10mg daily.

If a mother is receiving treatment for TB she will usually be under the care of the Chest Clinic or an Infectious Diseases physician, and a plan will have been made for the infant. This plan should be adhered to. If a plan is not available follow the recommendations below and contact the mother's physician at the earliest opportunity.

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INFECTION CONTROL

If the mother has been on treatment for more than 2 weeks, she is usually no longer infectious, and no special precautions would normally be needed for her.

The possibility that other close contacts of the mother may have been infected needs to be considered, and therefore it is important that the partner and other household contacts have been screened to exclude active TB before they are allowed into areas where they may have contact with neonates / children.

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PULMONARY TB

If pulmonary (or very rarely laryngeal) TB is newly diagnosed and the mother has not been on treatment for at least 2 weeks, she should be considered potentially infectious.

If she is in hospital, she should be in a side room with the door closed. If she needs to move to other areas (eg ultrasound, theatre, etc) she should wear a mask.

There is generally no need for staff to wear masks unless either:

• contact with the patient is prolonged (ie sharing the room for 8 hours continuously),
• cough inducing procedures (eg chest physiotherapy),
• Staff member is at increased risk (eg on immunosuppressive drugs)
• Mother has multi-drug resistant TB

See Hospital infection control policy for further details.

The Infection Control Team should be informed of such admissions and will advise accordingly (extensions 22691 or 66947).

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TREATMENT

Babies born to mothers on treatment

Babies born to mothers that have received rifampicin and/or isoniazid near term should both be given prophylactic Vitamin K to prevent haemorrhagic complications. The recommended dose is the standard post birth dose of 1-2mg Vitamin K directly after then 1-2mg vitamin K (phytomendaione) orally two to three times a week for the first two weeks after birth.

If the mother is on isoniazid and breastfeeding  5mg pyridoxine should be considered to be given daily to the baby (see Appendix).

When the mother is breastfeeding it is suggested she breastfeed and then take isoniazid in an attempt to avoid the Cmax (peak) at 1-2 hours

Babies born to mothers who have extra-pulmonary TB, or who have received at least 2 weeks TB treatment before delivery do not normally require chemoprophylaxis. These babies should be given neonatal BCG, regardless of ethnicity, unless there is a contraindication ( e.g. HIV).

Babies born to mothers with pulmonary TB that have not received 2 weeks treatment

Neonates born to mothers with pulmonary TB who have not received at least 2 weeks' anti-tuberculosis drug treatment should be treated as follows:

The baby should be started on isoniazid 10 mg/kg for 3 months. Enough should be prescribed that will last to the first follow-up out-patient appointment.

• Mantoux test performed after 3 months' treatment.
• Pyridoxine supplementation is recommended ( 5mg daily) See Appendix
• If the Mantoux test is
  • positive (5 mm or greater) the baby should be assessed for active TB. If this assessment is negative isoniazid should be continued for a total of 6 months.
  • negative (less than 5 mm), then isoniazid should be stopped and a BCG vaccination performed if no contra-indication (e.g HIV)

Babies born to mothers who have extra-pulmonary TB, or who have received at least 2 weeks TB treatment before delivery do not normally require chemoprophylaxis. These babies should be given neonatal BCG, regardless of ethnicity, unless there is a contraindication ( e.g. HIV).

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SCREENING CONTACTS

All babies with a mother or other household family member diagnosed with TB within the previous 5 years should have neonatal BCG, regardless of ethnicity, unless there is a contraindication. See neonatal BCG policy for further details.

If the mother is diagnosed on admission the TB team will not know. The family and relatives will not have been screened. Even if the mother is not infectious, someone in the family may be, so unscreened relatives should not have access to other babies.

TB nurses (contact via extension 22148) can arrange screening usually within a few days, but if necessary, relatives could have CXR done and a respiratory SpR check it.

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FOLLOW UP

Wherever possible, contact TB nurses before discharge and give appointment details to parents/carers before discharge.

If not possible (weekend/rapid discharge etc), take all info including mobile and home phone numbers and contact TB nurses ASAP.

TB nurses will give review appointment – usually 2-3 weeks and will also make contact with the family by phone and/or home visit to check all is well. They will often be seeing the mother anyway.

TB nurses can be contacted via the TB Clerks at the Chest Clinic, Martin Wing LGI. Telephone 22148.

If the baby requires chemoprophylaxis and Mantoux testing, it will be followed up by the Chest Clinic (currently at Martin Wing LGI).

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APPENDIX

Role of Pyridoxine
A common side effect of isoniazid treatment in children is peripheral neuropathy, but is more likely to occur in the presence of pre-existing risk factors such as diabetes, chronic renal failure, malnutrition and HIV infection. Pyridoxine is recommended for the prevention of isoniazid induced neuropathy in these patients and in infants who are exclusively breast fed.⁴ The recommended daily doses are ⁴:

• Neonate 5mg daily
• Child 1 month-12 years 5-10mg daily
• Child 12-18 years 10mg daily

It is immediately obvious that the dose of pyridoxine provided in childrens multivitamin drops is substantially less than the recommended doses for prevention of isonazid induced neuropathy, since these products are intended as vitamin supplements rather than treatments. This is particularly so for the recommended Healthy Start children's vitamin drops, which does not contain any of the vitamin B’s. Therefore, any infants who are treated with isoniazid, who would normally be advised to also take pyridoxine, should be prescribed the appropriate dose of pyridoxine, whether or not they are also Healthy Start beneficiaries.