Management of the Infant of a Mother with TB

If neonate is healthy and his CXR is not indicative of TB

If the neonate has clinical signs or CXR is suggestive of TB

Exclude active tuberculosis (TB) in neonate if exposed to a mother/or other close source with TB.

What represents close TB contact in an infant?

A mother with recently diagnosed TB (irrespective of type of TB or smear/culture result):

• Who is receiving TB treatment at the time of deliver or
• Whose sputum smear or culture has not yet concerted to negative or is unknown at the time of birth

Close contact with any sputum smear/culture-positive TB source case (usually adult)

*If contact is with drug-resistant source case, refer to specialist clinic for management

If neonate is healthy and his/her CXR is not indicative of TB

Give INH prophylaxis to the neonate at 10 mg/kg daily per os.

Do not give BCG at birth. Refer to TB-clinic to continue INH prophylaxis for 6 months.

Evaluate monthly for TB symptoms/signs and adapt INH dosage according to weight.

If infant is symptomatic at any stage, or Mantoux TST positive (≥ 10mm) or mother remains smear/culture positive, re-evaluate the infant for active TB.

Start treatment* if TB is suspected. If no active TB suspected, continue prophylaxis for 6 months.

If the mother/source case remains sputum smear/culture positive after 2 months of treatment, consider drug resistance and do drug susceptibility test on mother’s culture (check results).

Prophylaxis for infants with TB contact:

Commence prophylaxis in hospital and continue at (refer to) the local clinic. Isolation of neonate is usually not necessary. The infant may be breastfed (mother on treatment, wearing mask and infant on prophylaxis). Notification is not required.

Give ABIDEC (0.6ml) or Kiddy-Vit (0.6ml) daily during prophylaxis.

BCG is only considered after prophylaxis is completed. Do NOT give BCG to confirmed HIV-infected infants – refer for antiretroviral (ARV) therapy. Prophylaxis is according to mother’s TB status:

i. Active/infectious maternal/source case TN (mother infectious with any TB!)

Give neonate INH 10mg/kg per os daily for 6 months

ii. Multidrug-resistant (MDR) maternal TB

Neonates/infants in close contact with an adult MDR-TB source cases are at risk of disease and appropriate (specific) prophylaxis according to the drug susceptibility test results of the adult source should provided. Consult expert advice.

If the neonate has clinical signs of CXR or CXR is suggestive of TB

Congenital TB may present as abdominal TB (abdominal distension due to enlarged hepar and/or ascites), pulmonary infiltrates (pneumonia) not responding to antibiotics or abnormal CSF with predominance of lymphocytes. CXR signs are nodular opacification – miliary or bronchopneumonic picture; or tracheal/bronchial compression; or hilar/paratracheal lymphadenopathy; or opacification not responding to antibiotic therapy. 

If TB suspected do gastric aspirates (2-3) or tracheal aspirates (if intubated) for M. tuberculosis cultures and commence treatment* after collecting first specimen.

ACTIVE NEONATAL TB RX:

2 months INH (10 mg/kg/day)/RMP (10-20 mg/kg/day)/PZA 30-40 mg/kg/day followed by 4 months INH (10 mg/kg/day)/RMP (10-20 mg/kg/day).

Add Ethionamide 15-20 mg/kg/day if disseminated disease.