Tuberculosis (TB) in neonates

Key messages

Perinatal tuberculosis (TB) is extremely rare, but clinicians should be alert to potential symptoms.
TB presents a special risk during pregnancy and breastfeeding.
Its important to identify and treat maternal TB to prevent transmission to the fetus.
TB is not an indication for therapeutic termination of pregnancy.

On this page

Investigations for tuberculosis
Management of tuberculosis
More information

Please note that all guidance is currently under review and some may be out of date. We recommend that you also refer to more contemporaneous evidence in the interim.

While perinatal tuberculosis (TB) is extremely rare, clinicians should be alert to symptoms. The most effective way to prevent TB in the newborn is to identify and treat the infected mother.

TB is prevalent in most developing countries and constitutes a special risk during pregnancy and lactation to mothers and infants.

Mortality from TB is highest in patients less than five years of age.

Perinatal TB

Some factors to note about perinatal TB:

It is rare.
The placenta may be infected resulting in severe fetal involvement and fetal death.
Transplacental infection usually occurs when the pregnant woman has clinical tuberculosis or a recent primary infection.
Placental TB can spread to the fetus by the umbilical vein.
The primary complex may be in the fetal liver, gastrointestinal tract or mesenteric nodes. A placental tubercle may rupture causing tubercular amnionitis and possible fetal aspiration with primary complex in the fetal lung.
The infant may aspirate infected secretions at the time of birth.
Postnatal exposure may be from the infected mother or other infected family members.

Maternal tuberculosis

Some factors to note about maternal TB:

Identification and treatment of maternal TB is the best way of preventing TB in the newborn.
Skin testing and interferon gamma release assay (IGRA) should be done on pregnant women who:
- are HIV positive
- are suspected of having been exposed to TB
- are recent arrivals from a high prevalence area.
There is no significant increase in malformations for infants born to infected mothers.
There is no indication for therapeutic abortion.

Clinical features of perinatal tuberculosis

Clinical features may be present at birth or delayed until eight weeks of age. The mean time of onset is two to four weeks.

Clinical features of tuberculosis include:

respiratory distress
fever
hepatosplenomegaly
irritability, poor feeding and lethargy
lymphadenopathy
failure to thrive
jaundice.

Investigations for tuberculosis

Issues to be aware of:

The tuberculin skin test (TST) is likely to be negative for the first few weeks of life, even if the neonate has TB.
TST conversion may be delayed for up to six months.
IGRA performance is poorly understood in children and cannot be recommended for children under five years of age.
If congenital TB is suspected, the placenta should be examined and microscopy, culture and histology performed.

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Management of tuberculosis

Perinatal TB

If perinatal TB is suspected:

Chest x-ray, lumbar puncture and gastric aspirates (x 3) should be taken.
Anti-TB therapy should be commenced immediately; the decision regarding number and choice of antibiotics is difficult and warrants specialist advice.
Initial treatment should include isoniazid (INH), rifampicin pyrazinamide plus amikacin or ethionamide until the susceptibility of the infant or mother’s isolate is known.
Once antibiotic susceptibilities are known, treatment should continue with at least two antibiotics to which the organism is susceptible.
Breastfed infants should receive pyridoxine 10 mg daily.

Mother with active disease

If the mother has active disease:

Chest x-ray and gastric aspirates (x 3) should be taken.
If these do not yield evidence of TB, the infant should be treated with INH for six months.
TST should be performed at three and six months of age.
If positive at any time, the infant must be investigated and treated with anti-TB treatment as above.
Anyone with active disease who is in contact with the infant should use a face mask until their sputum is demonstrated to be smear negative.
BCG vaccine should be considered if there is any possibility of future exposure to TB.
Separation of mother and infant is only necessary if the mother is sick enough to require hospitalisation.

Mother without active infection

If the mother does not have active disease:

The infant may be at risk even if the mother's sputum is negative.
The infant should be treated with INH 10 mg/kg/day for six months and should have TST performed at three and six months of age.
If positive at any time, the infant must be investigated and treated with anti-TB treatment as above.
BCG vaccine should be considered if there is any possibility of future exposure to TB.
Breastfeeding is not contraindicated.

Nursery exposure

Management of TB due to hospital exposure:

Spread can occur from infected personnel or visitors; infants and children rarely transmit TB.
If exposure is significant, infants should have TST performed and if negative, treated with INH 10 mg/kg/day for six months.
TST should be repeated at six months.
If the TST is positive at any time, the infant must be investigated and treated with anti-TB treatment as above.
BCG vaccine should be considered if there is any possibility of future exposure to TB.

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More information

Clinical

Mycobacterium tuberculosis. In: Palasanthiran P, Starr M, Jones C, Giles M, editors. Management of Perinatal Infections. Australasian Society for Infectious Diseases (2014).

References

Mnyani C, McIntyre J. Tuberculosis in pregnancy. BJOG. 2011;118:226231.
Graham S. Treatment of paediatric TB: revised WHO guidelines. Paediatr Respir Rev. 2011;12:22-6.
Whittaker E, Kampmann B. Perinatal tuberculosis: new challenges in the diagnosis and treatment of tuberculosis in infants and the newborn. Early Hum Dev. 2008;84:795-9.