Management of congenital and neonatal TB

Treatment of congenital TB and neonatal TB is the same. Both should be managed by a clinician experienced in the management of paediatric TB. A complete investigation of mother and neonate should be undertaken. CXR should be done and appropriate specimens collected for Xpert MTB/RIF or Ultra to confirm the diagnosis of TB in the neonate (see Chapter 4). Treatment should be started based on the likelihood of TB, even before bacteriological confirmation is received, as TB can progress rapidly in neonates. Infants aged under 3 months or weighing less than 3 kg (including premature birth before 37 weeks) were not eligible for inclusion in the SHINE trial (86, 196). If PTB or tuberculous peripheral lymphadenitis is suspected or confirmed in these infants, they should be treated promptly with a 6-month treatment regimen (2HRZ(E)/4HR), as per the existing recommendation from the 2014 Guidance for national tuberculosis programmes on the management of tuberculosis in children (6). Treatment may require dose adjustment to reconcile the effect of age and possible toxicity in young infants. The decision to adjust doses should be taken by a clinician experienced in managing paediatric TB. WHO recommendations on treatment for DR-TB apply to neonates as well (see Chapter 5).

Dosages must take account of body weight and weight gain, which can be rapid in young infants. Pharmacokinetic data to inform appropriate dosages of TB medicines in neonates, especially preterm neonates, are very limited. 

A favourable response to treatment is indicated by increased appetite, weight gain and radiographic resolution. Breastfeeding is recommended, irrespective of the mother’s TB status. The risk of TB transmission through breast milk is negligible and, although the most commonly used TB medicines are excreted into breast milk in small amounts, there is no evidence that this induces drug resistance. Separation from the mother is not advised, especially in resource-limited settings, where establishing breastfeeding can be critical for the child’s survival. If TB is presumed or confirmed in the mother of an acutely ill neonate, the mother and her baby should be separated from the neonatal unit as soon as possible to prevent transmission to other neonates (6).

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