The Recommendations of the lAP Working Group on the Management of the newborn of
a mother with active tuberculosis(1) differs somewhat from that of other
authorities and hence has generated active debate. This communication is an
attempt to look into the principles and controversies on this subject.
The mother invariably will be having reactivation tuberculosis and hence the disease
will be localized to the lung. Unlike primary infection, blood borne
dissemination is unlikely in reactivation tuberculosis and hence the fetus is
unlikely" to be infected in utero. Thus congenital tuberculosis, which is
the acquisition of infection in utero, is extremely rare. In most
instance the newborn of mother with tuberculosis gets air borne infection after
birth. Thus there is a school of thought that the child should be separated from
mother soon after birth(2). However this is not practical in most Indian homes
and it deprives the child of beneficial effects of breast-feeding. Hence the lAP
rightly recommends. the breast feeding to be continued. In addition INH
treatment for the newborn has been so effective that separation of the mother
and child is not mandatory(2).
Many authorities recommend that such children must be given preventive treatment
with INH even if the X-ray is normal(3). There is always a doubt that if the
child is infected the bacilli may acquire resistance while on mono therapy with
INH. As the infant most often gets infection post natally, the INH therapy can
be considered as a "preventive therapy" started even before the organisms
establish themselves. A resistant mutant occurs once every 108
replications only(4). Here the treatment is started even before bacilli had a
foothold and hence bacterial divisions of this magnitude is not possible. Thus
the argument had been that there is no danger of resistant mutant even if INH
was used as a single drug. Now the scenario has changed and there are organisms
with primary drug resistance to INH in the community and hence the working group
recommended 2 drugs (HR) even for preventive therapy. The chance of the bacilli
being resistant to both INH and rifampicin is 1016. This number of
organisms are not seen even in. adults with extensive cavities(4) and hence a
3rd drug is unnecessary.
Giving BCG at birth will not protect the child as it takes 1-3 months for its
protective efficacy(1,3) by which time the organisms might have spread to
various regions- a fact well known in primary infection. Hence there is need for
additional preventive chemotherapy.
The standard recommendation is to give BCG after completion of chemo- therapy of
appropriate duration(3). However, the Working Group recommends that BCG be given
along with the start of chemotherapy
which should in all probability kill the BCG organisms. The Working Group itself
recommends INH for BCG adenitis thus recognizing it's potential to kill the BCG
organisms. BCG being attenuated organism with limited capacity for division it
is easy to tackle these and hence just a single drug therapy is enough. Thus, it
is clear that simultaneous BCG and chemotherapy will inactivate the live BCG
vaccine. There is no literature to show that killed BCG is effective. Attenuated
organ- isms are not-known to remain dormant and alive for the whole period of
treatment (If it is true the same should apply to the wild organisms making the
disease flare up once the treatment is stopped!).
The convener of the Working Group asserts that BCG will provide the immunity and
chemotherapy administered con-currently will prevent the natural infection(5).
This does not stand to reason. However the Working Group must have reasons for
their recommendation and I would be glad to update myself with relevant
published works in this regard. On the other hand if this protocol has not been
adequately field tested, the Working Group must consider revising their
A. Santosh Kumar,
Department of Pediatrics,
S.A.T. Medical College,
Thiruvananthapuram 695 011, India.
1. Treatment of childhood tuberculosis: Consensus statement of lAP Working
Group. Indian Pediatr 1997; 34: 1093- 1096.
2. Starke JR. Tuberculosis. In: Nelson Text Book of Pediatrics, 15th edn.
Eds. Behrman RE, Kliegman RM, Arvin AM. Phildelphia, W.B. Saunders Company,
1996; pp 834-846. -
3. Tuberculosis in children. Guidelines for diagnosis, prevention and treatment
(A statement of the scientific committees of the IUATLD). Bull Int Union Tuberc
Lung Dis 1991; 66: 61-67.
4. Iseman MD. Treatment of multi drug resistant tuberculosis. N Engl
Med 1993; 329:
5. Amdekar YK. Baby born to mother with tuberculosis. Indian Pediatr 1998; 35:
BCG Vaccination with Antitubercular Therapy
We have read with interest the letter by Yash
Paul(1) and have considered carefully the points raised on the subject. In reply
Amdekar(2) has stated. "It has been recommended to give BCG vaccine at birth to
a baby born to mothers suffering from tuberculosis, along with chemoprohylaxis
for 6 months even if the chest X-ray is normal. This is because such a baby may
be infected or not. If not infected, chemoprophylaxis will prevent risk of
maternal infection and BCG vaccine will provide immunity".
However, it is likely that the bactericidal drugs (RH) used in chemoprophylaxis
will kill the live attenuated bacilli of the BCG vaccine administered, before it
can evoke the desired immunity. In this context, we quote below some recent
1. While the child is on treatment with isoniazid, BCG should not be given(3).
Do not vaccinate with BCG at the same time as isoniazid is being administered(4).
2. Newborn infants born to mothers with sputum positive for acid fast bacilli
should be on chemoprophylaxis until the mother's sputum becomes bacteriologically
negative. Thereafter chemo- prophylaxis is stopped and BCG vaccination is
3. BCG should not be given during isoniazid prophylaxis because isoniazid
inhibits multiplication of BCG(6).
All the above recommendations are on the use of isoniazid alone in
chemoprophylaxis. The possible additive bactericidal effect of inclusion of
rifampicin in the regimen in strengthening the above views should also be
considered. Further clarification of this important issue is needed.
Department of Pediatrics,
Bankura Saminilani Medical College, Bankura, (West Bengal), India,
Post-graduate Student (PSM),
All India Institute of Hygiene and
Public Health, Calcutta, India.
1. Yash Paul. BCG
vaccination with anti- tubercular therapy. Indian Pediatr 1998; 35: 493.
2. Amdekar YK. Reply. Indian Pediatr 1998; 35: 493-494.
3. Samu N, Subramanya L. BCG. In: Child- hood Tuberculosis: A Practical
Approach, 1st edn. Madras, Sira and Co, 1991; p 38.
4. Crofton J, Horne N, Miller F. General guide to treatment: The newborn child.
In: Clinical Tuberculosis, 1st Indian edn. ,New Delhi, CBS Publisher and
Distributors, 1996; pp 152-153.
5. Ghai OP. Tuberculosis in childhood. In: Essential Pediatrics, 4th edn.
New Delhi, Interprint Publishers, 1996; p 166.
Speck WT. Infants born to
mothers with active tuberculosis.' In: Nelson Textbook of Pediatrics,
13th edn. Eds. Behrman RE, Vaughan VC, Nelson WE. Philadelphia, W.B. Saunders
Company, 1987; pp 637- 638.
The lAP Working Group in its Consensus Statement
on Treatment of Childh09d Tuberculosis has recommended use of BCG vaccine and
two-drug chemoprophylaxis for a baby born to a mother suffering from active
tuberculosis. This was formulated after due consideration of the following
increasing incidence of drug resistance,
two-drug (HR) chemoprophylaxis
2. At the end of three months of chemoprophylaxis, negative tuberculin reaction
may not guarantee absence of natural infection or disease. Tuberculin negative
tuberculosis is not rare. Therefore
it is ideal
to extend the
chemoprophylaxis for a period of six months. It provides adequate cover as a
preventive therapy for the uninfected and a curative therapy for the infected.
Hence the recommendation of 6HR.
3. Protective efficacy of BCG vaccine depends upon many variable factors
including age at vaccination and chance of exposure to atypical Mycobacterial
infection from the environment.
efficacy, may be
reduced if vaccinated
6 months of age than at birth. Ideally,
vaccine should be used only in tuberculin negative older infant, thus
necessitating tuberculin test. Thus ideal age for vaccination is at birth or as
early as possibly after birth.
4. BCG vaccine given along with chemo- prophylaxis does induce immune
response though may lessen the protective efficacy as compared to standard
vaccination at birth without drug therapy.
5. In effect, protective efficacy of BCG vaccine is either way reduced
whether given after 6 months of
age at the completion of therapy or given at birth along with chemotherapy.
Thus, choice rests equally between the two modalities of management as both the
methods sacrifice some benefits of BCG vaccination as compared to a standard
6. Considerihg the simplicity of implementing a standard protocol, the Working
Group suggested 6 HR drug therapy with BCG vaccine at birth. It entails no
further tuberculin testing with its inherent problems and limitations of
lAP Working Group of Tuberculosis,
Honorary Professor of Pediatrics,
College and J.J.
1. Joshua B, Satya
Sri S. Tuberculosis and Pregnancy. In: Textbook of Tuberculosis, 2nd edn.
New Delhi, Interprint, 1995; p 103.
2. Seth V. BCG vaccination. In: Essentials of Tuberculosis in Children.
New Delhi, Jaypee Brothers, 1997; p 42.
3. RF, Jacobs. Abernathy R. Management of tuberculosis in pregnancy and the
newborn. Clin Perinatal 1988; 15:305-317.
4. Kendig EL. The place of BCG vaccine in the management of infants born to
tuberculous mothers. N Engl
Med 1969; 281: