Influenza, a New Mom, and a Neonate

[[{"type":"media","view_mode":"media_crop","fid":"43024","attributes":{"alt":"","class":"media-image media-image-right","height":"295","id":"media_crop_696610600790","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4684","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"©RobertKneschke/Shutterstock.com ","typeof":"foaf:Image","width":"400"}}]]It is the middle of flu season when you get a call from one of the local obstetricians. He tells you he just delivered a baby who will be coming to your practice, but needs to ask you about something that he has not come across before. This does not bode well since you’re already behind schedule. He tells you that the mother arrived at the hospital with about 24 hours of fever, congestion, and malaise. A rapid flu test was positive. Mom had refused a flu vaccine during her pregnancy, not wanting to “expose her fetus to any foreign substances.” The OB tells you he would like to start mom on Tamiflu--but the mother is anxious to start breast feeding. The OB asks you if it is safe for her to breast feed and asks your opinion on a mask for mom.   

A pregnant pause ensues while you plumb the depths of your memory since this is not something you have ever come across before either. You tell the obstetrician that you will call him back in 5 minutes after you do a little research.

1. What does the CDC recommend in this situation?

A. Separate the ill mom from the baby. Use pumped milk if appropriate.

B. Mom needs to wear a mask and use careful hand washing.

C. The baby can stay in mom’s room but should be kept 6 feet away from the sick mother.

D. Both B and C are correct.

For answer, discussion, and next question, please click here.

Answer: A Separate the ill mom from the baby. Use pumped milk if appropriate.

Mom should be separated the mom from the baby until she has either been on antiviral meds for more than 48 hours, been afebrile for more than 24 hours, or is “able to control her cough and respiratory secretions.”  I’m not sure if I personally agree with this last condition. Even talking can result in respiratory droplets spreading flu viruses within a 6-ft radius.

The CDC does realize that “rooming in” is sometimes the only option in which case the baby should be kept 6 feet from mom and perhaps a curtain be placed between them; another healthy adult should provide care for the newborn. While these measures will seem somewhat draconian to some (particularly mom), newborns who become infected with influenza are at an increased risk of severe complications.

2. Should you start the infant on Tamiflu?

A. Yes; it is FDA approved for prophylaxis in this situation.

B. Not yet; it is FDA approved for treatment but not prophylaxis at this age.

C. No; use is not approved in infants less than 2 weeks of age.

D. Yes; it is not FDA approved for use, but the CDC does recommend its use in this situation.

For answer, discussion, and next question, please click here.

Answer: C. No, use is not approved in infants less than 2 weeks of age.

The FDA in 2012 did approve the use of Tamiflu in infants older than 2 weeks of age for the treatment of flu. Use of Tamiflu for prophylaxis is not approved or recommended by the CDC for children less than age 3 months unless the situation is “considered critical” becuase of the paucity of data on Tamiflu use in this age group.

3. Can mom breast feed while taking Tamiflu?

A. No; levels of Tamiflu in breast milk are high enough to result in a clinically significant dose to the newborn.

B. No; no data are available.

C. Yes; while levels of Tamiflu in breast milk are high enough to result in a clinically significant dose to the newborn, the benefit is thought to outweigh the risk.

D. Yes; levels of Tamiflu in breast milk are so low that the newborn will not receieve a clinically significant dose.

For answer and discussion, please click here.

Answer: D. Yes; levels of Tamiflu in breast milk are so low that the newborn will not receive a clinically significant dose.

The answer is yes, but data are sparse. In a study on exactly one subject taking the standard adult twice daily 75 mg dose, the maximum level of active metabolite in the breast milk was such that the relative infant dose was 0.5% of the maternal weight-adjusted dose. The CDC has recommended/approved Tamiflu’s use in breastfeeding moms.

References:

Hale T. Medications and Mothers' Milk. 15th Edition. Amarillo, TX: Hale Publishing, LP; 2015.

Centers for Disease Control and Prevention. Guidance for the Prevention and Control of Influenza in the Peri- and Postpartum Settings. http://www.cdc.gov/flu/professionals/infectioncontrol/peri-post-settings.htm