HSV1 – Transmission Risk to Child

[sprocket7475]

Hi Terri,
First, some background:
I am 39 years old and have had HSV-1 (oral herpes) since I was a child. The recurrences in my teen years, especially, were quite severe and frequent, affecting my mouth and chin area. Over the past 15 years or so, post-college, recurrences have been less frequent (perhaps 4 smaller outbreaks a year), UNTIL late 2013/early 2014 after my first child was born.

I developed a cold sore about a week after delivery (late December 2013). At that time, I actually was unaware of the seriousness of neonatal herpes (!), although of course I did not kiss my newborn while the sore was present. I then noticed a lesion on one of my nipples on the morning of New Year’s Day, 2014 (honestly, I don’t think I would have even noticed prodromal symptoms, as my breasts and nipples were extremely sensitive, sore, and irritated in the early days of breastfeeding/pumping). I had never had anything resembling a herpetic lesion anywhere other than my mouth/chin previously. My child was approximately 3 weeks old at the time and had breastfed the evening prior. Very long story short, the lesion was never cultured, so we cannot be 100% sure, but it definitely looked, felt, oozed, and crusted over just like a cold sore/fever blister. Alarmingly, I also developed a cold sore on my lip that very evening.

The following evening, after I had done some research and learned about neonatal herpes and the possibility of post-natal transmission, we took our child to Arkansas Children’s Hospital out of an abundance of caution, and they wound up admitting him, performing a spinal tap, blood work/PCR analysis, and administering IV acyclovir to him every 8 hours for 2.5 days, as a precaution, while we waited for the test results to come back. Thankfully, he tested negative for HSV (and he should have had good antibody protection from me, transferred via the placenta, as he was a full term baby and again, I have a long-standing HSV-1 infection).

Obviously, the experience of having my 3 week old admitted to the hospital, tested, and treated for a possible neonatal herpes infection was very traumatic.

In March of 2014, I had a root canal done, and I began having horrible cold sore outbreaks a few days later. I am sure they were exacerbated by the dental work, stress, and likely hormones, as well. I had 2.5 months of nearly constant outbreaks. I know what cold sore symptoms and outbreaks are – I have dealt with them nearly my entire life. On the advice of the infectious disease doctors at Arkansas Children’s Hospital, as well as my child’s pediatrician, I finally went on suppressive therapy, in the interest of protecting my son (I barely kissed him for the first 6 months of his life, after he was discharged from the hospital, as I was terrified of passing HSV to him).

I started with 500 mg of Valtrex/day, for 1 month, and continued to have outbreaks. So my dosage was increased – for approximately the past 8 months, I have taken 1 gram of Valtrex per day, and I have had NO outbreaks during that time. I also have not noticed hardly any tingling, itching, redness, puffiness/swelling, etc., which I sometimes think I get during what would be considered times of ‘asymptomatic’ shedding, when the virus likely travels to the surface of the skin but doesn’t fully manifest in the form of a sore, as I generally apply rubbing alcohol to my lips when these events occur (again, I am VERY in tune with my symptoms). So, I feel confident that the Valtrex (1 gram daily) has been doing its job.

I am now pregnant again. My OB has advised that I go OFF the suppressive therapy for the 1st and 2nd trimesters. He said I can go on it again in the 3rd trimester, if I want to guard against having a cold sore at the time of delivery. I will likely want to stay on the suppressive therapy for the first few months of my newborn’s life, as well.

My questions are:
1) I know that Valtrex is a class B drug for pregnancy. I have heard that some OBs will allow patients to take it throughout the pregnancy. My OB would rather I go off it for now, at least as a trial, and see what happens, particularly if there is no longer a serious risk to my now-13 month old if he were to contract herpes. Even though the drug is class B, his position is that no drug is considered 100% safe. Is this the approach that is generally followed, particularly for the 1st trimester? I want to protect my 13 month old from the virus, which I have vigilantly tried to do since he was discharged from the hospital, but of course, I want to do what is best for my unborn child, as well. I am very afraid, however, that I will have a slew of outbreaks once I go off the meds.

2) I have never kissed my now-13 month old on the mouth, only on the forehead or cheek. I have felt confident for the past 7 months (once I got past the horrible outbreaks I had in the March-May timeframe last year and the 1 gram/daily suppressive therapy seemed to have taken a good, proven hold) and have given him lots of kisses, allowed him to freely touch my face when we are playing or he is cuddling up to me to go to sleep, etc. With going off the Valtrex, I of course will not kiss him at all if I get a cold sore, but what about asymptomatic shedding? Can I pass HSV to my 13 month old son if I kiss him on the forehead or cheek, or if he touches my mouth (as he often does), during times of asymptomatic shedding? The Valtrex has provided me such peace of mind, knowing that any asymptomatic shedding was GREATLY reduced. I am feeling that I should not kiss him AT ALL while I am off the meds, and that I should wash his hands if he touches my mouth at ANY time.

3) If my 13 month old child were to get HSV at this point, could the infection be serious? I understand the infection is MOST serious for a neonate, still serious for a newborn, and that neonates who are infected with HSV are closely followed/monitored even up to 6 months. I am wondering if my son is more so ‘out of the danger zone’ – although clearly, I want to do all I can to protect him from contracting HSV at this early age. He is not in day care, and I do not allow others to kiss him on the mouth. I am very concerned about him developing a primary infection of the eye, or of the mouth and then touching his eye (he is too young to understand not to do so) and developing ocular herpes.

4) Finally, if I do go off the Valtrex/suppressive therapy, have you found that the body develops a ‘dependence’ on it – that is, that I may have even more frequent outbreaks after stopping the suppressive therapy than I generally did before starting it?

I am sure I will have follow-up questions, but let’s just start with the above for now. I appreciate your time and patience in your having read this far. 🙂

Thank you.

[Terri Warren]

You ask a difficult question. Yes, some OB providers continue antiviral therapy for the entire pregnancy, I’ve never heard of any complications from that. It is, however, usual to discontinue antiviral therapy upon learning of a pregnancy and restart some time during the third trimester. so your doc is following the usual pattern. How about if you give it a try and see how it goes? If you have lots of cold sores, you could discuss with him going back on therapy. There are some sensitive issues here regarding your relationship with your doctor.

I would not be concerned about transmitting HSV to your 13 month old son when you have no sores. The skin that a person has on it’s forehead or cheek is not vulnerable to infection because the skin is too thick. Also, if you did kiss your child on the lips, it is very unlikely that it would be transmitted because the way you kiss a child is not the way you would kiss an adult partner. Without a cold sore, I would not be concerned about kissing a child briefly on the lips. With a cold sore, I wouldn’t be kissing the child. However, at 13 months, your child should deal effectively with HSV 1 without a big concern. It is quite common for children to get cold sores at a year or two of age from parents who don’t know that cold sores are caused by herpes.

your body does not develop a dependence on the antiviral medicine. When you are off of the medicine for about 5 days, it will go back to it’s regular pattern. But remember that most people have fewer outbreaks over time, so just for the time that has passed, you may well have fewer outbreaks. you’ll just have to wait and see what happens off of therapy.

Now feel free to ask me follow up questions.

Terri

[sprocket7475]

Hi Terri,
Thanks so much for your reply and the valuable service you are providing here!

Thanks for confirming that my doctor is following the ‘usual’ pattern with regard to the use of Valtrex during pregnancy. I haven’t gotten to actually meet with him during this pregnancy yet (I am 5 weeks along and won’t have my first ultrasound until 8 weeks), so I have only been able to talk with his nurse about this. She then consulted with my dr and relayed his recommendation to me. She kept telling me – we’ve never had anyone take the medication for prophylactic reasons throughout pregnancy (and the impression I got was that they had never run across this question, which I find highly unlikely, as my dr is an experienced OB). Nevertheless, she did tell me to contact them if I have a cold sore outbreak after going off the meds. And I will be able to talk to my dr in more detail when I have my appointment next month.

Thanks also for the info regarding transmission risk to my (13 month old) son. I realized when rereading my original post that I said I only kiss him on the cheek or forehead – I should note that I also kiss him on other parts of his head (top, back, side, etc.). I assume those would be considered the same as the forehead (thick skin, not vulnerable to HSV infection), but please let me know if that’s not the case.

Regarding asymptomatic shedding – when not on the Valtrex, as I mentioned, I often get tingles, itching, irritation around the outer edge of my mouth, sometimes redness and swelling. I usually apply rubbing alcohol with a piece of tissue or Q-tip when those symptoms appear. And, in the vast majority of cases (as again, this happens very frequently), a cold sore doesn’t actually manifest. I always felt that those symptoms were related to my HSV, and now that I have learned more about ‘asymptomatic’ shedding (and also had the experience of those symptoms being GREATLY reduced when being on the Valtrex), I feel confident that they are indicative of shedding. These symptoms come and go – sometimes the irritation/swelling/redness will appear and be gone within an hour or two.

My follow-up questions are:

1) Even with the symptoms mentioned above (likely indicative of shedding), but no actual cold sore, do you still advise that it should be fine (basically zero transmission risk) to kiss my 13 month old on the cheek or head? I will not do so if I have actual swelling/redness/notable irritation, but as I mentioned, sometimes I can feel these symptoms and then an hour later they are gone, and then later in the day they may show up again, so given that they can sometimes be so frequent, I am worried that I may kiss him at one point and then a few hours later feel the tingles or notice irritation, or have felt tingles/noticed irritation a few hours prior to kissing him, and wonder if I was shedding the entire time. I understand that you said the cheek and (fore)head are not vulnerable to infection, but if there is enough of a viral load, might there be a concern? Again, I will never kiss my child with an active cold sore (or if I can feel an actual sore coming on – this is a different level of feeling, ickiness than that associated with the above).

2) Also given the above, should I be concerned (that is, constantly wash my child’s hands) if my son grabs my face, his hands touch my lips? Just tonight, for instance, when I was putting him to sleep, his hand grazed my lips, and then he rubbed his eye. He often puts his hands in his mouth, as well. Is there any concern of transmission here, just with asymptomatic shedding?

3) Regarding your comments about the body not developing a dependence on Valtrex – I guess I am trying to understand how robust the immune response will be once going off the meds. Granted, I am not very knowledgeable regarding antibody production, but if Valtrex has been disrupting the viral replication process for so long, and thus the immune system hasn’t had to work ‘as hard’ to respond to and fight the virus, could the Valtrex have effectively disrupted the production of antibodies? And/or could the level of HSV antibody in my blood have dropped (compared to pre-meds)?

I really appreciate your patience and help. I dealt with cold sores for years without being worried about the inconvenience and discomfort they caused me, personally – but now that a child is in the picture (and soon to be children!), I want to be super careful.

[Terri Warren]

1. This may well be prodrome for you but I still think there is little risk in kissing your child’s forehead and cheek.
2. I don’t feel that you need to wash your child’s hands when he touches your face when you have no cold sore
3. Once you stop the Valtrex for 5 days, the virus will resume it’s normal activity and your immune system will see the virus and mount it’s immune response. My guess is you’ve got a great immune response to herpes already as it has been years since you acquired HSV 1. I guess you could take an antibody test if this is still a worry for you. However, as you may already know, the usual screening test misses 1-2 out of 10 infections so if the antibody test was negative, you could not depend upon those results.

Terri

[sprocket7475]

Hi Terri,
Thanks for your previous help. I would like to ask my third question now.

I went off the Valtrex (1 gram daily dose), for the most part, a few weeks ago. I did take 250 mg (cut some 500 mg tablets I had in half) per day, probably foolishly thinking that perhaps a small amount would protect me/reduce shedding to some extent.

I developed a very active cold sore overnight, and this morning my (nearly 14 month old) son touched my mouth/the sore twice, and then immediately rubbed his eye. What is the risk of him developing ocular herpes from this type of exposure? And for what sort of symptoms should I watch (I’m guessing actual blisters, redness of the eye, etc)?

Ironically, I went to a new (my former) OB yesterday, as the OB I had been seeing wanted me to transfer to a high-risk doctor, since I will be 40 years old by time of delivery. I couldn’t get into the high-risk dr for another month, however, and I needed to have an initial ultrasound, to check on the baby and heartbeat, so I just went back to the OB-GYN I had seen for my last pregnancy. (I only switched from him because he is the busiest OB in town, has less time for his patients, and the wait times to see him are extremely long.) This OB said there is no issue with taking Valtrex, even now (still in first trimester). He did recommend that I drop from the 1 gram dose to 500 mg/day, and he even wrote me a prescription for the 500 mg suppression dose. He said the medicine is safe during pregnancy, and that if I am worried about transmission to my son, he would advise that I take it. Of course, that doesn’t help me now with regard to today’s incident, but it is very interesting how opinions can differ across doctors. Admittedly, this doctor is known to be less cautious than the other OB, but he is also very experienced (again, has the most patients of any doctor in town). And by the way, the baby looked great on the ultrasound!

Anyway, please let me know about the risk to my (nearly 14 month old) son from today’s exposure. I am very worried about him developing ocular herpes as a primary infection.

Thank you!

[Terri Warren]

well, I’m guessing that the contact was very brief, right? Did you wash his hands or anything?
I’m thinking that the risk is low. I would be looking for blisters around his eyes or irritation of any kind. Just take him into the pediatrician if you have concerns.
I also don’t think there is much concern about your taking Valtrex during your pregnancy but I don’t want you to perceive me giving you advice about this.
I know you will be obsessing about this, but you only really have to obsess for about 10 days.
Remember that I think your risk is low of him getting ocular herpes.
And I’m happy for you that the baby looks great.

Terri

• This reply was modified 8 years, 1 month ago by Terri Warren.

[sprocket7475]

Hi Terri,
I went ahead and purchased additional questions.

Yes, the contact was brief. He was lying next to me in bed this morning, and as he was waking up (consequently waking me up), he reached over and grabbed for my face. His hand grazed my lips, and the blistered area, twice. He then immediately raised his hand to his eye to rub it. It all happened so fast. I did pick him up and then go and wash his hands, but again, he had already touched his eye. I also tried to wash his eye somewhat, but of course I couldn’t get soap in it. And this was several minutes after the exposure, as I spent some time scrubbing my hands and then his.

I did notice a small spot of irritation (small red bump) underneath the involved eye tonight. But, I’m thinking that can’t possibly be related to this morning’s exposure – the incubation period would be at least 2 days, right?
I realize I was likely shedding prior to this morning, however, so I will watch the spot carefully.

And yes, I will obsess, and will watch him very closely. I gave the pediatrician’s office a pre-emptive call today (they know about my cold sore history, and concerns about transmission), just in case something should crop up – they said to bring him in if needed, and they would then get us to an eye doctor if necessary.

My husband and I agreed that I will begin taking the 500 mg dose of Valtrex. If I still have outbreaks on it, once the current one has cleared, then I will talk to the OB again. I tried the 500 mg dose (for a month) when I initially went on suppressive therapy, last year, but switched to 1 gram as I continued to have outbreaks during that month. However, again, that was post-root canal, when the virus seemed to be raging. So, we will see what happens now.

I wore a viral mask tonight when I put him to bed, to be cautious. He is sleeping in his crib now, and hopefully will stay there, but if he wakes during the night and winds up in our bed, my husband will sleep with him and I will sleep on the couch.

Thanks so much for your help. It is quite disconcerting to have this outbreak after having been outbreak-free for so many months on the 1 g/daily dose of Valtrex.

[Terri Warren]

I know you are afraid for your child. I understand.
But I honestly believe that your son will be fine.
Think about how many moms have cold sores! And children with herpes are getting more and more uncommon. The worst thing that could happen is that he might get cold sores also, right? He’s old enough to be able to withstand a herpes infection now. He’s not going to die from herpes.
I’m glad you are going back on your medicine and will have some greater sense of control over what is going on here. I’m not clear that anyone can put themselves in your place but I do have a sense of your anxiety.
Let me know if you have any other questions.

Terri

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