Tuberculosis (TB) in Children

Description

TB in children is an indicator of recent and ongoing transmission of M. tuberculosis in the community, as majority of children will develop tuberculosis disease within 1 year after infection.

Pulmonary TB is the commonest type of TB in children but extrapulmonary disease is also common estimated to be around 30-40% of cases.

Most immunocompetent children with TB disease present with nonspecific symptoms of a chronic disease. In infants the presentation may be more acute and can present as acute severe, recurrent, or persistent pneumonia. TB should be suspected when there is a poor response to appropriate conventional antibiotics.

Key risk factors for TB in children:

• Household contact with a newly diagnosed smear positive
• Age < 5 years
• HIV infection
• Severe malnutrition

Signs and Symptoms

Pulmonary TB

• Cough
• Fever
• Loss of appetite
• Weight loss or failure to
• Decreased

Other symptoms will depend on the anatomical site of tuberculosis disease. 

Extrapulmonary TB.

• Gibbus- Spinal TB, especially of recent
• Non-painful enlarged cervical lymphadenopathy, with or without fistula formation- TB
• Pleural effusion
• Pericardial effusion
• Distended abdomen with ascites- TB
• Non painful enlarged joints- Osteoarticular
• Meningitis not responding to antibiotic treatment - TB meningitis

Investigations

• Careful history (including history of TB contact and symptoms consistent with TB).
• Clinical examination (including growth assessment).
• Bacteriological confirmation with Xpert MTB/RIF or culture or smear microscopy).
• Chest X-ray
• Tuberculin skin testing
• Urinary lateral flow lipoarabinomannan (LAM) for HIV infected children or presumed severe TB
• Investigations relevant for suspected extra-pulmonary
• HIV testing

Appropriate specimens should be obtained for Xpert MTB/RIF testing, staining and microscopy, culture (and histopathological examination in extrapulmonary TB).

For pulmonary TB

• Samples for Xpert MTB/RIF or culture testing should be obtained using any the following methods depending on the age of the child;
• Gastric lavage
• Sputum induction
• Nasopharyngeal aspiration
• Expectorated sputum

For extrapulmonary TB

• Pleural fluid: Xpert MTB/RIF, biochemistry, cell count and
• Pericardial fluid: Xpert MTB/RIF, biochemistry, cell count and
• Lymph node biopsy or Fine-needle aspiration of enlarged lymph glands: Xpert MTB/RIF, ZN staining, culture and histology.
• CSF: Biochemistry, cell count, Xpert MTB/RIF.

In addition, appropriate imaging studies such as abdominal ultrasound, Echocardiogram, CT and MRI should be used depending of the site of disease of extrapulmonary disease

Treatment

Table 78: Recommended TB treatment regimens in children

Table 79: TB drug dosing

Rifampicin (R) – 15 mg/kg (range 10 – 20 mg/kg); maximum dose 600 mg/kg, Isoniazid (H) –10 mg/kg (range 7 – 15 mg/kg); maximum dose 300 mg/kg, Pyrazinamide (Z) – 35 mg/kg (30 – 40 mg/kg) and Ethambutol (E) – 20 mg/kg (15 – 25 mg/kg)

 Use of corticosteroids

Corticosteroids are indicated in the management of some complicated forms of TB such as:

• TB
• Complications of airway obstruction by TB lymph
• Pericardial

 Prednisolone: is recommended at a dose of 2mg/kg daily, increased to 4 mg/kg daily in the case of the most seriously ill children, with a maximum dosage of 60 mg/day for 4 weeks. The dose should then be gradually tapered over 1–2 weeks before stopping.

 Pyridoxine supplementation

Isoniazid may cause symptomatic pyridoxine deficiency, which presents as neuropathy, particularly in severely malnourished children and HIV-positive children on antiretroviral therapy (ART). Supplemental pyridoxine (5–10 mg/day) is recommended in HIV-positive or malnourished children being treated for TB.

Drug resistant tuberculosis in children.

Drug-resistant TB (DR TB) should be suspected under the following conditions:

• Close contact with a person known to have DR-TB including household and other
• Close contact with patient that died from TB, failed or is not adherent to TB
• History of previous TB treatment (in the past 6-12 months).
• Not improving after 2-3 months of first line TB treatment, including persistence of positive smear or culture,persistence of symptoms and failure to gain weight (radiological improvement is frequently delayed).
• A child who develops active TB while on Isoniazid (INH)

 Appropriate samples should be obtained in any suspected case of DR-TB. These should include the following:

• Xpert MTB-RIF
• Mycobacterial culture
• Drug susceptibility testing (DST)
• Line-probe assays (LPA)

Indications to initiate MDR TB regimen in children.

• Confirmed MDR TB by DST or
• RR on Xpert MTB/RIF.
• Smear positive case with confirmed MDR
• Child with TB and unconfirmed DST resulting who is not responding to standard TB therapy and is a known contact of an MDR TB case.

 For treatment of DR TB refer to the Guidelines for the Programmatic Management of Drug Resistant Tuberculosis.

Indications for Tuberculosis preventive therapy (TBT) in children

TB preventive therapy is recommended for the following at risk groups of children.

• Asymptomatic HIV negative children aged <5 years who are household contacts of bacteriologically confirmed tuberculosis in whom active TB disease has been excluded.
• All HIV infected children aged, regardless of TB contact status, in who are considered unlikely to have active TB For HIV infected infants preventive therapy is provided only when child has established TB contact.

Table 80:Recommended and dosing options for TBT in children