Pulmonary tuberculosis (TB), in children

A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0

• Diagnosis
• General Measures
• TB chemoprophylaxis/isoniazid preventive therapy (IPT), in children
• TB control programme: medicine regimens, in children

Most children acquire tuberculosis from infected adults by inhalation. Malnourished, immunosuppressed (HIV and AIDS) children and children < 5years of age are at increased risk for pulmonary tuberculosis.

DIAGNOSIS

Any child presenting with symptoms and signs suggestive of pulmonary TB is regarded as a case of TB if there is:

• A chest X-ray suggestive of TB,

AND/OR

• History of exposure to an infectious TB case and/or positive tuberculin skin test (TST) e.g. Mantoux.

A positive Xpert MTB/RIF and/or smear microscopy and/or culture, on early morning gastric aspirate or induced sputum, confirms TB disease.

Signs and symptoms include:

• unexplained weight loss or failure to thrive,
• unexplained fever for ≥ 2 weeks,
• chronic unremitting cough for > 14 days,
• lymphadenopathy (especially cervical, often matted),
• hepatosplenomegaly,
• consolidation and pleural effusion.

Tuberculin skin test (TST), e.g. Mantoux .

• A positive test: TST induration ≥ 10 mm.
• A TST may be falsely negative in the presence of:
  • malnutrition
  • immunodeficiency, e.g. HIV and AIDS
  • immunosuppression, e.g. steroid therapy, cancer chemotherapy
  • following overwhelming viral infection, e.g. measles or post vaccination

In these circumstances a TST induration ≥ 5 mm may be regarded as positive. Frequently, the TST will be non-reactive in these cases. TB treatment should be considered, despite a negative TST.

The following may be evident on chest X-ray:

• Direct or indirect evidence of hilar or mediastinal adenopathy with or without parenchymal opacification and/or bronchopneumonia.

GENERAL MEASURES

• Identify and treat the source case.
• Screen all contacts for TB infection.
• Monitor the nutritional status of the child to assess response to treatment.

TB CHEMOPROPHYLAXIS/ISONIAZID PREVENTIVE THERAPY (IPT) IN CHILDREN

Z20.1 + Z29.2

Consider TB chemoprophylaxis/isoniazid preventive therapy (IPT) in all children exposed to a pulmonary TB contact.

Exclude active TB (i.e. no signs or symptoms suggestive of TB):

• Refer to Pulmonary tuberculosis in children
• If any signs or symptoms of pulmonary TB are present, refer for chest X-ray.
• Never give IPT to children with active TB.

TB chemoprophylaxis/IPT is only used in:

• Children < 5 years of age.

OR

• Children of any age, who are HIV-infected.

WITH EITHER

• Close contact with an infectious pulmonary TB case. If child is re-exposed to a close contact, TB chemoprophylaxis must be repeated. (Previous IPT does not protect the child against subsequent TB exposure/ infection).
• Positive TST (only applicable on the first occasion of a positive TST).

MEDICINE TREATMENT

Preventive therapy in case of drug-sensitive TB contact:

• Isoniazid, oral, 10mg/kg daily for 6 months.
  • Maximum dose: 300 mg daily.

Preventive therapy in case of drug-resistant TB contact:

Isoniazid mono-resistant contact:

• Rifampicin, oral, 15 mg/kg daily for 4 months.
  • If child unable to swallow tablets

LoEIII [31]

Rifampicin mono-resistant contact:

• Isoniazid, oral, 10 mg/kg daily for 6 months (see table above).

LoEIII [32]

Children with HIV or malnutrition or existing neuropathy taking isoniazid:

ADD

• Pyridoxine, oral, daily for duration of prophylaxis:
  • Child < 5 years old: 12.5 mg
  • Child ≥ 5 years old: 25mg

LoEIII [33]

REFERRAL

Children with MDR and XDR TB contacts for expert advice.

TB CONTROL PROGRAMME: MEDICINE REGIMENS IN CHILDREN

A15.0-3/A15.7-8/A16.0-2/A16.7-8/B20.0

Directly observed therapy (DOT), short-course and using fixed medicine combinations are recommended. Treatment should be given daily in both the intensive (initial) and the continuation phases.

UNCOMPLICATED PULMONARY TB

Includes smear negative pulmonary TB with no more than mild to moderate lymph node enlargement and/or lung field opacification, or simple pleural effusion on chest x-ray.

Children ≤ 8 years of age

*For each dose, dissolve 150 mg dispersible (1 tablet) in 3 mL of water to prepare a concentration of 50 mg/mL (150 mg/3 mL)

Note: Give PZA 150 mg or 500 mg, and not both.

LoEIII [34]

AND

• Pyridoxine, oral, daily for 6 months if HIV-infected, malnourished, or have existing neuropathy:
  • Child < 5years old: 12.5 mg
  • Child ≥ 5 years old: 25mg

LoEIII [35]

Children ≥ 8 years and adolescents

AND

If HIV-infected, malnourished or have existing neuropathy:

• Pyridoxine, oral, daily for 6 months.
  • Child < 5 years old: 12.5 mg.
  • Child ≥ 5 years old: 25mg.
• Adjust treatment dosages to current body weight.
• If calculating dosages, rather give ½ tablet more than ½ tablet less.

LoEIII [36]

COMPLICATED PULMONARY TB

• Includes all other forms of pulmonary TB, such as smear positive TB, cavitating pulmonary TB, bronchopneumonic TB, large lesion pulmonary TB, tuberculous empyema.
• Refer all cases of miliary TB for exclusion of TB meningitis.

Children ≤ 8 years of age

Intensive phase:

• Standard dose 4-drug therapy daily (RHZE) for 2 months.

THEN

Continuation phase:

• Standard dose 2-drug therapy daily (INH+rifampicin) for 4–7 months.

* EMB For each dose, crush 400 mg (1 tablet) to a fine powder and dissolve in 8 mL of water to prepare a concentration of 400mg/8mL. Discard unused solution.

** PZA: For each dose, dissolve 150 mg dispersible (1 tablet) in 3 mL of water to prepare a concentration of 50 mg/mL (150 mg/3mL)

Note: Give PZA 150 mg or 500 mg, and not both.

*** Continuation phase may be prolonged to 7 months in slow responders and children with HIV.

AND

If HIV-infected, malnourished or have existing neuropathy:

• Pyridoxine, oral, daily for 6–9 months.
  • Child < 5 years old: 12.5 mg
  • Child ≥ 5 years old: 25mg

LoEIII [37]

Children ≥ 8 years and adolescents

AND

If HIV-infected, malnourished or have existing neuropathy:

• Pyridoxine, oral, daily for 6–9 months.

LoEIII [38]

• • Child < 5 years old: 12.5 mg
  • Child ≥ 5 years old: 25mg
• Weigh at each visit and adjust treatment dosages to body weight. If calculating dosages, rather give ½ tablet more than ½ tablet less.
• Keep strictly to the correct dose and the duration of treatment.
• The patient should be weighed regularly and the dose adjusted according to the current weight.

REFERRAL

• Disseminated forms of TB.
• All patients who cannot be managed on an ambulatory basis.
• Children < 12 years of age for a chest X-ray for diagnostic purposes.
• Retreatment cases of children.
• Children who are contacts of patients with open MDR or XDR TB.