Tuberculosis In Children

Childhood tuberculosis is caused by Mycobacterium tuberculosis and may involve the lungs, intrathoracic lymph nodes or virtually any extrapulmonary site.

Young children, especially those younger than 5 years, are at increased risk of progression from infection to active disease and of severe disseminated forms such as miliary TB and TB meningitis.

Children often have paucibacillary disease, making microbiological confirmation more difficult than in adults.

Pulmonary disease commonly presents with:

• Persistent cough
• Fever
• Poor weight gain or weight loss
• Reduced activity
• Night sweats
• Reduced appetite

Other features depend on site:

• Painless cervical lymphadenopathy
• Pleural effusion
• Abdominal distension or ascites
• Bone or joint pain
• Gibbus deformity
• Persistent headache or neurological deficit
• Meningism
• Cranial nerve palsies
• Disseminated disease with hepatosplenomegaly

TB should be considered in a child with persistent respiratory symptoms, poor growth, contact with a person with TB or pneumonia failing standard treatment.

Diagnosis combines clinical, epidemiological, microbiological and radiological evidence.

Assess:

• TB exposure history
• Weight and growth trajectory
• HIV status
• BCG scar where relevant
• Chest examination
• Lymph nodes

Obtain microbiological confirmation whenever possible using:

• Gastric aspirate
• Induced sputum
• Expectorated sputum in older children
• Nasopharyngeal or stool molecular testing where validated
• Tissue or fluid from extrapulmonary disease

Use a rapid molecular test such as Xpert MTB/RIF or equivalent as the preferred initial microbiological test where available.

Chest radiography may show hilar or mediastinal lymphadenopathy, consolidation, collapse, miliary nodules or cavitation.

A tuberculin skin test or IGRA supports evidence of infection but cannot distinguish latent infection from active TB.

For non severe drug susceptible TB in children aged 3 months to 16 years, a shortened regimen may be used:

2 months HRZ with or without ethambutol, followed by 2 months HR

Total duration 4 months

For disease not meeting non severe criteria:

2 months HRZE followed by 4 months HR

Total duration 6 months.

Severe extrapulmonary TB such as TB meningitis or osteoarticular TB generally requires longer disease specific treatment.

Use weight banded fixed dose combinations where available and recalculate doses as the child gains weight.
Give pyridoxine with isoniazid in children at increased risk of deficiency, including those with malnutrition, HIV, pregnancy in adolescents or neurological disease.
Test for HIV and assess household contacts.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Sepsis In Children

Sepsis is life threatening organ dysfunction caused by a dysregulated host response to infection. In children, deterioration can be rapid, and hypotension is a late sign. Early recognition depends on identifying abnormal perfusion, altered mental state, respiratory compromise, reduced urine output and other evidence of evolving organ dysfunction.

Common sources include pneumonia, meningitis, urinary infection, intra abdominal infection, skin and soft tissue infection, osteoarticular infection and bloodstream infection. Infants may present nonspecifically with poor feeding, lethargy, temperature instability or apnoea.

Features include:

• Fever or hypothermia
• Tachycardia
• Tachypnoea
• Altered mental state
• Poor feeding
• Reduced urine output
• Delayed capillary refill
• Weak peripheral pulses
• Cool mottled extremities or, in distributive shock, warm peripheries with bounding pulses
• Respiratory distress
• Hypoxaemia
• Hypotension in advanced disease

Red flags include:

• AVPU below Alert
• Persistent capillary refill prolongation
• Oliguria
• Lactate elevation
• Progressive respiratory failure
• Purpuric rash
• Recurrent seizures
• Shock

Sepsis is primarily a clinical diagnosis. Do not delay treatment while waiting for laboratory confirmation.

Obtain where feasible:

• Blood cultures before antibiotics if this causes no meaningful delay
• FBC
• Glucose
• Electrolytes and renal function
• Blood gas
• Lactate
• Liver function
• Coagulation profile in severe disease
• Urine microscopy and culture
• CSF where meningitis is suspected and lumbar puncture is safe
• Imaging directed at the suspected source

A normal initial white cell count does not exclude sepsis.

Repeated assessment is more important than a single laboratory result.

Stabilize airway, breathing and circulation immediately.

Give oxygen where hypoxaemia or respiratory compromise is present.

Establish IV or IO access.

Correct hypoglycaemia.

Obtain cultures rapidly, then give appropriate broad spectrum IV antibiotics without delay in septic shock or strongly suspected severe bacterial infection.

Empirical choice depends on age, source, prior antimicrobial exposure and local resistance. A commonly used regimen in an older infant or child with undifferentiated severe bacterial sepsis is:

Ceftriaxone 50 mg/kg IV every 12 hours, maximum 4 g/day

Adjust immediately when the source or microbiology becomes clearer.

For suspected staphylococcal infection, add appropriate antistaphylococcal therapy such as flucloxacillin.

Give isotonic crystalloid cautiously in shock, commonly 10 to 20 mL/kg per aliquot, with reassessment after every bolus. Do not continue fluid blindly when hepatomegaly, pulmonary oedema or worsening respiratory status develops.

Start vasoactive support early if shock persists despite appropriate fluid resuscitation or further fluid is unsafe.

Source control is essential. Drain abscesses, infected pleural collections or other drainable foci promptly.

Tuberculosis In Children

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management