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.