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    • Dr. SACHIN SONI DNB PEDIATRICS Indraprastha Apollo Hospital New Delhi www.dnbpediatrics.com
    •  Tuberculosis is caused by Mycobacterium tuberculosis (M. bovis and M. africanum)  Its mainly affect the lung peranchyma but can affect other organs as well  Children are more likely develop extrapulmonary and severe disseminated disease as compared to adult www.dnbpediatrics.com
    • Its one of the most widespread infections affecting almost one third of the worlds population  Globally about 1 million cases of pediatric TB are estimated to occur every year accounting for 10-15% of all TB cases  In INDIA: 1990 1995 2000 2005 2011 www.dnbpediatrics.com
    • Number (Millions) Rate Per 100,000 Persons 2.0 (1.6-2.4) 168 AFB positive 1.7 (1.3-2.1) 165 (126-204) Prevalence, all cases (2009 WHO estimate) 3.0 (1.3-5.0) 249 Incidence All cases (2009 WHO estimate) Period Prevalence (2000 estimate) www.dnbpediatrics.com
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    • The presence of three or more of the following should strongly suggest a diagnosis of TB: - Chronic symptoms suggestive of TB - Physical signs highly of suggestive of TB - A positive tuberculin skin test - Chest X-ray suggestive of TB www.dnbpediatrics.com
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    • All efforts should be made to demonstrate bacteriological evidence for diagnosis  In cases sputum is not available, alternative specimens:-Gastric lavage -Induced sputum -Broncho-alveolar lavage  www.dnbpediatrics.com
    • 2010 2012 Unexplained recent loss of weight pointer to suspicion of TB  Static weight /not growing well are not significant pointer toward diagonsis  www.dnbpediatrics.com  Loss of weight – used as a clinical marker for disease defined as a loss of more than 5% of the highest weight recorded in the past three months
    • 2010 Positive Tuberculin skin test/Mantoux test:An induration of 10 mm with Tuberculin 1 TU (RT 23)  If patient return for reading beyond 72 h but by 7th day positive test can still be read  www.dnbpediatrics.com 2012 Positive Tuberculin skin test/Mantoux test:- An induration of 10 mm or more, measured 48-72 hours after Intradermal injection with Tuberculin 2 TU (RT 23 or equivalent) and  No more than 5TU (RT23 or equivalent) should be used 
    •  No role for inaccurate/inconsistent diagnostics test like serology - IgM, IgG, IgA antibodies against MTB antigens, non validated commercial PCR tests and BCG test  No role of IGRAs in clinical practice for diagnosis of TB  Lymph Node TB suspect definitions revisited and greater clarity and updated guidance www.dnbpediatrics.com
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    • New case: Who has had no previous ATT or had it for less then 2 week duration  Failure to respond: Who fails to have bacteriological conversion to negative status or fails to respond clinically/or deteriorates after 12 weeks of compliant intensive phase  Relapse: A case of TB declared cured/completed therapy in past and has (clinical or bacteriological) evidence of recurrence  Treatment after default: Who has taken treatment for at least 4 weeks and comes after interruption of treatment for 2 months or more and has active disease (clinical or bacteriological  www.dnbpediatrics.com
    • TB chemotherapy should be based on two important microbiological considerations:  1. The combination of drugs to avoid the development of resistance.  2. The need for prolonged chemotherapy to prevent disease relapse www.dnbpediatrics.com
    •  All mono-therapeutic regimens (real or masked by combination with drugs to which bacilli are resistant) lead to treatment failure and to the development of resistance.  When three or more drugs are administered, the risk of resistance is practically very low. www.dnbpediatrics.com
    • 2012     2010 The intermittent therapy remain the mainstay of treatment Seriously ill admitted children or severe disseminated disease/ neurotuberculosis, vomiting or non-tolerance of oral drugs is high in the initial phase Such, patients can be given daily supervised therapy during their hospital stay After discharge they will be taken on thrice weekly DOT regimen www.dnbpediatrics.com  Tubecular bacilli exposed to certain concentration of most currently used ATT shows inhibition of growth for 1 to several days  Intermittent thrice weekly therapy with higher dose is as effective as alternative
    • New six weight bands (6-8,9-12,13-16,17-20,2124,and 25-30 kg) was created and keep them sufficiently narrow to avoid large fluctuations at the ends of the weight band  Attempt to create generic boxes for each of the weight band instead of current practice of having combine boxes which significantly increases pill burden in children of >18kgs  www.dnbpediatrics.com
    • Drugs Recommended daily doses (max doses) mg/kg/day Isoniazide (H) 10 mg/kg (max 300 mg/day) Major side effects Peripheral neuropathy, Hepatotoxicity Rifampicin (R) 10-12 mg/kg (max 600 mg/day) Hepatotoxicity, Gastitis, Flu- like illness Pirazinamide (Z) 30-35 mg/kg (max 2000 mg/day) Arthralgia,hepatotoxicity Streptomycin (S) 15 mg/kg (max 1g/day) Tinitus Ethambutol (E) 20-25 mg/kg (max 1500 mg/day) Occulotoxicity www.dnbpediatrics.com
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    • Strongly recommended using dispersible tablet formulations under the RNTCP programme  DOT centers will be provided with pestle and mortars for crushing the drugs  It will be responsibility of DOT provider to supervise process of drug consumption  Any child vomits within half an hour of period of observation, fresh dosages for all drugs vomited will be provided to the caregiver  www.dnbpediatrics.com
    • Cat III regimen: Though, there is utility of Cat III regimen in some pediatric TB cases  In evidence of relatively high INH resistance i(>5% cases) And  Increasing evidence of safety of Ethambutol in the doses used under RNTCP, Cat III need not be revisited  Only two treatment categories – Cat 1- New cases Cat 2- Previously treated cases  www.dnbpediatrics.com
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    • Streptomycin can be safely replaced by ethambutol in intensive phase of TBM because:1- Current evidence favoring safety and efficacy of Ethambutol 2- Lack of any value addition in efficacy using Streptomycin over ethambutol 3- Need to avoid problems of injection based treatment (lack of adequate muscle mass in malnourished, risks of unsafe Injections, need for a trained personnel, unpleasantness of the treatment).  While ethambutol was considered a better option to replace streptomycin in the treatment of new cases  Streptomycin continues to be recommended as the additional fifth drug in the retreatment  www.dnbpediatrics.com
    • Inadequate or no response (on smear or clinicoradiological basis) at 8 weeks of intensive phase should be given extension of IP for one more month  In patients with TB Meningitis, spinal TB, miliary/ disseminated TB and osteo-articular TB, continuation phase shall be extended by 3 months making the total duration of treatment of 9 months  A further extension may be done for 3 more months in continuation phase (making the total duration of treatment to 12 months) on a case to case basis in case of delayed response  www.dnbpediatrics.com
    •  RNTCP may explore and pilot test the feasibility and effectiveness of alternate approaches like “Mother or caregiver at home as DOT provider” in selected areas www.dnbpediatrics.com
    •       Currently Recommended dose of INH for chemoprophylaxis is 10 mg/kg (instead of currently recommended dosage of 5 mg/kg) administered daily for 6 months to:All asymptomatic contacts (under 6 years of age) of smear positive case, after ruling out active disease and irrespective of their BCG, TST or nutritional status. All HIV infected children who either had a known exposure to infectious TB case or are Tuberculin skin test (TST) positive (>=5 mm induration) but have no active TB disease All TST positive children who are receiving immunosuppressive therapy:Nephrotic syndrome, acute leukemia Child born to mother who was diagnosed to have TB in pregnancy should receive prophylaxis for 6 months BCG vaccination can be given at birth even if INH chemoprophylaxis is planned www.dnbpediatrics.com