Tb

1. 1
Tuberculosis in Children

2. 2
• Basic introduction to TB in children
• Diagnosis of TB in children
• Treatment and monitoring treatment
• Prevention of Tuberculosis in Children
O u t l i n e

3. 3
• Globally, there were 1 million new cases of
child TB – 10% of all new TB cases (10.4
million) in 2015
• TB is mainly caused by, Mycobateria
tuberculosis, transmitted through the air and
is spread to children by individuals with TB of
the lungs.
T B i n C h i l d r e n

4. 4
Pathogenesis
• When breathed in, bacteria maybe deposited in the lung air
sacs
• The body’s immune system attacks the bacteria causing a local
immune reaction leading to a lesion called Ghon focus
• Bacteria carried by the lymphatic vessels cause the lung lymph
nodes to enlarge
• Enlarged lymph node + Ghon focus = Ghon complex
• If the immune system does not stop TB, the child develops
Primary TB
• Children who develop TB disease usually do so within 2 years
after exposure and most (90%) within a year.
T B i n C h i l d r e n

5. 5
Risk factors for TB infection
• TB disease source case –
bacteriologically confirmed
more infectious
• Cavities on CXR
• Contact with source –
closeness and duration
• Increased exposure
– High TB endemic
communities
– Families with HIV
R i s k f a c t o r s o f T B i n C h i l d r e n
Risk factors for TB disease
• Age less than 5 years
• HIV infection
• Severe malnutrition
• Recent episode of measles
• Other immune suppressive
conditions e.g. diabetes,
children on chemotherapy
• Not BCG vaccinated (risk
for disseminated TB
disease)

6. 6
• Children present with either
PTB (75%) or EPTB(25%)
• Assessing for TB includes
– Screening the child for
TB using the TB
Intensified Case Finding
(ICF) Guide.
– History taking including
history of TB contact.
– Conducting a clinical
examination for signs
suggestive of TB.
– Conducting relevant
investigations.
A s s e s s m e n t o f c h i l d r e n f o r T B

7. 7

8. 8
New born
• Most important cue is maternal
history of TB or HIV infection
• Symptoms are non-specific but
may include:
1. Lethargy
2. Poor feeding
3. Low birth weight
4. Poor weight gain
P r e s e n t a t i o n o f T B i n c h i l d r e n
< 5years
PTB
• Persistent cough > 2weeks
• Persistent fever > 2 weeks
• Poor weight gain > 1 month
• Household contact – person with PTB
• Painless large swellings – neck,
armpit, groin
• Decreased activity in the presence of
the above
EPTB
• TB adenitis – swellings in the neck….
• TB meningitis
• Miliary TB – nonspecific symptoms

9. 9
> 5 years
PTB
• Persistent cough > 2weeks
• Persistent fever > 2 weeks
• Poor weight gain or weight loss
• Household contact – person with
PTB
• Excessive night sweats
• Coughing out blood (Haemoptysis)
• Chest pain
• Non painful swelling in the neck,
armpit, or groin
P r e s e n t a t i o n o f T B i n c h i l d r e n
> 5years
EPTB – in addition
• Abdominal TB: Abdominal swelling,
abdominal masses
• TB Spine: Deformity of the spine,
lower limb weakness, paralysis,
inability to walk
• Bone and joint TB: Swelling of end of
long bones, difficulty in movement
• Pericardial TB: Difficulty in breathing,
easy fatigability, palpitations, chest
pain

10. 10
• Dependent on clinical assessment
1. Laboratory diagnosis
– GeneXpert
– Smear microscopy
– TB culture
• If the above are positive – bacteriologically confirmed TB
and should be started on treatment
2. Clinical diagnosis
• Dependent on findings from TB screening, clinical
examination, radiological examination
• Applies to children with a negative lab test for TB or
children in whom a sample has not been obtained
D i a g n o s i s o f T B i n c h i l d r e n

11. 11
• FLDs include: Rifampicin (R), Isoniazid (H), Pyrazinamide (Z) and
Ethambutol (E)
– E is safe as long as recommended dose is not exceeded
• Streptomycin is no longer recommended for children
• Recommended treatment regimen for children
Tr e a t m e n t o f T B i n c h i l d r e n
Type of disease Regimen
Intensive Continuation
All forms of TB
(excluding TB meningitis and Bone TB)
2RHZ+E 4RH
TB meningitis
Bone (Osteoarticular) TB
2RHZ+E 10RH

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R e t r e a t m e n t c a s e s
What to do Comments
Children previously
treated for TB
(Re-treatment cases
e.g. relapse, lost to
follow up, treatment
failure)
Check adherence to
previous treatment
Assess for history of
contact with MDR TB
patient
Obtain a sample
Do GeneXpert to screen
for Rifampicin resistance
If GeneXpert reveals
Rifampicin sensitivity treat as
new patient under DOT
If GeneXpert reveals
Rifampicin resistance, refer
child to MDR treatment site
If unable to obtain a sample
or GeneXpert is negative refer

13. 13
TB Medicine
(Abbreviation)
Daily doses
mg /kg/body weight
(Range)
Maximum Daily
dose
Rifampicin (R) 15 (10- 20) 600 mg
Isoniazid (H) 10 (7-15) 300 mg
Pyrazinamide (Z) 35 (30- 40)
Ethambutol (E) 20 (15- 25)
R e c o m m e n d e d d o s e s

14. 14
Pyridoxine (Vitamin B6)
• Isoniazid interferes with the metabolism of pyridoxine leading to
its deficiency.
• Neuropathy mainly occurs in HIV+ children and severely
malnourished - prioritize
• Dose: 1-2 mg/kg/day; range of 10-50 mg/day.
Prednisolone
• used where there is severe inflammation e.g. TB meningitis and
complications of airway obstruction by TB lymph nodes.
• Dose: is 2mg/kg/day as a single dose for 4weeks, and then
reduced over a period of 1- 2weeks.
A d j u n c t T h e r a p y

15. 15
• Severe forms of TB including miliary TB with
respiratory distress,
• TB meningitis, TB pericarditis, and TB spine with
Neurological complications
• Severe malnutrition for nutritional rehabilitation
• Signs of severe pneumonia (i.e. chest in-drawing)
• Other co-morbidities e.g. severe anaemia
• Severe adverse reactions such as hepatotoxicity
I n d i c a t i o n s f o r h o s p i t a l i z a t i o n

16. 16
F o l l o w u p a n d M o n i t o r i n g t r e a t m e n t

17. 17
Approaches for TB prevention in children include:-
• BCG vaccination
• TB preventive therapy e.g. Isoniazid Preventive
Therapy (IPT)
• Contact Screening and Management
• TB Infection Control
• ART for HIV infected children
• Early diagnosis and treatment of PTB cases
P r e v e n t i o n o f T B i n c h i l d r e n