1. Dr. SACHIN SONI
DNB PEDIATRICS

2.  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

3.  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

4. Number (Millions) Rate Per 100,000
Persons
Incidence
All cases (2009
WHO estimate)
2.0 (1.6-2.4) 168
Period Prevalence
(2000 estimate)
AFB positive 1.7 (1.3-2.1) 165 (126-204)
Prevalence, all cases
(2009 WHO
estimate)
3.0 (1.3-5.0) 249

6. 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

12.  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

13. 2010 2012
 Unexplained recent loss
of weight pointer to
suspicion of TB
 Static weight /not
growing well are not
significant pointer
toward diagonsis
 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

14. 2010 2012
 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
 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

15.  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

17.  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

18. 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

19.  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.

20. 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
 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

21.  New six weight bands (6-8,9-12,13-16,17-20,21-
24,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

22. Drugs Recommended daily
doses (max doses)
mg/kg/day
Major side effects
Isoniazide (H) 10 mg/kg (max 300
mg/day)
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

25.  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

26.  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

29.  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

30.  Inadequate or no response (on smear or clinico-
radiological 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

31.  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

32.  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

33. THANK YOU