TB in Children

Administering Treatment in
Children 0 – 14 years old

Reagan S. Patriarca, RN
DOH - Representative
 Introduction
Tuberculosis (TB) among children is mild and
rarely infectious. However, the condition can
become serious, hence the need for early
diagnosis and treatment.

Key risk factors for TB in children are:

 Close contact with a smear positive TB case
 Age less than 5 years old
 Malnutrition
 HIV Positive
 Risk of developing TB disease
following infection

Age group Pulmonary TB Severe EPTB*

< 1 year 30 – 40% 10 - 20%

12 – 23 months 10 – 20% 2 – 5%

* EPTB – Extra Pulmonary Tuberculosis such as

TB meningitis or disseminated (miliary) TB
1. Identifying Children with Tuberculosis

WHO recommends the following approach

to diagnose TB in Children:

 Careful history and clinical examination

1. Clinical sign and symptoms
2. Past medical history
3. History of exposure
4. Clinical or Physical Exposure
B. Bacteriological Confirmation whenever
possible
1. Direct Sputum Smear Microscopy
(DSSM)
2. Culture and histopathological
examinations
C. Tuberculin Skin Test (TST)
aka Mantoux Test by using Purified
Protein Derivative (PPD)

TST is a method of demonstrating

INFECTION with M. Tuberculosis at
sometime in the past, whether recent or
remote.
A positive TST confirms both
exposure and infection
D. Other Diagnostic Test (ODT)

1. Chest X-ray (CXR)

2. Lumbar puncture, Abdominal
ultrasound
3. Other Serologic Test, Nucleic Acid
amplification, computerized chest
tomography and bronchoscopy
 Differentiate TB Exposure,
TB Infection and TB Disease

 TB Exposure
A child has TB Exposure if he/she is in
close contact with a source case but
without any signs and symptoms
presumptive of TB, TST negative and no
radiologic or laboratory findings
suggestive of TB
 Differentiate TB Exposure,
TB Infection and TB Disease
 TB Infection or Latent TB Infection (LTBI)
A child has TB Infection if he/she is found to
be positive TST but without signs and symptoms
presumptive of TB and no radiologic or
laboratory evidence suggestive of TB.

 TB Disease
A child has TB Disease if he/she is TB
symptomatic, positive TST and/or positive
radiologic or laboratory evidence suggestive of
TB
 Summary of Differences
TB TB TB
Exposure Infection Disease
Exposure Yes Yes Yes
Sign & Symptoms None None Positive

TST Negative Positive Positive

CXR Negative Negative Positive
DSSM Negative Negative Positive or
Negative

Other diagnostics Negative Negative Positive

 Classification of TB Disease
A. PULMONARY TB
1. Pulmonary TB sputum smear positive
2. Pulmonary TB sputum smear negative
2.a For children 10 – 14 yrs or younger
children who can expectorate and a
DSSM was done
2.b For children 0-9 yrs old w/ negative
DSSM or children 0-9 years old who
cannot expectorate, thus DSSM was not
performed and other diagnostic test
were done
 Classification of TB Disease
B. Extra Pulmonary TB – EPTB
- is characterized as one of the ff:
 Clinical and/or histological evidence
consistent with active TB outside the lungs
and decision by a physician to treat the
patient with anti-tuberculosis
chemotherapy
 One(1) mycobacterial culture positive
specimen from a site outside the lungs
 2. Administering Treatment
Types of TB Cases
 New – one who had never had TB in the
past, or who has previously taken anti-
tuberculosis drugs for less than one month
 Treatment Failure
- an initially smear positive patient who
remains or becomes smear positive on the
5th month of treatment
- a newly diagnosed TB patient whose TB
symptoms persisted and has failed to gain
weight after 6 months of treatment.
 Relapse – previously treated for TB, who
has been declared cured or treatment
completed and upon assessment is TB
symptomatic with one of the following:
- progressive deterioration or
worsening of CXR findings or recurrence
of CXR findings
- Smear positive or culture positive
 Transfer in – one who has been
transferred in DOTS facility from another
facility adopting policies with proper
referral
 Types of TB Cases
 Return After Default (RAD) – one who is
starting treatment again after interrupting
treatment for more than 2 months, has
persistent or recurrence of TB symptoms,
with or without weight gain. Positive
bacteriology (smear or culture) may or
may not be present
 Other – a type of TB patient that does not
fit in the definition of New,
 WHO Recommended Doses for
first-line Anti-TB drugs
First-line Drugs Daily dose Maximum dose
(mg/kg BW)
Isoniazid (H) 5 (4-6) 300 mg/day

Rifampicin (R) 10 (8-12) 600 mg/day

Pyrazinamide (Z) 25 (20-30) 2g

Ethambutol (E) 20 (15-25) 2.5 g

Streptomycin (S) 15 (12-18) 1g

 Recommended Category of Treatment Regimen
Category TB Case Regimen
Intensive Continuation
New Smear (-)
III (-) ODT & those other than in Cat. I 2HRZ 4HR
or less severe forms of pulmonary TB
New Smear(+)
New Smear (-) with extensive
parenchymal lesions on CXR 2HRZE 4HR
I
Severe forms of extra pulmonary TB
(other than TB meningitis)

Ia TB meningitis 2HRZS 4HR

II Relapse
RAD 2HRZES/ 5HRE
Treatment Failure 1HRZE
Other
IV Chronic (still smear positive after Refer to MDR-TB
supervised re-treatment) and MDR-TB Treatment Center
 Management of Side Effects
Side-effects Drug Responsible What to do?
Flu-like Syndrome R - Give antipyretic
Skin rash HR - Give antihistamine
Nausea, vomiting and R - Give medications at
abdominal pain bedtime
Arthralgia Z - Give paracetamol;
Ibuprofen; warm compress
Pain in the injection site S - Apply warm compress;
rotate site of injection
Jaundice ZHR - Discontinue anti-TB drugs;
Refer to MD. If symptom is
subsiding gradually resume
treatment and monitor
clinically.
 Management of Side Effects
Side-effects Drug Responsible
Peripheral neuritis
Blurring of vision
Psychosis
Thrombocytopenic purpura
Anuria
Deafness, ringing of the
ear
What to do?
H - Give Vit-B complex
E - Discontinue Ethambutol;
Refer to ophthalmologist
H - Discontinue Isoniazid
R - Discontinue Rifampicin
R - Discontinue Rifampicin and
refer patient to hospital.
S - Discontinue temporarily and
resume when symptoms
disappear
 3. Prevention of TB in Children
Three (3) Strategies recommended by WHO
 Universal use of BCG ( Bacillus Calmette
-Guerin)
 Early detection and treatment of infectious
TB cases
 Isoniazid Preventive Therapy (IPT) for
infants and young children who are at risk
of developing TB disease. Given for a 6
month course at 5 mg/kg once daily
 Isoniazid Preventive Therapy or IPT
 The National Consensus on Childhood TB(1997)
states that “prophylaxis aims to prevent the
development of infection among contact exposed to
active disease as well as to prevent progression of
the disease among those already infected. Primary
prophylaxis is recommended for children under 5
years or among those with other risk factors for
rapid development of disease, since disease may
set in even before conversion of TST. Several well
controlled studies have demonstrated the favorable
effect of Isoniazid (INH) on reduction of
complications due to lymphohematogenous and
pulmonary spread after infection. The protective
effect of INH in the latter situation has been shown
to last from 19 to 30 years.
 Children who will receive IPT
Children 0-4 years old who are:

1. Positive for TST (TB Infection)

2. Negative for TST but close contact to a
smear positive TB (TB Infection)
3. Close contact with a smear positive but
TST was not done because it was not
available.
 Baby born to a smear (+) mother
The risk of the baby being infected with TB is highest if a
mother was diagnosed with TB at the time of delivery or
shortly thereafter. In these case it is very important that we
should assess the newborn at once.
1. If the newborn is not well, refer them to a pediatrician
2. If the child is well (absence of any sign/s or symptom/s
presumptive of TB do not give BCG first, instead give
IPT for 3 months.
3. After 3 months, perform TST.
4. If TST is negative, stop IPT and give BCG.
5. If TST is positive and baby remains well, continue IPT
for 3 more months
6. After 6 months of IPT and the child remains well, give
BCG.
 Monitor compliance and response
to IPT
Children on IPT will be supervised daily by a
treatment partner and followed up on a
DOTS facility on a monthly basis so they
assess the following:
 presence of signs and symptoms
presumptive of TB – to ensure that these
children are not developing TB disease
 possible adverse effect of the drug
Treatment outcome of children on IPT
1. Completed IPT – a child who has completed 6
months of IPT and remains well or
asymptomatic during the entire period.
2. Defaulted IPT – a child who interrupted IPT for
2 consecutive months or more.
3. Died – a child who dies for any reason during
the course of IPT.
4. IPT Failed – a child who developed TB
disease (pulmonary or EPTB) anytime on IPT.
5. IPT Transferred out – a child who has been
transferred to another health facility with
proper referral slip of continuation of IPT and
whose treatment outcome is not known.
 HOPE YOU LEARNED
SOMETHING!!!

THANK YOU SO MUCH!!!