TUBERCULOSIS (TB) IN CHILDREN
Description
Tuberculosis (TB) in children is a marker of recent or ongoing M. tuberculosis transmission in the community. Most infected children progress to TB disease within 1 year of infection.
Pulmonary TB (PTB) is the most common, while extrapulmonary TB (EPTB) accounts for 30–40% of cases.
Immunocompetent children often present with non-specific, chronic symptoms, while infants may present more acutely, sometimes as severe or recurrent pneumonia unresponsive to conventional antibiotics.
Key Risk Factors
-
Household contact with a newly diagnosed smear-positive TB case
-
Age < 5 years
-
HIV infection
-
Severe malnutrition
Signs and Symptoms
Pulmonary TB
-
Chronic cough
-
Fever
-
Loss of appetite
-
Weight loss or failure to thrive
-
Reduced activity
Extrapulmonary TB
| Form | Key Features |
|---|---|
| Spinal TB | Gibbus deformity (especially new onset) |
| TB Lymphadenitis | Non-tender enlarged cervical lymph nodes ± fistula |
| Pleural TB | Pleural effusion |
| Pericardial TB | Pericardial effusion |
| TB abdomen | Distended abdomen with ascites |
| Osteoarticular TB | Non-painful enlarged joints |
| TB meningitis | Meningitis unresponsive to antibiotics |
Investigations
Standard Diagnostic Approach
-
Detailed history, including TB contact
-
Full clinical examination + growth assessment
-
Xpert MTB/RIF, culture, or smear microscopy
-
Chest X-ray
-
Tuberculin Skin Test (TST)
-
Urine LAM (HIV-positive or presumed severe disease)
-
HIV testing
-
Tests specific to EPTB site
Sample Collection Methods (Pulmonary TB)
| Age/Condition | Preferred Samples |
|---|---|
| Younger children | Gastric lavage |
| Any age | Induced sputum |
| Infants/young children | Nasopharyngeal aspiration |
| Older children | Expectorated sputum |
Sample Collection for Extrapulmonary TB
| Site | Investigations |
|---|---|
| Pleural | Xpert MTB/RIF, biochemistry, cell count, culture |
| Pericardial | Xpert MTB/RIF, biochemistry, cell count, culture |
| Lymph nodes | FNA or biopsy → Xpert, ZN stain, culture, histology |
| CSF | Xpert, biochemistry, cell count |
| Other sites | Ultrasound, CT, MRI as appropriate |
Treatment
4.1 Recommended Treatment Regimens
Table 1: TB Treatment Regimens
| TB Category | Intensive Phase | Continuation Phase |
|---|---|---|
| All non-severe PTB/EPTB | 2 months HRZE | 4 months HR |
| Severe TB (TB meningitis, spinal TB, osteoarticular TB, miliary TB, severe forms) | 2 months HRZE | 10 months HR |
4.2 Drug Dosing
Table 2: Number of Tablets per Weight Band
| Weight | RHZ (75/50/150 mg) | Ethambutol 100 mg | RH (75/50 mg) |
|---|---|---|---|
| 4–7 kg | 1 | 1 | 1 |
| 8–11 kg | 2 | 2 | 2 |
| 12–15 kg | 3 | 3 | 3 |
| 16–24 kg | 4 | 4 | 4 |
| ≥25 kg | Use adult doses | Use adult doses | Use adult doses |
Weight-Based Doses
-
Rifampicin 15 mg/kg (10–20 mg/kg) max 600 mg
-
Isoniazid 10 mg/kg (7–15 mg/kg) max 300 mg
-
Pyrazinamide 35 mg/kg (30–40 mg/kg)
-
Ethambutol 20 mg/kg (15–25 mg/kg)
4.3 Use of Corticosteroids
Indications:
-
TB meningitis
-
Airway obstruction from TB lymphadenitis
-
Pericardial TB
Prednisolone dosing:
-
2 mg/kg/day (up to 4 mg/kg/day for critically ill)
-
Max 60 mg/day
-
Duration: 4 weeks, then taper over 1–2 weeks
4.4 Pyridoxine Supplementation
Indicated in:
-
HIV-positive children
-
Malnourished children
-
Children on TB treatment receiving ART
Dose: 5–10 mg/day
Drug-Resistant TB (DR-TB) in Children
When to Suspect DR-TB
-
Close contact with DR-TB cases
-
Contact with someone who failed or defaulted treatment
-
TB recurrence within 6–12 months
-
No clinical improvement after 2–3 months of first-line therapy
-
TB developed while on isoniazid prophylaxis
Required Tests
-
Xpert MTB/RIF
-
Culture
-
Drug susceptibility testing
-
Line probe assay (LPA)
Indications to Start MDR-TB Regimen
-
Confirmed MDR-TB (DST or LPA)
-
Rifampicin resistance on Xpert
-
Smear-positive child with MDR contact
-
Non-responding TB in a child with MDR contact
(Management should follow the national DR-TB guidelines.)
TB Preventive Therapy (TPT)
Table 3: Preventive Therapy Options
| Regimen | Daily Dose (mg/kg) | Max Dose |
|---|---|---|
| Isoniazid daily 6–9 months | 10 mg (7–15 mg) | 300 mg |
| Isoniazid + Rifampicin daily 3–4 months | H: 10 mg; R: 15 mg | H: 300 mg; R: 600 mg |
| Isoniazid + Rifapentine weekly 3 months (12 doses) | Age ≥12y: H 15 mg/kg; Age 2–11y: H 25 mg/kg | Weight-based rifapentine doses: 10–14.9 kg = 300 mg 14.1–25 kg = 450 mg 25.1–32 kg = 600 mg 32.1–49.9 kg = 750 mg ≥50 kg = 900 mg |
Target Groups for TPT
-
HIV-negative children <5 years exposed to a bacteriologically confirmed TB case
-
All HIV-positive children AND active TB ruled out
-
HIV-positive infants only if definite TB exposure