CONTENTS




KINDLY
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Sources
This guide is the second part of a series based on the following article:
Management of tuberculosis in children in low-income countries.
P.M.Enarson, D.A.Enarson, R.Gie
INT J TUBERC LUNG DIS 9(12):1299-1304
which essentially contains a summary of a guide of International Union Against Tuberculosis and Lung Disease. The complete guide's title is "Management of Tuberculosis. A Guide for Low Income Countries". You may download it from the Union's site using this link:
IUATLD publications


Are children treated differently from adults?
The same DOTS strategy principles are applied. Treatment is completed in two phases: intensive (2 months) and continuation (4-6 months).
Most children: are smear-negative, don't have serious disease and don't require 4 drugs initially. In the case of smear-positive children or an x-ray showing cavities 4 drugs are needed in the intensive phase: isoniazid (H,INH), rifampicin (R), pyrazinamide (Z), ethambutol (E, EMB). EMB is replaced by streptomycin (S) when the child has disseminated TB or tuberculous meningitis.
Serious disease requiring 4 drugs initially:
  • lung disease with cavities
  • tuberculous meningitis
  • disseminated TB
  • spinal TB with neurologic signs
Medications:
MedicationDaily dose (mg/kg)Range (mg/kg)
Isoniazid (H)54-6
Rifampicin (R)108-12
Pyrazinamide (Ζ)2520-30
Ethambutol (Ε)1515-20
Streptomycin (S)1512-18

World Health Organization recommendations for first time TB treatment:
  1. New smear-negative PTB and EPTB without severe disease:
    • Intensive phase (2 months): daily HRZ
    • Continuation phase (4 months): daily HR or 3 times per week OR 6 months of HE dailly.
  2. New smear-positive PTB or other cases with severe disease:
    • Intensive phase (2 months): daily HRZS (or Ε)
    • Continuation phase (4 months): daily HR or 3 times per week OR 6 months of HE dailly.
  3. New cases with tuberculous meningitis, disseminated TB or spinal TB with neurological signs:
    • Intensive phase (2 months): daily HRZS
    • Continuation phase (7 months): daily HR
Smear-positive retreatment cases are rare. HIV-infected children are treated similarly but are more likely to die during treatment and relapse is more frequent.
TRIAL OF TREATMENT for tuberculosis should never be given.

How is treatment monitored?
Smear-positive children should have a sputum culture after 2, 4 and 6 months of treatment (6 month regimen) or after 2, 5 and 7 months (8 month regimen). Smear-negative or unable to provide smear children are followed as smear-negative or EPTB adults.
Follow-up visits should be scheduled every 14 days for the first 2 months and every month thereafter.

Recording and reporting
Adult principles apply fully. Diagnostic categories:

New case. Never been treated before for as much as one month
Relapse. Previously treated, declared cured, and developed TB again.
Treatment after failure. Patient who remained or became again smear-positive at 5 months or later during treatment.
Treatment after default. Patient who returned to health services smear-positive after interrupting treatment for more than 2 months.
Transfer in. patient registered at another unit and transferred for treatment.
Other. All other children treated for TB.

Definition of treatment outcomes:

Smear-negative (cured). Smear-positive patients who where smear-negative at last month of treatment and on one other occasion.
Smear not done (treatment completed). Treatment completed but neither 'smear-positive' nor 'smear-negative' criteria are met.
Smear-positive (failure). Any new smear-positive patient who remains or becomes again positive at 5 months or later during treatment.
Died. For any reason during treatment.
Defaulted. Failed to collect medication for more than 2 consecutive months after last attendance during treatment.
Transferred. To another unit, treatment results are unknown.

To monitor the situation and determine trends three age categories are used:
  • children up to 2 years of age (up to 24 months)
  • those between 2 and 5 (up to 59 months)
  • children between 6 and 14
TB in children under 5 years of age is a sensitive indicator of TB in the community.

Protecting children from TB in the community
Three strategies have been established:
  1. early detection and treatment of infectious adult cases
  2. preventive treatment for children under 5 years of age who are in contact with cases of smear-positive PTB
  3. universal BCG vaccination

Preventive treatment
All children under 5 who have recently been exposed to a smear-positive patient or those who are known to be infected must receive preventive treatment (reduces mortality and prevents disseminated disease).
  • First ensure that the child does not have active TB
  • Then administer INH (5mg/kg) daily for 6 months

Previous BCG vaccination is irrelevant.

Babies born to mothers with newly diagnosed TB are in great risk of developing severe disease:
  • If the baby is symptomatic, it is possible that the baby has active disease.
  • If asymptomatic, the baby should receive INH 5 mg/kg/day for 6 months. BCG vaccination should be postponed and administered after preventive treatment completion.
  • If tuberculin skin testing is available, the baby can be tested after 3 months of INH treatment and, if non-reactive and the mother has become smear-negative, the treatment can be stopped and the child given BCG vaccination.
Breast milk concentration of anti-TB drugs are very low. A newly diagnosed mother should continue breastfeeding after the baby has been evaluated for TB and preventive treatment has started..

Vaccination
BCG provides children with a certain degree of protection against serious TB. It is uaually given soon after birth. There is no value in revaccination. Asymptomatic HIV-infected children should receive BCG.

Images from Greece...