Overview/Definition
Definition:
• Tuberculosis (TB) in children is infectious disease caused by Mycobacterium tuberculosis complex, presenting unique diagnostic challenges due to paucibacillary nature, difficulty in specimen collection, and atypical presentations
Accounts for 10-15% of all TB cases globally with higher mortality rates in children under 5 years.
Epidemiology:
• India has highest TB burden globally with 2.64 million active cases, children comprising 6-8% of total TB cases (150,000-200,000 cases annually)
Higher prevalence in malnutrition, HIV-infected children, household contacts
Case fatality rate 5-10% in children, higher in disseminated TB and MDR-TB.
Age Distribution:
• Infants (<1 year): Highest risk for severe forms - miliary TB, tuberculous meningitis
Children (1-5 years): Primary TB complex most common, higher extrapulmonary TB rates
School age (6-12 years): Adult-like pulmonary presentations emerge
Adolescents (13-18 years): Similar to adult TB patterns, higher MDR-TB risk.
Clinical Significance:
• Critical topic for DNB Pediatrics and NEET SS examinations focusing on diagnostic algorithms, treatment modifications, and contact tracing
Understanding limitations of conventional diagnostics and role of newer molecular tests essential
Knowledge of RNTCP guidelines and drug-resistant TB management mandatory.
Age-Specific Considerations
Newborn:
• Neonates (0-28 days): Congenital TB rare but possible with maternal genital TB
BCG vaccination contraindicated in symptomatic infants
High risk for disseminated disease
Empirical anti-TB therapy often required based on maternal history
Close monitoring in NICU settings with isolation precautions.
Infant:
• Infants (1-24 months): Primary TB complex most common presentation
Higher risk for progressive primary TB, miliary TB, tuberculous meningitis
BCG vaccination provides partial protection against disseminated forms
Diagnostic challenges due to inability to produce sputum
Gastric aspirate samples for diagnosis.
Child:
• Children (2-12 years): Primary TB complex with hilar lymphadenopathy classical presentation
Contact tracing reveals household exposure in 80-90% cases
TST interpretation affected by BCG vaccination and malnutrition
Better cooperation for clinical examination and specimen collection.
Adolescent:
• Adolescents (12-18 years): Adult-like secondary TB patterns with cavitary disease
Higher risk for MDR-TB and treatment default
Peer pressure affects treatment compliance
Reproductive health counseling important for females
Risk of transmission to contacts increases.
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Clinical Presentation
Symptoms:
• Prolonged fever >2 weeks, often low-grade in nature
Chronic cough lasting >3 weeks, initially dry progressing to productive
Weight loss or failure to thrive in 80-90% cases
Night sweats, anorexia, fatigue
Hemoptysis rare in children <5 years, more common in adolescents.
Physical Signs:
• Lymphadenopathy: Hilar on chest X-ray, peripheral nodes (cervical, axillary) may be palpable
Digital clubbing in chronic cases
Hepatosplenomegaly in miliary TB
Pallor indicating chronic illness or anemia
Growth parameters: Height and weight below expected for age.
Severity Assessment:
• Intrathoracic TB: Primary complex, progressive primary TB, pleural effusion
Extrapulmonary TB: Lymph node TB, bone and joint TB, abdominal TB, CNS TB
Severe forms: Miliary TB, tuberculous meningitis requiring immediate treatment
Drug-resistant TB: MDR, XDR patterns.
Differential Diagnosis:
• Pneumonia: Acute onset, rapid response to antibiotics
Malignancy: Lymphoma, solid tumors with mediastinal involvement
Other mycobacteria: Atypical mycobacterial infections
Sarcoidosis: Rare in children
Foreign body aspiration: Unilateral involvement, acute history.
Diagnostic Approach
History Taking:
• Detailed contact history: Household TB contact in preceding 2 years
BCG vaccination history and scar examination
Previous anti-TB treatment history
HIV status and other immunocompromising conditions
Malnutrition assessment, socioeconomic factors.
Investigations:
• Tuberculin Skin Test (TST): 5 TU PPD intradermal, read at 48-72 hours
GeneXpert MTB/RIF: Rapid molecular test for M
tuberculosis and rifampicin resistance
Chest X-ray: Hilar lymphadenopathy, consolidation, miliary pattern
Gastric aspirate microscopy and culture in young children.
Normal Values:
• TST interpretation: ≥5 mm positive in HIV/immunocompromised, ≥10 mm positive in high-risk groups, ≥15 mm positive in low-risk individuals
GeneXpert: Qualitative result - M
tuberculosis detected/not detected, rifampicin resistance detected/not detected
Normal chest X-ray in 15-20% active TB cases.
Interpretation:
• TST limitations: False positive due to BCG vaccination, environmental mycobacteria
False negative in malnutrition, immunosuppression, disseminated TB
GeneXpert advantages: Rapid results (2 hours), higher sensitivity than microscopy, rifampicin resistance detection
Limited sensitivity in extrapulmonary specimens.
Management/Treatment
Acute Management:
• Category I (new cases): Intensive phase 2 months HRZE (Isoniazid, Rifampin, Ethambutol, Pyrazinamide), continuation phase 4 months HR
Category II (retreatment): 2 months HRZES + 1 month HRZE, followed by 5 months HRE
DOT (Directly Observed Treatment) for all pediatric cases.
Chronic Management:
• Drug-resistant TB: Based on drug sensitivity testing, minimum 18-24 months treatment
Contact screening: Household contacts and close contacts
Nutritional support with therapeutic feeding if malnourished
Micronutrient supplementation especially vitamin D, zinc.
Lifestyle Modifications:
• Isolation precautions for infectious cases until 2 weeks of effective treatment
Adequate nutrition with high-calorie, high-protein diet
School attendance possible after 2 weeks of treatment if clinically improving
Family education on infection control measures.
Follow Up:
• Monthly clinical assessment and weight monitoring
Sputum examination monthly (if possible) until conversion
Chest X-ray at 2, 6 months and end of treatment
Contact tracing and screening at diagnosis and during treatment
Treatment completion assessment.
Age-Specific Dosing
Medications:
• First-line anti-TB drugs (daily dosing): Isoniazid 10-15 mg/kg (max 300 mg), Rifampin 15-20 mg/kg (max 600 mg), Ethambutol 20-25 mg/kg (max 1200 mg), Pyrazinamide 30-35 mg/kg (max 2000 mg)
Streptomycin 20-30 mg/kg IM (max 1000 mg) if required.
Formulations:
• Pediatric fixed-dose combinations (FDCs): 2-drug (HR), 3-drug (HRZ), 4-drug (HRZE) formulations available
Dispersible tablet formulations for easy administration
Liquid formulations for infants and young children
Weight-band based dosing charts for field use.
Safety Considerations:
• Hepatotoxicity monitoring: Baseline and monthly liver function tests
Visual assessment monthly with ethambutol use (contraindicated <5 years)
Audiometry with streptomycin use
Drug interactions: Rifampin induces hepatic enzymes
Pyridoxine supplementation with isoniazid in malnourished children.
Monitoring:
• Monthly weight gain assessment as treatment response indicator
Clinical improvement: Fever resolution, appetite improvement, activity increase
Laboratory monitoring: Monthly liver enzymes if elevated baseline
Drug susceptibility testing for treatment failures or close contacts of drug-resistant cases.
Prevention & Follow-up
Prevention Strategies:
• BCG vaccination at birth providing 60-80% protection against severe forms (miliary TB, tuberculous meningitis)
Infection control measures: Cough etiquette, ventilation improvement
Contact investigation and screening
Treatment of latent TB infection in high-risk contacts.
Vaccination Considerations:
• BCG vaccine schedule: Single dose at birth or first contact with health services
Contraindications: Symptomatic HIV infection, immunodeficiency, active TB
Revaccination not recommended by WHO
Scar formation indicates successful vaccination but doesn't guarantee immunity.
Follow Up Schedule:
• Intensive phase: Weekly for first month, then monthly
Continuation phase: Monthly clinical and weight assessment
End of treatment: Clinical and radiological assessment
Post-treatment: Annual follow-up for 2 years to detect recurrence
Contact screening at 3, 6, 12 months.
Monitoring Parameters:
• Treatment adherence monitoring through DOT
Household contact screening with TST/IGRA
Nutritional status improvement assessment
School performance evaluation
Social support assessment for treatment completion.
Complications
Acute Complications:
• Drug-induced hepatotoxicity: ALT >3 times normal with symptoms or >5 times without symptoms requires drug modification
Cutaneous reactions: Rash, Stevens-Johnson syndrome rare
Ototoxicity and nephrotoxicity with streptomycin
Treatment interruption due to adverse effects.
Chronic Complications:
• Treatment default leading to drug resistance development
Relapse after treatment completion in 5-10% cases
Paradoxical reaction during treatment: Worsening of lymph node size, new lesions
Long-term sequelae: Bronchiectasis, chronic respiratory insufficiency.
Warning Signs:
• Persistent fever after 2 weeks of treatment suggesting drug resistance or treatment failure
Clinical deterioration during treatment
Signs of hepatotoxicity: Jaundice, vomiting, abdominal pain
Severe adverse drug reactions requiring treatment modification.
Emergency Referral:
• Immediate referral for severe forms: Miliary TB, tuberculous meningitis, severe respiratory distress
Drug-resistant TB requiring specialized center management
Severe adverse drug reactions
Treatment failure after 2-3 months of therapy
HIV-TB coinfection management.
Parent Education Points
Counseling Points:
• TB is completely curable with proper treatment completion
Importance of regular medication intake and DOT
Understanding of treatment duration and necessity of completion
Contact screening importance for family protection
Stigma reduction and community education.
Home Care:
• Medication administration: Regular timing, with or after food to reduce gastric irritation
Nutritional support: High-protein, high-calorie diet
Isolation precautions: Separate utensils until 2 weeks of treatment
Cough etiquette and hand hygiene
Adequate ventilation at home.
Medication Administration:
• Daily medication timing consistency important for efficacy
Crush tablets and mix with food if child cannot swallow
Store medications in cool, dry place away from children
Monitor for side effects: Rash, vomiting, yellow discoloration of urine (normal with rifampin).
When To Seek Help:
• Immediate medical attention for severe side effects: Jaundice, severe vomiting, skin rash
Persistent fever after 2 weeks of treatment
Signs of treatment failure: Worsening symptoms, new symptoms
Any concerns about medication adherence or side effects.