TB in Children

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 < 1 year 12 – 23 months Pulmonary TB 30 – 40% 10 – 20% Severe EPTB* 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
Exposure Sign & Symptoms TST CXR DSSM Yes None Negative Negative Negative Yes None Positive Negative

TB TB TB Exposure Infection Disease Yes Positive Positive Positive

Negative Positive or Negative Negative Positive

Other diagnostics

Negative

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 antituberculosis 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 Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S) Daily dose (mg/kg BW) 5 (4-6) 10 (8-12) 25 (20-30) 20 (15-25) 15 (12-18) Maximum dose 300 mg/day 600 mg/day 2g 2.5 g 1g

Recommended Category of Treatment Regimen
Category TB Case New Smear (-) (-) ODT & those other than in Cat. I or less severe forms of pulmonary TB New Smear(+) New Smear (-) with extensive parenchymal lesions on CXR Severe forms of extra pulmonary TB (other than TB meningitis) TB meningitis Relapse RAD Treatment Failure Other Chronic (still smear positive after supervised re-treatment) and MDR-TB Regimen Intensive Continuation

III

2HRZ

4HR

I Ia II

2HRZE

4HR

2HRZS 2HRZES/ 1HRZE

4HR 5HRE

IV

Refer to MDR-TB Treatment Center

Management of Side Effects
Side-effects Flu-like Syndrome Skin rash Nausea, vomiting and abdominal pain Arthralgia Pain in the injection site Jaundice Drug Responsible R HR R Z S ZHR What to do?

- Give antipyretic - Give antihistamine - Give medications at
bedtime - Give paracetamol; Ibuprofen; warm compress - Apply warm compress; rotate site of injection - Discontinue anti-TB drugs; Refer to MD. If symptom is subsiding gradually resume treatment and monitor clinically.

Management of Side Effects
Side-effects Peripheral neuritis Blurring of vision Psychosis Thrombocytopenic purpura Anuria Deafness, ringing of the ear Drug Responsible H E H R R S What to do?

- Give Vit-B complex - Discontinue Ethambutol;
Refer to ophthalmologist - Discontinue Isoniazid - Discontinue Rifampicin

- Discontinue Rifampicin and
refer patient to hospital. - 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 2. 3. 4. 5.
months of IPT and remains well or asymptomatic during the entire period. Defaulted IPT – a child who interrupted IPT for 2 consecutive months or more. Died – a child who dies for any reason during the course of IPT. IPT Failed – a child who developed TB disease (pulmonary or EPTB) anytime on IPT. 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.

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