India has the largest burden of tuberculosis. The disease is gradually extending its storm into the paediatric age group, the manifest in which is severe and tortous. So a preventive approach is always better than a curative approach

1. Dr. Meely Panda
Junior Resident
Community Medicine

2. CONTENTS
 INTRODUCTION
 KEY RISK FACTORS
 DIAGNOSIS
 DIAGNOSTIC ALGORITHM
 TREATMENT
 WHO GUIDELINES AND RECOMMENDATIONS
 DRUG RESISTANCE
 CONTACT SCREENING
 RESEARCH NEEDS

3. Introduction
 It is estimated that 1/3rd of the world’s population is
infected with Mycobacterium tuberculosis.
 Each year, about 9 million people develop TB, of
whom about 1.5 million die.
 WHO has estimated that around 10% of global
tuberculosis case load occurs in children(0-14 years).
 Of these childhood cases, 75% occur annually in 22
high-burden countries that together account for 80%
of the world’s estimated incident cases.

4. Introduction
 Children are also susceptible to the dual epidemic of
TB/HIV. HIV-infected children are at 20-times greater risk of
TB disease than HIV-uninfected children and at much higher
risk of TB-related death.
 Most surveys conducted have focused on pulmonary TB and
no significant population based studies on extrapulmonary
TB are available.
 Children can present with TB at any age, but the majority of
cases present between 1 - 4 years.
 Disease usually develops within 1 year of infection –the
younger, the earlier and the more disseminated.

5. Introduction
 Pulmonary TB is primarily an adult disease in our country &
it has been estimated that 0-19 yr old population contains
7% of total prevalent cases. PTB is usually smear negative.
 However often childhood TB is accorded low priority by
National TB Control programmes. Probable reasons include:
– Diagnostic difficulties
– Rarely infectious
– Limited resources
– Misplaced faith in BCG
– Lack of data on treatment

6. Key risk factors
 Household contact with a newly
diagnosed smear-positive case
 Age less than 5 years
 HIV infection
 Severe malnutrition.

7. Diagnosis of TB in children
1. Careful history (including history of TB contact
and symptoms consistent with TB)
2. Clinical examination (including growth
assessment)
3. Tuberculin skin testing
4. Bacteriological confirmation whenever possible
5. Investigations relevant for suspected pulmonary
TB and suspected extrapulmonary TB
6. HIV testing (in high HIV prevalence areas)

8. 1. Careful history
Contact
 Close contact is defined as living in the same
household or in frequent contact with a source case
(e.g. the child’s caregiver) with sputum smear-positive
pulmonary TB.
 History of contact with a suspected or diagnosed case
of active TB disease within the last 2 years.
 Source cases that are sputum smear-negative but
culture-positive are also infectious, but to a much
lesser degree.

9. Careful history
 All children aged 0–4 years and children aged 5 years
and above who are symptomatic, who have been in
close contact with a smear-positive TB case, must be
screened for TB
 When any child (<15 years) is diagnosed with TB, an
effort should be made to detect the source case and any
other undiagnosed cases in the household.
 Children are regarded as infectious if they have sputum
smear-positive pulmonary TB or cavitary TB on CXR.
If a child presents with infectious TB, child contacts
must be sought & screened, as for any smear-positive
source case.

10. Careful history
Suspect cases
 Chronic cough
An unremitting cough that is not improving and has been
present for more than 2 weeks.
 Fever
Body temperature of >38 °C for 14 days, after common
causes such as malaria or pneumonia have been excluded.
 Weight loss or failure to thrive
Loss of 5% of the highest weight recorded in the last 3
months.

11. 2. Clinical examination
 No specific signs clinically, which are suggestive of
pulmonary TB.
 Physical signs highly suggestive of extrapulmonary TB:
 Gibbus, non-painful enlarged cervical lymphadenopathy with fistula
formation
 Physical signs requiring investigation to exclude
extrapulmonary TB:
 Meningitis not responding to antibiotic treatment, pleural effusion,
pericardial effusion, distended abdomen with ascites, non-painful
enlarged lymph nodes.

12. 3. Tuberculin skin test
 A positive TST occurs when a person is
infected with M. tuberculosis, but does not
necessarily indicate disease.
 TST can be used as an adjunct in diagnosing
TB in children with signs and symptoms of TB
and when used in conjunction with other
diagnostic tests.
 Mantoux test is the recommended method
done with 2 TU of tuberculin PPD RT23.

13. Results of TST
A TST should be regarded as positive as follows:
• >5 mm diameter of induration;
In high-riskchildren
(includes HIV-infected
children and severely
malnourished children)
• >10 mm diameter of induration.
In all other children
(whether they have received a
BCG or not):

14. Importance of the TST
 Used to screen children exposed to TB (e.g. from
household contact with TB), though children can still
receive chemoprophylaxis even if the TST is not
available.
 Useful in HIV-infected children to identify those with
dual TB/HIV infection & as an aid in diagnosis of TB,
although fewer HIV-infected children will have a
positive TST, as normal immune response is required
to produce positive test.
 It is useful to repeat the TST in children once their
nutritional status has improved or their severe illness
has resolved, as they may be initially TST negative, but
positive after 2–3 months on treatment.
 A negative TST never rules out TB in a child.

15. 4. Bacteriological confirmation
 Bacteriological confirmation is especially important for
children who have:
 suspected drug-resistant TB
 HIV infection
 complicated or severe cases of disease
 an uncertain diagnosis.
 Appropriate specimens from the suspected sites of
involvement should be obtained for microscopy and,
where facilities and resources are available, for culture.
 In addition to increasing the yield of confirmed TB cases,
mycobacterial culture is the only way to differentiate M.
tuberculosis from other non - tuberculous mycobacteria.

16. Samples for smear microscopy
a. Expectoration
 Sputum should always be obtained in adults and older
children (10 years of age or older) who are pulmonary
TB suspects.
 Among younger children, especially children <5 years
of age, sputum is difficult to obtain and most children
are sputum smear-negative.
 As with adult TB suspects, 2 sputum specimens should
be obtained: an on-the-spot specimen (at first
evaluation) & an early morning specimen.
.

17. b. Gastric aspiration
 Early morning gastric aspiration using a nasogastric
feeding tube can be performed in young children who
are unable or unwilling to expectorate sputum.
 Gastric aspirates should be sent for smear microscopy
and mycobacterial culture.
c. Sputum induction
 Several recent studies have found that sputum induction
is safe and effective in children of all ages and the
bacterial yields are as good as or better than for gastric
aspirates. It is done by nebulising 20 ml of 3%
hypertonic saline solution.

18. 5. OTHER RELEVANT INVESTIGATIONS
Chest radiography
 The commonest picture is that of
persistent / miliary opacification in the
lung together with enlarged hilar or
subcarinal lymph glands.
 Patients with persistent opacification which does not improve after
a course of antibiotics should be investigated by a radiologist or a
health-care worker trained in their reading.
Other tests
 Serological and nucleic acid amplification (PCR) tests are not
currently recommended for routine diagnosis, as they have been
inadequately studied in children and have performed poorly in
studies.

19. Common forms of extra-pulmonary TB in children
 Peripheral lymph nodes ------- Lymph node biopsy or
FNAC
 Miliary TB ------- Chest X-ray
 TB meningitis ------- Lumbar puncture
 Pleural effusion ------- Chest X-ray, pleural tap
for biochemical analysis
 Abdominal TB ------- Abdominal USG and
ascitic tap
 Osteoarticular TB ------- X-ray, joint tap or
synovial biopsy
 Pericardial TB ------- Ultrasound and
pericardial tap
Site Practical approach to diagnosis

20. 6. HIV testing
HIGH PREVALENCE OF HIV
(infection in the general population,
where TB and HIV infection are likely
to coexist)
HIV counselling & testing done:
•all TB patients as part of their
routine management.
LOWER HIV PREVALENCE
HIV counselling and testing is
indicated for TB patients with
•symptoms and/or signs of HIV-
related conditions
•TB patients having a history
suggestive of high risk of HIV
exposure.

21. DIAGNOSTIC ALGORITHM

22. DIAGNOSTIC ALGORITHM

23. Anti-TB treatment in children

24. Treatment of Pediatric TB
Guidelines for use of Pediatric
Patient Wise boxes
Under the Revised National Tuberculosis
Control Programme

25. Pediatric Patient Wise boxes
 The regimen recommended was
 2(HRZ)3 / 4(HR)3 ----- ≤ 6 years of age.
 Same regimen as for adults ----- > 6 years
 In early 2004, in consultation with Indian Academy of
Pediatrics, the recommendations were revised whereby
ethambutol was included for treatment of pediatric cases
even under 6 years of age.
 Haryana is the first state in the country where paediatric
Patient Wise Boxes for the treatment of children suffering
from tuberculosis (TB) are given under Directly Observed
Treatment, Short Course (DOTS) strategy.

26.  The Programme had difficulty in administering the
drugs to smaller children as the available
formulations needed to be broken up to meet the
patients’ individual weights.
 To overcome these problems, RNTCP in consultation
with IAP, has taken steps to make pediatric drugs
available in patient-wise boxes (PWBs) similar to
those supplied for adult patients under RNTCP.
 With the availability of pediatric PWBs, all new
pediatric patients diagnosed and registered for
treatment under RNTCP, would be initiated on
pediatric patient wise boxes.
 This will enable optimum dosage for the patients,
without resorting to further breaking of the tablets, as
per respective weight bands.

27.  The new formulations to be used in RNTCP are:
 For the purpose of treatment, the pediatric
population is divided into four weight bands:
Rifampicin – 75 / 150 mg
Isoniazid – 75 / 150 mg
Ethambutol – 200 / 400 mg
Pyrazinamide – 250 / 500 mg
6 – 10 kgs
11 – 17 kgs
18 – 25 kgs
26 – 30 kgs

28.  The anti TB drugs for pediatric patients are
available in the form of 2 generic patient wise
boxes i.e. Product Code 13 and Product Code
14.
 Product Code 15 and 16 are available for the
prolongation of the intensive phase, if required
and also to facilitate conversion of the boxes
into Category II and for reconstitution, if
required.

29. Product Code 13
 Treatment box
 24 Combi - packs in one pouch and
 18 multi-blister calendar Combi - pack in another pouch.
 Intensive phase
 H – 75mg, R – 75mg, Z – 250mg, E – 200mg
 2(HRZE)3 to be given under direct observation (thrice a week on
alternate days for 2 months - 24 doses).
 Continuation phase
 H – 75mg, R – 75mg
 4 (HR)3 blister being directly observed (thrice a week on alternate
days : 18 X 3 = 54 doses)
6-10 Kg

30. Product Code 13 (Yellow)

31. Product Code 14
 Treatment box
24 Combi-packs in one pouch
18 multi-blister calendar Combi-pack in another pouch
 Intensive phase
 H – 150mg, R – 150mg, Z – 500mg, E – 400mg
 2(HRZE)3 given under direct observation (thrice a week on
alternate days for 2 months 24 doses).
 Continuation phase
 H – 150mg, R – 150mg
 4 (HR)3 blister being directly observed (thrice a week on
alternate days 18 weeks; 54 doses)
11-17 Kg

32. Product Code 14 (Orange)

33. Product Code 15
 Prolongation of intensive phase of pediatric cases
 Each box containing 5 pouches and each pouch
containing 12 blister Combi pack.
 The pouch consists of
 H – 75mg, R – 75mg, Z – 250mg, E – 200mg
 1(HRZE)3 to be given under direct observation thrice a
week on alternate days for 1 month -12 doses).
6-10 kg & 18-25 kg

34. Product Code 15 (Purple)

35. Product Code 16
 Prolongation of intensive phase of pediatric cases.
 Each box containing 5 pouches and each pouch
containing 12 blister Combi packs.
 Prolongation Pouch consists of
 H – 150mg, R – 150mg, Z – 500mg, E – 400mg
 1(HRZE)3 to be given under direct observation
(thrice a week on alternate days for 1 month12
doses).
11-17 kg, 18-25 kg
& 26-30 kg

36. Product Code 16 (Grey)

37. Product Code (PC) 13 and 14
Prolongation of Intensive Phase
CATEGORY 1
6 – 10 kg --- 1 box of PC 13
11 – 17 kg --- 1 box of PC 14
18 – 25 kg --- 1 box of PC 13 & 1 box of PC14.
26 – 30 kg --- 2 boxes of Product Code 14.
6 – 10 kg -- 1 box of PC 15
11 – 17 kg -- 1 box of PC 16
18 – 25 kg -- 1 box of PC 15 & 1 box of PC 16.
26 – 30 kg -- 2 boxes of Product Code 16.

38. Cat 1 Cat 2
 2HRZE 2HRZES
1HRZE
 4HR 5HRE
 2HRZES – Add inj. Streptomycin
 1HRZE – Add prolongation pouch for prolongation
of IP for 1 month.
 5HRE _ For 4 month CP - add prolongation pouch
after removing pyrizinamide.
1 Month CP – Add Ethambutol tablets
from supply of loose drugs.
CATEGORY 2

39. Updated WHO’s Guidelines for TB treatment in children
 WHO first published guidance for national tuberculosis
control programmes on managing tuberculosis in children
in 2006 --- 2010 ---- 2013
 In 2010, WHO updated the Guidance through a series of
coordinated efforts to review and synthesize evidence on
the correct dosages of antituberculosis medicines for use
in children and the regimens that should be used for
different manifestations of the disease in children

41. The Four Guiding Principles
1. Do no harm
Introducing changes that preserve access for those children who are
sickest and most in need.
2. Ensure access and equity
Ensuring that all children with tuberculosis have access to treatment
with fair and equitable distribution of diagnostic and treatment
services.
3. Promote quality and efficiency
Delivering the highest standards of care within a public health
approach so as to achieve the greatest health impact with the optimal
use of available human and financial resources.
4. Ensure sustainability
Understanding the long-term consequences of change with the vision
of providing continued access to ATT for those in need.

42. Key recommendations

43. Recommendation 1
Given the risk of drug-induced hepatotoxicity, WHO
recommends following dosages of antituberculosis medicines
for the treatment of tuberculosis in children:
 Isoniazid (H) – 10 mg/kg (range 10–15 mg/kg);
maximum dose 300 mg/day
 Rifampicin (R) – 15 mg/kg (range 10–20 mg/kg);
maximum dose 600 mg/day
 Pyrazinamide (Z) – 35 mg/kg (30–40 mg/kg)
 Ethambutol (E) – 20 mg/kg (15–25 mg/kg)

44. Recommendation 2
Children living in settings where the prevalence of the HIV is high
or where resistance to isoniazid is high should be treated with:
HRZE for 2 months followed by HR for 4 months:
 Isoniazid (H) – 10 mg/kg (10–15 mg/kg);
max dose 300 mg/day
 Rifampicin (R) – 15 mg/kg (10–20 mg/kg);
max dose 600 mg/day
 Pyrazinamide (Z) – 35 mg/kg (30–40 mg/kg)
 Ethambutol (E) – 20 mg/kg (15-25 mg/kg)

45. Recommendation 3
Children with suspected or confirmed pulmonary tuberculosis or
tuberculous peripheral lymphadenitis who live in settings with
low HIV prevalence or low resistance to isoniazid and children
who are HIV-negative can be treated with:
 Three drug regimen (HRZ) for 2 months followed by a two-
drug (HR) regimen for 4 months:
 Isoniazid (H) – 10 mg/kg (10–15 mg/kg);
max dose 300 mg/day
 Rifampicin (R) – 15 mg/kg (10–20 mg/kg);
max dose 600 mg/day
 Pyrazinamide (Z) – 35 mg/kg (30–40 mg/kg)

46. Recommendation 4
 Infants (aged 0–3 months) with suspected or
confirmed pulmonary tuberculosis or tuberculous
peripheral lymphadenitis should be promptly treated
with the standard treatment regimens.

47. Recommendation 5
 Streptomycin should not be used as part of
first-line treatment regimens for children with
pulmonary tuberculosis or tuberculous
peripheral lymphadenitis.

48. Recommendation 6
 Children with suspected or confirmed tuberculous
meningitis should be treated with
 Four-drug regimen (HRZE) for 2 months, followed by
a two-drug regimen (HR) for 10 months; the total
duration of treatment being 12 months.
 The dosages recommended for the treatment of
tuberculous meningitis are the same as those described
for pulmonary tuberculosis.

49. Recommendation 7
 Children with suspected or confirmed osteoarticular
tuberculosis should be treated with a
 Four-drug regimen (HRZE) for 2 months followed by
a two-drug regimen (HR) for 10 months; the total
duration of treatment being 12 months.
 The doses recommended for the treatment of
osteoarticular tuberculosis are the same as those
described for pulmonary tuberculosis.

50. Recommendation 8
Children with proven or suspected pulmonary
tuberculosis or tuberculous meningitis caused by
multiple drug-resistant bacilli can be treated with a
 Fluoroquinolone in the context of a well-functioning
MDR-TB control programme and within an appropriate
MDR-TB regimen.
 The decision to treat should be taken by a clinician
experienced in managing paediatric tuberculosis.

52. Drug-resistant TB
 Multidrug resistance (MDR) – is resistance to both isoniazid
and rifampicin, with or without resistance to other first-line
drugs.
 Extensively drug-resistant TB (XDR) – in addition to
rifampicin and isoniazid, is resistant to fluoroquinolones and
injectable second line agents.
 Childhood TB is usually pauci-bacillary, making the
acquisition of drug resistance in previously treated patients
less likely, since the chance of resistance arising is
proportional to the mycobacterial load.

53. WHO guidelines for MDR TB
The WHO guidelines state that MDR-TB is a laboratory
diagnosis but should be considered in any child with any
of the following features:
1.Contact with a source case with features suggestive of
drug resistant TB
2.Contact with a known case of drug resistant TB
3.Remains sputum smear-positive after 3 months of
treatment

54. MDR TB
 Treat the child according to the drug susceptibility
pattern of the source case’s M. tuberculosis strain if an
isolate from the child is not available.
 Children with MDR-TB should be treated with the
first-line drugs to which their M. tuberculosis strain is
susceptible, including streptomycin, ethambutol and
pyrazinamide.
 Ethambutol is bactericidal at higher doses, so daily
doses up to 25 mg/kg should be used in children being
treated for MDR-TB.

55. 2nd line drugs for MDR TB
 Fluoroquinolones
 Ofloxacin, Levofloxacin, Moxifloxacin,
Gatifloxacin, Ciprofloxacin
 Aminoglycosides
 Kanamycin, Amikacin, Capreomycin
 Cycloserine
 para-Aminosalicylic acid & Ethionamide or
prothionamide

56. Children with TB, co-infected with HIV
 Most current international guidelines recommend that
TB in HIV-infected children should be treated with a 6-
month regimen as in HIV-uninfected children.
 Where possible, HIV-infected children should be
treated with rifampicin for the entire treatment
duration, as higher relapse rates among HIV infected
adults have been found when ethambutol is used in
the continuation phase.
 Most children with TB, including those who are HIV-
infected, have a good response to the 6-month regimen.

57. Conditions that merit hospitalization
 TB meningitis and miliary TB, preferably for at least the
first 2 months
 Respiratory distress
 Spinal TB, and
 Severe adverse events, such as clinical signs of
hepatotoxicity (e.g. jaundice).
 If it is not possible to ensure good adherence and
treatment outcome on an outpatient basis, some children
may require hospitalization for social or logistic reasons.

58. Follow-up
 Ideally, each child should be assessed
2 weeks after treatment initiation ----
At the end of the intensive phase ----
Every 2 months until treatment completion.
 Minimum assessment should include: symptom assessment,
assessment of treatment adherence, enquiry about adverse
events and weight measurement.
 Adherence should be assessed by reviewing the treatment
card.

59. Follow Up
 Follow-up CXRs are not routinely required in
children, as many children will have a slow
radiological response to treatment.
 A child who is not responding to anti-TB
treatment should be referred for further
assessment and management.

60. TREATMENT CARD

61. Contact Screening
 Source case - A case of pulmonary TB (usually
sputum smear-positive) which results in infection or
disease among contacts
 Contacts for screening - All children aged under 5
years (whether sick or well) and children 5 years or
older if symptomatic, who are in close contact with a
source case
 Close contact - Living in the same household as a
source case (e.g. the child’s caregiver) or in frequent
contact with a source case

62. Approach to contact management
Child in
close contact
with source
case of
smear-
positive
pulmonary
TB
Under 5 years of
age
Well 6 m Isoniazid
10 mg/kgbw
If
symptomatic
Symptomatic
Evaluate for TB
& give full
course of ATT
Over 5 years of
age
Symptomatic
Well
No treatment
If becomes
symptomatic
TST after 3 m
+ complete rest 3m
_ stop CT

63. Monitoring and evaluation
 Pediatric-focused monitoring may preferably be an
integral part of the programme.
 Wherever possible, follow-up sputum examination is
to be performed with the same frequency as in adults.
 Clinical or symptomatic improvement is to be
assessed at the end of the intensive phase of treatment
and at the end of treatment. Improvement should be
judged by absence of fever or cough, a decrease in the
size of lymph node(s), weight gain.
 Radiological improvement is to be assessed by Chest
X-ray examination in all smear-negative pulmonary
TB cases at the end of treatment.

64. Research needs
 A randomized trial of different lengths of treatment of
tuberculous meningitis.
 A large population-based pharmacokinetics study of all
four first-line medicines at the newly recommended
dosages, including in children with HIV.
 High-quality studies to evaluate the risk of hepatotoxicity
of isoniazid at the increased dose of 10 mg/kg.
 Pharmacokinetic studies in infants of rifampicin, isoniazid
and pyrazinamide
 A randomized trial or high-quality observational studies to
define optimal preventive chemotherapy in children in
contact with a confirmed source case of multidrug-resistant
tuberculosis.

66. REFERENCES
 National Guidelines on diagnosis and treatment of
PediatricTuberculosis, 2010.
 Pediatric Tuberculosis – Challenges Associated
With Diagnosis and Treatment; Jeffrey R. Starke,
M.D, Andrea T. Cruz, MD, MPH,department of
Pediatrics.
 WHO Library Cataloguing-in-Publication Data,
definitions and reporting framework for tuberculosis
– 2013 revision.
 Manual of practical community medicine; Ramesh
Verma
 Text book of Health policies and programmes in
India; 11th edition, D.K Taneja.
 Text book of National health programmes of India
by J. Kishore