TB in Children

TB in ChildrenTB in ChildrenAdministering Treatment in Administering Treatment in Children 0 – 14 years oldChildren 0 – 14 years old

Reagan S. Patriarca, RNReagan S. Patriarca, RN

DOH - RepresentativeDOH - Representative

IntroductionIntroduction

Tuberculosis (TB) among children is mild and Tuberculosis (TB) among children is mild and rarely infectious. However, the condition can rarely infectious. However, the condition can become serious, hence the need for early become serious, hence the need for early diagnosis and treatment.diagnosis and treatment.

Key risk factors for TB in children are:Key risk factors for TB in children are: Close contact with a smear positive TB caseClose contact with a smear positive TB case Age less than 5 years oldAge less than 5 years old MalnutritionMalnutrition HIV PositiveHIV Positive

Risk of developing TB disease Risk of developing TB disease following infectionfollowing infection

Age groupAge group PulmonaryPulmonary TB TB Severe EPTB*Severe EPTB*

< 1 year< 1 year 30 – 40%30 – 40% 10 - 20%10 - 20%

12 – 23 months12 – 23 months 10 – 20%10 – 20% 2 – 5%2 – 5%

* EPTB – Extra Pulmonary Tuberculosis such as TB meningitis or disseminated (miliary) TB

1. Identifying Children with Tuberculosis1. Identifying Children with Tuberculosis

WHO recommends the following approachWHO recommends the following approachto diagnose TB in Children:to diagnose TB in Children:

Careful history and clinical examinationCareful history and clinical examination1. Clinical sign and symptoms1. Clinical sign and symptoms2. Past medical history2. Past medical history3. History of exposure3. History of exposure4. Clinical or Physical Exposure4. Clinical or Physical Exposure

B. Bacteriological Confirmation whenever B. Bacteriological Confirmation whenever

possiblepossible

1. Direct Sputum Smear Microscopy 1. Direct Sputum Smear Microscopy

(DSSM)(DSSM)

2. Culture and histopathological2. Culture and histopathological

examinationsexaminations

C. Tuberculin Skin Test (TST) C. Tuberculin Skin Test (TST)

aka Mantoux Test by using Purifiedaka Mantoux Test by using PurifiedProtein Derivative (PPD)Protein Derivative (PPD)

TSTTST is a method of demonstrating is a method of demonstrating INFECTIONINFECTION with M. Tuberculosis at with M. Tuberculosis at sometime in the past, whether sometime in the past, whether recent or recent or remote.remote.

A A positive TST positive TST confirms both confirms both exposure and infectionexposure and infection

D. Other Diagnostic Test (ODT)D. Other Diagnostic Test (ODT)

1. Chest X-ray (CXR)1. Chest X-ray (CXR)

2. Lumbar puncture, Abdominal ultrasound2. Lumbar puncture, Abdominal ultrasound

3. Other Serologic Test, Nucleic Acid3. Other Serologic Test, Nucleic Acid

amplification, computerized chestamplification, computerized chest

tomography and bronchoscopytomography and bronchoscopy

Differentiate Differentiate TB Exposure, TB Exposure, TB Infection and TB DiseaseTB Infection and TB Disease

TB ExposureTB Exposure

A child has TB Exposure if he/she is A child has TB Exposure if he/she is in close contact with a source case but in close contact with a source case but without any signs and symptoms without any signs and symptoms presumptive of TB, TST negative and no presumptive of TB, TST negative and no radiologic or laboratory findings suggestive radiologic or laboratory findings suggestive of TBof TB

TB Infection or Latent TB Infection (LTBI)TB Infection or Latent TB Infection (LTBI)A child has TB Infection if he/she is found A child has TB Infection if he/she is found

to be positive TST but without signs and to be positive TST but without signs and symptoms presumptive of TB and no radiologic symptoms presumptive of TB and no radiologic or laboratory evidence suggestive of TB.or laboratory evidence suggestive of TB.

TB DiseaseTB DiseaseA child has TB Disease if he/she is TB A child has TB Disease if he/she is TB

symptomatic, positive TST and/or positive symptomatic, positive TST and/or positive radiologic or laboratory evidence suggestive of radiologic or laboratory evidence suggestive of TBTB

Differentiate Differentiate TB Exposure, TB Exposure, TB Infection and TB DiseaseTB Infection and TB Disease

Summary of DifferencesSummary of DifferencesTB TB

ExposureExposure

TB TB InfectionInfection

TB TB DiseaseDisease

ExposureExposure YesYes YesYes YesYes

Sign & Sign & SymptomsSymptoms

NoneNone NoneNone PositivePositive

TSTTST NegativeNegative PositivePositive PositivePositive

CXRCXR NegativeNegative NegativeNegative PositivePositive

DSSMDSSM NegativeNegative NegativeNegative Positive Positive or or

NegativeNegative

Other diagnosticsOther diagnostics NegativeNegative NegativeNegative PositivePositive

Classification of TB DiseaseClassification of TB DiseaseA. PULMONARY TBA. PULMONARY TB

1. Pulmonary TB sputum smear positive1. Pulmonary TB sputum smear positive2. Pulmonary TB sputum smear negative2. Pulmonary TB sputum smear negative

2.a For children 10 – 14 yrs or younger2.a For children 10 – 14 yrs or younger children who can expectorate and achildren who can expectorate and a DSSM was doneDSSM was done2.b For children 0-9 yrs old w/ negative2.b For children 0-9 yrs old w/ negative DSSM or children 0-9 years old whoDSSM or children 0-9 years old who cannot expectorate, thus DSSM was notcannot expectorate, thus DSSM was not performed and other diagnostic test performed and other diagnostic test

were donewere done

B. Extra Pulmonary TB – EPTBB. Extra Pulmonary TB – EPTB- is characterized as one of the ff:- is characterized as one of the ff:

Clinical and/or histological evidence Clinical and/or histological evidence consistent with active TB outside the lungs consistent with active TB outside the lungs and decision by a physician to treat the and decision by a physician to treat the patient with anti-tuberculosis patient with anti-tuberculosis chemotherapychemotherapy

One(1) mycobacterial culture positive One(1) mycobacterial culture positive specimen from a site outside the lungsspecimen from a site outside the lungs

Classification of TB DiseaseClassification of TB Disease

2. Administering Treatment2. Administering TreatmentTypes of TB CasesTypes of TB Cases New – one who had never had TB in the New – one who had never had TB in the

past, or who has previously taken anti-past, or who has previously taken anti-tuberculosis drugs for less than one monthtuberculosis drugs for less than one month

Treatment FailureTreatment Failure- an initially smear positive patient who - an initially smear positive patient who remains or becomes smear positive on the remains or becomes smear positive on the 55thth month of treatment month of treatment- a newly diagnosed TB patient whose TB - a newly diagnosed TB patient whose TB symptoms persisted and has failed to gain symptoms persisted and has failed to gain weight after 6 months of treatment.weight after 6 months of treatment.

Relapse – previously treated for TB, who Relapse – previously treated for TB, who has been declared cured or treatment has been declared cured or treatment completed and upon assessment is TB completed and upon assessment is TB symptomatic with one of the following:symptomatic with one of the following:

- progressive deterioration or - progressive deterioration or worsening of CXR findings or recurrence worsening of CXR findings or recurrence of CXR findingsof CXR findings

- Smear positive or culture positive- Smear positive or culture positive Transfer in – one who has been Transfer in – one who has been

transferred in DOTS facility from another transferred in DOTS facility from another facility adopting policies with proper facility adopting policies with proper referralreferral

Return After Default (RAD) – one who is Return After Default (RAD) – one who is starting treatment again after interrupting starting treatment again after interrupting treatment for more than 2 months, has treatment for more than 2 months, has persistent or recurrence of TB symptoms, persistent or recurrence of TB symptoms, with or without weight gain. Positive with or without weight gain. Positive bacteriology (smear or culture) may or bacteriology (smear or culture) may or may not be presentmay not be present

Other – a type of TB patient that does not Other – a type of TB patient that does not fit in the definition of New, fit in the definition of New,

Types of TB CasesTypes of TB Cases

WHO Recommended Doses for WHO Recommended Doses for first-line Anti-TB drugsfirst-line Anti-TB drugs

First-line DrugsFirst-line Drugs Daily dose Daily dose (mg/kg BW)(mg/kg BW)

Maximum Maximum dosedose

Isoniazid (H)Isoniazid (H) 5 (4-6)5 (4-6) 300 mg/day300 mg/day

Rifampicin (R)Rifampicin (R) 10 (8-12)10 (8-12) 600 mg/day600 mg/day

Pyrazinamide (Z)Pyrazinamide (Z) 25 (20-30)25 (20-30) 2 g2 g

Ethambutol (E)Ethambutol (E) 20 (15-25)20 (15-25) 2.5 g2.5 g

Streptomycin (S)Streptomycin (S) 15 (12-18)15 (12-18) 1 g1 g

RecommendedRecommended Category of Treatment RegimenCategory of Treatment Regimen

CategoryCategory TB CaseTB Case RegimenRegimen

IntensiveIntensive ContinuationContinuation

IIIIII

New Smear (-)New Smear (-)

(-) ODT & those other than in Cat. I (-) ODT & those other than in Cat. I

or less severe forms of pulmonary TBor less severe forms of pulmonary TB

2HRZ2HRZ 4HR4HR

II

New Smear(+)New Smear(+)

New Smear (-) with extensive New Smear (-) with extensive parenchymal lesions on CXRparenchymal lesions on CXR

Severe forms of extra pulmonary TB Severe forms of extra pulmonary TB (other than TB meningitis)(other than TB meningitis)

2HRZE2HRZE 4HR4HR

IaIa TB meningitisTB meningitis 2HRZS2HRZS 4HR4HR

IIII RelapseRelapse

RADRAD

Treatment FailureTreatment Failure

OtherOther

2HRZES/2HRZES/

1HRZE1HRZE

5HRE5HRE

IVIV Chronic (still smear positive after Chronic (still smear positive after supervised re-treatment) and MDR-TBsupervised re-treatment) and MDR-TB

Refer to MDR-TBRefer to MDR-TB

Treatment CenterTreatment Center

Management of Side EffectsManagement of Side Effects

Side-effectsSide-effects Drug ResponsibleDrug Responsible What to do?What to do?

Flu-like SyndromeFlu-like Syndrome

Skin rashSkin rash

Nausea, vomiting and Nausea, vomiting and abdominal painabdominal pain

ArthralgiaArthralgia

Pain in the injection sitePain in the injection site

JaundiceJaundice

RR

HRHR

RR

ZZ

SS

ZHRZHR

- Give antipyreticGive antipyretic

- Give antihistamineGive antihistamine

- Give medications atGive medications at

bedtimebedtime

- Give paracetamol;Give paracetamol;

Ibuprofen; warm compressIbuprofen; warm compress

- Apply warm compress;Apply warm compress;

rotate site of injectionrotate site of injection

- Discontinue anti-TB drugs;Discontinue anti-TB drugs;

Refer to MD. If symptom isRefer to MD. If symptom is

subsiding gradually resumesubsiding gradually resume

treatment and monitortreatment and monitor

clinically.clinically.

Management of Side EffectsManagement of Side Effects

Side-effectsSide-effects Drug ResponsibleDrug Responsible What to do?What to do?

Peripheral neuritisPeripheral neuritis

Blurring of visionBlurring of vision

PsychosisPsychosis

Thrombocytopenic Thrombocytopenic purpurapurpura

AnuriaAnuria

Deafness, ringing of the Deafness, ringing of the earear

HH

EE

HH

RR

RR

SS

- Give Vit-B complexGive Vit-B complex

- Discontinue Ethambutol;Discontinue Ethambutol;

Refer to ophthalmologistRefer to ophthalmologist

- Discontinue IsoniazidDiscontinue Isoniazid

- Discontinue RifampicinDiscontinue Rifampicin

- Discontinue Rifampicin andDiscontinue Rifampicin and

refer patient to hospital.refer patient to hospital.

- Discontinue temporarily andDiscontinue temporarily and

resume when symptomsresume when symptoms

disappeardisappear

3. Prevention of TB in Children3. Prevention of TB in Children

Three (3) Strategies recommended by WHOThree (3) Strategies recommended by WHO Universal use of BCG ( Bacillus Calmette -Universal use of BCG ( Bacillus Calmette -

Guerin)Guerin) Early detection and treatment of infectious Early detection and treatment of infectious

TB casesTB cases Isoniazid Preventive Therapy (IPT) for Isoniazid Preventive Therapy (IPT) for

infants and young children who are at risk infants and young children who are at risk of developing TB disease. Given for a 6 of developing TB disease. Given for a 6 month course at 5 mg/kg once dailymonth course at 5 mg/kg once daily

Isoniazid Preventive Therapy or IPTIsoniazid Preventive Therapy or IPT The National Consensus on Childhood TB(1997) The National Consensus on Childhood TB(1997)

states that “prophylaxis aims to prevent the states that “prophylaxis aims to prevent the development of infection among contact exposed to development of infection among contact exposed to active disease as well as to prevent progression of active disease as well as to prevent progression of the disease among those already infected. Primary the disease among those already infected. Primary prophylaxis is recommended for children under 5 prophylaxis is recommended for children under 5 years or among those with other risk factors for years or among those with other risk factors for rapid development of disease, since disease may rapid development of disease, since disease may set in even before conversion of TST. Several well set in even before conversion of TST. Several well controlled studies have demonstrated the favorable controlled studies have demonstrated the favorable effect of Isoniazid (INH) on reduction of effect of Isoniazid (INH) on reduction of complications due to lymphohematogenous and complications due to lymphohematogenous and pulmonary spread after infection. The protective pulmonary spread after infection. The protective effect of INH in the latter situation has been shown effect of INH in the latter situation has been shown to last from 19 to 30 years.to last from 19 to 30 years.

Children who will receive IPTChildren who will receive IPT

Children 0-4 years old who are:Children 0-4 years old who are:

1.1. Positive for TST (TB Infection)Positive for TST (TB Infection)

2.2. Negative for TST but close contact to a Negative for TST but close contact to a smear positive TB (TB Infection)smear positive TB (TB Infection)

3.3. Close contact with a smear positive but Close contact with a smear positive but TST was not done because it was not TST was not done because it was not available.available.

Baby born to a smear (+) motherBaby born to a smear (+) mother

The risk of the baby being infected with TB is highest if aThe risk of the baby being infected with TB is highest if amother was diagnosed with TB at the time of delivery ormother was diagnosed with TB at the time of delivery orshortly thereafter. In these case it is very important that weshortly thereafter. In these case it is very important that weshould assess the newborn at once.should assess the newborn at once.

1. If the newborn is not well, refer them to a pediatrician1. If the newborn is not well, refer them to a pediatrician2. If the child is well (absence of any sign/s or symptom/s 2. If the child is well (absence of any sign/s or symptom/s

presumptive of TB do not give BCG first, instead givepresumptive of TB do not give BCG first, instead give IPT for 3 months.IPT for 3 months.3. After 3 months, perform TST.3. After 3 months, perform TST.4. If TST is negative, stop IPT and give BCG.4. If TST is negative, stop IPT and give BCG.5. If TST is positive and baby remains well, continue IPT5. If TST is positive and baby remains well, continue IPT for 3 more monthsfor 3 more months6. After 6 months of IPT and the child remains well, give6. After 6 months of IPT and the child remains well, give

BCG.BCG.

Monitor compliance and response Monitor compliance and response to IPTto IPT

Children on IPT will be supervised daily by a Children on IPT will be supervised daily by a

treatment partner and followed up on atreatment partner and followed up on a

DOTS facility on a monthly basis so theyDOTS facility on a monthly basis so they

assess the following:assess the following: presence of signs and symptoms presence of signs and symptoms

presumptive of TB – to ensure that these presumptive of TB – to ensure that these children are not developing TB diseasechildren are not developing TB disease

possible adverse effect of the drugpossible adverse effect of the drug

Treatment outcome of children on IPTTreatment outcome of children on IPT

1.1. Completed IPT Completed IPT – a child who has completed 6 – a child who has completed 6 months of IPT and remains well or months of IPT and remains well or asymptomatic during the entire period.asymptomatic during the entire period.

2.2. Defaulted IPT Defaulted IPT – a child who interrupted IPT for – a child who interrupted IPT for 2 consecutive months or more.2 consecutive months or more.

3.3. Died Died – a child who dies for any reason during – a child who dies for any reason during the course of IPT.the course of IPT.

4.4. IPT Failed IPT Failed – a child who developed TB – a child who developed TB disease (pulmonary or EPTB) anytime on IPT.disease (pulmonary or EPTB) anytime on IPT.

5.5. IPT Transferred out IPT Transferred out – a child who has been – a child who has been transferred to another health facility with transferred to another health facility with proper referral slip of continuation of IPT and proper referral slip of continuation of IPT and whose treatment outcome is not known.whose treatment outcome is not known.

HOPE YOU LEARNED HOPE YOU LEARNED SOMETHING!!!SOMETHING!!!

THANK YOU SO MUCH!!!THANK YOU SO MUCH!!!