Tuberculosis Clinical Care for Children

Special considerations

Health care providers can contact their state TB program or the TB Centers of Excellence for Training, Education, and Medical Consultation for assistance in diagnosing and treating latent TB infection in children.

Health care providers should contact a pediatric TB expert before treating a child for TB disease.

Risk

Anyone can get TB. But people at higher risk for TB fall into two categories:

• People at higher risk of being exposed to TB bacteria, and
• People at higher risk of developing active TB disease once infected with TB bacteria.

Increased risk of exposure

People who were born in or frequently travel to countries where TB is common, including some countries in Asia, Africa, and Latin America, are at increased risk of being infected with TB bacteria.

Increased risk of developing TB disease

Because of their age, infants and young children with TB infection are more likely to have been recently infected with TB bacteria. They are at high risk for progressing to TB disease. The greatest number of TB disease cases among children are in those younger than five years of age and adolescents older than 10 years of age.

Infants and young children are more likely than older children and adults to experience life-threatening forms of TB disease, especially meningeal and disseminated disease.

Symptoms

Symptoms of TB disease in children include:

• Cough
• Feelings of sickness or weakness, lethargy, or reduced playfulness
• Weight loss or failure to thrive
• Fever
• Night sweats

The most common form of TB disease occurs in the lungs, but it can also affect other parts of the body. Symptoms of TB disease in other parts of the body depend on the affected area. For example, TB meningitis can cause symptoms such as sleepiness, headache, irritability, and seizures or convulsions.

Testing and diagnosis

Testing

In the absence of symptoms, usually the only sign of TB infection is a positive reaction to the TB blood test (Interferon Gamma Release Assay) or TB skin test.

Current recommend the TB skin test as the method of testing children younger than five years of age, while noting some experts use TB blood tests in children younger than five years of age. Health care providers may choose to consult the guidance1 on the use of TB blood tests in children.

Interpretation of the TB blood test results depend on the test. Interpreting a TB skin test reaction depends on the size of the induration (firm swelling) and the person’s risk factors for TB disease. In the absence of other risk factors, an induration of 10 or more millimeters is considered a positive reaction for:

• Children younger than five years of age
• Infants, children, and adolescents exposed to adults in high-risk categories.

Testing for TB infection if the child has received the Bacille Calmette-Guérin (BCG) vaccine

The BCG vaccine may cause a false-positive TB skin test reaction. There is no reliable way to distinguish a positive TB skin test reaction caused by BCG vaccination from a reaction caused by true TB infection. Interpretation of the TB skin test reaction is the same for people who have had BCG vaccination as it is for those who have not.

Health care providers should recommend the TB blood test if a child:

1. Is five years of age or older and
2. Has ever received the BCG vaccine (TB vaccine).

Unlike the TB skin test, TB blood tests are not affected by the BCG vaccine.

Conducting a medical evaluation

Health care providers should conduct a medical evaluation for TB disease for all children who have:

• A positive test result for TB infection (TB blood test or TB skin test),
• Symptoms of TB disease, or
• Exposure to a person with TB disease.

A medical evaluation for TB disease includes:

1. Medical history
2. Physical examination
3. Test for TB infection (TB blood test or TB skin test)
4. Chest x-ray
5. Laboratory tests to see if TB bacteria are present (sputum smear, nucleic acid amplification test, and culture)
6. Laboratory tests for drug resistance (if TB disease is diagnosed)

Diagnosis

Latent TB infection

A health care provider may diagnose a patient with latent TB infection if the patient has a positive TB blood test or TB skin test result, but there is no evidence of TB disease after a medical evaluation, which at a minimum requires physical examination and normal findings on chest radiography.

Health care providers must ensure the patient does not have TB disease before beginning treatment for latent TB infection.

TB disease

Confirming the diagnosis of TB disease in children can be challenging.

Collecting sputum (phlegm) specimens

It is often difficult to collect sputum (phlegm) specimens from infants and young children. Health care providers may choose to perform a gastric aspiration procedure to collect a sputum (phlegm) specimen. This procedure is particularly useful for diagnosis in children, who are often unable to cough up sputum voluntarily.

During the procedure, a health care provider inserts a tube through the patient's mouth or nose and into the stomach. The tube collects sputum that the patient coughs into the throat and swallows.

Gastric aspiration often requires hospitalization. It is best to perform the procedure in the morning before the patient gets out of bed or eats. Transport the specimens to the laboratory immediately for neutralization or neutralize the specimens immediately at the site of collection.

Conducting laboratory tests

TB disease in young children can be caused by fewer TB bacteria (sometimes called "paucibacillary") compared to the number of bacteria in adolescents and older children who have TB disease. As a result, laboratory tests for TB bacteria in a sputum specimen are less likely to have a positive result.

A health care provider may diagnose a child with TB disease even when the laboratory does not confirm that TB bacteria are present. This may be due to other factors pointing to TB disease, which include:

• Symptoms of TB disease,
• Positive TB blood test or TB skin test result,
• Abnormal chest x-ray, and
• Time spent with a person with TB disease.

Treatment

It is very important that the patient takes the medicine exactly as prescribed and finishes the medicine.

Latent TB infection

Children with latent TB infection can be treated to prevent TB disease.

Treatment regimens for children with latent TB infection include:

• Three-month once-weekly regimen of isoniazid (H) and rifapentine (P), also called 3HP
  • Recommended for children older than 2 years of age.

• Four-month daily regimen of rifampin (R) also called 4R
  • Recommended for children of any age.

• Three-month daily regimen of isonaizid and rifampin, also called 3HR
  • Recommended for children of any age.

• Six- or nine-month daily regimen of isonaizid, also called 6H or 9H
  • Recommended alternative treatment regimens for children of any age.

Patient monitoring

Health care providers should help patients adhere to treatment and monitor for adverse effects. Risk of isonaizid-related hepatitis in infants, children, and adolescents is less than for older age groups. Routine monitoring of serum liver enzymes is not necessary unless the child has risk factors for hepatotoxicity.

Directly observed therapy (DOT)

Health care providers should consider directly observed therapy (DOT) for latent TB infection treatment for persons who are at high risk for TB disease (e.g., young children) and either taking an intermittent regimen or likely to have difficulty with treatment adherence.

DOT is a component of case management that helps ensure patients adhere to therapy. During DOT, a health care worker observes (in-person or virtually) patients ingest their medications, monitors them for adverse events, and provides social support.

Window prophylaxis

Children less than five years of age who have spent time with an adult with TB disease should receive treatment for latent TB infection even if the initial TB blood test or TB skin test result is negative and less than eight to 10 weeks have passed since the child's last exposure to TB disease. This is called window prophylaxis.

Before starting window prophylaxis, health care providers should rule out TB disease by x-ray and symptom review.

Health care providers should administer a second TB blood test or TB skin test eight to 10 weeks after the last exposure to someone with TB disease. If repeating the test, use the same type of test (TB blood test or TB skin test).

• If the repeat test result is positive, continue treatment.
• If the repeat test result is negative, treatment can usually be discontinued.

Health care providers can discontinue window prophylaxis if the infant or child is six months of age or older and meets all of the following conditions:

• The second TB blood test or TB skin test result is also negative.
• The second TB blood test or TB skin test was performed eight or more weeks after they spent time with an adult with TB disease.

In certain instances, health care providers might decide to prescribe a complete course of treatment for latent TB infection.

Treatment guidelines for latent TB infection

TB disease

Health care providers should choose the TB disease treatment regimen based on:

• Drug-susceptibility results for a M. tuberculosis isolate from the patient or a presumed source case,
• Coexisting medical conditions, and
• Potential for drug-drug interactions.

TB disease treatment regimens for patients with special considerations (including infants and children) require special management. For example, health care providers should consider a child's age, weight, and other factors when prescribing treatment.

Treatment regimens for known or presumed drug-susceptible TB disease in children include:

• Two months of isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E), followed by two months of isonaizid and rifampin, also called 2HRZE/2HR
  • Recommended for children and adolescents between three months and 16 years of age with non-severe TB disease
  • Non-severe TB disease is defined as peripheral lymph node TB, intrathoracic lymph node TB without airway obstruction, uncomplicated TB pleural effusion, or paucibacillary and non-cavitary disease confined to one lobe of the lungs, or without a miliary pattern.
• Two months of isoniazid (H), rifampin (R), pyrazinamide (Z), and ethambutol (E), followed by four months of isonaizid and rifampin, also called 2HRZ(E)/4HR
  • Recommended for children and adolescents between 3 months and 16 years of age who do not meet the criteria for non-severe TB disease
• Two months of isonaizid (H), rifapentine (P), pyrazinamide (Z), and moxifloxacin (M) followed by two months of isonaizid, rifapentine, and moxifloxacin, also called 2HPZM/2HPM
  • Recommended for children with severe or non-severe pulmonary TB disease who are 12 years and older and who weigh at least 40 kilograms

Extrapulmonary TB disease

Children commonly experience pulmonary TB disease, which typically affects the middle and lower lung. Among infants, TB disease is much more likely to disseminate (i.e., spread from the lungs to other parts of the body). Therefore, health care providers should start treatment as soon as they suspect TB disease. The organ site of TB disease is a factor in the treatment regimen and duration of treatment.

The 2HRZ(E)/4HR regimen for pulmonary TB disease can treat most forms of extrapulmonary TB disease among children. Exceptions are disseminated TB and TB meningitis, which require treatment for nine to 12 months. Consult a pediatric TB expert for cases of TB meningitis.

Directly observed therapy

All children and adolescents with TB disease should receive treatment for TB disease using DOT.

Children with HIV and TB disease

Children with HIV and TB disease are at greater risk for severe, life-threatening manifestations (e.g., disseminated TB disease or TB meningitis).

State TB programs and the TB Centers of Excellence for Training, Education, and Medical Consultation provide assistance and support for health care providers treating children with HIV and TB disease.

Health care providers may also consult .

Drug-resistant TB disease

Children who have spent time with a person with drug-resistant TB disease are at risk of developing drug-resistant TB disease.

The nature of TB disease in children makes microbiologic confirmation much more difficult, including drug susceptibility testing. Therefore, it is important to link the child to a source case and know the drug susceptibility of the source case, when possible. Health care providers can coordinate with public health officials to see if the drug susceptibility of a source case is available.

State TB programs and the TB Centers of Excellence for Training, Education, and Medical Consultation provide assistance and support for health care providers treating children with drug-resistant TB disease.

Treatment guidelines for TB disease

Bacille Calmette-Guérin (BCG) vaccine

Bacille Calmette-Guérin (BCG) is a vaccine for TB disease or decreasing its severity. It protects children from getting severe forms of TB disease, such as TB meningitis.

The vaccine is not generally used in the United States. It is given to infants and small children in countries where TB is common.

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