Statement on TB Disease in Children
Case Finding
Effective contact investigations of adults with tuberculosis are the best means of identifying cases of TB in children. School-based skin testing programs are inefficient and ineffective in identifying children with TB.
The Role of the Local Health Department
The local health department (LHD) will assign a case manager to each patient with TB. The LHD is responsible for complete contact investigations, assuring that all TB cases in the jurisdiction complete an adequate course of anti-tuberculosis medication, and regular communication with the treating physician. The TB Medical Advisory Board has previously issued guidance on the role of local health departments in TB control.
Diagnosis
Obtaining a bacteriological diagnosis may be very difficult in children. If a child’s clinical picture is consistent with TB, and there is known contact with a culture-confirmed adult case of tuberculosis, aggressive diagnostic procedures to obtain sputum may not be indicated. The local health department can provide the susceptibility data on the adult source case, and treatment decisions can be based on this information.
A more aggressive diagnostic work-up should be considered when TB is suspected in children without a known source case, or when disseminated or extra-pulmonary disease is suspected. Diagnostic options in the American Academy of Pediatrics Red Book include: isolation of tubercle bacilli by culture from early morning gastric aspirates; from sputum, pleural fluid, cerebrospinal fluid (CSF), urine, or other body fluids; or biopsy material. In a young child (or when the cough is nonproductive or absent), the best culture material for the diagnosis of pulmonary tuberculosis is an early morning gastric aspirate. Gastric aspirates should be obtained with a nasogastric tube upon awakening the child and prior to ambulation or feeding. The NG tube should be placed the night before to prevent vomiting or swallowing which stimulates the stomach to empty prior to obtaining the specimen. Specimens from three aspirates, collected 24 hours apart, should be submitted unless a stained smear (or polymerase chain reaction test) of the first aspirate is positive. Regardless of the results of the AFB smears (which are rarely positive), each specimen should be cultured.
Hospitalization
Hospitalization of young children with tuberculosis is indicated when a diagnostic work-up (e.g., gastric aspirates x 3) must be performed, when disseminated disease is suspected or confirmed, if the child is not clinically stable, or if the child fails to respond to therapy. Hospitalization should be strongly considered in any child less than one year of age with active TB until disseminated disease can be excluded conclusively. The practitioner must carefully consider the child’s clinical status and make an individual decision on whether to hospitalize.
Treatment
Indiana has £ 4% INH resistance. Multi-drug resistant TB (resistant to both INH and rifampin) is rare. Until susceptibility results are available, three or four-drug therapy is recommended, with INH, rifampin, pyrazinamide, and ethambutol as the fourth drug. The ethambutol may be dropped as soon as the tuberculosis isolate (from the child or adult source case) is known to be susceptible. For cases in which drug susceptibilities are not available because an isolate cannot be obtained, ISDH or the local health department can assist the practitioner in the choice of drug regimen, based on local susceptibility patterns and the case history. More detailed treatment recommendations are available from the American Academy of Pediatrics Red Book, or the ISDH TB Medical Advisory Board.
The recommended treatment regimens are as follows:
|
Initial Phase |
Continuation Phase | |||
|---|---|---|---|---|
|
Drugs |
Interval and Duration |
Drugs |
Interval and Duration | |
|
Option I RIF PZA EMB |
Daily for 2 weeks, and then . . . |
Twice weekly for six weeks under direct observation |
INH RIF |
Twice weekly for 16 weeks under direct observation |
|
Option II INHRIF PZA EMB |
Daily for two months (60 doses) |
INH RIF |
Daily for four months (120 doses) | |
Doses for anti-tuberculosis medications are as follows:
|
Drugs |
Daily Dose of Anti-tuberculosis Medications |
Twice Weekly Dose of Anti-tuberculosis Medications | ||
|---|---|---|---|---|
|
Adults |
Children |
Adults |
Children | |
|
INH |
5 |
10-20 |
15 |
20-40 |
|
RIF |
10 |
10-20 |
10 |
10-20 |
|
PZA |
15-30 |
15-30 |
50-70 |
50-70 |
|
EMB |
15-25 |
15-25 |
50 |
50 |
Contacts of Cases with Tuberculosis
Children who are HIV infected or are household contacts under the age of four should have a skin test and chest x-ray, and be given isoniazid preventive therapy, even if the skin test is negative. The skin test should be repeated three months after contact is broken with the active case. If the second skin test is negative, isoniazid can be discontinued.
Consultation and Referral
Indiana has a low incidence of tuberculosis in children. In young children, TB can rapidly progress to disseminated disease. Practitioners are urged – in the strongest possible terms – to manage pediatric tuberculosis in consultation with experts. Consultation can be arranged through the Indiana State Department of Health, your local health department, or TB Medical Advisory Board members.
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