Children and adolescents with TB disease frequently present with failure to thrive or weight loss (see Chapter 4). Severe malnutrition is one of the key risk factors for TB in children. Children receiving therapeutic nutritional treatment or nutritional supplementation but still not gaining weight, or continuing to lose weight, should be considered as having a chronic disease such as TB and evaluated accordingly (6). Malnutrition may cause a false-negative TST through its impact on the cell-mediated
immune response (6, 230).
SAM puts a child at high risk of rapid progression of TB disease (see Chapter 4). When using the integrated treatment decision algorithms, a child with SAM (defined as weight-for-height Z-score of less than −3) should be assessed using all steps of Algorithm A or B (depending on availability of CXR), including the scoring section. If available, an mWRD (Xpert MTB/RIF or Ultra) or LF-LAM if the child is also living with HIV should be done and treatment started if the test is positive. If the child has
a documented contact with a person with bacteriologically confirmed TB, the child should be started on TB treatment as well. In the absence of a TB contact, if the total score from signs and symptoms (and CXR if applicable) is more than 10, a decision to start TB treatment should be made.
Severely malnourished children with a decision to start TB treatment should be started on a 6-month course of treatment (2HRZ(E)/4HR). These children should not be treated with the 4-month treatment regimen as there was limited evidence in the SHINE trial on this subgroup (3, 86). If there is a high likelihood of DR-TB, they should be started on a second-line treatment regimen or referred to the appropriate level of care. Children and adolescents living with HIV who have TB who are severely malnourished have a high risk for a poor treatment response and mortality and should be monitored closely (6).