Management of tuberculosis in children and adolescents

Table 5.3 shows the recommended dosages for first-line TB medicines for children. These dosages are applicable to all children, irrespective of the type of TB (except for TBM treated with the short intensive regimen) and HIV status. They also apply to the 12-month TBM regimen. Evidence on alternative compositions or dosages in the longer TBM regimen has not been assessed by WHO. For implications of interactions between ART and TB medicines, see Section 7.1 on TB/HIV coinfection.

As in adults, TB treatment in children and adolescents includes a 2-month intensive phase followed by a continuation phase of 2–4 months. In the intensive phase, TB bacilli are rapidly killed to prevent disease progression, transmission and development of drug resistance. In the continuation phase, dormant bacilli are eliminated to effect cure and prevent relapse. The choice of TB treatment regimen (including whether to include a fourth medicine – ethambutol – in the intensive phase) depends on the prevalence of HIV and isoniazid resistance in the setting, severity of disease and age.

In most cases, children with TB disease develop chronic unremitting symptoms that persist for more than 2 weeks without sustained improvement or resolution following treatment for alternative diagnoses (e.g. antibiotics for pneumonia, antimalarials for fever, nutritional rehabilitation for failure to thrive or malnutrition). The most common clinical presentation of PTB in children is persistent cough and poor weight gain. Figure 4.2 illustrates different cough patterns, which may be useful to visualize how a persistent, non-remitting cough presents.

Infants and children are dependent on caregivers to administer medicines. Barriers faced by adult caregivers can contribute to children missing doses. Considerations for adherence in adolescents are covered in Section 7.4.

Potential barriers for children include the following:

The WHO task force on pharmacokinetics and pharmacodynamics analysed available evidence from clinical trials of rifapentine and suggested a simplified dose for various weight bands for 3HP and 1HP for the 2020 WHO consolidated guidelines on tuberculosis. Module 1: prevention – tuberculosis preventive treatment (28). Table 3.2 presents standard dosing for the recommended TPT regimens by age and body weight.

The choice of TPT regimen depends on the age of the child, the HIV and ART status, and the availability and affordability of suitable (child-friendly) formulations.¹⁴ Rifampicin- and rifapentine-containing regimens should be prescribed with caution in children and adolescents living with HIV and on ART because of potential drug–drug interactions (see Section 7.1 and Tables 7.2 and 7.3). Table 3.1 summarizes the options for different target and age groups.

As highlighted in Box 2.7, systematic screening for TB disease should be conducted among adolescents living with HIV using the WHO-recommended four-symptom screen (W4SS). Those who report any one of the symptoms of current cough, fever, weight loss or night sweats may have TB and should be evaluated for TB and other diseases. Adolescents living with HIV may also be screened using CRP (using a cut-off of >5 mg/L), CXR or mWRDs.

Children living with HIV should be followed up closely in the health care system. Those living in high TB incidence settings should be screened for TB at every contact with the health care system. Given the high risk of progression to TB disease and the high mortality rate, combined symptom screening should also be done at every contact with the health care system, including events such as vaccination days, maternal health appointments, nutritional screening and food support programme visits.

There are currently inadequate data to extrapolate use of CXR, point-of-care C-reactive protein (CRP)-based TB screening or mWRDs as screening tests in adults to children aged under 10 years living with HIV. CXR can be used for screening children living with HIV who are close contacts of people with infectious TB (see Section 2.3.1). Tests for TB infection such as IGRA are not useful for TB screening.