Operational Handbooks

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).

Adolescents on treatment for TB disease are at risk for poor adherence in terms of missed doses and loss to follow-up. Predictors of poor treatment adherence for drug-susceptible TB include TB/HIV coinfection, age 15–19 years, prior TB treatment and male gender.

The review identified specific challenges of providing TB care to adolescents around substance abuse, late presentation to care and treatment adherence. Adolescence is a time when individuals may engage in reward-seeking and risk-taking behaviours, including substance use. This may increase the risk of developing TB disease, more severe disease or more unfavourable treatment outcomes. Further research is required to better understand how to co-manage TB and substance use in adolescents.

Stigma and hierarchical models of care such as facility-based treatment may undermine adolescent agency.²⁷ Threats to social networks related to TB and its treatment and the increase in mental health challenges may impact adolescent resilience.²⁸ Some adolescents with TB, however, demonstrate resilience by forming strong relationships with peers who are on treatment or by finding a sense of purpose or meaning from their illness experience (see web annex 4

Adolescents experience disruptions to their education due to TB and its treatment. The time needed for facility-based treatment support can interfere with education, and the need for education may in turn disrupt engagement with TB services. Disruption or delays in education may be further affected by prolonged isolation or hospitalization. As a result, TB and associated treatment may have a significant impact on adolescents’ future livelihoods (see web annex 4).

Adolescents with TB may experience threats to their human rights, including rights to safety, basic needs, access to health care without discrimination, protection against unnecessary hospitalization, and benefit from scientific progress. Adolescents and their families may incur devastating financial impacts, loss of income and food insecurity from TB and its treatment. Social and economic vulnerabilities increase the risk for poorer treatment outcomes, including loss to follow-up, treatment failure and death.

Prolonged isolation and hospitalization have substantial psychosocial and emotional impacts on adolescents, for whom peer and family relationships are critical from a developmental standpoint. TB-related stigma impacts on adolescents’ well-being and ability to engage with TB services. Family and peer relationships may, in turn, be disrupted or strained by isolation, separation or the effects of stigma.

Adolescents are at risk of TB infection, progression to TB disease, and loss to follow-up from TB care. Adolescents with MDR-TB or with TB/HIV coinfection are at particular risk of poor treatment outcomes, including death. Adherence, stigma, mental health and quality of life are impacted negatively by adverse effects of TB treatment, especially second-line treatment.

Treatment of congenital TB and neonatal TB is the same. Both should be managed by a clinician experienced in the management of paediatric TB. A complete investigation of mother and neonate should be undertaken. CXR should be done and appropriate specimens collected for Xpert MTB/RIF or Ultra to confirm the diagnosis of TB in the neonate (see Chapter 4). Treatment should be started based on the likelihood of TB, even before bacteriological confirmation is received, as TB can progress rapidly in neonates.

Congenital TB is TB disease acquired in utero through haematogenous spread via the umbilical cord or at the time of delivery through aspiration or ingestion of infected amniotic fluid or cervicovaginal secretions. Congenital TB usually presents in the first 3 weeks of life and has a high mortality rate. Neonatal TB is TB acquired after birth through exposure to a person with infectious TB (usually the mother but sometimes another close contact). It is often difficult to distinguish between congenital and neonatal TB.  Management is the same.