Operational Handbooks

Children and adolescents with TB, their parents, other family members and other caregivers should receive education about TB and the importance of completing treatment. Especially for younger children, the support of their parents, caregivers and immediate family is important for successful treatment. In many settings, HCWs can observe or administer treatment to children or adolescents.

Early signs of ethambutol toxicity can be tested in older children using a colour perception test for red–green colour deficiencies (e.g. Ishihara test cards). Monitoring for optic neuritis can be sought early when there is clinical concern.

Isoniazid may cause symptomatic pyridoxine (vitamin B6) deficiency, particularly in severely malnourished children and children living with HIV. Peripheral neuropathy is characterized by pain, burning or tingling in the hands or feet, numbness or loss of sensation in the arms and legs, muscle cramps or twitching. In young children, this may result in changes to gait or refusal to walk. Supplemental pyridoxine at a dosage of 0.5–1 mg/kg/day is recommended in severely malnourished children, children living with HIV, and adolescents who are pregnant.

Children and adolescents experience adverse events caused by TB medicines much less frequently than adults (6). The most important adverse event is the development of liver toxicity (hepatotoxicity), which can be caused by isoniazid, rifampicin or pyrazinamide. It is not necessary to monitor serum liver enzyme levels routinely, as mild elevation of serum liver enzymes (less than five times the upper normal value) without clinical symptoms is not an indication to stop TB treatment (106).

Table 5.9 gives an overview of common adverse events and their management.

Table 5.9. Significant and common adverse events of TB medicines by system

Malnutrition results in the reduction of cell-mediated immunity, thereby increasing the risk of diseases such as TB. The catabolic effect of TB disease results in weight loss and wasting, which in turn worsens the malnutrition, creating a vicious cycle (104).

Corticosteroids should be used as part of the treatment for TBM and may be used for the treatment of tuberculous pericarditis. Corticosteroids are sometimes used for other complicated forms of TB (e.g. complications of airway obstruction by TB lymph nodes; severely ill children and adolescents with disseminated TB), but there are no WHO recommendations regarding use of corticosteroids for forms of EPTB disease other than TBM and tuberculous pericarditis (102).

All children and adolescents with severe forms of TB (TBM, peritonitis, pericarditis, renal, spinal, disseminated or osteoarticular TB) and those suspected of having MDR/RR-TB (in contact with a person with confirmed or suspected MDR/RR-TB, or children and adolescents diagnosed with TB who are not responding to first-line TB treatment) should be referred to a specialist for further management if management capacity where they present is insufficient.

For children and adolescents weighing 25 kg or over, adult guidance and dose recommendations should be followed. These children and adolescents can be treated with adult formulations.

The recommended dosages by weight band for the 6-month intensive regimen (6HRZEto) to treat bacteriologically confirmed or clinically diagnosed TBM (without suspicion or evidence of MDR/RR-TB) in children and adolescents weighing less than 35 kg are shown in Table 5.6. These dosages were developed to limit formulation manipulation (splitting tablets), top-up with standalone medicines, number of weight bands and pill burden.