Operational Handbooks

For many years, ethambutol was not recommended for use in children aged under 5 years. The concern was that it might cause optic neuritis in children who were too young to report the early visual symptoms, which could lead to irreversible blindness. A review of pharmacokinetic and safety data on ethambutol in children concluded that the risk of ocular toxicity was negligible if recommended dosages were adhered to, especially considering the fact that the use of ethambutol is limited to the intensive phase of treatment (88, 89).

The 4-month regimen including rifapentine and moxifloxacin (2HPMZ/2HPM) may be selected for adolescents aged 12 years and over and weighing at least 40 kg with PTB, regardless of disease severity (88). The following factors should be considered before selecting this regimen:

Daily dosing throughout treatment in the intensive and continuation phases is recommended for all treatment regimens for drug-susceptible TB in children.

Young children with TB usually have paucibacillary TB disease (TB disease forms with a lower burden of M. tuberculosis than is typical in adult-type cavitary TB disease) and are at lower risk for transmitting TB to other children or adults (6). School-aged children and adolescents, however, may have bacteriologically confirmed TB, sometimes with cavities on CXR (6).

To achieve the goals of successful TB treatment in children and adolescents, clinical and programmatic management should include the following components and skills:

The clinical presentation of DR-TB in a child or adolescent is similar to that of other forms of TB in a child or adolescent. When DR-TB is suspected, it is important to collect respiratory samples (stool, expectorated or induced sputum, NPA sample or gastric aspirate) for bacteriological confirmation by Xpert MTB/RIF or Xpert Ultra when possible. Truenat MTB or MTB Plus may also be used for sputum specimens. Xpert and

EPTB refers to any bacteriologically confirmed or clinically diagnosed case of TB involving organs other than the lungs (e.g. pleura, peripheral lymph nodes, abdomen, genitourinary tract, skin, joints and bones, meninges) (71). The classification of intrathoracic lymphadenopathy in children was updated following an expert consultation in September 2021 as PTB. EPTB is common in young children and in children and adolescents living with HIV.

In children with presumptive PTB attending health care facilities, integrated treatment decision algorithms may be used to diagnose PTB. This is an interim conditional recommendation valid until 2024, after which new evidence will be reviewed (see Box 4.6).

CXR remains an important tool in the diagnosis of TB in children, especially those with negative bacteriological tests or where bacteriological testing is not available or not feasible. Most children with PTB have radiographic changes suggestive of TB. If possible, anteroposterior and lateral films should be obtained in children aged under 5 years, and posteroanterior films in older children and adolescents.

Abnormalities on CXR suggestive of PTB include: