Children and Adolescents

A person with treatment failure is defined as one whose treatment regimen needed to be terminated or permanently changed to a new regimen or treatment strategy. Reasons for such a change include no clinical or bacteriological response, adverse drug reactions, and evidence of resistance to medicines in the regimen (108).

The possibility of treatment failure should be considered in a child or adolescent who is receiving TB treatment and (72):

Interruption in the treatment of drug-susceptible TB should be managed carefully. The duration, time on treatment at which the interruption occurs, and bacteriological status of the child or adolescent before and after the interruption should be considered. Table 5.10 has been modified from existing medical society guidelines to show the management of treatment interruption (109).

Table 5.10. Management of treatment interruption in children and adolescents on drugsusceptible TB treatment

All patients and caregivers should be counselled to return to the clinic if there is a recurrence of TB symptoms after successful completion of treatment. Children and adolescents may experience a relapse of TB disease or reinfection. Scheduled clinical monitoring is not required for children or adolescents after successful completion of a 6-month course of drug-susceptible TB treatment.

All children and adolescents initiated on TB treatment should undergo a monitoring assessment at the following intervals as a minimum:

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).