Children and Adolescents

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.

The use of FDC child-friendly tablets is recommended instead of separate formulations in the treatment of children with drug-susceptible TB (100). FDC tablets have advantages over single medicines as they reduce the pill burden and the likelihood of prescription errors. By reducing selective non-adherence, FDC tablets can reduce the risk of development of drug resistance.

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.

Following infection with M. tuberculosis, young children are at high risk of developing the most severe forms of disease, of which the most devastating is TBM. This mainly affects young children (4). Up to 15% of childhood TB presents as TBM (92). With a decreasing incidence of bacterial meningitis attributed to other causes, TB is the leading cause of bacterial meningitis in many settings (93). TBM is associated with significant mortality and morbidity.

Children aged between 3 months and 16 years with EPTB limited to peripheral lymph nodes (i.e. without involvement of other sites of disease) should be treated with the shorter regimen (2HRZ(E)/2HR). Children with forms of drug-susceptible EPTB other than TBM and osteoarticular TB should be treated with a 6-month treatment regimen of 2HRZE/4HR. Children with osteoarticular TB should be treated with 2HRZE/10HR.