Children and Adolescents

Although there are no findings on clinical examination that can confirm TB, some clinical signs are highly suggestive. In addition, a variety of nonspecific signs should raise clinical suspicion and prompt an evaluation for TB disease. The following clinical features can alert care providers that the child may have TB (6, 72):

TB may present in atypical ways, such as acute severe pneumonia (more common in children aged under 2 years and children living with HIV) or fixed airway wheezing (more common in young children aged under 5 years) (72).

Signs of severe pneumonia include:

In most cases, children with TB disease develop chronic unremitting symptoms that persist for more than 2 weeks without sustained improvement or resolution following treatment for alternative diagnoses (e.g. antibiotics for pneumonia, antimalarials for fever, nutritional rehabilitation for failure to thrive or malnutrition). The most common clinical presentation of PTB in children is persistent cough and poor weight gain.

PTB refers to any bacteriologically confirmed or clinically diagnosed case of TB involving the lung parenchyma or tracheobronchial tree. Tuberculous mediastinal and/or hilar intrathoracic lymphadenopathy is also classified as PTB, following an expert consultation convened by WHO in September 2021.¹⁵ Miliary TB is classified as PTB because there are lesions in the lungs. Tuberculous pleural effusion without radiographic abnormalities in the lungs constitutes EPTB. A person with both PTB and EPTB should be classified as having PTB (71).

Diagnostic evaluation is the step in the care cascade after screening. Children and adolescents who screen positive during contact investigation or at health facility-based screening, and those who present to a health care facility with signs and symptoms of TB and who are identified as having presumptive TB must be evaluated further for TB disease.

The End TB Strategy emphasizes the need for prevention across all efforts to end the TB epidemic, including infection prevention and control in health care services and other high-transmission settings (7). Infection prevention and control practices are critical to reduce the risk of M. tuberculosis transmission, by reducing the concentration of infectious droplet nuclei in the air and the exposure of susceptible people to such aerosols.

Infants and children are dependent on caregivers to administer medicines. Barriers faced by adult caregivers can contribute to children missing doses. Considerations for adherence in adolescents are covered in Section 7.4.

Potential barriers for children include the following:

Household contacts of people with MDR-TB or isoniazid monoresistance are at higher risk of TB infection than contacts exposed to people with drug-susceptible TB. The risk of progression to TB disease does not differ among contacts in either group (67). Studies have reported approximately 90% reduction in MDR-TB incidence with TPT after known exposure (68). WHO recommends using TPT for contacts exposed to people with MDR-TB following consideration of the intensity of exposure, confirming the source patient and their drug resistance pattern (i.e.

The choice of TPT regimen depends on the age of the child, the HIV and ART status, and the availability and affordability of suitable (child-friendly) formulations.¹⁴ Rifampicin- and rifapentine-containing regimens should be prescribed with caution in children and adolescents living with HIV and on ART because of potential drug–drug interactions (see Section 7.1 and Tables 7.2 and 7.3). Table 3.1 summarizes the options for different target and age g