Children and Adolescents

This section describes a practical approach to the treatment of children with rifampicin-resistant tuberculosis (RR-TB) and MDR-TB (resistant to both rifampicin and isoniazid). It covers identifying children who should be treated for MDR/RR-TB, deciding on the most appropriate treatment regimen, monitoring, and other implementation issues related to treatment.

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).

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).