Children and Adolescents

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.

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.

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.

Given the increased risk of treatment failure and drug resistance, children and adolescents who had been treated in the preceding 2 years were not eligible for inclusion in the SHINE trial. These children should be treated with the 6-month treatment regimen (2HRZ(E)/4HR).

Children and young adolescents with PTB who do not meet the eligibility criteria for the 4-month regimen should be treated with a standard 6-month regimen that includes a fourth drug – ethambutol – in the intensive phase (2HRZE/4HR).