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Children presenting with severe acute pneumonia who are diagnosed with TB should be treated for 6 months (2HRZE/4HR) in view of the severity of their symptoms, which, according to the definition of severe acute pneumonia, include cough or difficulty in breathing with at least one of the following:
No separate subgroup analysis could be conducted for children with SAM (defined as weight-forheight Z-score below −3 or mid-upper arm circumference below 115 mm (91)) in the SHINE trial due to the low numbers (30 children with SAM in the 16-week arm and 33 in the 24-week arm). As SAM is defined as a danger sign, even if children with SAM have a non-severe form of TB they should preferably receive 6 months of TB treatment.
Children and young adolescents living with HIV were eligible for enrolment in the SHINE trial. A total of 65 children and adolescents living with HIV (11%) were enrolled in the 16-week arm and 62 (10%) in the 24-week arm. The 16-week regimen was non-inferior when compared with the 24-week regimen (risk difference −4.3, 95% CI −14.9 to 6.2) (86).
Although the numbers of children with peripheral lymph node TB in the SHINE trial were small (N = 19 in the 16-week arm, N = 21 in the 24-week arm), there was no difference in the proportion of unfavourable outcomes between the two arms (86). These results may provide reassurance for clinicians regarding a seemingly delayed clinical response to TB treatment, frequently seen in children with peripheral lymph node TB (where lymph nodes remain enlarged even after treatment), even if these children are treated for 4 months.
For many years, ethambutol was not recommended for use in children aged under 5 years. The concern was that it might cause optic neuritis in children who were too young to report the early visual symptoms, which could lead to irreversible blindness. A review of pharmacokinetic and safety data on ethambutol in children concluded that the risk of ocular toxicity was negligible if recommended dosages were adhered to, especially considering the fact that the use of ethambutol is limited to the intensive phase of treatment (88, 89).
The 4-month regimen including rifapentine and moxifloxacin (2HPMZ/2HPM) may be selected for adolescents aged 12 years and over and weighing at least 40 kg with PTB, regardless of disease severity (88). The following factors should be considered before selecting this regimen:
Daily dosing throughout treatment in the intensive and continuation phases is recommended for all treatment regimens for drug-susceptible TB in children.
Young children with TB usually have paucibacillary TB disease (TB disease forms with a lower burden of M. tuberculosis than is typical in adult-type cavitary TB disease) and are at lower risk for transmitting TB to other children or adults (6). School-aged children and adolescents, however, may have bacteriologically confirmed TB, sometimes with cavities on CXR (6).
To achieve the goals of successful TB treatment in children and adolescents, clinical and programmatic management should include the following components and skills:
BCG in children living with HIV