Children and Adolescents

• Dosing guidance is based on currently available data and may be revised once additional data are available.
• For patients weighing ≥46 kg, please refer to Table A in Annex 1 of the WHO operational handbook on tuberculosis.

Infants aged under 3 months or weighing less than 3 kg (including premature birth (under 37 weeks) were not eligible for inclusion in the SHINE trial. No new data on treatment of congenital TB and very young infants aged 0–3 months with TB disease were received following a call for data.

As in adults, TB treatment in children and adolescents includes a 2-month intensive phase followed by a continuation phase of 2–4 months. In the intensive phase, TB bacilli are rapidly killed to prevent disease progression, transmission and development of drug resistance. In the continuation phase, dormant bacilli are eliminated to effect cure and prevent relapse.

By reducing cell-mediated immunity, undernutrition increases the risk of TB, while the catabolic effect of TB disease results in weight loss and wasting, creating a vicious cycle (105, 228). Globally, about 45% of deaths in children aged under 5 years are attributable to undernutrition (228). Undernutrition may be acute or chronic and categorized as moderate or severe.

In general, TB medicines should be dosed according to body weight. Dosing of bedaquiline and delamanid for children and young adolescents aged under 15 years was updated in 2021 following an expert consultation meeting convened by WHO. These dosing recommendations are included in Annex 6 and may be updated as evidence emerges, especially for the youngest age groups, for which there is very limited evidence.

Based on modelling estimates, between 25 000 and 32 000 children and young adolescents aged under 15 years develop MDR-TB disease annually (110). When treated, outcomes of children with MDR/RR-TB are good, with favourable outcomes in 78% (111) and over 90% in some cohorts (112). Despite these good outcomes, relatively few children are diagnosed and treated for MDR/RR-TB each year, with only 12 220 starting treatment between 2018 and 2020 (11% of the United Nations General Assembly High-level Meeting target of 115 000) (1, 9).

1. Global tuberculosis report 2021. Geneva: World Health Organization; 2021 (https://apps.who.int/iris/handle/10665/346387, accessed 1 December 2021).
2. Snow KJ, Sismanidis C, Denholm J, et al. The incidence of tuberculosis among adolescents and young adults: a global estimate. Eur Respir J. 2018;51(2):1702352.
3. WHO consolidated guidelines on tuberculosis. Module 5: management of tuberculosis in children and adolescents.

The approach to designing MDR/RR-TB treatment regimens is largely the same for all children and adolescents, regardless of HIV status, although potential drug–drug interactions should be avoided through the careful selection of TB medicines in the regimen.¹⁹