Children and Adolescents

WHO-recommended clinical samples for the diagnosis of PTB in children and adolescents using Xpert MTB/RIF or Ultra include sputum (expectorated or induced), gastric or nasopharyngeal aspirates, and stool. Other mWRDs using respiratory samples have only been validated on sputum samples. Each of these specimen types has distinct advantages and disadvantages (Table 4.1). Annex 3 summarizes the types of respiratory and non-respiratory specimens.

Despite challenges with bacteriological confirmation of paucibacillary TB in young children, every effort should be made to establish bacteriological confirmation. In adolescents, who usually have adult-type disease, bacteriological confirmation is common.

Bacteriological confirmation is even more important for children and adolescents who:

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:

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):

The index patient is the initially identified person of any age with new or recurrent TB in a specific household or other comparable setting to which others may have been exposed. An index case is the person on whom a contact investigation is centred but is not necessarily the source case (28).

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).

Young children have a higher risk of developing TB compared with other age groups (4). Risk of TB disease is more pronounced among children and adolescents who:

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.