2022 5.2.

Childhood Tuberculosis
DR. FELMA UNGSON GARCIA | 04/07/2021
PEDIATRICS II

OUTLINE Immunologic
I. Definition • Purified Protein Derivative (PPD) positive tuberculin skin test
II. Epidemiology
III. Diagnosis Radiologic
IV. Treatment
• Abnormal chest radiograph suggestive of TB
• usually perihilar lymphadenopathy
• most of the time radiographic result of patient with primary complex are
LEGEND normal
Remember Lecturer Book Previous Trans Presentation
HELLO Laboratory
• Histological
WHAT IS CHILDHOOD TB? • Cytological
• AKA primary complex • Biochemical
• TB among children 14 years and below • Immunological/molecular
• Not as contagious as the adult TB
DIAGNOSING CHILDHOOD TUBERCULOSIS -
ENDING TB, ARE WE THERE YET? WHAT DO WE HAVE?
• In the Philippines, there are a lot of cases diagnosed and undiagnosed
due to crowding
• “Know your epidemic"
− TB in children (0-14 yrs) 358,521 reported in 2014
○ 30% more than in 2013
− “Best” estimates:
○ 1,000,000 cases (UI: 900,000-1,100,000) or
○ 10.4% of total caseload
○ 140,000 deaths
• Child TB burden in Philippines
− WHO Global report 2014
○ Among 97 221 new cases: 2,065 (2%) cases children (<15 yrs)
○ M:F ratio: 2.3
• WHO Global report 2015
− Among 97 578 new and relapse cases: 12 191 (12%) cases • History → high negative predictive value
children − You have to rule out if somebody in the family who has been
− M:F ratio: 1.8 coughing and losing weight and if he has been diagnosed as a
• TB national profile (WHO,2014) case of TB
− 6th leading cause of mortality and morbidity − Encourage the family to have that member see a doctor
− 9th among the 22 countries with highest TB-burden • Tuberculin Skin Test (1890) → indication of infection with
− Incidence rate 288/100,000 -non HIV patients limitation
− HIV positive-2.6/100,000 • Chest X-ray → low specificity
• During the pandemic, people tend to stay in their homes, those who − Most of the time it will reveal a normal result
are undiagnosed with TB might be contaminating the other • Bacteriology → low sensitivity
household members − Because in PTB, the cause is bacillary, meaning it needs only a
little amount of TB bacilli for the patient to have primary complex
HOW DO WE DIAGNOSE CHILDHOOD TB? − Ex: An adult needs at least 100,000 TB bacilli for that adult to be
• Very hard to diagnose because it mimics asthma, pneumonia, acute infected with TB
upper respiratory tract infection and even malnutrition because of − A child needs at least 10 TB bacilli for them to acquire primary
its complication complex

CRITERIA FOR DIAGNOSIS OF TB WHAT IS A POSITIVE TUBERCULIN SKIN TEST (TST)?

Epidemiology PPS Recommendation: 2008
• Exposure to index patient usually adult or adolescent • Using 5 TU PPD Mantoux test
• read at 48-72 hours
Clinical • regardless of BCG status
• an induration of > 5mm is considered positive in the presence of any
• Poor weight gain / weight loss for the past few months or all of the following:
− Familiarize with the normal weight gain of a child depending on − History of contact
age group
− clinical findings suggestive of tb
− Ex: ○ poor weight gain, chronic cough, unexplained fever
○ Infants: average weight gain is 500 grams per month
− CXR suggestive of tb
○ 1-3 years old: 200-300 grams per month
○ Perihilar lymphadenopathy
• Cough / wheezing for the past 2 weeks or more ○ Cavitary lesion
− No improvement and persistence of wheezing after treatment with ○ Miliary TB
SABA, corticosteroids, with avoidance of trigger factors − Immunosuppressed condition
• Unexplained fever for the past 2 weeks or more • Otherwise, an induration of > 10 mm is considered positive Grade A
− May mimic Leukemia with fever of 38-40 degrees
− In TB, usually nighttime fever of 38-39 degrees and no
improvement even with antibiotics

Trans Group 5: Agbuya, Crisologo, Garcia, Guilang, Landingin, Pacio, Zamudio EDITORS: Garcia & Guilang 1 of 6
 2022 5.2. Childhood Tuberculosis
DR. FELMA UNGSON GARCIA | 04/07/2021
PEDIATRICS II

PPS recommendation 2016 TST and IGRA testing for TB infection and disease:
• Definition of positive TST KEY FACTS
• Induration of >5mm in the ff: • TST and IGRA should not be tested on persons with low risk of TB
− Severely malnourished children (marasmus or kwashiorkor) • Both cannot distinguish infection from TB
− Immunocompromised • Routine testing for both is not recommended
○ Congenital immune deficiencies • IGRA can distinguish LTBI from BCG
○ HIV-AIDS − LTBI is a positive TST with no signs and symptoms of TB with
○ History of prolonged intake of immunosuppressants normal radiologic findings
○ History of contact − If patient is LTBI, there’s only 2 types of medication which is
○ Clinical findings suggestive of tb rifampicin and isoniazid given for 6 months
○ CXR suggestive of tb • IGRA is the test of choice in 2 instances
• Induration of >10mm − Person who received BCG as vaccine or chemotherapy
− considered positive in all patient regardless of the BCG status − Unlikely to return for TST reading
− Applies to the Philippines which has predominant TB cases ○ Patient has to be back after 3 days
• Induration of >15mm - no risk factors • TST is preferred over IGRA for children less than 5 years of age
− among westerners who have no risk factor or who are not living in
a place where there is increase population of TB patient
WHAT ARE THE CHEST RADIOGRAPH FINDINGS MOST
Limitations of PPD SUGGESTIVE OF CHILDHOOD TUBERCULOSIS?
• Technique in administering the test
• Reader
• Nutritional status of the patient
− if the patient is severely malnourished, there will be no yield for
positive PPD in protein deficient patients
• Drug used
− use of steroids

Reading the Mantoux Test

(a) Perihilar lymphadenopathy

(b) Segmental atelectasis, with hyperaeration (presumed to be due to
lymph node that is compressing the airway which also causes
wheezing)

• The reaction should be evaluated 48-72 hours after the injection

• Only the induration, which is a hard, dense, raised formation, is
measured.
• The area of erythema is not included in the measurement.
• Sometimes, there is induration without erythema specially among (c) Calcified Lymph Nodes - may or may not indicate an active TB
dark colored skin children so we need to do the ball point technique (d) Pleural Effusion - should not be managed with test tube because
− slide the ballpen toward the induration site after 2 weeks of anti-TB medication, pleural effusion will resolve itself
− measure the end of the ballpen marker
− if 10mm or more in the patient who are well with no signs and
symptoms, it is considered positive
− if the patient is malnourished and very sick, on steroid and 5mm
induration, it is positive

INTERFERON GAMMA RELEASE ASSAYS (IGRA)

• Diagnostic tool for Latent TB Infection (LTBI)
• Indicate cellular immune response to M. tuberculosis
• Currently available IGRA
− QuantiFERON TB gold in tube test (QFT-GIT)
− T-SPOT TB

LIMITATIONS OF IGRA
• Availability
• Cost
• Errors in collecting/transporting blood specimens or in running and Black dots: Common sites of perihilar lymphadenopathy
assay interpretation White arrows: Active TB and perihilar lymphadenopathy
• False positive result in those with other mycobacterial organism If there is compression of the airway, there will be wheezing
• Challenge in blood extraction
• Reduced sensitivity over IGRA

Trans Group 5: Agbuya, Crisologo, Garcia, Guilang, Landingin, Pacio, Zamudio EDITORS: Garcia & Guilang 2 of 6
 2022 5.2. Childhood Tuberculosis
DR. FELMA UNGSON GARCIA | 04/07/2021
PEDIATRICS II

PPS Recommendation: 2008 WHEN IS MICROBIOLOGIC DIAGNOSIS OF CHILDHOOD

• The findings suggestive of pulmonary tuberculosis on CXR include TUBERCULOSIS RECOMMENDED?
− hilar or paratracheal adenopathy PPS Recommendation:
− consolidation & air-trapping • Obtain microbiologic dx, utilizing at least 3 specimens by AFB smear
& culture when:
Q: How to differentiate TB from Pneumonia?
− MDRTB is suspected in the absence of a culture positive index
A: Initially, if you have consolidation, you think of Pneumonia but there Multi drug resistant tb
case including treatment failure
are diagnoses of TB-Pneumonia. You give antibiotics for 7-14 days. If
− when tuberculosis is strongly considered in a sick child but
there is no resolution of the consolidation, you continue treating with anti-
diagnosis cannot be made by other criteria
TB drugs. Air trapping is caused by the enlargement of the lymph nodes.
− the reason why we do not do microbiologic diagnosis among
pediatric age group, can only do it if suspecting multiple drug
• CXR cannot be used alone in the diagnosis of childhood pulmonary
resistance and TB culture will be out after 3 months
tuberculosis unless the finding seen is miliary tuberculosis.
− If you are suspecting of MDR, the child will show progression of TB
− If you have miliary TB, the CXR can stand alone as a diagnosis for
after 2 months, you add another drug and do not wait for the
TB but if is it only lymphadenopathy, CXR cannot be used alone
culture results. It is important to note which drug the TB is resistant
− Other criteria for diagnosis must be looked for
to.

Diagnostic Accuracy of Chest Radiography in Detecting WHAT IS THE BEST SPECIMEN TO OBTAIN FOR
Mediastinal Lymphadenopathy in Suspected Pulmonary MICROBIOLOGIC DIAGNOSIS?
Tuberculosis PPS Recommendation:
• Sensitivity = 67%
• In patients 10 years old & above
• Specificity = 59%
− SPUTUM is the best specimen to collect
• In younger patients
Observer Variation in Detecting Lymphadenopathy on − gastric aspirate/ lavage
Chest Radiography − the patient will not have milk for 12 hours and you do it for 3
• Inter-observer agreement = 0.33 consecutive days
− If a CXR was done in Nazareth and it was brought to another • Grade A level III
radiologist from another hospital
• Intra-observer agreement = 0.55 HOW CAN A DIAGNOSIS OF LATENT TUBERCULOSIS
− If a CXR was done in Nazareth and it was brought to another INFECTION (LTBI) BE MADE?
radiologist in the same hospital Recommendation:
RADIOLOGIC FINDINGS • A TST result of > 10 mm using 5TU PPD is recommended to define a
person as having LTBI provided there are no clinical findings of TB
• NO SPECIFIC FEATURE disease & the CXR does not show findings of TB disease or only
• Maybe normal in 10% of patients with active TB shows healed infection.

Q: If a patient has history of exposure with signs and symptoms of TB and WHAT IS THE VALUE OF NEW DIAGNOSTIC TESTS FOR TB?
a positive PPD, is a chest X ray still necessary?
A: No. It must at least satisfy 3 out of 5 criteria previously mentioned.
Recommendation:
(History of Exposure & Signs and Symptoms – only 1 criterion, Positive • Newer diagnostic tests utilizing PCR, serology or other assays are not
PPD – 1 criterion). You can already treat the patient with anti-TB, however, recommended for routine diagnosis of pulmonary tuberculosis in
a chest x-ray provides baseline for comparison with any future children.
examination. For example, this patient has been taking anti-TB drugs for 2 − Not available and not cost-effective
months and the patient developed Pneumonia, you can compare if it is a • 2008, 2016 TB consensus
new or old lesion. • Who recommends use of xpert MTB/RF assay in MDRTB suspects
− Unprocessed sputum
AFTER THE TREATMENT, IS IT NECESSARY TO REPEAT A CHEST − Gastric lavage/aspirate
RADIOGRAPH? − CSF
PPS 2016 GUIDELINE − Lymph node tissue

• In the first 3 months of treatment there may be worsening of

radiographic findings like enlargement of lymph nodes and extension
of parenchymal involvement even in compliant patients
• Clearing usually occurs 6 months to 2 years after treatment.
• A: You may not repeat the chest x-ray as long as the child has gain
weight, no cough and cold, improved after the treatment. If the parents
insist on repeating the chest x-ray after the therapy, then it may be
done a year after completion of treatment

Q: When do we request for a repeat chest radiograph study?

A: Repeat CXR in patients who are not responding to treatment. We
expect improvement after 2 weeks of TB treatment. If after 2 months,
the patient still has poor weight gain, coughing, still with signs and • Red circle: In children, diagnosis is made by signs and symptoms
symptoms of TB initially present, we should think of resistance. We must clinically which is very different in adults because we rely more on the
repeat chest x-ray and TB culture. results of the smear
• Smear has very low yield in children
• Xpert cannot be used to rule out TB
• Xpert needs research on implementation to inform optimal usage in
children

Trans Group 5: Agbuya, Crisologo, Garcia, Guilang, Landingin, Pacio, Zamudio EDITORS: Garcia & Guilang 3 of 6
 2022 5.2. Childhood Tuberculosis
DR. FELMA UNGSON GARCIA | 04/07/2021
PEDIATRICS II

MOLECULAR DIAGNOSTIC TESTS • Unavailability of medicines

• Nucleic acid amplification tests (NAATS) • Lack of support activities
− 4-90% sensitivity
− False positive results PPS STAND ON ETHAMBUTOL USE
− Result should always be interpreted in conjunction with other • Can be used in any age
parameters because presence of other Mycobacterium may yield a • use as 4th drug in HIV infested area
positive result • Used in intensive phase
• Line probe assays • Adverse effect: temporary colorblindness
− Extraction of DNA from mycobacterial isolates or directly from • Disadvantage: No liquid form
clinical specimens
− PCR amplification ETHAMBUTOL IN TUBERCULOSIS: TIME TO RECONSIDER?
− Available tests • Ethambutol is recommended as fourth drug in intensive phase of
○ INNO-LIPA RIF TB first-line regimens
○ Geno type MTBDR/MTBDRplus • Risk of toxicity is dose-related and related to duration of therapy
○ Geno type MTBDRsl • The risk of toxicity is negligible for children of any age when
• Gene Xpert MTB/RIF ethambutol is used at recommended dosages - especially as duration
− Sensitivity 55-90% is usually limited to 2 months
− Specificity 93-100% • Ethambutol can be safely used at recommended dosages in all ages
− WHO recommends use of this test over conventional microscopy as
the initial diagnostic test in the ff IS HIGH DOSE (15MKD MAX OF 300MG) ISONIAZID IN
○ Children and adults
○ Suspected risk for drug resistant TB CHILDREN, SAFE?
○ HIV associated TB • Young children (<5 years) eliminate INH faster than older children and
adults and require a higher mg/kg INH dosage to achieve serum
concentrations comparable to adults
TREATMENT - AIMS AND BASIC PRINCIPLES OF THERAPY
• Peak INH concentrations were < 3 mg/liter in 70% of children receiving
OBJECTIVES OF TREATMENT 4-6 mg/kg and 58% lower in children receiving 4-6 mg/kg compared to
• Cure of patient those receiving 8-10 mg/kg
• Prevention of death • Receiving 10 (range 6-15) mg/kg of rifampin, mean 2-hour rifampin
• Prevention of relapse concentration in 54 children (mean age 4 years) of 3.9 (HIV-infected)
− Very high 1 year after treatment and 4.8 (HIV-uninfected) mg/liter - considerably less than the
• Prevention of drug resistance suggested lower limit of 8 mg/liter
− Properly diagnose to prevent overtreating the patient
• Decrease TB transmission to others RAPID ADVICE
− It is not necessary to separate the eating utensils • Treatment of tuberculosis in children
• Ethambutol efficacy and toxicity: literature review and
TREATMENT OF TB IN CHILDREN recommendations for daily and intermittent dosage in children
• Principles of treatment of TB in children are same as for adults with
similar regimens Revised dosages for children:
− Intensive (4 drugs) and continuation phase (2 drugs) Rifampicin 15 (7-20) mg/kg/day was 10 (8-12)
• Most young children have paucibacillary disease which is why fourth
drug is less critical in young children Isoniazid 10 (7-15) mg/kg/day was 5 (4-6)
− Depends on the area, in Dagupan where there is an increased Pyrazinamide 35 (30-40) mg/kg/day was 25 (20-30)
cases of HIV cases, quadruple treatment is advised
Ethambutol 20 (15-25) mg/kg/day was 15 (10-20)
• Children with TB usually respond well with symptomatic
improvement during intensive phase and good outcome Revisions based on pharmacokinetic data not clinical outcome
− Educate the parents that after 2 months, if the patient has already
gained weight, good appetite, no episodes of coughing, These are the revised dosages (WHO 2014) for children up to 25 kgs:
encourage to continue the medications in the continuation phase.
Rifampicin 15 (7-20) mg/kg/day
REASONS OF TREATMENT FAILURE AND NON-COMPLIANCE Isoniazid 10 (7-15) mg/kg/day
Max 300mg/day still used
OF TREATMENT
Pyrazinamide 35 (30-40) mg/kg/day
• Poor compliance
− Taste of medicine Ethambutol 20 (15-25) mg/kg/day
○ Rifampicin (thick, bitter, orange) and Pyrazinamide (banana From 25 kgs, can change to adult dosages and preparations
flavor) do not taste good
− Tired of taking the medicine
Source: Guidance for national tuberculosis programmes on the
○ If they have bone TB, they have to take the medications for 1
management of tuberculosis in children (Second edition) by the World
year
Health Organization (WHO)
○ If they have a small scrofula, 6 months is enough
− "1 hour before bfast protocol” is hard to follow
• Note also other revisions to recommendations:
○ Very difficult especially those who are bottle feeding
1. Four drugs (RHZE) in intensive phase for new cases in HIV
○ Encourage a follow-up after 2 weeks because the 1st 2 weeks
endemic setting
is very difficult in patients with increased TB bacilli that 2. No intermittent regimens in HIV-endemic setting
experiences gastric discomfort (vomit, poor appetite) and 3. 12-month regimens for TB Meningitis (TBM) and osteo-articular
worsening of other symptoms. Next will be monthly for 2
TB (Pott’s disease)
consecutive months and then every 2 months, thereafter. 4. Streptomycin (or Cat II regimen) no longer recommended for
○ Monitor if there is jaundice, persistence of abdominal children (given intramuscularly)
discomfort, size of liver due to AE of isoniazid, weight gain,
and response

Trans Group 5: Agbuya, Crisologo, Garcia, Guilang, Landingin, Pacio, Zamudio EDITORS: Garcia & Guilang 4 of 6
 2022 5.2. Childhood Tuberculosis
DR. FELMA UNGSON GARCIA | 04/07/2021
PEDIATRICS II

HOW DO WE ADDRESS THE POOR COMPLIANCE IN Available approaches to prevent TB

CHILDHOOD TB DUE TO TASTE? Improved case-finding and Early identification and effective
management treatment of infectious
DEVELOPMENT OF A NEW FDC
• Simple to use, affordable, "child-friendly" formulations TB cases will reduce transmission
• In Dec. 2015, first manufacturer Macleods made available new child- of infection and therefore disease
friendly correctly dosed fixed-dosed combinations of the generic drugs
used to treat TB: BCG Neonatal BCG immunization is
− Rifampicin 75 mg + Isoniazid 50 mg + Pyrazinamide 150 mg used widely but efficacy is
(two-month intensive phase) variable
− Rifampicin 75 mg + Isoniazid 50 mg (four-month continuation
phase) Only has 30% protection against
• Product attributes: Correct, WHO recommended doses, Dispersible in pulmonary TB
liquid, Palatable fruit flavors
• The average treatment costs is $15.54 through the Global Drug Facility The main proven benefit of
(GDF) neonatal BCG is protection against
severe disseminated forms of TB in
children

Contact screening and Focus of preventive therapy is on

management individuals infected with TB that
have greatest likelihood of
developing active TB disease
following infection - this includes
infants, young children and HIV-
infected persons of any age

Widely recommended but uptake

by eligible groups and
implementation by NTP are poor in
TB endemic settings
INFORMAL CONSULTATION ON THE DEVELOPMENT OF NEW Families with a child < 5 years old
PAEDIATRIC FIXED DOSE FORMULATIONS who has primary TB, all family
• New additions and preferably dispersible or crushable members 15 years and above are
− RHZ 75/50/150 mandated to have a CXR
− RH 75/50
• Do not include Ethambutol in FDC Infection control Reduce infection risk at health
• Retain following products and add that prefer dispersible facilities – TB wards; TB clinics;
− H 50 & H 100 tablet HIV clinics
− E 100 tablet
− Z 150 tablet
• Cut-off for child dosages as < 25 kg BARRIERS TO PREVENTIVE THERAPY
• Revise range for isoniazid to 7-15 mg/kg • Screening includes investigations – TST and CXR
• Facility-based implementation - travel and waiting
Numbers of tablets • Lack of understanding of rationale
Intensive Phase Continuation • Time required by health workers
Phase • Lots of myths and misperceptions
RHZ E RH • Lack of suitable preparations
• Adherence a common challenge - long regimens
Weight bands 75/50/150 100 75/50
• Transport costs
4-7kg 1 1 1 • Medication costs
8-11kg 2 2 2
12-15kg 3 3 3
SHORTER, SIMPLER PREVENTIVE THERAPY REGIMENS
• Standard regimen is 9H or 6H
16-24 kg 4 4 4 • Dosage in young children 10 mg/kg daily
Go to adult dosages and preparations • INH + Rifapentine (3HP) versus 9H -
For example: 2 RHZE 150/75/400/275 − 3HP - Discouraged due to MDRTB
− Weekly (12 dosages) versus daily (270 dosages)
ADVANTAGES OF NEW FIXED DOSE COMBINATION − Meet non-inferiority criteria: 7 TB cases/3986 3HP versus 15/3745
• Can be used for all first-line regimens (i.e. +/-E) 9H (cumulative rate 0.43%) Sterling TR, et al. NEJM 2011
• Ratio of drugs, especially rifampicin: isoniazid allow use of revised − Meet non-inferiority criteria in 2-17 years of age: 0/471 3HP v 3/434
recommended dosages in young children 9H (cumulative rate 0.74%) Villarino ME, et al. JAMA Pediatr 2015
• No breaking of tablets required − Less hepatotoxic 0.4% (3HP) versus 1.8% (9H) Bliven-Sizemore EE,
• Dispersible - easier to swallow et al. UTLD 2015 Now US recommendations except < 2 years,
• Flavored PLHIV on ART, pregnancy, presumptive infection with DR TB
• Inexpensive • 3RH routinely used in UK
• Solid preparations simple for transport and storage • Pyrazinamide containing e.g. 2RZ unacceptable frequency of
• Challenge is to ensure co-availability of single drug preparations for hepatotoxicity - observations in adults
use as preventive therapy (e.g. IPT) or MDR treatment (e.g. PZA)

Trans Group 5: Agbuya, Crisologo, Garcia, Guilang, Landingin, Pacio, Zamudio EDITORS: Garcia & Guilang 5 of 6
 2022 5.2. Childhood Tuberculosis
DR. FELMA UNGSON GARCIA | 04/07/2021
PEDIATRICS II

KEY ISSUES IN DELAYING TREATMENT OF TB Screening Tools:

• Complications of TB occurs during the first five years after initial • Full history taking (ask about objective weight loss. persistent non-
infection remitting cough and fatigue)
• An arrested or silent lesion may reactivate heralding complications • Full clinical examination
• 1-3 months after the primary infection • TST (where available)
− Meningitis • IGRA assay (where available)
− Disseminated / miliary TB
• 4-7 Months after primary infection
Diagnostic Tools:
− Endobronchial TB (EBTB) – most contagious form
− Pleural effusion • Chest radiograph
• 1-3 years after primary complex • XPERT MTB-RF - NPA, IS, GA, stool
− Osteoarticular TB (Pott’s disease) • "microscopy and culture - IS, GA, CSF
• 5-25 YEARS after primary complex • DST - if Rif resistant
− Renal TB
• Presence of calcification after primary complex TBI - Isoniazid Preventative for 6 months
− Adult type tb may occur
− Lesser chance if TB calcification is more than 3 years Confirmed DS TB
○ TB IN INFANCY AND CHILDHOOD, 4TH ED, 2016 • Non-severe
− Rif + Z+ INH (2 months)
WHAT ARE THE OTHER SUPPORT ACTIVITIES THAT I CAN − Rif-INH (4 months)
GIVE TO MY PATIENT WHILE ON TREATMENT? • severe - above regimen + ETH for first 2 months
SUPPORT ACTIVITIES ON CHILDHOOD TB
• Identify and treat the source Unconfirmed TB
• Nutritional support • no bacteriological confirmation but high suspicion of TB disease
− Because most of the time patients are underweight or • treats as for confirmed TB
malnourished
• Deworming Drug Resistant TB -
• Dental evaluation
• Health education • Including RUR
• treat as per fig 2
IMPORTANT POINTS TO REMEMBER
‘Porke ba payat, TB na ??di ba pwedeng on diet lang?
• Do not over-diagnose
• Do not over and under treat
‘ang payat mo mukha kang may TB”
• Ensure that your instructions are complete and clear
• Look for source of infection ADDITIONAL READINGS
• Monitor for patients regularly • Integration of childhood TB into guidelines for the management of
• Inform of the adverse effects of the drugs acute malnutrition in high burden countries by L. N. Patel,' A. K. Detjen
− Ex: Rifampicin may cause orange-colored urine or saliva − https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493091/

UPDATE ON TRENDS IN CHILDHOOD TB FRY ET AL. REFERENCES

• TUBERCULOSIS IN INFANCY AND CHILDHOOD 4th edition 2016
• Treatment of childhood TB: issues and controversies
• Clinical Practice Guidelines for the DIAGNOSIS, TREATMENT,
PREVENTION AND CONTROL OF TUBERCULOSIS in Adult Filipinos
2016 Update

" There are many, contributions which the pediatrician can make to a
TB control program. First the negativism about tuberculosis so
prevalent in pediatrics must be overcome...”
- Edith Lincoln, 1961

Child Contact
• high risk identifier
• co morbidities (HIV, malnutrition)
• young age
• confirmed DR or DS source case

Trans Group 5: Agbuya, Crisologo, Garcia, Guilang, Landingin, Pacio, Zamudio EDITORS: Garcia & Guilang 6 of 6