Tuberculosis in Children

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Annexure

Issues in therapy for Tuberculous in Pediatric Office Practice

Single Drug Vs fixed drug combinations

  • Fixed Drug combination of INH and RMP is acceptable.
  • It is ideal to use PZA separately.
  • Pharmacokinetic
    data regarding triple fixed combinations in children is not adequate. Change in prescription from Triple fixed dose combination to double fixed dose combination, after first 2 months of treatment may be confusing to the patients.

Indications for Steroid therapy in childhood tuberculosis

  • Neurotuberculosis
  • Miliary tuberculosis
  • Tuberculosis of the serosa
  • Endobronchial tuberculosis
  • Genitourinary tuberculosis
  • Sinus formation
  • Prednisolone 1 mg/kg/Day 4 to 8 weeks
  • For Neurotuberculosis 8-12 weeks

Toxicity to the Anti tubercular Drugs

  • Commonest is Hepatotoxicity. Usually seen in vulnerable children, like those with PEM or disseminated tuberculosis. Clinical symptoms, hepatomegaly and jaundice, merits lab tests and temporary cessation of the hepatotoxic drugs (HRZ). Routine SGPT monitoring is not recommended.

Suggested actions:

  • Stop INH, RMP and PZA
  • Start SM and EBM
  • When SGPT returns to normal (2-4 weeks),restart 5 mg/kg INH
  • Continue SM and EMB
  • Restart RMP after 1 wee, stop EMB and SM.
  • Restart PZA after 1 week if stoppage occured in the intensive phase of therapy.

Defaulters

  • Defined as discontinuing treatment for more than 1 week duration, against medical advice
  • Lost to treatment indicates a period of default of more than 1 month duration
  • Suggested actions in defaulters:
  • If default period 1 week to 1 month, continue the same phase of treatment for additional 1 month.
  • If default period is >1 month, restart full treatment.

Drug resistance

  • If a patient on prescribed treatment does not respond, check the compliance, confirm the diagnosis and assess for probable adult contact with multidrug resistance tuberculosis. A child with cavitatory lesion, or with the history of past treatment for tuberculosis is vulnerable. Arrange for bacteriological study if MDR - tuberculosis is suspected.
  • In case of suspected drug resistance in the absence of Bacteriological proof, suggest therapy with 2SHREZ/1HRZE/6HRE
  • In case of proved drug resistance, suggested regimen is as follows:

INH RMP MULTI DRUG

HIV- 12 RZE 18-24 HZE 3 sensitive drug for 2 years after culture negative.

HIV+ 18 RZE or 18-24 HZE or 3 sensitive drug for 2 12 m after cul 12 m after cul. years after culture negative negative negative.

Relapse

  • Relapse is defined as reappearance of signs and symptoms of tuberculous disease within 2 years of cure i.e. after completion of specified therapy. Relapses are rare in children.
  • Suggested regimen: treat as suspected drug resistance in the absence of bacteriological evidence.

Contact

  • Any child who lives in a household with an adult taking ATT or has taken ATT in the past 2 years.
  • Preventive therapy with 6HR is necessary for contacts < 3 years of age/< 5 years of age with grade III or IV malnutrition/adolescents. Close surviellence is necessary for 5-12 years old contacts.

BCG adenitis

  • For lymphnodes <1.5 cms no treatment is required.
  • If the node is increasing in size or is fluctuant - excision or 3-6H
  • Sinus formation - Excision

* Grades of Malnutrition I-II-III-IV

**Indian Association of Paediatrics

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KrishnanS 

Very simple, informative and good coverage of the topic.
Dr S krishnan
Apollo-Hyderabad

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