TB Manual

• In Canada, pediatric tuberculosis (TB) is largely a disease of Canadian-born Indigenous children, foreign-born children and children of foreign-born parents.

• TB disease in young children (typically <5 years of age) is a sentinel event that should prompt a search for an infectious source case.

• Children under the age of 5 years are at high risk of progression to severe forms of TB disease after TB infection.

• Multiple sputum samples should be collected, as yield of sputum Acid-Fast Bacilli (AFB) smear microscopy and culture in children <10 years old is low.

• In children who are clinically stable who are unable to produce an expectorated sputum specimen, gastric aspirates or induced sputa should be collected before treatment for TB disease is initiated. In critically ill children, where the index of suspicion is high for TB disease, therapy should be initiated rapidly and collection of appropriate specimens should be completed as soon as possible.

• TB disease in children is most often a clinical diagnosis that is made using a combination of: (1) a positive tuberculin skin test (TST) or interferon-gamma release assay (IGRA); (2) contact with an infectious source case; (3) abnormal chest x-ray with typical findings of TB disease; and (4) compatible clinical signs or symptoms.

• A negative TST or IGRA is expected in up to 30% of children with TB disease and should not be used to exclude this diagnosis.

• Severe adverse events due to TB medications are rare in children. The onset of medication toxicity is vague in infants, toddlers and pre-teens and caregivers should be counseled about the risks of therapy and signs/symptoms for concerning side effects, and provided with support(s) to manage these.

• Targeted testing for TB infection is recommended based on likelihood of TB infection and progression to disease.

• For children less than 2 years, the recommended regimen for TB preventive therapy is 4 months of daily rifampin. Nine months of daily isoniazid is an acceptable alternative. In certain situations, 9 months of observed, twice-weekly isoniazid may be more appropriate (ie, issues of compliance, patient preference, directly observed therapy (DOT) worker availability etc).

• For children more than 2 years, the recommended regimens for TB preventive therapy are 4 months of daily rifampin or 12 weekly doses of combination isoniazid and rifapentine. Nine months of daily isoniazid is an acceptable alternative.

• For treatment of TB disease in children, daily therapy is strongly recommended over intermittent regimens.

• Ethambutol is now routinely used as part of initial empiric therapy of TB disease (pending sensitivities) in infants and children, unless contraindicated or if the source case if known to have fully drug-susceptible tuberculosis.

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