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Care priority and warning signs
Care priority
Initiate Treatment / Link to TB Clinic
Red flags
- Signs of TB meningitis (stiff neck, altered consciousness, convulsions).
- Signs of respiratory distress (severe pneumonia).
- Signs of miliary TB (severe illness, hepatosplenomegaly).
- Signs of spinal TB (back swelling, neurological deficit).
- Any general danger sign.
Assessment
- Ask (Symptoms suggestive of TB):
- Has the child been coughing for 14 days or more?
- Has the child had persistent fever (≥14 days)?
- Has the child had poor weight gain in the last month? (Defined as: Weight loss >5% since last visit OR Weight-for-age < -3 Z-score OR Weight-for-age < -2 Z-score OR Growth curve flattening OR Red/Yellow MUAC colour code).
- Ask (History of contact):
- Has the child had contact with a person with Pulmonary TB or chronic cough?
- Look/Feel (Physical signs suggestive of TB):
- Look/Feel for swellings in the neck or armpit (lymphadenopathy).
- Look/Feel for swelling on the back (e.g., gibbus).
- Look/Feel for stiff neck.
- Listen for persistent wheeze not responding to bronchodilators.
- Check HIV status (HIV positive status increases suspicion/risk).
- Review available diagnostic tests: Collect sample for GeneXpert or smear microscopy if available. Chest X-Ray results if available.
Classification
- Criteria for TB Classification:
- (HIV Negative Child): Two or more of the following: (Cough ≥14d) OR (Fever ≥14d) OR (Poor weight gain*) OR (Positive contact history) OR (Suggestive physical sign: neck/axilla/back swelling, stiff neck, persistent wheeze).
- (HIV Positive Child): One or more of the following: (Cough ≥14d) OR (Fever ≥14d) OR (Poor weight gain*) OR (Positive contact history) OR (Suggestive physical sign).
- OR A positive GeneXpert or smear microscopy test.
- -> Classify as TB
Key features
- Diagnosis often based on a combination of symptoms, contact history, and signs, especially in young children where bacteriological confirmation is difficult.
- Criteria differ slightly based on HIV status: >=2 symptoms/signs if HIV Neg, >=1 symptom/sign if HIV Pos.
- Positive contact history is significant.
- Positive GeneXpert or smear microscopy confirms TB.
- Requires multi-drug anti-TB treatment regimen.
Management
Non-pharmacological management
- Provide nutritional support counselling.
- Counsel on adherence to long-term treatment.
- Trace contacts of the child (especially the source case) for screening.
Pharmacological treatment
- Initiate TB treatment using appropriate regimen based on national guidelines (typically involves Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), +/- Ethambutol (E) in intensive phase, followed by HR in continuation phase).
- Use weight-band dosing for fixed-dose combinations (FDCs) if available (See Page 19 for RHZ 75/50/150 and E100 weight bands: 4-7kg: 1 tab RHZ, 1 tab E; 8-11kg: 2 tabs RHZ, 2 tabs E; 12-15kg: 3 tabs RHZ, 3 tabs E; 16-24kg: 4 tabs RHZ, 4 tabs E).
- Intensive Phase (First 2 months): Typically 2RHZE or 2RHZ.
- Continuation Phase (Next 4 or 10 months): Typically 4RH or 10RH (longer for TB meningitis/bone TB). See Page 19: 4RH for most forms, 10RH for TB meningitis/osteoarticular TB.
- Link the child to the nearest TB clinic for registration, ongoing treatment, monitoring, and follow-up.
- If GeneXpert or smear microscopy test is not available or negative, but clinical suspicion is high based on criteria, initiate treatment and refer for further assessment/confirmation.
- Treat, counsel, and follow up any co-infections (e.g., HIV, malnutrition).
- If available, give Pyridoxine (Vitamin B6) 12.5mg/day for children <5 years on Isoniazid to prevent neuropathy (absence should not delay starting TB meds).
Pre-referral treatment
- If signs of severe TB (meningitis, respiratory distress) or other severe classification present, provide appropriate pre-referral treatments (antibiotics, manage danger signs) before urgent referral to hospital (TB treatment may be initiated at hospital).
Follow-up
- Requires regular follow-up at the TB clinic (e.g., monthly) for monitoring treatment response, side effects, adherence, and weight gain.
- Contact tracing follow-up.
Counselling points
- Explain the diagnosis (TB) and the need for long-term treatment (usually 6 months).
- Explain the importance of taking medications every day exactly as prescribed.
- Teach how to give the TB medicines (crushing/dispersing tablets if needed).
- Explain potential side effects and when to return if they occur (e.g., yellow eyes, skin rash).
- Counsel on good nutrition to support recovery.
- Explain importance of follow-up visits at TB clinic.
- Discuss infection control measures within the household (e.g., cough hygiene, ventilation) if relevant.
- Ask about the caregiver's health (possible source case) and advise screening if needed.
- Counsel on contact tracing for other household members, especially young children.
Differential diagnosis
- Persistent bacterial pneumonia
- Asthma (persistent wheeze)
- Chronic lung disease
- Lymphoma or other malignancy (lymphadenopathy)
- HIV-related complications (poor weight gain, fever)
- Malnutrition (poor weight gain)
- Other chronic infections
Complications
- TB Meningitis
- Miliary TB
- Spinal TB (Pott's disease)
- Pleural effusion
- Bronchiectasis
- Treatment failure / Drug resistance
- Drug toxicity (e.g., hepatitis, neuropathy)
- Malnutrition
- Death
Prevention
- BCG vaccination at birth (protects mainly against severe forms like meningitis).
- Isoniazid Preventive Therapy (IPT) for eligible contacts (especially HIV+ children and children <5y who are close contacts) - see TB Exposure classification.
- Early diagnosis and treatment of infectious TB cases (source control).
- Infection control measures (ventilation, cough hygiene).
- HIV prevention and treatment (reduces TB risk).
References
IMCI Chart Booklet - Page 9, Page 19 (TB Regimens, Dosing), Page 20 (IPT)