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COMPED 2006
Dr. Prof. N. L. Phuljhele (M.D.)
Prof & Head of Department, Department of Pediatrics,
Dr. B.R.A.M. Hospital, Raipur (C.G.)
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| EPIDIMIOLOGY:
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It has been assumed that 10% of the total TB cases are found amongst children. Global estimates
of 1.5 million new cases and 130,000 deaths due to TB per year amongst children are
reported. However, these figures appear to be an underestimate of the size of the
problem. Kochi A. The global tuberculosis situation and the new control strategy of
the World Health Organization. Tubercle 1991;72:1. World Health Organization (WHO).
WHO report on the Tuberculosis epidemic. Geneva: WHO;1996.
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| Childhood TB prevalence indicates:
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- Community prevalence of sputum smear positive pulmonary tuberculosis (PTB)
- Age-related prevalence of sputum smear positive PTB
- Prevalence of childhood risk factors for disease
- Stage of epidemic
Proper identification
and treatment of infectious cases will prevent childhood TB. However often childhood TB is
accorded low priority by National TB Control Programmes in Children.
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| Probable reasons include:
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- Diagnostic difficulties
- Rarely infectious
- Limited resources
- Misplaced faith in BCG
- Lack of data on treatment
But this disregards
the impact of tuberculosis on childhood morbidity and mortality. Children can present with TB
at any age, but the majority of cases present between age of 1 and 4 years. Disease usually
develops within one year of infection – the younger, the earlier and the more disseminated.
The PTB prevalence is normally low between the ages of 5 and 12 years, and then increases in
adolescence when PTB manifests like adult PTB (post primary tuberculosis)3. PTB in children
is usually smear negative. Pulmonary to extra-pulmonary TB (EPTB) ratio is around 3:1.
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| Treatment of Childhood Tuberculosis: |
Consensus statement of
IAP working Group Indian Pediatric 1997;34:1093-1096.In order to optimize
treatment protocol, tuberculosis is classified into 5 groups based on
clinical types. The suggested regimen for drug therapy in each of these groups is as follows:
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| GROUP 1 (PREVENTIVE THERAPY)
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Asymptomatic Mantoux positive <3 years.
Asymptomatic Mantoux positive <5 years with Grades 3 or 4 malnutrition.
Mantoux +ve – Recent converter/no signs.
Children <3 years with H/O +ve contact.
Children <5 years – Grades 3 or 4 malnutrition with H/O +ve contact.
Treat with 6 months of INH and Rifampicin.
GROUP 2
Primary Complex (lung)
Symptomatic Mantoux +ve <3 years without localization.
Symptomatic Mantoux +ve <5 years with Grades 3 or 4 malnutrition without localization.
Isolated lymphadenitis
Pleural effusion
Treat with 2 months of INH, Rifampicin and Pyrizanamide followed by 4 months of INH and
Rifampicin.
GROUP 3
Progressive pulmonary disease
Tubercular lymphadenitis – Multiple
Treat 2 months of INH, Rifampicin, Pyrazinamide and Ethambutol followed by 4 months of INH and Rifampicin.
Continuation phase extended by 3 months in event of non-resolution.
GROUP 4
Miliary/Disseminated disease
Cavitatory disease/Bronchopneumonia
Osteoarticular disease
Abdominal, Pericardial, Genitourinary disease.
Treat with 2 months of INH, Rifampicin, Pyrazinamide and Ethambutol followed by 7 months of INH and Rifampicin.
GROUP 5
Neuro tuberculosis
Treat with 2 months INH, Rifampicin, Pyrazinamide and Ethambutol followed by 10 months of INH, Rifampicin and Ethambutol.
Dosage recommendations:
Isoniazid - 5 mg/kg (to be rounded to the closest higher dose)
Rifampicin - 10 mg/kg
Pyrazinamide - 25 mg/kg
Ethambutol - 20 mg/kg
Streptomycin - 20 mg/kg
Prednisolone - 1-2 mg/kg
All the drugs should be administered in a single daily dose on an empty stomach.
Indications for Prednisolone: Neurotuberculosis, Miliary tuberculosis, Tuberculosis
involving serous layers, Endobronchial tuberculosis, Genito-urinary tuberculosis / sinus
formation.
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| TREATMENT:
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During the last few years
dramatic changes have occurred in the therapeutic approaches to childhood TB as a result of large
number of treatment trials for children and increased concern about the development of resistance
to antituberculosis drugs. Short-course chemotherapy, with the treatment duration as short as
6 months, has become the standard practice. Intermittent regimens have been documented to be as
effective as daily regimen in the paediatric population. Biddulph J. Short-course chemotherapy
for childhood tuberculosis. (Ped.Inf Dis J 1990;9:794-801, Dr. Perkins et al, twice weekly vs
daily chemotherapy for childhood tuberculosis. Ped. Inf Dis J 2000;19:405-410).
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| REVISED NATIONAL TB CONTROL PROGRAMME: |
India has had a National
Tuberculosis programme (NTP) in operation since 1962. In 1992, a joint Government of
India / World Health Organization review found that despite the existence of the NTP TB
patients were not being accurately diagnosed and that the majority of diagnosed did not
complete treatment. Based on the recommendations of the review, the Revised National TB
Control Programme (RNTCP), incorporating the internationally recommended DOTS strategy,
was developed. In 1993, RNTCP was started in pilot areas covering a population of 18 million.
Large-scale implementation of the RNTCP began in 1998, with a World Bank credit of Rs.604 crore.
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| Treatment guidelines as per WHO for National Programme: |
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The DOTS strategy is applicable to all patients with tuberculosis, including children. High success rates
(over 95%) are achievable in children with PTB and less severe forms of EPTB such as
TB lymphadenopathy. Thioacetazone can cause severe and often fatal reactions in HIV-endemic
regions. It has been replaced by ethambutol.There has been
understandable caution with the use of ethambutol in children too young to report early
visual deterioration, but ethambutol has been safely used in infants and young children
at recommended dosages.
Directly observed therapy short-course (DOTS) has been successfully used in adults but there are no studies
in children. An observational trial evaluated directly observed therapy 6-month regimen
for pulmonary, pleural and lymph node tuberculosis in children. This regimen showed results
comparable with those of 6-month regimens with longer durations of daily therapy.
Starke J R et al, Ped. Inf Dis J 2002;21:91-97.
The major problem
in inclusion of children in DOTS is difficulty in demonstration of AFB and classification
of different clinical manifestations according to categories described for adults. A
classification was developed and evaluated in the tuberculosis clinic of a tertiary
care hospital. (Kabra S K ; Seth V et al. Category based treatment of tuberculosis in
children. Indian Pediatric 2004;41:927-37).
The authors concluded
that it is feasible to classify and manage various types of tuberculosis in children in
different categories similar to WHO guidelines for adult tuberculosis (Kabra S K; Seth V et al.
Category based treatment of tuberculosis in children. Indian Pediatric 2004;41:927-37).
Recently a consensus
statement jointly prepared by Indian Academy of Pediatrics and Revised National Tuberculosis
Control Program 9RNTCP) has also proposed a classification of different types of tuberculosis
in children into three categories (Chauhan L S, Arora V K et al. Management of Pediatric
Tuberculosis Under the Revised National Tuberculosis Control Programme, Indian Pediatrics
2004;41:901-906
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| Management of Pediatric Tuberculosis Under the Revised National Tuberculosis Control Programme |
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DOTS is the recommended
strategy for treatment of TB and all Pediatric TB and all Pediatric TB patients should be
registered under RNTCP. Recommended treatment regimens are given in [Table – 1]
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| Category of treatment |
Type of patients |
TB treatment regime |
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Intensive Phase |
Continuation Phase |
| Category I |
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New sputum smear positive PTB
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Seriously ill sputum smear negative PTB with extensive parenchymal involvement (acute military, segmental/lobar opacity)
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Seriously ill extra-pulmonary TB includes disseminated/military TB, TB pericarditis, TB peritonitis and intestinal TB, bilateral or extensive pleurisy, genitor-urinary tract TB, bone and joint TB.
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2H3R3Z3E3 |
4H3R3 |
Category I |
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2H3R3Z3S3 |
6-7H3R3 |
Category II |
- Sputum smear-positive relapse, (with evidence of tubercular features)
- Sputum smear-positive treatment failure, (with evidence of tubercular features)
- Sputum smear-positive treatment after default, (with evidence of tubercular features)
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2S3H3R3Z3E3/
1 H3R3Z3E3 |
5 H3R3E3 |
Category III |
- Sputum smear-negative and Extra-pulmonary TB, not seriously ill (TB adenitis, mediastinal lymphadenopathy, skin TB and not seriously ill abdominal TB)
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2H3R3Z3 |
4H3R3 |
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The drug dosages per kilogram are the same for children and adults.
Essential Antituberculosis drugs:
Essential drugs |
Recommended dosages in mg/kg |
Daily |
3 times weekly |
Isoniazid (H) |
5 (4-6) |
10 (8-12) |
Rifampicin ® |
10 (8-12) |
10 (8-12) |
Pyrazinamide (Z) |
25 (20-30) |
35 (30-40) |
Streptomycin (S) |
15 (12-18) |
15 (12-18) |
Ethambutol (E) |
15 (15-20) |
30 (20-35) |
Thioacetazone (T) |
2.5 |
Not applicable |
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WHO does not recommend twice weekly regime |
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In children’s with TBM streptomycin (or ethionamide) should be used instead
of ethambutol because it does not cross blood brain barrier.
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Corticosteroids may sometimes useful in TBM or in lobar/segmental opacity due to
lymphadenopathy, Miliary tuberculosis, Tuberculosis involving serous layers, Endobronchial
tuberculosis, sinus formation.
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Effectiveness of ethambutol in maintenance or continuation phase never been studied in
children’s whereas Rifampicin and Isoniazid proven efficacy.
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Antibubercular drugs available here in following strength:
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Antitubercular drugs |
Strength |
Isoniazid (H)
Rifampicin (R )
Pyrazinamide (Z)
Ethambutol (E)
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100 mg
150 mg
500 mg
800 mg |
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All Antitubercular drugs are available in loose form at DOTS centre for RNTCP.
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To assist in calculating required dosages and administration of anti-TB drugs
for children, the medication may be made available in the form of combipacks in patient
wise-boxes, linked to the child’s weight.
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Last Updated on 15-01-2007
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| How to cite this url |
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Comped 2006 - Conference Abstracts.Pediatric Oncall [serial online] 2007 [cited 15 January 2007(Supplement 1)];4. Available from:
http://www.pediatriconcall.com/fordoctor/Conference_abstracts/
comped/Tuber.asp
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