TUBERCULOSIS AND NEWBORN

ELISHA JR

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Introduction

• Tuberculosis is a chronic infectious disease caused by an organism called mycobacterium tuberculosis (© M O H-DRH/DOMC/DLTLD/JHPIEGO, 2007).

• Most children infected with M. tuberculosis do not develop TB. The only evidence of infection may be a positive skin test.

• The development of TB depends on the competence of the immune system to resist multiplication of the M. tuberculosis infection.

• This competence varies with age, being least in the very young.

(WHO pocket book of hospital care for children, 2013).

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•HIV infection and malnutrition lower the body’s defenses, and measles and whooping cough temporarily impair the strength of the immune system. In the presence of any of these conditions, TB can develop more easily (WHO pocket book of hospital care for children, 2013).

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Types of Tuberculosis

Pulmonary tuberculosis(PTB) is the most common andinfectious type of TB.– It affects the lungs.Extra Pulmonary Tuberculosis(outside of the lungs)any organ of the body such as the kidney, bladder,ovaries, testes, eyes, bones or joints, intestines, skinor glands, and meninges– The most common extra pulmonary TB is TB of the glands alsocalled TB lymphadenitis.

(©MOH-DRH/DOMC/DLTLD/JHPIEGO,2007)

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• TB is most often severe when it is located in the lungs, meninges or kidney. Cervical lymph nodes, bones, joints, abdomen, ears, eyes and skin may also be affected (WHO pocket book of hospital care for children, 2013).

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Signs and symptoms of TB

•Many children present only with failure to grow normally

•Weight loss

• prolonged fever and

•Cough for > 14 days

(WHO pocket book of hospital care for children, 2013).

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History questions

• When it started

A history of:

• unexplained weight loss or failure to grow normally

• unexplained fever, especially when it continues for longer than 2 weeks

• chronic cough (i.e. cough for > 14 days, with or without a wheeze)

• exposure to an adult with probable or definite infectious pulmonary TB.

• History of BCG vaccine

• Ask about other danger signs.

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Physical examination

• Fluid on one side of the chest (reduced air entry, stony dullness to percussion).

• Enlarged non-tender lymph nodes or a lymph node abscess, especially inthe neck.

• Signs of meningitis, especially when these develop over several days and the spinal fluid contains mostly lymphocytes and elevated protein.

• Abdominal swelling, with or without palpable lumps.

• Progressive swelling or deformity in the bone or a joint, including the spine.

(WHO pocket book of hospital care for children, 2013).

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Differential diagnosis

• Tuberculosis

• Pneumonia

• Infection

• Sepsis

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Laboratory value

• The diagnosis of TB in children can be very difficult owing to the wide range of symptoms.

• Sputum cannot often be obtained from children and in any case it is often negative even on culture. Symptoms in children are not typical.

• The diagnosis should therefore be based on clinical findings, family history of contact with a smear positive case, X-ray examination andtuberculin testing

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Tuberculin Testing

• The tuberculin skin test is valuable as a diagnostic tool in children, in child who did not receive a BCG vaccine an induration of 10mm or more interpreted as positive, if a child did receive a BCG, the induration should be at least 15mm to be positive.

• Test may be negative in children with TB who have HIV/AIDS, miliary disease, severe malnutrition or recent measles.

• Absence of a response does not exclude TB because individuals of the condition above may not have sufficient immunity for a positive Mantouxtest despite active TB

(WHO pocket book of hospital care for children, 2013;Tanzania standard treatment guideline, 2013).

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• Obtain a chest X-ray. A diagnosis of TB is supported when a chest X-ray shows a miliary pattern of infiltrates or a persistent area of infiltrate or consolidation, often with pleural effusion, or a primary complex.

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Treatment

• To reduce the risk for drug-induced hepatotoxicity in children, follow the recommended dosages:– Isoniazid (H): 10 mg/kg (range, 10–15 mg/kg); maximum dose, 300 mg/day– Rifampicin (R): 15 mg/kg (range, 10–20 mg/kg); maximum dose, 600 mg/kg per day

– Pyrazinamide (Z): 35 mg/kg (range, 30–40 mg/kg)

– Ethambutol (E): 20 mg/kg (range, 15–25 mg/kg).

(WHO pocket book of hospital care for children, 2013).

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Management

• MonitoringConfirm that the medication is being taken as instructed, by direct observation of each dose. Monitor the child’s weight gain daily and temperature twice a day in order to check for resolution of fever. These are signs of response to therapy.

• When treatment is given for suspected TB, improvement should be seen within 1 month. If this does not occur, review the patient, check compliance, re-investigate and reconsider the diagnosis.

(WHO pocket book of hospital care for children, 2013).

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• Children < 5 years of age who are household or close contacts of people with TB and who, after an appropriate clinical evaluation, are found not to have active TB should be given 6 months of isoniazid preventive therapy (10 mg/kg/day, range 7–15 mg/kg, maximum dose 300 mg/day) (WHO pocket book of hospital care for children, 2013).

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References

• United republic of Tanzania ministry of health and social welfare (2013).Standard treatment guideline and national essential medicine list, Tanzania main land.

• WHO (2013) .Pocket book of hospital care for children guideline for the management of common childhood illness.

• ©MOH-DRH/DOMC/DLTLD/JHPIEGO(2007). Focused antenatal care; malaria in pregnancy prevention of mother-to-child transmission tuberculosis; orientation package for service providers.

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