🦠 Tuberculosis (TB) in Children

📘 Definition:

Tuberculosis (TB) is a chronic infectious disease caused by the bacterium Mycobacterium tuberculosis, primarily affecting the lungs (pulmonary TB) but can also involve other organs (extrapulmonary TB) such as lymph nodes, spine, brain, and kidneys.

TB spreads mainly through airborne droplets when an infected person coughs, sneezes, or speaks. Children are usually infected by contact with an adult TB case, especially in households.

🩺 Identification / Diagnosis of TB in Children:

Diagnosing TB in children is challenging, as they often present with non-specific symptoms and less obvious sputum production.

🔍 1. Clinical History & Symptoms:

• Persistent cough (>2 weeks)
• Low-grade fever, often in the evening
• Weight loss or failure to gain weight
• Loss of appetite
• Fatigue and irritability
• Night sweats
• History of TB contact in family or surroundings

A child with no weight gain or unexplained fever/cough lasting >2 weeks should be investigated for TB.

🧪 2. Physical Examination:

• Respiratory signs (e.g., wheezing, rales)
• Enlarged lymph nodes
• Spinal tenderness (in TB spine)
• Meningeal signs (in TB meningitis)

🧫 3. Tuberculin Skin Test (Mantoux Test):

• Intradermal injection of PPD (Purified Protein Derivative)
• Induration (swelling) measured after 48–72 hours
• Positive if induration ≥10 mm (or ≥5 mm in high-risk children like HIV-positive)

Indicates TB exposure, not active disease

🦠 4. Microbiological Tests:

• Gastric aspirate or induced sputum (for children who can’t produce sputum)
• CBNAAT (GeneXpert MTB/RIF):
  • Rapid test that detects TB and rifampicin resistance
• AFB (Acid-Fast Bacilli) smear: Low sensitivity in children
• Culture of Mycobacterium tuberculosis: Most confirmatory, but takes 2–6 weeks

📸 5. Chest X-ray:

• Shows typical findings like:
  • Hilar lymphadenopathy
  • Infiltrates or consolidation
  • Cavitation (in older children)
• Suggestive but not diagnostic alone

🧪 6. Blood Tests:

• Elevated ESR
• CBC: May show anemia or lymphocytosis

🧠 7. Other Investigations (if extrapulmonary TB):

• CSF analysis – for TB meningitis
• Ultrasound/CT – for abdominal or spinal TB
• Fine needle aspiration – for TB lymphadenitis

📑 8. Scoring Systems (e.g., National TB Elimination Programme – NTEP):

• Used in India for clinical diagnosis of pediatric TB
• Based on:
  • Clinical signs
  • Nutritional status
  • History of contact
  • X-ray findings
  • Mantoux results

✅ Treatment of TB in Children (Based on NTEP Guidelines – India)

📌 Goal:

To completely eliminate TB bacteria, prevent drug resistance, and promote complete recovery.

🔷 1. First-Line Anti-TB Treatment (ATT) – for Drug-Sensitive TB:

Two Phases – Intensive Phase (IP) + Continuation Phase (CP)

Phase	Duration	Drugs Given
Intensive Phase	2 months	HRZE – Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E)
Continuation Phase	4 months	HR – Isoniazid, Rifampicin

Doses are weight-based using fixed-dose combinations (FDCs).

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🔷 2. Special Situations:

• TB Meningitis / TB of spine with neurological complications:
  • Extended treatment: 2HRZE + 10HR (Total 12 months)
• HIV co-infection:
  • ATT along with antiretroviral therapy (ART)
• Drug-resistant TB (DR-TB):
  • Requires second-line drugs (e.g., levofloxacin, linezolid)
  • Treated at specialized DR-TB centers
• Steroids (e.g., prednisolone) may be added for:
  • TB meningitis
  • Pericardial or pleural effusion
  • Miliary TB

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🔷 3. Nutritional Support:

• Essential for recovery in children with malnutrition
• Provide calorie-rich, protein-dense diet
• Nutritional supplements if needed (under Nikshay Poshan Yojana in India)

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🔷 4. BCG Vaccine:

• Preventive vaccine given at birth in TB-endemic countries
• Does not prevent infection, but reduces risk of severe forms of TB (e.g., TB meningitis)

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👩‍⚕️ Nursing Management of Pediatric TB

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🧩 1. Assessment:

• Monitor cough, fever, weight loss, or failure to thrive
• Observe adherence to ATT regimen
• Assess for drug side effects (jaundice, vomiting, vision changes, rash)
• Check for family history/contact with TB

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📝 2. Nursing Diagnoses:

• Ineffective airway clearance related to pulmonary involvement
• Imbalanced nutrition: Less than body requirements
• Deficient knowledge related to disease and long-term therapy
• Risk for infection transmission
• Risk for noncompliance with prolonged treatment

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🛡️ 3. Nursing Interventions:

💊 A. Medication Adherence & DOTS (Directly Observed Treatment):

• Ensure child receives medicines daily under supervision
• Educate caregivers about importance of completing full course
• Observe and document dose taken, and missed doses

🩺 B. Monitoring & Managing Side Effects:

• Watch for signs of:
  • Hepatitis (yellow eyes, nausea)
  • Rash or fever (hypersensitivity)
  • Blurred vision (ethambutol toxicity)
• Report adverse reactions to physician immediately

🥣 C. Nutritional Support:

• Provide nutritious, well-balanced meals
• Encourage small, frequent feedings
• Monitor weight gain weekly or monthly
• Link with nutrition programs (if available)

🧼 D. Infection Control:

• Educate on respiratory hygiene (cover mouth while coughing)
• Ensure good ventilation at home
• Avoid school or daycare during initial phase of treatment
• Encourage screening and treatment of close contacts

📚 E. Family & Child Education:

• Teach about:
  • TB as treatable and curable
  • Need for long-term follow-up
  • How to prevent spread of infection
• Counsel on stigma reduction and social support

💬 F. Psychosocial Support:

• Provide emotional support to child and family
• Address school absenteeism, peer issues, or social isolation
• Refer to support groups if needed

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📈 4. Evaluation:

• Child shows improvement in appetite, weight, and activity
• Cough and fever subside
• Child completes full course of ATT without interruption
• Family demonstrates understanding of treatment plan
• No drug resistance or complications develop

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✅ Prognosis:

• Excellent in children if TB is detected early and treatment is completed fully
• Risk of relapse or complications if non-adherent to therapy
• Long-term follow-up needed in TB meningitis or extensive lung disease

🏨 Hospital Management of TB in Children:

🧾 When is Hospitalization Needed?

• Severe disease (e.g., TB meningitis, miliary TB)
• Drug-resistant TB (DR-TB)
• Severe malnutrition or dehydration
• Respiratory distress or complications
• Poor adherence or treatment failure
• To initiate second-line drugs or for monitoring side effects

👩‍⚕️ Nursing Role in Hospital:

• Administer anti-TB medications on time
• Monitor for adverse drug reactions
• Ensure isolation precautions (especially in the infectious phase)
• Nutritional support – high-calorie, protein-rich diet
• Encourage fluid intake
• Monitor weight, vital signs, intake-output
• Educate family on disease, hygiene, and medication adherence

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🏠 In-Home Care of TB in Children:

Most children with TB are managed at home, especially after the first few weeks of treatment.

🏡 Key Points in Home-Based Care:

1. Ventilation:
   • Keep windows open; ensure fresh air circulation
2. Separate Sleeping Area (if possible):
   • To minimize exposure to others (especially infants or immunocompromised)
3. Cough Etiquette:
   • Child should cover mouth while coughing/sneezing
   • Use handkerchief or tissue, dispose of properly
4. Daily Medication:
   • Ensure Directly Observed Therapy (DOT) by a trained family member or health worker
5. Nutrition:
   • Encourage balanced meals, with extra calories and protein
   • Give iron, zinc, and vitamin supplements if prescribed
6. Follow-Up:
   • Monthly follow-up at DOT center or hospital
   • Monitor sputum (if applicable), weight gain, and symptom improvement
7. Emotional Support:
   • Provide comfort, reduce stigma, maintain routine activities as tolerated

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🛡️ Control & Prevention of TB (Especially in Pediatric Settings):

✅ 1. Early Detection and Treatment:

• Prompt screening of children with prolonged cough or contact history
• Treatment of latent TB in high-risk children (e.g., HIV-positive, malnourished)

✅ 2. BCG Vaccination:

• Given at birth to prevent severe forms of TB (like meningitis, miliary TB)

✅ 3. Contact Tracing:

• Screen close household contacts, especially under-5 children
• Provide Isoniazid Preventive Therapy (IPT) if eligible

✅ 4. Infection Control in Community:

• Raise awareness of symptoms of TB
• Encourage timely medical evaluation
• Avoid spitting in public, and promote cough hygiene

✅ 5. Infection Control in Hospital:

• Use airborne precautions (N95 mask for staff)
• Place child in a well-ventilated room
• Minimize unnecessary contact with unexposed infants or immunocompromised

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📚 Role of Nurses in TB Prevention & Control:

• Health education to family, school, and community
• Monitoring adherence to medications under DOTS
• Conduct household visits for contact tracing
• Promote early diagnosis through awareness
• Work with community health workers and TB programs (like NTEP in India)