Melomed Articles


13 February 2019 - Dr. Michelle  Roos

Tuberculosis in Children


In 1882 the German physician Dr Robert Koch discovered that Tuberculosis (TB) is caused by a slow growing bacteria inside the human body. He announced his findings on the 24th of March that year, forever changing the course of history, and opening the door to further research about its diagnosis and treatment.

World TB day is commemorated every year on the 24th of March to raise awareness about the health, social and economic effects of this devastating disease.The theme this year, Wanted: Leaders for a TB-free world, seeks to engage not only leaders in the political and health sectors, but also emphasizes the role to be played by community leaders, and all those infected and affected by TB. All of us, no matter how insubstantial we think our contribution may be, have a commitment to ending the TB epidemic.

The cause and spread of TB
Tuberculosis is caused by a slow-growing bacteria called Mycobacterium Tuberculosis. In most cases it only affects the lungs, but virtually any site in the body may be involved. TB is spread from person to person by inhaling little droplets that contain the bacteria, usually when someone with active TB sneezes, coughs or spits. 

The facts
South Africa is one of the highest TB burden countries in the world, and with India, Indonesia, China, the Philippines, Pakistan and Nigeria, account for almost 70% of TB globally. In 2016 an estimated 1 million children in the world became ill with TB, and 250 00 died due to the disease.

Symptoms of TB in children
Children most commonly present with TB affecting the lungs (pulmonary TB). 
The most common symptoms are:
  • A chronic unremitting cough for more than 2 weeks
  • A fever for at least 2 weeks, for which no common cause could be found
  • Weight loss or failure to gain weight appropriately
  • A history of coming into close contact with a person that has suspected or proven TB, especially if it is a household contact.

  • Making the diagnosis of TB
    It is often difficult to confirm the presence of TB in children with a laboratory test only, and health care workers rely on the history provided by caretakers as well as the clinical signs the child presents with to make the diagnosis. 
    In children that have been exposed to TB from a relative or close contact, a Tuberculin skin test (TST) is usually performed as one of the first line investigations. A tiny amount of fluid, called Tuberculin, is injected just underneath the skin of the forearm. It contains inactive TB bacteria and will swell up (much like an insect bite) within 48 to 72 hours if someone has been exposed or infected with TB. A chest X-ray is a very useful tool for diagnosing TB and can show enlarged glands in the chest or infected lung tissue. 

    The TB bacteria lives and multiplies inside the lungs and can often be detected in the sputum of a person with active disease. In young children, who tend to swallow their sputum rather than cough it out, a specimen of stomach fluid is collected and tested for TB. Bigger children and teenagers are usually able to cough effectively but may struggle to provide enough sputum for the test. They can be assisted with a nebulisation or mist of salt water and medication to open up the lungs. These samples are sent off to experienced technicians in the laboratory where various tests are performed: detection of the DNA of the bacteria, examination of the sample under a microscope and allowing the bacteria to multiply in a culture medium to test its type and sensitivity to treatment.

    TB treatment
    TB is a treatable and curable disease but needs a combination of medication that is taken regularly, for a long period of time, to eradicate the bacteria completely. We need to engage the family as a whole when a child in the household is diagnosed with TB. The first step of treatment is to find out who the source case of TB is. All household contacts and frequent visitors with symptoms need to undergo testing at a local clinic or hospital. Without tracing the source of TB, we will never be able to stop its progression. Active TB is treated with a combination of four anti-microbial drugs for at least 6 months. Complicated TB or TB outside the lungs may need more drugs and will require a longer course of treatment.

    Prophylaxis of TB
    Prophylaxis is the treatment given to prevent a disease from occurring. We can prevent the spread of Tuberculosis to children and those at high risk of getting the disease by administering a daily dose of anti-tuberculous medication. Prophylaxis with Isoniazid is one of the most under-utilised tools in the fight against TB. Only 13% of eligible children received preventative treatment in 2016. All children under the age of 5 years, and all HIV infected children, irrespective of their age, should receive preventative treatment if they were in close contact with someone that has TB.  

    The future
    Although TB is still a very prevalent and debilitating disease in South Africa, health and political leaders worldwide have taken hands to work tirelessly in achieving the goal of ending the TB epidemic by 2030. Between 2000 and 2016 an estimated 53 million lives were saved through TB diagnosis and treatment. In September 2018 heads of state will come from all over the world to participate in the first ever United Nations general assembly high-level meeting on TB in New York. They will again commit to end TB on all levels and to be leaders for a TB-free world. Do your part by raising awareness in your community, urging those who are ill to get tested and treated, and protecting your children from TB. You too can be a leader for a TB-free world.

    References: 
    1. World Health Organisation (Internet). Media Centre TB fact sheet; (updated January 2018). 
    2. Adams LV, Jeffrey RS. Tuberculosis in Children. UpToDate; (updated 2017 November). 


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