Extracts from 'Tuberculosis in Children: Diagnosis and follow up'

Item

Title: Extracts from 'Tuberculosis in Children: Diagnosis and follow up'
Creator: Susie Graham Jones
Date: 1984
extracted text: Extracts from ’Tuberculosis in Children ; Diagnosis, and follow up1
by Susie Graham J ncsz Medical Officer, Save the Children Fund,
Chautara Project, Sindhupalchowks Souvenir Nepas J. 1984, 3 (1)
61-73.
Tuberculosis in Children,.; Diagnosis, and follow up

introduction
The incidence and prcvalcnc- of tuberculosis (TB) in children
in Nepal is not knewn. The adult prcvalcnc. is about 1.6% (sputum
positive) Diagnosis in children is a problematic affair, as there
are n: r liable diagnostic tests. Chest r.-rays arc net diagnostic
in children? Mantoux tests arc unreliable, especially in rnalnourished ch i1ore n; and .the- pick up rate from laryngeal swabs and
gastric washings is poor, even when facilities are available. Sputum
tests are rarely ?f any use in children.

Nevertheless the experience f the Save the Children Fund (SCF)
Mother and Child health clinics in 4 districts in Nepal shows that
childhood TB is common and carries a high mortality. This report*
of the TB cases, diagnosed at the new SCF clinic in Sindhupalchcwk
between Srawan -2039 and Kartik 2040 (15 months) is a follow up
to a report on TB child patients at the Surkhct SCF clinic (Wiseman,
1980) . VJe emphasise that health workers can be trained to make a
clinical diagnosis of TB without any laboratory investigations, and
that progress can bo monitored by weight gain as well as regression
of symptoms. A search has b^cn made fcr factors associated with
good cr poor outcome of tr atment.

1. Diagnosis of TB in Children
Fellowing 'Wiseman (1980), wo lock first for. a history of illness
of more than eno month in duration, and make enquiries for a
suggestive family history cf chronic illness. On examination, we
lock for signs of localized disease in lymph nodes and lungs, and
for chr nic atypical skin lesions. We also maintain a high index
cf suspicion in children whe are chronically undernourished or
unwell, but who do not have localized symptoms or signs. These
children may show deterioration and anorexia after meisles cr
whooping cough. There arc also the children who do not respond tc
conventional treatment for chest infections, diarrhoea, or skin
lesions.

W~ rarely diagnose TB, except for obvious gland TB, on a child’s
first visit to the clinic. But if we suspect it, we call patients
back tc the clinic within 2 weeks for a repent history and examina
tion. Family history is often elicited mere fully at this second
interview, and we ask for sputum tests from suspect adults. We also
use the BCG vaccination as an abjunct to diagnosis. Unfortunately,
scarpositive BCG does not seem to give a very good protection
against TB in children in South India (’WHO, 1979 b) .But an early
r .action to BCG taking the form of skin ulceration over the injection
site within 2Z weeks of vaccination (as opposed to the normal reaction
which takes 1-2 months to develop as a.small scar) may indicate
active tuberculosis. This is a rather more sensitive test than
the standard Mantoux test (Miller, 1978).
Training fcr clinic staff, health post staff,., and field workers
in cur programme has included much discussion and comparison of
the signfe and symptoms of TB in adults and children. We use posters
and flip charts including emphasis on BCG vaccination .for children,
and referral cf patients tc health services. These visual aids, and
train! g booklets produced by the Britain-Nepal Medical Trust
(enmt/ Biratnagar,.and by the Shining.Hospital, Pokhara, are also
USS' in health education sessions in schools, for patients at health
po^Cs, and in the clinic. Wo encourage health workers and field
W' kers tc attend the weekly TB follow up clinics at the Chautara
oiinic to see patients at various stages of treatment. The parents
Of these TB patients are often the most enthusiastic teachers.
.....2

1
2
II. Trc atment

We continue to use the standard TB drugs available to hospitals
-'.nd health posts through the Tuberculosis Control Project (HMG),
The mainstay cf treatment in children is ISONIAZID (Iscnex) which
is both bactericidal and bacteriostatic and causes very few side
off cts in appropriate doses. It is combined with THIACATAZONE
(TB 1) in most cases, a convenient formulation being RD-ZONE
FORTE (isoniazid 300 mg + TB 1 150 mg): but in order to avoid
the side effects associated with thio.cetazone ’ wc use the following
dosage schedule according to the- child’s weight, including
extra isoniazid and a relatively smaller dose cf thiucetazc-ne .
TABLE 1

Dosage

f TB Drugs (Oral) According to Child’s Weight
RD-ZONE FORTE + Extra Isoniazid

’Weight less' than 5 kg
6-14 kg
15-20 kg
21 kg upwards

\ tab
\ tab

+

h tab

+

50 mg
100 mg
100 mg

1 tab

This oral regimes seems sufficient for many children with
pulmonary disease,
3land TB, skin TB and for those with non
gland
specific signs and avoids the. necessity for injections and
frequent clinic attendances. In seriously ill children, especia
lly those with bone or meningeal disease, we start streptomycin
injections (40 mg/kg up to a maximum dose for children of 500 mg)
doily for in patients or 3 times weekly for out patients, always
combined with the above oral regime. Streptomycin is given for
2 months, if possible. Isoniazid alone is given occasionally to
children less than twe years old who are not seriously ill,
have no localized symptoms and are unlikely to develop resistant s
strains of mycobacteria. All patients arc expected to continue
treatment for a minimum of 12 months and this is made clear at
the start. A special review is undertaken at 12 menths to decide
which patients should continue for a further 6 menths. In a few
cases with persistence of symptoms, ethambutol has been given for c
a two month trial period at 20-25 mg/kg.
Other medicines are kept to an absolute minimum in order
not to confuse the parents. Anemia (Hb ^10g%) is treated
with ferrous sulphate, and nutrition is discussed with all
parents.
7

VI, Treatment regimes and side effects of TB drugs
No severe side effects have been reported during the study
period, and drugs have not had to be changed because cf side
effects. Mild side effects were reported in 5 cases within
2 menths cf starting treatment:

1. vomiting in a thr-.c yer Id on oral INH and TB 1
2 . vomiting in. a 9 m- nth old on streptomycin and oral
INH and TB 1
diarrhoea end vomiting in at 2 year eld on oral INH and
TB 1
4. itchy rash at 2 weeks after.starting oral INH and TB 1
in a 2 year old
5. fever in a five’ year old- on streptomycin and oral
■INH and tb 1

This low incidence of side effects is probably due to the
sore with which dosage is related to the child’s weight.

3

r
3
The isoniazod only regime has boon used in 4 children
under 2 ye rs of age wh ' have been followed up; Twc have c?.< no
well and tw have sh wn cnly slight improvement. This regime
cannot yet be properly assessed.

Ethambutcl has been ad cd to oral INH and TB in 3 cider
children with persistent symptoms afe’r 6 months of the
standard regime, Two. are now improving and ther<. have been
nc sice effects.
Vile DISCUSSION

Diagnosis of TB in Children

With specific training for clinic health workers, TB
diagncscs have risen fr.m 3 c about 18 cases per month at
the Chautara MCH clinic, out of an average of 225 new patients
seen per m.nth. Wo now estimate that about 10% of the total
work loa ’ of the clinic is associated with TB diagnosis and
follow up. This is one of the main topics for the in-service
training programme for HMG health workers at the Chautara MCH
project.
Follow up of TB in children - whose job?

Follow up rates in -most TB programmes are disappointing,
since patients have to be exceptionally well motivated to
continue attending 'hen symptoms have subsided In this study,
30% of newly diagnosed TB patients (under 10 years old) were
not fallowed up at all; and there was a 45% drop out rate at
2 months after- diagnosis, by the time the programme had running
for 15 months.

At present, the defaulter chasing duties of Tuberculosis
Central Project staff (HMG)) are restricted to sputum positive
adult case., who are the most infectious group. In this field
district, we are working together with TBCP staff, health
post staff, MCH/FP workers, and other agencies to try to ensure
that ’1 at risk* individuals such as TB defaulters of all ages
can be rapidly contacted.
Outcome of Treatment

Symptomatic improvement was marked in 40% of patients
followed up t^ at least 2 months in this study. The mortality
rate was 10% in the 15 month study period. Improvement in
nutritional status was well defined. Wasting was present
in 42% of newly diagnosed TB cases but cnly 14% in those
followed up at 2 months and 6% in those followed up
at
6 mnths. Once weight gain has started, pro- ress can be rapid;
of those who gained weight at all, the average weight gain
was 269% of refer.nee weight gain at 2 months, and 169% at
6 months. More than half of all patients followed up gained
weight frstor than the expected reference rate of weight
gadn for children of
similar ages.
Ccrrelatj on of weight gain with reported clinical progress,
however, vias not reliable. This is partly due to reporting of
intercut, ent iJIness, and partly also to improvement unrelated
to weight gain.

The s.r.rch for factors indicating likely outcome of
treatment

in this study, factors such as sex, pn-ivjnus bcc
immunization, family history, ethnic gr.up, presenting symptoms,
4

and different drug regimes were found not t. carry predictive
power. The only useful indicator so far discover d is age of
tl'.e child TB patient.
Younger children definitely bear a higher risk than cider
ones. A poor clinical outcome is found in 2’1% of the TB
patients under 3 years old at the time of diagnosis, but in
only 9% of those aged between 3 and 10 years, And there are
relatively more ‘under threes’ in all.the poor outcome groups
than in the good outcome groups, whichever outcome measure
is us 3d.

Malnutrition at the time of ciagn/sis may be followed
Ly rapic weight gain during the first few months of treatment,
and is not per sc an indicator of peer prognosis. When outcome
is assessed clinically the good -me poor outcome groups both
contain approximately 30% of wasted children. This percentage
falls faster in the good outcome group than in the poor-outcome
group.
There may be a small group of wasted children who do not
gain weight well on TE treatment. Further analysis on a
larger sample will be needed to see if there are other charac
teristics of this group which would help to detect them early
on as needing special care.
REFERENCES

- Wiseman, David (1980) J. Inst Med, 2, 31-36 Tuberculosis
Report for Surkhet District
- WHO (1979b) Bull Wld Hlth Org., 57, 819-827
Trial of BCG vaccinations in South India for tuberculosis
prevention; first report
- WHO (1979a) Publication FAP/79.1, Geneva
gudeline for the measurement of nutritional impact of
supplementary feeding programmes aimed at vulnerable
groups.
- Miller F J W (1978) Tuberculosis in Children. Londons
Churchill Livingstone
- Shining Hospital, Pokhara (1979) TB Handbook (English
and Nepali versions)
- Britain Nepal Medical Trust (1981) Treatment of Tuberculosis
- Ratliff, W. (1981) d Base II. California: Ashton Tate Ltd.
Note: Mos. Ill (Presenting features of children diagnosed
as having tb) ; IV (Follow up of TB patients); and
V (Outcome assessment) are not included in this
extract. For full text;
refer the journal mentioned.

Item sets: TB and Society - 1985 Annual Meet - medico friend circle

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