Written by Hannah Harp
Spoon Feed
This clinical review describes updated screening, diagnostic, and treatment guidelines for tuberculosis in children.
TB, or not TB?
Screening and testing:
– Screen for TB exposure risk factors at well visits or school physicals. Patients with travel to high-risk countries, exposure to suspected tuberculosis, living in congregate settings, diagnosis of HIV, or immunocompromise since their last negative tuberculin skin test (TST) or interferon-gamma related assay (IGRA) should be tested.
Testing for TB infection:
– TST/PPD: a cutaneous test that measures immune response to tuberculin antigen. It has low specificity and is often false positive if given a BCG vaccine as an infant.
– IGRA (T-spot or Quantiferon Gold): these are serum tests that measure the immune response to various M tuberculosis-specific proteins and ability to mount an immune response. These are highly sensitive, and specificity is much higher than TST. Important: these are recommended at any age.
Diagnosing active TB disease:
– If a positive TST or IGRA, obtain a chest XR. Look for perihilar lymphadenopathy, cavitary lesions, miliary pattern, or large infiltrate. For infants <1 year, a lumbar puncture is also recommended regardless of presence of CNS symptoms.
– If active disease is suspected, AFB staining, cultures, and PCR should be performed on gastric secretions, provoked sputum, CSF, or urine.
Treating a known exposure to active TB:
– Perform an IGRA and give either INH or rifampin post-exposure prophylaxis (PEP) for 2 months before repeating IGRA. If both tests are negative, discontinue treatment. If either is positive, give a full course for active TB disease. Patients with a known exposure to active TB, positive TST or IGRA, and radiologic findings on XR do not need further workup and can be treated according to the cultures and susceptibilities from the index case.
Treating a latent infection:
– INH + rifapentine can be given for 3 months, rifampin daily for 4 months, or INH + rifampin daily for 3 months. Routine liver function testing is not recommended in otherwise healthy and asymptomatic kids.
Treating active disease:
– Depending on susceptibilities, uncomplicated TB can be treated using either a 4-month or 6-month regimen. RIPE therapy (rifampin, isoniazid, pyrazinamide, ethambutol) is still the cornerstone of treatment.
How does this change my practice?
There are so many parents out there who will be happy to hear that 9 months of isoniazid treatment is no longer necessary for their picky toddler! This review is a great refresher on PEP, too.
Source
Update in the Diagnosis and Treatment of Tuberculosis in Children. Pediatr Rev. 2025 Mar 1;46(3):148-158. doi: 10.1542/pir.2024-006539. PMID: 40020731
