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Guidelines for management of Tuberculosis in children: Focus on treatment regimens and drug dosing
The Ministry of Health "Guidelines for Tuberculosis Control in New Zealand 2010" are now outdated but are still available on the MOH website. Chapter 5 "Tuberculosis in Children" has a focus on basic principles in management of paediatric Tuberculosis but Table 2.1 should no longer be used. The basic principles covered in Chapter 5 (drug formulations, pyridoxine use, steroid use, monitoring and management in neonates) remain correct and should be used in conjunction with the updated detail below.
This guideline provides updated information on regimens for treatment of latent tuberculosis (TB) infection.
TB drug doses and treatment regimens
Table 1: Dosage recommendations for anti-tuberculosis agents for children (WHO 2010)
|Medication||Daily dose mg/kg (range)|
|First line agents|
Max dose/day = 300mg/day
Max dose/day = 600mg/day
Max dose/day = 2g/day
Max dose/day = 1.2g/day
Max dose/day = 1g
Children's weight needs to be monitored frequently and dose adjustments made accordingly
*Ethambutol has been associated with optic neuritis and this has resulted in limited use in young children due to difficulty monitoring visual symptoms. A review by WHO has concluded that ethambutol is safe to use in children if recommended doses are adhered to. Children requiring ethambutol should have regular vision and ophthalmology review.
Table 2: Treatment regimens for children (WHO 2010)
|TB disease||Intensive phase||Continuation phase|
|Pulmonary disease or TB peripheral lymphadenitis (HIV negative)||2HRZ||4HR|
|Extensive pulmonary disease||2HRZE||4HR|
|MDR-TB||Refer to paediatrician experienced in TB|
2=2 months, 4=4 months, 10=10 months
H=isoniazid, R=rifampicin, Z= pyrazinamide, E=ethambutol
*Treatment duration can vary and should consider discussing management regimen with paediatrician experienced in TB management. In management of TB meningitis consideration of longer duration of intensive phase maybe considered in some individuals. Prothionamide has better CSF penetration and maybe considered as an alternative to ethambutol in TB meningitis.
Rifampicin is the only first line TB drug with a commercially available suspension. Isoniazid is available as 100mg tablets. There is no commercial suspension available. The tablets can be crushed and mixed with water immediately prior to administration. The mixing agent should not be apple sauce, or a vitamin C containing product as these can alter the bioavailability of the drug. Pyrazinamide is only available as 500mg tablets which can be halved and crushed.
Fixed dose combination tablets of isoniazid/rifampicin are available. Either Rifinah 150 = rifampicin 150mg + isoniazid 100mg or Rifinah 300 = rifampicin 300mg + isoniazid 150mg.
Adverse effects are uncommon but hepatotoxicity can be caused by isoniazid, rifampicin and pyrazinamide. If baseline liver functions are normal - no further routine laboratory monitoring is required but clinical symptomatology should be regularly assessed. If symptoms suggestive of liver toxicity occur, medication should be discontinued and full evaluation should take place.
Latent TB infection (LTBI)
Table 3: Management of children with TB exposure or infection
|Regimen||Dose (max)||Duration||Indications for use|
INH 3X weekly
Until second TST placed(usually 8 weeks after last contact)#:
If negative stop;
If positive complete full course for LTBI
Intermittent therapy requires direct observation
INH monoresistance in source case, INH intolerance
INH, 3X weekly
INH 10-15mg/kg (300mg)
Rif 10-15mg/kg (600mg)
Intermittent therapy requires DOT^
INH monoresistance in source case, INH intolerance
Shorter course regimen may improve adherence
Table modified from Cruz & Martinez 2015 INH=isoniazid, Rif =rifampicin
# May be longer than 8 weeks in young infants
*Equivalence has been shown between INH 6 months monotherapy and INH+Rif 3 months combinaton. Isoniazid monotherapy should be used in children on concurrent medication that may interact with rifampicin.
^DOT = Directly Observed Treatment
If child is known to be HIV infected - isoniazid for 6 months should be used
Graham SM. Treatment of paediatric TB: revised WHO guidelines. Pediatr Resp Rev 2011; 12:22-26
NICE TB clinical guidelines 2011
Ena J, Valls V. Short-course therapy with rifampicin plus isoniazid compared with standard therapy with isoniazid for latent tuberculous infection: a meta-analysis. CID 2005: 40:670-676
Cruz AT, Martinez BJ. Childhood tuberculosis in the United States: shifting the focus to prevention. Int J Tuberc Lung Dis 2015: 19:550-553
Marais B.J. et al (2011). Management of Tuberculosis in Children and New Treatment Options. Infectious Disorders - Drug Targets, 11, 144-156
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- Date last published: 22 March 2017
- Document type: Clinical Guideline
- Services responsible: Paediatric Infectious Diseases
- Owner: Lesley Voss
- Editor: Greg Williams
- Review frequency: 2 years
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