Download Practice Guidelines for Treatment of Children with LTBI

PRACTICE GUIDELINE FOR
TREATMENT OF CHILDREN WITH LATENT TUBERCULOSIS INFECTION

INITIAL VISIT
Tuberculin skin test (TST):
 TST > 10 mm = positive
 TST > 5 mm = positive if immunosuppressed or history of exposure to active TB













History:
History of present illness and past medical history
Possible TB exposure, sick contacts, or travel outside the United States
BCG history
Medications
Diet
Physical Examination:
General physical
 Attention to pulmonary, lymphatic, and hepatic examination
 Lymph node inflammation and/or enlargement > 1 cm without other cause may indicate
TB disease. Consultation with a pediatric TB or infectious disease specialist is
recommended.
Clinically rule out meningitis
Laboratory:
Chest Radiograph (CXR):
 PA and lateral
 Check specifically for:
 pulmonary infiltrates and/or
 hilar or peritracheal lymphadenopathy
 If abnormal the child may have TB disease. Consultation with a pediatric TB or
infectious disease specialist is recommended.
Liver function tests indicated only if:
 risk factors for hepatitis or signs or symptoms of hepatitis
 taking additional hepatotoxic medications (i.e. griseofulvin or anticonvulsants)
Dilantin levels should be monitored if taking dilantin




Public health:
Report to the health department (some states require reporting of latent TB infection)
If CXR is normal, child is not contagious, and may to return to school
All household contacts should be skin tested
Household members with positive TST should be referred to their PCP or to the health
department for evaluation and CXR




Treatment:
Isoniazid (INH) 10-15 mg/kg/day x 9 months, daily
Round to the nearest 50 mg, max dose 300 mg
Tablets available as 100 mg or 300 mg, scored
Liquid INH may cause diarrhea, so many experts do not use it






If tablets cannot be swallowed whole, crush and dissolve in water, juice, or mix in other
foods
Directly observed preventive therapy (DOPT) is available through some local health
departments and should be arranged if possible. Dose 20-40 mg/kg/dose (Max 900 mg/dose)
given twice weekly for 9 months.
Vitamin B6 supplementation is recommended for breast fed infants and children with poor
nutrition (Dose: children: 25 mg tab/day; infants: 12 mg/day)
Education:
 Provide educational information to the family regarding:
 Tuberculosis infection in children
 TB literature is available through the American Lung Association, the Centers for
Disease Control and Prevention and many local health departments.
 Possible side effects of INH:
 The family should call if the child develops symptoms of toxicity, such as:
nausea, loss of appetite, vomiting, diarrhea, abdominal pain that last more than a
few days, jaundice, dark tea-colored urine, or a rash.

















FOLLOW UP VISITS:
Every 4-6 weeks during therapy
Review symptoms of hepatotoxicity or other problems
General physical examination, specifically check for jaundice or liver enlargement
If signs or symptoms of toxicity:
 hold medication
 send liver function tests (elevations of up to 3 times normal may be acceptable in
asymptomatic patients)
If taking dilantin, check dilantin levels and liver function tests for first 2-3 visits
If taking other hepatotoxic medications, check liver function tests at first 2-3 visits
 If normal, can monitor clinically
Medication adherence:
 Check bottle date and pill count
 Call pharmacy to verify amount dispensed if not clear
 Refill medication for 30-45 day supply
Ask about TST results of family members and CXR results of those with positive TST
If TB cultures available on source case for child’s infection, confirm sensitivity to INH
Call and reschedule patients who miss follow up appointments
For questions or problems call your local or state health department or a pediatric TB or
infectious disease specialist for assistance.
Completion of therapy:
Give family documentation verifying completion of therapy. This should be kept with the
child’s immunization record, as it may be needed for school or employment in the future.
No tuberculin skin test ever again, as it will be positive for life.
Repeat CXR only if child develops symptoms of pneumonia or has re-exposure to active TB.
File completion report with the health department if required in your state.