TUBERCULOSIS IN CHILDREN-1 Paediatrics.pptx

TB children

1. PULMONARY TUBERCULOSIS CONFUCIUS MWEEMBA EN/RN/RM/BSC-STUDENT PAEDIATRICS AND PAEDIATRIC NURSING

2. At the end of the topic, students should acquire knowledge on TB disease. GENERAL OBJECTIVE

3. At the end of the lesson students should be able to: Define TB Outline the causes of TB Mention the mode of spread of TB State the predisposing factors to TB Outline the types and classification of TB SPECIFIC OBJECTIVES

4. Describe the pathophysiology of TB State the signs and symptoms of TB Discuss the management of TB SPECIFIC OBJT CONT..

5. TB is communicable, chronic granulomatous disease caused by mycobacterium tuberculosis. Usually involves the lungs but may affect any organ or tissue of the body. TB is a major cause of morbidity and mortality among children especially those under the age of five years INTRODUCTION

6. This is because TB in children progress faster due to immature immunity hence leading to high death rate. Therefore, early diagnosis and recognition of the symptoms is very cardinal in order to initiate treatment at an earliest time so as to avoid severe complications. INTRODUCTION CONT..

7. It is a chronic infectious pulmonary disease caused by mycobacterium tubercle usually characterized by cough for more than three weeks, night sweats, fever especially at night, weight loss and dyspnea . DEFINITION

8. Mycobacterium tuberculosis (commonly affects humans) Mycobacterium bovis (in animals though may affect humans) Mycobacterium Avium (rare) CAUSES

9. Air borne Direct droplet spread; from person to person through coughing or sneezing. Indirect spread; via dishes, clothing or articles of daily use laden with bacilli Via ingested milk; contaminated, unpasteurized milk MODE OF SPREAD

10. Environmental factors that lower body resistance. Overcrowding Alcoholism and heavy smoking Occupation e.g. health workers Immune suppressive therapy PREDISPOSING FACTORS

11. HIV infection Contact with infected person Poor socio economic status Mulnutrition PREDISPOSING FACTORS CONT..

12. Pathological factors with lower immunity; HIV/AIDS DM Steroids, cytotoxics Chronic lung disease lymphomas PREDISPOSING FACTORS CONT..

13. TB can be either Primary TB or secondary (post primary) TB Primary TB ; This is the first infection which may remain sub clinical if the immunity is strong enough or manifest in TB disease if the immunity is unable to suppress the infection. Secondary TB will result from activation of the primary infection. TYPES OF TB

14. Pulmonary tuberculosis : Comfined to the lung Extra Pulmonary TB : Any where outside the lungs e.g. bones, meninges , Milliary TB : wide spread of the bacilli via the blood stream CLASSIFICATION OF TB

15. PTB

16. SPINAL AND MENINGITIS TB

17. MILLIARY TB

18. When a person inhale the infectious agent it goes to the alveoli where it will start multiplying. Later the organism may be carried via the lymphatic to the near by lymph node like the hilar nodes. The presence of the bacteria will provoke an immune reaction causing inflammation in the lung PATHOPHYSIOLOGY

19. Neutrophils and other macrophages will migrate to the area and engulf the bacteria without necessarily bringing about total destruction of the bacteria The neutrophils ,macrophages will interact with the T lymphocyte resulting in development of cellular immunity. PATHOPHYSIOLOGY CONT..

20. The macrophages will surround the bacterial and then change into giant multinucleated cell and epithelioid cell this results in the formation of the tubercle The central part of the tubercle will undergo necrosis resulting in the formation of the necrotic cheese like substance called caseation necrosis. PATHOPHYSIOLOGY CONT..

21. This cheese like substance may be coughed up as purulent sputum leaving a cavity or become calcified after healing. This is called a primary lesion of ghon’s focus. This may be seen on x ray as patches. These primary lesion contain tubercle bacilli lying dormant but may be reactivated later when the immunity goes down causing what is called post primary TB or secondary TB. PATHOPHYSIOLOGY CONT..

22. Productive cough for more than three weeks due to irritation of the respiratory tract by the bacilli causing the inflammatory process Fever at night due to infection and activity of the bacilli at night. Chest pains due to irritation of the sensory neurons by the inflammatory process SIGNS AND SYMPTOMS

23. Haemoptysis due to rupture of the blood vessels in the lung Malaise and fatigue due to tissue hypoxia Dyspnea due to destruction of the lung tissue by the inflammatory process and necrosis Night sweats due to fever at night S & S CONT..

24. Enlargement of the lymph nodes of the neck axilla or groin Weight loss due to anorexia Anorexia due to G.I.T. involvement Headache due to cerebral hypoxia S & S CONT..

25. Diagnosis History will reveal cough for more than three weeks Extrapulmonary forms of TB occurs more frequently in children. Bacteriological confirmation is often difficult in children due to inability to collect a suitable specimen for laboratory analysis MEDICAL MANAGEMENT

26. Therefore ensure that all specimen collected from children should be subjected to more sensitive diagnostic tools such as culture and Xpert MTB/RIF tests. For this reason, most children with TB are diagnosed based on clinical grounds MEDICAL MGT CONT..

27. Presentation of TB in children The symptoms below show typical symptoms of TB in children especially if they persist for more than 2-3 weeks without improvement following other treatments ( broad- spectrum antibiotics). Persistent Cough Weight loss or failure to gain weight (failure to thrive) MEDICAL MGT CONT..

28. 3. Fever and / or night sweats 4. fatigue, reduced activity Plus: History of contact with TB sources i.e close contact from within the house or outside the house e.g neighbour Note: most of the children develop TB within 2 years after exposure 90% is within the first year. MEDICAL MGT CONT..

29. A typical clinical presentation of PTB Acute severe pneumonia Wheeze – asymmetrical and persistent wheeze can be caused by airway compression due to enlarged Tuberculous hilar lymph nodes MEDICAL MGT CONT..

30. Specimen collection Sputum is collected in children of all age group by means of: Sputum expectoration Gastric lavage Nasopharyngeal aspiration Induced sputum . MEDICAL MGT CONT..

31. When sample is collected, it should be sent for Xpert MTB/RIF and or culture. In places where these services are not available or inaccessible, a smear microscopy should be done MEDICAL MGT CONT..

32. Other investigations includes: Chest X-ray= very important in children who are smear negative or those who cannot produce sputum. The following abnormalities are suggestive of TB. Enlarged hilar lymphnodes Opacification in the lung tissue Miliary mottling in lung tissue MEDICAL MGT CONT..

33. Cavitations ( tends to occur in older children) Pleural or pericardial effusion 2. HIV test MEDICAL MGT CONT..

34. 3. Tuberculin skin test=used as a suppotive diagnosis of TB in children with suggestive clinical features who are bacteriologically negative or those who cannot produce sputum. A positive TST indicates infection and not an active TB disease. A TST >/= 10MM is considered positive in any child, regardless of BCG immunization status . MEDICAL MGT CONT..

35. Drug Daily dosage in mg per kg (range) Maximum dose Isoniazid (H) 10mg/kg (7-15mg) 300mg/day Rifampicin (R) 15mg/kg (10-20mg) 600mg/day Pyrazinamide (Z) 35mg/kg (30-40mg) Ethambuto (E) 20mg/kg (15-25mg) Recommended dosage for children

36. TB disease category Intensive phase Continuous phase All non-severe forms of pulmonary TB and extrapulmonary TB 2 months (HRZE) 4 months (HR) Severe forms: TB meningitis, osteo-articular TB, spinal TB, miliary TB, and other severe forms of TB 2 months (HRZE) 10 months (HR) TB disease category & recommended treatment in children

37. Weight bands Number of tablets Intensive phase Continuation phase RHZ (75/50/150mg) E (100mg) RH (75/50mg) 4-7 kg 1 1 1 8-11 kg 2 2 2 12-15 kg 3 3 3 16-24 kg 4 4 4 25 kg and above Use adult dosage & formulation TB dosage by weight band for children

38. Other treatment : Panadol for pain and fever 100-500mg Pyridoxine 5-10mg OD Multi vitamins 1- 2 tablets od to promote appetite High protein diet to promote quick recovery Oxygen therapy 1-2 litre /minute MEDICAL MGT CONT..

39. Risk factors for DR-TB in children include: Close contact with a confirmed DR-TB patient Close contact with a patient that has failed DR-TB treatment, is poorly adherent to DR-TB treatment, or has recently died of DR-TB A history of previous treatment for DR-TB in the past 6-12 months. Not improving after 2-3months of treatment for (drug susceptibility) DS-TB. DRUG RESISTANT

40. Diagnosis X-per MTB/RIF is the recommended first-line diagnostic test in children Culture/DST (drug susceptibility test) LINE PROBE ASSY (LPA) Decision on treatment duration, if unable to be determined from bacteriologic results, should be based on clinical improvement or standards duration. DRUG RESISTANT CONT..

41. WHO recommends shorter regimen for children and adolescents that have uncomplicated DR-TB. If a child or adolescent symptomatic for DR-TB is a known close household contact of a patient with pre-XDR (extensive drug resistant) or XDR-TB, the child should not be considered for the shorter regimen. DRUG RESISTANT CONT..

42. The shorter regimen recommended for children and adolescents is the same as in adults. 4-6 months =Km- Mfx - Cfz -E-H 5 months= Mfx - Cfz -E-Z Add vitamin B6 1-2mg/kg/day in intensive phase DRUG RESISTANT CONT..

43. Drug Weight group 30-33kg 33-50kg >50kg Kanamycin ( 1 gm vial ) 15mg/kg 15mg/kg 1gm Moxifloxacin (400mg tablet) 400mg (1 tablet) 600mg (1 and ½ tablet) 800mg (2 tablet) Clofazimine (50 and 100mg capsules) 50mg (1 capsule) 100mg (1 capsule 100mg) 100mg ( 1 capsule 100mg) Thio namide (250mg tablet) 250mg (1 tablet) 500mg (1 morning + 1 evening tablets) 750mg (2 morning + 1 evening tablets) Isoniazid -high dose (300mg tablet) 300mg (1 tablet) 400mg ( 1 and ½ tablets) 600mg (2 tablets) Ethambutol ( 400mg tablet) 800mg (2 tablets) 800mg (2 tablets) 1200mg (3 tablets) Pyrazinamide (400mg tablet) 1,000mg (3 and ½ tablets) 1,600mg (4 tablet) 2,000mg (5 tablets) Pyridoxine 100mg

44. In case of extension of intensive phase after month 4, kanamycin will be given three times per week. Criteria to change from the shorter regimen to an individualised regimen Lack of response to treatment (e.g. no culture conversion by 6 months or deterioration of clinic condition despite treatment). DRUG RESISTANT CONT..

45. Culture reversion in the continuation phase after conversion to negative. Evidence of resistance to a FQ or SLI (Second line injectable ). Adverse drug reaction requiring discontinuation of >= 1 drug in the shorter regimen A patient becomes pregnant during the intensive phase of the shorter regimen ( 2 nd line injectable agents are contraindicated in pregnancy). DRUG RESISTANT CONT..

46. Use of DR drugs Moxifloxacin the tablets are bitter and difficult to tolerate when crushed. < 14kg, levofloxacin at a dose of 15-20mg/kg/ day >14kg, standard dose of moxifloxacin at 10mg/kg/day Over 14yrs old consider adult dosing of moxifloxacin ( 600mg for the shorter regimen). DRUG RESISTANT CONT..

47. Clofazimine There is no pediatric friendly formulation ( capsules of 50mg should be made available) 2-3mg/kg/day sometimes 5mg/kg/day, the dose should not exceed 100mg /day. DRUG RESISTANT CONT..

48. Individualized treatment regimen in children Patient who are not eligible for the shorter DR-TB regimen should be initiated on an individualized DR-TB regimen, including patients with MDR-TB treatment failure , pre-XDR-TB and XDR-TB. This regimen will include new and repurposed drugs e.g : DRUG RESISTANT CONT..

49. Group A. Fluoroquinolones Levofloxacin moxifloxacin Lfx Mfx Group B. second-line injectable agents Amikacin Capreomycin kanamycin Am Cm km Group C. other core second-line agents Ethionamide / prothionamide Cycloserine / terizidone Linezolid Clofazimine Eto / Pto Cs/ Trd Lzd Cfz Group D. add-on agents ( not part of the core MDR-TB regimine ) D1 Pyrazinamide High -dose isoniazid Ethambutol D2 Bedaquiline Delamanid D3 para-aminosalicylic acid imipenem / cilastatin Meropenem+amoxicillin-clavulanate ( Thioacetazone ) Z H E Bdq Dlm PAS Ipm Mpm+Amx-Clv T Medicines recommended for the individualized treatment of RR-TB and MDR-TB

50. Bedaquiline ( Bdq ): used in adolescent >18 Delamanid ( Dlm ): used in children > 6 years who weigh more than 20kg) and for adolescent who are not eligible for short term regimen. Linezolid : give pyridoxine ( vit B6) to children to prevent or minimize peripheral neuropathy and myelosuppression . Dose is 1-2mg/kg/day. Then 10-50mg/day for peditric patient at risk for neurologic problems. DRUG RESISTANT CONT..

51. Note: infants and children below 6 years old (or < 20kg) that need an individualised DR-TB regimen with new drugs should be referred to international experts for consensus regarding regimen design in addition to the National CEC ( Clinical expert committee). DRUG RESISTANT CONT..

52. DR-TB/HIV co-infection in children Cotrimoxazole preventive therapy (CPT) is given Commence ART within 2-8 weeks after starting DR-TB treatment. HIV-positive DR-TB patients < 18years: if on LPV/r based regimen, no change in ART when starting DR-TB treatment. DRUG RESISTANT CONT..

53. If on EFV, the non-nucleoside reverse transcriptase inhibitor (NNRTI) should be switched to LPV/r or other ART regimen (ATV/r) based on weight and national pediatric HIV guidelines. DRUG RESISTANT CONT..

54. Aims: Prevent spread of infection Promote compliance with treatment Promote quick recovery To relieve dyspnoea Promote good nutritional status Alley anxiety Prevent complications NURSING CARE

55. Environment Patient will be nursed in an isolation ward to prevent spread of infection Patient will be nursed in a well ventilated room to prevent spread of infection oxygen giving apparatus and suction machine will be within reach for use when in need. NURSING CARE CONT..

56. Position Patient will be nursed in fowlers position to promote lung expansion and relieve dyspnea As the condition improves the patient will adopt any position of comfort to promote rest NURSING CARE CONT..

57. Rest the patient is nursed in a quiet room to promote rest procedures will be done in blocks to promote rest prescribed analgesics will be administered in order to promote rest NURSING CARE CONT..

58. observations vital sign and BP will be checked to act as the base line data in order to know if the condition is improving or deteriorating observe for cyanosis if improving or getting worse and give oxygen therapy when necessary observe Dyspnoea if present, prop up the patient to promote lung expansion hence relieve dyspnoea NURSING CARE CONT..

59. observe the sputum for colour amount and consistency to detect Haemoptysis and report observe the feeding pattern of my patient and take measures like giving small frequent meals to promote appetite I will observe the respirations to detect tachycardia and report accordingly NURSING CARE CONT..

60. Psychological care explain the disease process in order to raise the knowledge levels and thereby alley anxiety explain all procedures to my patient in order to allay anxiety involve a successfully managed case to come and talk to my patient in order to allow the patient improve the out look on his condition NURSING CARE CONT..

61. Hygiene mouth care will be done to prevent halitosis and to improve appetite Any soiled linen and clothes will be changed to promote comfort provide a sputum mug to prevent indiscriminate spitting NURSING CARE CONT..

62. Nutrition provide energy giving foods like nshima to provide the energy needed for the metabolic processes provide protein foods like fish and beans to promote replacement of worn out tissues Vegetables and fruits will be provided to raise the immunity and promote skin and mucous membrane integrity provide a lot of oral fluids to prevent dehydration due to excessive sweating and promote bringing up of sputum NURSING CARE CONT..

63. Medication administer prescribed analgesic like panadol at the right time to promote rest give prescribed anti TB drugs in order to promote recovery ensure that the drugs are swallowed in your presence to promote recovery. NURSING CARE CONT..

64. IEC educate the patient about his condition in order to create awareness and prevent recurrence of the condition explain the need for taking the medication in order to promote recovery educate the patient about the sign and symptoms of the condition for early diagnosis and treatment thereby preventing complications NURSING CARE CONT..

65. talk to the patient about the need to take a balanced diet using locally available foods in order to boost the immunity educate the patient about the need keep the review dates so that his progress is monitored to ensure full recovery NURSING CARE CONT..

66. advise the patient to avoid smocking to prevent continued irritation of the air way thereby preventing recurrence of the condition. advise the patient to ensure that children receive the BCG vaccination in order to prevent contraction of TB NURSING CARE CONT..

67. TB meningitis TB of the bones TB peritonitis Milliary TB Pleural effusion COMPLICATIONS

68. Vaccination of children with BCG Avoiding over crowded places Balanced diet using locally available foods Constructing well ventilated houses Use of protective wear for health workers Adequate treatment of cases Contact tracing and treatment of those found to have the disease PREVENTION