Tuberculosis in children from diagnosis to decision to treat

Setting: Confirmation of tuberculosis (TB) in children is difficult, so clinicians use different procedures when deciding to treat.

Objective: Identify criteria to initiate and maintain TB treatment in children younger than 5 years-old, without diagnosis confirmation.

Design: A web-based survey was distributed by email to the corresponding authors of journal articles on childhood TB. The observations were clustered into disjoint groups, and analyzed by Ward's method.

Results: We sent out 260 questionnaires and received 64 (24.6%) responses. Forty-six respondents (71.9%) said that microbiological confirmation was not important for initiation of anti-TB treatment, and that the epidemiological context and signs/symptoms suggestive of disease were most important. Sixty-one respondents (95.3%) said that the decision to continue therapy was mainly dependent on clinical improvement. A cluster of older respondents (median age: 52 years-old) who were active at a hospital or primary health care centre placed the most value on immunological test results and chest X-rays. A cluster of younger respondents (median age: 38 years-old) who were less experienced in management of TB placed more value on Interferon Gamma Release Assay (IGRA) results and chest computed tomography (CT) scans. A cluster of respondents with more experience in treating TB and working at specialized TB centres placed greater value on the clinical results and specific radiological alterations ("tree-in-bud" pattern and pleural effusion).

Conclusion: TB management varied according to the age, work location and experience of the clinicians. It is necessary to establish standardized guidelines used for the diagnosis and decision to treat TB in children.