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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Paediatric tuberculosis

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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TB meningitis, miliary disease or airway compromise

Altered consciousness, focal neurology, seizure, raised intracranial-pressure signs, respiratory failure, severe wasting or an obstructing mediastinal node may represent disseminated or central-nervous-system tuberculosis, especially in a young child.

Action: Admit urgently under paediatric and TB specialists, stabilise airway, breathing, circulation and glucose, obtain rapid microbiological and imaging evidence where safe, and start an appropriate multidrug regimen without waiting for culture when the clinical diagnosis requires treatment. Add corticosteroid treatment for central-nervous-system TB and involve critical care or neurosurgery as indicated.

Synopsis

Recognise pulmonary and extrapulmonary tuberculosis in children, investigate paucibacillary disease without over-relying on one test, start age-appropriate contact prevention and specialist multidrug treatment, and manage notification and adherence.

  • Think of TB with prolonged cough or fever, weight loss or poor growth, night sweats, painless lymphadenopathy, persistent pneumonia or a known household source, particularly after residence or travel in a high-incidence country.
  • Children often have paucibacillary primary disease and may not produce sputum, so negative smear, culture, NAAT, Mantoux or IGRA cannot individually exclude active TB.
  • First-line assessment is exact exposure history, symptom and growth trajectory, full examination and chest radiograph, followed by microbiological sampling planned with paediatric TB specialists.
  • In children aged 15 or younger with suspected pulmonary TB, NICE recommends rapid NAAT for M. tuberculosis complex on relevant specimens, alongside microscopy, culture and drug-susceptibility testing.
  • Obtain multiple respiratory specimens when possible. Use spontaneous or induced sputum, gastric aspirate or lavage, bronchoscopy or another site-specific sample according to age and disease location.
  • Mantoux and IGRA identify immune sensitisation, not the anatomical site or activity of disease. Interpret them with exposure, imaging, microbiology and immune status.
  • For a contact aged 2 to 17 years, offer Mantoux testing; 5 mm or more is positive regardless of BCG history. A negative early test is repeated with IGRA after the window period specified by NICE.
  • A close-contact child under 2 years needs immediate specialist assessment and usually preventive treatment while active disease is excluded; neonatal and 4-week-to-2-year algorithms differ.
  • Standard drug-susceptible active TB without CNS involvement is daily isoniazid with pyridoxine, rifampicin, pyrazinamide and ethambutol for 2 months, then isoniazid with pyridoxine and rifampicin for 4 months.
  • CNS TB uses the same four-drug first 2 months then isoniazid and rifampicin for a further 10 months, plus dexamethasone or prednisolone tapered over 4 to 8 weeks.
  • Active TB in a child must be managed by a trained paediatric TB team, notified within 3 working days, and linked to source-case investigation and contact tracing.
  • Reweigh regularly and recalculate doses. Monitor adherence, liver toxicity, vision with ethambutol, interactions with rifampicin, culture susceptibility and clinical response.

Key red flags

A child with TB exposure and persistent headache, vomiting, altered behaviour, cranial-nerve change, seizure or focal neurology needs emergency assessment for TB meningitis.

Infants and children under 5 have the greatest risk of rapid progression, miliary spread and meningitis after infection, so contact pathways must not await symptoms.

Breathing difficulty, stridor, unilateral wheeze, lobar collapse or superior vena cava features may reflect airway or vascular compression by lymph nodes.

Severe weight loss, hepatosplenomegaly, diffuse respiratory signs, cytopenias or multisystem findings suggests disseminated TB and requires urgent specialist care.

Possible multidrug resistance, a source case with resistance, treatment abroad, previous incomplete therapy or clinical failure requires immediate expert and public-health escalation.

Acute visual change, jaundice, persistent vomiting, severe rash or neurological symptoms during treatment may represent serious drug toxicity and needs same-day review.

Investigation priorities

01
First-line: chest radiographFirst stepFirst line

Identify intrathoracic nodes, airway effect, parenchymal disease, pleural fluid, miliary change or cavitation.

02
Reference standard: mycobacterial cultureReference standard

Confirm M. tuberculosis complex and provide phenotypic drug-susceptibility testing.

Management branches

Suspected diseaseInvestigate through a paediatric TB team

Symptoms, exposure or imaging makes active TB possible.

  1. Refer promptly to a paediatrician trained in TB and coordinate safe respiratory infection-control assessment.
  2. Obtain chest radiography and multiple site-appropriate specimens for smear, culture, NAAT and susceptibility.
  3. Assess extrapulmonary sites and immune status, then start treatment before culture when the clinical diagnosis is sufficiently strong.

Key medicines

Standard active-TB regimenGive daily weight-based isoniazid with pyridoxine, rifampicin, pyrazinamide and ethambutol for 2 months, then isoniazid with pyridoxine and rifampicin for 4 months without CNS involvement or 10 months with CNS involvement.A paediatric TB specialist must calculate current BNFC doses and re-dose with weight gain. Monitor liver toxicity, interactions, adherence, ethambutol vision and susceptibility; rifampicin colours secretions and reduces many medicine concentrations.
Latent-TB preventive treatmentAfter active disease is excluded, give either daily isoniazid with pyridoxine plus rifampicin for 3 months or daily isoniazid with pyridoxine for 6 months, selected by the TB team.Exclude active disease before a preventive-only regimen. Check liver risk, interactions and source susceptibility; use the specific neonatal or under-2 contact algorithm rather than waiting for an early negative test.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG33 tuberculosis recommendationsPaediatric contact testing, diagnostic specimens and NAAT, active and latent regimens, infection control and follow-up.
  • UKHSA TB diagnosis and management collectionCurrent national diagnostic, laboratory, screening, prevention and surveillance resources.
  • UKHSA active-TB notification guidanceNotification criteria, timing, urgent scenarios and National TB Surveillance System route.
  • UKHSA paediatric TB epidemiologyCurrent England age-risk context, presentation and treatment-completion data for children.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom