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Maphalle, L.N.F.;  Michniak-Kohn, B.B.;  Ogunrombi, M.O.;  Adeleke, O.A. Pediatric Tuberculosis Management. Encyclopedia. Available online: https://encyclopedia.pub/entry/26757 (accessed on 06 December 2025).
Maphalle LNF,  Michniak-Kohn BB,  Ogunrombi MO,  Adeleke OA. Pediatric Tuberculosis Management. Encyclopedia. Available at: https://encyclopedia.pub/entry/26757. Accessed December 06, 2025.
Maphalle, Lehlogonolo N. F., Bozena B. Michniak-Kohn, Modupe O. Ogunrombi, Oluwatoyin A. Adeleke. "Pediatric Tuberculosis Management" Encyclopedia, https://encyclopedia.pub/entry/26757 (accessed December 06, 2025).
Maphalle, L.N.F.,  Michniak-Kohn, B.B.,  Ogunrombi, M.O., & Adeleke, O.A. (2022, August 31). Pediatric Tuberculosis Management. In Encyclopedia. https://encyclopedia.pub/entry/26757
Maphalle, Lehlogonolo N. F., et al. "Pediatric Tuberculosis Management." Encyclopedia. Web. 31 August, 2022.
Pediatric Tuberculosis Management
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This entry is adapted from the peer-reviewed paper 10.3390/children9081120

Managing pediatric tuberculosis (TB) remains a public health problem requiring urgent and long-lasting solutions as TB is one of the top ten causes of ill health and death in children as well as adolescents universally. Minors are particularly susceptible to this severe illness that can be fatal post-infection or even serve as reservoirs for future disease outbreaks

pediatrics pulmonary tuberculosis extrapulmonary tuberculosis

1. Introduction

Until the recent emergence of the coronavirus pandemic, a serious threat to global public health and wellness, tuberculosis (TB) was the leading cause of death from a single infectious agent, ranking above infections caused by the Human Immunodeficiency Virus (HIV) and acquired immunodeficiency syndrome (AIDS) [1][2][3]. Even though TB is an ancient disease, it affects people of all ages and gender and remains a major global public health problem to date [2][4][5][6]. TB is an important source of economic devastation, revolving poverty, and illness, which has ensnared families, societies, and even countries globally, with the most vulnerable groups being women, children, and HIV patients [3][6][7]. Since the World Health Organization (WHO) declared the “global tuberculosis emergency” in 2013, a consistent spike in scholarly journals addressing important aspects of the burden, management, diagnosis, and control has occurred, but generally, the emphasis in most cases has been on adult disease. Unexpectedly, pediatric TB has been comparatively neglected, primarily because of the (i) greater challenges associated with its diagnosis and management; (ii) lower priority placed on children by most TB control programs; (iii) considerations around pediatrics being ineffective transmitters of the bacillus; (iv) historical lack of political will and persistent limited availability of required management tools. Thus, research endeavors deliberately focused on pediatrics are noticeably uncommon worldwide [8][9][10][11].
The global burden of pediatric TB remains considerably high, and many cases are seen in children under the age of fifteen. With approximately 1.1 million cases and 230,000 deaths (80% were younger than five years old) reported annually worldwide, plus a much higher risk of severe illness and even death within this fragile group relative to adults; pediatric TB continues to be an ongoing public health challenge, especially in developing countries where there are limited public health infrastructures [6][8][9][10][11][12].
To date, the Bacille Calmette–Guérin (BCG) inoculation is the only vaccine that confers limited protection against TB infection, which often fades away after childhood. Despite the broad diversity in disease pathogenesis and presentation within the pediatric population, TB treatment and prophylaxis are still lengthy, adopt a one-size-fits-all approach, and often contain active drugs that are not yet available in child-friendly dosage forms. Moreover, effective diagnostics are not accessible to pediatric patients and the most reliable, commonly used bacteriological culture approach generally misses about 80% of children with clinically diagnosed infection [10]. 

2. Tuberculosis at a Glance

Tuberculosis (TB) is an infectious disease caused by the bacteria, Mycobacterium tuberculosis (Mtb). TB is spread through the air in the form of droplet nuclei that are released when an infected person coughs, speaks, or laughs [13]. The droplet nuclei could remain in the air for hours following their release; thus, insufficient ventilation, a lack of ultraviolet light, and minimal aerosolization often accelerate the rate at which the disease is transmitted in an enclosed space [14]. The epidemiology of TB is unevenly distributed, and this is closely related to social determinants such as poverty, increasing populations, and malnutrition. These social determinants influence a person’s vulnerability to TB exposure as well as the potential of individuals to recover from TB infection [15]. Tuberculosis is listed among the top three poverty-related diseases. It is prevalent in areas with poor housing, large and condensed populations, and places where people are highly affected by poverty and malnutrition. The congested accommodations, such as in squatter camps and ghettos, are settings that do not promote adequate cross ventilation and thus aid person-to-person spread. Furthermore, malnutrition, which is common in locations occupied by the poor, results in compromised immune systems; thus, overcrowding, and poor housing will inevitably accelerate the transmission of TB in such settings. Successful control of TB relies on the integration of diagnosis and treatment, as well as the improvement of social determinants. This is evidenced by the relationship between mathematical models and social determinants, which have proved that rates of TB infection in countries offering reduced funding towards TB control systems, in response to a recession, experienced an alarmingly high TB infection rate and significantly reduced case detection [16][17]. The intensity of interventions on proximal factors such as smoking, indoor air pollution, and malnutrition has been known to accelerate the decline in new infections and, consequently, TB incidence [18][19].
Following the coronavirus disease, TB is now the second leading cause of death from a single infectious agent, still ranking above human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). In 2020, the WHO reported about 10 million new active infections, and 1.5 million HIV-negative deaths, with an additional 214,000 fatalities among HIV-positive individuals [20]. Tuberculosis is a major global concern and has led to the institution of WHO’s END-TB strategy, which is in line with the United Nation’s sustainable development goals that aim to eliminate the incidence of TB by the year 2035 [21]. A 95% reduction in TB incidence and a 90% decrease in the total number of TB deaths are to be considered as indicators for the satisfaction of the END-TB strategy. Accordingly, the end of TB as a health problem will be best indicated by the incidence rate of fewer than 10 cases/100,000 people, and complete elimination would be defined as having an incidence rate of less than one case/100,000 population [21][22].
Post-Mtb transmission and infection, the bacteria may affect the lungs or other organs in the body and therefore result in pulmonary or extrapulmonary TB, respectively. The strength of the host’s immune system determines the severity of the disease that will develop. This can either be latent, active, or miliary TB [13][23]. Latent TB refers to a state of post-infection when Mtb is dormant, and non-replicating but triggers persistent immune responses within the host without clinical manifestations or symptoms of active disease [24][25][26]. Active TB develops when the host’s immune system is relatively compromised and has the characteristic symptoms of TB, which include chronic cough with bloody sputum, fever, night sweats, and weight loss [27]. Miliary TB occurs when Mtb enters the bloodstream and migrates to other extrapulmonary body parts. It is often rapidly fatal and highly likely to develop when the host’s immune system is severely compromised [27][28].

3. Pediatric Tuberculosis

3.1. Etiology, Epidemiology, Immunopathology, and Pathophysiology

The incidence recorded in children reflects the failure to control TB in adults [29]. Children are most vulnerable to TB infection because of their immaturity and ultimately impaired immune system [8]. Research has shown that the impaired innate pulmonary defense mechanisms in neonates and children are attributable to the reduced killing of microbes and diminished recruitment of monocytes to the infection site, thus disabling the ability of the immune system to induce necessary responses against the Mtb pathogen [8][30]. Furthermore, children are born with ineffective and immature antigen-presenting cells and T helper cells, which disable them from being able to produce interleukin-12 [8][31], which is essential for the initial phase of Type 1 T helper cells (Th1) polarization and for maintaining the efficiency of interferon-γ transcription [32]. This makes children particularly vulnerable to TB infection, accounting for the estimated 10% of all TB cases being those of children under the age of five [27].
About 1.1 million children fall ill with TB annually and approximately 230,000 deaths (including those living with HIV) were recorded in 2020 [2][20][33]. Studies have shown that reported statistics do not provide a true reflection of the global pediatric TB burden because most often, many cases go undiagnosed or unreported and as such, the global statistics could be much higher [6][20][33][34]. It has been observed that most reported pediatric fatalities occur in children who are not receiving any TB treatment, meaning that efforts geared towards identifying groups at risk of infection, effective diagnosis, and appropriate treatment require urgent improvement and implementation to significantly reduce TB mortality in children. Tuberculosis is considered one of the top ten causes of death in children under 15 years, but an important component of the past analysis is the focus on under 5-year-old mortalities. Mathematical estimates of available epidemiological data predicted that TB may be the sixth highest cause of death among children ages one to fifty-nine months, resulting in more mortalities than even meningitis, HIV/AIDS, measles, and pertussis. Moreover, some deaths, often thought to originate from pneumonia, meningitis, or AIDS, may have been caused by TB infection. Thus, some TB-related fatalities were probably not represented in the available global estimates and overall reported numbers are lower than what they really are [35][36][37].
Despite this, pulmonary TB in children remains in the shadows because most incidents are smear-negative and are thus said to have a minor contribution to the spread of the disease [10][38]. Although TB in children is not regarded as a major contributing factor to community spread, it is a key cause of high mortality and morbidity rates among this group largely due to the unlikelihood of early detection, especially in those under 5 years of age, thus accounting for an estimate of over 500,000 new TB cases each year. Most deaths due to active TB infection in pediatric patients are frequently attributed to other diseases such as pneumonia, which is the leading cause of death in children under 5 years [39][40][41]. Although this is underdiagnosed in most cases of pneumonia in children, Mtb is a causative agent for both tuberculosis and pneumonia. Literature has reported autopsy results showing that approximately 1–23% of all pneumonia-related cases also presented with TB [40]. This then further supports the notion that pediatric TB cases are underreported. Without a proper estimate of the global TB burden, there would be inadequate allocation of resources for diagnosis, treatment, vaccination, and the market size for potential drug development, which would ultimately motivate pharmaceutical industries to prioritize anti-TB drug development. All these factors are essential tools for the advocacy and control of TB in children [36].
The spectrum of the disease in children ranges from paucibacillary lymphadenitis to severe disseminated disease [23]. Children under 2 years of age, especially fetuses and neonates, are most susceptible to TB infection and are more prone to developing severe disease because their immune systems are underdeveloped. Typically, they have no protection against harmful pro-inflammatory cytokine responses because they are still transitioning from the supposedly sterile intrauterine environment into the antigen-exposed external environment [34][42]. Children less than 5 years are often known not to develop active disease immediately post Mtb infection but have a 10% chance of experiencing active disease reactivation during their adulthood [43][44][45]. Moreover, pediatric patients are at greater risk of becoming infected and developing active disease following contact with adult patients who have TB. Children therefore form an important group of patients requiring latent TB infection (LTBI) testing and therapy [23]. Children serve as potential reservoirs for active TB later in their lifetime and this is evidenced by the fact that globally, around 67 million children are carriers of latent TB infection. This poses a significant threat to the success of the World Health Organization’s global “END-TB” strategy [6][27].

3.2. Transmission in Children

When children are infected with Mtb, they are often more susceptible to getting sick faster than adults who are equally exposed. Relative to the pediatric population, TB disease in adults is typically associated with a previous dormant infection that subsequently develops into an active illness years later, due to immune system weakening often resulting from underlying diseases, drugs, or other environmental factors [46]. In most instances, the transmission of TB amongst pediatrics is because of close and lengthy contact with adults who have infectious pulmonary TB [47][48]. Since children, especially those under the age of two years, are dependent on extensive adult supervision, they will most likely get the TB infection from a close household member, caregiver, or an older child with whom they spend a lot of time. Older children, however, are less dependent on adults and are more social; hence, they usually become infected from an outside source. It can therefore be inferred that transmission in children is not only dependent on social factors such as poverty and overpopulation, but also on the prevalence within communities and the age of the child [42][49][50]. Studies have identified a bimodal risk profile for TB infection in children, which shows that the risk of transmission is highest in those in their late teenage ages and under two years, while the risk decreases significantly for children between five and ten years old [42]. Although it is not considered a major contributing factor toward the spread of infection within the community [39], pediatric TB spread is synonymous with recent infections in societies. The burden of pediatric TB thus provides a more accurate indication of the transmission rates of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of Mycobacterium [49][51][52]. Children often require approximately twelve months post-infection to progress to an active disease state, which frequently develops into severe forms of extrapulmonary infection such as TB meningitis or miliary TB that may end up being fatal [42][53]. Host-specific factors such as age, history of Bacillus Calmette–Guérin (BCG) vaccination, malnutrition, HIV/AIDS status, etc., can significantly impact the rate and extent of transmission, risk of infection, and progression to active or latent TB [48][54].

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Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register : Lehlogonolo N. F. Maphalle , Bozena B. Michniak-Kohn ,
Modupe O. Ogunrombi
, Oluwatoyin A. Adeleke
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