Abstract
Effective management of tuberculosis (TB) in children and important data of disease burden continue to rely on a clinical approach to diagnosis, as diagnosis of childhood TB is not confirmed in the majority. Many diagnostic scoring systems have been developed to aid with diagnosis. This article reviews the use and evaluation of these approaches. The diagnostic systems are often closely related and all rely on the well-known clinical features associated with TB disease in children. The scoring systems are not well validated and validation is limited by the lack of a gold standard for comparison. When they have been validated, some systems perform reasonably well but may bias to identify the most obvious clinical cases. They perform less well in important sub-groups that pose the greatest diagnostic challenge and are at greatest risk for poor outcome, such as the young, malnourished or HIV-infected. There is marked variation in performance between these diagnostic approaches. The better validated systems may have a role as a screening tool in some settings, but this would need careful consideration as to the most useful and safest approach. More attention is being given to improving diagnosis and management of child TB, including within National TB Programmes. Research with new diagnostics should include children so that there is less reliance on clinical features alone. However, the clinical approach will continue to be relevant and so it is important to strive to improve the diagnostic approach to TB in children, and to validate the approach in different settings.
Similar content being viewed by others
References
Swaminathan S, Rekha B. Pediatric tuberculosis: global overview and challenges. Clin Infect Dis. 2010;50:S184–94.
Nelson LJ, Wells CD. Global epidemiology of childhood tuberculosis. Int J Tuberc Lung Dis. 2004;8:636–47.
van Rie A, Beyers N, Gie RP, Kunneke M, Zietsman L, Donald PR. Childhood tuberculosis in an urban population in South Africa: burden and risk factor. Arch Dis Child. 1999;80:433–7.
Harries AD, Hargreaves NJ, Graham SM, et al. Childhood tuberculosis in Malawi: nationwide case-finding and treatment outcomes. Int J Tuberc Lung Dis. 2002;6:424–31.
Marais BJ, Hesseling AC, Gie RP, Schaaf HS, Beyers N. The burden of childhood tuberculosis and the accuracy of community-based surveillance data. Int J Tuberc Lung Dis. 2006;10:259–63.
Law I, Poka H, Vince J, et al. The burden of childhood tuberculosis in Papua New Guinea: 2005-2006. Int J Tuberc Lung Dis. 2008;12:S96.
Donald PR. Childhood tuberculosis: out of control? Curr Opin Pulm Med. 2002;8:178–82.
Graham SM, Marais BJ, Gie RP. Clinical features and index of suspicion of TB in children. In: Schaaf HS, Zumla A, editors. Tuberculosis: a comprehensive clinical reference. UK: Elsevier; 2009. p. 154–63.
Marais BJ, Gie RP, Schaaf HS, et al. The clinical epidemiology of childhood pulmonary tuberculosis: a critical review of the literature from the pre-chemotherapy era. Int J Tuberc Lung Dis. 2004;8:278–85.
Seth V, Singhal PK, Semwal OP, Kabra SK, Jain Y. Childhood tuberculosis in a referral centre: clinical profile and risk factors. Indian Pediatr. 1993;30:479–85.
Hesseling AC, Cotton MF, Jennings T, et al. High incidence of tuberculosis among HIV-infected infants: evidence from a South African population-based study highlights the need for improved tuberculosis control strategies. Clin Infect Dis. 2009;48:108–14.
Hesseling AC, Westra AE, Werschkull H, et al. Outcome of HIV infected children with culture confirmed tuberculosis. Arch Dis Child. 2005;90:1171–4.
Weismuller MM, Graham SM, Claessens NJM, Meijnen S, Salaniponi F, Harries AD. Diagnosis of childhood tuberculosis in Malawi: an audit of hospital practice. Int J Tuberc Lung Dis. 2002;6:432–8.
Zar HJ, Hanslo D, Apolles P, Swingler G, Hussey G. Induced sputum versus gastric lavage for microbiological confirmation of pulmonary tuberculosis in infants and young children: a prospective study. Lancet. 2005;365:130–4.
Oberhelman RA, Sato-Castellares G, Gilman GH, et al. Diagnostic approaches for paediatric tuberculosis by use of different specimen types, culture methods, and PCR: a prospective case-control study. Lancet Infect Dis. 2010;10:612–20.
Boehme CC, Nabeta P, Hillemann D, et al. Rapid molecular detection of tuberculosis and rifampin resistance. N Engl J Med. 2010;363:1005–15.
Graham SM. Research into tuberculosis diagnosis in children. Lancet Infect Dis. 2010;10:581–2.
Kiwanuka J, Graham SM, Coulter JBS, Gondwe JS, Chilewani N, Hart CA. The diagnosis of pulmonary tuberculosis in an HIV endemic area, Malawi. Ann Trop Paediatr. 2001;21:5–14.
Hesseling AC, Schaaf HS, Gie RP, Starke JR, Beyers N. A critical review of diagnostic approaches used in the diagnosis of childhood tuberculosis. Int J Lung Dis. 2002;6:1038–45.
World Health Organization. Guidance for National Tuberculosis Programmes on the management of tuberculosis in children. WHO, Geneva, Switzerland. WHO/HTM/TB/2006.371.
Harries AD, Maher D. TB/HIV: a clinical manual. 1st ed. WHO, Geneva, Switzerland. WHO/TB/96.200.
Edwards K. The diagnosis of childhood tuberculosis. PNG Med J. 1987;30:169–78.
Nair PM, Philip E. A scoring system for the diagnosis of tuberculosis in children. Indian Pediatr. 1981;18:299–303.
Seth V. Diagnosis and treatment of tuberculosis: an overview. In: Seth V, editor. Tuberculosis in children. New Delhi: Indian Academy of Paediatrics; 1991. p. 8–19.
Stegen G, Jones K, Kaplan P. Criteria for guidance in the diagnosis of tuberculosis. Pediatrics. 1969;43:260–3.
Toledo A, Katz F, Montiel J, Rico FG. Diagnostic criteria for pediatric tuberculosis. Rev Mex Pediatr. 1979;46:239–43.
Brasil Ministério da Saúde, Fundação Nacional de Saúde. Controle da tuberculose: uma proposta de integração ensino-serviço. 5th edition. Rio de Janerio, Brazil: Centro de Referência Prof. Hélio Fraga, 2002.
Sant’Anna CC, Santos MARC, Franco R. Diagnosis of pulmonary tuberculosis by score system in children and adolescents: a trial in a reference center in Bahia, Brazil. Braz J Infect Dis. 2004;8:305–10.
Fourie PB, Leitch AG, Becker PJ, et al. Procedures for developing a simple scoring method based on unsophisticated criteria for screening children for tuberculosis. Int J Tuberc Lung Dis. 1998;2:116–23.
Van Beekhuizen HJ. Tuberculosis score chart in children in Aitape, Papua New Guinea. Trop Doct. 1998;28:155–60.
Van Rheenen P. The use of the paediatric tuberculosis score chart in an HIV-endemic area. Trop Med Int Health. 2002;7:435–41.
Houwert KAF, Borggreven PA, Schaaf HS, Nel E, Donald PR, Stolk J. Prospective evaluation of World Health Organisation criteria to assist diagnosis of tuberculosis in children. Eur Respir J. 1998;11:1116–20.
Sant’Anna CC, Orfaliais CT, MdeF M, Conde MB. Evaluation of a proposed diagnostic scoring system for pulmonary tuberculosis in Brazilian children. Int J Tuberc Lung Dis. 2006;10:463–5.
Pedrozo C, Sant’Anna C, de Fátima March M, Lucena S. Clinical scoring system for paediatric tuberculosis in HIV-infected and non-infected children in Rio de Janeiro. Int J Tuberc Lung Dis. 2009;13:413–5.
Marais BJ, Gie RP, Obihara CC, Hesseling AC, Schaaf HS, Beyers N. Well-defined symptoms are of value in the diagnosis of childhood pulmonary tuberculosis. Arch Dis Child. 2005;90:1162–5.
Marais BJ, Gie RP, Hesseling AC, et al. A refined symptom-based approach to diagnose pulmonary tuberculosis in children. Pediatrics. 2006;118:e1350–9.
Edwards DJ, Kitetele F, Van Rie A. Agreement between clinical scoring systems used for the diagnosis of pediatric tuberculosis in the HIV era. Int J Tuberc Lung Dis. 2007;11:263–9.
Hatherill M, Hanslo M, Hawkridge T, et al. Structured approaches for the screening and diagnosis of childhood tuberculosis in a high prevalence region of South Africa. Bull World Health Organ. 2010;88:312–20.
Marais BJ, Graham SM, Cotton MF, Beyers N. Diagnostic and management challenges of childhood TB in the era of HIV. J Infect Dis. 2007;196:S76–85.
Working Group on Tuberculosis, Indian Academy of Pediatrics. Consensus statement on childhood tuberculosis. Indian Pediatr. 2010; 47:41–55.
Moore DP, Schaaf HS, Nuttall J, Marais BJ. Childhood tuberculosis guidelines of the Southern African Society for Paediatric Infectious Diseases. South Afr J Epidemiol Infect. 2009;24:57–68.
Conflict of Interest
None.
Role of Funding Source
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Graham, S.M. The Use of Diagnostic Systems for Tuberculosis in Children. Indian J Pediatr 78, 334–339 (2011). https://doi.org/10.1007/s12098-010-0307-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12098-010-0307-7