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Childhood Pulmonary Tuberculosis

Old Wisdom and New Challenges

Desmond Tutu Tuberculosis Centre and Department of Pediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa; and Infectious Diseases Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas

Correspondence and requests for reprints should be addressed to B.J. Marais, M.R.C.P. (Paed UK), F.C.P. (Paed SA), M.Med. (Paed), Department of Paediatrics and Child Health, Desmond Tutu Tuberculosis Centre, Faculty of Health Sciences, Stellenbosch University, P.O. Box 19063, Tygerberg 7505, South Africa. E-mail: bjmarais{at}sun.ac.za

Childhood tuberculosis is neglected in endemic areas with resource constraints, as children are considered to develop mild forms of disease and to contribute little to the maintenance of the tuberculosis epidemic. However, children contribute a significant proportion of the disease burden and suffer severe tuberculosis-related morbidity and mortality, particularly in endemic areas. This review provides an overview of well-documented concepts and principles, and demonstrates how this "old wisdom" applies to current and future challenges in the field of childhood tuberculosis; the aim was to articulate some of the most pressing issues, to provide a rational framework for discussion, and to stimulate thought and further scientific study. The prechemotherapy literature that described the natural history of disease in children identified three central concepts: (1) the need for accurate case definitions, (2) the importance of risk stratification, and (3) the diverse spectrum of disease pathology, which necessitates accurate disease classification. The relevance of these concepts and their application to pertinent issues such as the diagnosis of childhood tuberculosis are discussed. The concepts are also linked to the basic principles of antituberculosis treatment, providing a simplified approach to the diagnosis and treatment of childhood tuberculosis that is independent of resource constraints. The main challenges for future research are highlighted and in conclusion it is emphasized that the infrastructure provided by the directly observed therapy, short-course strategy, combined with well-targeted interventions, slightly improved resources, and greatly improved political commitment, may lead to a dramatic reduction in tuberculosis-related morbidity and mortality among children.

Key Words: childhood tuberculosis • classification • diagnosis • treatment

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