Tuberculosis in children is a major health problem in the developing countries. It is caused by mycobacterium tuberculosis, an acid-fast bacilli.
The types of tubercle bacillus causing disease in man are the human and bovine. The bovine type is transmitted through milk. Tubercle bacilli enter the body through inhalation, ingestion, and inoculation. The tubercle bacilli from the lungs of infected adults are expelled as microdroplets during a cough or a sneeze.
Most common infections initially have infections in lungs. Bacilli reach the finest bronchioles. First there is an inflammatory reaction with polymorphoneuclear leukocytes. Tubercle bacilli multiply in these leukocytes. The tubercle is formed with the center; area of caseation necrosis surrounded by a ring of small round lymphocytes. This is called a primary focus.
Commonly it is found in the subpleural area of lower part of upper right lobe. It is also called Ghon focus. From there the infection is spread through the lymph nodes such as hialar nodes. The regional lymph glands become caseous and enlarged.
A primary complex is formed with the primary focus, regional lymph nodes that are caseous and enlarged, and pleural reaction. This is the reaction of the body tissue to the tubercle bacilli when they enter the body for the first time.
After the first few months of primary infection, the bacilli may enter the lymphatic and blood stream and may be carried to the different parts of the body. This depends on the age, health status, and the resistance power of the children.
There may be a natural control or the disease may progress. In untreated primary complex, when resistance lowers, the children may have local infection of the lymph glands. Heamatogenous spread is also common.
Tuberculous meningitis and miliary tuberculosis are such examples. Young children have greater risk of complications rather adults.
Signs and symptoms:
In some children it may be asymptomatic. Symptoms vary according to the age and health status of children. General symptoms are low-grade fever, loss of weight, anorexia, and fatigue. The specific symptoms may be related to the site of infection such as in the lungs, brain, bone, or kidney.
In pulmonary tuberculosis many a times, lung infection may not produce a cough. Gradually the disease progresses over weeks or months. The affected side of the lung has decreased movements and breath sounds. Total respiratory difficulty increases. The child develops-chronic low-grade fever, anemia, pallar, weakness, and loss of weight.
Tuberculin test (Montoux): The tuberculin test is done to diagnose the children with tuberculosis. The hypersensitivity reaction to the test is checked two to ten weeks after the infection.
This test may produce false negative reaction with intercurrent infection, viral vaccines, corticosteroids, severe malnutrition, use of impotent material of vaccine, and overwhelming infection of tuberculous infection.
Montoux test is done with protein-purified derivatives. The 0.1ml. of the standard diluted vaccine is injected into the anterior left forearm to raise a wheel of 6-8 mm.
The result of the test is read after 48-72 hours and the size of in duration is measured. The diameter of the induration, below 5 mm. shows negative, while the diameter between 5 mm and 9 mm. is positive and shows that the children had exposure to the infection.
The diameter of in duration, above 10 mm. or more is a positive reaction.
The X - ray of the chest may reveal the primary focus and any pulmonary lesion. Examination of the smear from the sputum or other lesion is examined for acid-fast bacilli. Cerebrospinal fluid is examined for diagnosing tuberculosis meningitis.
Early diagnosis and treatment can prevent the danger of Tuberculous meningitis, miliary tuberculosis, and bone tuberculosis. The treatment depends on the severity of infection and the extent to which the organ is involved. Usually following line of treatment is given.
i. Antituberculosis drugs:
Standard antituberculosis drugs are streptomycin, isonicotinic acid hydrazide (INH), pyrazinamide and Ethionamide. In the primary tuberculosis, the treatment may be initiated-with these drugs.
Other drugs are Ethambutal, ethionamide, parazinamide, viamycin, xanamycin and rifampin. The physician may select the drugs according to the case. The regime with three or more drugs in combination is found effective, such as;
1. INH-Rifampin - Streptomycin
2. INH - Ethambutal - Rifampin
Duration, of the chemotherapy depends on the age, health status of children, and severity of the disease. It may vary from nine months to two years.
ii. Corticosteroids :
Corticosteroids may be used in the early part of the disease. It is prescribed for six to eight weeks and then the dose is gradually decreased over the next four weeks. It may be used in tuberculosis meningitis, pleural effusion, miliary tuberculosis, and overwhelming infection with malnutrition.
iii. Surgical Treatment:
Sometimes surgical treatment is necessary for resection of the segment or removal of the affected part.
1. Pulmonary tuberculosis in children is noninfectious so there is no need for isolation. The proper disinfection of the body discharges is required.
2. Rest and comfort may be necessary in the cases with a fever and severe illness. The child is allowed to enjoy normal activities as his condition improves. Fresh air and sunshine helps in the recovery.
Important principles to remember in paediatric nursing care:
The nurse should begin to build a working relationship with the parents and their children, from the time of first contact with them.
1. The nurse should be aware that all behaviours should be meaningful.
2. The nurse should accept parents and their children exactly as they are.
3. The nurse should have an empathy for parents and children. This implies an appreciation of how they feel inwardly, and how things are for them.
4. The nurse should let them know that their problems are important, and the nurse is there to aid in their solutions.
5. The nurse must be willing to acknowledge the parents' right to their own decisions concerning their children.
6. The nurse allows the parents and the children to express their emotions, even negative emotions.
7. The nurse should ask Questions limited to a single data
8. The nurse should ask questions limited to a single idea or reference.
9. The nurse should speak a language understandable to the parent and children.
The team members of health must help the parents to feel that there is unity among them.