Adherence Difficulties in a Child with Tuberculosis

June 2008

Case History

A 15 month old child with active pulmonary tuberculosis became a significant management challenge to his public health nursing providers because of his consistent refusal to take medications.

The child developed pulmonary tuberculosis following contact with his mother who had smear-positive cavitary tuberculosis. The mother was AFB sputum smear positive and culture positive for Mycobacterium tuberculosis. Her chest x-ray was abnormal with a cavitary infiltrate and her culture isolate was resistant to INH at low level but susceptible at the higher testing measurement. She was started on standard four drug therapy and was very compliant.

The child was born in Mexico with extended family there. Several family members in Mexico have had, or died from, tuberculosis. The infant's father concurrently received rifampin for latent TB infection (LTBI).

At the time of the initial contact investigation, the child was asymptomatic and had a normal physical exam. The initial chest x-ray revealed a nodular opacity in the apical segment of the upper left lobe. Because neither bronchial washings nor gastric aspirates were obtained, the child was diagnosed with active tuberculosis disease on the basis of the abnormal chest x-ray and close contact to his mother. Although his mother, the source case, had low level Isoniazid (INH)-resistant disease, the child received only INH, rifampin and PZA. Ethambutol was not included in the regimen.

The child was placed on directly observed therapy (DOT) administered five days a week for the first two weeks. During the initial two weeks of therapy, he vomited or spit out two doses. A note in the record described the child as "very difficult and stubborn when taking the TB medications." Difficulties with medication delivery intensified once the treatment dosing interval was changed to twice weekly. It took both parents to restrain the infant while the health department staff administered the TB medications. His parents were very cooperative and supportive of health department staff, but concerned with the child's ongoing struggle. Several notes by the health department nurse indicated the child was "likely ingesting no more than a quarter to half of the medication in any one dosing day."

Clinically and radiographically the child was doing well. He was playful, friendly, cheerful (when not taking medications), and performing age appropriate tasks including feeding himself and drinking from a regular cup.

Heartland National TB Center was consulted regarding the following three concerns:

  1. Is the treatment regimen appropriate for this child?
  2. Should the length of treatment be extended because of the number of missed doses?
  3. The infant frequently spits out, vomits or refuses to take TB medications. It is necessary for the parents to restrain the infant and force him to take her medications. The behavior isn't improving and parents and HD staff are very frustrated. What recommendations do you have for administrating medications to infants and toddlers?

Recommendations

"Tuberculosis Medication Delivery Tips" from Anne Loeffler, MD

Liquid:

  • INH suspension is available commercially in sorbitol. The large osmotic load is poorly tolerated by most children as it can cause diarrhea, but it may be better tolerated by babies.
  • Other TB medications are not commercially available as liquids. Medications may be suspended by local pharmacies but the stability and homogeneity are not guaranteed.

Pills and capsules taken intact or in halves: This is the easiest way! Tip the head back to swallow pills and tip the head forward to swallow capsules. If the child can swallow capsules, but not tablets, crush the pulls and place the powder in commercially available empty capsules

Pills fragmented (with a knife or commercial pill cutter) or crushed (by commercial pill crusher, mortar and pestle, spoon against spoon or bowl); capsules can be opened. The crushed pills have a strong flavor; small fragments of the pill taste better. Crush or fragment pills right before administering (with in 30 minutes); do not prepare ahead of time.

  • Put a thin layer of soft food onto a spoon. Place the pill fragments or powder on top of the food layer and top with more yummy food. Give the child the dose of medication in this "sandwich." Teach them to swallow it without chewing by practicing without the medication in place first. Some suggested foods:
    • Chocolate frosting, sauce, pudding, fudge sauce, ice cream, etc.
    • Jelly or marmalade (the texture hides the powder granularity)
    • Apple sauce or berry-sauce (better to hide the red rifampin color)
    • Nutella or peanut butter
    • Cream cheese or chili con carne
    • Whatever the family can make work
    OR
  • Suspend in a SMALL AMOUNT of liquid. Water is best. (INH is not stable in sugary liquids; do not mix with other medications in sugary solutions. Only use liquid INH in the commercially mixed sorbitol.) Dispense with:
    • Syringe (it is difficult to get the pulverized INH through regular tip syringe; other drugs crush finer and dissolve better)
    • Medicine dropper with larger tip; available at many pharmacies
    • Baby bottle (may need to make hole larger)
    • Special Rx MediBottle with internal sleeve for syringe; available at many pharmacies. Pulverized INH is very difficult to get through this syringe. I suggest giving the other meds with this bottle and then giving INH separately or by the liquid product if it is tolerated by the baby.
    • Medicine delivering pacifier; available at many pharmacies) holes will need to be enlarged)

Teaching Points

References

American Academy of Pediatrics. AAP.ORG. Red Book 27th Edition P.678-698 (1): 8E—Red Book. http://aapredbook.aappublications.org/cgi/content/full/2006/1/E8

Charles P. Felton National Tuberculosis Center at Harlem Hospital. "Pediatrics." American Academy of Pediatrics. Supplement to Pediatrics. October 2004.

Loeffler, Ann, MD "When a Child is a Contact to a TB Case." Pediatric TB: An Online Presentation. Produced by the Francis J. Curry National Tuberculosis Center.

Loeffler, Ann, MD. "Tuberculosis Medication Delivery Tips." Pediatric TB: An Online Presentation. Produced by the Francis J. Curry National Tuberculosis Center.

Smith, Kim Connelly MD, MPH. "Tuberculosis in Children." Department of Pediatrics, Community and General Pediatrics Children's Tuberculosis Clinics, University of Texas-Houston Medical School, Houston, Texas. 2001.

Stop TB Partnership Childhood TB Subgroup. "Chapter 2: Anti-tuberculosis Treatment in Children." International Journal of Tuberculosis Lung Disease 10(11): 1205-1211. Official Statement. World Health Organization, Geneva, Switzerland. 2006 The Union.

Heartland National TB Center provides a Medical Consultation Line that is staffed Monday to Friday, 8:00 AM to 5:00 PM (CST). After business hours, voice mail is available and will be returned in one business day.

Heartland National TB Center
2303 SE Military Drive
San Antonio, Texas 78223
Phone: 1 (800) TEX-LUNG
Fax: (210) 531-4590
http://www.heartlandntbc.org/