CHILDHOOD TUBERCULOSIS

(1992)

PHILIPPINE PEDIATRIC SOCIETY

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

CHILDHOOD TUBERCULOSIS

PHILCAT - PPS
The Working Committee on Prevention and
Initial Treatment of Childhood Tuberculosis
Estrella Paje - Villar, M.D. Chair
Josefina C. Carlos, M.D. Co-Chair

223

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

Algorithm for the Prevention

Therapy of Childhood Tuberculosis
1
TB Exposure
(Class I)
(A)
2

Patient
< 5 yrs old?
(B)

Start 3 months
Isoniazid
(B.D)

Repeat
Mantoux
after 3 months
positive

N
discontinue H
if no BCG scar,
give BCG

225

Repeat
Mantoux
after 3 months
positive

N
TB infection
(Class II)
Continue Isoniazid
>/ 6 months (F)

TB Disease
(Class III)
Multiple drug
therapy (G)

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

Footnotes
A. TB Exposure (Class I): includes persons with significant contact with adolescent/adult source case
but who are symptomatic, with negative Mantoux
Test and normal radiologic findings.
B. Children particularly those under 5 years old, can
develop severe TB in less than 3 months (6-8 weeks
in meningitis and disseminated disease) because of
the short incubation period of pulmonary, CNS and
disseminated diseases. Hence, infants and children
in the exposure stage should receive preventive
therapy. In older children preventive therapy in TB
exposure is more controversial since the disease
is slower in progression. However, some experts
recommend early treatment in the children to prevent establishment of infection after deposition of
infected droplet nuclei in the alveoli, especially in
the presence of risk factors like severe undemutrition and other immunocompromised states.
C. Mantoux test positive = 5 mm induration in those
without BCG scar; >10 mm induration in those
without BCG scar in the absence of any other findings suggestive of TB since BCG vaccination can
cause increased reactivity to a subsequent tuberculin
test. Virtually all children vaccinated at birth have
non-reactive Mantoux test by 5 years of age.

D. For persons exposed to infectious TB but not yet

infected isoniazid (H) is given to prevent establishment of infection (primary chemoprophylaxis).
In this case isoniazid is protective only while the
person is receiving the drug.
E. Assuming that infector has been given inadequate
multiple drug therapy.
F. TB infection: includes those positive with Mantoux
test but without signs and symptoms and radiologic
evidences suggestive of TB. Virtually all infected
children should be treated to prevent development
of TB disease in the near or distant future (secondary chemoprophylaxis). The duration ranges
from 6 months to 12 months. The AAP and CDC
recommend a 9-month administration of Isoniazid,
5-10 mg/Kg/day, not exceeding 300 mg/day. In the
immunocompromised host, the total duration of preventive therapy is extended to 12 months. Isoniazid
is extremely effective in preventing progression
of TB infection to TB disease. It produces a 90%
reduction in TB disease during the 1st year after
treatment and the protective effect can last for at
least 30 years. In the presence of primary isoniazid
resistance, rifampicin is used instead.
G. TB Disease (Class III) - see algorithm (Figure 2).

Table 1. Guidelines for TB Chemoprophylaxis

Category
Population at risk of infection/

disease

Duration of Isoniazid (H) Use

Primary
Newborn of an infected mother
chemoprophylaxis

PPD (-) infants and children under

5 years exposed to TB

3 months initially; after 3 months of PPD (-),

discontinue Isoniazid provided the infector
is under adequate therapy and give BCG; if
PPD (+) continue Isoniazid for 9 months more;
if abnormal chest x-ray, and 2 more drugs,
e.g. Rifampicin and Pyrazinamide, and treat
as disease

Secondary
Chemoprophylaxis

HIV infection/persons with risk

factors for HIV infection whose
HIV infection is unknown

12 months

PPD (+) not due to BCG with

negative chest x-ray and no benefit
to previous TB chemotherapy

9 months

PPD (+) with stable or healed

parenchymal lesions and no
previous chemotherapy

9 months

Recent tuberculin conversion (within 9 months

1-2 years) with negative chest x-ray

PPD (+) with stable or healed TB

lesions with previous TB chemo
therapy but are at risk of

reactivation due to

a. Measles/pertussis, etc.

b. Conditions/drugs that induce
immunosuppression (IDDM,
chronic dialysis, leukemia)

1-2 months

for the duration of the

immunosuppression
226

227
20-30
(max 1 g)

Streptomycin (S)
1 g vial (IM)
(as sulfate)

(max 1 g 3x/wk)

25-30
(max 1.5 g 2x/wk)

30 (3x/wk)
50 (2x/wk)
(max 2.5 g)

50-70
(max 4 g)

10-20
(max 600 mg)

20-40
(max 900 mg)

(max 1 g 3x/wk)

25-30
(max 1.5 g 2x/wk)

30 (3x/wk)
50 (2x/wk)
(max 2.5 g)

50-70
(max 4 g)

10
(max 600 mg)

15
(Max 900 mg)

2-3x/Week (DOT)
</ 12 yrs
> 12 yrs

N.B. H and R must be given on empty stomach (1 hour before or 2 hours after meals

+ H absorption is implied by food and antacids; pyridoxine is recommended in children with nutritional deficiency, breastfeeding infant, pregnant
women, and in renal failure.
* R absorption is impaired by food; bioavailability is very dependent on the formulation.
0
E is generally not recommended in children (< yrs) whose visual acuity is difficult to monitor. However it should be considered for all children with
resistant organisms when susceptability to E is likely or has been demonstrated. Absorption is unaffected by food but delayed by aluminum hydroxide.

15
(max 1 g)

15-25
15-25
first 2 months
(max 2.5 g)
then 15 (max 2.5 g)

15-30
(max 2 g)

10
(max 600 mg)

Ethambutol (E)0
200 mg & 400 mg tab
(as HCl)

10-15
(max 600 mg)

5
(Max 300 mg)

> 12 yrs

Dosage (mg/Kg)

15-30
(max 2 g)

-150 mg, 300 mg, 450 mg

& 600 mg tab/cap
-100 mg & 200 mg/5 mL
suspension
-60 mg/mL, 10 mL vial
(IV infusion)

Rifampicin (R)*

5-10
(max 300 mg)

</ 12 yrs

Daily

Pyrazinamide (Z)
500 mg tab/cap

-100 mg, 300 mg &

400 mg tab
-100 mg & 200 mg
/5 mL syr

Isoniazid (H)+

Drugs
Dosage Forms

Table 2. Dosage Recommendation for the Initial Treatment of Tuberculosis

CHILDHOOD TUBERCULOSIS
CPM 1ST EDITION

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

Algorithm for the Initial Treatment

of Childhood Tuberculosis
1
Pulmonary TB
(Class III PTB
(A)

2
Drug
resistance likely
or unknown?
(C)
N

3
C and S
available?

Start
2 EHRZ or
2 SHRZ
(E, F, J)

Start
2 HRZ
(D.E)

Do C & S
Start
2 EHRZ or 2 SHRZ
Revise regimen
as appropriate

8
Continue
4 HR or 4 HR3
(D,E,H,I)

Continue 4 HR
+/ E/S
or 4 HR +/ E/S
(G,E,H,I,J)

Figure 2

Legend:
H - isoniazid
R - rifampicin
Z - pyrazinamide
E - ethambutol
S - streptomycin

C&S - culture and sensitivity test

Number before a group of letters - number of months of drug administration
Number after a group of letters - number of doses per week
No number after a group of letters - group of drugs given daily

See Notes for the letters in paresthesis

228

CHILDHOOD TUBERCULOSIS

Footnotes
A. PTB disease based on at least three of the following:
history of exposure to a source case
Mantoux test positive
suggestive symptoms and signs
suggestive Chest x-ray (PA and lateral views)
suggestive biopsy/histologic findings
N.B. Isolation of M. tuberculosis (positive smear and/or
culture) is the gold standard but is very rarely present
in infants and children
B. Based on
source case with fully susceptible M. tuberculosis
local prevalence of primary isoniazid resistance
(< 10%)
no history of previous use of anti-TB drugs
C. Drug resistance likely

big bacillary population (e.g cavitary lesion)

previous use of anti-TB drugs
close contact with drug resistant source case
residence in a place with high primary isoniazid
resistance (10%)

D. For fully susceptible M. tuberculosis a 6 month

regimen with 2 months isoniazid, rifampicin and
pyrazinamide (HRZ) daily intensive therapy followed by 4 months isoniazid and rifampicin (HR)
or 4 months isoniazid and rifampicin 3x a wk (HRg)
continuation phase is adequate.
E. Supervised/direct observation therapy (DOT) is
as effective and safe and is preferred. The health
system must develop an infrastructure with the
expertise and resources for strict implementation
of the DOT programme.
F. A four-drug regimen for the intensive phase is recommended where primary resistance is suspected or
when the resistance status is unknown. S is preferred
in infants and children (< 6 yrs) too young for monitoring visual acuity and color perception. For older
age group, E is preferred since monitoring of visual
acuity and color perception will be less difficult and
the pain and dangers of IM injections are avoided.
G. E or S may be continued in the continuation phase
in patients with suspected primary drug resistance
to delay further development of resistance.
H. Extrapulmonary tuberculosis is managed essentially
the same manner as pulmonary tuberculosis except
229

CPM 1ST EDITION

that in serious life-threatening infections such as

meningitis, miliary and bone and joint disease, the
continuation phase is extended to a minimum of 10
months.
I. In immunocompromised patients (e.g. with HIV/
AIDS), the continuation phase is extended to 7
months (i.e. total duration of 9 months chemotherapy) or for at least 6 months after sputum conversion (if applicable) whichever is longer. If drug
susceptibility results are not available, ethambutol or
streptomycin should be given for the entire course of
therapy because of the risk of rapid disease progression while on inadequate therapy
J. In pregnant or nursing mothers, S and other
aminoglycosides, ethionamide and prothionamide
are contraindicated. The regimen recommended
is 2 months ethambutol, isoniazid, rifampicin
and pyrazinamide (EHRZ) intensive phase then 4
months isoniazid, rifampicin and ethambutol (HRE)
or three doses a week of isoniazid, rifampicin and
ethambutol (HREg) continuation phase.
References
1. Mitchison DA. The action of antituberculosis drugs
in short course chemotherapy. Tubercle 1985;
66:219
2. Davies PDO (ed). Clinical tuberculosis. Chapman
and Hall, London. 1994 pp. 129-156
3. Committee on Treatment of International Union
Against Tuberculosis and Lung Disease Antituberculosis regimen of Chemotherapy. Bull Int. Un.
Tubercle 1988; 63:60
4. Abemathy et. al. Short course chemotherapy for tuberculosis in children. Pediatric 1983; 72:801-806
5. Biddulph J. Short course therapy for childhood tuberculosis in children. Pediatrics 1990; 9:794-801
6. Jacobs R, Abemathy. The treatment of tuberculosis
in children. Pediatrics 1985; 4:513-517
7. Jacobs RF, Sunakom P. Chotpitayasunonah et al. Intensive short course chemotherapy for tuberculosis
meningitis. Pedia. Infec. Dis. J. 1992; 11:194-198
8. Kumar C, Dhand R, Singh PD et al. A randomized
trial of fully intermittent short course chemotherapy
for childhood tuberculosis. Pediatr. Infect. Dis. J.
1990; 9:802-805
9. Starke JR, Taylor-Watts. Six month chemotherapy
of intrathoracic tuberculosis in children. Am. Rev.
Respi. Dis. 1989; 139 (suppi) A 314
10. Tsakilidis D, Pratsidou P, Hitoglou - Makedou A, et
al. Intensive short course chemotherapy for treatment of Greek children with tuberculosis. Pediatr.
Infect. Dis. J. 1992; 1036-1040
11. Starke JR: Multidrug therapy for tuberculosis in
children, Pediatr. Infec. Dis J. 1990; 9:785

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

12. Starke JR and Correa AG. Management of mycobacterial infection and disease in children. Pediatr
Infect. Dis. J. 1995 14:455-70
13. American Academy of Pediatrics. Chemotherapy
of tuberculosis in infants and children. Pediatrics
1992; 89:61-64
14. Centers for Disease Control and Prevention: Initial
therapy of tuberculosis in the era of multidrug
resistance: Recommendation of the A d v i s o r y
Council for the elimination of tuberculosis. MMWR
1993; 42 (RR-7): 1-8
15. American Thoracic Society: Treatment of tuberculosis and tuberculous infections in adults and children.
Am. J. Resp. Crit. Care Med. 1994; 149:1359-94
16. Treatment of tuberculosis: Guidelines for national
programmes. World Health Organization, Geneva
1993
17. Jacobs RF: Pediatric tuberculosis in Rossman MD.
Mac Gregor RR (eds). Tuberculosis Clinical Management and New Challenges, McGraw-Hill, Inc.
1995; Chapter 8 pp. 129-144
18. First National Consensus in Tuberculosis. Chest
Dis. 1989; 16:16-20
19. Starke JR. Tuberculosis in Behrman RE, Kleigman
RM, Nelson W., Vaughan VC (eds). Nelson Textbook of Pediatrics WB Saunders Co. Philadelphia.
15th edition 1996. Chapter 199, pp. 834-847
20. Chaulet P, et al. Childhood tuberculosis still with us.
Children in the Tropics, Review of the International
Children's Centre. 1992; 53 57
21. A statement of the Committee on the Treatment of
ILJATLD Bull. Int. Un. Tuberc 1987: 62:1-2:5860
22. A statement of the Scientific Committees of the
IUATLD Bull. Int. Un. Tuberc. 1991; 66:65-71
23. Udani PM: Tuberculosis in general Udani PM (ed)
Textbook of Pediatrics. 1991, Jaypee Brothers
Medical Publishers. New Delhi, India. Chapter 16
pp. 995-1175
24. Smith MHD, Starke ]R, Marquiz JR. Tuberculosis
and opportunistic mycobacterial infections in Feigin RD and Cherry ]D (eds) Textbook of Pediatric
Infectious Dis. WB Saunders Co. Philadelphia. 3rd
edition 1992 Chapter 130 pp. 1321-1362
25. Seifart HI, Parkin DP. Donald PR: Stability of isoniazid, rifampicin and pyrazinamide in suspension
used for the treatment of tuberculosis in children.
Pediatr. infect. Dis. J. 1991; 10-827-31
26. Acocella G et al: Bioavailability of isoniazid, rifampicin and pyrazinamide (in free combination
of fixed triple formulation) in intermittent antituberculous chemotherapy. Monald Arch Chest Dis.
1993; 48:205-209
27. Leonin T, Leyson MO, Marfil LP, Tan GA et al:
Multicenter clinical trial of short course chemotherapy of pulmonary tuberculosis in the Philippines
(unpublished)
230

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CPM 1ST EDITION

Drugs Mentioned in the Treatment Guideline

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing Information of these
drugs can be found in the Philippine Pharmaceutical Directory (PPD) 1997. Opposite the brand name is its page
number in the PPD 1997.
Bisobutol..............................89
Ethambutol
SCC Kit................................94
Combi Pack..........................89
Ethambin..............................84
Sthamizide............................94
Comprilex Pediatric
Odetol...................................84
Tres.......................................95
Syrup.................................89
Isoniazid
Tripack..................................95
Continukit.............................89
DLI-Isoniazid ........................8
Trisofort................................95
Continupack..........................89
UL Isoniazid ........................85
Trisovit..................................95
Coxiform ..............................89
Morphazinamide
UL Ethambutol HCI.............95
4D.........................................89
Piazolina ..............................85
UL Isoniazid 400 .................95
Ebutol...................................89
Pyrazinamide
USA-Ethambutol +
Econokit ..............................89
Braccopiral ..........................85
INH+B6........................... 95
Econopack............................90
DLI-Pyrazinamide................85
Framed ................................85 EMB Forte ...........................90
Etham 500 ............................90
Pharex-Pyrazinamide...........85
Ethambin-INH......................90
Pyrazinamide-Boie...............85
Ethamizid..............................90
Py/amed................................85
Forbutol................................90
PZA-CIBA...........................85
Genamzid/
UL Pyrazinamide.................85
Genamzid Forte................90
Zinastat ................................85
Isoetam ................................90
Rifampicin
Koccid...................................90
AKT-S .................................86
Kyur Kit I.............................90
Canarif..................................86
Kyur Kit II............................91
Crisarfam ............................86
Lederrif-INH.........................91
Dipicin ................................86
Molecure l & 2......................91
DLI-Rifampicin ...................86
MOP/M-0 Compliance
Flemodan ............................86
Pack................................. 91
Koccifam .............................86
Myambutol+INH
Medifam...............................86
+ B6 .................................92
Mycofam .............................86
Niretal...................................92
Natridn ................................86
Odinah..................................92
Patriot-Rifampicin................86
Pacibutol...............................92
Pharex-Rifampicin...............86
Pediambutol w/
PMI Rifampiein....................86
INH-B6 Syrup...................92
Rafromide ...........................86
Pharex-Isoniazid...................92
Ramicin ...............................87
Primafort...............................92
Refam...................................87
Primafort-325 ......................92
Resimin................................87
Pyrifort..................................92
Ribosin.................................87
Pyrina ..................................93
Ricyn....................................87
Pyrobin-H.............................93
Rifadin..................................88
Quadpack..............................93
Rifastat.................................88
Rambutol..............................93
Rimactane.............................88
Ramicin-Iso..........................93
Rimaped Suspension............88
Resimin+H/
T-Bicin.................................88
Resimin 225+H.................93
UL Rifampiein......................88
Rifater...................................93
USA Rifampiein...................88
Rifinah .................................93
Streptomycin
Rimactazid 225/
YSS Streptomycin
Rimactazid 300/
Sulfate...............................88
Rimactazid 450..........94
Drug Combination
Ronah-500............................94
Abbutol-INH-B6..................88
Rotazid..................................94
Amyco .................................88
231

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

DIARRHEAL DISEASES
IN CHILDREN

232

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

Algorithm for the Management

of Acute Respiratory Infection (ARI)/
Pneumonia for 2 mos. to 4 yrs. old
1
Patients

Assess
hydration
status

Does patient
have severe
dehydration?

Plan C
IV therapy
deficit/
replacement
therapy

5
Does patient
have severe
dehydration?

6
Y

Plan A or B

Continue
Plan C

Does patient
have severe
dehydration?

Patient has no
dehydration

13

Plan A
ORS/
home fluids
continue feeding

Is there
persistent vomiting
or does patient
refuses to drink?
N

Insert NGT*

14

12

Plan B
ORS; encourage
to continue
breastfeeding

11

10

Y
Does patient

improve?

16

Plan C
*NGT - Nasogastric Tube

233

15
Plan A

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

Guidelines for the Management

of Patients with Diarrhea
USE THIS CHART FOR PATIENTS WITH:
loose or watery stools
loose stools with blood

Diagnosis

1. First, assess your patient for dehydration

Treatment Plan
A
B
1. LOOK AT;
Condition
Well, alert
*Restless, irritable*

C
*Lethargic or
unconscious;
floppy*

Eyes

Normal

Sunken

Very sunken and dry

Tears

Present

Absent

Absent

Mouth and Tongue

Moist

Dry

Very dry

Thirst

Drinks normally,
not thirsty

*Thirsty, drinks
eagerly*

*Drinks poorly or not

able to drink*

2.FEEL:
Skin Pinch
Goes back quickly
*Goes back slowly*

*Goes back very

slowly*

3. DECIDE:
The patient has
If the patient has two or

NO SIGNS OF
more signs including at

DEHYDRATION
least one *sign*, there is

SOME DEHYDRATION

If the patient has two

or more signs, inclu-
ding at least one
*sign*, there is SEVERE
DEHYDRATION

4. TREAT
Use Treatment

Plan A

Weigh the patient, if

possible, and use
Treatment Plan B

Weigh the patient and

use Treatment Plan C
URGENTLY

2. Then, ask for other problems

ASK ABOUT BLOOD
IF BLOOD IS PRESENT
IN THE STOOL
Treat for 5 days with an oral antibiotic recommended for
Shigella in your area

Teach the mother to feed the child as described in Plan A

See the child again after 2 days if:

under 1 year of age

initially dehydrated

there is still blood in the stool

not getting better

If the stool is still bloody after 2 days, change to a second oral
antibiotic recommended for Shigella in your area. Give it for 5 days.
ASK WHEN THIS
IF DIARRHEA HAS LASTED AT LEAST 14 DAYS:
EPISODE OF
Refer to hospital if:
DIARRHEA BEGAN - the child is under 6 months old
- dehydration is present. (Refer the child after treatment of
dehydration).
234

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

Otherwise, teach the mother to feed her child as in Plan A, except:

- dilute any animal milk with an equal volume of water or
replace it with a fermented milk product, such as yoghurt.
- Assure full energy intake by giving 6 meals a day of thick cereal
and added oil, mixed with vegetables, pulses, meat, or fish.

Tell the mother to bring the child back after 5 days:
- if diarrhea has not stopped, refer to hospital
- if diarrhea has stopped, tell the mother to:
> use the same foods for the child's regular diet
> after 1 more week, gradually resume the usual animal milk.
> give an extra meal each day for at least 1 month.
LOOK FOR SEVERE
IF THE CHILD HAS SEVERE
UNDERNUTRITION
UNDERNUTRITION:

Do not attempt rehydration; refer to hospital for management.

Provide the mother with ORS solution and show her how to
give 5mL/Kg/hr during the trip.
ASK ABOUT FEVER
IF TEMPERATURE IS 39C OR GREATER:
AND TAKE
Give paracetamol.
TEMPERATURE

IF THERE IS Falciparum malariae IN THE AREA, and the
child has any fever (38 or above) or history of fever in the
past 5 days.

Give an antimalarial (or manage according to your malaria
programme recommendation).

Treatment Plan A:
To Treat Diarrhea at Home
Use this plan to teach the mother to:
Continue to treat at home her child's current episode
of diarrhea.
Give early treatment for future episodes of diarrhea.
A. Explain the 3 rules for treating diarrhea at
home:
1. Give the child more fluids than usual to prevent
dehydration:
Use a recommended home fluid, such as a
cereal gruel. If this is not possible, give plain
water. Use ORS solution for children
described in the box below.
Give as much of these fluids as the child will
take. Use the amounts shown below for ORS as
a guide.
Continue giving these fluids until the diarrhea
stops.
2. Give the child plenty of food to prevent undemutrition:
Continue to breast-feed frequently.
If the child is not breast-fed, give the usual
milk. If the child is less than 6 months old and
235

not yet taking solid food, dilute milk or

formula with an equal amount of water for 2
days.
If the child is 6 months or older, or alread
solid food:
- Also give cereal or another starchy food, mixed,
if possible, with pulses, vegetables, and meat
or fish. Add 1 or 2 teaspoonfuls of vegetable
oil to each serving.
- Give fresh fruit juice or mashed banana to
provide potassium.
- Give freshly prepared foods. Cook and mash
or grind food well.
- Encourage the child to eat; offer food at least 6
times a day.
- Give the same foods after diarrhea stops, and
give an extra meal each day for two weeks.
3. Take the child to the health worker if the child
does not get better in 3 days or develops any of
the following:
Many water stools
Repeated vomiting
Marked thirst
Eating or drinking poorly
Fever
Blood in the stool
Children should be given ORS Solution at home if:
They have been on Treatment Plan B or C
They cannot return to the health worker if the

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

diarrhea gets worse.

It is national policy to give ORS to all children
who see a health worker for diarrhea.
B. If the child will be given ORS solution at home,
show the mother how much ORS solution to give
after each loose stool &: give her enough packets
for 2 days:
Age

Amount of ORS Amount of ORS

to give after each to provide for use
loose stool
at home

Less than
24 months

50-100 mL

500 mL/day

2 up to
10 years

100-200 mL

1000 mL/day

10 years or
more

As much as
wanted

2000 mL/day

Describe and show the amount to be given after

each stool using a Local measure.

C. Show the mother how to mix ORS:

D. Show her how to give ORS:
Give a teaspoonful every 1-2 minutes for a child
under 2 years.
Give frequent sips from a cup for an older child.
If the child vomits, wait 10 minutes. Then give
the solution more slowly (for example, a
spoonful every 2-3 minutes).
If diarrhea continues after the ORS packets are
used up, tell the mother to give other fluids as
described in the first rule above or return for
more ORS.

Treatment Plan B: To Treat Dehydration

A. Approximate amount of ORS solution to give in the first 4 hours:
Age:*
Less than 4
4-11 months 12-23 months 2-4 years
5-14 year 15 years or
months older
Weight Less than 5 Kg
5-7.9 Kg
8-10.9 Kg
11-15.9 Kg
16-29.9 Kg 30 Kg or
more
in mL
200-400
400-600
600-800
800-1200
1200-2200 2200-4000
in local
measure
* Use the patient's age only when you do not know the
weight. The approximate amount of ORS required (in
mL) can also be calculated by multiplying the patient's
weight (in grams) times 0.075.
If the child wants more ORS than shown, give
more.
Encourage the mother to continue breast-feeding.
For infants under 6 months who are not breast-fed,
also give 100-200 mL clean water during this
period.
B. Observe the child carefully and help the mother
give ORS solution:
Show her how much solution to give her child.
Show her how to give it - a teaspoonful every 1-2
minutes for a child under 2 years, frequent sips
from a cup for an older child.
Check from time to time to see if there are
problems.
If the child vomits, wait 10 minutes and then

continue giving ORS, but more slowly, for

example, a spoonful every 2-3 minutes.
If the child's eyelids become puffy, stop ORS and
give plain water or breast milk. Give ORS
according to Plan A when the puffiness is gone.
C. After 4 hours, reassess the child using the
Assessment Chart. Then select Plan A, B or C to
continue treatment.

If there are no signs of dehydration, shift to Plan
A. When dehydration has been corrected, the
child usually passes urine and may also be tired
and fall asleep.
If signs indicating some dehydration are still
present, repeat Plan B, but start to offer food, milk
and juice as described in Plan A.
If signs indicating severe dehydration have
appeared, shift to Plan C.
D. If the mother must leave before completing treat236

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

ment Plan B:
Show her how much ORS to give to finish the 4-hour
treatment at home.
Give her enough ORS packets to complete rehydration, and for 2 more days as shown in Plan A.
Show her how to prepare ORS solution.
Explain to her the three rules in Plan A for treating
her child at home:
- to give ORS or other fluids until diarrhea stops
- to feed the child
- to bring the child back to the health worker, if
necessary.
Use of Drugs for Children with Diarrhea
ANTIBIOTICS should ONLY be used for dysentery and suspected cholera. Otherwise, they are
ineffective and should NOT be given.
ANTIPARASITIC drugs should ONLY be used
for:
Amoebiasis, after antibiotic, treatment of
bloody diarrhea for Shigella has failed or tro
phozoites of . Histolytica containing red
blood cells are seen in the feces.
Giardiasis, when diarrhea has lasted at least
14 days and cysts or trophozoites of Giardia
are seen in feces or small bowel fluid.
ANTIDIARRHEAL DRUGS and ANTIEMETICS should NEVER be used. None has been
proven of practical value. Some are dangerous.

237

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

Start IV fluids immediately. If the patient can drink, give ORS by mouth

Can you give

IV fluids
immediately!

while the drip is set up. Give 100 mL/Kg Ringer's Lactate Solution (or, if
not available, normal saline), divided as follows:

First give
30 mL/Kg in:
1 hour*
30 minutes*

Then give
70 mL/Kg in:
5 hours
2 1/2 hours

* Repeat once if radial pulse is still very weak or not detectable.

Reassess the patient every 1-2 hours. If hydration is not improving, give
the IV drip more rapidly.
Also give ORS (about 5 mL/Kg/hour) as soon as the patient can drink:
usually after 3-4 hours (infants) or 1-2 hours (older patients).
After 6 hours (infants) or 3 hours (older patients), evaluate the patient using the assessment chart. Then choose the appropriate Plan (A, B or C) to
continue treatment.

Is IV treatment
available nearby,
(within 30 min)!

Send the patient immediately for IV treatment.

If the patient can drink, provide the mother with ORS solution and show
her how to give it during the trip.

N
3

Start rehydrationby tube w/ ORS solution: Give 20 mL/Kg/hr for 6 hours

(total of 120 mL/Kg).
Reassess the patient every 1-2 hours:
- If there is repeated vomiting or increasing abdominal distension, give
the fluid more slowly.
- If hydration is not improving after 3 hours, send the patient for
IV therapy.
After 6 hours, reassess the patient and choose the appropriate
Treatment Plan.

Are you trained

to use a nasogastnc
(NG) tube for
rehydration;

Start rehydration by mouth with ORS solution, giving 20 mL/Kg/hour for

Can the
patient drink?

Age
Infants
(under 12 mos)
Older child

6 hours (total of 120 mL/Kg).

Reassess the patient every 1-2 hours:
- If there is repeated vomiting, give the fluid more slowly.
- If hydration is not improving after 3 hours, send the patient for
IV therapy.
After 6 hours, reassess the patient and choose the appropriate Treatment
Plan.

URGENT:
Send the patient
for IV or
NG treatment

NOTES:
If possible, observe the patient at least 6 hours after rehydration to be sure the mother can maintain
hydration giving ORS solution by mouth.
If the patient is above 2 years and there is cholera in your area, give an appropriate oral antibiotic after
the patient is alert.

238

Reference

World Health Organization Circular, Revised 1990

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

Drugs Mentioned in the Treatment Guideline

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing Information of these
drugs can be found in the Philippine Pharmaceutical Directory (PPD) 1997. Opposite the brand name is its page
number in the PPD 1997.
Antibacterials
Genzaprim/Genzaprim
Tetracycline HC1Ampicillin
Forte..................................81
Upjohn...............................76
Allidcil..................................60
Groprim/Groprim Forte........81
UL Tetracycline....................76
Amibenz...............................60
Lagatrim................................81
Unimycin .............................76
Amopen................................60
Lextrizole ............................81
Antiprotozoals
Ampedia ..............................60 Macromed ...........................81
Diloxanide furoate
Ampidllin-Boie.....................60
Microbid/Microbid DS.........81
Entamizole.........................272
Ampicillin Sodium-YSS......60
Pharex-Cotrimoxazole..........82
Furamide............................269
Ampicin...............................60
Septrim.................................82
Etofamide
Ampimydn...........................60
Servitrim ..............................82
Kitnos.................................269
Amplivadi ...........................61
Sulfotrim .............................82
Furazolidone
Apamadn..............................61
Syltrifil..................................82
Furoxone ...........................264
Apothecon Ampicillin..........61
Syndal...................................82
Metronidazole
Bactimed .............................61
Thoprim ...............................82
Anerobia.............................269
Chrisolin...............................61
Triforam................................82
DLI-Metronidazole.............270
Cordroxyl ............................61 Trimetazole...........................82
Elizol..................................270
DLI-Ampidllin.....................61
Trimezol-Scanpharm............84
Flagyl.................................270
Exdllin..................................61
Trizole Suspension...............84
Histox ................................270
Foramydn ............................61
UL Cotrimoxazole ...............84
Metroxyn............................270
Genaxin ...............................62
USA-Cotrimoxazole.............84
Metronidazole-Boie............270
Knolidn ...............................62
Doxycycline
Metroxyn............................271
Leoplex................................62
Atrax.....................................74
Patriot-Metronidazole .......271
Metadyl................................62
Doryx....................................74
Pharex-Metronidazole....... 271
Patriot-Ampidllin.................62
Doxiron ...............................74
Servizol...............................271
Penbritin...............................62
Doxin 100.............................74
USA-Metronidazole...........271
Pensyn .................................62
Scrvidoxyne..........................74
Vermoxzole .......................271
Pentrexyl...............................62
Vibramydn ...........................74
Paromomycin
Pharex-Ampidllin ................62
Erythromycin
Humagel ............................266
Spedllin.................................62
Ditron ................................. 50
Secnidazole
Terampidn ...........................63
DLI-Erythromydn................50
Flagentyl.............................271
UL Ampidllin ......................63
Erydn....................................50
Tinidazole
Wyeth Omnipen...................63
Ery-Max...............................50
Fasigyn ......................271, 281
Ciprofloxacin
Erythrodn/
Intravenous Fluids
Ciprobay...............................72
Erythrodn DS ...................52
Lactated Ringer's
Cotrimoxazole
Erythromydn-Allied.............52
Solution-Euro-Med.........248
Atomexin ............................78
Ethiodn ................................52
Oral Rehydration Solution
Baddal..................................78
Gentrodn...............................52
Allyte I & II........................246
Badam..................................78
llosone .................................52
Cholyte-50..........................246
BactilleTS ...........................78
Macrodn ..............................52
Elotrans..............................246
Badrim ................................78
Phamaco-Erythromycin........52
Glucolyte............................246
Bacxal................................. 80
Pharex-Eryhtromycin...........52
Glucost ..............................246
Bestofens .............................80
Romaxin ..............................53
Hydrite ..............................247
Cotrimoxazole-Ashford.......80
Sarazine................................53
Pedialyte 45/90...................247
Cotrimoxazole-Boie.............80
Servitrodn.............................53
ServidratLS.........................247
Cotrimoxazole-Varnsler.......80
UL Erythromycin .................53
Dhatrin.................................80
USA-Erythromycin .............53
DLI-Cotrimoxazole..............80
Tetracyline
Dodrimox ............................80
Cydabid ...............................76
Elitrim,.................................80
DLI-Tetracyline ...................76
Genoxzole/Genoxzole
Hostacydine .........................76
Forte.................................81
Tetracydine-B.......................76
239

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

IMMUNIZATIONS

Philippine Pediatric Society, Inc.

Committte on Handbook of Infectious Diseases,
1996-1998
Josefina C. Carlos, M.D., Chair
Margaret L. Fong, M.D., Co-Chair
Melba V. Masigan, M.D., Co-Chair

240

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

Immunizations
Definition
Prevention of infectious disease can be achieved in
two ways:
I. Active Immunization - entails the giving of an antigen usually prior to natural exposure to an infectious
agent to stimulate the individual to develop his own
antibody.
II. Passive Immunization - entails the giving of preformed human or animal antibody to temporarily
protect the recipient.
ACTIVE IMMUNIZATION
1. Involves the administration of all or part of a microorganism or a modified product of the microorganism
(e.g. toxoid) to elicit an immunological response
simulating that of natural infection but which
presents little or no danger to the recipient.
2. Types of protection induced:
Complete protection for life
Partial protection so that booster doses are
administered at intervals.
3. Efficacy is assessed by the evidence of protection
against the particular disease. Antibody formation
is an indirect measure of protection, but in some
instance the immunologic response responsible for
protection is poorly understood and serum antibody
concentration is not always predictive of protection.
4.

Characteristics of an ideal immunizing agent:

Easy to produce
Potency is durable and easily measured
Easy to adminster
Does not in itself produce disease in the
recipient or susceptible contacts
Induce long-lasting (ideally permanent)
immunity that is measurable using common
and inexpensive technique.
Free of contaminating substances
Adverse reactions should be minimal (ideally
absent). Except for the available immunizing
agents, all of these objectives are rarely, if ever
met, hence, incomplete immunization may
occur, undesirable side effects or reactions
may occur in small number of subjects, and
infrequently, morbid effects may be
encountered.

Inactivated exotoxins (toxoid) - incapable of

replicating in the host, hence must contain
a sufficient antigenic mass to stimulate the
desired response provided by live attenuated
agents; maintenance of long- lasting immunity
often requires periodic administration of booster
doses.

6. Fluid may contain proteins or other constituents

derived from the medium in which the vaccine was
produced, preservatives, stabilizers, antibiotics, and
selective adjuvants (e.g. aluminum) to retain the
antigen at the depot site to prolong its stimulating
effect.
7. Timing: critical for the success of the procedure. In
general, vaccines are recommended for the youngest age group at risk for the natural infection and its
complications that will demonstrate an acceptable
level of immune response following vaccine administration.
8. Recommended dose: derived from theoretical
considerations, experimental vaccine trials and
significance; exceeding the recommended dose
volume may be hazardous because of excessive local
or systemic concentrations of immunizing antigens;
underdosage may result in an inadequate serologic
response and protection.
9. Route of administration: may determine the type and
duration of immunologic response; recommended
routes are based on clinical trials demonstrating
safety and efficacy. Injectable vaccines (intramuscular and subcutaneous) should be administered
in areas unlikely to cause local neural, vascular or
tissue injury e.g. anterolateral aspect of the upper
thigh in infants and the deltoid muscle of the upper
arm in older children.

5. Types of antigen for active immunization:

Live attenuated virus or bacteria
Killed microorganisms
241

242

* If measles vaccine is not indicated

NOTE: Interruption a/schedule, with a delay between doses, does not interfere with the final immunity achieved nor does it necessitate starting with the series afflin,
regardless of
the length of time elapsed.

Immunizing Agents
Age
Dose
Route
Contraindications Adverse Reactions
BCG
Newborn
0.05 mL
Intradermal Immune deficiency, progressive
Abscess or ulcers at the site of injection

>1 month 0.1 mL
dermatoses
axillary lymphadenopathy which may


caseate, disseminated BCG 0.1/100,000

vaccinees; BCG osteitis 0.1-0.3/100,000

vaccinees
Diphteria - tetanus
2,4,6 months
0.5 mL
IM
Acute febrile illness. Convulsions
Fever; at times associated with somnolence &/
and pertussis vaccine
18 months
or other severe reactions (anaphylaxis
or convulsions attributed to pertussis
(DTP)
4-6 years
or collapse) to previous dose of DTP
vaccine; prolonged crying

give DT instead
Trivalent Oral
2,4,6 months
0.5 mL
PO
Altered immune states (leukemia,
Paralysis (0.06 million doses among
Polio-Virus
18 months
lymphoma, malignancy, therapy with
recipients 0.14 million doses among
Vaccine (TOPV)
4-6 years
alkylating drugs, antimetabolites,
contacts of recipients)

steroids or radiation; pregnancy
DTP + Inactivated
2,4,6 and 18
0.5 mL
IM
Acute febrile illnesses
Fever local reaction erythema, pain,
Polio Virus
mos, 4-6 years
edema
(IPV) Vaccine
Attenuated measles
6 months
0.5 mL
SC
Altered immune state as listed above
Local reaction simulating an Arthus
vaccine (Edmondston
Acute febrile illness
phenomenon, 1-8 days after vacZagreb strain) or
Untreated active tuberculosis
cination; fever with or without
Live further attenuated 9 months
SC
Immunoglobulin administration
measles - like manifestations about
(Schwartz strain)
within 3 months
6th-12th days after vaccination
measles virus vaccine
Marked hypersensitivity to vaccine
Measles, Mumps,
components;
Fever, malaise, encephalitis, skin eruptions;
Rubella vaccine
Allergy to eggs;
Fever, hypersensitivity reactions, rash,
(MMR)
Pregnancy
unilateral nerve deafness; transient

arthralgia and peripheral neuritis
Live mumps virus
15 months
0.5 mL
SC
vaccine*
11-12 years
Live rubella virus
15 months
0.5 mL
SC
vaccine*
Diphtheria -
14-16 years
0.5 mL
IM
Acute febrile illnesses
Fever
tetanus toxoids
& every
adult type (Td)
10 years

thereafter

TABLE I. ACTIVE IMMUNIZATION OF INFANTS AND CHILDREN

CHILDHOOD TUBERCULOSIS
CPM 1ST EDITION

Altered immune state as listed

above
Acute febrile illness
Untreated active TB
Immunoglobulin administration
within 3 months

General reactions: Fever, papulovesicular

reactions noted 7-21 days after
immunization

Local pain and erythema

*1. When immunization is initiated at 7-11 months, recommended regimens/or toth HBOC and PRP-OMP and PRP-T are identical viz. 3 doses-first 2
doses yven at 1 months interval, 3rd dose pven at 15-18 months ofay. Any conjugate vaccine for 3rd dose.
2. When immunization is initiated at 11-li months, the recommended regimens for these three vaccines are identical viz. 2 doses
given at 2-3 months interval.
3. When immunization is initiated at 15 months or older, the recommended regimen is a single dose of any licensed conjugate vaccine
(HBOC or PRP-OMP, PRP-T).

Live attenuated varicella 9 months

1
SC
vaccine

TABLE I. ACTIVE IMMUNIZATION OF INFANTS AND CHILDREN

Immunizing Agents
Age
Dose
Route
Contraindications
Adverse Reactions
Hepatitis A Vaccine
>2 years
Follow
IM
Hypersensitivity to any component
Local reactions include erythema,

manufacturer's
of the vaccine swelling and

recommendation
warmth.
Hepatitis B Vaccine
Birth
Follow
IM
Hypersensitivity to any component
Systemic complaints include fever,

manufacturer's
of the vaccine malaise, fatigue, headache,

recommendation
dizziness, myalgia and nausea.
Hemophilus influenzae
B vaccine (Hib)
a. HBOC
2,4,6 months
IM
None
None
(conjugated with
booster
Diphtheria toxoid)*
15 months

b.PRP-OMP
2,4 months
IM
None
None
(conjugated
with N. memnytidis)
booster
Follow

12 months

manufacturer'
c.PRP-T (conjugated 2,4,6 months
IM
None
None
with tetanus toxoid)
booster
instructions

15 months

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

243

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

TABLE II.
RECOMMENDED IMMUNIZATION SCHEDULE FOR CHILDREN
NOT IMMUNIZED IN THE FIRST YEAR OF LIFE
Recommended Time

Immunizations

Comments

Less than 7 years old

First visit
DTP, TOPV or DTP

IPV, MMR, Hib* HBV

MMR - if child 5 months old;

tuberculin testing (TT) should be
done; if TT negative, give BCG

Interval after first visit

2 months
DTP, TOPV or DTP

IPV; HBV (Hib)

4 months

Second dose of HIB is indicated

only in infants whose 1st dose
was received <15 months.

DTP, TOPV or DTP

IPV

10-16 months
DTP, TOPV or DTP

IPV HBV

Age 4-6 years
DTP, TOPV or DTP
(at or before school entry)
IPV


Age 11-12 years

MMR

Age 14-16 years

Td
life

DTP, not necessary if the fourth

dose was given after 4th birthday;
not necessary if 3rd dose was
given after 4th birthday.

Repeat every 10 years throughout

7 years old and older

First visit

Td; TOPV or IPV,

MMR, HVB

Interval after first visit

2 months

Td, TOPV pr IPV

8-14 months

Td, TOPV or IPV

11-12 years

MMR

10 years later

Td

* HBCV - Hemophilus influenzae type B conjugate vaccine

244

Repeat every 10 years throughout life

TABLE III. ACTIVE IMMUNIZATION NOT ROUTINELY GIVEN TO INFANTS AND CHILDREN
Immunizing Agent
Dose
Route
Indications
Contraindications
Adverse Reactions
Cholera Vaccine
a.Classic (Ogawa &
1.0 mL
Residence in endemic areas, threat Age: below 1 year
Inaba strains)
every 6 months
SC
of epidemic
Acute febrile illness
b. El Tor
Travel to & from countries where
Strong reaction to previous immunization

cholera is rampant
c. Attenuated strain
Vibrio cholerae
1 sachet
Oral
Age: below 2 years; concomitant
Transient mild diarrhea, nausea,
CVD103-HgR
(2x102 viable
antibiotic use; hypersensitivity to the
abdominal cramps

organisms
vaccine and the buffer components;

of attenuated
congenital or acquired immune

strain)
defficiency, concomitant treatment with

immunosuppressive or antimitotic
Cholera - Typhoid
0.5 mL, 2 doses,
SC
Residence in endemic areas
drugs
Vaccine
1 mo apart yearly
Rabies Vaccine
Rabies post-exposure prophylaxis
a.HumanDiploid
1.0 mL on the
IM
is recommended for all persons 1.)
Anaphylactic, neuropara-lytic
Cell Vaccine
day of the bite
itten or scratched by wild or
reactions (rare)
(HDCV)
(DO) & repeated
domestic animals that may be
Fever, nausea

doses at D3, D7,
infected, 2.) who report having an
In view of gravity of disease all
Pain, erythema & indura-tion at

D14 & D28(D90
open wound or mucous membrane contraindications are secondary in
site of injection

optional)
contaminated with saliva or other
casesof suspected rabies
Fever, malaise, myalgia
b.Inactivated
0.5mLDO,D3,
IM
potentially infectious material (eg
contamination
Serum sickness
Rabies
D7,D14,
brain tissue) from a rabid animal,
Neuroparalytic reactions (rare)
(vero cell)
D30(D90 optional) SC
3.) who report a possibly infectious

exposure (eg bite, scratch, or open
c. Duck Embryo
1.0mLDO,D3,
SC
wound or mucous membrane
Vaccine (DEV)
D7,D14,
contaminated with saliva or othe

D28.D90
IM
infectious material) to a human

with rabies.
Typhoid Vaccine
a.Parenteral
1-4 years: 0.25 mL SC

> 5 years: 0.5 mL
Residence in endemic areas
Age: below 2 years
Pain at site of injection

2 doses, 1 month
Acute febrile ilhess; proteinuria,
Fever, convulsions or chills,

apart,
progressive disease; Pregnancy
headache, malaise

every 3 years
b.Oral
1 cap to be taken
Oral
Residence in endemic areas
Acute intestinal & febrile infections
Mild gastrointestinal

1 hour before a
Immune deficiency-
disturbances, rarely

meal on Dl, D3, D5
congenital or acquired

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

245

246

Polio
6 weeks
2 drops or 3
3
PO
Mouth
4 weeks

depending on

manufacturer's

instructions
Hepatitis Minimum age
Follow
3
IM
Antero-lateral
4 weeks
B Vaccine Birth
manufacturer's
aspect, thigh

instructions
(infants)
Measles Minimum age
0.5 mL
1
SC
Outer part of

6 months
BCG2
at school entry
0.1 mL
1
Intradermal
left deltoid

whether or not

child has BCG

scar
Tetanus Women of child 0.5 mL
5
IM
deltoid region
TTl at 1st contact,
toxoid
bearing age
TT2 at least 4 wks

after TTl

TT3 at least 6 wks

after TT2,

TT4 at least 1 year

after TT3,

TT5 at least 1 year

after TT4

For those not given primary

immunizations in infancy
and childhood

Vaccine damaged by heat

and sunlight

Vaccine easily damaged

by heat
Vaccine destroyed by heat
and sunlight

Vaccine destroyed by
freezing and heat

Vaccine easily damaged

by heat

TABLE IV. EXPANDED PROGRAM ON IMMUNIZATION (EPI) OF THE DEPARTMENT OF HEALTH

Vaccine Minimum Age
Dose
Number
Route of
Site of
Minimum Interval
Remarks

of Dose Administration
Administration
between doses
BCG 1
Birth; any time
0.05 mL for
1
Intradermal
Right deltoid
Vaccine destroyed

after or 6 weeks newborns; 0.1
region of the arm
by heat and sun

mL for older
light

infants
DTP
6 weeks
0.5 mL
3
IM
upper outer
4 weeks
Vaccine damaged by heat

portion of thigh
and freezing; DTP not

given to > 6 years old
give Td if available

CHILDHOOD TUBERCULOSIS
CPM 1ST EDITION

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

PASSIVE IMMUNIZATION
1. Indications for the administration of preformed
antibody to provide temporary protection to an
unimmune recipient.
Congenital or acquired 6-lymphocyte cell
defects alone or in combination with other
immunodeficiencies.
When no vaccine for a given disease is avail
able and prevention or modification is possible
by anti body.
When time does not permit adequate protection
by active immunization alone (e.g. postexpo-
sure to measles, rabies, hepatitis B or tetanus
prophylaxis).
When a specific toxic effect of venom is best
managed by antibody administration (e.g.
poisonous snake bite).
Therapeutically, when a disease is already
present, and antibody may ameliorate or aid
in suppressing the toxin effects (e.g. botulism,
diphtheria, tetanus).
N.B. Passive immunization must be given as
soon as possible after exposure to be able to
prevent the infection.
2. Types of products available for passive immunization
Normal (standard) human immunoglobulin for
general use (gamma globulin)
a. Intramuscular immunoglobulin (IGIM)
b. Intravenous immunoglobulin (IGIV)
Specific (special) human immunoglobulin
(for intramuscular use only) - e.g. Hepatitis B,
Varicella-Zoster, Rabies, Tetanus immunoglobu
lins, etc.
Human plasma/blood
Animal sera and antitoxins - Tetanus antitoxin,
Diphtheria antitoxin. Rabies immune serum,
Botulism antiserum, Black widow spider anti
venin. Snake bite antivenin, etc.

247

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

TABLE V. PASSIVE IMMUNIZATION IN INFANTS AND CHILDREN

Disease

Preparation

Antibody
IGIM
Immunodeficiency

Goal and Dose

Treatment: 0.7 mL/Kg
every 2-4 weeks

Indications/Comments
Double dose at onset of therapy;
give at multiple sites.

IGIV
Treatment: 2 mL/Kg of

5% preparation; 3.3 mL/

Kg of 3% preparation

Also for ITP& Kawasaki disease;

more predictable blood levels
but more frequent side effects
and higher cost.

Diphtheria
Diphtheria
Prevention: 5,000 units
Antitoxin

For symptom-free, positive

culture and positive Schick test.

Treatment:

See below*
40,000-120,000 units

Hepatitis A
IGIM

Prevention: Single
exposure - 0.04 mL/Kg

Household contacts: higher dose

in adults with heavy exposure.

Continuous exposure:
0.02 - 0.06 mL/Kg

Repeat in 4-5 months if exposure

continues.

Hepatitis B
IGIM

Prevention:
0.06 - 0.12 mL/Kg

Use if HBIG is unavailable or

exposure is uncertain.

Hepatitis B
Postexposure prophylaxis

Immuno-
in newborns: 0.5 mL at

birth within 12 hours

Others: 0.06 mL/Kg or 5

mL for adults within 24

hours; repeat 4 weeks later

for those who choose not to

receive Hepatitis B vaccine

For newborns delivered from

mothers with Hepatitis B
(HBsAg+globulin(HBIG)
especially those with HBeAg+).
Accidental puncture of skin by
contaminated needle.
Splashing of infected blood into
mucous membrane.
Accidental injection of infected
blood.

Hepatitis C
IGIM
Prevention: 0.12 mL/Kg
(non A, non B)

Use with transfusions under

special circumstances.

Measles
IGIM

Susceptible normal infants &

children**
Susceptible
immunocompromised patients

Prevention:
0.25 - 0.50 mL/Kg
Prevention: 0.50 mL/Kg
(max 15 mL)
Modification: 0.05 mL/Kg

Measles
Prevention: 0.04 mL/Kg
Immuno-

For susceptible normal infants

and children

* Suggested doses: Mild nasal or pharyngeal

-40,000units

Moderately severe pharyngeal
- 80,000 units

Severe pharyngeal or laryngeal or extensive diseases > 48 hour duration,

or brawny swelling of the neck
-120,000 units
** If modified measles did not occur, vaccinate with live attenuated measles vaccine after 3 months.
248

CPM 1ST EDITION

CHILDHOOD TUBERCULOSIS

TABLE V. PASSIVE IMMUNIZATION IN INFANTS AND CHILDREN

Disease

Preparation

Goal and Dose

Indications/Comments

Varicella
VZIG
Modification: 2-5 mL

Newboms whose mother developed

varicella prior to or soon after
delivery; patients on corticosteroids,
altered immune status.

IGIM

Use in high risk patients if VZIG is

unavailable or unaffordable.

Modification:
0.6 -1.2 mL/Kg

Rabies
Rabies human
Prevention: 20.0 iu/Kg

immunoglobulin
1/2 IM 1/2 around

(RIG)
wound

Multiple bites regardless of the

presence or absence of signs of
rabies in animals; single bites in
whom rabies cannot be ruled out.

Use only if RIG is unavailable or

unaffordable.

Anti-rabies
Prevention: 40.0 iu/Kg
equine serum
(ARS)

Rubella
IGIM


Tetanus
Tetanus human

immunoglobulin

(TIG)

Prevention: 0.55 mL/Kg

or 20 mL

Use only during pregnancy;

efficacy unreliable

Prevention: 250 units

Treatment: 500 units

Susceptible infants and children*

Tetanus antitoxin

(ATS)

Prevention: 3,000-5,000
Use when TIG is unavailable or
units
unaffordable**
Treatment: 500 units/Kg
or 5,000 units to newborns, 10,000 units to
children, 20,000 units to
adults

Poliomyelitis

Prevention: 0.15 mL/Kg

IGIM

Rarely indicated

As antitoxin to neutralize circulating toxin: Tetanus Immune Globulin (TIG) is preferred, 3,000 - 6,000 units,
intramuscularly, although some experts claim that 500 units is just as effective as a larger dose (part may be
infiltrated around the wound); repeated doses are not reauired.

As control measure in Passive Immunization: TIG, 250 - 500 units, intramuscularly or Tetanus antitoxin,
3,000 - 5,000 units, intramuscularly (after careful screening and testing for sensitivity to it.
** Alternative drug: Tetanus Antitoxin (ATS), 500 units/Kg BWor 5,000 units to newboms, 10,000 units to children,
20,000 units to adults; 1/2 intravenously and the rest intramuscularly. Intradermal test must be done one
hour before serum administration except in newborns in whom sensitivity testing can be dispensed with.

As control measure in Passive Immunization: TIG, 250 - 500 units, intramuscularly or Tetanus antitoxin,
3,000 - 5,000 units, intramuscularly (after careful screening and testing for sensitivity to it).

Reference

Handbook on Infectious Diseases, Philippine Pediatric Society, Inc.,

1992 Edition, pp. 2-11
249

CHILDHOOD TUBERCULOSIS

CPM 1ST EDITION

Drugs Mentioned in the Treatment Guideline

This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing Information of these
drugs can be found in the Philippine Pharmaceutical Directory (PPD) 1997. Opposite the brand name is its page
number in the PPD 1997.
Active Immunization
BCG
Lyophilized BCG
Vaccine...........................120
Diphtheria, Tetanus,
Pertussis, Polio Myelitis
(DPTIOPV)
Anatetall.............................113
Difpertetall.........................113
Diftetall Ped/Diftetall
Adult Use........................113
Dite Anatoxal Berna
(Chldn)/DiteAnatoxal
Bema (Adult)..................113
Diteper Anatoxal
Bema...............................113
D.P.T.................................. 113
Pentact-HIB........................113
Polioral/Polio
Vaccine............................113
Polio Sabin.........................113
Poliovirus Vaccine Live
Oral Trivalent..................113
Te Anatoxal Bema..............114
Tetavax...............................114
Tetracoq..............................114
Tetract-HIB........................114
Tritanrix............................NP*
Influenza
Act-Hib..............................120
Hibtiter................................120
Inflexal Berna ....................120
Vaxigrip..............................120
Measles, Mumps, Rubella
(MMR)
Biviraten Bema...................114
Ervevax .............................114
Gunevax.............................114
Lirugen...............................114
MMR II..............................114
Moraten Bema....................116
Morbilvax...........................116
Morupar..............................116
Mumaten Bema..................116
MumeruVax........................116
Rimevax ............................116
RubeatenBema...................116
Trimovax Merieux ............116

Triviraten Bema ................116

Hepatitis B
Engerix-B...........................116
Tritanrix............................NP*
H-B-Vax II..........................118
Hepavax-B..........................118
RecomvaxB........................118
Passive Immunization
Diphtheria, Tetanus
IG Tetano/Tetanus
Immune Globulin
(Human)..........................120
Purified Tetanus
Antitoxin.........................120
Tetaglobuline......................121
Tetanus Antitoxin
Bema...............................121
Tetuman Berna ..................121
Tosuman Bema...................121
Hepatitis A &B
GlobumanBema..............121
Globuman Hepatitis
Bema...............................121
Hepabig...............................121
Measles
MorumanBema...................121
Rabies
Imogam Rabies...................121
Pasteur Antirabies
Serum..............................121
Rabies Antiserum
Bema..................................121
Rabuman Berna..................121
Other Immunologicals
GlobumanBema..................122
IG Gamma..........................122
Sandoglobulin.....................122

*NP - Product Information can be found in PPD 19971st Supplement

250