TB in children: How South Africa’s new pediatric TB guidelines aim to close the childhood TB diagnostic gap
By: Aphelele Buqwana
In many South African homes, a child’s cough is often dismissed as a cold, something spurred on by cold weather or a throat itch that will pass. But for thousands of children, that cough could be a sign of TB.
According to experts, children are often the most overlooked group affected by the disease. Those under the age of five and children living with HIV face a higher risk. Their vulnerability is linked to different clinical presentations and challenges in screening, diagnosing, treating and preventing childhood TB.
In 2024, about 249 000 people developed TB in South Africa and an estimated 22 000 of them were children. Many of these children are either diagnosed too late or missed entirely from the health system, contributing to preventable illness and deaths.
The World Health Organization (WHO) estimates that while just over 16,500 children under the age of 15 were reported with TB in 2022, nearly 27,000 of them likely develop the disease each year. This means around 39% of cases are not captured by the health system.
It is in this persistent gap in diagnosing children with TB that South Africa updated its National Paediatric TB guidelines, released in September 2024, which aimed to close this gap.
Dr Karen Du Preez, Chair of South Africa TB Think Tank Child, Adolescent and Maternal TB Task Team and a leading expert in paediatric TB, says the revised guidelines presented more than a technical update and mark a change towards making childhood TB diagnosis and treatment more accessible at primary healthcare level.
“The guidelines included important updates for children, such as the addition of additional types of specimens for diagnosis, the use of a treatment decision algorithm and treatment shortening for children with non-severe drug-susceptible TB,” says Du Preez. “These changes aim to reduce the diagnostic gap in children and enable healthcare workers at lower levels of care, such as primary healthcare (PHC) facilities, to make the diagnosis with the diagnostic tools they have available.”
Diagnosing TB in children has long been a challenge. According to WHO and South Africa’s 2024 paediatric guidelines, children with TB often cannot produce the sputum needed for standard TB tests and the disease typically contains fewer bacteria, making laboratory confirmation difficult.
Symptoms such as cough, fever and weight loss are often non-specific and can be mistaken for other childhood illnesses. Limited access to chest X-rays at primary healthcare level and a health system historically designed around adult TB have further compounded the problem.
Du Preez, describes this as a “persistent diagnostic gap” that leaves thousands of children undiagnosed each year.
Following the release of the 2024 paediatric TB guidelines, the National TB Think Tank’s Child, Adolescent and Maternal TB Task Team developed a “Management of Tuberculosis in Children and Adolescents – A Quick Reference Guide” to support healthcare workers at the point of diagnosis, which was released in September 2025.
The guide incorporates not only the updated TB guidelines, but also guidance on TB prevention and the management of drug-resistant TB.
“It is designed to make it easier for healthcare workers to diagnose and manage TB in children using the tools they have at primary care facilities,” says Du Preez.
The team also collaborated with Aquity Innovations to create resources for caregivers and families, helping them support children through diagnosis and treatment.
“Both tools were released recently and will support healthcare workers on the ground in closing the diagnostic gap for TB in children in South Africa,” she adds.
Prevention gaps remain
Even with better tools for diagnosis and treatment, preventing TB in children is still a major challenge in the country. Du Preez says TB contact management and TB preventive therapy (TPT) are “critically important” in the efforts to reduce the TB burden in children and explains that young children remain at the highest risk of developing TB after exposure, making it vital to strengthen prevention strategies in high-burden communities.
She also adds that the updated guidelines aim to make TPT more practical.
“As shorter preventive therapy regimens become available, we need to make sure children can access them in formulations that are suitable for them.”
Changing how TB is diagnosed
An important innovation in the new guidelines is the introduction of a treatment decision algorithm (TDA). The algorithm allows clinicians to make a clinical diagnosis of TB even in primary healthcare settings without access to chest X-rays (CXRs) or microbiological testing.
Training healthcare workers on the TDA is expected to not only increase the diagnosis of non-severe TB in children but also encourage more cases to be identified at lower levels of care, rather than being referred to hospital for investigation.
“Training healthcare workers on using the TDA can increase diagnosis of non-severe TB in children and encourage diagnosis at lower levels of healthcare,” explains Du Preez.
She adds that ongoing mentoring of primary healthcare personnel will be critical to build confidence and expertise, optimising the implementation of the TDA.
Implementation challenges
The updated guidelines simplify treatment dosing and introduce a shortened four-month regimen for children with non-severe TB. This aims to reduce the treatment burden on children and their families, while maintaining excellent treatment outcomes.
“Treatment outcomes in children are generally very good, but shortening treatment by two months significantly reduces the burden on children, families and healthcare services,” she states. This recommendation, according to Du Preez, allows more children to complete treatment successfully and supports better overall adherence.
While the guidelines provide new tools, implementing them in practice comes with challenges, especially in rural or resource-limited areas. Access to Chest radiography (CXRs) remains limited at primary healthcare level and interpreting imaging often falls outside the scope of nurses, who are frequently the first point of care.
“To address this gap, the TDA allows clinicians to diagnose TB without a CXR. However, I think that one of the main challenges is often the lack of confidence at PHC level to diagnose TB in children,” she says.
Prof Du Preez explains that “inexperienced PHC clinicians might find it difficult to decide if a child is eligible for treatment shortening if they do not have a CXR, which may result in children not benefitting from the new treatment shortening recommendations.”
She points out the need for digital and ultraportable CXRs, supported by computer-aided detection (CAD) software trained specifically for children.
“Portable and ultraportable CXR devices are already being tested and we are expecting CAD software specifically trained for children to become available within the next 12–18 months,” she says.
Another challenge that Du Preez has raised in implementing the new guidelines is the documentation of shortened treatment. She states that “the current TB surveillance data tools are not able to capture successful outcomes for shorter treatment durations than the standard 6 months.”
However, despite these hurdles, she believes the new guidelines bring South Africa closer to its child TB elimination targets.
“It definitely moves us closer, but there are still a lot for us to do,” she says. “We also need to monitor and evaluate the impact and implementation practices of the new guidelines in urban and rural settings across the country.”
Recent successes and future outlook
According to Du Preez, the country has made significant progress over the past decade in paediatric TB diagnosis, treatment and prevention. Advances in technology and guideline development are helping to close the gap in childhood TB care.
She says digital chest X-rays supported by CAD software are a major step forward.
“In my opinion, digital CXRs with CAD to identify TB in children will be a very important step forward for us.”
Looking ahead, she stresses the need of ongoing collaboration and support for healthcare workers.
“If we really want to address the diagnostic gap for childhood TB, we need to continue working together across sectors and disciplines to find new and better diagnostic tools and approaches. We also need to support healthcare workers to optimise implementation of new and existing evidence-based interventions,” Du Preez adds.
Link to the guidelines which was released in 2024:
https://knowledgehub.health.gov.za/elibrary/management-tuberculosis-children-and-adolescents
The link to the new resources that was recently released:
Management of Tuberculosis in Children and Adolescents – A Quick Reference Guide