Post-tuberculosis lung disease in children and adolescents: Myth or reality – A narrative review

INTRODUCTION

Childhood tuberculosis (TB) is a major cause of illness in high-burden settings, with an estimated 1.2 million new cases and 174,000 deaths among children under 15 years in 2024.^[1] Africa bears a disproportionate share of this burden, with many African countries among the 30 high TB burden countries globally, highlighting a significant number of incident and undiagnosed cases.^[1] Moreover, programmatic efforts have tended to prioritize bacteriological cure and treatment completion in adults, with limited emphasis on long-term respiratory outcomes, especially in children.^[2]

Historically, clinicians believed that children recover fully after TB treatment, largely because of the often paucibacillary and non-cavitary nature of pediatric disease, and because structured post-treatment follow-up has generally been lacking.^[3] However, emerging evidence now challenges this assumption and highlights the need for systematic evaluation of post-treatment lung health and well-being alongside traditional cure metrics.^[4]

Post-TB lung disease (PTLD) refers to chronic respiratory impairment that is at least partially attributable to prior TB, diagnosed after excluding active TB and other common causes of chronic lung disease.^[5] Recognition of PTLD typically relies on the presence of persistent respiratory symptoms, impaired lung function, or imaging abnormalities after treatment.^[6,7] In many cases, the lack of pre-TB baseline data complicates attribution of post-TB impairments to the TB disease.^[8] Most mechanistic insights are extrapolated from adult studies, underscoring the need for pediatric-specific evidence. Current recommendations support structured follow-up for children, especially after severe disease or persistent symptoms, using symptom screening, age-appropriate lung function testing, and chest imaging.^[5]

This narrative review synthesizes evidence establishing PTLD as a clinically relevant outcome of pediatric TB. We first explore how the traditional focus on bacteriological cure has limited recognition of long-term impairment. We review current research on post-treatment symptoms and the clinical, functional, and radiological features of pediatric PTLD, including age-related trajectories and emerging considerations for adolescents. Finally, we identify research and policy priorities, including harmonized definitions, practical screening strategies, and rehabilitative interventions, as well as implementation considerations for integrating post-TB follow-up within African health systems. We conclude by emphasizing the need to integrate structured post-TB follow-up into child health services and strengthen diagnostic capacity and pediatric lung-health expertise, particularly in Africa. To frame this argument, we next describe how biological, diagnostic, and programmatic factors contributed to PTLD in children being viewed as a “myth.”

For this review, we searched PubMed for English-language literature on PTLD and respiratory outcomes in children and adolescents, with no date or study design restrictions (through December 2025), prioritizing evidence from high-burden African settings. Consistent with a narrative approach, studies were selected on the basis of relevance and expert judgment rather than a formal protocol-driven search; where pediatric evidence was limited, we drew on adult data and have identified it as such.

THE DEVELOPING LUNG AND THE ORIGINS OF THE MYTH OF PTLD IN CHILDREN

Myth sustained by invisibility

Taken together, the assumption of full recovery, the difficulty of attributing later abnormalities to past TB, and systemic neglect have reinforced the belief that PTLD in children is either rare or irrelevant, even though the biological vulnerability of the developing lung points the other way. Emerging data now challenge this view. Across multiple studies in high-burden settings, evidence shows that respiratory abnormalities often persist after TB treatment completion in children, even when cure has been achieved.^[33-37] The persistence of the myth reflects not an absence of disease, but an absence of structured follow-up, accessible diagnostics, and a workforce equipped to detect and manage it [Figure 1].

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Figure 1: The pediatric post-tuberculosis lung disease (PTLD) paradigm: From myth to integrated action. An assumption of full recovery, together with disease-related and systemic factors, sustained the perception that PTLD in children is rare or unimportant. The biological vulnerability of the developing lung instead underpins the plausibility of PTLD, and emerging evidence redefines it as a real, measurable outcome of childhood tuberculosis (TB), motivating the integration of structured PTLD care into pediatric TB services.

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The following section summarizes the evidence that has begun to redefine PTLD in children as a measurable clinical entity.

WHAT THE EVIDENCE SHOWS: PEDIATRIC PTLD AS A CLINICAL REALITY

Evidence from prospective cohorts and post-treatment assessments increasingly demonstrates that PTLD is a clinically relevant outcome of childhood TB, characterized by persistent symptoms, radiological abnormalities, and functional impairments that often continue after treatment completion.^[33-37] These abnormalities are heterogeneous and often go undetected without a structured post-treatment assessment.

Recent studies further suggest that the burden and phenotype of PTLD are age-dependent, likely reflecting differences in disease spectrum and the timing of TB relative to critical windows of lung development. Across recent cohorts, older children and adolescents show a higher prevalence of post-treatment lung function impairment than younger children, affecting approximately 40% of those aged 5–10 years and rising to around 60–65% among those older than 10 years.^[33,37,38]

The Drakenstein Child Health Study in South Africa provides particularly strong causal evidence linking TB to later respiratory impairment.^[34] In this birth cohort with repeated pre- and post-TB lung assessments, TB occurring in the first 5 years of life was associated with reduced lung function independent of premorbid lung function, supporting a direct effect of TB on lung development. Children who developed TB were more likely to wheeze and, by age 5, showed reduced tidal-breathing indices compared with their peers. Importantly, respiratory outcomes varied by age at disease onset, with distinct lung function trajectories observed among children who developed TB in infancy compared with those infected between 1 and 4 years of age.

Other longitudinal studies from across Africa have compared children with microbiologically confirmed TB to those with non-TB lower respiratory tract infections.^[37,38] These studies show divergent lung function trajectories, with confirmed TB often associated with persistently reduced lung function and, in some cases, progressive decline. Control groups, including asymptomatic peers and those with non-TB respiratory illness, also showed poor lung function, suggesting a broader population-level burden likely driven by undernutrition, air pollution, tobacco smoke, and recurrent lower respiratory tract infections in these settings.^[36,37]

TB appears to add an additional and distinct layer of impairment within this vulnerable baseline. Risk appears greatest in children with more severe disease, destructive parenchymal involvement, or airway complications, and in those who remain symptomatic at treatment completion.^[39] However, this evidence derives almost entirely from southern and western Africa, with little or no pediatric data from north or central Africa. Similarly, children under five remain under-represented, largely because reliable lung function testing is difficult in this age group.

Clinically, PTLD manifests in multiple ways.^[35-38] Children frequently report exertional breathlessness, persistent or recurrent cough, and fatigue. Spirometry may demonstrate restrictive, obstructive, or mixed patterns of impairment, with restrictive abnormalities reported most commonly, as seen in adults.^[20] Systematic radiological reporting remains limited; however, chest radiographs often show fibrotic bands, volume loss, peribronchial thickening, or hyperinflation. Bronchiectasis is observed in a subset of children, particularly those with severe or recurrent TB. Importantly, these features do not consistently align; symptoms, imaging findings, and lung function findings may be discordant, reinforcing the need for combined assessment using multiple modalities.^[40]

Computed tomography (CT) is the gold standard for characterizing structural lung abnormalities in children and adolescents with TB and following treatment completion. However, its use remains limited in most African settings because of cost, radiation exposure, and restricted availability outside tertiary centers.^[41] As a result, CT is typically reserved for complex cases requiring referral. For the majority of children, chest radiography combined with symptom assessment and spirometry provides the most feasible basis for detection and clinical decision-making in routine care.

Adolescents, though rarely studied in detail, may be at particular risk. They are more likely to experience adult-type TB, including cavitation and delayed diagnosis, both of which increase the likelihood of long-term lung injury.^[42] Few longitudinal studies focus specifically on adolescent TB survivors, but emerging data suggest that PTLD may impair physical health, school attendance, and psychosocial well-being during this critical developmental stage.^[36,43,44]

While evidence remains limited, there is growing interest in developing structured follow-up approaches within TB programs in Africa. Some observational studies and pilot initiatives have incorporated symptom review, growth monitoring, oxygen saturation, spirometry, and chest radiography to identify children and adolescents with persistent impairment.^[35-38] These emerging models point toward the potential value of integrated PTLD assessment but require further evaluation to confirm feasibility, cost-effectiveness, and sustainability in routine care; they also highlight the policy and health-system requirements discussed in the next section.

RESPONDING TO PEDIATRIC PTLD: CURRENT PRACTICES, INNOVATIONS, AND REMAINING GAPS

A CALL TO ACTION: INTEGRATING PTLD INTO PEDIATRIC TB CARE

Pediatric TB care should not end at treatment completion. A shift is required from cure-centered metrics to recovery-oriented care that recognizes long-term lung health as a core outcome of TB programs.^[47,62] This is particularly relevant in Africa, where children face overlapping respiratory risks and constrained access to respiratory services.^[20,63] Embedding PTLD monitoring within routine care also supports progress toward universal health coverage by strengthening chronic disease follow-up, continuity of care, and equitable access to essential diagnostics and rehabilitation.^[64]

A practical starting point is to institutionalize structured post-treatment follow-up as a standard component of pediatric TB management. At a minimum, children with severe disease, drug-resistant TB, or persistent respiratory symptoms should receive scheduled assessments at treatment completion, with at least one additional follow-up visit in the subsequent year, and longer surveillance for higher-risk children where feasible.^[8,46] These visits should focus on symptom review, growth and nutritional assessment, oxygen saturation where available, age-appropriate lung function testing, and chest imaging.^[5,46] This combined approach is summarized as a pragmatic framework for recognizing PTLD in routine care [Figure 2]. Care pathways should define clear thresholds for referral, recognizing that symptoms, lung function, and imaging may not align, and that combined assessment offers the most reliable basis for clinical decision-making in programmatic settings.

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Figure 2: A pragmatic framework for recognizing post-tuberculosis lung disease (PTLD) in children and adolescents in routine care. A conceptual framework to support recognition of PTLD in routine care; it is not a validated or definitive algorithm.

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Delivering this shift requires system-level investments in capacity, service organization, and referral networks. Training frontline clinicians to recognize PTLD and perform or refer for lung function testing is essential, but training alone is insufficient without functional pathways for supervision, quality assurance, and escalation.^[65] National TB programs and child health services should jointly establish referral routes linking peripheral clinics to district or regional facilities with spirometry, imaging interpretation support, and access to physiotherapy and rehabilitation.^[65] Rehabilitation packages should be pragmatic and scalable, including graded activity, breathing exercises, airway clearance techniques where appropriate, optimization of comorbidities, and nutritional support.^[57] Where specialist services are limited, remote mentorship and telemedicine-supported interpretation can extend expertise beyond tertiary centers and improve continuity of care.

Policy integration is the critical enabler. National TB guidelines should explicitly incorporate pediatric PTLD follow-up requirements, define minimum assessment components, and embed PTLD indicators into monitoring and evaluation systems. Indicators could include the proportion of eligible children assessed after treatment completion, proportions with persistent symptoms, abnormal lung function or imaging, referrals completed, and uptake of rehabilitation or follow-up care.^[46] This approach aligns with ongoing global policy momentum to improve outcomes across the full TB cascade, including initiatives such as the World Health Organization Child and Adolescent TB roadmap, which emphasizes child-centered models of care, better follow-up, and stronger health-system integration.^[25] For implementation to be durable, PTLD care should be linked to broader child health strategies and incorporated into essential service packages rather than treated as a vertical add-on.^[64]

Research priorities should focus on what is needed to operationalize PTLD care in real-world African settings. This includes harmonizing pediatric definitions and minimum datasets, validating feasible tools for younger children, and establishing longitudinal cohorts to characterize lung growth trajectories after TB across age groups, including adolescents.^[8] Implementation research is urgently needed to evaluate feasible delivery models at the district level, including workforce requirements, acceptability to families, costs, and pathways to sustainability.^[61] Intervention studies should assess the benefit of rehabilitation, nutritional and environmental risk mitigation, and integrated care models that combine TB follow-up with routine child health visits.^[66] Where advanced diagnostics are limited, research should also clarify which combinations of symptom screening, spirometry, and chest radiography provide the best yield for identifying clinically meaningful PTLD.

Finally, African-led innovation must be positioned as a central solution rather than a peripheral ambition.^[59,63] Regional networks can accelerate progress through shared protocols, South–South collaboration, and co-development of training materials, quality assurance approaches, and low-cost follow-up tools.^[58] Digital systems that support appointment tracking, symptom monitoring, and structured reporting can reduce missed follow-ups and improve continuity.^[67,68] With coordinated leadership from ministries of health, national TB programs, professional societies, and academic partners, post-TB care can evolve from an aspirational concept to a defined and measurable part of pediatric TB management.^[69,70]

In summary, pediatric PTLD is a credible and clinically meaningful consequence of childhood TB that requires a deliberate shift from cure to long-term recovery. Integrating structured follow-up into routine services, strengthening diagnostic and rehabilitation capacity, embedding PTLD indicators into program monitoring, and investing in African-led research and innovation are essential steps to reduce lifelong disability and improve the respiratory futures of children and adolescents affected by TB [Table 1].