The prevention, diagnosis, and treatment of tuberculosis (TB) in children are of particular importance in developing countries where TB is endemic 
. Child contacts of an adult with sputum smear–positive TB are at high risk of infection with Mycobacterium tuberculosis
and subsequent early progression to TB disease 
. Anti-tubercular antibiotic prophylaxis is highly effective in preventing progression to disease in children infected with M. tuberculosis
, with protection of up to 90% 
. Therefore, the World Health Organization (WHO) recommends that all children <5 years who are a household contact of a sputum smear–positive case should receive preventive treatment, once TB disease has been ruled out 
. Box 1
summarises the 2006 WHO recommendation for contact management as a symptom-based approach, whereby most child contacts can be placed immediately on preventive treatment without the need for formal clinical evaluation.
Box 1. A symptom-based approach to child contacts of adult TB cases
Children who are household contacts of a sputum smear–positive adult TB case are initially evaluated in the community. If asymptomatic and less than 5 years of age, they are immediately commenced on preventive treatment. If they have symptoms consistent with TB disease they are referred for clinical workup. Those diagnosed with TB disease undergo a full course of multi-drug treatment. Those less than 5 years of age who are not diagnosed with TB disease receive preventive treatment.
2006 WHO Guidance for National Tuberculosis Programmes on the Management of Tuberculosis in Children.
Of concern, the WHO recommendation for the management of child contacts of a sputum smear–positive index case is rarely implemented, despite being incorporated widely into National TB Control Program (NTP) guidelines 
. Possible reasons for this include that limited NTP resources are focused on the management of TB disease, the perceived need for specialised services and investigations to provide adequate clinical evaluation, and concerns regarding re-infection and poor adherence in relation to the development of resistance 
. Furthermore, attempts to implement the policy have been characterised by low attendance for screening, poor adherence to preventive treatment, and high defaulting rates 
. Specific barriers in relation to preventive treatment that have been identified include issues of knowledge, understanding, and perception in TB patients and TB program staff 
, lack of an appropriate management structure and necessary tools 
, treatment side effects 
, transport difficulties, and cost 
. However, the literature with respect to barriers in the management of child contacts of TB cases in developing countries is relatively sparse.
It is clear that there is a policy-practice gap that needs to be addressed. Here, we propose an evidence-based approach to close this gap and show how this can lead to the management of child contacts of TB cases being properly incorporated into NTP activities, applied in the community and clinic, and formally evaluated.