Despite recommendations to provide isoniazid preventive therapy (IPT) to eligible children aged <5 years who are in close contact with an infectious tuberculosis (TB) case, IPT delivery in high-burden settings remains poor. To evaluate the current system supporting IPT delivery to children in an urban community, South Africa, we reviewed the recording practices of a local clinic regarding management of children exposed to a current adult TB case. No standardised IPT management tools existed. Only 21% of children eligible for IPT had documentation of IPT delivery. There is a need to implement systems that support IPT recommendations in high-burden settings.