Pneumonia in children can be caused by viruses like RSV or bacteria like S. pneumoniae. Clinical features include fever, cough, respiratory distress. Chest x-ray confirms diagnosis and shows lobar consolidation in bacterial pneumonia. Treatment involves antibiotics for bacterial cases. Children under 6 months, with severe distress, or not improving require hospitalization. Complications include pleural effusions, empyema, or hematologic spread causing meningitis.

1. Pneumonia in childrenPneumonia in children
Presentation by: Dr. Sundar KarkiPresentation by: Dr. Sundar Karki

2. IntroductionIntroduction
 Pneumonia is an inflammation of thePneumonia is an inflammation of the
parenchyma of the lungs.parenchyma of the lungs.
 Pneumonia can be classified anatomically asPneumonia can be classified anatomically as
lobar or lobularlobar or lobular,, bronchopnemoniabronchopnemonia andand
interstitial pneumoniainterstitial pneumonia..
 Pathologically there is consolidation of alveoliPathologically there is consolidation of alveoli
or infiltration of the interstitial tissue withor infiltration of the interstitial tissue with
inflammatory cell or bothinflammatory cell or both

3. EtiologyEtiology
 ViralViral: It can be caused by RSV, influenza,: It can be caused by RSV, influenza,
parainfluenza or adenovirusparainfluenza or adenovirus
 BacterialBacterial: In first 2 months the common agents: In first 2 months the common agents
include klebsiella, E. coli, and staphylococci.include klebsiella, E. coli, and staphylococci.
Between 3 month to 3 years common bacteriaBetween 3 month to 3 years common bacteria
include S. pneumonia, H. influenza andinclude S. pneumonia, H. influenza and
staphylococci. After 3 years of age commonstaphylococci. After 3 years of age common
bacteria include S. pneumonia andbacteria include S. pneumonia and
staphylococci.staphylococci.

4. EtiologyEtiology
 Atypical organismAtypical organism: Chalmydia sps and: Chalmydia sps and
Mycoplasm in CAP in adult and children haveMycoplasm in CAP in adult and children have
more evidence.more evidence.
 Pnemuocystis cariniiPnemuocystis carinii: causes pneumonia in: causes pneumonia in
imunnocompromised children.imunnocompromised children.

5. Some termsSome terms
 Recurrent pneumoniaRecurrent pneumonia is definedis defined as 2 oras 2 or
moremore episodes in a single yrepisodes in a single yr or 3 or moreor 3 or more
episodes ever, with radiographic clearingepisodes ever, with radiographic clearing
between occurrences.between occurrences.
 Slowly resolving pneumoniaSlowly resolving pneumonia refers to therefers to the
persistence of symptoms or radiographicpersistence of symptoms or radiographic
abnormalities beyond the expected timeabnormalities beyond the expected time
course.course.

6. Clinical featuresClinical features
 Onset of pneumonia may be insidious startingOnset of pneumonia may be insidious starting
with URTI or may be acute with high fever,with URTI or may be acute with high fever,
dypsnea and grunting respiration.dypsnea and grunting respiration. RespiratoryRespiratory
raterate is alwaysis always increasedincreased..
 Rarely pneumonia may be present with acuteRarely pneumonia may be present with acute
abdominal emergency which is due to referredabdominal emergency which is due to referred
pain from the pleura. Apical pneumonia maypain from the pleura. Apical pneumonia may
sometime be associated with meningmus andsometime be associated with meningmus and
convulsion.convulsion.

7. Clinical featuresClinical features
 On examination there is flaring of alae nasi,On examination there is flaring of alae nasi,
retraction of lower chest and intercostalretraction of lower chest and intercostal
spaces.spaces.
 Signs of consolidation(diminished expansion,Signs of consolidation(diminished expansion,
dull percussion note, increased tactile vocaldull percussion note, increased tactile vocal
fremitus/vocal resonance, bronchial breathing)fremitus/vocal resonance, bronchial breathing)
can be seen in lobar pneumonia.can be seen in lobar pneumonia.

8. Clinical FeaturesClinical Features
 ViralViral: URTI, low grade fever, tachypnea,: URTI, low grade fever, tachypnea,
crackles, wheezing.crackles, wheezing.
 Bacterial- PneumococcalBacterial- Pneumococcal
- acute onset shaking chills with high fever,- acute onset shaking chills with high fever,
cough, chest pain, respiratory distress.cough, chest pain, respiratory distress.
-decreased breath sound, rales, dullness to-decreased breath sound, rales, dullness to
percussionpercussion

9. DiagnosisDiagnosis
 The chest radiograph confirms the diagnosis ofThe chest radiograph confirms the diagnosis of
pneumonia and may indicate a complication such as apneumonia and may indicate a complication such as a
pleural effusion or empyema.pleural effusion or empyema.
 Viral pneumonia is usually characterized byViral pneumonia is usually characterized by
hyperinflation with bilateral interstitial infiltrates andhyperinflation with bilateral interstitial infiltrates and
peribronchial cuffing.peribronchial cuffing.
 Confluent lobar consolidation is typically seen withConfluent lobar consolidation is typically seen with
pneumococcal pneumonia. If pneumatocele thinkpneumococcal pneumonia. If pneumatocele think
about staphylococci.about staphylococci.
 The radiographic appearance alone is not diagnosticThe radiographic appearance alone is not diagnostic
and other clinical features must be considered.and other clinical features must be considered.

10. DiagnosisDiagnosis
 The peripheral white blood cell (WBC) count can beThe peripheral white blood cell (WBC) count can be
useful in differentiating viral from bacterialuseful in differentiating viral from bacterial
pneumonia.pneumonia.
 In viral pneumonia, the WBC count can be normal orIn viral pneumonia, the WBC count can be normal or
elevated but is usually not higher than 20,000/mm3,elevated but is usually not higher than 20,000/mm3,
with a lymphocyte predominance. Bacterialwith a lymphocyte predominance. Bacterial
pneumonia (occasionally, adenovirus pneumonia) ispneumonia (occasionally, adenovirus pneumonia) is
often associated with an elevated WBC count in theoften associated with an elevated WBC count in the
range of 15,000-40,000/mm3 and a predominance ofrange of 15,000-40,000/mm3 and a predominance of
granulocytes.granulocytes.

11. DiagnosisDiagnosis
 Viral: viral culture or antigen isolation inViral: viral culture or antigen isolation in
respiratory secretion. Growth of respiratoryrespiratory secretion. Growth of respiratory
viruses in tissue culture usually requires 5–10viruses in tissue culture usually requires 5–10
days.days.
 Bacterial: sputum culture, no value in children.Bacterial: sputum culture, no value in children.
 Mycoplasm: IgM titersMycoplasm: IgM titers

12. TreatmentTreatment
 Treatment of suspected bacterial pneumonia is basedTreatment of suspected bacterial pneumonia is based
on the presumptive cause and the clinical appearanceon the presumptive cause and the clinical appearance
of the child.of the child.
 For mildly ill children who do not requireFor mildly ill children who do not require
hospitalization, amoxicillin is recommended. Inhospitalization, amoxicillin is recommended. In
communities with a high percentage of penicillin-communities with a high percentage of penicillin-
resistant pneumococci, high doses of amoxicillin (80–resistant pneumococci, high doses of amoxicillin (80–
90 mg/kg/24 hr) should be prescribed.90 mg/kg/24 hr) should be prescribed.
 Therapeutic alternatives include cefuroxime axetil orTherapeutic alternatives include cefuroxime axetil or
amoxicillin/clavulanateamoxicillin/clavulanate

13. TreatmentTreatment
 For school-aged children and in those in whomFor school-aged children and in those in whom
infection withinfection with M. pneumoniaeM. pneumoniae oror C.C.
pneumoniaepneumoniae (atypical pneumonias) is(atypical pneumonias) is
suggested, a macrolide antibiotic such assuggested, a macrolide antibiotic such as
azithromycin is an appropriate choice.azithromycin is an appropriate choice.
 In adolescents, a respiratory fluoroquinoloneIn adolescents, a respiratory fluoroquinolone
(levofloxacin, gatifloxacin, moxifloxacin,(levofloxacin, gatifloxacin, moxifloxacin,
gemifloxacin) may be considered for atypicalgemifloxacin) may be considered for atypical
pneumonias.pneumonias.

14. TreatmentTreatment
 The empirical treatment of suspected bacterialThe empirical treatment of suspected bacterial
pneumonia in a hospitalized child requires anpneumonia in a hospitalized child requires an
approach based on the clinical manifestations at theapproach based on the clinical manifestations at the
time of presentation.time of presentation.
 Parenteral cefuroxime (150 mg/kg/24 hr),Parenteral cefuroxime (150 mg/kg/24 hr),
cefotaxime, or ceftriaxone is the mainstay of therapycefotaxime, or ceftriaxone is the mainstay of therapy
when bacterial pneumonia is suggested.when bacterial pneumonia is suggested.
 If clinical features suggest staphylococcal pneumoniaIf clinical features suggest staphylococcal pneumonia
(pneumatoceles, empyema), initial antimicrobial(pneumatoceles, empyema), initial antimicrobial
therapy should also include vancomycin ortherapy should also include vancomycin or
clindamycin.clindamycin.

15. TreatmentTreatment
 If viral pneumonia is suspected, it isIf viral pneumonia is suspected, it is
reasonable to withhold antibiotic therapy,reasonable to withhold antibiotic therapy,
especially for those patients who are mildly ill,especially for those patients who are mildly ill,
have clinical evidence suggesting viralhave clinical evidence suggesting viral
infection, and are in no respiratory distress.infection, and are in no respiratory distress.
 Up to 30% of patients with known viralUp to 30% of patients with known viral
infection may have coexisting bacterialinfection may have coexisting bacterial
pathogens.pathogens.

16. TreatmentTreatment
 Therefore, if the decision is made to withholdTherefore, if the decision is made to withhold
antibiotic therapy based on presumptiveantibiotic therapy based on presumptive
diagnosis of a viral infection, deterioration indiagnosis of a viral infection, deterioration in
clinical status should signal the possibility ofclinical status should signal the possibility of
superimposed bacterial infection and antibioticsuperimposed bacterial infection and antibiotic
therapy should be initiated.therapy should be initiated.

17. Need of Hospital Admission ofNeed of Hospital Admission of
children with pneumoniachildren with pneumonia
 Age <6 monthsAge <6 months
 Sickle cell anemia with acute chest syndromeSickle cell anemia with acute chest syndrome
 Multiple lobe involvementMultiple lobe involvement
 Immunocompromised stateImmunocompromised state
 Toxic appearanceToxic appearance
 Severe respiratory distressSevere respiratory distress
 Requirement for supplemental oxygenRequirement for supplemental oxygen
 DehydrationDehydration
 VomitingVomiting
 No response to appropriate oral antibiotic therapyNo response to appropriate oral antibiotic therapy
 Noncompliant parentsNoncompliant parents

18. Clinical Classification to facilitateClinical Classification to facilitate
treatmenttreatment
Signs nSigns n
symptomssymptoms
classificationclassification therapytherapy Where toWhere to
treattreat
Cough or coldCough or cold
No fast breathingNo fast breathing
No chest indrawing orNo chest indrawing or
indicators of severe illnessindicators of severe illness
No pneumoniaNo pneumonia Home remediesHome remedies HomeHome
RR ageRR age
60 or more < 2 months60 or more < 2 months
50 or more 2-12 months50 or more 2-12 months
40 or more 12-60 months40 or more 12-60 months
PneumoniaPneumonia ClotrimoxazoleClotrimoxazole HomeHome
Chest IndrawingChest Indrawing Severe PneumoniaSevere Pneumonia IV/IM PenicillinIV/IM Penicillin HospitalHospital
Cyanosis, severe chestCyanosis, severe chest
indrawing, inability to feedindrawing, inability to feed
Very Severe PneumoniaVery Severe Pneumonia IV ChloramphenicolIV Chloramphenicol HospitalHospital

19. Response to the treatmentResponse to the treatment
 Typically, patients with uncomplicatedTypically, patients with uncomplicated
community-acquired bacterial pneumoniacommunity-acquired bacterial pneumonia
respond to therapy with improvement inrespond to therapy with improvement in
clinical symptoms (fever, cough, tachypnea,clinical symptoms (fever, cough, tachypnea,
chest pain) within 48–96 hr of initiation ofchest pain) within 48–96 hr of initiation of
antibiotics.antibiotics.
 Radiographic evidence of improvementRadiographic evidence of improvement
substantially lags behind clinicalsubstantially lags behind clinical
improvement.improvement.

20. Response to the treatmentResponse to the treatment
 A number of factors must be considered when aA number of factors must be considered when a
patient does not improve on appropriate antibioticpatient does not improve on appropriate antibiotic
therapy (therapy (slowly resolving pneumoniaslowly resolving pneumonia): (1)): (1)
complications (2) bacterial resistance; (3)complications (2) bacterial resistance; (3)
nonbacterial etiologies (4) bronchial obstructionnonbacterial etiologies (4) bronchial obstruction
from (5) pre-existing diseases (6) other noninfectiousfrom (5) pre-existing diseases (6) other noninfectious
causes.causes.
 A repeat chest x-ray is the 1st step in determining theA repeat chest x-ray is the 1st step in determining the
reason for delay in response to treatment.reason for delay in response to treatment.

21. ComplicationsComplications
 Complications of pneumonia are usually theComplications of pneumonia are usually the
result of direct spread of bacterial infectionresult of direct spread of bacterial infection
within the thoracic cavity (pleural effusion,within the thoracic cavity (pleural effusion,
empyema, pericarditis) or bacteremia andempyema, pericarditis) or bacteremia and
hematologic spread.hematologic spread.
 Meningitis, suppurative arthritis, andMeningitis, suppurative arthritis, and
osteomyelitis are rare complications ofosteomyelitis are rare complications of
hematologic spread of pneumococcal orhematologic spread of pneumococcal or H.H.
influenzaeinfluenzae type b infection.type b infection.

22. ReferencesReferences
 Nelson Textbook of Pediatrics- 18Nelson Textbook of Pediatrics- 18thth
editionedition
 Ghai Essential Pediatrics- 7Ghai Essential Pediatrics- 7thth
editionedition
 Kaplan USMLE 2010Kaplan USMLE 2010