Pneumonia in Children

1. PEDIATRIC PNEUMONIA
Dr. V K Pandey
MBBS, DCH, MD (Ped.)
International Fellow, American Academy of Pediatrics)

2. QUIZ QUESTION 1
What illness is the number one killer of
children?
 A. Diarrheal Disease
 B. HIV/AIDS
 C. Malaria
 D. Pneumonia

3. QUIZ QUESTION 2
What is the most sensitive and specific sign
of
pneumonia in children?
 A. Difficulty breathing
 B. Fever
 C. Tachypnea (Fast Breathing)
 D. Tachycardia (Fast Heart Rate)

4. QUIZ QUESTION 3
If available, a chest x-ray should be done
for
children with possible pneumonia:
 A. When a diagnosis is made
 B. When a history of tachypnea is
present
 C. When antibiotics are started
 D. When complications are suspected

5. QUIZ QUESTION 4
Which of the following immunization
effectively reduce pneumonia mortality in
children?
 A. Haemophilus influenzae b Vaccine
 B. Pneumococcal Conjugate Vaccine
 C. Measles Vaccine
 D. All of the above

6. WHAT IS PNEUMONIA?
 Pneumonia: an acute infection of the
pulmonary parenchyma
 The term “Lower Respiratory Tract
Infection” (LRTI) may include pneumonia,
bronchiolitis and/or bronchitis

7. EPIDEMIOLOGY
 Pneumonia kills more children under
the age of five than any other illness in
every region of the world.
 It is estimated that of the 9 million child
deaths in 2007, 20% (1.8 million) were
due to pneumonia
 Approximately 98% of children who die of
pneumonia are in developing countries.

9. BASIC PATHOPHYSIOLOGY
 Most cases of pneumonia are caused by
the aspiration of infective particles into
the lower respiratory tract.
 Organisms that colonize a child’s upper
airway can cause pneumonia.
 Pneumonia can be caused by person to
person transmission via airborne
droplets.

10. PNEUMONIA - COMMON PATHOGENS
Age Group Common Pathogens (in Order of Frequency)
Newborn Group B Streptococci
Gram-negative bacilli
Listeria monocytogenes
Herpes Simplex
Cytomegalovirus
Rubella
1-3 months Chlamydia trachomatis
Respiratory Syncytial virus
Other respiratory viruses
3-12 months Respiratory Syncytial virus
Other respiratory viruses
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

11. PNEUMONIA - COMMON PATHOGENS
Age Group Common Pathogens (in Order of Frequency)
2-5 years Respiratory Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae
5-18 years Mycoplasma pneumoniae
Streptococcus pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Influenza viruses A and B
Adenoviruses
Other respiratory viruses
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

12. PNEUMONIA HISTORY FUNDAMENTALS
 Age
 Presence of cough, difficulty breathing,
shortness of breath, chest pain
 Fever
 Recent upper respiratory tract infections
 Associated symptoms (e.g.. headache,
lethargy, pharyngitis, nausea, vomiting,
diarrhea, abdominal pain, rash)
 Duration of symptoms

13. PNEUMONIA HISTORY
 Immunizations status
 TB exposure
 Ill contacts
 Travel history
 Past Medical History
 Birth History
 Medications

14. RECOGNITION OF SIGNS OF
PNEUMONIA
 Tachypnea is the most sensitive and
specific sign of pneumonia

15. WHO DEFINITION OF TACHYPNEA
Age Respiratory
Rate
(breaths/min)
Indication of
severe
infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5
years
> 40 >50
Greater than 5
years
> 20

16. OTHER SIGNS OF PNEUMONIA -
INDRAWING
out---breathing---in
Lower chest wall indrawing: with inspiration,
the lower chest wall moves in
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

17. OTHER SIGNS OF PNEUMONIA -
NASAL FLARE
Nasal flaring: with inspiration, the side of the
nostrils flares outwards
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

18. DIAGNOSIS IN COMMUNITY SETTING
SIGNS Classify AS Treatment
•Tachypnea
•Lower chest wall
indrawing
•Stridor in a calm child
Severe Pneumonia •Refer urgently to hospital for
injectable antibiotics and oxygen
if needed
•Give first dose of appropriate
antibiotic
•Tachypnea Non-Severe
Pneumonia
•Prescribe appropriate antibiotic
•Advise caregiver of other
supportive measure and when to
return for a follow-up visit
•Normal respiratory rate Other respiratory
illness
•Advise caregiver on other
supportive measures and when to
return if symptoms persist or
worsen
From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Children’s Fund (UNICEF), 2006.

19. INFANTS AT RISK OF PNEUMONIA
 Infants less than 3 months old with signs
of pneumonia should be referred
immediately to the nearest health facility
because they are at high risk of severe
illness and death.
 Infants who were premature, and those
with congenital heart disease or chronic
lung disease are also at increased risk.

20. DIFFERENTIAL DIAGNOSIS:
A FOCUS ON RESPIRATORY SYNCYTIAL
VIRUS (RSV)

21. RESPIRATORY SYNCYTIAL VIRUS (RSV)
 RSV is the most common cause of LRTIs in
children less than 1.
 Infants and young children typically present
with pneumonia or bronchiolitis.
 Older children may have upper respiratory tract
infection symptoms.
 RSV is associated with apnea in infants.
 Wheezing is common.

22. RSV SEASONALITY
 Seasonal outbreaks occur throughout the
world.
 In the southern hemisphere outbreaks peak in
May, June and July.
 In tropical climates outbreaks are often
associated with the rainy season.

23. DIFFERENTIAL DIAGNOSIS:
CONSIDER TUBERCULOSIS

24. TUBERCULOSIS
Common symptoms of tuberculosis
include:
 Chronic cough that has been present for
more than 3 weeks and is not improving
 Fever greater than 38°C for at least two
weeks, not attributable to other common
causes
 Weight loss or failure to thrive

25. TUBERCULOSIS
 Physical exam findings of children with
pulmonary tuberculosis are similar to those
of a lower respiratory tract infection.
 In children less than age five tuberculosis can
progress rapidly from latent infection to active
disease and serve as a sentinel case in the
community.
 Consider the diagnosis of tuberculosis,
especially in those children who fail to respond
appropriately to routine treatment for
pneumonia.

26. PNEUMONIA AND HIV INFECTED
CHILDREN
 The prevalence of HIV-1 in children admitted with severe
pneumonia (by WHO criteria) in Africa is 55-65%.
 The case fatality rate is 20-34%.
 This case fatality rate is 3-6 times higher for children
infected with HIV compared to those not infected with
HIV.
 Pneumonia caused by Pneumocystis jiroveci may be
the first indicator of HIV infection, and lead to HIV testing
and diagnosis.

27. ADMISSION CONSIDERATIONS
 If caregivers are unable to care for the child, or
to commit to following a treatment plan, the
child should be admitted to a health care
facility.
 Any child less than three months of age.
 Failure of outpatient treatment (worsening or
no response to treatment after 24 to 72 hours).
 Family lives in a remote area.

28. INDICATIONS FOR ADMISSION - IMCI
 All Children with Very Severe Pneumonia
need admission
 Very Severe Pneumonia includes any of:
 Cough or difficult breathing plus at least one of the
following:
 Central cyanosis
 Inability to breastfeed or drink, or vomiting everything
 Convulsions, lethargy or unconsciousness
 Severe respiratory distress (e.g. head nodding)
 Some or all of the other signs of pneumonia
(tachypnea, grunting, nasal flare, indrawing, changes

29. IN-PATIENT MANAGEMENT
 Consideration must be given to the provision of
adequate hydration, oxygenation, nutrition,
antipyretics and pain control.
 Monitoring should include:
 Respiratory rate
 Work of breathing
 Temperature
 Heart rate
 Oxygen saturation (if available)
 Findings on auscultation.

30. IN-PATIENT CONSIDERATIONS
 Due to the risk of transmission, a child
suspected of having pneumonia should be
cared for in an area that is isolated from others
to who are at risk of becoming infected.
 Contact precautions by health care workers
such as hand washing, gloves, gowns and
masks to prevent transmission between
patients are often appropriate.

31. CRITERIA FOR INTENSIVE CARE
If intensive care is available consider the following:
 The patient is failing to maintain an oxygen
saturation of > 92% in FiO2 of > 0.6.
 The patient is in shock.
 There is a rising respiratory rate and rising pulse
rate with clinical evidence of severe respiratory
distress and exhaustion, with or without a raised
arterial carbon dioxide tension (PaCO2).
 There is recurrent apnea or slow irregular
breathing.

32. FURTHER TESTING

33. CHEST X-RAY
 Confirmation of pneumonia by chest x-
ray is not indicated in children with mild,
uncomplicated lower respiratory tract
infections who will be treated at
outpatients.

34. CHEST X-RAY
 A study in South Africa randomized children age
2-59 months who met the WHO case definition
of pneumonia to have a chest x-ray, or not.
 There was no clinically identifiable subgroup of
children within the WHO case definition who
were found to benefit from a chest x-ray.
 It was concluded that there was no benefit in
routine chest x-ray of ambulatory children with
lower respiratory-tract infection over two months
of age.

35. CHEST X-RAY
Consider if available and:
 Infection is severe
 Diagnosis is otherwise inconclusive
 To exclude other causes of shortness of breath
(e.g.. foreign body, heart failure)
 To look for complications of pneumonia
unresponsive to treatment (e.g.. empyema,
pleural effusion)
 To exclude pneumonia in an infant less than
three months with fever

36. RIGHT UPPER LOBE PNEUMONIA

37. RIGHT MIDDLE LOBE PNEUMONIA

38. LABORATORY INVESTIGATIONS
 Routine blood work is not required in children
with uncomplicated lower respiratory tract
infections who will be treated as outpatients
 Tests to consider if available:
 FBC, particularly WBC
 Electrolytes, particularly Sodium
 Consider blood cultures, sputum cultures
 HIV and TB testing as appropriate

39. COMPLICATIONS

40. COMPLICATIONS OF PNEUMONIA
 Pleural effusion – fluid in the pleural space as
the result of inflammation.
 Empyema – bacterial infection in the pleural
space.
 Parapneumonic effusions develop in
approximately 40% of patients admitted to
hospital with bacterial pneumonia.
 If an effusion is present and the patient is
persistently febrile, the pleural space should be
drained.

41. COMPLICATIONS OF PNEUMONIA
 Necrotizing Pneumonia – necrosis or liquefaction
of lung parenchyma.
 Lung Abscess – A collection of inflammatory cells
leading to tissue destruction resulting in one or
more cavities in the lungs. A rare complication.
 Treatment of both Necrotizing Pneumonia and
Lung Abscess involves long term parenteral
antibiotics for 2-4 weeks, or 2 weeks after the
patient is afebrile, and has clinically improved.

42. COMPLICATIONS OF PNEUMONIA
 Pneumatocele – thin walled, air filled
cysts of the lung, often occurs with
empyema.
 Pneumatoceles often resolve
spontaneously, but may lead to
pneumothorax.

43. TREATMENT

44. TREATMENT - EPIDEMIOLOGY
 Antibiotics serve an essential role in reducing
child deaths from pneumonia.
 Limited data suggest that in the early 1990’s
less than one in five children with pneumonia
received antibiotics.
 Children in urban areas, and those with well
educated mothers were more likely to receive
antibiotics.

45. TREATMENT – ORAL ANTIBIOTICS
Common medications for treating pneumonia:
 Penicillins: Amoxicillin, Amoxicillin-
Clavulanate
 Sulfonamides: Co-trimoxazole
 Macrolides: Azithromycin, Clarithromycin,
Erythromycin
 2nd generation Cephalosporins: Cefaclor
 Dose according to child’s weight

46. TREATMENT – IV ANTIBIOTICS
Common medications for treating pneumonia:
 Penicillins: Amoxicillin, Ampicillin, Benzyl
Penicillin
 2nd generation Cephalosporins: Cefuroxime
 3rd generation Cephalosporins: Cefotaxime
 Dose according to child’s weight

47. TREATMENT – IMCI GUIDELINES
 Antibiotic therapy
 Chloramphenicol (25 mg/kg IM or IV every 8 hours)
until the child has improved. Then continue orally 3
x/ day for a total course of 10 days.
 If chloramphenicol is not available, give
benzylpenicillin (50 000 units/kg IM or IV every 6
hours) and gentamicin (7.5 mg/kg IM once a day)
for 10 days.

48. TREATMENT – IMCI GUIDELINES
 If the child does not improve within 48 hours,
Switch to gentamicin (7.5 mg/kg IM once a
day) and cloxacillin (50 mg/kg IM or IV every 6
hours), for staphylococcal pneumonia.
When the child improves, continue cloxacillin
(or dicloxacillin) orally 4 times a day for a total
course of 3 weeks.

49. INPATIENT ANTIBIOTIC CHOICE
 Consider IV 3rd Generation
Cephalosporin in a child less than 1 year
of age, or who is not fully immunized, or
with severe illness.
 Consider IV Ampicillin or Penicillin in a
child over 1 year of age in areas that do
not have a high prevalence of penicillin-
resistant Streptococcus Pneumoniae.

50. SUPPORTIVE TREATMENT – IMCI
GUIDELINES
 Oxygen therapy
 If fever (=>39oC) causing distress, give
paracetamol
 If wheeze is present, give a rapid-acting broncho-
dilator
 Gentle suction any thick secretions in the throat,
which the child cannot clear.

51. SUPPORTIVE TREATMENT – IMCI
GUIDELINES
 Ensure that the child receives daily maintenance fluids for
the child's age - avoid overhydration.
 Encourage breastfeeding and oral fluids.
 If the child cannot drink, insert a NG tube and give
maintenance fluids in frequent small amounts.
 If the child is taking fluids adequately by mouth, do not use a NG
tube as it increases the risk of aspiration pneumonia.
 If oxygen is given by nasopharyngeal catheter at the same time
as NG fluids, pass both tubes through the same nostril.
 Encourage the child to eat as soon as food can be taken.

52. INTERVENTIONS TO PROTECT AGAINST
PNEUMONIA

53. INTERVENTIONS TO PROTECT AGAINST
PNEUMONIA
 It is estimated that hand washing, when
combined with improved water and
sanitation could lead to a 3% reduction in
all child deaths.
 Promote exclusive breast feeding for 6
months. Impact 15-23% reduction in
pneumonia incidence. 13% reduction in
all child deaths. Shown to be cost
effective.

54. INTERVENTIONS TO PROTECT AGAINST
PNEUMONIA
 Adequate nutrition throughout the
first five years of life, including
adequate micronutrient intake. Impact
6% reduction in all child deaths for
adequate complementary feeding (age 6-
23 months).
 Reduce incidence of low birth weight.

55. PUBLIC AWARENESS
 Tachypnea and respiratory distress are
considered the most important signs in
the diagnosis of pneumonia.
 Only 1 in 5 caregivers know that fast
breathing and respiratory distress are a
reason to seek care immediately.

56. INTERVENTION TO PROTECT AGAINST
PNEUMONIA
 Reducing indoor air pollution, by
changing to cleaner gas or liquid fuels or
high-quality, well maintained biomass
stoves, may reduce the incidence of
pneumonia by 22 to 46% in appropriate
settings. This intervention may be cost-
effective in low-income settings.

57. INTERVENTION TO PROTECT AGAINST
PNEUMONIA
 Reduce Exposure to Second-Hand
Tobacco Smoke.
 Both maternal and paternal smoking
cause lower respiratory tract illnesses
such as pneumonia and bronchitis,
particularly during the first year of life.

58. PREVENTION STRATEGIES
 Vaccination against measles, Streptococcus
pneumoniae, and Haemophilus influenzae
type b
 Zinc supplementation
 Prevention of HIV in Children
 Co-trimoxazole prophylaxis for HIV-infected
children

59. SUMMARY

60. KEY POINTS
 Pneumonia is an acute infection of the
pulmonary parenchyma
 Pneumonia kills more children under the age of
five than any other illness.
 A diagnosis of pneumonia should be
considered in all children with tachypnea and
difficulty breathing.
 Common first-line antibiotics include amoxicillin
and co-trimoxazole .

61. THANK YOU