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Infectious Pediatric Pneumonia

Quiz Question
What is the most sensitive and specific sign of
pneumonia in children?
A. Difficulty breathing
B. Fever
C. Tachypnea
D. Tachycardia

Quiz Question
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

Quiz Question
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

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

Epidemiology and Pathophysiology

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.

Basic Pathophysiology
Most cases of pneumonia are caused by
the aspiration of infective particles into the
lower respiratory tract.
Organisms that colonize a childs upper
airway can cause pneumonia.
Pneumonia can be caused by person to
person transmission via airborne droplets.

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.

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.

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

Recognition of Signs of Pneumonia


Tachypnea is the most sensitive and
specific sign of pneumonia
Tachypnea had a Sensitivity of 61% and
79% and Specificity of 79% and 65% for
pneumonia in malnourished and wellnourished Gambian children respectively

WHO Definition of Tachypnea


Age

Respiratory
Rate
(breaths/min)

< 2 months
2 to 12 months
12 months to 5
years
Greater than 5
years

> 60
> 50
> 40
> 20

Indication of
severe
infection
(breaths/min)
>70
>50

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

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

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 Childrens Fund (UNICEF), 2006.

Pneumonia Severity Assessment


Mild

Severe

Infants

Temperature <38.5 C
RR < 50 breaths/min
Mild recession
Taking full feeds

Temperature >38.5 C
RR > 70 breaths/min
Moderate to severe recession
Nasal Flaring
Cyanosis
Intermittent Apnea
Grunting Respirations
Not feeding

Older Children

Temperature <38.5 C
RR < 50 breaths/min
Mild breathlessness
No vomiting

Temperature >38.5 C
RR > 50 breaths/min
Severe difficulty in breathing
Nasal Flaring
Cyanosis
Grunting Respirations
Signs of dehydration

From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Childrens Fund (UNICEF), 2006.

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 in auscultation)

Indications for Admission


Age Group

Indications for Admission to Hospital

Infants

Oxygen Saturation <= 92%, cyanosis


RR > 70 breaths /min
Difficulty in breathing
Intermittent apnea, grunting
Not feeding
Family not able to provide appropriate observation or
supervision

Older Children

Oxygen Saturation <= 92%, cyanosis


RR > 50 breaths /min
Difficulty in breathing
Grunting
Signs of Dehydration
Family not able to provide appropriate observation or
supervision

From: British Thoracic Society (BTS) of Standards of Care Committee.


BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002;57: i1-i24.

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.

Right Upper Lobe Pneumonia

Right Middle Lobe Pneumonia

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:
CBC, particularly WBC
Electrolytes, particularly Sodium
Consider blood cultures, sputum cultures
HIV and TB testing as appropriate

Treatment IV Antibiotics
Common medications for treating pneumonia:
Penicillins: Amoxicillin, Ampicillin, Benzyl
Penicillin
2nd generation Cephalosporins: Cefuroxime
3rd generation Cephalosporins: Cefotaxime
Dose according to childs weight

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.

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.

Supportive Treatment IMCI


Guidelines
Oxygen therapy
If fever (=>39oC) causing distress, give
paracetamol
If wheeze is present, give a rapid-acting bronchodilator
Gentle suction any thick secretions in the throat,
which the child cannot clear.

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.

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 .

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