Professional Documents
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Pediatricpneumonia
Pediatricpneumonia
Learning Objectives
To describe the presentation of pediatric
pneumonia
To outline the management of pediatric
pneumonia
To summarize the complications of pediatric
pneumonia
To highlight interventions to prevent and
protect against pediatric pneumonia
Outline
Quiz
Epidemiology and Pathophysiology
Patient History
Presentation and Diagnosis
Management and Disposition
Further Testing
Complications
Treatment
Interventions to Protect
Interventions to Prevent
Summary Key Points
Case
Quiz Results
Quiz Question 1
What illness is the number one killer of
children?
A. Diarrheal Disease
B. HIV/AIDS
C. Malaria
D. Pneumonia
Quiz Question 2
What is the most sensitive and specific sign of
pneumonia in children?
A. Difficulty breathing
B. Fever
C. Tachypnea
D. Tachycardia
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
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
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
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.
Question:
Is reducing the incidence, morbidity, and
mortality of pneumonia in children a high
priority in the region where you practice?
What is being done in your area?
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.
Etiology
The common pathogens are a function of the
patients age.
The specific agent causing pneumonia can be
determined in 1/3 to 2/3 of cases when
cultures, antigen detection and serologic
techniques are available.
It is helpful to be aware of local outbreaks as
clustering of cases is common.
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
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
Pneumonia History
Immunizations status
TB exposure
Maternal Chlamydia, Group B Strep status
during pregnancy
Choking episodes
Previous episodes
Previous antibiotics
Pneumonia History
Ill contacts
Travel history
Day care attendance
Animal exposure
History Fundamentals
Diagnosis
Diagnosis Objectives
Respiratory
Rate
(breaths/min)
Indication of
severe
infection
(breaths/min)
< 2 months
2 to 12 months
12 months to 5
years
> 60
> 50
> 40
>70
Greater than 5
years
> 20
>50
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
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
Classify AS
Tachypnea
Lower chest wall
indrawing
Stridor in a calm
child
Tachypnea
Non-Severe
Pneumonia
Normal respiratory
rate
Other respiratory
illness
Treatment
Prescribe appropriate
antibiotic
Advise caregiver of other
supportive measure and
when to return for a followup visit
Respiratory Rate
Heart Rate
Temperature
Oxygen saturation (if available)
Vital Signs
Both heart rate and respiratory rate are
influenced by the presence of fever.
Heart rate increases by approximately 10
beats per minute for each 1 degree Celsius.
Respiratory Rate has been estimated to
vary by 0.5-2 breath per minute to 5-11
breaths per minute for each 1 degree
Celsius.
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 Children
Differential Diagnosis:
A Focus on Respiratory Syncytial Virus
(RSV)
RSV Seasonality
Seasonal outbreaks occur throughout the
world.
In the northern hemisphere outbreaks peak in
January and February.
In the southern hemisphere outbreaks peak in
May, June and July.
In tropical climates outbreaks are often
associated with the rainy season.
Differential Diagnosis:
Consider Tuberculosis
Tuberculosis
Common symptoms of tuberculosis include:
Chronic cough that has been present for
more than 3 weeks and is not improving
Fever greater than 38C for at least two
weeks, not attributable to other common
causes
Weight loss or failure to thrive
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.
Pneumonia in Malnourished
Children
Question:
How are children who may have pulmonary
tuberculosis identified and treated?
Malnourished children, and children with
HIV are at high-risk for complications
associated with pneumonia. How are these
children managed where you practice?
Disposition
The decision whether the patient would be best
managed at home or in a heath care setting is
based on many factors, including the resources
available.
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.
Infants
Older
Children
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.
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.
Airway
Support the airway (position of comfort for
the child) or open the airway (chin lift or jaw
thrust).
Clear the airway (suction nose and mouth,
remove any foreign body).
Insert an oropharyngeal or nasopharyngeal
airway as indicated.
Breathing
Assist ventilation (e.g., bag-mask
ventilation) as needed
Provide oxygen
Continuously monitor oxygen saturation
Consider use of CPAP or BIPAP
Prepare for endotracheal intubation as
needed
Administer medications as needed
Circulation
Monitor heart rate and rhythm
Establish vascular access as indicated (for
fluid therapy and medications)
Intubation Pointers
Detailed Pediatric Airway management is
beyond the scope of this module
Endotracheal tube size calculations:
Uncuffed tube = 4 + (age in years/4)
Cuffed tube = 3.5 + (age in years/4)
Question:
What resources do you have available to
care for children with pneumonia?
What are the criteria for hospital admission/
transfer to another facility/intensive care
where you practice?
Further Testing
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.
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.
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
Laboratory Investigations
Question:
What tests do you have readily available to
assist in the management of a child with
complications of pneumonia?
What other testing could reasonably be
arranged?
Complications
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.
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.
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.
Complications of Pneumonia
Hyponatremia:
Serum sodium <135 mmol/L.
Studies in India (1992) revealed that in children
hospitalized with pneumonia, 27% had
hyponatremia and 4% had hypernatremia.
SIADH was the most common cause of
hyponatremia.
Hyponatremia is associated with increased hospital
stay, complications and increased mortality,
however most cases were found to be mild.
Treatment
Treatment - Epidemiology
Antibiotics serve an essential role in reducing
child deaths from pneumonia.
Limited data suggest that in the early 1990s
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.
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
In a study conducted in areas of Pakistan
with high levels of Streptococcus
pneumoniae and Haemophilus Influenzae
b resistance to co-trimoxazole, cotrimoxazole was found to be over 90%
effective in treating cases of non-severe
pneumonia.
In cases of severe pneumonia, amoxicillin
was more effective than co-trimoxazole.
Treatment
Three studies (two in Gambia, one in
Turkey) published between 1988 and 1995
comparing co-trimoxazole treatment with
parenteral procaine penicillin G, ampicillin,
or chloramphenicol showed no significant
improvement in efficacy with the alternative
antibiotic regimens.
Antibiotic Resistance
Expanded and continued use of antibiotics to
treat pneumonia could make antibiotic
resistance an increasing challenge in the
future.
Increased treatment of pneumonia with
antibiotics must be accompanied by
appropriate training of health care workers to
ensure proper diagnosis and treatment of
pneumonia.
Question:
What antibiotics are commonly used and/or
readily available where you practice?
What are the costs?
What is the antibiotic resistance in your
local area?
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.
Question:
Are parents and/or caregivers in your area
aware of the signs that indicate their child
should see a health care provider?
Question:
Would changing to cleaner cooking options
be helpful in the region where you
practice? Are there cultural barriers to
change?
Would education on smoking cessation be
helpful in your area?
Interventions to Prevent
Pneumonia
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
Prevention - Vaccination
Three vaccinations have the potential to
significantly reduce childhood deaths from
pneumonia
Haemophilus Influenzae type B (Hib) vaccine and
Pneumococcal conjugate vaccine prevent
infections that directly cause pneumonia
Pneumonia is a possible complication of Measles,
thus prevention of measles would decrease the
incidence of pneumonia.
Prevention - Vaccination
The implementation of Haemophilus
influenzae type b (Hib) and Streptococcus
pneumoniae immunization through an
existing immunization program has been
shown to be cost effective in reducing
pneumonia mortality.
Measles immunization coverage is high
(making cost effectiveness estimates
difficult).
Question:
What immunizations are given in your
area?
Are there plans to expand immunization
programs in your area?
Prevention Co-trimoxazole
Prophylaxis for HIV-infected Children
Children with features of HIV should receive
daily Co-trimoxazole even in areas of high
bacterial resistance this medicine.
Daily Co-trimoxazole prophylaxis has been
shown to decrease mortality in HIV infected
children.
Co-trimoxazole Prophylaxis
In the CHAP study in Zambia (Lancet, 2004), a
double-blind, randomized placebo controlled
trial, at 19 months the mortality rate for enrolled
children was 28% in the Co-trimoxazole group
and 42% in the placebo group.
The study was stopped early with the
conclusion that all HIV infected children in
resource poor areas should receive Cotrimoxazole prophylaxis.
Summary
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 .
Vital Signs
Vital signs are as follows: Temperature
38.7, Pulse 150, Respiratory Rate 54,
Oxygen Saturation 94% on room air.
Physical Examination
On observation the patient clearly appears
septic. Mild respiratory distress is present.
Skin is mottled.
Diagnosis
It is reasonable to make a presumptive
diagnosis of pneumonia based on the
history and vital signs.
Initial Treatment
A presumptive diagnosis of pneumonia is
made. The patient is admitted to the
hospital and started on broad spectrum IV
antibiotics and appropriate hydration and
re-feeding.
The patient does not seem to improve
initially.
What is your differential diagnosis?
Differential Diagnosis
Differential Diagnosis includes:
Pneumonia +/- complications (e.g. Empyema)
Pneumonia in a patient with HIV
Tuberculosis
Clinical Course
The patient begins to improve clinically.
Fever, cough and respiratory distress resolve.
However, over the next few weeks of
appropriate re-feeding, the patient fails to gain
weight despite remaining on broad spectrum
antibiotics.
What other investigations would you consider?
Other Investigations
HIV test negative
TB skin test unreactive
Sputum culture unable to induce sputum
*Important Note: The mother is no longer with
the patient. Another family member reports that
she is sick with a cough, fever, and weight loss.*
What other courses of treatment should be
considered in this case?
Learning Point
This patients x-ray revealed a lobar infiltrate.
Pneumonia commonly presents as a lobar
infiltrate.
Reactivation of TB tends to be apical, but
acute TB can present as a lobar infiltrate.
TB should remain as a differential diagnosis
and be reconsidered if there is a poor
response to treatment, or a possible exposure
history.
Post-Test
Quiz Question 1
What illness is the number one killer of
children?
A. Diarrheal Disease
B. HIV/AIDS
C. Malaria
D. Pneumonia
Quiz Question 2
What is the most sensitive and specific sign of
pneumonia in children?
A. Difficulty breathing
B. Fever
C. Tachypnea
D. Tachycardia
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
Quiz Question 4
Which of the following immunizations
effectively reduce pneumonia mortality in
children?
A. Haemophilus influenzae b Vaccine
B. Pneumococcal Conjugate Vaccine
C. Measles Vaccine
D. All of the above
Quiz Answers:
1. D. Pneumonia
2. C. Tachypnea
3. D. When complications are suspected
4. D. All of the above
Further Reading
Considerable content and structure for this presentation
is based on the following reports, which are
recommended for further reading:
Global Action Plan for Prevention and Control of
Pneumonia (GAPP). Geneva: World Health
Organization (WHO)/United Nations Childrens Fund
(UNICEF), 2009.
Pneumonia The Forgotten Killer of Children. Geneva:
World Health Organization (WHO)/United Nations
Childrens Fund (UNICEF), 2006.