Pediatrics

EXIMIUS 2021
PEDIATRIC COMMUNITY ACQUIRED PENUMONIA SPUP School of Medicine
Group 3 and 7

Objectives: DEVELOPMENTAL HISTORY

• To discuss the case of a 4-month old patient with a chief o Gross motor – holds head steady
complaint of DOB o Fine motor – brings hands to mouth
• To provide differential diagnoses for PCAP o Language – begins to babble
• To discuss the pathophysiology of PCAP o Personal-social – smiles spontaneously
• To discuss diagnostic approaches for PCAP
• To discuss management and treatment for PCAP IMMUNIZATION HISTORY
VACCINE DOSE WHEN
GENERAL DATA
BCG 1 At birth
• NM, 4-month old baby boy, born on June 2, 2020, a
Filipino who lives in Solana Cagayan, a Roman Catholic, HepB 1 At birth
admitted for the first time last October 1, 2020.
Penta 2 6 weeks, 10 weeks
• Informant: Mother; 100% reliability
OPV 2 6 weeks, 10 weeks
CHIEF COMPLAINT
• Difficulty of Breathing PCV 2 6 weeks, 10 weeks
Given at the Rural Health Unit
HISTORY OF PRESENT ILLNESS No adverse reactions
• 4 days PTA
o (+) intermittent low-grade fever *The vaccination status of this patient is not updated: must already
o Gave Tempra drops, 0.5 mL, every 4 hours have 3 doses of PCV and Penta.
o No other signs & symptoms
o No consultation done FAMILY HISTORY
• 2 days PTA MATERNAL PATERNAL
o (+) fever (+) cough, (+) colds
(-) HTN (-) HTN
o Gave salbutamol syrup, 1 mL, every 8 hours
(-) DM (-) DM
o No consultation done
(-) Kidney Disease (-) Kidney Disease
• Few hours PTA
(-) TB (-) TB
o Persistence of symptoms
(-) Asthma (-) Asthma
o (+) DOB (-) Blood disorders (-) Blood disorders
o (+) irritability (-) Malignancy (-) Malignancy
o Consulted at CVMC

PAST MEDICAL HISTORY PERSONAL AND SOCIAL HISTORY

• No similar conditions in the past o 2nd child in a brood of 2
• No previous hospitalization o Father – 41 yo, farmer
o Mother – 37 yo, teacher
• No previous surgery
o Bungalow house with adequate ventilation
• No known allergy to food and medication
o Drinking water – mineral water
PRENATAL HISTORY
REVIEW OF SYSTEMS
o Regular PNCU at RHU
INTEGUMENTARY No rashes, no cyanosis
§ Medications: Ferrous sulfate, Ascorbic Acid,
Folic Acid CARDIORESPIRATORY No interrupted feeding
o Non-smoker, non-alcoholic drinker GASTROINTESTINAL (+) 1 vomiting episode
o No maternal illness, infection, bleeding GENITOURINARY No oliguria, no hematuria
o No radiation exposure
NEUROLOGIC No seizures
o No OTC drugs taken
HEMATOLOGIC No epistaxis, no gum bleeding
ENDOCRINE Decreased frequency in feeding
BIRTH HISTORY
o Fullterm, 38 weeks AOG, 32 yo, G2P2 (2002)
o NSD at CVMC delivered by physician *always ask for the onset of the different pertinent data on the ROS
o BW: 3 kg because it could be a part of the HPI.
o No feto-maternal complications
PHYSICAL EXAMINATION
o Immediately roomed-in few hours after birth
o General Survey: The patient is awake, irritable, weak
NEONATAL HISTORY looking and in cardio-respiratory distress.
o Normal pinkish skin color, good cry, good suck, no o Vital Signs:
meconium staining T: 38.3 ˚C Weight: 5.1 kg
HR: 130 bpm Length: 54 cm
o No cyanosis, jaundice, respiratory distress, and
congenital defects RR: 66 cpm BMI: 17.5
o Vit K, BCG, HepB, Crede’s prophylaxis given
NUTRITIONAL HISTORY
o Exclusively breastfed since birth

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Pediatrics
EXIMIUS 2021
PEDIATRIC COMMUNITY ACQUIRED PENUMONIA SPUP School of Medicine
Group 3 and 7

• Abdomen: globular, no scars, striae, visible dilated veins or

rashes. Umbilicus is everted bulging. No pulsation/peristalsis
were on abdomen. NABS, soft, non tender
• Genitourinary: grossly male
• Extremity: warm to touch, no edema, no tenderness, cavus
are noted. Brachial, radial popliteal and dorsalis pedis pulses
2+ symmetric.
• Neurological
• MSE: Irritable
• Cranial Nerves
o CN I: not able to assess
o CN II: no visual impairment, blinks eyes spontaneously
o CN III IV VI: intact extaoccular eye movement, no
nystagmus
o CN V: sensory corneal reflex intact on both eyes.
Facial sensitive on both sides
o CN VII: no facial paralysis
o CN VIII: turns head to sound
o CN IX X: uvula is in midline, swallowing reflex
o CN XII: elevate with difficulty
• Motor: able to move extremities in different directions,
symmetric, spontaneous movement without limitations.
• DTR: Patella 2+ Triceps 2+
• Primitive: (+) babinski (+) moro reflex
• Pathological: (-) brudzinski (-) kernig sign (-) nuchard rigidity

SALIENT FEATURES
o 4 months old
o Solana, Cagayan
o Difficulty of breathing
o (+) fever
o (+) cough
o (+) colds
o Irritability
o Alar flaring
o Vomiting episode
o Decreased frequency in feeding
o Tachypneic
o Tachycardic
o (+) Subcostal retractions
• Skin: No pallor, No cyanosis, no jaundice, warm to touch o Rales on bibasal lung fields
with good skin turgor
• HEENT: TAKE OFF POINT: TACHYPNEA
o Head: thin, black and equally distributed
throughout the head, scalp has no lesions nor mass. DIFFERENTIAL DIAGNOSIS
Head is normocephalic, atraumatic, no facial BRONCHIOLITIS
paralysis, no tenderness. Rule In Rule Out
o Eyes: both symmetrical, no lesion. Anicteric sclera, 4 months old (-) wheezes/ crackles
clear cornea, pink palpebral conjunctiva, no Male (-) hyperresonance
nodules nor discharge. Both pupils constrict from 2- (+) fever (-) prolonged expiratory phase
3mm and is responsive to direct and consensual (+) cough (-) hypoxia
right after reflux and accommodation (+) colds
o Ear: symmetric, no external deformities, (exudates
(+) tachypnea
or sign of inflammation) no lumps, skin lesion, pain,
(+) retractions
discharge. No inflammation.
o Nose: symmetric, no obstruction (+) clear (+) decrease feeding frequency
discharge, no signs of inflammation, alar flaring (+) irritability
o Mouth and throat: lips symmetric, moist no lumps,
Alar flaring
no tenderness upon palpation, thyroid not palpable
• Cardiovascular: no visible pulsation, precordium adynamic.
PMI at 4 ICS MCL no murmur and extra heard sounds
• Chest/Lungs: Symmetric chest expansions, (+) subcostal
retractions, rales on bibasal lung fields

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Pediatrics
EXIMIUS 2021
PEDIATRIC COMMUNITY ACQUIRED PENUMONIA SPUP School of Medicine
Group 3 and 7

ACUTE BROCHITIS COURSE IN THE WARD

Rule In Rule Out ADMISSION
(+) fever (-) malaise
(+) cough (-) dry hacking cough S O A P
(+) colds (-) rhinitis (+) HR: 130 Pediatric Diagnostics:
tachypnea RR: 66 Community • CBC
(+) tachypnea (-) conjunctivitis
(+) febrile T: 38.3°C Acquired • OPS/NPS
(+) retractions episodes O2 sat: Pneumonia • Chest X-ray
(+) rales (+) cough 99% (at - Moderate Management:
Cold season (+) DOB room air) Risk, • NPO
Alar flaring (+) (-) alar COVID-19 temporarily
irritability flaring Suspect • (mild) D5LRS
COVID-19- SUSPECT (+) (+) • (100)
decrease subcostal Cefuroxime
Rule In
feeding retraction q8hrs
(+) fever
frequency (+) rales • (10)
(+) cough
bilateral Paracetamol
(+) tachypnea
lung fields q4hrs PRN
(+) DOB
for fever
(+) vomiting
(+) irritability
Complete Blood Count
(+) rales on bilateral lung fields
(+) subcostal retractions PARAMETERS RESULT NORMAL VALUE
Lives in Solana, Cagayan Hemoglobin 116 130-160
Hematocrit 0.32 0.36-0.50
PNEUMONIA
Erythrocyte 4.74 4.50-5.30
Rule In Rule Out
Platelet Count 357 150-400
(+) fever
(+) cough MCV 85 79-98

(+) tachypnea MCH 31 25-35

(+) dyspnea MCHC 366 320-360
(+) decrease feeding frequency WBC Count 14 4.5-13
(+) irritability Neutrophil 70.1 34-64
(+) rales on bilateral lung fields Lymphocyte 19.4 25-45
Monocyte 6.6 2-8
(+) subcostal retractions
Eosinophil 0.1 0-5
Alar flaring Basophil 0.2 0.0-1.0

RADIOGRAPHY

● A- trachea is on the midline, with good inspiratory effort

● B- no fracture noted
● C- CT radio of 0.55
● E- no effusion noted , no blunting of costophrenic sulci
● F – no foreign body noted, ***Bilateral streaky densities on
both lung fields with hyperaeration seen as flattening of the
diaphragm and the ribs
INITIAL IMPRESSION: PCAP C- Moderate Risk; COVID-19 Suspect
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Pediatrics
EXIMIUS 2021
PEDIATRIC COMMUNITY ACQUIRED PENUMONIA SPUP School of Medicine
Group 3 and 7

DAY 1 OF HOSPITALIZATION
Subjective Objective Assessment Planning

(+) HR: 120 Pediatric • Patient was

decreased RR: 38 Community transferred
tachypnea T: 37 Acquired to regular
(+) O2 Sat : 99 Pneumonia- Ward
decreased @ room Moderate • BF with SAP
febrile air risk • D5LRS
episode (-)alar shifted to
Good flaring mild
appetite No Dehydration
OPS/NPS : retractions • Cefuroxime
NEGATIVE (+) rales 100 mg IV
bilateral for a day
lung fields • Paracetamol
10 mg IV
every 4
hours as
needed for
fever(>
37.8)

DAY 2 OF HOSPITALIZATION
Subjective Objective Assessment Planning
Pathophysiology on the last page
No HR: 112 Pediatric • MGH
tachypnea RR: 32 Community • Take home DIAGNOSTICS
No febrile T: 37 Acquired Meds: According to the Clinical Practice Guidelines in the evaluation
episode O2 Sat : 99 Pneumonia- 1. Cefuroxime and management of Pediatric Community Acquired Pneumonia,
Good @ room Moderate 250mg/ml patients who are classified as PCAP-A or PCAP B or those that are
appetite air risk at 30 (20- managed in an outpatient basis does not routinely require the need
(-)alar 30mkd for laboratory and imaging examinations. This is to limit or avoid
flaring q12hr) unnecessary exposure of patients to such procedures. However,
No 2. Zinc drops those who are classified as PCAP-C or PCAP D or those who are
retractions 2 ml once a managed in an outpatient basis, the flowing diagnostic procedures
(+) rales day are routinely requested:
bilateral 3. Ascorbic • Chest X-ray (PA-L) to assess pulmonary complications
lung fields Acid Drops such as empyema or pleural effusion.
5 ml once a • White Cell Count which usually shows neutrophilia in a
day bacterial infection and lymphocytosis in a viral infection.
• BF c SAP • Culture and sensitivity of:
• Advised o Blood for PCAP D and those who are not responding
to treatment or have clinical deterioration.
o Pleural fluid following diagnostic thoracocentesis
FINAL DIAGNOSIS: PCAP - MODERATE RISK for pleural effusion
o Trachea aspirate upon initial intubation
CASE DISCUSSION
• Blood gas and/or pulse oximetry for those who require
admission
EPIDEMIOLOGY
o Pneumonia is the leading cause of death globally among
COMPLICATIONS
children younger than 5 years.
• result of direct spread of bacterial infection w/in thoracic
o Pneumonia is most prevalent in South Asia and sub-Saharan
cavity (pleural effusion, empyema, pericarditis)
Africa
• bacteremia & hematologic spread
o Pneumonia is still Philippines top killer.
• meningitis & osteomyelitis
• rare complications of pneumococcal or H.
ETIOLOGY influenzae type b infection
o Streptococcus pneumonia : most common bacterial • S. pneumoniae: abscess, empyema
pathogen (3 weeks to 4 years old)
• H. influenzae: pleural effusion
o Haemophilus influenza: 2nd most common bacterial cause
• S. aureus: empyema, pneumothorax, lung abscess
o Respiratory Syncytial Virus: most common viral cause
o Pneumocystis jiroveci

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Pediatrics
EXIMIUS 2021
PEDIATRIC COMMUNITY ACQUIRED PENUMONIA SPUP School of Medicine
Group 3 and 7

PREVENTION Enteric Gram-

• Frequent Hand Washing negative bacilli
• Good personal hygiene Legionella
• Pneumococcal Vaccine pneumophila
• Hygienic handling of foods Anaerobes (risk
of aspiration
Hib High-Risk CAP Streptococcus No risk for P. aeruginosa:
ü < 6 months – 4 doses pneumoniae IV non-antipseudomonal
q First 3 doses – 2 months apart Haemophilus β-lactam +IV extended
q fourth dose – 1 year after after the 3rd dose influenza macrolide or IV
Chlamydphila respiratory FQ
ü 1 year old – 1 dose only pneumoniae With risk for P.
ü 6-12 months – 2 doses – 1 month apart Mycoplasma aeruginosa:
booster – 1 year after the 2nd dose pneumoniae IV antipneumococcal
Moraxella antipseudomonal β-
Pneumococcal Vaccine catarrhalis lactam + IV extended
• Thirteen valent pneumococcal vaccine Enteric Gram- macrolide +
ü 4 dose negative bacilli aminoglycoside
ü 2-4-6 months Legionella or
ü booster @ 15 months pneumophila IV antipneumococal
ü 2 yrs old Anaerobes (risk antipseudomonal β-
q 1 dose of aspiration), lactam + IV
ü 1-2 yrs old – Sau, Pae ciprofloxacin/levofloxacin
q 2 doses – 2 months apart (high-dose)
ü 7-11 months
q 2 doses – 1 month after
q 3rd dose - @ 2 yrs old
Amoxicillin
• Pneumo23 • first-line agent in children in whom pneumococcal disease is
ü given only after @ 2 years old strongly suspected.
ü give every 5 years if @ high risk • previously healthy, appropriately immunized infants and
ü if not – 1 dose only preschool children with mild to moderate community
ü high risk adults – give every 5 years acquired pneumonia suspected to be of bacterial origin.
• Advantages: relatively palatable and having a tid-dosing
TREATMENT schedule
RISK POTENTIAL EMPIRIC THERAPY • Disadvantage: but it has limited activity against gram-
STRATIFICATION PATHOGENS negative bacteria due to resistance.
Low-Risk CAP Streptococcus Previously healthy: • 80-90mg/kg/24hr
pneumoniae Amoxicillin or extended • for penicillin-resistant pneumococci communities
Haemophilus macrolides
influenza (suspected atypical • Alternatives:
Chlamydphila pathogen) • Cefuroxime & amox/clavulanate
pneumoniae With stable comorbid
Mycoplasma illness: Bacterial pneumonia
pneumoniae β-lactam / β-lactamase • Parenteral Cefuroxime
Moraxella inhibitor combination • 75-150mg/kg/24hr
catarrhalis (BLIC) or second-
Enteric Gram- generation oral Infection with Staphylococcal pneumonia
negative bacilli cephalosporin + extended • Vancomycin or Clindamycin
(among those macrolides
with co-morbids) Alternative: Infection with M. pneumoniae
Third-generation oral • macrolide antibiotic (Azithromycin)
cephalosporin • primarily school-aged children and adolescents
+extended macrolide 30% of px w/ known viral infection have coexisting bacterial
Moderate-Risk CAP Streptococcus IV non-antipseudomonal pathogens
pneumoniae β-lactam (BLIC,
Haemophilus cephalosporin or Zinc PO (20mg/kg) – accelerate recovery
influenza carbapenem) + extended Complicated pneumonia: Chloramphenicol (cover for possible
Chlamydphila macrolide or IV non- intracranial complications)
pneumoniae antipseudomonal β-
Mycoplasma lactam +IV extended
pneumoniae macrolide or IV
Moraxella respiratory FQ
catarrhalis
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Pediatrics
EXIMIUS 2021
PEDIATRIC COMMUNITY ACQUIRED PENUMONIA SPUP School of Medicine
Group 3 and 7

CRITERIA FOR HOSPITALIZATION

1. < 3 mos(whatever the severity)
2. Fever(>38.5), refusal to feed/vomiting; dehydration; inability
to maintain hydration orally
3. Moderate to severe respiratory distress: Respiratory rate >70
breaths/minute for infants <12 months of age and >50
breaths per minute for older children; retractions; nasal
flaring; difficulty breathing; apnea; grunting; requiring
supplemental oxygenation
4. Multiple lobe involvement
5. Immunocompromised status
6. Failure of previous therapy
7. Noncompliant parents

PROGNOSIS
• most children recover rapidly and completely
• with treatment, most types of bacterial pneumonia can be
cured w/ in 1-2 weeks
• viral pneumonia is a self-limiting condition and may last
longer than bacterial pneumonia
• long term alteration of pulmonary function is rare, even in
children with pneumonia that has been complicated by
empyema or lung abscess.

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