Integrated Management of Childhood Illness

Respiratory Tract Infection

(Pneumonia)

By : Irwan Junawanto , MD
Ivon L. Goutama , MD ( internship )
 General Facts
• Respiratory tract infections are the main cause of morbidity and mortality
in children, especially in the developing world.

• According to the World Health Organization reports they are responsible

for 1.6 - 2.2 million deaths globally in children under 5 years old.

• Pneumonia is one of the main causes responsible for the above deaths.
They occupy most of the consultation time in primary care as well as in
hospital care settings.

Source : NATIONAL GUIDELINES FOR MANAGEMENT OF RESPIRATORY TRACT INFECTIONS

SRI LANKA
 Pneumonia in Childhood
• Pneumonia is an inflammation of the parenchyma of the
lungs.

• It is one of the leading causes of mortality in hospital

admissions in the paediatric age group.

Source : Kliegman, R. Et al. Nelson Textbook of Pediatric 19th ed. Philadephia: Elsevier
Sauders. 2011
Source : Kliegman, R. Et al. Nelson Textbook of Pediatric 19th ed. Philadephia: Elsevier
Sauders. 2011
 Clinical Manifestation
• Tachypnoea, intercostal and subcostal recessions, restlessness
and drowsiness may indicate the severity of pneumonia.

• Tachypnoea with chest indrawing is the best predictor of

pneumonia of children in all age groups.

Source : NATIONAL GUIDELINES FOR MANAGEMENT OF RESPIRATORY TRACT INFECTIONS

SRI LANKA
 Clinical Manifestation

Source : NATIONAL GUIDELINES FOR MANAGEMENT OF RESPIRATORY TRACT INFECTIONS

SRI LANKA
Radiograph
 Indicators for Admission to Hospital
• Oxygen saturation (SaO2) less than 92%, cyanosis
• Respiratory rate over 70 breaths/min (infants), 50 breaths/min (older
children)
• Difficulty in breathing
• Intermittent apnoea, grunting
• Poor feeding (approximately reduction by half)
• Family not being able to provide appropriate observation or supervision.
• Signs of dehydration

Source : NATIONAL GUIDELINES FOR MANAGEMENT OF RESPIRATORY TRACT INFECTIONS

SRI LANKA
 Treatment (Early 1980)
Classification Manifestation Treatment
Pneumonia fast breathing given oral antibiotic,
cotrimoxazole, to take at
home for 5 days
Severe Pneumonia chest indrawing with or referred to the closest
without fast breathing higher level health facility
for treatment with
injectable penicillin
Very Severe Disease general danger signs received a first dose of oral
antibiotic and were then
urgently referred to a
higher level health facility
for further evaluation and
treatment with parenteral
antibiotics.

Source : Revised WHO Classification and Treatment of Childhood Pneumonia at Health Facilities :
Evidence Summaries. 2011
 Revised Recommendation IMCI 2010
• Recommendation 1

Children with fast breathing pneumonia with no chest indrawing or

general danger sign should be treated with oral amoxicillin : at least
40mg/kg/dose twice daily (80mg/kg/day) for five days. In areas with low
HIV prevalencr, give amoxicillin for three days

Children with fast breathing pneumonia who fail on first line treatment
with amoxicillin should have the option of referral to a facility where there
is appropriate second line treatment.
 Revised Recommendation IMCI 2010
• Recommendation 2

Children age 2-59 months with chest indrawing pneumonia should be

treated with oral amoxicillin: at least 40mg/kg/dose twice daily for five
days
 Revised Recommendation IMCI 2010
• Recommendation 3
Children aged 2-59 months with severe pneumonia should be treated with
parenteral ampicillin (or penicillin) and gentamicin as a first line
treatment.

 Ampicillin : 50 mg/kg, or benzyl penicillin: 50,000 units per kg IM/IV every

6 hours for at least 5 days.
 Gentamicin : 7.5mg/kg IM/IV once a day for at least 5 days

Ceftriaxone should be used as a second line treatment in children with

severe pneumonia having failed on the first line treatment.
 Revised Recommendation IMCI 2010
• Recommendation 4
Ampicillin (or penicillin when ampicillin is not available) plus gentamicin or
ceftriaxone are recommended as a first line antibiotic regimen for HIV
infected and exposed infants and for children under 5 years of age with
chest indrawing pneumonia or severe pneumonia.

For HIV infected and exposed infants and for children with chest indrawing
pneumonia or severe pneumonia, who do not respond treatment with
ampicillin or penicillin plus gentamicin, ceftriaxone alone is recommended
for use as second line treatment
 Revised Recommendation IMCI 2010
• Recommendation 5
Empiric cotrimoxazole treatment for suspected Pneumocystis jirovecii
(previously Pneumocystis carinii) pneumonia (PCP) is recommended as an
additional treatment for HIV infected and exposed infants aged from 2
months up to 1 year with chest indrawing or severe pneumonia

Empirical cotrimoxazole treatment for Pneumocystis jirovecii pneumonia

(PCP) is not recommended for HIV infected and exposed children over 1
year of age with chest indrawing or severe pneumonia
Integrated Management of Childhood Illness
2014

The New Approach

 First line for pneumonia / ear infection

Age or Weight Amoxicillin

Tablet 250 mg syrup 250 mg / 5 cc

2 months up to 12 months (4-<10 kg ) 1 5 cc

12 months up to 3 years (10-<14 kg ) 2 10 cc

3 years up to 5 years (14-19 kg) 3 15 cc