Pneumonia in children

Rehema Marando (Pediatrician)

MD,MMED.
December 9, 2022
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
Back to Basics
• What is pneumonia?
• What is the Pathophysiology?
• Who gets what?
• How do you treat?
• To Admit or Not to Admit
• Management and follow up
Anatomy and physiology
• The respiratory tract extends from the nose to the
alveoli and includes not only the air-conducting
passages also but the blood supply
• The primary purpose of the respiratory system is
gas exchange, which involves the transfer of
oxygen and carbon dioxide between the
atmosphere and the blood.
• The respiratory system is divided into two parts:
the upper respiratory tract and the
• lower respiratory tract
 The upper respiratory tract includes

• The nose
• pharynx
• adenoids
• tonsils
• epiglottis
• larynx,
• and trachea.
The lower respiratory tract
consists of
• The bronchi,
• Bronchioles
• alveolar ducts
• and alveoli
• With the exception of the right and left main-
stem bronchi, all lower airway structures are
contained within the lungs.
Background
Definition:
Pneumonia can be generally defined as inflammation of
the lung parenchyma, in which consolidation of the affected
part and a filling of the alveolar air spaces with exudate,
inflammatory cells, and fibrin is characteristic.

 Infection by bacteria or viruses is the most common

cause, although inhalation of chemicals, trauma to the
chest wall, or infection by other infectious agents such as
rickettsiae, fungi, and yeasts may occur.
Epidemiology
• Extremely common and potentially serious infection of
children

• Annual incidence <5yo, 34-40 cases per 1000 in Europe

and North America

• Annual incidence in Tanzania about 60-100 per 1000

children

• Worldwide, more than 2 million children die of

pneumonia annually (mostly in developing countries).

• Clinical and radiographic features do not reliably

distinguish between viral and bacterial causes
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.
Pathophysiology
Pulmonary injuries are caused directly and/or indirectly by
invading microorganisms or foreign material and
inappropriate responses by the host defense system that may
damage healthy host tissues as badly or worse than the
invading agent.

Direct injury by the invading agent usually results from

synthesis and secretion of microbial enzymes, proteins, toxic
lipids, and toxins that disrupt host cell membranes, metabolic
machinery, and the extracellular matrix that usually inhibits
microbial migration.
Cont.
 Bacterial infections
This consolidation leads to decreased air entry and
dullness to percussion; inflammation in the small airways
leads to crackles.
Viral infections
are characterized by the accumulation of mononuclear cells
in the submucosa and perivascular space, resulting in partial
obstruction of the airway.
Patients with these infections present with wheezing and
crackles
Etiology
• The common pathogens are a function of the
patient’s 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.
Pneumonia - Common Pathogens
Age Group
Age Group Common
CommonPathogens
Pathogens(in(inOrder
OrderofofFrequency)
Frequency)
Newborn
Newborn Group
GroupB BStreptococci,
StreptococciE Coli
Gram-negative
Gram-negativebacilli
bacilli
Listeria
Listeriamonocytogenes
monocytogenes
Herpes
HerpesSimplex
Simplex
Cytomegalovirus
Cytomegalovirus
Rubella
Rubella
1-31-3 months
months Chlamydiatrachomatis
Chlamydia trachomatis
RespiratorySyncytial
Respiratory Syncytialvirus
virus
Otherrespiratory
Other respiratoryviruses
viruses
3-12
3-12 months
months RespiratorySyncytial
Respiratory Syncytialvirus
virus
Otherrespiratory
Other respiratoryviruses
viruses
Streptococcuspneumoniae
Streptococcus pneumoniae
Haemophilusinfluenzae
Haemophilus influenzae
Chlamydiatrachomatis
Chlamydia trachomatis
Mycoplasmapneumoniae
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
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
• Past Medical History
• Birth History
• Allergies
• Family History
Pneumonia History
• Immunizations status
• TB exposure
• Maternal Chlamydia, Group B Strep status
during pregnancy
• Choking episodes
Diagnosis
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 well-nourished Gambian
children respectively
WHO Definition of Tachypnea

Age Respiratory Indication of

Rate severe
(breaths/min) infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5 > 40 >50
years
Greater than 5 > 20
years
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
 WHO pneumonia classification
Sign or symptom Classification Treatment
•Cough or difficult in breathing Severe •Admit to hospital
with: •Give Oxygen if saturation <90%
Oxygen saturation<90% or pneumonia •Manage the airway as appropriate
Central cyanosis •Give recommended antibiotic
Severe respiratory distress •Treat high fever if present
( e.g. grunting, very severe
chest wall in drawing)
Signs of pneumonia with a
general danger sign (inability to
breastfeed or drink, Lethargy or
reduced level of consciousness,
convulsions

•Fast breathing Pneumonia •Home care

•<2 months RR ≥60 •Give appropriate antibiotic for 5 days
•2-11 months RR ≥50 •Advise the mother when to return immediately if the
•1-5 years RR ≥40 symptoms of severe pneumonia
•Chest indrawing •Follow up in 3 days

•No Signs of pneumonia or No pneumonia, •Home care

severe pneumonia •Soothe the throat and relieve cough with a safe remedy
cough or cold •Advise the mother when to return
•Follow up in 5 days if not improving
•If coughing >14 days, evaluate for chronic cough
Diagnosis in a Health Care
Setting
• Vital signs that should routinely be taken in an
Emergency Care setting include:
• Respiratory Rate
• Heart Rate
• Temperature
• Oxygen saturation (if available)

• Any child with an increased respiratory rate

should be immediately identified as having
possible pneumonia.
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.
Differential Diagnosis:
A Focus on Respiratory Syncytial Virus
(RSV)
Respiratory Syncytial Virus
(RSV)
• RSV is the most common cause of LRTIs in
children less than 1 year.
• 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.
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
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 - investigations
 Pulse oximetry
 Chest x-ray, especially in:
– Severe pneumonia
– Severe pneumonia not responding to treatment or with
complications
– HIV infection
 To consider:
– Full blood picture
• Increased WBC with neutrophilia suggests bacterial process
– Blood cultures
– Induced sputums or gastric aspirates for AFB smear and
culture if not responding to treatment
MANAGEMENT
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.
Management of Respiratory Distress and
Respiratory Failure: ABC’s and
Intubation
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)
Indications for Intubation
• Inadequate oxygenation or ventilation
• Inability to maintain and/or protect the airway
• Potential for clinical deterioration
• Prolonged patient transport or diagnostic studies
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
Normal Chest x ray
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
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
• Pneumatocele – thin walled, air filled cysts of the lung, often
occurs with empyema.
• Pneumatoceles often resolve spontaneously, but may lead to
pneumothorax.
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.
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.
Severe pneumonia - antibiotics
Give intravenous ampicillin( or benzyl penicillin) and
gentamycin
 Ampicillin (50 mg/kg every 6 hours) or benzyl penicillin 50
000 U/kg IM or IV every 6 hours for at least 5 days
 gentamicin (7.5 mg/kg daily) for 5 days
• Can change ampicillin to PO amoxicillin after 5 days if
improving
Alternatively
Use Ceftriaxone (80 mg/kg IM or IV once daily) in cases of
failure of first line treatment
If no improvement within 48 hours, consider complications and
change to cloxacillin (50 mg/kg every 6 hours) + gentamicin
Pneumonia - management

Amoxicillin (40 mg/kg BD for 3 days)

Amoxillin 25mg/kg tds for 5 days
Amoxicillin preferred if pneumonia develops in an HIV-
positive child using CTX for PCP prophylaxis
‘Atypical’ pathogens
Mycoplasma pneumoniae and Chlamydia
pneumoniae
Generally more common in older children >5
years
Treat with macrolide antbiotics
• Erythromycin 12.5 mg/kg QDS
OR
• Azithromycin 10 mg/kg OD day 1, 5 mg/kg
OD days 2-5
Aspiration pneumonia – predisposing
conditions
Altered consciousness
Dysphagia
Neurologic disorder
Mechanical disruption of usual defenses
• NG tube
Other
• Protracted vomiting
• Gastric outlet obstruction
• Large volume NG tube feedings
• Recumbent positioning
Aspiration pneumonia treatment

Coverage of oral anaerobes important (if there

are teeth)
Treat with
• (cephalosporin) AND metronidazole 7.5 mg/kg
IV/PO TDS
• Alternatives if available
• Clindamycin 10 mg/kg IV/PO TDS
• Amoxicillin/ clavulanate (Augmentin) 10
mg/kg PO TDS
Summary
 Pneumonia is a common, deadly condition in childhood
 Pneumonia is a clinical diagnosis
 Antibiotics and other therapies are given according to clinical assessment of severity
– Be aggressive with antibiotics when necessary (hypoxemia, severe tachypnea, HIV,
malnutrition, etc.)
– Be more judicious when children are less sick and without significant comorbidities
 HIV, TB, and malnutrition complicate the management of pneumonia significantly in
our setting
 Children with HIV need to be managed more aggressively with special attention to PCP
in infants <1 year
 In HIV-negative children with severe pneumonia, outpatient therapy with high-dose
amoxicillin may be as effective as hospitalization and IV antibiotics
– May be more effective if they never make it to hospital
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
Case Presentation
9 yo boy presents with a 10 day history of sore throat,
dry cough, and fever. On physical exam, the child is
well appearing. He has a temperature of 39.2C, a
respiratory rate of 28 breaths/min, and scattered
rales bilaterally. A CXR reveals bilateral basilar
insterstitial infiltrates. The most likely diagnosis and
etiologic agent of this boy’s illness is….
References
• References
• Hazir T, et al. Lancet 2008;371:49-56.
• Nelson Textbook of Pediatrics, 17th edition.
• WHO pocket book of Hospital care for children
homework