PNEUMONIA in

CHILDREN
Dr. Tripti Srivastava
AP, DEPARTMENT OF PAEDIATRICS
Introduction
Pneumonia is an inflammation of the parenchyma of the lungs.
(Microscopic air sacs called alveoli)

EPIDEMIOLOGY

Most common cause of mortality(18-20%) in children less then five

years of age, 98% mortality from developing countries.
ANATOMICALLY
PATHOLOGICAL CLASSIFICATION
• Consolidation of alveoli (filled with fluid or pus ,contains bacteria and
blood)
• Infiltration of Interstitial tissue with inflammatory cells.
• BOTH
 RISK FACTORS:-
• LBW
• Malnutrition
• Lack of breast feeding
• Vit A deficiency
• Passive smoking
• Large family size
• Family history of bronchitis
• Advanced birth order
• Overcrowding
• Young age
• Air pollution
• Winter months
• Reduced host resistance
• Complications of measles, Varicella, pertussis, influenza
• Cystic fibrosis
• Staphylococcal pyoderma
• Diabetes mellitus
• Macrophage dysfunction
• Recent viral respiratory infection – cold, laryngitis
• Chronic heart diseases
• Chronic liver diseases
• Impaired consciousness due to dementia/other neurological
conditions
• GERD
• TEF/ Other congenital anomalies of upper respiratory tract
 ETIOLOGY

• Viral: It can be caused by :-

RSV ( Most common less then six months)
Influenza,
Parainfluenza
Adenovirus
Human meta pneumo
Rhino
Measles
Chicken pox
Bacterial:
• In first 2 months the common agents include klebsiella, E. coli,
Pseudomonas ( gram negative) , B group Steptococcus and
Staphylococci.
• Between 3 month to 3 years common bacteria include S. pneumonia,
H. influenza and Staphylococci.
• After 3 years of age common bacteria include S. pneumonia and
Staphylococci.
FUNGAL
• Oral thrush (candidiasis)
• Moniliasis
• Histoplasmosis
• Pneumocystis jirovecii

( In immunocompromised children e.g HIV)

ATYPICAL ORGANISMS
• Mycoplasma pneumoniae
• Chlamydia pneumoniae
• Legionella pneumophilia
( More then five years and community acquired)

VARIOUS CHEMICALS:- Hydrocarbon( kerosene)

ASPIRATION PNEUMONITIS
Clinical features:-
• Onset of pneumonia
• Insidious (Viral )starting with URTI
• Acute:- (Bacterial )
• Symptoms
• high fever with shaking chills.
• Headache
• Malaise/ fatigue
• Myalgia
• Cough (mostly dry ) May be with sputum
• Mucoid in atypical pneumonia
• Thick rusty in pneumococcal
• Streaked sputum streptococcal
• Red current jelly klebsiella
• Greenish color H.influenza, Pseudomonas , Pneumococcal
• Foul smelling anaerobic bacteria
• difficulty in breathing
• Bluish discoloration of skin and mucus membranes
• grunting respiration.
• Breathing rate is always increased.
• Chest pain (continuous ,on deep breathing or on coughing)
• Rarely pneumonia may be present with acute abdominal emergency which is
due to referred pain from the pleura.
• Sometimes shoulder pain
• Apical pneumonia may sometime be associated with meningsmus and
convulsion.
• Nausea ,vomiting and diarrhea
• Difficulty in feeding.
SIGNS:-
• flaring of alae nasi
• TACHYPNEA ( 2 months >60, 2- 12 mths >50, 12-60 mths >40, >5 year
>30)
• Retractions of supracostal , intercostal, infracostal (lower chest
indrawing), supraclavicular, infraclavicular, suprasternal,infrasternal
• Cyanosis
• Diminished expansion of chest
• Cervical lymphadenopathy
• Pharyngeal congestion ATYPICAL PNEUMONIA
• Dull/impaired percussion note
• Increased tactile fremitus
• Increased vocal resonance
• Decreased breathe sounds
• Bronchial breathing
• Crepitations /crackles
• Rhonchi/rales
• Bronchophony
• Whispering Pectoriloquy
In Lobar Pneumonia
 INVESTIGATION
Chest Radiograph :- PA/LAT View
• confirms the diagnosis of pneumonia
• Indicate a complication such as a pleural effusion or empyema.
• To exclude pneumonia in infants <3 months with fever
• To exclude other causes of dyspnea (foreign body, CHF)
• Infection is severe
FINDINGS
• Confluent lobar consolidation is typically seen with Pneumococcal and
Atypical(lower lobe) pneumonia.
• Multiple patchy area of consolidation/Bronchopneumonia in
Staphylococcal, H influenza and Pseudomonas
• Viral ,Atypical , streptococcal pneumonia is usually characterized by
• hyperinflation with bilateral interstitial infiltrates
• Peri bronchial cuffing/densities/infiltrates
• poorly defined, hazy, fluffy ,diffused perihilar exudates.
• Enlarged hilar lymph nodes:- Atypical
• Pleural effusion :- Streptococcal, Atypical
• Empyema, pericarditis:-Staphylococcal ,H influenzae
• Pneumothorax :-staphylococcal
• Pneumatoceles :-Staphylococcal, Klebsiella and E coli
• BLOOD EXAMINATION
• The peripheral white blood cell (WBC) count can be useful
in differentiating viral from bacterial pneumonia.
• In Viral pneumonia, the WBC count can be normal or elevated but is
usually not higher than 20,000/mm3, with a Lymphocyte
predominance.
• Bacterial pneumonia (occasionally, Adenovirus pneumonia) is often
associated with an elevated WBC count in the range of 15,000-
40,000/mm3 and a predominance of Granulocytes.
• ESR raised in tubercular, bacterial also
• CRP raised in bacterial
• MOUNTOX TEST:- To rule out Tb.
Blood culture indications :-
• who failed to improve
• have clinical deterioration
•Complications
•Require hospitalization
Positive in only 5 -10% cases
SPUTUM :-in children
1. Gram staining for Bacteria
2. Culture for Bacteria and Mycobacterium tuberculosis
3. AFB for Mycobacterium tuberculosis
4. CBNAAT for Mycobacterium tuberculosis
5. PCR for Mycoplasma pneumoniae
• Respiratory secretion(Nasopharyngeal/oropharyngeal):-
Viral Culture or Antigen isolation, Growth of respiratory viruses in
tissue culture usually requires 5–10 days.
• IGM Abs by ELISA:- Mycoplasma pneumoniae
• Pleural fluid examination:- 1.Cells 2. protein 3. sugar 4. gram
staining 5. culture 6.ADA 7. AFB 8.CBNAAT
• Bronchoalveolar lavage by bronchoscopy for Viral Antigen and
Genome
•Lung biopsy
USG CHEST:-
• Lung consolidation
• Pleural effusion
• Air bronchogram
• HRCT CHEST ( In Slowly resolving pneumonia)
• Persistence of symptoms
• Persistence of radiographic abnormalities beyond the expected time
and course
• RECURRENT Pneumonia-1. Two or more episodes in a single year
2.Three or more episodes ever with radiographic clearing between
occurrences
Treatment
based on the
• Presumptive cause
• The clinical appearance of the child.
• Age of child
• Vaccination status of child.
MILD INFANTS CHILDREN

HOME MANAGMENT TEMPERATURE <38.5 TEMP. < 38.5 DEGREE

DEGREE CEN. CEN.

RR <50/MIN RR <50/MIN

MILD CHEST MILD

RECESSION BREATHLESSNESS

TAKING FULL FEEDS NO VOMITING

 HOME MANAGMENT
1. INCREASE ORAL INTAKE
2. ADEQUATE REST
3. FREQUENTLY CHECK TEMP. and GIVE ANTIPYRETIC (PCM
15MG/KG/DOSE 4-6 HRLY)
4. PLACE CHILD IN UPRIGHT POSITION
5. REGULAR FOLLOW UP
6. ABS – AMOXYCILLIN 40mg/kg/day TDS for 5 days
INDICATION OF HOSPITAL ADMISSION
1. Age less then 6 months.
2. Sickle cell anemia with acute chest syndrome
3. Multiple lobe involvement
4. Immunocompromised child(HIV)
5. Toxic app.
6. Severe dehydration
7. Vomiting or inability to tolerate oral fluid and medications
8. No response to oral Abs therapy
9. Non compliant parents , unable to provide app observation,
supervision and administer medication at home or follow up
10. MODERATE TO SEVERE PNEUMONIA :- Severe
Respiratory Distress
C/F INFANTS CHILDREN
TEMP. >38.5 >38.5
RR >70/MIN >50/MIN
CHEST RECESSION MODERATE TO SEVERE SEVERE
NASAL FLARING PRESENT PRESENT
CYANOSIS PRESENT PRESENT
GRUNTING PRESENT PRESENT
OXYGEN SAT. <= 92 <= 92
FEEDING NOT NOT and signs of dehydration
APNEA INTERMITTENT NOT
SENSORIUM ALTERED/LETHARGIC/DROWSY/SEIZ ALTERED/LETHARGIC/DROWSY/SEIZ

ABDOMEN DISTENDED DISTENTED

STRIDOR ABSENT PRESENT

HOSPITAL MANAGMENT
1. Assement of child and monitor vitals signs:-
1.Temp.
2.RR over 2 times 30 sec. or over 1 min.
3.HR
4.SPO2
5.CRT
6.HYDRATION
7.SENSORIUM
8.URINE OUTPUT
2. Determine causative org.:-
AGE/ CLINICAL FEATURES
CHEST XRAY
BLOOD CUL.

3. Control of fever :-ANTIPYRETIC PCM 15 Mg / kg /dose 4-6 hrs.

4. Maintain patent airway
5. Gentle oral/ nasal suction to be done for thick secretions .
6. Provision of high humidified O2 by Hood, Nasal prongs and mask
7. If needed CPAP/Mechanical ventilation
8. Upright posture
9.Rest
10.Provision of appropriate and adequate fluids- encourage breast feeds/oral
feeds/NG/OG if needed
11. CHEST PHYSIOTHERAPY
12. If wheeze NEB with broncho dialators [Levo salbutamol and Ipratropium bromide)
13. ANTIBIOTICS Choice depends on :-
1local epidemiology
2Immunization status of the child
3Clinical manifestation at the time of presentation
IN AREAS:-
.1 Without substantial high level penicillin resistance among step.
Pneumoniae
2. Who are fully immunized against H. influenzae and
pneumococcus
.3 Not severely ill
. We give Benzylpenicillin/ Ampicillin/Amoxicillin/Amoxycillin-
clavulanate
. Who do not meet these criteria we give cefotaxime/ ceftriaxone
• If Staphylococcal infection (pneumatocele/empyema) add
Vancomycin / Linezolid/Tecoplanin
• In neonates/early infants add Aminoglycosides( Genta/Amika)
for gram negative orgs.
• For Pseudomonas add Ceftazidime,Piptaz
• For Atypical Pneumoniae add Macrolides.
(Erythro/Azithro/Clarithromycin
• For Pneumocystis jirovecii give Cotrimoxazole
• For 10 -14 days except in staphylococcal pyo pneumothorax
for 2-6 weeks
14. Prevention of complications
15. Support and education of parents
16. If pneumonia is complication of measles, Vit A treatment
also given on 1st 2nd and 28th days as 50 k units , 1 lakh units ,2
lakh units for children aged 6 mths, 1 yr, and >1 yr respectively
 RESPONSE TO TREATMENT
• Improvement in clinical symptoms(fever, cough, increased RR and chest
pain) within 48 -96 hrs. of ABS initiation in community acquired
bacterial Pneumonia
• Radiographic evidence of improvement substantially lags behind the
clinical improvement
• Slowly resolving pneumonia due to :-
1. Complications:-
A. Direct spread of bacterial inf. In thoracic cavity (pleural effusion , para
pneumonic eff, pyothorax , pneumothorax, lung abscess, and pericarditis)
B. Hematological spread (sepsis, abscesses in muscles , bones , joints, brain
mastoid, liver and pericardium ,meningitis, endocarditis, septic polyarthritis ,
osteomyelitis)
C. Shock
D. Respiratory failure
E. Activation of latent TB

2. Bacterial resistance to antibiotics

3. Non bacterial cause(viral/fungal/foreign body/ aspiration of food)
4. Bronchial obs. (foreign body/mucus plug/endobronchial lesions)
5. Pre existing dis.(Ciliary dyskinesia /immunodeficiency /cystic fibrosis)
6. Other non inf. Causes ( Eosinophilic pneumoniae ,hypersenstivity
granulomatosis)
REPEAT CHEST XRAY is 1ST STEP IN DETERMINING THE CAUSE
HRCT may be needed
 PROGNOSIS
Depends on:-
• Age
• Nutritional status
• Vaccination status
• Type of pneumonia
• Adequacy of treatment
Most pts. do not have long term sequelae
1. Streptococcus- good with treatment
2. Staphylococcal- mortality rate 10-30%
3. H Influenza - mortality rate very high due to complications
4. Recovery of Mycoplasma pneumoniae - very slow
5. Upto 45% of children have symptoms of asthma 5 yrs after hosp. for Pneumonia
PREVENTION
• Should encourage EBF and complimentary feeding after 6 mths of
age
• Treat malnutrition earliest and appropriately
• Treat underlying illnesses (HIV/heart dis./cystic fibrosis/D.M etc…)
• Cotrimoxazole prophylaxis for HIV Infected children
• Vaccination for pneumococcus/H Influenza /Varicella
Measles/Pertussis/Influenza virus should be given to all children
• Educate parents about hygiene/passive smoking
THANK YOU