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JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS
HEALTH HISTORY

Place of Interview: Pediatric Ward, Ospital ng Maynila Medical Center


Informant: Mother (85% reliability)
PATIENTS PROFILE/ GENERAL DATA:
C.B., 1-year old Filipino male born on January 15, 2015, currently residing at Paco, Manila.
Patient is currently admitted for the first time at the Pediatric Ward of the Ospital ng Maynila
Medical Center on October 12, 2015.
CHIEF COMPLAINT
Difficulty of breathing
HISTORY OF PRESENT ILLNESS
7 days PTA: Patient had cough with whitish phlegm and white mucus discharge in nose. Mild fever
was noted, mother reported it to be less than 38 C. He was irritable, always crying and had
decreased interest in play. However, no change in appetite observed. Patient consulted at Philippine
General Hospital and was prescribed with cefuroxime 250 mg syrup 2x/day and Salbutamol nebule
every 6 hrs. This afforded relief of symptoms.
5 days PTA:Patients cough recurred which worsened at night along with increased frequency of
whitish phlegm and mucus discharge in the nose despite regular intake of prescribed antibiotics.
Undocumented fever was noted. Patient continued to take the abovementioned prescribed
medication however only afforded relief from fever but still with cough. No consult done.
In the interim, there was noted labored breathing along with productive cough and white to
yellowish phlegm. Difficulty in feeding the patient was noted.
1 day PTA, still with the above symptoms, the parents also noted retractions in the chest area.
There was associated anorexia, increasing irritability and vomiting of ingested milk twice.
Few hours prior to admission: There was noted difficulty of breathing, increased irritability,
inconsolable crying and decreased appetite. Patient was nebulized with salbutamol but afforded no
relief. Hence, the consultation at OMMC and subsequent admission.
REVIEW OF SYSTEMS
CONSTITUTIONAL: The patient has good appetite, fed via mixed breastfeeding and
formula milk for 6-8 times daily. The mother reported weight loss, delay in growth, and
decrease in activity level.
CUTANEOUS: No rashes, hair loss and increase in pigmentation were reported and
observed.
HEENT: Presence of nasal discharge; Absence of headache, retroorbital pain,dizziness,
visual difficulty, lacrimation, hearing, aural discharge or sore throat.
CARDIOVASCULAR: No cyanosis was observed.
RESPIRATORY: Difficulty of breathing and cough noted. Absence of hemoptysis and chest
pain observed.
GASTROINTESTINAL: No vomiting, diarrhea, constipation, jaundice, and food intolerance
were noted.

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

GENITOURINARY: No pain in urination, bleeding, incontinence, and discharges were


noted.
ENDOCRINE: No palpitations, polyuria, polydipsia and polyphagia observed.
NERVOUS/BEHAVIORAL: No sleep problems, convulsions and eating problems noted.
MUSCULOSKELETAL: No stiffness and swelling of extremities noted.
HEMATOPOIETIC: No bleeding and pallor noted.
PERSONAL HISTORY
Gestational History
The patients mother, G3P3 (3-0-0-3), was 27 years old when she gave birth to C.B. She
claimed to be healthy and in good condition when she was pregnant. She also reported that
she had complete prenatal check-ups. She took folic acid vitamin supplements during
pregnancy and denied use of illicit drugs, smoking, drinking and exposure to radiation
during her pregnancy. There was no incident of nausea, vomiting, edema, hypertension and
vaginal bleeding during pregnancy.
Birth and Neonatal History
The patient was born term (39 weeks AOG) via normal spontaneous delivery weighing 2.5
kg at a lying-in center at Sta. Ana, Paco, Manila. No congenital abnormalities and birth
injuries were noted post-delivery. Patient had good cry, good muscle activity, no cyanosis or
pallor, hemorrhage or episodes of convulsions.
Feeding History
Exclusively breastfed until 3 months old. From 3 months until present, mixed breastfeeding
and formula milk (6-8 times daily, 8 ounce bottle). Multivitamins taken are Tiki-tiki and
Celeen.The mother reported that the patient had poor feeding pattern, sometimes unable to
consume a bottle of milk.
Developmental History
Patient was able to crawl at 5 months , sits with support at 8 months, first tooth eruption
also at 8 months old. Patient sits without support at 9 months and first word was ate also
at 9 months. He was able to stand with support at 12 months and had 4 teeth also at 12
months. There were no unusual developmental delay and no neurological concerns were
reported.
Past Illnesses
Patient was diagnosed with VSD at 5 months old. In his first year of life, he was confined
due to pneumonia three times at Santa Ana Hospital at ages 2 months, 4 months and 10
months old. No surgery or medications given to manage the defect.
Patient had no known allergies to food, medications, pollen or animal dander. He has not
contracted measles or chicken pox. The patient had no history of previous surgery.
IMMUNIZATION HISTORY
According to the report of the mother, patient is a fully immunized child, having completed
all the required immunizations for his age such as BCG x1 dose, Hep B x 3 doses, Measles x
1dose, DPT x 3 doses, OPV x 3 doses and Hib x3 doses at a health center in their locality.
Patient has no pneumococcal vaccine.

FAMILY HEALTH HISTORY

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

Patients mother is 28 years old, a housewife, while his father is 25 years old and a waiter.
Patient is third among his siblings. He has a 10 year old half brother and a 5 year-old half
sister. Household members have no present illnesses or similar conditions as patient. Great
grandfather on his mothers side has history of asthma. No history of cancer, mental illness,
other infectious diseases, cardiovascular diseases, hereditary hematological disorders,
mental retardation and congenital defects.
SOCIOECONOMC HISTORY
Patient lives with his parents and grandmother at Paco, Manila in an apartment. Primary
caregiver is the mother, with the aid of his maternal grandparents. Father provides for the
family and works as a waiter in a restaurant.
ENVIRONMENTAL HISTORY

None of the family members is a known smoker. Their residence is exposed to cigarette
smoking and fumes from burning garbage. Also, mother claimed increasing incidence of
childen coughing in their neighborhood.
They own a flush type toilet and their source of drinking water is from a refilling station.
Water used for bathing and washing clothes is from Maynilad. Garbage is collected every
morning by truck.

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS
PHYSICAL ASSESSMENT

VITAL SIGNS
T: 36.9 (axillary)
RR: 46 cpm (tachypneic)
HR: 126 bpm (Tachycardic)
ANTHROPOMETRIC MEASUREMENT
HT: 70 cm (0.7 meters)
Weight: 6.2 kg
BMI: 12.65
Head circumference: 34.4 cm
Chest Circumference: 41.9 cm
Abdominal Circumference: 40 cm

***Based on the WHO child growth standards, C.B.


measuring 70cm in length is severely stunted for his age (z score: Below -3).
***Based on the WHO child growth standards, C.B. weighing 6.2 kg is severely underweight his age (z score: Below -3).
***Based on the WHO child growth standards, C.B. weighing 6.2 kg is severely wasted for his length (z score: Below -3).
***Based on the WHO child growth standards ,C.B. with a BMI of weighing 6.2 kg is severely wasted for his length (z score:
Below -3).

GENERAL SURVEY
Patient is ectomorphic, poorly developed and appears younger than actual age. He is
conscious but irritable.There are no signs of distress and pain.

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

SKIN
The skin is fair, pale but smooth and with good skin turgor. There are no visible scars,
rashes, and hemorrhages. No jaundice, flushing or cyanosis present.
HEENT
Head

Head is normocephalic and symmetrical. No palpable depressions, masses or lumps.


Fontanelles are closed. Hair is black, dry, shiny and equally distributed. Scales and
lesions are not present. Facial features are symmetrical. There are no visible gross
deformities.

Eyes
skin

The eyes are symmetrical. There are no lid lags, ptosis, swelling, edema, bulges,

and

Ears
patient

lesions and lid slanting. The sclerae are anicteric, palpebral conjunctivae are pink
cornea was clear. The pupils are equally round and reactive to light and
accommodation constricting from 3 mm to 2 mm. Extraocular muscles are intact.
Fundoscopy was not done.
Ears are symmetrical. Masses and discharge are not present on both ears. The
turns her head towards mothers voice. Tympanic membranes are intact and the

cone
Nose
in

of light on both ears are visible.


Nose and nasolabial folds are symmetrical. Nasal flaring is not observed. Septum is
midline. There are whitish watery nasal discharge, nasal redness but non-swollen.

Mouth and Throat


Lips are pale but gums and tongue are pink with no apparent lesions, masses, sores
or
ulcerations. Tongue is midline. Tonsils not inflammed and uvula not deviated.
Neck
palpable.

There are no swelling or scars noted. Lymph nodes and thyroid gland are not
The trachea was in midline.

CHEST AND LUNGS


Inspection
Palpation
Percussion
Auscultation
HEART

Inspection
Palpation
Auscultation

Chest is symmetrical in shape, no deformities, visible masses or


lesions;
Subcostal and intercostal retractions are observed.
Increased tactile fremitus
Dull upon percussion at the right lower lung field
Decreased breath sounds on right lower lung field
Adynamic precordium
PMI located on 4th ICS, left MCL; (+) thrills . No palpable heaves, lifts
Normal heart sounds (S1 maximal at apex; S2 maximal at base; S3
heard at apex); (+) Grade 3 Murmur

ABDOMEN
Inspection
Auscultation
Percussion

Abdomen is scaphoid; No visible masses, scars, striae, pulsations,


peristaltic movements and dilated veins;
Normal bowel sounds (10 bowel sounds per minute)
Not performed

JI PATI, GRACE ANTONETTE


Palpation

DEPARTMENT OF PEDIATRICS

Liver is palpable 2 cm below the costal margin. Spleen is not


palpable; No muscle guarding and tenderness upon palpation.

GENITALIA
No discharge, mass, lesion, inflammation
Equal size scrotal sac with descended testes

EXTREMITIES
There are no deformities, scars, and skin discoloration seen on the extremities. Patients
nail beds were pale but without clubbing. CRT is 3sec. There are no joint swelling and
tenderness. No edema present. Muscle tone and symmetry are normal.

JI PATI, GRACE ANTONETTE

History

Physical Examination

DEPARTMENT OF PEDIATRICS

CASE DISCUSSION
SALIENT FEATURES
1 year-old Male
diagnosed with VSD at 5 months old
recurrent pneumonia for the past months
3 day history of productive cough
(+) mucus phlegm and nasal watery discharge
(+) difficulty of breathing
(+) irritability and inconsolable crying
poor feeding history
(+) weight loss for the past several months
(+) exposure to secondhand smoke from the neighborhood
(+) increased incidence of pneumonia in the neighborhood
Maternal grandfather has asthma
No pneumococcal vaccine
Severely wasted, stuntend and underweight
Tachycardic
Tachypneic
irritable
Pale nailbeds, conjunctiva and lips
(+) Intercostal and subcostal retractions
Abdomen scaphoid

APPROACH TO DIAGNOSIS

Clinical manifestations of the patient indicated that the main organ system involved in our
case is the respiratory system. Fever allowed us to further eliminate non-infectious entities for the
probable diagnosis. The three main diseases that we entertained are the following: Bronchiolitis,
Pneumonia, and Pulmonary Tuberculosis.

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

These diseases were considered mainly due to its clinical presentation. Basing on history,
the patient had cough with whitish phlegm and nasal discharge. Patient also had fever and had
became dyspneic as the disease progresses along with increasing irritability as evidenced by report
of inconsolable crying resulting to a decreased appetite. Furthermore, the physical examination
showed a tachypneic and tachycardic patient with subcostal and intercostal retractions. All of three
conditions considered in this case is known to present with fever, dyspnea, tachypnea, tachycardia,
retractions, and irritability in an infant patient.
Bronchiolitis was taken into consideration mainly because of the infants exposure to smoke
and fumes (e.g. cigarette smoking) in the neighborhood. Cases are usually tachypneic and in
respiratory distress. Physical examination is dominated by wheezing which is not seen in our patient
upon physical examination. Auscultation of the lungs usually reveals fine crackles and wheezes, with
prolongation of expiratory phase of breathing. Hyperinflation also suggests this condition. Findings
of the physical examination in our patient are inconsistent with the usual presentation of this
condition. Acute bronchiolitis is unlikely the diagnosis for this case but further evaluation is needed
to completely rule it out.
Pneumonia is also considered for the probable diagnosis of this case. It was noted that the
patient has missed her immunization schedule for pneumococcal vaccine. This is an important risk
factor of this disease. Clinical manifestations seen in this patient are consistent and points out to
this disease. Tachypnea is the most consistent clinical manifestation of pneumonia. It may be
accompanied with colds, fever, retractions, and dyspnea. Auscultation may reveal crackles and
wheezing but its absence on our findings cannot strongly rule out pneumonia as our diagnosis.
Furthermore, the history of the patient revealed that the patient had been hospitalized for three
times in the past due to recurrences of pneumonia which strongly suggest that the present
admission strongly suggest another recurrence.
Pulmonary tuberculosis in very young children may manifest the same symptoms with
pneumonia. Distinguishing pneumonia from PTB is often not possible clinically. But usually, patients
present with non-productive cough, weight loss, night sweats, and failure to thrive. As we can see,
our has been reported to have weight loss for the past several months and as seen in the WHO
growth chart, the patient is severely wasted, stunted and underweight. Further evaluation and
workup is needed to completely rule out.
Deliberation of these three diseases lead us to pneumonia as our primary diagnosis.
Pneumonia is a more likely diagnosis due to the increased predisposition of the patient to such
respiratory infection having been diagnosed with ventral septal defect on his 5 th month of life.
Infants with VSD oftentimes presents with poor feeding, rapid and difficulty of breathing, trouble of
gaining weight and frequent and recurrent lung infections, most especially lower respiratory tract
infection involving the parenchyma, 66% of which is pneumonia. These are very similar clinical
findings and manifestation in this case.
WORKING IMPRESSION
COMMUNITY ACQUIRED PNEUMONIA SECONDARY TO VENTRAL SEPTAL DEFECT
TO RULE OUT BRONCHIOLITIS AND PRIMARY TUBERCULOSIS

Pediatric Community Acquired Bacterial Pneumonia


According to the World Health Organization, pneumonia affects children and adults
everywhere, however most child deaths occur in the worlds poorest regions with highest incidence
in sub-Saharan Africa and South Asia. Streptococcus pneumonia, Haemophilus influenzae type b
(Hib) and respiratory syncytial virus are the most common causes of pneumonia in healthy people.
At this point, the patient already completed his 3 doses of Haemophilus influenzae type b (Hib)
vaccination, and therefore the etiologic agent in this case must be another bacterial agent such as
streptococcus pneumonia or a viral agent such as RSV which also common in infant patients. In the
Clinical Practice Guidelines for Pediatric Pneumonia (2012), it is cited that age is the best predictor
of the underlying etiologic agent wherein for the first 2 years of life viruses are most frequently

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

implicated and as age increases bacterial pathogens become more prevalent. The Philippines is one
of the 15 countries that together account for 75% of childhood pneumonia cases worldwide. In
children aged under 5 years, pneumonia is the leading cause of mortality with a mortalitily rate of
23.4 x 100,000 population recorded in 2009 and 22.3 X 100,000 pop in 2014. In NCR together
with regions VI, VII and VIII of the Philippines, the total number of children under five years of age
with pneumonia that have been seen and given treatment from January to December 2012 were
89,221 and 85,923, respectively.
Major risk factors for developing pneumonia are:

A weakened immune system due to malnutrition or undernourishment (especially in


infants not exclusively breastfed), HIV and other pre-existing illnesses such as
measles

Environmental factors including indoor air pollution (cooking/heating with wood,


dung, or other biomass fuels), living in crowded houses and parental smoking

Pneumonia may have a range of symptoms depending on the age and the cause of the
infection. Viral and bacterial pneumonia have similar symptoms, although there may be more
symptoms with viral pneumonia. Cough and difficult and painful breathing are key symptoms of
pneumonia; fever is also common.
In children under five years of age, difficult breathing manifests as (WHO protocol):

Rapid breathing (>50 bpm for 2-12 months old; >40 bpm for >12 months - 5years
old)

Lower chest indrawing, where chest moves in or retracts during inhalation, also
called retraction (Figure 1)

Flaring of the nostrils with every breath

Grunting with every exhalation

Wheezing, more commonly with viral infections

Severely ill infants may be unable to feed or drink and may experience
unconsciousness, hypothermia, and convulsions

Association of Pneumonia and Congenital Heart Defect (VSD)


66 out of 100 children with VSD had at least 2 pneumonia within a year (WHO,2012).
Ventricular septal defect (VSD), patent ductus arteriosus (PDA) and atrioventricular septal defect
(AVSD) are common acyanotic CHD in childhood that predispose to bronchopneumonia. In the
acyanotic CHD because of a left to right shunting of blood, via a septal defect or the arterial duct,
there is pulmonary overcirculation and pulmonary edema. The pulmonary edema leads to
congestive heart failure and becomes a nidus of infection for the lower respiratory tract. The
patients with CHD with increased pulmonary blood flow thus presents with pneumonia and
congestive heart failure (CHF) amongst other features. Thus pneumonia and CHF may be the first
signs of an underlying CHD. Most previous reports identified CHD as an underlying cause of
recurrent pneumonia i.e. when there are two or more pneumonia episodes in a year. Studies that
identify features that predict underlying CHD in children with pneumonia at the first pneumonia

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

episode will thus be worthwhile, since pneumonia is a major contributor to under five mortality. This
is more so as the co-existence of pneumonia and CHD may increase the mortality associated with
pneumonia in children. The age at onset of and the severity of symptoms in children with CHD is
dependent on the size of the defects. Children with large sized VSD and PDAs tend to present early
and have more severe disease including pneumonia. (Sadoh et al., 2013)

DIAGNOSTIC WORK-UP

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

Source: Clinical Practice Guidelines in the Evaluation and Management of Pediatric Community Acquired
Pneumonia

RATIONALE FOR ADMISSION:


According to the clinical guidelines, the patient is a PCAP C moderate risk patient and the
plan for intervention was to admit in a regular ward. Another reason for admission is the patients
age which is 1 year old, very susceptible to respiratory distress and dehydration. Also, due to the
presence of the chest retractions, which is an excellent sign for selecting children needing admission
for more intensive intervention ( CPG in the Evaluation and Management of Pediatric Community
Acquired Pneumonia, 2012). Furthermore, according to the same guidelines, tachypnea, chest
retractions, young age and malnutrition were independently associated with hospitalization.

THE FOLLOWING SHOULD BE ROUTINELY REQUESTED :


Chest x-ray PA lateral
Chest radiographic evaluation is primarily utilized as an integral part of a clinical
prediction rule in identifying the presence of a bacterial pathogen. As an individual
tool, it can be used to assess severity and presence of complications, and to predict
subsequent course of illness. It has been shown to accurately diagnose cases of
pneumonia in children and young adults.
Complete Blood Count with WBC Differential Count, Erythrocyte Sedimentation
Rate, C-reactive protein
WBC or CRP has a limited value as an individual test in differentiating bacterial from
viral pneumonia. A CRP level [ 12 mg/dl] is associated with necrotizing pneumonia
and/or empyema. It is usually requested to determine appropriate antibiotic usage.
Culture and sensitivity testing
Culture and sensitivity testing may be requested to determine the etiologic agent of
the infection. It is also used in the decision of usage of antibiotics.
Serology

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

Serology may be done if etiologic agent was not isolated with culture and sensitivity
testing.

2D Echo
Monitor and evaluate the degree of severity of the ventral septal defect and
also to provide proper treatment for the defect.
MANAGEMENT OF COMMUNITY ACQUIRED PNEUMONIA
Pharmacologic
Bacterial Etiology
According to the guidelines, for a patient classified as PCAP C without previous antibiotic
and who has completed or without the primary immunization against Haemophilus influenza type b,
Pen G 100,000u/kg/day in 4 divided doses should be given. However, since patient had been
having recurrent hospitalizations due to pneumonia, it suggested previous antibiotic medications, so
if above drug is not effective within 72 hours, antibiotic can be shifted to IV Ampicillin
(100mg/kg/day in 4 divided doses) or cefuroxime, co-amoxiclav, sultamicillin or cefpodoxime.
Viral Etiology
Oseltamivir (30 mg twice a day for 15 kg body weight, 45 mg twice a day for >15-23 kg,
60 mg twice a day for >23- 40 kg, and 75 mg twice a day for >40 kg) remains to be the drug of
choice for laboratory confirmed or clinically suspected cases of influenza.
Ancillary treatment

Inhaled B2 agonists if with good response such as nebulization with salbutamol for
management of airway secretions.

Intravenous paracetamol should be given to alleviate high fever (>38.5 C).

Oxygen and hydration should be given if needed

Observe cautious hydration. Give isotonic intravenous fluid titrated as indicated (e.g.
D5W. Provide oxygenation to facilitate adequate ventilation and perfusion.Tepid
sponge bath every 1 or 2 hours is indicated to help in alleviating the fever.
Note: Cough preparations, chest physiotherapy, bronchial hygiene, nebulization using normal saline
solutions, steam inhalation, topical solution, bronchodilators and herbal medicines
are not
routinely given in community-acquired pneumonia (Grade D).
Monitoring
Decrease in respiratory signs (particularly tachypnea ) and defervescence within 72 hours after
initiation of antibiotic are predictors of favorable therapeutic response.
Persistence of symptoms beyond 72 hours after initiation of antibiotics requires reevaluation.
If the patient is not responding to the current antibiotic within 72 hours, consider consultation with a
specialist because of the following possibilities.
a. penicillin resistant Streptococcus pneumoniae; or
b. Presence of complications (pulmonary or extrapulmonary ); or
c. Other diagnosis
Switch from intravenous antibiotic administration to oral form 2-3 days after initiation of antibiotic is
recommended in a patient who
a. Is responding to the initial antibiotic therapy ,
b. Is able to feed with intact gastrointestinal absorption; and
c. Does not have any pulmonary or extrapulmonary complications
PREVENTION AND CONTROL OF COMMUNITY ACQUIRED PNEUMONIA

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

MANAGEMENT FOR VSD:


The most practical and best strategy to prevent recurrences of pneumonia in this case is to
treat the underlying condition which is to manage the ventral septal defect. Surgical closure is
needed especially if the patient is already symptomatic and is already presented with
decompensation such as heart failure and pleural effusions. VSD surgery is occasionally necessary,
especially in the setting of a large or moderate size VSD. Indications for surgery in infancy include
symptoms unresponsive to medication, elevated blood pressure in the lungs, and significant dilation
of the heart due to excess blood flow. Usually the need for surgery in an infant becomes clear by 612 months of age, and often much earlier. Less common indications for surgery are infection of
heart tissue due to the VSD, and damage to the aortic valve secondary to the VSD. VSD surgery
usually involves the placement of a patch over the hole to close it. The risk of surgery for a VSD in
this day and age is relatively low. The vast majority of children do very well with no significant long
term problems.
In children with larger VSDs who are symptomatic, medication may help. The most
commonly used medicine is furosemide (Lasix), a diuretic that works by decreasing excess lung fluid
caused by the extra blood flow to the lungs. Furosemide may be given anywhere from 1 to 4 times
daily. Side effects are uncommon; abnormalities of electrolytes can occasionally be seen with larger
doses. Another medication frequently used in the setting of a VSD is digoxin (Lanoxin). Digoxin
increases calcium levels in heart cells, thereby improving overall heart function.
PUBLIC HEALTH INTERVENTIONS TO PREVENT PNEUMONIA INCLUDE:

Immunization against pathogens that directly cause pneumonia (S. pneumonia and H.
influenza type b) and pathogens that lead to pneumonia as complication of the infection (eg.
measles and pertussis)

The most important available vaccines to prevent pneumonia are


conjugate vaccine, Hib vaccine, measles and pertussis vaccine

Adequate nutrition to improve natural defense and strength of respiratory muscles (which
aid in clearance of secretions)

Exclusive breastfeeding for the first six months of life

Zinc and Vitamin A supplementation

In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk
of contracting pneumonia

pneumococcal

EPIDEMIC MEASURES

Addressing environmental factors such as indoor air pollution by providing affordable clean
indoor stoves and encouraging good hygiene in crowded homes can reduce the number of
children who fall ill with pneumonia

Immunization against S. pneumonia, H. influenza type b, pertussis and measles are the
most effective way to prevent pneumonia when the cause of pneumonia has been identified

n 2013, WHO and UNICEF launched the integrated Global action plan for pneumonia and
diarrhoea (GAPPD). The aim is to accelerate pneumonia control with a combination of
interventions to protect, prevent and treat pneumonia in children with actions to:

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

Protect children from pneumonia include promoting exclusive breastfeeding and


adequate complementary feeding

Prevent pneumonia with vaccinations, hand washing with soap, reducing household
air pollution, HIV prevention and cotrimoxazole prophylaxis for HIV-infected and
exposed children

Treat pneumonia which are focused on making sure that every sick child has access
to the right kind of care -- either from a community-based health worker, or in a
health facility if the disease is severe -- and can get the antibiotics and oxygen they
need to get well .

REFERENCE
WHO (2009). Dengue Guidelines for diagnosis,Treatment, prevention and control. World Health
Organization catalogue.Geneva: Switzerland.

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

Halstead SB (2007). Dengue. Lancet. 2007 Nov 10. 370(9599):1644-52.


World Health Organization. Impact of Dengue. Available at
http://www.who.int/csr/disease/dengue/impact/en/index.html. Accessed: September 12,
2015.
DOH (2012). Revised Dengue Guidelines. Available at
http://www.thefilipinodoctor.com/cpm_pdf/CPM3rd%20Dengue.pdf accessed: September
12, 2015.
Centers for Disease Control and Prevention Web site. CDC traveler's health page. Dengue. Available
at
http://www.cdc.gov/Dengue/travelOutbreaks/. Accessed: September 12, 2015.
Rothman AL, Ennis FA. Immunopathogenesis of Dengue hemorrhagic fever. Virology. 1999 Apr 25.
257(1):1-6.
Kliegman et al. (2011). Nelson Textbook of Pediatrics. 19th edition. Elsevier Saunders.

Sadoh, W., & Osarogiagbon, W. (2013). Underlying congenital heart disease in Nigerian children with
pneumonia. African Health Sciences, 13(3), 607612. http://doi.org/10.4314/ahs.v13i3.13

JI PATI, GRACE ANTONETTE

APPENDIX: GROWTH CHART PLOT

DEPARTMENT OF PEDIATRICS

JI PATI, GRACE ANTONETTE

DEPARTMENT OF PEDIATRICS

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