Pneumonia in children

Presentation by: Dr. Sundar Karki

 Introduction
 Pneumonia is an inflammation of the
parenchyma of the lungs.
 Pneumonia can be classified anatomically as
lobar or lobular, bronchopnemonia and
interstitial pneumonia.
 Pathologically there is consolidation of alveoli
or infiltration of the interstitial tissue with
inflammatory cell or both
 Etiology
 Viral: It can be caused by RSV, influenza,
parainfluenza or adenovirus
 Bacterial: In first 2 months the common agents
include klebsiella, E. coli, 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.
 Etiology
 Atypical organism: Chalmydia sps and
Mycoplasm in CAP in adult and children have
more evidence.
 Pnemuocystis carinii: causes pneumonia in
imunnocompromised children.
 Some terms
 Recurrent pneumonia is defined as 2 or
more episodes in a single yr or 3 or more
episodes ever, with radiographic clearing
between occurrences.
 Slowly resolving pneumonia refers to the
persistence of symptoms or radiographic
abnormalities beyond the expected time
course.
 Clinical features
 Onset of pneumonia may be insidious starting
with URTI or may be acute with high fever,
dypsnea and grunting respiration. Respiratory
rate is always increased.
 Rarely pneumonia may be present with acute
abdominal emergency which is due to referred
pain from the pleura. Apical pneumonia may
sometime be associated with meningmus and
convulsion.
 Clinical features
 On examination there is flaring of alae nasi,
retraction of lower chest and intercostal
spaces.
 Signs of consolidation(diminished expansion,
dull percussion note, increased tactile vocal
fremitus/vocal resonance, bronchial breathing)
can be seen in lobar pneumonia.
 Clinical Features
 Viral: URTI, low grade fever, tachypnea,
crackles, wheezing.
 Bacterial- Pneumococcal

- acute onset shaking chills with high fever,

cough, chest pain, respiratory distress.
-decreased breath sound, rales, dullness to
percussion
 Diagnosis
 The chest radiograph confirms the diagnosis of
pneumonia and may indicate a complication such as a
pleural effusion or empyema.
 Viral pneumonia is usually characterized by
hyperinflation with bilateral interstitial infiltrates and
peribronchial cuffing.
 Confluent lobar consolidation is typically seen with
pneumococcal pneumonia. If pneumatocele think
about staphylococci.
 The radiographic appearance alone is not diagnostic
and other clinical features must be considered.
 Diagnosis
 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.
 Diagnosis
 Viral: viral culture or antigen isolation in
respiratory secretion. Growth of respiratory
viruses in tissue culture usually requires 5–10
days.
 Bacterial: sputum culture, no value in children.
 Mycoplasm: IgM titers
 Treatment
 Treatment of suspected bacterial pneumonia is based
on the presumptive cause and the clinical appearance
of the child.
 For mildly ill children who do not require
hospitalization, amoxicillin is recommended. In
communities with a high percentage of penicillin-
resistant pneumococci, high doses of amoxicillin (80–
90 mg/kg/24 hr) should be prescribed.
 Therapeutic alternatives include cefuroxime axetil or
amoxicillin/clavulanate
 Treatment
 For school-aged children and in those in whom
infection with M. pneumoniae or C.
pneumoniae (atypical pneumonias) is
suggested, a macrolide antibiotic such as
azithromycin is an appropriate choice.
 In adolescents, a respiratory fluoroquinolone
(levofloxacin, gatifloxacin, moxifloxacin,
gemifloxacin) may be considered for atypical
pneumonias.
 Treatment
 The empirical treatment of suspected bacterial
pneumonia in a hospitalized child requires an
approach based on the clinical manifestations at the
time of presentation.
 Parenteral cefuroxime (150 mg/kg/24 hr),
cefotaxime, or ceftriaxone is the mainstay of therapy
when bacterial pneumonia is suggested.
 If clinical features suggest staphylococcal pneumonia
(pneumatoceles, empyema), initial antimicrobial
therapy should also include vancomycin or
clindamycin.
 Treatment
 If viral pneumonia is suspected, it is
reasonable to withhold antibiotic therapy,
especially for those patients who are mildly ill,
have clinical evidence suggesting viral
infection, and are in no respiratory distress.
 Up to 30% of patients with known viral
infection may have coexisting bacterial
pathogens.
 Treatment
 Therefore, if the decision is made to withhold
antibiotic therapy based on presumptive
diagnosis of a viral infection, deterioration in
clinical status should signal the possibility of
superimposed bacterial infection and antibiotic
therapy should be initiated.
 Need of Hospital Admission of
children with pneumonia
 Age <6 months
 Sickle cell anemia with acute chest syndrome
 Multiple lobe involvement
 Immunocompromised state
 Toxic appearance
 Severe respiratory distress
 Requirement for supplemental oxygen
 Dehydration
 Vomiting
 No response to appropriate oral antibiotic therapy
 Noncompliant parents
 Clinical Classification to facilitate
treatment
Signs n classification therapy Where to
symptoms treat
Cough or cold No pneumonia Home remedies Home
No fast breathing
No chest indrawing or
indicators of severe illness

RR age Pneumonia Clotrimoxazole Home

60 or more < 2 months
50 or more 2-12 months
40 or more 12-60 months

Chest Indrawing Severe Pneumonia IV/IM Penicillin Hospital

Cyanosis, severe chest Very Severe Pneumonia IV Chloramphenicol Hospital

indrawing, inability to feed
 Response to the treatment
 Typically, patients with uncomplicated
community-acquired bacterial pneumonia
respond to therapy with improvement in
clinical symptoms (fever, cough, tachypnea,
chest pain) within 48–96 hr of initiation of
antibiotics.
 Radiographic evidence of improvement
substantially lags behind clinical
improvement.
 Response to the treatment
 A number of factors must be considered when a
patient does not improve on appropriate antibiotic
therapy (slowly resolving pneumonia): (1)
complications (2) bacterial resistance; (3)
nonbacterial etiologies (4) bronchial obstruction
from (5) pre-existing diseases (6) other noninfectious
causes.
 A repeat chest x-ray is the 1st step in determining the
reason for delay in response to treatment.
 Complications
 Complications of pneumonia are usually the
result of direct spread of bacterial infection
within the thoracic cavity (pleural effusion,
empyema, pericarditis) or bacteremia and
hematologic spread.
 Meningitis, suppurative arthritis, and
osteomyelitis are rare complications of
hematologic spread of pneumococcal or H.
influenzae type b infection.
 References
 Nelson Textbook of Pediatrics- 18th edition
 Ghai Essential Pediatrics- 7th edition
 Kaplan USMLE 2010