PNEUMONIA IN CHILDREN

dr.Rodman Tarigan,SpA.,MKes

HISTORY OF THE TERM

THE RESPIRATORY DISEASE described by HYPPOCRATES

(4th century BC) and called PERIPNEUMONIA
1603
: The first record for using this word in English
language
Until 1822: pneumonia =pneumonitis
Since 1960s
: attempts to distinguish these two terms
PNEUMONIA
: inflammatory conditions (infective condition)
PNEUMONITIS: inflammatory conditions (non infective)
- not consistently applied
- anomalies
(i.e: rheumatic pneumonia and rheumatic pneumonitis
both are associated with varicella infection)

Now

pneumonia infective condition

pneumonitis non-infective condition
(such as radiation-induced lung
injury)
This distinction is not consistent

DEFINITION

No single definition of pneumonia: there

is controversy on how best to define it
Definitions may depend upon:
the use they are put
the objectives
(I.e. health-care worker in the field in developing
country may differ from that employed in clinical study
in a developed country)

PNEUMONIA A clinical illness defined in terms of

the clinical symtoms and signs, and
it course
Two typical clinical definition :
Bronchopneumonia:
febrile illness, cough, respiratory distress, rale on
physical examination, chest X-ray evidence of
localized or
genelized patchy infiltrate
Lobar pneumonia:
Similar to bronchopneumonia exept that physical
examination and chest X-ray indicate lobar
consolidation
NOTE: in many developing countries, X-ray facilities may be
basic, or even absent and that in such situations clinical signs
and symptoms are the only diagnostic

Lower lobe pneumonia

PNEUMONIA

WHO DEFINITION

Countries
PNEUMONIA

limited health-care faciliti

a febrile illness with tachypno

- The gold standard for the diagnosis of pneumonia in

an ambulatory setting in developing countries
- This board definition results in the inclusion of
patients who do not have pneumonia but other
condition, i.e. asthma and systemic infection
- 100% sensitivity for pneumonia
- from 20% pneumonia detected by WHO criteria
2-3% have severe pneumonia, and probably have

EPIDEMIOLOGY

 INFECTION OF LOWER RESPIRATORY TRACT = LRI

including croup, bronchiolitis, pneumonia most
common problem
(50 illmesses/1000 children less than 6 years of age)
Most of these episodes are PNEUMONIA

In developing countries PNEUMONIA occurs 210

times more frequently in children and is
responsible for
a quarter of all death in underfive children

(The incidence of Acute respiratory tract infections=

Examples of annual incidence of pneumonia in

developing and develop countries
Place

Age (years)

Developed country
Chapel Hill, USA
Seattle, USA
Developing coubtry
Bangkok, Thailand
Gadchiorii, India
Gilgit, Pakistan
Maragna, Kenya
Haryana, India
Papua new Guinea

Annual incidence of
pneumonia per 100

<5
<5

3.6
3.0

<
<
<
<
<
<
<

7.0
13.0
30.0
18.0
40.0
30.0
25.6

5
5
5
5
1a
1b
1

Low birth weight

b
Normal birth weight
a

Highest frequency 2- 3 years

(Denny FW. J PEDIATR 1086; 108:635-46)

 RISK FACTORS :

- low birth weight

- poor nutrition (general and vitamin A
deficiency)
- nasopharingeal carrage of pathogens,
- enviromental factors

Nasopharyngeal carriage of Streptococcus

pneumonia and Haemophilus influenzae type B
in children
Place

Haem.
Strep.
No.of
Age
Subjec (years) Pneumonia influenzae
t

Developed country
Goteborg,Sweden
67
North Wales, UK
996
Nebraska, USA
1084
North Carolina, USA
81
Virginia, USA
18

1-9
0-5
407
0-9
0-5

28.3%
44.0%
37.8%

1.1%
2.0%
-

Developing coubtry
Basse, Gambia
Maragua, Kenya
Goroka, PNG
Rawalpindi, Pakistan
Dakar, Senegal

0-4
0-4
0-5
0-2
0-4

98.0%
89.0%
97.6%
93.5%
72.2%

12.9%
9.0%
6.1%
88.0%
-

401
331
165
108
205

ETIOLOGY

- The etiologi very with the age, immunologyc status,

some
enviromental conditions
1. INFECTION (viral, bacterial, mycoplasma,
chlamydia,
parasites, fungi, mycobacterium,
ricketsia)
Viruses account for the majority of cases
(RSV,
adenovirus, parainfluenza, and influenza
virus)
2. NON-INFECTION (food aspiration, foreign body,
drugs,
radiation, etc)

- Factors increase the risk of bacterial pneumonia

conginetal anatomic defects
deficits in immun function (by drug or disease)
developmental and genetic disease
(tracheoesophageal fistula, cystic fibrosis, etc)
aspiration of a foreign body
gastroesophageal reflux
mechanical ventilation
prolonged hopitalization

Frequency of pathogens in community-acquired

childhood pneumonia in developed countries
Pathogen

<3

month

Streptococcus pneumoniae+++
Viruses
+++
Enteric bacilli
+++
Group B streptococci
+++
Chlamydia trachomatis
+++
Staphylococcus aureus
++
Haemophilus influenzae
+
Grup A strreptococci
Mycoplasma pneumoniae

Chlamidia pneumoniae
-

month

-5

+++
+++
+
+
+
+++
+
++
+

years

>5

years

+++
++
+

+
+
+
+++
++

+++, very frequent; ++, moderately frequent; +, rare; -, abs

CLINICAL MANIFESTATION

 Varies with age, extent of the disease, and the etiologic

agent
Occasionally absent particularly in young infants
Non-specific signs and symptoms (fever, chills, headache,
restlessness, malaise, and irritability, gastrointestinal
complaint)
General signs of lower respiratory tract disease (nasal
flaring, tachypnea, dyspnea, grunting, and retraction of the
accessory intercostal and abdominal muscle)
Signs of pneumonia may be subtle in the young infant,
percussion is rarely of any value)

Typical features of bacterial, viral and mycoplasma

pneumonia in children
Bacterial

Viral

Mycoplasm
a

Age
5-15 years
Any
Any
Season
All year
Winter
Winter
Onset
Insidious
Abrupt
Variable
Fever
Low grade
High
Variable
Tachypnea
Uncommon
Common
Common
Cough
Productive
Nonproductive Nonproductive
Assosiated symptoms Mild coryza
Bullous myringiti
Coryza
Pharyngitis
Abdominal pain
Physical findings
Fine crackles
Evidence of
Variable
Heezing
consolidation
Few crackles
Leukocytosis
Uncommon
Common
Variable
Radiographic findings Consolidation Bilateral diffuse Variable
infiltrates
Pleural effusion
Small in 10-20%
Common
Rare
(adenovirus)

RADIOGRAPHIC EXAMINATION

 Remain the diagnostic mainstay in

childhood
pneumonia, support the clinical
impression
and defining extent the disease
Posteroanterior and lateral view of Xray
should be made
Pneumomatoceles and pleural effusions
frequently assosiated with Staphyloccocal
pneumonia

DIAGNOSIS

Diagnosis of bacterial pneumonia

demonstration of pathogenic bacteria in the lung
difficulty lies in obtaining a specimen that is
not contaminated with the flora of the upper
airways
Specimens from bronchoalveolar lavage,
transtracheal aspirates, transthoracic needle
aspirates, pleural fluid, blood cult, lung puncture
not contaminated, but difficult to performed
and invasive procedure
Definitive etiologic identification of pneumonia
difficult & time consuming
Thus, estabilishing the diagnosis depends upon
-

index of suspicion of a particular Pathogen

(age, clinical settings)

MANAGEMENT

Depends on the patient's age

EMPIRIC ANTIBIOTIC THERAPY
during

monitoring
24-72 hours

Lack of response after 2-3 days

of
factors

investigate
complicating

Supportive care
- supplemental oxygen
- humidifications of the airways ( pulmonary
toilet
with postural drainage and
percussion)
- adequate hydration and nutrition

COMPLICATIONS

1. Empyema
2. Lung abscess
3. Pneumothorax
4. Pericarditis
5. Pneumatocele