Pneumonia in pediatric age group

1. Dr. Virendra Kumar Gupta
Assiociate Professor
Department Of Pediatrics
NIMS Medical College & Hospital , Jaipur

2.  Pneumonia is definedas inflammation of the lung parenchyma.
(Ref: Nelson Text Book of Pediatrics 20th)

3. Epidemiology ..
 Each year, about 156 million new episodes of pneumonia occur world
wide.
 Among which 151 million episodes in developing countries.
(Ref: Epidemiology and Etiology of Childhood Pneumonia. Rudan I, Campbell, et al. Bull World
Health Organ 2008, May; 86(5):408-16.)

4.  It is the leading cause of U5 mortality, globally accounting 16%of all U5 deaths.
Ref: WHO Fact sheet onPneumonia.
Epidemiology ..

5. Risk factors
1. Malnutrition (Z <-2)
2. LBW-(<2500gm)
3. Non exclusive BF
4. Lack of Immunization-(Measles,
Pentavalent Hib, Varicella)
5. Indoor air Pollution
6. Parental smoking
7. Overcrowding
8. Zinc deficiency
9. Poor care giving practice
10.Concomitant diseases (Diarrhoea,
Heart Diseases, Asthma etc.)

6. Pneumonia : Classification
Clinical
classification
Etiological
classification
Anatomical
classification
Infectous
Non-
Infectous1. Communityacquired
2. Nosocomial pneumonia.
3. Pneumonia in
immunocompromised
Typical
Atypical
Pneumonia developed within
48 hours of hospitaladmission

7. Etiological Classification
 INFECTIOUS:
 Bacteria
 Virus
 Fungus(Histoplasma,
Blastomyces,Aspergillus,
Coccidiodes, Cryptococcus.
 Parasites:Ascaris,
Srongiloides.
 NON-INFECTIOUS :
 Aspiration of food, gastric acid, foreign
body, hydrocarbons, lipoid substances.
 Hypersensitivity reactions,
 Drugs/radiation induced pneumonitis.

8. Etiology according to age
Age group Frequent pathogens
Neonates
( < 3 wk )
Group B streptococcus, E. coli & other Gram -vebacilli,
S. pneumoniae, H. influenziae typeb.
3 wk – 3 mo RSV & other respiratory viruses, S. pneumoniae,H.
influenziae type b, Chlamydiatrachomatis.
4 mo – 4 yr RSV & other respiratory viruses, S.pneumoniae, H.
influenziae type b, Mycoplasma pneumoniae,GAS.
≥ 5 yr Mycoplasma, Chlamydophila pneumoniae, Legionella, Str
pneumoniae, H. influenzae type b, Respiratoryviruses.

9. RECURRENT PNEUMONIA
 Defined as 2 or more episodes in a single year or 3 or more episodes
ever, with radiographic clearing between occurrences.
 An underlying disorder should be considered if a child experiences
recurrent pneumonia:

10. Recurrent pneumonia causes:
A. Hereditary disorders: Cystic Fibrosis, Sickle Cell Disease.
B. Disorders
Selective
of Immunity: HIV/AIDS, Brutons agammaglobinemia,
Ig deficiency, SCID, Chronic Granulomatous disease,
Leucocyte adhesiondefect.
C. Disorders of cilia: Kartagener syndrome, Immotile ciliasyndrome.
Disorders:D. Anatomic Pulmonary sequestration, Lobar emphysema,
GER, TEF (H type), Bronchiectasis.

11. Mode of Transmission
1. Droplet Nuclei
2. Nosocomial
3. Endogenous
4. Blood Borne

12. Pathogenesis
•Inhalation of droplet nuclei
•Hematogenous seeding
•Aspiration
Colonization of organism in
respiratory passage
Inflammatory reaction in
respiratory tract including lung
parenchyma

13. Stages of pneumonia
 Stage of congestion: Lung parenchyma filled with inflammatory
exudate.
 Stage of red hepatization: massive exudation with red cells,
neutrophil & fibrin inalveoli.
 Stage of grey hepatization: progressive disintegration of RBC with
greyish brown discoloration.
 Stage of resolution: Progressive removal of exudate from alveolar
space.

14.  In VIRAL PNEUMONIA, low grade fever is usually present, along with
other features of respiratorydistress:
1. Tachypnea ( mostconsistent C/F),
2. Increased work of breathing evident by intercostal, subcostal, and
suprasternal retractions, nasal flaring, and use of accessory muscles,
4. hyper resonant chests
3. cyanosis and lethargy in case of severeinfection,
with crackles & wheezing.
Clinical Manifestations

15.  BACTERIAL pneumonia is characterized by:
1. sudden high grade fever, cough, and chestpain.
2. Drowsiness , occasionally with delirium
3. Along with usual signs of respiratory distress, i.e. tachypnea,
grunting, nasal f laring; retractions of the supraclavicular, intercostal,
and subcostal areas & oftencyanosis.

16. IMCI (2m – 5y)

18. IMCI: Day1 – 2m
 Fast breathing,
 Severe chest indrawing ,
 grunting,
 hypo/ hyperthermia,
 not feeding well,
 convulsion.
Anyof these is classified as very severedisease.

19. Investigations
 X-Ray Chest
 CBC
 ESR, C-Reactive Proteins.
 Blood culture.
 MantouxTest

20. Chest X-Ray
 Viral pneumonia is usually characterized by:
1. hyperinflation with bilateral interstitial infiltrates and
2. peribronchial cuffing .
 Confluent lobar consolidation &/or pleural effusion is typically seen
with pneumococcal pneumonia .

21. Viral vs Bacterial Pneumonia

22. CBC
 In viral pneumonia: WBC-normal or usually not higher than
20,000/mm3, with a lymphocyte predominance.
 In bacterial pneumonia: Elevated WBC count, 15,000-
40,000/mm3 with predominance of granulocytes.

23.  Acute phase reactants (ESR, CRP):
Higher in bacterial, normal or slightly raised in viral pneumonia.
Blood culture: Blood culture results are positive in only10%.

24. TREATMENT
 Treatment of suspected bacterial pneumonia is based on the presumptive
cause,age and clinical appearance of the child.
 For mildly ill children who do not require hospitalization, amoxicillin is
recommended.
 With the emergence of penicillin-resistant pneumococci, high doses of
amoxicillin (80-90 mg/kg/24 hr) should be prescribed.
 Therapeutic alternatives include cefuroxime axetil and amoxicillin/clavulanate.

25.  For school-aged children and in children with suggested infection of
M. Pneumoniae or C. pneumoniae , a macrolide antibiotic such as
azithromycin is an appropriatechoice.
 In adolescents, a respiratory f luoroquinolone (levofloxacin,
moxifloxacin) may be considered as analternative.

26.  The empiric treatment of suspected bacterial pneumonia in a hospitalized
child start on theclinical manifestations at the time ofpresentation.

27. Indications for admission to hospital
 Young age - < 6 months ofage;
 Toxicappearance
 Moderate to severe respiratorydistress
 Inabilityof family toprovidecareat home;
 Failure of outpatienttherapy;
 Complicated pneumonia
 Vomiting or inability to tolerateoral fluid or medications.
 Immunocompromised state

28. Treatment after hospital admission
 Supportive care forchildren
 Oxygen, if needed (SpO2-<92%)
 Fluids and ensurehydration
 Antipyretics, analgesics
 Antibiotics

29. 1. In areas without substantial high-level penicillin resistance among S.
pneumoniae,
immunized against H. inf luenzae type b and S.2. children who are fully
pneumoniaeand
3. are not severely ill should receiveampicillin or penicillin G.
 For children who do not meet these criteria, ceftriaxone or cefotaxime should be
pneumonia initial antimicrobial
used.
 If clinical features suggest staphylococcal
therapy vancomycin orclindamycin.

30. to withhold If viral pneumonia is suspected, it is reasonable
antibiotic therapy, especially for thosepatients
 who are mildlyill,
 have clinical evidencesuggesting viral infection and
 are in no respiratory distress.

31.  The optimal duration of antibiotic treatment for pneumonia has not been well-
established in controlled studies.
 Antibiotics should generally be continued until the patient has been afebrile for
72 hr, and the total duration should not be < 10 days (or 5 days forazithromycin).
 Shorter courses (5-7 days) may also be effective, particularly for children
managed on an outpatientbasis.
 In developing countries, oral zinc (10 mg/day for <12 mo, 20 mg/day for ≥12 mo)
is advised toreduce mortality among children.

32. Complications
 Pleural effusion
 Empyema
 Lung abscess
 Pneumothorax
 Pneumatocele
 Delayed Resolution
 Respiratory Failure
 Metastatic Septiclesions
 Activation of latentTB

33. Complicated pneumonia

34. Prognosis
 Typically, patients with uncomplicated community-acquired bacterial
cough,pneumonia show improvement in clinical symptoms (fever,
tachypnea, chest pain), within 48-96 hours of initiation of antibiotics.
 Radiographic evidence of improvement lags substantially behind clinical
improvement. It may take 6 to 8 weeks to return to normal.

35.  When a patientdoes not improvewith appropriateantibiotic therapy
complications, suchas
1. empyema
2. bacterial resistance
3. nonbacterial etiologies such as virusesor fungi and aspirationof foreign
bodies orfood
4. preexisting diseasessuch as immuno deficiencies, ciliary dyskinesia,cystic
fibrosis, pulmonary sequestration or congenital pulmonary airway
malformation and
5. other noninfectiouscauses including bronchiolitis obliterans,
hypersensitivity pneumonitis, eosinophilic pneumonia, aspirationand
granulomatosis with polyangitis are suspected.

36. is done to determine the reason for delay in response to A repeat chest X-ray
treatment.
 Bronchoalveolar lavage may be indicated in children with respiratory failure.
 High-resolution CT scans may better to identify complications or an anatomic
reason.

37. Prevention
1.Exclusive Breastfeeding up to 6 months of age .
2.Immunization against with-- Hib, PCV,Measles,
Pertussis, Varicella.
3.Adequete Nutrition---Under nutritioncauses >1 millionsdeath under 5
due toPneumonia.
4.Hand washing, safe water drinking & prevention of Diarrhoea.
5.Avoidanceof parental orothersortsof secondary & tertiary smoking.
6.Free from indoor airpollution.
7.Zincsupplementation.

39. Q-1 Most dangerous sign in LRTI in Children is ?
A-Abdominal Breathing
B-Chest Retraction
C-Grunting
D-Tachypnoea

40. Q-2 WHO criteria for hospital Admission in Pneumonia ?
A-High Fever
B-Nasal Flaring
C-Difficulty in breathing
D-Chest Indrawing

41. Q-3 Which is the following is leading cause of mortality in Under 5 children in
developing countries?
A-Malaria
B-Acute lower respiratory tract infections
C- Hepatits
D-Prematurity

42. Q-4 Pneumothorax Could be a complication of ?
A-Staphyllococcal Pneumonia
B-Pneumococcal Pneumonia
C-Klebsiella Pneumonia
D-Viral Pneomonia

43. Q-5 A 4 year old malnourished child is brought to subcentre with breathing rate
of 55/ min., Excessive crying, irritability, fever and not taking feeds. The ANM
assesses the child and categorizes under the IMNCI guidelines for the
management of ARI as ?
A-No Pneumonia
B-Very Severe Disease
C-Pneumonia
D-Upper Respiratory Tract infection

44. ANSWERS
Q-1 (C)-Grunting
Q-2 (C)-Difficulty in breathing
Q-3 (B)-Acute lower respiratory tract infections
Q-4 (A)-Staphyllococcal Pneumonia
Q-5 (B)-Very Severe Disease

45. Viral vs Bacterial Pneumonia

46. Staphylococcal vs Streptococcal pneumonia