PEDIATRIC PNEUMONIA

Dr. V K PandeyMBBS, DCH, MD (Ped.)International Fellow, American Academy of Pediatrics)

QUIZ QUESTION 1

What illness is the number one killer of

children? A. Diarrheal Disease B. HIV/AIDS C. Malaria D. Pneumonia

QUIZ QUESTION 2

What is the most sensitive and specific sign of

pneumonia in children? A. Difficulty breathing B. Fever C. Tachypnea (Fast Breathing) D. Tachycardia (Fast Heart Rate)

QUIZ QUESTION 3

If available, a chest x-ray should be done for

children with possible pneumonia: A. When a diagnosis is made B. When a history of tachypnea is

present C. When antibiotics are started D. When complications are

suspected

QUIZ QUESTION 4

Which of the following immunizationeffectively reduce pneumonia

mortality inchildren? A. Haemophilus influenzae b

Vaccine B. Pneumococcal Conjugate Vaccine C. Measles Vaccine D. All of the above

WHAT IS PNEUMONIA?

Pneumonia: an acute infection of the pulmonary parenchyma

The term “Lower Respiratory Tract Infection” (LRTI) may include pneumonia, bronchiolitis and/or bronchitis

EPIDEMIOLOGY

Pneumonia kills more children under the age of five than any other illness in every region of the world.

It is estimated that of the 9 million child deaths in 2007, 20% (1.8 million) were due to pneumonia

Approximately 98% of children who die of pneumonia are in developing countries.

BASIC PATHOPHYSIOLOGY

Most cases of pneumonia are caused by the aspiration of infective particles into the lower respiratory tract.

Organisms that colonize a child’s upper airway can cause pneumonia.

Pneumonia can be caused by person to person transmission via airborne droplets.

PNEUMONIA - COMMON PATHOGENS

Age Group Common Pathogens (in Order of Frequency)

Newborn Group B StreptococciGram-negative bacilliListeria monocytogenesHerpes SimplexCytomegalovirusRubella

1-3 months Chlamydia trachomatisRespiratory Syncytial virusOther respiratory viruses

3-12 months Respiratory Syncytial virusOther respiratory virusesStreptococcus pneumoniaeHaemophilus influenzaeChlamydia trachomatisMycoplasma pneumoniae

From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

PNEUMONIA - COMMON PATHOGENS

Age Group Common Pathogens (in Order of Frequency)

2-5 years Respiratory VirusesStreptococcus pneumoniaeHaemophilus influenzaeMycoplasma pneumoniaeChlamydia pneumoniae

5-18 years Mycoplasma pneumoniaeStreptococcus pneumoniaeChlamydia pneumoniaeHaemophilus influenzaeInfluenza viruses A and BAdenovirusesOther respiratory viruses

From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

PNEUMONIA HISTORY FUNDAMENTALS

Age Presence of cough, difficulty breathing, shortness of breath, chest pain Fever Recent upper respiratory tract infections Associated symptoms (e.g.. headache, lethargy, pharyngitis, nausea, vomiting, diarrhea, abdominal pain, rash) Duration of symptoms

PNEUMONIA HISTORY Immunizations status TB exposure Ill contacts Travel history Past Medical History Birth History Medications

RECOGNITION OF SIGNS OF PNEUMONIA

Tachypnea is the most sensitive and specific sign of pneumonia

WHO DEFINITION OF TACHYPNEAAge Respiratory

Rate(breaths/min)

Indication of severe infection (breaths/min)

< 2 months > 60 >702 to 12 months > 5012 months to 5 years

> 40 >50

Greater than 5 years

> 20

OTHER SIGNS OF PNEUMONIA -INDRAWING

out---breathing---in Lower chest wall indrawing: with inspiration,

the lower chest wall moves in

From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

OTHER SIGNS OF PNEUMONIA - NASAL FLARE

Nasal flaring: with inspiration, the side of the nostrils flares outwards

From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

DIAGNOSIS IN COMMUNITY SETTING

SIGNS Classify AS Treatment

•Tachypnea•Lower chest wall indrawing•Stridor in a calm child

Severe Pneumonia •Refer urgently to hospital for injectable antibiotics and oxygen if needed•Give first dose of appropriate antibiotic

•Tachypnea Non-Severe Pneumonia

•Prescribe appropriate antibiotic•Advise caregiver of other supportive measure and when to return for a follow-up visit

•Normal respiratory rate Other respiratory illness

•Advise caregiver on other supportive measures and when to return if symptoms persist or worsen

From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Children’s Fund (UNICEF), 2006.

INFANTS AT RISK OF PNEUMONIA

Infants less than 3 months old with signs of pneumonia should be referred immediately to the nearest health facility because they are at high risk of severe illness and death.

Infants who were premature, and those with congenital heart disease or chronic lung disease are also at increased risk.

DIFFERENTIAL DIAGNOSIS: A FOCUS ON RESPIRATORY SYNCYTIAL VIRUS (RSV)

RESPIRATORY SYNCYTIAL VIRUS (RSV)

RSV is the most common cause of LRTIs in children less than 1.

Infants and young children typically present with pneumonia or bronchiolitis.

Older children may have upper respiratory tract infection symptoms.

RSV is associated with apnea in infants. Wheezing is common.

RSV SEASONALITY

Seasonal outbreaks occur throughout the world.

In the southern hemisphere outbreaks peak in May, June and July.

In tropical climates outbreaks are often associated with the rainy season.

DIFFERENTIAL DIAGNOSIS: CONSIDER TUBERCULOSIS

TUBERCULOSIS

Common symptoms of tuberculosis include:

Chronic cough that has been present for more than 3 weeks and is not improving

Fever greater than 38°C for at least two weeks, not attributable to other common causes

Weight loss or failure to thrive

TUBERCULOSIS Physical exam findings of children

with pulmonary tuberculosis are similar to those of a lower respiratory tract infection.

In children less than age five tuberculosis can progress rapidly from latent infection to active disease and serve as a sentinel case in the community.

Consider the diagnosis of tuberculosis, especially in those children who fail to respond appropriately to routine treatment for pneumonia.

PNEUMONIA AND HIV INFECTED CHILDREN

The prevalence of HIV-1 in children admitted with severe pneumonia (by WHO criteria) in Africa is 55-65%.

The case fatality rate is 20-34%. This case fatality rate is 3-6 times higher for

children infected with HIV compared to those not infected with HIV.

Pneumonia caused by Pneumocystis jiroveci may be the first indicator of HIV infection, and lead to HIV testing and diagnosis.

ADMISSION CONSIDERATIONS If caregivers are unable to care for the

child, or to commit to following a treatment plan, the child should be admitted to a health care facility.

Any child less than three months of age. Failure of outpatient treatment

(worsening or no response to treatment after 24 to 72 hours).

Family lives in a remote area.

INDICATIONS FOR ADMISSION - IMCI

All Children with Very Severe Pneumonia need admission

Very Severe Pneumonia includes any of: Cough or difficult breathing plus at least one

of the following: Central cyanosis Inability to breastfeed or drink, or vomiting

everything Convulsions, lethargy or unconsciousness Severe respiratory distress (e.g. head

nodding) Some or all of the other signs of pneumonia

(tachypnea, grunting, nasal flare, indrawing, changes in auscultation)

IN-PATIENT MANAGEMENT Consideration must be given to the provision

of adequate hydration, oxygenation, nutrition, antipyretics and pain control.

Monitoring should include: Respiratory rate Work of breathing Temperature Heart rate Oxygen saturation (if available) Findings on auscultation.

IN-PATIENT CONSIDERATIONS

Due to the risk of transmission, a child suspected of having pneumonia should be cared for in an area that is isolated from others to who are at risk of becoming infected.

Contact precautions by health care workers such as hand washing, gloves, gowns and masks to prevent transmission between patients are often appropriate.

CRITERIA FOR INTENSIVE CARE

If intensive care is available consider the following: The patient is failing to maintain an oxygen

saturation of > 92% in FiO2 of > 0.6. The patient is in shock. There is a rising respiratory rate and rising pulse

rate with clinical evidence of severe respiratory distress and exhaustion, with or without a raised arterial carbon dioxide tension (PaCO2).

There is recurrent apnea or slow irregular breathing.

FURTHER TESTING

CHEST X-RAY

Confirmation of pneumonia by chest x-ray is not indicated in children with mild, uncomplicated lower respiratory tract infections who will be treated at outpatients.

CHEST X-RAY

A study in South Africa randomized children age 2-59 months who met the WHO case definition of pneumonia to have a chest x-ray, or not.

There was no clinically identifiable subgroup of children within the WHO case definition who were found to benefit from a chest x-ray.

It was concluded that there was no benefit in routine chest x-ray of ambulatory children with lower respiratory-tract infection over two months of age.

CHEST X-RAYConsider if available and: Infection is severe Diagnosis is otherwise inconclusive To exclude other causes of shortness of

breath (e.g.. foreign body, heart failure) To look for complications of pneumonia

unresponsive to treatment (e.g.. empyema, pleural effusion)

To exclude pneumonia in an infant less than three months with fever

RIGHT UPPER LOBE PNEUMONIA

RIGHT MIDDLE LOBE PNEUMONIA

LABORATORY INVESTIGATIONS

Routine blood work is not required in children with uncomplicated lower respiratory tract infections who will be treated as outpatients

Tests to consider if available: FBC, particularly WBC Electrolytes, particularly Sodium Consider blood cultures, sputum cultures HIV and TB testing as appropriate

COMPLICATIONS

COMPLICATIONS OF PNEUMONIA Pleural effusion – fluid in the pleural

space as the result of inflammation. Empyema – bacterial infection in the

pleural space. Parapneumonic effusions develop in

approximately 40% of patients admitted to hospital with bacterial pneumonia.

If an effusion is present and the patient is persistently febrile, the pleural space should be drained.

COMPLICATIONS OF PNEUMONIA Necrotizing Pneumonia – necrosis or

liquefaction of lung parenchyma. Lung Abscess – A collection of

inflammatory cells leading to tissue destruction resulting in one or more cavities in the lungs. A rare complication.

Treatment of both Necrotizing Pneumonia and Lung Abscess involves long term parenteral antibiotics for 2-4 weeks, or 2 weeks after the patient is afebrile, and has clinically improved.

COMPLICATIONS OF PNEUMONIA

Pneumatocele – thin walled, air filled cysts of the lung, often occurs with empyema.

Pneumatoceles often resolve spontaneously, but may lead to pneumothorax.

TREATMENT

TREATMENT - EPIDEMIOLOGY Antibiotics serve an essential role in

reducing child deaths from pneumonia. Limited data suggest that in the early

1990’s less than one in five children with pneumonia received antibiotics.

Children in urban areas, and those with well educated mothers were more likely to receive antibiotics.

TREATMENT – ORAL ANTIBIOTICS

Common medications for treating pneumonia:

Penicillins: Amoxicillin, Amoxicillin-Clavulanate

Sulfonamides: Co-trimoxazole Macrolides: Azithromycin,

Clarithromycin, Erythromycin 2nd generation Cephalosporins: Cefaclor Dose according to child’s weight

TREATMENT – IV ANTIBIOTICS

Common medications for treating pneumonia:

Penicillins: Amoxicillin, Ampicillin, Benzyl Penicillin

2nd generation Cephalosporins: Cefuroxime

3rd generation Cephalosporins: Cefotaxime

Dose according to child’s weight

TREATMENT – IMCI GUIDELINES

Antibiotic therapy Chloramphenicol (25 mg/kg IM or IV every 8

hours) until the child has improved. Then continue orally 3 x/ day for a total course of 10 days.

If chloramphenicol is not available, give benzylpenicillin (50 000 units/kg IM or IV every 6 hours) and gentamicin (7.5 mg/kg IM once a day) for 10 days.

TREATMENT – IMCI GUIDELINES

If the child does not improve within 48 hours,

Switch to gentamicin (7.5 mg/kg IM once a day) and cloxacillin (50 mg/kg IM or IV every 6 hours), for staphylococcal pneumonia.

When the child improves, continue cloxacillin (or dicloxacillin) orally 4 times a day for a total course of 3 weeks.

INPATIENT ANTIBIOTIC CHOICE

Consider IV 3rd Generation Cephalosporin in a child less than 1 year of age, or who is not fully immunized, or with severe illness.

Consider IV Ampicillin or Penicillin in a child over 1 year of age in areas that do not have a high prevalence of penicillin-resistant Streptococcus Pneumoniae.

SUPPORTIVE TREATMENT – IMCI GUIDELINES

Oxygen therapy

If fever (=>39oC) causing distress, give paracetamol

If wheeze is present, give a rapid-acting broncho-dilator

Gentle suction any thick secretions in the throat, which the child cannot clear.

SUPPORTIVE TREATMENT – IMCI GUIDELINES

Ensure that the child receives daily maintenance fluids for the child's age - avoid overhydration.

Encourage breastfeeding and oral fluids. If the child cannot drink, insert a NG tube and give

maintenance fluids in frequent small amounts. If the child is taking fluids adequately by mouth, do not

use a NG tube as it increases the risk of aspiration pneumonia.

If oxygen is given by nasopharyngeal catheter at the same time as NG fluids, pass both tubes through the same nostril.

Encourage the child to eat as soon as food can be taken.

INTERVENTIONS TO PROTECT AGAINST PNEUMONIA

INTERVENTIONS TO PROTECT AGAINST PNEUMONIA

It is estimated that hand washing, when combined with improved water and sanitation could lead to a 3% reduction in all child deaths.

Promote exclusive breast feeding for 6 months. Impact 15-23% reduction in pneumonia incidence. 13% reduction in all child deaths. Shown to be cost effective.

INTERVENTIONS TO PROTECT AGAINST PNEUMONIA

Adequate nutrition throughout the first five years of life, including adequate micronutrient intake. Impact 6% reduction in all child deaths for adequate complementary feeding (age 6-23 months).

Reduce incidence of low birth weight.

PUBLIC AWARENESS

Tachypnea and respiratory distress are considered the most important signs in the diagnosis of pneumonia.

Only 1 in 5 caregivers know that fast breathing and respiratory distress are a reason to seek care immediately.

INTERVENTION TO PROTECT AGAINST PNEUMONIA

Reducing indoor air pollution, by changing to cleaner gas or liquid fuels or high-quality, well maintained biomass stoves, may reduce the incidence of pneumonia by 22 to 46% in appropriate settings. This intervention may be cost-effective in low-income settings.

INTERVENTION TO PROTECT AGAINST PNEUMONIA

Reduce Exposure to Second-Hand Tobacco Smoke.

Both maternal and paternal smoking cause lower respiratory tract illnesses such as pneumonia and bronchitis, particularly during the first year of life.

PREVENTION STRATEGIES Vaccination against measles,

Streptococcus pneumoniae, and Haemophilus influenzae type b

Zinc supplementation Prevention of HIV in Children Co-trimoxazole prophylaxis for HIV-

infected children

SUMMARY

KEY POINTS Pneumonia is an acute infection of the

pulmonary parenchyma Pneumonia kills more children under the

age of five than any other illness. A diagnosis of pneumonia should be

considered in all children with tachypnea and difficulty breathing.

Common first-line antibiotics include amoxicillin and co-trimoxazole .

THANK YOU