Pneumonia in childrenPneumonia in children

Presentation by: Dr. Sundar Karki Presentation by: Dr. Sundar Karki

IntroductionIntroduction

Pneumonia is an inflammation of the parenchyPneumonia is an inflammation of the parenchyma of the lungs.ma of the lungs.

Pneumonia can be classified anatomically as Pneumonia can be classified anatomically as lolobar or lobularbar or lobular, , bronchopnemoniabronchopnemonia and and interstitiainterstitial pneumonial pneumonia..

Pathologically there is consolidation of alveoli Pathologically there is consolidation of alveoli or infiltration of the interstitial tissue with inflaor infiltration of the interstitial tissue with inflammatory cell or both mmatory cell or both

EtiologyEtiology

ViralViral: It can be caused by RSV, influenza, : It can be caused by RSV, influenza, parainfluenza or adenovirusparainfluenza or adenovirus

BacterialBacterial: In first 2 months the common agents : In first 2 months the common agents include klebsiella, E. coli, and staphylococci. include klebsiella, E. coli, and staphylococci. Between 3 month to 3 years common bacteria Between 3 month to 3 years common bacteria include S. pneumonia, H. influenza and include S. pneumonia, H. influenza and staphylococci. After 3 years of age common staphylococci. After 3 years of age common bacteria include S. pneumonia and bacteria include S. pneumonia and staphylococci.staphylococci.

EtiologyEtiology

Atypical organismAtypical organism: Chalmydia sps and Mycop: Chalmydia sps and Mycoplasm in CAP in adult and children have more elasm in CAP in adult and children have more evidence.vidence.

Pnemuocystis cariniiPnemuocystis carinii: causes pneumonia in im: causes pneumonia in imunnocompromised children. unnocompromised children.

Some termsSome terms

Recurrent pneumoniaRecurrent pneumonia is defined is defined as 2 or as 2 or moremore episodes in a single yr episodes in a single yr or 3 or moreor 3 or more episodes ever, with radiographic clearing episodes ever, with radiographic clearing between occurrences. between occurrences.

Slowly resolving pneumoniaSlowly resolving pneumonia refers to the refers to the persistence of symptoms or radiographic persistence of symptoms or radiographic abnormalities beyond the expected time abnormalities beyond the expected time course. course.

Clinical featuresClinical features

Onset of pneumonia may be insidious starting Onset of pneumonia may be insidious starting with URTI or may be acute with high fever, dywith URTI or may be acute with high fever, dypsnea and grunting respiration. psnea and grunting respiration. Respiratory ratRespiratory ratee is always is always increasedincreased..

Rarely pneumonia may be present with acute aRarely pneumonia may be present with acute abdominal emergency which is due to referred bdominal emergency which is due to referred pain from the pleura. Apical pneumonia may spain from the pleura. Apical pneumonia may sometime be associated with meningmus and coometime be associated with meningmus and convulsion.nvulsion.

Clinical featuresClinical features

On examination there is flaring of alae nasi, retOn examination there is flaring of alae nasi, retraction of lower chest and intercostal spaces.raction of lower chest and intercostal spaces.

Signs of consolidation(diminished expansion, Signs of consolidation(diminished expansion, dull percussion note, increased tactile vocal fredull percussion note, increased tactile vocal fremitus/vocal resonance, bronchial breathing) camitus/vocal resonance, bronchial breathing) can be seen in lobar pneumonia.n be seen in lobar pneumonia.

Clinical FeaturesClinical Features

ViralViral: URTI, low grade fever, tachypnea, crackl: URTI, low grade fever, tachypnea, crackles, wheezing.es, wheezing.

Bacterial- PneumococcalBacterial- Pneumococcal

- acute onset shaking chills with high fever, - acute onset shaking chills with high fever, cough, chest pain, respiratory distress.cough, chest pain, respiratory distress.

-decreased breath sound, rales, dullness to percu-decreased breath sound, rales, dullness to percussion ssion

DiagnosisDiagnosis The chest radiograph confirms the diagnosis of pneuThe chest radiograph confirms the diagnosis of pneu

monia and may indicate a complication such as a pleumonia and may indicate a complication such as a pleural effusion or empyema. ral effusion or empyema.

Viral pneumonia is usually characterized by hyperinflViral pneumonia is usually characterized by hyperinflation with bilateral interstitial infiltrates and peribronation with bilateral interstitial infiltrates and peribronchial cuffing. chial cuffing.

Confluent lobar consolidation is typically seen with pConfluent lobar consolidation is typically seen with pneumococcal pneumonia. If pneumatocele think abouneumococcal pneumonia. If pneumatocele think about staphylococci.t staphylococci.

The radiographic appearance alone is not diagnostic aThe radiographic appearance alone is not diagnostic and other clinical features must be considered.nd other clinical features must be considered.

DiagnosisDiagnosis

The peripheral white blood cell (WBC) count can be The peripheral white blood cell (WBC) count can be useful in differentiating viral from bacterial useful in differentiating viral from bacterial pneumonia.pneumonia.

In viral pneumonia, the WBC count can be normal or In viral pneumonia, the WBC count can be normal or elevated but is usually not higher than 20,000/mm3, elevated but is usually not higher than 20,000/mm3, with a lymphocyte predominance. Bacterial with a lymphocyte predominance. Bacterial pneumonia (occasionally, adenovirus pneumonia) is pneumonia (occasionally, adenovirus pneumonia) is often associated with an elevated WBC count in the often associated with an elevated WBC count in the range of 15,000-40,000/mm3 and a predominance of range of 15,000-40,000/mm3 and a predominance of granulocytes. granulocytes.

DiagnosisDiagnosis

Viral: viral culture or antigen isolation in respiViral: viral culture or antigen isolation in respiratory secretion. Growth of respiratory viruses ratory secretion. Growth of respiratory viruses in tissue culture usually requires 5–10 days.in tissue culture usually requires 5–10 days.

Bacterial: sputum culture, no value in children.Bacterial: sputum culture, no value in children. Mycoplasm: IgM titers Mycoplasm: IgM titers

Treatment Treatment

Treatment of suspected bacterial pneumonia is based Treatment of suspected bacterial pneumonia is based on the presumptive cause and the clinical appearance on the presumptive cause and the clinical appearance of the child.of the child.

For mildly ill children who do not require hospitalizaFor mildly ill children who do not require hospitalization, amoxicillin is recommended. In communities wition, amoxicillin is recommended. In communities with a high percentage of penicillin-resistant pneumocoth a high percentage of penicillin-resistant pneumococci, high doses of amoxicillin (80–90 mg/kg/24 hr) shcci, high doses of amoxicillin (80–90 mg/kg/24 hr) should be prescribed. ould be prescribed.

Therapeutic alternatives include cefuroxime axetil or Therapeutic alternatives include cefuroxime axetil or amoxicillin/clavulanate amoxicillin/clavulanate

TreatmentTreatment

For school-aged children and in those in whom For school-aged children and in those in whom infection with infection with M. pneumoniaeM. pneumoniae or or C. pneumoniC. pneumoniaeae (atypical pneumonias) is suggested, a macr (atypical pneumonias) is suggested, a macrolide antibiotic such as azithromycin is an approlide antibiotic such as azithromycin is an appropriate choice. opriate choice.

In adolescents, a respiratory fluoroquinolone (lIn adolescents, a respiratory fluoroquinolone (levofloxacin, gatifloxacin, moxifloxacin, gemifevofloxacin, gatifloxacin, moxifloxacin, gemifloxacin) may be considered for atypical pneumloxacin) may be considered for atypical pneumonias. onias.

TreatmentTreatment

The empirical treatment of suspected bacterial pneumThe empirical treatment of suspected bacterial pneumonia in a hospitalized child requires an approach baseonia in a hospitalized child requires an approach based on the clinical manifestations at the time of presentad on the clinical manifestations at the time of presentation.tion.

Parenteral cefuroxime (150 mg/kg/24 hr), cefotaxime,Parenteral cefuroxime (150 mg/kg/24 hr), cefotaxime, or ceftriaxone is the mainstay of therapy when bacter or ceftriaxone is the mainstay of therapy when bacterial pneumonia is suggested.ial pneumonia is suggested.

If clinical features suggest staphylococcal pneumonia If clinical features suggest staphylococcal pneumonia (pneumatoceles, empyema), initial antimicrobial thera(pneumatoceles, empyema), initial antimicrobial therapy should also include vancomycin or clindamycin. py should also include vancomycin or clindamycin.

TreatmentTreatment

If viral pneumonia is suspected, it is If viral pneumonia is suspected, it is reasonable to withhold antibiotic therapy, reasonable to withhold antibiotic therapy, especially for those patients who are mildly ill, especially for those patients who are mildly ill, have clinical evidence suggesting viral have clinical evidence suggesting viral infection, and are in no respiratory distress.infection, and are in no respiratory distress.

Up to 30% of patients with known viral Up to 30% of patients with known viral infection may have coexisting bacterial infection may have coexisting bacterial pathogens. pathogens.

Treatment Treatment

Therefore, if the decision is made to withhold Therefore, if the decision is made to withhold antibiotic therapy based on presumptive antibiotic therapy based on presumptive diagnosis of a viral infection, deterioration in diagnosis of a viral infection, deterioration in clinical status should signal the possibility of clinical status should signal the possibility of superimposed bacterial infection and antibiotic superimposed bacterial infection and antibiotic therapy should be initiated. therapy should be initiated.

Need of Hospital Admission of Need of Hospital Admission of children with pneumoniachildren with pneumonia

Age <6 months  Age <6 months   Sickle cell anemia with acute chest syndrome Sickle cell anemia with acute chest syndrome    Multiple lobe involvement  Multiple lobe involvement   Immunocompromised state  Immunocompromised state   Toxic appearance  Toxic appearance   Severe respiratory distress  Severe respiratory distress   Requirement for supplemental oxygen  Requirement for supplemental oxygen   Dehydration  Dehydration   Vomiting  Vomiting   No response to appropriate oral antibiotic therapy  No response to appropriate oral antibiotic therapy   Noncompliant parentsNoncompliant parents

Clinical Classification to facilitate Clinical Classification to facilitate treatmenttreatment

Signs n Signs n symptomssymptoms

classificationclassification therapytherapy Where to Where to treat treat

Cough or coldCough or cold

No fast breathingNo fast breathing

No chest indrawing or indicatorNo chest indrawing or indicators of severe illness s of severe illness

No pneumoniaNo pneumonia Home remedies Home remedies Home Home

RR ageRR age

60 or more < 2 months60 or more < 2 months

50 or more 2-12 months 50 or more 2-12 months

40 or more 12-60 months40 or more 12-60 months

Pneumonia Pneumonia Clotrimoxazole Clotrimoxazole Home Home

Chest Indrawing Chest Indrawing Severe PneumoniaSevere Pneumonia IV/IM PenicillinIV/IM Penicillin Hospital Hospital

Cyanosis, severe chest indrCyanosis, severe chest indrawing, inability to feedawing, inability to feed

Very Severe Pneumonia Very Severe Pneumonia IV ChloramphenicolIV Chloramphenicol Hospital Hospital

Response to the treatmentResponse to the treatment

Typically, patients with uncomplicated commuTypically, patients with uncomplicated community-acquired bacterial pneumonia respond to tnity-acquired bacterial pneumonia respond to therapy with improvement in clinical symptomherapy with improvement in clinical symptoms (fever, cough, tachypnea, chest pain) within s (fever, cough, tachypnea, chest pain) within 48–96 hr of initiation of antibiotics.48–96 hr of initiation of antibiotics.

Radiographic evidence of improvement substaRadiographic evidence of improvement substantially lags behind clinical improvement. ntially lags behind clinical improvement.

Response to the treatmentResponse to the treatment

A number of factors must be considered when a A number of factors must be considered when a patient does not improve on appropriate antibiotic patient does not improve on appropriate antibiotic therapy (therapy (slowly resolving pneumoniaslowly resolving pneumonia): (1) ): (1) complications (2) bacterial resistance; (3) complications (2) bacterial resistance; (3) nonbacterial etiologies (4) bronchial obstruction nonbacterial etiologies (4) bronchial obstruction from (5) pre-existing diseases (6) other noninfectious from (5) pre-existing diseases (6) other noninfectious causes.causes.

A repeat chest x-ray is the 1st step in determining the A repeat chest x-ray is the 1st step in determining the reason for delay in response to treatment. reason for delay in response to treatment.

Complications Complications

Complications of pneumonia are usually the reComplications of pneumonia are usually the result of direct spread of bacterial infection withisult of direct spread of bacterial infection within the thoracic cavity (pleural effusion, empyen the thoracic cavity (pleural effusion, empyema, pericarditis) or bacteremia and hematologima, pericarditis) or bacteremia and hematologic spread.c spread.

Meningitis, suppurative arthritis, and osteomyMeningitis, suppurative arthritis, and osteomyelitis are rare complications of hematologic sprelitis are rare complications of hematologic spread of pneumococcal or ead of pneumococcal or H. influenzaeH. influenzae type b i type b infection. nfection.

ReferencesReferences

Nelson Textbook of Pediatrics- 18Nelson Textbook of Pediatrics- 18 thth edition edition Ghai Essential Pediatrics- 7Ghai Essential Pediatrics- 7thth edition edition Kaplan USMLE 2010 Kaplan USMLE 2010