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Pneumonia in children

Pneumonia in children

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Pneumonia in children

  1. 1. Pneumonia in children
  2. 2. Introduction • Definition— inflammation of the lung parenchyma. And term chest infetion should not be used. • Pneumonia continues to be the biggest killer worldwide of children under five years of age. • Although the implementation of safe, effective and affordable interventions has reduced pneumonia mortality from 4 million in 1981 to just over one million in 2013 , pneumonia still accounts for nearly one-fifth of childhood deaths worldwide.
  3. 3. Aetiology o It is caused by a variety of viruses and bacteria, although in over 50% of cases no causative pathogen is identified. o Viruses are the most common cause in younger children, whereas bacteria are more common in older children. o In clinical practice, it is difficult to distinguish between viral and bacterial pneumonia.
  4. 4. Aetiology o The most common pathogens causing pneumonia vary according to the child’s age: o • Newborn – organisms from the mother’s genital tract, particularly group B streptococcus, but also Gram-negative enterococci and bacilli. o • Infants and young children – respiratory viruses, particularly RSV, are most common, but bacterial infections include Streptococcus pneumoniae or H. influenzae. Bordetella pertussis and Chlamydia trachomatis can also cause pneumonia at this age. An infrequent but serious cause is Staphylococcus aureus.
  5. 5. Aetiology o • Children over 5 years – Mycoplasma pneumoniae, Streptococcus pneumoniae, and Chlamydia pneumoniae are the main causes. o • At all ages Mycobacterium tuberculosis should be considered.
  6. 6. Pathogens causing pneumonia in infants and children PathogensAge Pathogens Group B streptococci Escherichia coli Chlamydia trachomatis Listeria monocytogenes Neonates (<1 month) Respiratory viruses, major pathogen: RSV. Others: parainfluenza, influenza, adenovirus Infants Streptococcus pneumoniae Haemophilus influenzae Bordetella pertussis Streptococcus pneumoniae Haemophilus influenzae Group A streptococci Children Mycoplasma pneumonia (>5 years of age)
  7. 7. Clinical features o Fever, cough and rapid breathing are the most common presenting symptoms. o These are usually preceded by a URTI. o Other symptoms include lethargy, poor feeding, and an ‘unwell’ child. o Some children do not have a cough at presentation. o Localized chest, abdominal, or neck pain is a feature of pleural irritation and suggests bacterial infection.
  8. 8. Clinical features o Examination reveals tachypnoea, nasal flaring and chest indrawing. o In contrast to asthma, the most sensitive clinical sign of pneumonia in children is increased respiratory rate, and pneumonia can sometimes be missed if the respiratory rate is not measured in a febrile child (so-called silent pneumonia). o There may be end-inspiratory coarse crackles over the affected area o but the classic signs of consolidation with dullness on percussion, decreased breath sounds and bronchial breathing over the affected area are often absent in young children. o Oxygen saturation may be decreased.
  9. 9. Clinical Findings o Viral: • Usually several days of URI symptoms; low-grade fever • Most consistent manifestation is tachypnea • If severe—cyanosis, respiratory fatigue • Examination—scattered crackles and wheezing • Difficult to localize source in young children with hyper-resonant chests; • difficult to clinically distinguish viral versus nonviral
  10. 10. o Bacterial pneumonia: • Sudden shaking chills with high fever, acute onset • Significant cough and chest pain • Tachypnea; productive cough • Splinting on affected side—minimize pleuritic pain • Examination—diminished breath sounds, localized crackles, rhonchi early; • with increasing consolidation, markedly diminished breath sounds and dullness to percussion Clinical Findings
  11. 11. o Chlamydia trachomatis pneumonia: • No fever or wheezing (serves to distinguish from RSV) • 1–3 months of age, with insidious onset • May or may not have conjunctivitis at birth • Mild interstitial chest x-ray findings • Staccato cough • Peripheral eosinophilia Clinical Findings
  12. 12. o Mycoplasma pneumoniae : • Atypical, insidious pneumonia; constitutional symptoms • Bronchopneumonia; gradual onset of constitutional symptoms with persistence of cough and hoarseness; coryza is unusual (usually viral) • Cough worsens with dyspnea over 2 weeks, then gradual improvement over next 2 weeks; becomes more productive; rales are most consistent finding(basilar) Clinical Findings
  13. 13. Diagnosis o A chest X-ray may confirm the diagnosis but cannot reliably differentiate between bacterial and viral pneumonia. o Viral—hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing • Pneumococcal—confluent lobar consolidation • Mycoplasma—unilateral or bilateral lower-lobe interstitial pneumonia; looks worse than presentation.
  14. 14. o Blood tests: including full blood count and acute- phase reactants are generally unhelpful in differentiating between a viral and bacterial cause. o White blood cells: • Viral—usually normal or low with lymphocyte predominance • Bacterial—usually 15,000–40,000/mm3 with mostly granulocytes • Chlamydia—eosinophilia Diagnosis
  15. 15. o Definitive diagnosis: • Viral: nasopharyngeal aspirate may identify viral causes; PCR, rapid reagents available for RSV, parainfluenza, influenza, and adenovirus. • Bacterial—isolation of organism from blood (positive in only 10–30% of children with S. pneumoniae), pleural fluid, or lung; sputum cultures are of no value in children. • For mycoplasma: PCR (had been IgM titers). Diagnosis
  16. 16. Clinical Findings in Viral Versus Bacterial Pneumonia Feature Viral Bacterial Temperature ↑ ↑ ↑ ↑ Upper respiratory infection ++ — Toxicity + +++ Rales Scattered Localized WBC Normal to ↓ ↑ ↑ ↑ Chest x-ray Streaking, patchy Lobar Diagnosis Nasopharyngeal washings, PCR Blood culture, transtracheal aspirate (rarely done)
  17. 17. • Most affected children can be managed at home • but indications for admission include: • oxygen saturation <92%, • recurrent apnoea, grunting • inability to maintain adequate fluid/feed intake. Treatment
  18. 18. Treatment o Antibiotics o General supportive care: should include o oxygen for hypoxia and o analgesia if there is pain. o Intravenous fluids should be given if necessary to correct dehydration and maintain adequate hydration and sodium balance. o Physiotherapy has no proven role. o Nutritional status should be monitored during and after hospitalisation for children with pneumonia.
  19. 19. • The choice of antibiotic should be based on international and local guidelines and take into consideration local patterns of antibiotic resistance and whether the child has any underlying comorbidities. • Up to 30% viral pneumonia may have coexisting bacterial pathogens. Antibiotics
  20. 20. • The choice of antibiotic is determined by the child’s age and the severity of illness. • Newborns require broad spectrum intravenous antibiotics. • Most older infants can be managed with oral amoxicillin, with broader spectrum antibiotics such as co-amoxiclav reserved for complicated or unresponsive pneumonia. • For children over 5 years of age, either amoxicillin or an oral macrolide such as Azithromycin is the treatment of choice. • There is no advantage in giving intravenous rather than oral treatment in mild/moderate pneumonia. According to (British Thoracic Society)
  21. 21. • For moderate and sever pneumonia: • High-dose penicillin or ampicillin, amoxicillin– clavulanic acid, or third-generation cephalosporin (eg, cefotaxime, or ceftriaxone) are often used intravenously. • In areas where there is a high prevalence of meticillin-resistant S aureus, vancomycin should be used as an additional first-line agent until culture results are available. Antibiotics
  22. 22. • A multicentre, randomised trial showed that ceftaroline produced similar clinical response rates to ceftriaxone plus vancomycin in children. • Ceftaroline is a novel fifth-generation cephalosporin, which exhibits broad-spectrum activity against Gram-positive bacteria, including MRSA and extensively-resistant strains, such as vancomycin-resistant S. aureus (VRSA). Antibiotics
  23. 23. • When M pneumoniae infection is documented, treatment should also include a macrolide. • Macrolides should never be used as the sole antibiotic in complicated pneumonia. • Ensuring that there is cover against S pneumoniae and S aureus is important, given the high prevalence of mixed infections and increasing incidence of macrolide resistance. Antibiotics
  24. 24. • Coverage of anaerobic organisms with metronidazole should be added for patients with lung abscesses when aspiration is suspected. • Children with Pneumonia caused by M tuberculosis should be treated according to standard guidelines. Antibiotics
  25. 25. • The duration of intravenous antibiotic therapy to prescribe is controversial, and oral antibiotic therapy should be started as soon as possible. • A course of 2–3 weeks of intravenous antibiotic therapy is usually sufficient, often with a transition to oral therapy when fever has abated for at least 24–48 h, there is no respiratory distress or evidence of uncontrolled sepsis, the child is tolerating enteral feeds and has an improved mood and playfulness, and when inflammatory markers are reducing. Antibiotics
  26. 26. WHO Recommendation for treatment of Pneumonia • Recommendation 1 • Children with fast breathing pneumonia with no chest indrawing or general danger sign should be treated with oral amoxicillin: at least 40mg/kg/dose twice daily (80mg/kg/day) for five days. In areas with low HIV prevalence, give amoxicillin for three days. • Children with fast-breathing pneumonia who fail on first-line treatment with amoxicillin should have the option of referral to a facility where there is appropriate second-line treatment.
  27. 27. • Recommendation 2 • Children age 2–59 months with chest indrawing pneumonia should be treated with oral amoxicillin: at least 40mg/kg/dose twice daily for five days. • Recommendation 3 • Children aged 2–59 months with severe pneumonia should be treated with parenteral ampicillin (or penicillin) and gentamicin as a first-line treatment for at least five days • Ceftriaxone should be used as a second-line treatment in children with severe pneumonia having failed on the first-line treatment. WHO Recommendation for treatment of Pneumonia
  28. 28. • Recommendation 4 • Empiric cotrimoxazole treatment for suspected Pneumocystis jirovecii (previously Pneumocystis carinii) pneumonia (PCP) is recommended as an additional treatment for children with chest indrawing or severe pneumonia. WHO Recommendation for treatment of Pneumonia
  29. 29. Corticosteroids • The mechanisms of action and the anti-inflammatory effects of corticosteroids in paediatric respiratory diseases have been reviewed in Four studies: found that corticosteroid therapy reduced mortality and morbidity in children with severe pneumonia , and • reduced morbidity , in children with non-severe pneumonia. • At present, systemic corticosteroids cannot be recommended for patients with pneumonia and more studies are necessary.
  30. 30. Prognosis and follow-up • Follow-up is not generally required for children with simple consolidation on chest X-ray and who recover clinically. • Those with evidence of lobar collapse or atelectasis should have a repeat chest X-ray after 4–6 weeks to check that the lung fields look normal. • Virtually all children with pneumonia, even those with empyema, make a full recovery.
  31. 31. THANKS FOR YOUR Attention

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