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Pneumonia in children
• Definition— inflammation of the lung
parenchyma. And term chest infetion should not
• 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
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.
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.
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.
Pathogens causing pneumonia in infants and
Group B streptococci
Neonates (<1 month)
major pathogen: RSV.
Others: parainfluenza, influenza, adenovirus
Group A streptococci
(>5 years of age)
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
o Localized chest, abdominal, or neck pain is a
feature of pleural irritation and suggests bacterial
o Examination reveals tachypnoea, nasal flaring and chest
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
o There may be end-inspiratory coarse crackles over the
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
o Oxygen saturation may be decreased.
• Usually several days of URI symptoms; low-grade
• Most consistent manifestation is tachypnea
• If severe—cyanosis, respiratory fatigue
• Examination—scattered crackles and wheezing
• Difficult to localize source in young children with
• difficult to clinically distinguish viral versus
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
o Chlamydia trachomatis pneumonia:
• No fever or wheezing (serves to distinguish
• 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
o Mycoplasma pneumoniae :
• Atypical, insidious pneumonia; constitutional
• Bronchopneumonia; gradual onset of
constitutional symptoms with persistence of
cough and hoarseness; coryza is unusual (usually
• Cough worsens with dyspnea over 2 weeks, then
gradual improvement over next 2 weeks;
becomes more productive; rales are most
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
o Blood tests: including full blood count and acute-
phase reactants are generally unhelpful in
differentiating between a viral and bacterial
o White blood cells:
• Viral—usually normal or low with lymphocyte
• Bacterial—usually 15,000–40,000/mm3 with
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).
Clinical Findings in Viral Versus
Feature Viral Bacterial
Temperature ↑ ↑ ↑ ↑
Toxicity + +++
Rales Scattered Localized
WBC Normal to ↓ ↑ ↑ ↑
Chest x-ray Streaking, patchy Lobar
aspirate (rarely done)
• Most affected children can be managed at
• but indications for admission include:
• oxygen saturation <92%,
• recurrent apnoea, grunting
• inability to maintain adequate fluid/feed
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.
• 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
• Up to 30% viral pneumonia may have
coexisting bacterial pathogens.
• 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
• There is no advantage in giving intravenous rather than
oral treatment in mild/moderate pneumonia.
(British Thoracic Society)
• 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.
• 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).
• 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.
• Coverage of anaerobic organisms with
metronidazole should be added for patients
with lung abscesses when aspiration is
• Children with Pneumonia caused by M
tuberculosis should be treated according to
• 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.
WHO Recommendation for treatment
• 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.
• 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
WHO Recommendation for treatment
• 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
WHO Recommendation for treatment
• 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
• At present, systemic corticosteroids cannot be
recommended for patients with pneumonia and more
studies are necessary.
Prognosis and follow-up
• Follow-up is not generally required for children
with simple consolidation on chest X-ray and who
• 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
• Virtually all children with pneumonia, even those
with empyema, make a full recovery.
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