This is the first line of treatment in bronchopneumonia.

Along with the above treatment additionally proper food supplementation, hydration by giving adequate water, vegetable juices made up of carrot, and spinach can be given. Pneumococcal vactionation is advised in children. Related Topics

Bronchopneumonia Treatment | Symptoms, Causes of Broncho Pneumonia Iga Deficiency In Children: Symptoms And Treatment For Low IgA In Kids Children with Cystic Fibrosis: Causes, Symptoms, Remedies, Treatment Pneumonia In Children Under 5: Symptoms And Treatment For Pneumonia Enlarged Heart In Children: Symptoms, Causes And Treatment

Etiology
Pneumonia can be caused by a myriad of microorganisms. Clinical suspicion of a particular offending agent is derived from clues obtained during the history and physical examination. While virtually any microorganism can lead to pneumonia, specific bacterial, viral, fungal, and mycobacterial infections are most common in previously healthy children. The age of infection, exposure history, risk factors for unusual pathogens, and immunization history all provide clues to the infecting agent. In a prospective multicenter study of 154 hospitalized children with acute community-acquired pneumonia (CAP) in whom a comprehensive search for an etiology was sought, a pathogen was identified in 79% of children. Pyogenic bacteria accounted for 60% of cases, of which 73% were due to Streptococcus pneumoniae, while the atypical bacteria Mycoplasma pneumoniae and Chlamydophila pneumoniae were detected in 14% and 9%, respectively. Viruses were documented in 45% of children. Notably, 23% of the children had concurrent acute viral and bacterial disease. In the study, preschool-aged children had as many episodes of atypical bacterial lower respiratory infections as older children. Multivariable analyses revealed that high temperature (38.4C) within 72 hours after admission and the presence of pleural effusion were significantly associated with bacterial pneumonia.[4] Specific etiologic agents vary based on age groups (ie, newborns, young infants, infants and toddlers, 5-year-olds, school-aged children and young adolescents, older adolescents).

Newborns
In newborns (age 0-30 d), organisms responsible for infectious pneumonia typically mirror those responsible for early onset neonatal sepsis. This is not surprising in view of the role that maternal

genitourinary and gastrointestinal tract flora play in both processes. Infections with group B Streptococcus, Listeria monocytogenes, or gram-negative rods (eg, Escherichia coli, Klebsiella pneumoniae) are common causes of bacterial pneumonia. These pathogens can be acquired in utero, via aspiration of organisms present in the birth canal, or by postnatal contact with other people or contaminated equipment. Group B Streptococcus (GBS) was the most common bacterial isolate in most locales from the late 1960s to the late 1990s, when the impact of intrapartum chemoprophylaxis in reducing neonatal and maternal infection by this organism became evident. E coli has become the most common bacterial isolate among VLBW infants (1500 g or less) since that time.[5] Other potential bacterial organisms include the following:

Nontypeable Haemophilus influenzae (NTHi) Other gram-negative bacilli Enterococci Staphylococcus aureus

Some organisms acquired perinatally may not cause illness until later in infancy, including Chlamydia trachomatis, U urealyticum, Mycoplasma hominis, CMV, and Pneumocystis carinii. C trachomatis organisms are presumably transmitted at birth during passage through an infected birth canal, although most infants are asymptomatic during the first 24 hours and develop pneumonia only after the first 2 weeks of life. Group B streptococci infections are most often transmitted to the fetus in utero, usually as a result of colonization of the mother's vagina and cervix by the organism. Agents of chronic congenital infection, such as CMV, Treponema pallidum (the cause of pneumonia alba), Toxoplasma gondii, and others, may cause pneumonia in the first 24 hours of life. The clinical presentation usually involves other organ systems as well. Community-acquired viral infections occur in newborns, although less commonly than in older infants. The most commonly isolated virus is respiratory syncytial virus (RSV). The transfer of maternal antibodies is important in protecting newborns and young infants from such infections, making premature infants (who may not have benefited from sufficient transfer of transplacental immunoglobulin [Ig] G]) especially vulnerable to lower-tract disease. In addition, premature infants may have chronic lung disease of prematurity, with associated hyperreactive airways, fewer functional alveoli, and baseline increased oxygen requirements. Newborns may also be affected by the bacteria and viruses that commonly cause infections in older infants and children. Risk factors for infection include older siblings, group daycare, and lack of immunization.

Young infants
In the young infant (aged 1-3 mo), continued concern about the perinatally acquired pathogens mentioned above remains. However, most bacterial pneumonia in this age group is community acquired and involves S pneumoniae, S aureus, and nontypeable H influenzae. S pneumoniae is

by far the most common bacterial pathogen in this age group. Infection with any of these pyogenic bacteria may be complicated by lung abscess, parapneumonic effusions, and empyema, although S aureus is notorious for such complications.[6] At this age, infants are incompletely immunized and remain at higher risk for H influenzae type B and pneumococcal disease, although herd immunity gained from widespread immunization of the population has been broadly protective. It is important to note that the current conjugate pneumococcal vaccine provides protection against 13 common pneumococcal types, but nonvaccine types remain problematic. Most lower respiratory tract disease in young infants occurs during the respiratory virus season and is viral in origin, particularly in the patient with clinical bronchiolitis. The most common viral agents include RSV, parainfluenza viruses, influenza virus, adenovirus, and human metapneumovirus (hMPV). Atypical organisms may rarely cause infection in infants. Of these, C trachomatis, U urealyticum, CMV, and P carinii are described. Bordetella pertussis infection leads to pneumonia in as many as 20% of infected infants (as a complication of the whooping cough infection). Among other potential atypical bacterial pathogens, U urealyticum and U parvum have been recovered from endotracheal aspirates shortly after birth in very low birth weight (VLBW) infants and have been variably associated with various adverse pulmonary outcomes, including bronchopulmonary dysplasia (BPD).[7, 8, 9, 10] Whether these organisms are causal or simply a marker of increased risk is unclear.

Infants, toddlers, and preschool-aged children

Viruses remain the most common cause of pneumonia in this age group, accounting for approximately 90% of all lower respiratory tract infections. Tsolia et al identified a viral infection among 65% of hospitalized children with community-acquired pneumonia.[11] RSV is the most common viral pathogen, followed by parainfluenza types 1, 2, and 3 and influenza A or B. RSV infection occurs in the winter and early spring. Parainfluenza type 3 infection occurs in the spring, and types 1 and 2 occur in the fall. Influenza occurs in the winter. Other viruses that cause pneumonia less frequently in infants and young children include adenovirus, enterovirus, rhinovirus, and coronavirus. A recent addition to this list is hMPV, which causes an illness similar to RSV and may be responsible for one third to one half of nonRSV bronchiolitis. The herpesviruses (HSV, VZV, and CMV) may rarely cause pneumonia, particularly in children with impaired immune systems. Bacterial infections in this age group are seen on a regular basis. S pneumoniae is by far the most common bacterial cause of pneumonia. Among hospitalized children with bacterial pneumonia, S

pneumoniae accounts for 21-44% of disease.[4, 12, 13] Other agents to consider include H influenzae type B (HiB) (very uncommon in immunized children[14] ), S pyogenes, and S aureus. Children younger than 5 years, children enrolled in daycare, or those with frequent ear infections are at increased risk for invasive pneumococcal disease and infection with resistant pneumococcal strains. Evidence suggests that breastfeeding has a protective effect against invasive pneumococcal infection.

School-aged children and young adolescents

M pneumoniae is the most frequent cause of pneumonia among older children and adolescents. Mycoplasma accounts for 14-35% of pneumonia hospitalizations in this age group.[4, 11, 15] Children in homeless shelters and group homes and those with household contacts are at particular risk. Similarly, the diagnosis must be considered in immunocompromised children. In this age group, pyogenic bacterial pneumonia remains a concern, usually caused by S pneumoniae. Other pyogenic bacterial pathogens to consider include S aureus and S pyogenes. Chlamydophila pneumoniae also causes pneumonia. The related organism, C psittaci, is an unusual cause of pneumonia that occurs in people who work with and handle birds. In immunosuppressed individuals, opportunistic infections with organisms such as Aspergillus species, Pneumocystis jirovecii, and CMV can occur. Viral pneumonia remains common in this age group. Influenza pneumonia is a particular concern because ongoing infection with this virus predisposes to the development of bacterial superinfection, usually with S pneumoniae or S aureus.

Older adolescents
M pneumoniae is the most common cause of community-acquired pneumonia during the teenage and young adult years. Atypical pneumonia caused by C pneumoniae can present with identical signs and symptoms. Bacterial pneumonia caused by S pneumoniae is also seen. Pulmonary infections caused by dimorphic fungi are also seen in this age group. Histoplasma capsulatum, which is found in nitrate-rich soil, is usually acquired as a result of inhalation of spores. Chicken coops and other bird roosts and decaying wood are often-cited sources. Cryptococcus neoformans is a common infection among pigeon breeders, but it is unusual in other immunocompetent individuals. Blastomyces dermatitides, another dimorphic fungus, is found in certain geographic locations, most notably the Ohio and Mississippi River valleys. As with histoplasmosis, blastomycosis is acquired by inhalation of spores. Although 3 distinct forms of infection exist, the most common is acute pneumonia, which, in previously healthy individuals, most often resolves without treatment.

Viral pneumonias are common in this age group are usually mild and self-limited, but influenza pneumonia can be severe or protracted, particularly when a bacterial infection follows. TB pneumonia in children warrants special mention. It can occur in any age group, and it is important to remember that children with TB usually do not present with symptoms until 1-6 months after primary infection. Any child with pneumonia who has a history of TB exposure, or who has traveled to a TB-endemic area of the world needs to be fully evaluated for the possibility of tuberculosis. Legionella pneumophila, the agent of Legionnaires disease, can also cause pneumonia, although it is uncommon in the pediatric age group. Not all pneumonia is caused by infectious agents. Children who have severe gastroesophageal reflux (GERD) may develop chemical pneumonitis secondary to recurrent aspiration. Inhalation of certain chemicals or smoke may cause pulmonary inflammation. Additionally, aspiration pneumonia is more common in children with neurologic impairment, swallowing abnormalities, gastrointestinal motility, or a gastrostomy tube. Oral anaerobic flora, with or without aerobes, is the most common etiologic agent.

Immunocompromised children
Some children who are immunocompromised, whether secondary to HIV infection/AIDS, an immune disorder, or chemotherapy for a malignancy, are at risk for pneumonias with opportunistic agents. Virtually any bacteria, virus, fungus, or even parasite can invade and infect the lungs if the immune system is sufficiently impaired. Carefully obtained samples for appropriate microbiologic testing are paramount in such patients so that therapy can be optimized. Children with cystic fibrosis are especially prone to develop infections with S aureus, Pseudomonas aeruginosa, Burkholderia cepacia, and other multidrug-resistant organisms. P jirovecii pneumonia (PCP) is common in the most severely compromised children and can lead to respiratory failure and death in those who are profoundly immunocompromised. Adenovirus infections can be severe in these children as well, leading to bronchiolitis obliterans or hyperlucent lung syndrome. In addition, CMV poses a great risk to immunocompromised patients. Fungal pneumonia, caused by Aspergillus, Zygomycetes, or other related fungi, occur in immunocompromised patients who undergo prolonged hospitalization, have prolonged neutropenia, and/or have received broad-spectrum antibiotics. Patients with underlying hematologic malignancies are at the highest risk. Patients with sickle cell disease have problems with their complement system as well as functional asplenia, which predisposes them to infection with encapsulated organisms such as S pneumoniae and H influenzae type B. M pneumoniae is also a common agent of pneumonia is this group of patients.

Epidemiology
United States statistics
Pneumonia can occur at any age, although it is more common in younger children. Pneumonia accounts for 13% of all infectious illnesses in infants younger than 2 years. In a large community-based study conducted by Denny and Clyde, the annual incidence rate of pneumonia was 4 cases per 100 children in the preschool-aged group, 2 cases per 100 children aged 5-9 years, and 1 case per 100 children aged 9-15 years.[16] Thompson et al reported that, after elderly persons, the second highest rates of influenzaassociated hospitalizations in the United States were in children younger than 5 years.[17] The investigators evaluated annual influenza-associated hospitalizations by hospital discharge category, discharge type, and age group. In a randomized double-blind trial, the heptavalent pneumococcal vaccine reduced the incidence of clinically diagnosed and radiographically diagnosed pneumonia among children younger than 5 years by 4% and 20%, respectively.[18] Although the overall rate of pneumonia has decreased in the United States with the use of the 7-valent vaccine, the rate of empyema and complicated pneumonia has increased.[19] With the use of the 13-valent conjugated pneumococcal polysaccharide vaccine, the overall rates of pneumonia are anticipated to drop further. The new vaccine includes serotypes that have become associated with complicated or antibiotic-resistant disease (19A and 6A, for example). In school-aged children and adolescents, bronchopneumonia occurs in 0.8-2% of all pertussis cases and 16-20% of hospitalized cases. M pneumoniae accounts for 14-35% of pneumonia hospitalizations in this age group,[4, 11, 15] and mycobacterial pneumonia has recently been noted with increasing frequency in some inner-city areas, particularly children in homeless shelters and group homes and those with household contacts.

International statistics
Pneumonia and other lower respiratory tract infections are the leading cause of death worldwide. The WHO Child Health Epidemiology Reference Group estimated the median global incidence of clinical pneumonia to be 0.28 episodes per child-year.[20] This equates to an annual incidence of 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to require hospital admission. Ninety-five percent of all episodes of clinical pneumonia in young children worldwide occur in developing countries. Approximately 150 million new cases of pneumonia occur annually among children younger than 5 years worldwide, accounting for approximately 10-20 million hospitalizations.[16] A WHO Child Health Epidemiology Reference Group publication cited the incidence of communityacquired pneumonia among children younger than 5 years in developed countries as approximately 0.026 episodes per child-year,[20] and a study conducted in the United Kingdom showed that 59% of deaths from pertussis are associated with pneumonia.

Prognosis
Overall, the prognosis is good. Most cases of viral pneumonia resolve without treatment; common bacterial pathogens and atypical organisms respond to antimicrobial therapy (see Treatment and Management). Long-term alteration of pulmonary function is rare, even in children with pneumonia that has been complicated by empyema or lung abscess. Patients placed on a protocol-driven pneumonia clinical pathway are more likely to have favorable outcomes. The prognosis for varicella pneumonia is somewhat more guarded. Staphylococcal pneumonia, although rare, can be very serious despite treatment.

Morbidity
Although viral pneumonias are common in school-aged children and adolescents and are usually mild and self-limited, these pneumonias are occasionally severe and can rapidly progress to respiratory failure, either as a primary manifestation of viral infection or as a consequence of subsequent bacterial infection. Morbidity and mortality from RSV and other viral infections is higher among premature infants and infants with underlying lung disease. Significant sequelae occur with adenoviral disease, including bronchiolitis obliterans and necrotizing bronchiolitis. With neonatal pneumonia, even if the infection is eradicated, many hosts develop long-lasting or permanent pulmonary changes that affect lung function, the quality of life, and susceptibility to later infections. Infants and postpubertal adolescents with TB pneumonia are at increased risk of disease progression. If TB is not treated during the early stages of infection, approximately 25% of children younger than 15 years develop extrapulmonary disease. Bronchopneumonia occurs in 0.8-2% of all pertussis cases and 16-20% of hospitalized cases; the survival rate of these patients is much lower than in those with pneumonia that is attributed to other causes. Immunocompromised children, those with underlying lung disease, and neonates are at high risk for severe sequelae, and they are also susceptible to various comorbidities. Cryptococcosis may occur in as many as 5-10% of patients with AIDS, and acute chest syndrome occurs in 15-43% of patients with sickle cell disease. Individuals with sickle cell disease not only have problems with their complement system, but they also have functional asplenia, which predisposes them to infection with encapsulated organisms such as S pneumoniae and H influenzae type B.

Mortality
The United Nations Children's Fund (UNICEF) estimates that 3 million children die worldwide from pneumonia each year; these deaths almost exclusively occur in children with underlying conditions, such as chronic lung disease of prematurity, congenital heart disease, and immunosuppression. Although most fatalities occur in developing countries, pneumonia remains a significant cause of morbidity in industrialized nations.

According to the WHOs Global Burden of Disease 2000 Project, lower respiratory infections were the second leading cause of death in children younger than 5 years (about 2.1 million [19.6%]).[20] Most children are treated as outpatients and fully recover. However, in young infants and immunocompromised individuals, mortality is much higher. In studies of adults with pneumonia, a higher mortality rate is associated with abnormal vital signs, immunodeficiency, and certain pathogens.

Patient Education project

Counsel parents regarding the need to prevent exposure of infants to tobacco smoke, and, as part of anticipatory primary care, educate parents regarding later infectious exposures in daycare centers, schools, and similar settings as well as the importance of hand washing. In addition, discuss the benefit infants may receive from pneumococcal immunization and annual influenza immunization and the potential benefits and costs of RSV immune globulin (see Prevention). Emphasize careful longitudinal surveillance for long-term problems with growth, development, otitis, reactive airway disease, and other complications. Most children treated with outpatient antibiotics are much improved within 48 hours after the initiation of treatment. Educate parents about and caution them to look for the signs of increasing respiratory distress and to seek medical attention immediately should any of these signs appear. For excellent patient education resources, visit eMedicine's Procedures Center and Pneumonia Center. Also, see eMedicine's patient education articles Bronchoscopy, Viral Pneumonia, and Bacterial Pneumonia. 1. Metinko AP. Neonatal pulmonary host defense mechanisms. In: Polin RA, Fox WW, eds. Fetal and Neonatal Physiology. 3rd ed. Philadelphia, Pa: WB Saunders Co; 2004:162073. 2. Barnett ED, Klein JO. Bacterial infections of the respiratory tract. In: Remington JS, Klein JO, eds. Infectious Diseases of the Fetus and Newborn Infant. 6th ed. Philadelphia, Pa: Elsevier Saunders Co; 2006:297-317. 3. Bone RC, Grodzin CJ, Balk RA. Sepsis: a new hypothesis for pathogenesis of the disease process. Chest. Jul 1997;112(1):235-43. [Medline]. 4. Michelow IC, Olsen K, Lozano J, Rollins NK, Duffy LB, Ziegler T, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics. Apr 2004;113(4):701-7. [Medline]. 5. Stoll BJ, Hansen NI, Higgins RD, Fanaroff AA, Duara S, Goldberg R, et al. Very low birth weight preterm infants with early onset neonatal sepsis: the predominance of gramnegative infections continues in the National Institute of Child Health and Human Development Neonatal Research Network, 2002-2003. Pediatr Infect Dis J. Jul 2005;24(7):635-9. [Medline]. 6. Mishaan AM, Mason EO Jr, Martinez-Aguilar G, Hammerman W, Propst JJ, Lupski JR, et al. Emergence of a predominant clone of community-acquired Staphylococcus aureus among children in Houston, Texas. Pediatr Infect Dis J. Mar 2005;24(3):201-6. [Medline].

7. Kotecha S, Hodge R, Schaber JA, Miralles R, Silverman M, Grant WD. Pulmonary Ureaplasma urealyticum is associated with the development of acute lung inflammation and chronic lung disease in preterm infants. Pediatr Res. Jan 2004;55(1):61-8. [Medline]. 8. Katz B, Patel P, Duffy L, Schelonka RL, Dimmitt RA, Waites KB. Characterization of ureaplasmas isolated from preterm infants with and without bronchopulmonary dysplasia. J Clin Microbiol. Sep 2005;43(9):4852-4. [Medline]. [Full Text]. 9. Heggie AD, Bar-Shain D, Boxerbaum B, Fanaroff AA, O'Riordan MA, Robertson JA. Identification and quantification of ureaplasmas colonizing the respiratory tract and assessment of their role in the development of chronic lung disease in preterm infants. Pediatr Infect Dis J. Sep 2001;20(9):854-9. [Medline]. 10. Ballard HO, Bernard P, Whitehead V, et al. Determining the incidence of Ureaplasma spp. and its role in development of bronchopulmonary dysplasia. [Abstract 3858.111]. Pediatric Academic Societies Meeting 2009. Baltimore, MD. May 3, 2009. aps-spr.org. Available at http://www.abstracts2view.com/pas/view.php?nu=PAS09L1_3037. Accessed November 5, 2010. 11. Tsolia MN, Psarras S, Bossios A, Audi H, Paldanius M, Gourgiotis D, et al. Etiology of community-acquired pneumonia in hospitalized school-age children: evidence for high prevalence of viral infections. Clin Infect Dis. Sep 1 2004;39(5):681-6. [Medline]. 12. Nascimento-Carvalho CM, Ribeiro CT, Cardoso MR, Barral A, Arajo-Neto CA, Oliveira JR, et al. The role of respiratory viral infections among children hospitalized for community-acquired pneumonia in a developing country. Pediatr Infect Dis J. Oct 2008;27(10):939-41. [Medline]. 13. Juvn T, Mertsola J, Waris M, Leinonen M, Meurman O, Roivainen M, et al. Etiology of community-acquired pneumonia in 254 hospitalized children. Pediatr Infect Dis J. Apr 2000;19(4):293-8. [Medline]. 14. [Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Recommended childhood and adolescent immunization schedules--United States, 2009. Pediatrics. Jan 2009;123(1):189-90. [Medline]. 15. Tajima T, Nakayama E, Kondo Y, Hirai F, Ito H, Iitsuka T, et al. Etiology and clinical study of community-acquired pneumonia in 157 hospitalized children. J Infect Chemother. Dec 2006;12(6):372-9. [Medline]. 16. Denny FW, Clyde WA Jr. Acute lower respiratory tract infections in nonhospitalized children. J Pediatr. May 1986;108(5 Pt 1):635-46. [Medline]. 17. Thompson WW, Shay DK, Weintraub E, Brammer L, Bridges CB, Cox NJ, et al. Influenza-associated hospitalizations in the United States. JAMA. Sep 15 2004;292(11):1333-40. [Medline]. 18. Black SB, Shinefield HR, Ling S, Hansen J, Fireman B, Spring D, et al. Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than five years of age for prevention of pneumonia. Pediatr Infect Dis J. Sep 2002;21(9):810-5. [Medline]. 19. Li ST, Tancredi DJ. Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine. Pediatrics. Jan 2010;125(1):26-33. [Medline]. 20. Rudan I, Tomaskovic L, Boschi-Pinto C, Campbell H. Global estimate of the incidence of clinical pneumonia among children under five years of age. Bull World Health Organ. Dec 2004;82(12):895-903. [Medline]. [Full Text].

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literature

Conclusions
About 156 million new episodes of childhood clinical pneumonia occurred globally in 2000, more than 95% of them in developing countries. Of all the pneumonia cases occurring in those countries, 8.7% are severe enough to be life-threatening and require hospital admission. About 2 million pneumonia deaths occur each year in children aged less than 5 years, mainly in the African and South-East Asia Regions. The main bacterial causes of clinical pneumonia in developing countries are S. pneumoniae and Hib, and the main viral cause is respiratory syncytial virus, but estimates of their relative importance vary in different settings. The only vaccines for the prevention of bacterial pneumonia (excluding pertussis) are Hib and pneumococcal vaccines. Future studies, with new molecular techniques to better detect infections due to the wide range of pathogens, will broaden our understanding of the cause of pneumonia and may highlight which pathogens should be the targets for new vaccines. Despite the lack of data, mainly for the developing regions of the world, morbidity and mortality estimates and the main risk factors presented in this review could contribute to an understanding of the burden of acute lower respiratory infections in children aged less than 5 years in developing countries and to informed care and vaccine policy.
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