PNEUMONIA IN CHILDREN

By Dr L N Gachare
Paediatrician/Pulmonologist
Pneumonia in Children
Pneumonia Definition: Inflammation of lung tissue by
an infectious agent with a resultant damage to the lung
tissue.
It refers mainly to community acquired
Pneumonia(the commonest)
The resolution of damage may be partial or complete.
Other different definitions occur based on their
aetiology.
The clinical picture is influenced by the age of the
patient, the nature of the infecting organism and the
presence of comorbidities e.g HIV, PEM, etc.
Bacterial infections are frequently preceded by viral or
mycoplasma pneumonia infections.
Clinical Features by age groups
1.New born(Young infant < 2/12)
Non-specific.
Similar to causes of Sepsis, Meningitis, CCF, intra-
ventricular haemorrhage etc.
Features: poor sucking, refusal to feed, lethargy,
hypotonia, apnoeic spells, hypoxia, head nodding,
grunting, hypothermia/hyperthermia, abdominal dis-
tention, tachypnoea(RR >_ 60/min on two consecutive
counts),tachycardia, severe lower chest wall indrawing.
Cough is weak, and it is often absent.
Physical exam may not yield much.
2. Infant and young children 2/12 – 5 years
Tachypnoea RR >50/min for 2/12 – 1 yr
>40/min for 1-5 yrs
Dysponea
- Flaring of alae nasi
- Intercostal recessions
- Use of sternomastoid muscles
- Lower chest wall indrawing
- Head nodding.
Fever
Cough
+ abdominal distension especially in < 1 yr.
Refusal to eat or drink.
Wheezing especially if preceded by viral infection or mycoplasma infection
(also seen in aspiration syndromes).
Exam: crackles on auscultation.
3. Older Child(> 5yrs)
Fever – usually quite high(>39) + Rigors
Myalgia, arthralgia, headache
Cough + productive
Tachypnoea – (RR > 30/min 5 – 12 years)
Dyspnoea: intercostal & subcostal recessions.
+ Haemoptysis
Pleuritic chest pain -> may radiate to abdomen or tip
of shoulder.
Exam: crackles, dull percussion notes, bronchial
breath sounds.
If pneumoccocal + herpes celialis
Investigations
1. Full haemogram
WBC >15 x 10 9/ in bacterial pneumonias; Neutrophils
predominant
Mycoplasma and other atypical pneumonias – no significant
change in WBCs.
Viral pneumonias – neutrophils and lymphocytes about
equal.
Severe infection in neonates
> neutropenia vs neutrophilcytosis
Raised platelets – sometimes indicative of empyema and
viral infection.
2. Sputum (induced with 3% - 5% hypertonic saline)
Not a reliable specimen for bacterial pneumonia in
children due to ease of contamination.
 If obtained in BAL (bronchoalveolar lavage) or
tracheal aspirate then it may be useful.
Gram stain, ZN stain, stain for fungi, silver stain for
PCP if indicated must be performed on it.
 Culture and sensitivity especially if obtained under
sterile conditions and for very sick patients.
3. Blood culture/sensitivity especially for severe
pneumonia

Yield even in best of facilities is very poor (<27%)

4. Chest x-ray AP, PA & Lateral of the more pathological
side
- Clearly delineates the extent of disease
- May pick up congenital lesions.
- Will pick up pleural effusions.
5. Arterial blood gases: gives indication of severity:
PaO2 less than 60mmHg
PaCO2 more than 50mmHg
Helps to decide on time for ventilatory support.
6. Pleural tap
- Distinguishes between early and late loculation of the
effusion. Also if it is pussy.

 If obtained, it should be subjected to Gram stain,

Biochemical studies, ZN stain for TB, Gene xpert and
culture for TB if suspected, culture and
sensitivity for bacteria and fungi.
Classification of Pneumonia
1.By source of infection
i) Community Acquired
The commonest
Leading single course or mortality.
>70% cases occur in sub Sahara Africa and South East Asia.
4 -5 million deaths occur in the world annually in children < 5 years.
The commonest organisms are S.Pneumoniae and H. Influenza type b
(Hib), S. aureus. M. Catarrhalis. Mycoplasma Pneumonia especially in
school going children. Most are preceded by viral infections in young
children and mycoplasma pneumoniae in bigger ones.
Risk factors: Day care and kindergarten settings where children pass
infection to each other; overcrowding; polluted environments etc
ii) Hospital Acquired Pneumonia(Nosocomial)
Common in patients undergoing procedures in
hospitals e.g catheterization.
Many have underlying co-morbidity e.g malignancy,
prolonged steroid therapy, PEM etc which worsen the
prognosis.
Organisms may be Gram +ve or Gram -ve
e.g pneumoniae
E. Coli
Pseudomonas aeruginosa
It is associated with higher mortality.
iii)Aspiration Pneumonia
Can be from above, in patients with swallowing
problems or from below for patients with severe reflux
or if unconscious when they may aspirate the vomitus
If vomitus aspirated chemical pneumonitis is a feature.
Common in infancy and childhood
Organisms usually aerobes but anaerobes in older
children and adults commoner e.g Fragilis Fusiformis.
iv)Pneumonia of Immuno-Compromised Host
Affected patients are: with HIV, hypo-
gammaglobulinaemia, prolonged steroid therapy or
malignancy.
Wide range of micro-organisms are found: can be
bacteria, fungi, parasites and usually of low
pathogenecity e.g Pneumocystitis Jiroveci (fungus)
Candida albicans
May rapidly become life threatening due to lack of
immune defenses.
2.Classification by Infectious Agent
i) Bacterial Pneumonia
Commonest
Clinically and otherwise not easy to differentiate a
pneumonia by one micro-organism from another.
e.g S.Pneumoniae -> causes pneumonia usually in healthy
children of all ages.
H. Influenza
S. aureus especially after viral infection
M. Catarrhalis
K. Pneumoniae – especially in immune-compromised host
ii) Atypical Pneumonia
Common in school going children.
Prototype of atypical organism causing the atypical
pneumonia is Mycoplasma Pneumoniae.
Others:
Chlamydia Trachomatis especially in neonates
Legionella Pneumophila especially associated with
swimming pools.
Coxiella Burnetti.
iii)Viral Pneumonia
Common in infants and children causing
Bronchiolitis
Organisms: Influenza A and B, parainfluenza 1,2,3;
RSV, CMV and Herpes simplex in immuno-
compromised hosts.
iv) Pneumonia by fungi and Parasites
Some of the fungi: Candida albicans,
Cryptococcus neoformans and Aspergillus fumingatus.
Fungi often come as secondary infections
Example of parasites: Helminths like Ascaris larvae in
lungs , E. histolytica and Toxoplasma gondii
3.Classification by Site of
Infection
i) Bronchopneumonia
Seen on chest x-ray. Should not be a clinical diagnosis
label.
Usually as a result of viral respiratory infection
complicating with bacterial infection.
Patchy and widespread throughout the lungs.
Commonest in infancy and young children
ii)Lobar Pneumonia
Commoner in bacterial pneumonia
Less common in infants unless there is a congenital
malformation or presence of a foreign body in a major
airway causing obstruction.
iii) Interstitial pneumonia
Interstitium rather than alveoli is involved.
Typical in some viral infections and non-infective
conditions e.g Lymphocytic interstitial Pneumonia
(LIP) of HIV.
WHO classification of Pneumonia
and treatment
Classification is based on clinical signs.
It determines the treatment mode.
1. No Pneumonia: cough/cold
Signs:
Cough/difficult breathing.
No tachypnoea
Management:
First rule out infections in upper respiratory tract
If no infection of ears or throat exudates seen:
=>There is no need for antibiotics instead local home
made remedies/honey to soothe the throat is
advised.
->Maintain a dry nose and clear excessive mucus
-saline nose drops useful in this case. Avoid medicated nose drops.
->Advise plenty of warm oral fluids.
Chronic cough: lasting >2 weeks
Various causes.
Each condition has its own specific management.
Chronic cough i.e > 2 weeks
Various causes
Each condition has its own specific management
Examples – not exclusive
PTB
Asthma
Foreign body aspiration
Atypical infections
Pertussis(whooping cough)
Bronchiectasis
Lung abscess
Gastro-aesophageal reflux
Disordered swallowing.
2. Pneumonia
Signs: cough/difficult breathing
Main feature: Tachypnoea and/or lower chest wall indrawing in a calm
child
+ Others: Crackles on auscultation, reduced breath
sounds, bronchial breathing.
Antibiotics of choice
Oral Amoxicillin/Amoxicillin–clavulanic acid @ 40mg/kg/dose twice
daily for 5 – 7 days
1st and 2nd generation cephalosporins.
e.g cephalexin @25 mg/kg/dose every 8 hrs for 5-7 days.
 Refer to a higher health facility if no satisfactory response in three (3)
days or reclassify the pneumonia.
3. Severe Pneumonia
Signs: cough/difficult breathing.
Main feature:
one or more of the following danger signs seen: central cyanosis,
not able to drink/breastfeed or vomiting out everything, altered
level of consciousness, convulsions/lethargy, severe PEM.
Other features: nasal flaring
. Grunting in young infants
. Tachypnoea
. Crackles / reduced breath sounds/
bronchial breathing.
Management of Severe Pneumonia
Admit the child
Supportive care e.g oxygen therapy if SaO2 < 92%
Encourage oral fluid intake
Antibiotics of choice
iv Benzyl Penicillin 50,000 units/kg/dose every 6hours
or
iv Amoxicillin (+ Clavulanic acid)at 30mg/kg/dose every 8hours
plus
iv Gentamycin @ 7.5mg/kg/24hrs
0r
iv amikacin @ 15mg/kg/24hrs
Ceftriaxone used as second line for failed treatment in this area.
Refer to a higher health facility if no improvement seen.
If Staphyloccal pneumonia is suspected, consider
iv Cloxacillin @50mg/kg every 6hrs
or
iv Flucloxacillin @50mg/kg/day every 6hrs
If good response, continue with oral cloxacillin or oral
flucloxacillin @25-50mg/kg/day every 8 hours for a
total of 21 days.
Atypical pneumonia
For all stages of pneumonia, if atypical pneumonia is
suspected, add a macrolide antibiotic.
Erythromycin @ 40mg/kg/day – every 6hours 5 – 7
days
Azithromycin @10-15mg/kg/day – once daily 3 – 5 days
Clarithromycin 15mg/kg/day divided every 12hours for
5 -7days
Complications of Pneumonia
1.Staphyloccocal Pneumonia
Chest x-ray may show pneumatocoeles,
pneumothorax, pleural effusion/empyema.
Surgical measures may have to be considered.
If failed treatment with cloxacillin or flucloxacillin,
think methicillin resistant staph aureus (MRSA)
infection.
Give iv Vancomycin @ 40-60mg/kg/day every 6hours
for 7-10days.
2.Pleural effusion/Empyema
Main Feature is persistent fever
If respiration not compromised and good progress is
seen with the antibiotics, complete the course of
antibiotics.
If respiration is compromised, the fluid must be
drained out by chest drain and analyzed for bacteria,
tuberculosis and fungi etc.
3. Necrotizing Pneumonia.

4. Lung abscess.