4. pneumonia paediatrics

PNEUMONIASITI MARIAM BINTI MOHD HAMZAH

Is an infection of the lower respiratory tract that involves the airways and parenchyma with consolidation of the

alveolar spaces.

LOBAR PNEUMONIABRONCHOPNEUMONIAINTERSTITIAL PNEUMONIA

Pneumonia may be classified anatomically as

The pathogens causing pneumonia may vary according to the child’s age:

Age group PathogensNewborn - Organisms from the mother’s genital tract

particularly group B streptococcus, but could be also gram –ve enterococci

Infants and young children

- Respiratory viruses (RSV are most common)- Bacterial infections include Streptococcus

pneumoniae or H. influenza, Bordetella pertussis and Chlamydia trachomatis.

- Staphylococcus aureus, infrequent but serious caused.

Children over 5 years - Mycoplasma pneumoniae, streptococcus pneumoniae and Chlamydia pneumoniae

*at all ages Mycobacterium tuberculosis should be considered.

Bacteria invasion of lung parenchyma

Inflammatory immune response

Filling of bronchi / alveolar sacs with exudates

CONSOLIDATIONDecrease diameter airways passageWHEEZING

CLINICAL MANIFESTATIONS

IMPORTANT POINT TO ASSESS-RR• WHO respiratory rate thresholds for identifying children with

pneumonia :Children younger than 2 months

>= 60 breaths/min

Children aged 2-11 months

>= 50 breaths/min

Children aged 12-59 months

>= 40 breaths/min

CLINICAL MANIFESTATIONS• Age is a determinant in the clinical manifestations of pneumonia

Neonates - Fever or hypoxia only, with subtle or absent physical examinations findings

Young infant - Apnea may be the first signsOlder infants and children

- fever, chills, tachypnea, cough, malaise, pleuritic chest pain, retractions, and nasal flaring, because of difficulty in breathing or SOB

Viral pneumonia Bacterial pneumonia- Associated more often with cough,

wheezing, or stridor- Mucosal congestion and upper airway

inflammation

- Higher fever, chills, cough, dyspnea, and auscultatory findings on lung consolidation

- Localised chest, abdominal or neck pain; feature of pleural irritation

INVESTIGATIONS• Complete blood count & differential count

– in WBC count,• often normal or mildly elevated with predominance of lymphocytes in case of viral

pneumonias, whereas with bacterial pneumonias the WBC count is elevated >20,000 /mm3 with a predominance of neutrophils

• Mild eosinophilia is characteristics of infant C. trachomatis pneumonia.• Pulse oximetry assess oxygen saturation• Blood/ sputum culture

– Nasopharyngeal aspirate– Throat swab– Bronchoalveolar lavage– Lung aspirates

In addition- Mantoux test ( M. tuberculosis)- Serology test- Urinary antigen (Legionella

pneumophila)

INVESTIGATIONS• Chest radiography

– To localize disease and adequately visualize retrocardiac infiltrates Bacterial pneumonia Shows lobar consolidation, or a

round pneumonia, with pleural effusion in 10% or 30% of cases

Viral pneumonia Shows diffuse, streaky infiltrates of bronchopneumonia and hyperinflation

Atypical pneumonia (M. pneumoniae and C. pneumoniae)

Shows increased interstitial markings or bronchopneumonia

TREATMENT & MANAGEMENT• Therapy for pneumonia includes supportive and specific treatments and

depends on the degree of illness, complications, and knowledge of the infectious agent likely causing the pneumonia

• Children with hypoxemia, inability to maintain adequate hydration, or moderate to severe respiratory distress should be hospitalized

• Hospitalization should be considered in infants under 6 months with suspected bacterial pneumonia, those in whom there is a concern for a pathogen with increased virulence, or when concern exists about a family’s ability to care for the child and to assess symptom progression.

WHO REVISED RECOMMENDATION (published on 2014)Children with fast breathing pneumonia

with no chest indrawing or general danger sign

oral amoxicillin: at least 40mg/kg/dose twice daily (80mg/kg/day) for 5 days. In areas with low HIV prevalence, give amoxicillin for 3 days.

Children with fast-breathing pneumonia who fail on first-line treatment with amoxicillin shouldhave the option of referral to a facility where there is appropriate second-line treatment.

Children age 2–59 months with chest indrawing pneumonia

oral amoxicillin: at least 40mg/kg/dose twice daily for 5 days.

Children aged 2–59 months with severe pneumonia*Not able to drink, persistent vomiting, convulsions, lethargic or unconscious, stridor in a calm child or severe malnutrition

parenteral ampicillin (or penicillin) and gentamicin as a first-line treatment.• Ampicillin: 50 mg/kg, or benzyl penicillin:

50 000 units per kg IM/IV every 6 hours for at least 5 days

• Gentamicin: 7.5 mg/kg IM/IV once a day for at least 5 days

*Ceftriaxone should be used as a second-line treatment in children with severe pneumonia havingfailed on the first-line treatment.

for HIV-infected and -exposed infants and for children under 5 years of age with chest indrawing pneumonia or severe pneumonia

– Ampicillin (or penicillin when ampicillin is not available) plus gentamicin or ceftriaxone are recommended as a first-line antibiotic regimen

– For who do not respond to treatment with ampicillin or penicillin plus gentamicin, ceftriaxone alone is recommended for use as second-line treatment.

• Oseltamivir or zanamivir should be used if influenza is identified or suspected, ideally within 48 hours of symptom onset.

• Oseltamivir is recommended by the CDC and American Academy of Pediatrics (AAP) for the treatment of influenza in persons aged 2 weeks and older, and for the prevention of influenza in persons aged 3 months and older.

• Zanamivir is recommended for the treatment of influenza in persons aged 7 years and older, and for the prevention of influenza in persons aged 5 years and older.

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