Global distribution of deaths among children under age 5, by cause, 2010
a lobar consolidation and a pleural effusion on the right
Right-middle-lobe infiltrate in a 2-month-old boy with pneumonia due to respiratory syncytial virus (RSV).
Peadiatric pneumonia by Teo Yan
Definition Pneumonia is an inflammation of the pulmonary parenchyma Most caused by microorganisms, noninfectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons, and lipoid substances, hypersensitivity reactions, and drug- or radiation-induced pneumonitis
classified as community-acquired, hospital- acquired, or ventilator-associated -40–80% of children with community- acquired pneumonia.-Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen
Epidemiology Pneumonia is substantial cause of morbidity and mortality in childhood (particularly among children <5 yr of age) Estimated approximately 4 million deaths children among worldwide
Global distribution of deaths among children under age5, by cause, 2010
Organisms of pneumonia bacterial or viral cause of pneumonia can be identified in 40–80% of children with community-acquired pneumonia. Streptococcus pneumoniae (pneumococcus) is the most common bacterial pathogen, followed by Chlamydia pneumoniae and Mycoplasma pneumoniae
Leading Etiologic Agents of Pneumonia Infantsand Children S.aureus S.aureus
Pathophysiology Virusairbornedropletsmouth or noselungsvirus incaded cells lining airway and alveoli cell death(protective process) immune system responds more lung damage fluid leak into alveoli(due to WBC,lymphocytes activate) interrupts normal transportation of oxygen
Bacterial invasion triggers the immune system to send neutrophils kill the offending organisms, and also release cytokines fever, chills, and fatigue
Types of pneumonia Classify by clinically: Lobar pneumonia-infection that only involves a single lobe, or section. Bronchopneumonia - affects the lungs in patches around the tubes (bronchi or bronchioles)
Physial examination Tachypnoea,nasal flaring and chest indrawing Consolidation with dullness on percussion End –inspiratory respiratory coarse carckles over the effeted area Decreased breath sounds and bronchial breathing
Assessment of severity ofpneumonia The predictve value of respiratory rate for the diagnosis of pneumonia Tachypnoea is deﬁned as follows : < 2 months age: > 60 /min 2- 12 months age: > 50 /min 12 months – 5 years age: > 40 /min
Assessment the severity of pneumoniaAGE < 2months AGE>2 months – 5yrs oldSevera pneumonia Mild pneumonia severe chest indrawing fast breathing or fast breathing Severe pneumoniaVery severe pneumonia chest indrawing not feeding convulsion Very severe pneumonia abnormally sleepy or difficult to not able to drinkwake convulsions fever/low body temperature drowsiness hypopnoea with slow irregular malnutritionbreathing
Investigations elevated WBC count in the range of 15,000- 40,000/mm and a predominance of granulocytes erythrocyte sedimentation rate (ESR) C–reactive protein (CRP) anti-streptolysin O (ASO) titer useful in the diagnosis of group A streptococcal pneumonia
Viral pneumonia several days of symptoms of an upper respiratory tract infection eg: rhinitis and cough Fever, lower than in bacterial pneumonia Tachypnea intercostal, subcostal, and suprasternal retractions, nasal flaring, and use of accessory muscles cyanosis
Investigations Reliable DNA or RNA tests for the rapid detection of RSV PCR test seroconversion in an IgG assay
Myocoplasma pneumonia Headaches and malasia precede the chest symptoms by 1-5 days Cough may not obvious chest may be scanty
chest X-ray - one lobe is involved but sometimes may shadowing in both lungs frequently no correlation between the X-ray appearances and the clinical state of the patient.
Investigation Serology : acute phase serumtitre > 1:160 or paired samples taken 2-4 weeks apart showing a 4 fold rise is a good indicator of Mycoplasma pneumoniae infection This test should be considered for children aged ﬁve years or older
Management Assessment of oxygenation The best objective measurement of hypoxia is by pulse oximetry which avoids the need for arterial blood gases. It is a good indicator of the severity of pneumonia
Criteria forhospitalization community acquired pneumonia can be treated at home it is crucial to identify indicators of severity in children who may need admission. Failure to recognise the severity of pneumonia may lead to death.
The following indicators can be used as aguide for admission: children aged 3 months and below, whatever the severity of pneumonia. fever ( more than 38.5 ⁰C ), refusal to feed and vomiting fast breathing with or without cyanosis associated systemic manifestation failure of previous antibiotic therapy recurrent pneumonia severe underlying disorder ( i.e. immunodeﬁ ciency )
Antibiotics Bacterial pathogens of children and the recommended antimicrobial agents to be used:Pathogen Antimicrobial agentBeta-lactam susceptibleStreptococcus pneumonia penicillin, cephalosporinsHaemophilus inﬂuenzae type b ampicillin, chloramphenicol, cephalosporinsStaphylococcus aureus cloxacillinGroup A Streptococcus penicillin, cephalosporinMycoplasma pneumoniae macrolides , e.g. erythromycin, azithromycinChlamydia pneumoniae macrolides , e.g. erythromycin, azithromycinBordetella pertussis macrolides , e.g. erythromycin, azithromycin
Children with severe pneumonia, the followingantibiotics are recommended:Suggested antimicrobial agents for inpatienttreatment of pneumonia1st line beta-lactam drugs : benzylpenicillin, amoxycillin, ampicillin, amoxycillin-clavulanate2nd line cephalosporins : cefotaxime, cefuroxime, ceftazidime3rd line carbapenem: imipenamOthers aminoglycosides: gentamicin, amikacin
• second line antibiotics need to be considered when : - there are no signs of recovery - patients remain toxic and ill with spiking temperature for 48 - 72 hours• a macrolide antibiotic is used if Mycoplasma or Chlamydia are the causative agents• a child admitied to hospital with severe community acquired pneumonia must receive parenteral antibiotics. As a rule, in severe cases of pneumonia, combination therapy using a second or third generation cephalosporins and macrolide should be given.
Supportive treatment Fluids Oxygen Temperature control Chest physiotherapy
Org Strep Staph Mycoplasm RSV HIV(PCP Comparism of common organisms causing a ) pneumonia incom Commonest PaedIv drugs users or population -acq with cental venous catheters Any ageAge 3mth -childhood Noenatal-- >5yrs <3mths infancy high fever,Clinical Broncho in young Fever Headaches, upper respiratory breathlessFeature child Tachypnea Malaise, ness and Lobar/consolidation Cyanosis Chest tract infection, dry cough in older Extremely ill symptoms. Fever,tachyp F,Rusty sputum nea diffuse Haemoptysis bilateral Pleuritic pain alveolar O/E- and interstitial shadowinInv- CXR multi lobar Not Infiltr ate g perihilar consolidati on, correlate In affect- regions cavitation, with clinical ed area spread out pneumatocoel state in a es butterfly patternTx 1st line Iv flucloxacillin Erythromycin, HAART 2nd line (200mg/kg/d) Clarithromycin