pediatric community acquired pneumonia

1. By
Dr. Samiaa Hamdy Sadek
Assistant Professor Chest
Department
Assiut University
Pediatric CAP

2. Definition:
Community acquired pneumonia (CAP)
is chest infection acquired outside a
hospital or long-term care facility. CAP
occurs within 48 hours of hospital
admittance or in a patient presenting
with pneumonia who has no features of
healthcare-associated pneumonia

3. key facts:
Pneumonia accounts for 15% of all deaths of
children under 5 years old, killing 808 694
children in 2017.
Pneumonia can be caused by viruses,
bacteria, or fungi.
Pneumonia can be prevented by immunization,
adequate nutrition, and by addressing
environmental factors.
Pneumonia caused by bacteria can be treated
with antibiotics, but only one third of children
with pneumonia receive the antibiotics they
need.

4. Aetiology:
Pneumonia is caused by a number of infectious
agents, including viruses, bacteria and fungi. The
most common are:
Streptococcus pneumoniae – the most common
cause of bacterial pneumonia in children;
Haemophilus influenzae type b (Hib) – the second
most common cause of bacterial pneumonia;
respiratory syncytial virus is the most common
viral cause of pneumonia;
in infants infected with HIV, Pneumocystis
jiroveci is one of the most common causes of
pneumonia, responsible for at least one quarter of
all pneumonia deaths in HIV-infected infants.

5. Aetiology (cont)
 Between the end of the last century and the beginning of
the current one, significant changes occurred in the
childhood CAP scenario.
 Firstly, the progressive implementation of bacterial
conjugate vaccines, specifically the Haemophilus
influenzae type b (Hib) vaccine and the pneumococcal
conjugate vaccines (PCVs), the most frequent bacterial
causative agents of CAP among children under 5 year. It
has been recognized that the widespread use of Hib
vaccine and PCV in countries with high child mortality
has been associated with reductions in Hib and
pneumococcal cases and deaths.
 Secondly, the successively widespread use of
amplification nucleic acid techniques (PCRs) has been
impacting on the estimation of the proportion of
respiratory virus infections in childhood CAP

6. Risk factors:
While most healthy children can fight the infection
with their natural defences, children whose immune
systems are compromised are at higher risk of
developing pneumonia. A child's immune system may
be weakened by malnutrition or undernourishment,
especially in infants who are not exclusively breastfed.
Pre-existing illnesses, such as symptomatic HIV
infections and measles, also increase a child's risk of
contracting pneumonia.
The following environmental factors also increase a
child's susceptibility to pneumonia:
indoor air pollution caused by cooking and heating
with biomass fuels (such as wood or dung)
living in crowded homes
parental smoking.

7. Presenting features:
The presenting features of viral and bacterial pneumonia
are similar. However, the symptoms of viral pneumonia may
be more numerous than the symptoms of bacterial
pneumonia.
Newborns with pneumonia rarely cough; more commonly
they present with poor feeding and irritability, as well as
tachypnea, retractions, grunting, and hypoxemia.
After the first month of life, cough is the most common
presenting symptom of pneumonia.
Infants with bacterial pneumonia are often febrile. But
those with viral pneumonia or pneumonia caused by
atypical organisms may have a low-grade fever or may be
afebrile.
 Wheezing is more common in viral infections.
Very severely ill infants may be unable to feed or drink and

8. Toddlers and preschoolers most often present
with fever, cough tachypnea, and congestion.
They may have some vomiting, particularly post-
tussive emesis.
Older children and adolescents may also present
with fever, cough (productive or nonproductive),
congestion, chest pain, dehydration, and lethargy.
In addition to the symptoms reported in younger
children, adolescents may have other
constitutional symptoms, such as headache,
pleuritic chest pain, and vague abdominal pain.
Vomiting, diarrhea, pharyngitis, and otalgia/otitis
are other common symptoms.

9. Since the early 1990’s, the WHO has rec-ommended
the use of quantitative tachypnea (age-
specificelevated respiratory rates) to identify
children that would require treatment with
antibiotics for possible pneumonia.
The WHO thresholds are as follows:
Children younger than 2 months: Greater than or
equal to 60 breaths/min
Children aged 2-12 months: Greater than or equal
to 50 breaths/min
Children aged 1-5 years: Greater than or equal to
40 breaths/min

10. In a recently published systematic review of the
accuracy of symptoms and physical examination
findings to identify cases with radiographic pneumonia
among children younger than 5 years, 23 prospective
cohort studies of children were included.
The presence of moderate hypoxemia (oxygen
saturation≤96%) and increased work of breathing
(grunting, flaring, and retractions) were signs most
associated with pneumonia, whereas normal
oxygenation (oxygen saturation >96%)decreased the
likelihood of pneumonia.
Curiously, tachypnea (respiratory rate >40 breaths/min)
was not strongly associated with pneumonia diagnosis.
Indeed, the limitations of respiratory rate-based
pneumonia diagnosis also include overdiagnosis, due to
the inclusion of cases of asthma and other respiratory
illness that compromise the lower respiratory tract

11. Diagnostic tests:
A. Complete blood count: Routine estimation of the
complete blood count is not essential in all cases
of suspected CAP managed in an outpatient
setting but it may be helpful for the assessment of
patients who require hospital admission.
B. Acute-phase reactants such as the erythrocyte
sedimentation rate and C-reactive protein can
support a clinical assessment for managing the
development strategy and in a response to therapy
evaluation, particularly for complicated CAP.

12. Diagnostic tests (continue):
C. Serum procalcitonin (PCT)
PCT does not need to be measured routinely.
However, if available, it may be helpful for
differentiating the etiology of pneumonia and severity
when used in addition to clinical, epidemiological,
and other diagnostic testing.
 PCT concentrations <0.25 ng/mL are strongly
associated with a decreased likelihood of detecting
common typical bacteria and reduced disease
severity.
 PCT concentrations < 0.1 ng/mL have a very high
negative predictive value, where they efficiently
exclude typical bacterial CAP

13. Diagnostic tests (continue):
D. Blood culture
 Blood culture (outpatient): Blood culture is not
necessary routinely unless the patient's condition
is deteriorating post antibiotic therapy.
 Blood culture (inpatient): Blood culture should be
conducted for children who require hospitalization
for assumed bacterial CAP.
 Sufficient volumes of blood will probably yield a
pathogen, so the microbiology laboratory should
be contacted for the recommended blood volume
required according to the age of the patient.

14. Diagnostic tests (continue):
E. Respiratory viral studies
 Tests for influenza virus infection and other
respiratory viruses ((i.e., direct fluorescent antibody or
enzyme immunoassay tests) should be utilized as a
part of the assessment of children with CAP, if
available.
 If available, nasopharyngeal aspiration for viral
multiplex PCR may help to determine a viral cause and
reduce the need for antibiotics.
F. Chest radiography
 Chest radiographs (outpatient): Posteroanterior chest
radiographs are not required to confirm the CAP
diagnosis but they should be performed for patients
with suspected or recorded hypoxia or those with
significant respiratory distress, as well as for patients
who fail to respond to initial antimicrobial treatment to
check for pneumonia complications.

15. Diagnostic tests (continue):
 Chest radiographs (Inpatient): Perform chest
radiographs for all patients hospitalized with CAP to
outline the size and characteristics of parenchymal
infiltrates, and to recognize complications of pneumonia
that may require prompt intervention rather than
antimicrobial therapy.
 Follow-up chest radiographs o Repeat chest imaging in
individuals who do not exhibit improvement within 48 -
72 hours following initiation of appropriate antimicrobial
therapy.
 For complicated pneumonia with parapneumonic
effusion status post-therapeutic intervention, repeated
imaging is not recommended daily if the patient is
clinically stable.
 Repeat chest radiography if a patient with complicated
pneumonia becomes unstable, worsens clinically, or has
persistent fever for over 48 - 72 hours while receiving

16. Diagnostic tests (continue):
 Data show that point-of-care chest
ultrasonography accurately helps to diagnose
most cases of pneumonia in children and young
adults. In a study of 200 babies, children, and
young adults (≤21 years), chest ultrasonography
had an overall sensitivity of 86% and a specificity
of 89% for diagnosing pneumonia.
Ultrasonography may eventually come to replace
radiographs for diagnosis.
Jones BP, Tay ET, Elikashvili I, et al. Feasibility and safety of substituting lung
ultrasonography for chest radiography when diagnosing pneumonia in children: a
randomized controlled trial. Chest. 2016 Jul. 150 (1):131-8.

17. Treatment

18. Criteria to consider hospitalization for pediatric
CAP
Underlying conditions/comorbidities
that:
May predispose patients to a more
serious course (e.g., cardiopulmonary
disease, genetic syndromes,
neurocognitive disorders,
neuromuscular disorders)
May be worsened by pneumonia
(e.g., metabolic disorder)
May adversely affect response to
treatment (e.g., immunocompromised
host, sickle cell disease)
 Complications (e.g., effusion and/or
empyema)
 Failure of outpatient therapy (48 -72
h with no clinical response)
 Caretaker unable to provide
appropriate observation or to comply
with prescribed home therapy
Hypoxemia (oxygen saturations
<90% in room air)
 Infants (3-6) months of age with
suspected bacterial CAP
 Tachypnea:
Infants <12 months of age:
respiratory rate >70 breaths per min
Children: respiratory rate >50
breaths per min
 Respiratory distress: apnea,
grunting, difficulty breathing, and poor
feeding
 Signs of dehydration or inability to
maintain hydration or oral intake
 Capillary refill time >2 s
 Infants and children with toxic
appearance
Suspected or confirmed to have
infection with a virulent organism ex
(MERSA, group A Streptococcus)
*Adapted from Messinger AI, Kupfer O, Hurst A, Parker S. Management of Pediatric Community-acquired
Bacterial Pneumonia. Pediatrics in review. 2017 Sep;38(9):394.

19. Criteria to Consider IMCU/ICU admission for
Pediatric CAP*.
A child should be admitted
to an ICU:
Pulse oximetry measurement
of <92% on fractional inspired
oxygen concentration of >0.50.
If the child requires invasive
ventilation via artificial airway
(e.g., endotracheal tube).
A child should be admitted
to an ICU or IMCU:
If the child acutely requires use
of noninvasive positive pressure
ventilation
If the child has impending
respiratory failure.
If the child has sustained
tachycardia, inadequate blood
pressure or need for
pharmacologic support of blood
pressure or perfusion.
If the child has altered mental
status, whether due to
hypercarbia or hypoxia, because
of pneumonia.Adapted with modification from Messinger AI, Kupfer O, Hurst A, Parker S. Management of Pediatric Community-
acquired Bacterial Pneumonia. Pediatrics in review. 2017 Sep; 38(9):394

20. Treatment (cont):
 Remarkably, the WHO significantly altered its
recom-mendation in 2012: for children with fast
breathing and wheezing, but no chest indrawing,
danger signs, nor fever(<38◦C), antibiotics should
not routinely be recommended, as the cause is
most likely viral infection.
World Health Organization (WHO) [cited 2019 Jul 20]. Availablefrom: Recommendations for management of common child-hood
conditions: evidence for
technical update of pocket bookrecommendations: newborn conditions, dysentery, pneumo-nia, oxygen use and delivery, common
causes of fever, severeacute
malnutrition and supportive care. Geneva: WHO; 2012http://apps.who.int/iris/handle/10665/44774.

21. Treatment (cont):
• There is a general agreement among distinct
international guidelines that orally
administered amoxicillin is the first line option
to treat outpatients, and ampicillin or aqueous
penicillin G or amoxicillin (initiated initially by
intravenous route) are the first line options to
treat inpatients with CAP in the under-5 years
group.

22. Treatment (cont):
It is important to recall that the key
pharmacodynamics parameter for amoxicillin
efficacy is length of time over the minimal
inhibitory concentration (MIC), which should be
≥40% - 50% of the dosing interval during
treatment of pneumococcal CAP.
That indicates that the appropriateness of the
50 mg/kg/day dose of amoxicillin needs to be re-
evaluated according to the MIC of the
pneumococcal strains isolated in the region.

23. Treatment (cont):
 For instance, Canadian authors have recently
advised against the routine use of higher
doses of amoxicillin to treat non-severe CAP
cases in Canada, as only 0.6% of
pneumococcal strains presented intermediate
resistance (MIC = 4 ug/mL)to amoxicillin.
 A common practical question is whether
macrolides should be given empirically in the
first-line option to treat children with CAP;
several attempts have been made to address
this question.

24. Treatment (cont):
 The strongest evidence has been provided by a
Brazilian study: 703 children under 5years with
non-severe CAP were given amoxicillin and were
prospectively followed-up; The authors concluded
that it was not necessary to treat atypical bacterial
infection in every child aged between 2 and 59
months with non-severe CAP; on the contrary,
macrolide use could be reserved for those rare
cases in which amoxicillin was not effective
(Nascimento-Carvalho CM, Xavier-Souza G, Vilas-Boas AL, Fon-toura MH, Barral A, Puolakkainen M, et al. Evolution of
acuteinfection with atypical
bacteria in a prospective cohort ofchildren with community-acquired pneumonia receiving amox-icillin. J Antimicrob
Chemother. 2017;72:2378---
84.23

25. Treatment (cont):
 In hospitalized patients for whom ampicillin or aqueous
penicillin G or amoxicillin (initiated initially by
intravenousroute) are the first line options, the American
guide-line states that the third generation
cephalosporins could be the first choice only in those
places with high prevalence of pneumococcal resistance
to penicillin, that is, with MIC ≥4 ug/mL.
Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, HarrisonC, et al. The management of community-acquired pneumoniain infants and children
older
than 3 months of age: clinicalpractice guidelines by the Pediatric Infectious Diseases Soci-ety and Infectious Diseases Society of America. Clin Infect
Dis.2011;53:e25---76.
 The use of ceftriaxone in cases with very severe disease
or the association of oxacillin or macrolide should occur
in specific situations, where it is possible to assume the
presence of high penicillin resistant pneumococcus, or
lactamase producing H. influenzae (ceftriaxone
indication), or Staphy-lococcus aureus (oxacillin
indication), or even atypical bacteria (macrolide
indication).

26. Treatment (cont):
 Patients under 2 months of age should be hospitalized
and receive intravenous antibiotics once they have
higher chance of dying from CAP, regardless of other
factors when compared with children older than 2
months.
 In this age stratum, group B streptococcus, Gram-
negative intestinal bacteria, Listeria monocytogenes, and
S. pneumoniae are potential causative agents.
 Then, antibiotic therapy in this age group includes
administration of either intravenous (IV) or intramuscular
(IM) ampicillin associated with amynoglycosides
throughout the whole treatment and from 1-week-old
upwards, it is possible to substitute amynoglycosides
for third-generation cephalosporins.
 If age is<1 month, cefotaxime is the first choice drug,
considering hyperbilirubinemia and prematurity
 C. trachomatis should be suspected in the presence of
conjunctivitis. In this case, the recommended antibiotic
choice is erythromycin

27. Treatment (cont):
 A further practical question regards the length of
antibiotic therapy. Treatment courses of 10 days
have been best studied, although shorter courses
may be just as effective, particularly for more mild
disease managed on an outpatient basis.
• A systematic review published in 2008 evaluated
the efficacy of short and long courses of the same
antibiotic, in children aged 2- 59 months with non-
severe CAP, and identified two clinical trials in
which three and five days of amoxicillin use were
compared

28. Treatment (cont):
 Neither study indicated differences in the efficacy
per treatment length. It is of utmost importance to
notice that these studies diagnosed CAP patients
according to WHO diagnostics criteria: presence
of tachypnea. Evidently, cases of asthma,
bronchiolitis, and other lower respiratory tract
diseases were included.
Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-
acquiredpneumonia in children aged 2 months to
59 months. CochraneDatabase Syst Rev. 2008:CD005976.62.
 Another clinical trial published in 2014: children
aged 6-59 months,with radiological finding of
alveolar infiltrate on the chest radiograph taken
upon admission, temperature ≥38.5◦C, leucocyte
total count ≥15.000 mm3, without dangers signs

29. Treatment (cont):
 Authors concluded that five days of amoxicillin
are enough to treat CAP with alveolar infiltrate,
without danger signs or complications.
Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-ZivJ, Dagan R. Short-course treatment for community-acquiredalveolar
pneumonia in ambulatory
children: a double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J.2014;33:136---42.

30. Treatment (cont):
 To date, the role of corticosteroids in adjunctive
chemical therapy of childhood CAP is yet to be
established.
 A Spanish study was performed where Sixty
children, aged from1 month to 14 years, with
CAP and pleural effusion were included. Those
authors described faster recovery rate,
measured objectively in hours, in the group that
received dexamethasone (DXM) 0.15 mg/kg,
every 6 h, for 48 h, plus cefotaxime, when
compared with the control group. There were no
significant differences in adverse events
attributable to the study drugs, except for
hyperglycemia.

31. Treatment (cont):
 Another systematic review identified four
randomized controlled trials that included 310
children; corticosteroids reduced early clinical
failure rates (RR 0.41 [95% CI: 0.24---0.70]; high-
quality evidence) based on two small, clinically
heterogeneous trials, and reduced time to
clinical cure.
 Further support is needed to recommend the
use of corticosteroids in clinical practice across
distinct severity subgroups and in association
with different antibiotics.
Tagarro A, Otheo E, Baquero-Artigao F, Navarro ML, VelascoR, Ruiz M, et al. Dexamethasone for parapneumonic
pleuraleffusion: a randomized, double-blind, clinical trial. J Pediatr.2017;185:117---23.
Stern A, Skalsky K, Avni T, Carrara E, Leicovici L, Paul M.Corticosteroids for pneumonia. Cochrane Database Syst
Rev.2017;12:CD007720.

32. Influenza antiviral therapy
Influenza antiviral therapy should be administered as
soon as possible to children with moderate to severe
CAP consistent with influenza virus infection during
widespread local circulation of influenza viruses,
particularly for those with clinically worsening
disease documented at the time of an outpatient visit.
Early antiviral treatment has been shown to provide
maximal benefit, so the treatment should not be
delayed until confirmation of positive influenza test
results.
Negative results of influenza diagnostic tests,
especially rapid antigen tests, do not conclusively
exclude influenza disease.

33. Empiric antimicrobial strategies for pediatric
community-acquired pneumonia:
Atypical
Pneumonia
Bacterial
Pneumoni
a
PopulationOutpatient
AzithromycinAmoxicillinPreferredPreschool
(<5 y)
Clarithromycin or
erythromycin
Amoxiciilin/cla
vulanate
Alternative(s)
AzithromycinAmoxicillinPreferred5–17 y
Clarithromycin or
Erythromycin
Doxycycline if >7
y
Amoxiciilin/cla
vulanate
Alternative(s)

34. Empiric antimicrobial strategies for pediatric
community-acquired pneumonia:
Atypical PneumoniaBacterial PneumoniaPopulationInpatient
N/AAmpicillin +
gentamicin
PreferredNeonates
N/AAmpicillin +
cefotaxime
Alternative(s)
N/ACefotaximePreferred1–3 mo
N/AAzithromycin if
suspect C
trachomatis or B
pertussis
Alternative(s)
Azithromycin
Clarithromycin or
erythromycin
Doxycycline if >7 y
Levofloxacin for those
who have reached
skeletal maturity
Ampicillin or penicillin
G
Ceftriaxone or
cefotaxime
Antistaphylococcal
coverage for
suspected S aureus,
including clindamycin
or vancomycin in
methicillin-resistant S
aureus–prevalent
Preferred
Alternative(s)
3 mo–17 y, fully
immunized, local
epidemiology
indicates low
prevalence of
penicillin
nonsusceptible
Streptococcus
pneumoniae

35. Empiric antimicrobial strategies for pediatric
community-acquired pneumonia:
Atypical
Pneumonia
Bacterial
Pneumonia
Populatio
n
Inpatient
Azithromycin
Clarithromycin or
erythromycin
Doxycycline if >7 y
Levofloxacin for
those
who have reached
skeletal maturity
Ceftriaxone or
Cefotaxime
Levofloxacin
Antistaphylococcal
coverage for
suspected S aureus,
including
clindamycin
or vancomycin in
methicillin-resistant
S
aureus–prevalent
regions
Preferred
Alternative(s)
3 mo–17 y, not
fully
immunized, or
local
epidemiology
indicates
moderate
to high
prevalence
of penicillin
nonsusceptible
Streptococcus
pneumoniaeAdapted from Bradley JS, Byington CL, Shah SS, et al. Empiric therapy for pediatric communityacquired pneumonia
(CAP). The management of community-acquired pneumonia in infants and children older than 3 months of age:
clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of
America. Clin Infect Dis 2011;53:e34. Table 7; with
permission.

36. Influenza Antiviral Therapy

37. Complicated pneumonia:
•Pneumonia is sometimes associated with a
complication such as parapneumonic effusion,
empyema, lung abscess, or necrotizing pneumonia.
•Empyema is suspected if fever>7 days, absence of
response to antibiotic >48 h, severe CAP, cyanosis,
pleuritic chest pain, signs of pleural effusion.
•Confirmed by chest x ray, and chet ultrasound.
•If the Gram stain or the culture result from the pleural
fluid is positive or the WBC count is higher than 1000
cells/mL, by definition, the patient has an empyema,
which may require drainage for complete resolution.
•In case of empyema in addition to drainage, course
of antibiotics may extended for further 1-4 weeks

39. List of complications of CAP:
SystemicMetastaticPulmonary
Systemic
inflammatory
response
syndrome or
sepsis
Hemolytic
uremic syndrome
Meningitis
Central nervous
system abscess
Pericarditis
Endocarditis
Osteomyelitis
Septic arthritis
Pleural effusion
or empyema
Pneumothorax
Lung abscess
Bronchopleural
fistula
Necrotizing
pneumonia
Acute
respiratory
failure

40. COVID 19
Children of all ages can get COVID-19, although
they appear to be affected less frequently than
adults.
COVID-19 in children is usually mild, although
severe cases have been reported, including cases
with hypotension and multisystem involvement.
Children with COVID-19 and severe or critical lower
respiratory tract disease generally require hospital
admission.

41. ASSESSMENT OF SEVERITY
•Mild- Symptomatic patients meeting the case definition
for COVID-19 without evidence of viral pneumonia or
hypoxia.
• Moderate disease – Child with clinical signs of non-
severe pneumonia (cough or difficulty breathing + fast
breathing and/or chest indrawing), No new or increased
supplemental oxygen requirement
•Severe disease – New requirement for supplemental
oxygen or increased requirement from baseline without
new or increased need for ventilatory support
(noninvasive or invasive) , Central cyanosis or SpO2 < 90%;
severe respiratory distress (e.g. fast breathing, grunting, very severe
chest indrawing); general danger sign: inability to breastfeed or
drink, lethargy or unconsciousness, or convulsions.
•Critical disease – New or increased need for noninvasive
or invasive mechanical ventilation, sepsis, multiorgan

42. Suggested priorities for SARS-CoV-2 (COVID-19) testing
Infectious Diseases Society of America. COVID-19 Prioritization of Diagnostic Testing. Available at:
http://www.idsociety.org/globalassets/idsa/public-health/covid-19-prioritization-of-dx-testing.pdf (Accessed on March 26, 2020).

43. Supportive care (eg, respiratory support, fluid and electrolyte
support, monitoring for cytokine release syndrome) is the
mainstay of therapy for children with severe or critical COVID-
19.
antiviral therapy should be considered on a case-by-case
basis and preferably occur in the context of a clinical trial, if a
clinical trial is available
Decisions regarding antiviral therapy should be individualized
according to disease severity, clinical trajectory, and underlying
conditions that may increase the risk for progression.
When a decision is made to use antiviral therapy in a child
who cannot be enrolled in a clinical trial, we suggest remdesivir
rather than other antiviral agents (Grade 2C). Randomized trials
in adults suggest a potential benefit.
We recommend not using hydroxychloroquine or chloroquine
except in the context of a clinical trial (Grade 1B). Its
emergency use authorization has been revoked, its clinical
benefit is unproven, and it has potential toxicity.

44. For hospitalized children who cannot be enrolled
in a clinical trial, the use of adjunctive therapies for
immune-mediated complications (eg,
glucocorticoids, interleukin-6 inhibitors,
convalescent plasma) of COVID-19 should be on a
case-by-case basis.
Children with documented or suspected COVID-19
and mild symptoms (eg, fever, cough, pharyngitis,
other respiratory symptoms) generally should be
managed at home unless they have a chronic
condition that increases their risk of severe
disease. Management is focused on prevention of
transmission to others (ie, isolation), monitoring for
clinical deterioration (eg, difficulty breathing,
cyanosis, symptoms of shock), and supportive
care.

45. Supportive care:
Provision of respiratory support, including supplemental
oxygen and ventilatory support
Provision of fluid and electrolyte support.
Provision of empiric antibiotics as indicated for community-
acquired or health care-associated pneumonia; continuation
of empiric antibiotics should be determined by cultures and
other microbial tests and clinical condition. Bacterial
coinfections appear to be infrequent
Monitoring for cytokine release syndrome by monitoring
blood pressure for hypotension, oxygen saturation for
worsening hypoxemia, and biomarkers.
Obtain baseline C-reactive protein (CRP), D-dimer, ferritin,
lactate dehydrogenase (LDH), and interleukin-6 (IL-6).
Monitor CRP, D-dimer, ferritin, and LDH two or three times per
week or if there is concern for worsening disease. IL-6 is
performed offsite; repeat it twice per week if it is elevated at
baseline or if there is concern for worsening disease.

46. Remdesivir
•Although data regarding the benefits of remdesivir
for children with COVID-19 are lacking, it is preferred
to other antiviral agents because data from
randomized trials and case series in adult patients
suggest that it is moderately beneficial (particularly in
patients who are not critically ill) and appears to be
well tolerated .When the supply of remdesivir is
limited, it should be prioritized for patients with
severe rather than critical disease (as defined above);
the benefits for those with critical disease are
uncertain .

47. •Remdesivir is dosed according to weight as
follows:
 ≥3.5 to <40 kg: 5 mg/kg intravenous (IV) loading
dose on day 1, followed by 2.5 mg/kg IV every 24
hours
 ≥40 kg: 200 mg IV loading dose on day 1,
followed by 100 mg IV every 24 hours
The usual duration of therapy is up to 5 days for
children with severe disease; for children with
critical disease who are not improving after 5 days,
the duration may be extended to up to 10 days

48. Glucocorticoids:
 For select children with severe or critical COVID-19 who
cannot participate in a clinical trial (ie, those who require
mechanical ventilation or those who require supplemental
oxygen and have risk factors for disease progression), low-
dose glucocorticoids may be warrantedthe duration of
therapy is up to 10 days or until discharge, whichever is
shorter. Low-dose glucocorticoid regimens include one of the
following
 Dexamethasone 0.15 mg/kg orally, intravenously (IV), or
nasogastrically (NG) once daily (maximum dose 6 mg)
 Prednisolone 1 mg/kg orally or NG once daily (maximum dose
40 mg)
 Methylprednisolone 0.8 mg/kg IV once daily (maximum dose
32 mg)
 Hydrocortisone
•For neonates (<1 month of age): 0.5 mg/kg IV every 12 hours
for 7 days followed by 0.5 mg/kg IV once daily for 3 days
•For children ≥1 month: 1.3 mg/kg IV every 8 hours (maximum

49. Prevention of CAP:
Immunization against Hib, pneumococcus, measles and
whooping cough (pertussis) is the most effective way to
prevent pneumonia.
Adequate nutrition is key to improving children's natural
defences, starting with exclusive breastfeeding for the
first 6 months of life. In addition to being effective in
preventing pneumonia, it also helps to reduce the length
of the illness if a child does become ill.
Addressing environmental factors such as indoor air
pollution (by providing affordable clean indoor stoves, for
example) and encouraging good hygiene in crowded
homes also reduces the number of children who fall ill
with pneumonia.
In children infected with HIV, the antibiotic cotrimoxazole
is given daily to decrease the risk of contracting

50. Prevention of CAP:
 Preventing pneumonia in children is an essential
component of a strategy to reduce child mortality.
Immunization against Hib, pneumococcus, measles and
whooping cough (pertussis) is the most effective way to
prevent pneumonia.
 Adequate nutrition is key to improving children's natural
defences, starting with exclusive breastfeeding for the first
6 months of life. In addition to being effective in preventing
pneumonia, it also helps to reduce the length of the illness
if a child does become ill.
 Addressing environmental factors such as indoor air
pollution (by providing affordable clean indoor stoves, for
example) and encouraging good hygiene in crowded
homes also reduces the number of children who fall ill with
pneumonia.
 In children infected with HIV, the antibiotic cotrimoxazole is