Pneumonia is a prevalent and serious illness in children characterized by lung inflammation and consolidation, typically caused by infections from bacteria or viruses. Diagnosis relies on clinical assessment of symptoms like tachypnea, and management varies based on severity, with severe cases warranting aggressive antibiotic treatment, especially in children with additional health challenges like HIV. Prevention strategies include vaccinations, breastfeeding, and addressing malnutrition to reduce the risks associated with pneumonia.

1. Pneumonia in children
Dr Joyce Mwatonoka
MD, Resident Mmed PCH
February 12, 2025

2. Outline
• What is pneumonia?
• What is the Pathophysiology?
• Who gets what?
• How do you treat?
• To Admit or Not to Admit
• Management and follow up

3. Anatomy and physiology
• The respiratory tract extends from the nose to the
alveoli and includes not only the air-conducting
passages also but the blood supply
• The primary purpose of the respiratory system is
gas exchange.
• The respiratory system is divided into two parts:
the upper respiratory tract and the lower respiratory
tract

4. • The nose
• pharynx
• adenoids
• tonsils
• epiglottis
• larynx
The upper respiratory tract includes

5. The lower respiratory tract
consists of
• The trachea
• Bronchi
• Bronchioles
• Alveolar ducts
• Alveoli

7. Background
Definition:
Pneumonia can be generally defined as inflammation of
the lung parenchyma, in which consolidation of the affected
part and a filling of the alveolar air spaces with exudate,
inflammatory cells, and fibrin is characteristic.
Infection by bacteria or viruses is the most common
cause, although inhalation of chemicals, trauma to the
chest wall, or infection by other infectious agents such as
rickettsiae, fungi, and yeasts may occur.

8. Epidemiology
• The incidence of pneumonia is more than 10-fold higher,
and the number of childhood-related deaths from
pneumonia ≈2,000 fold higher, in developing than in
developed countries
• Annual incidence in Tanzania about 60-100 per 1000
children
• Worldwide, more than 2 million children die of
pneumonia annually (mostly in developing countries).
• Clinical and radiographic features do not reliably
distinguish between viral and bacterial causes

9. Classification of pneumonia
1. Etiological classification
• Infectious - commonest (bacterial, viral, fungal, parasitic)
• Non-infectious (aspiration, hypersensitivity, drug induced)
2. Anatomical classification
• Lobar pneumonia (involves one lobe, S pneumoniae)
• Bronchopneumonia (patchy consolidation)
• Interstitial pneumonia (between alveoli, bilateral, usually viral)
3. According to severity (clinical classification)
• No pneumonia
• Pneumonia
• Severe pneumonia
©
2007
Baylor
College
of
Medicine

10. Basic Pathophysiology
• Most cases of pneumonia are caused by the
aspiration of infective particles into the lower
respiratory tract
• Organisms that colonize a child’s upper airway
can cause pneumonia
• Pneumonia can be caused by person to person
transmission via airborne droplets

11. Pathophysiology
 Pulmonary injuries are caused directly and/or indirectly by
invading microorganisms or foreign material and
inappropriate responses by the host defense system that may
damage healthy host tissues as badly or worse than the
invading agent
 Direct injury by the invading agent usually results from
synthesis and secretion of microbial enzymes, proteins, toxic
lipids, and toxins that disrupt host cell membranes, metabolic
machinery, and the extracellular matrix that usually inhibits
microbial migration

12. Cont.
 Bacterial infections
Causes consolidation, leads to decreased air entry and
dullness to percussion; inflammation in the small airways
leads to crackles
 Viral infections
are characterized by the accumulation of mononuclear cells
in the submucosa and perivascular space, resulting in partial
obstruction of the airway.
Patients with these infections present with wheezing and
crackles

13. Etiology
• The common pathogens are a function of the
patient’s age
• The specific agent causing pneumonia can be
determined in 1/3 to 2/3 of cases when cultures,
antigen detection and serologic techniques are
available.
• It is helpful to be aware of local outbreaks as
clustering of cases is common.

14. Community acquired pneumonia -
Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
Newborn Group B Streptococci
Gram-negative bacilli
Listeria monocytogenes
Herpes Simplex
Cytomegalovirus
Rubella
1-3 months Chlamydia trachomatis
Respiratory Syncytial virus
Other respiratory viruses
3-12 months Respiratory Syncytial virus
Other respiratory viruses
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae
Age Group Common Pathogens (in Order of Frequency)
Newborn Group B Streptococci, E Coli
Gram-negative bacilli
Listeria monocytogenes
Herpes Simplex
Cytomegalovirus
Rubella
1-3 months Chlamydia trachomatis (if afebrile)
Respiratory Syncytial virus
Other respiratory viruses
3-12 months Respiratory Syncytial virus
Other respiratory viruses
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

15. Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
2-5 years Respiratory Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae
5-18 years Mycoplasma pneumoniae
Streptococcus pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Influenza viruses A and B
Adenoviruses
Other respiratory viruses
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

16. Pneumonia History

17. Pneumonia History
Fundamentals
• Age
• Presence of cough, difficulty breathing, shortness of
breath, chest pain
• Fever
• Recent upper respiratory tract infections
• Associated symptoms (e.g.. headache, lethargy,
pharyngitis, nausea, vomiting, diarrhea, abdominal
pain, rash)
• Duration of symptoms
• Past Medical History
• Birth History
• Allergies
• Family History

18. Pneumonia History
• Immunizations status
• TB exposure
• Maternal Chlamydia, Group B Strep status
during pregnancy
• Choking episodes

19. Diagnosis

20. Recognition of Signs of Pneumonia
• Tachypnea is the most sensitive and specific sign
of pneumonia
• Tachypnea had a Sensitivity of 61% and 79% and
Specificity of 79% and 65% for pneumonia in
malnourished and well-nourished Gambian
children respectively

21. WHO Definition of Tachypnea
Age Respiratory
Rate
(breaths/min)
Indication of
severe
infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5
years
> 40 >50
Greater than 5
years
> 20

22. Other signs of pneumonia -
Indrawing
out---breathing---in
Lower chest wall indrawing: with inspiration,
the lower chest wall moves in
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

23. Other signs of pneumonia -
Nasal Flare
Nasal flaring: with inspiration, the side of the
nostrils flares outwards
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

24. WHO pneumonia classification
Sign or symptom Classification Treatment
•Cough or difficult in breathing
with:
Oxygen saturation<90% or
Central cyanosis
Severe respiratory distress
( e.g. grunting, very severe
chest wall in drawing)
Signs of pneumonia with a
general danger sign (inability to
breastfeed or drink, Lethargy or
reduced level of consciousness,
convulsions
Severe
pneumonia
•Admit to hospital
•Give Oxygen if saturation <90%
•Manage the airway as appropriate
•Give recommended antibiotic
•Treat high fever if present
•Fast breathing
•<2 months RR ≥60
•2-11 months RR ≥50
•1-5 years RR ≥40
•Definite crackles on
auscultation
•Chest indrawing
Pneumonia •Home care
•Give appropriate antibiotic for 5 days
•Advise the mother when to return immediately if the
symptoms of severe pneumonia
•Follow up in 3 days
•No Signs of pneumonia or
severe pneumonia
No pneumonia,
cough or cold
•Home care
•Soothe the throat and relieve cough with a safe remedy
•Advise the mother when to return
•Follow up in 5 days if not improving
•If coughing >30 days, evaluate for chronic cough

25. Diagnosis in a Health Care
Setting
• Vital signs that should routinely be taken in an
Emergency Care setting include:
• Respiratory Rate
• Heart Rate
• Temperature
• Oxygen saturation
• Any child with an increased respiratory rate
should be immediately identified as having
possible pneumonia.

26. Vital Signs
• Both heart rate and respiratory rate are
influenced by the presence of fever
• Heart rate increases by approximately 10 beats
per minute for each 1 degree Celsius
• Respiratory Rate has been estimated to vary by
0.5-2 breath per minute to 5-11 breaths per
minute for each 1 degree Celsius

27. Differential Diagnoses

28. Respiratory Syncytial Virus
(RSV)
• RSV is the most common cause of LRTIs in
children less than 1 year
• Infants and young children typically present with
pneumonia or bronchiolitis
• Older children may have upper respiratory tract
infection symptoms
• RSV is associated with apnea in infants.
• Wheezing is common

29. Tuberculosis
Common symptoms of tuberculosis include:
• Chronic cough that has been present for more
than 2 weeks and is not improving
• Fever greater than 38°C for at least two weeks,
not attributable to other common causes
• Weight loss or failure to thrive

30. Tuberculosis
Physical exam findings of children with
pulmonary tuberculosis are similar to those of a
lower respiratory tract infection
In children less than age five tuberculosis can
progress rapidly from latent infection to active
disease and serve as a sentinel case in the
community
Consider the diagnosis of tuberculosis,
especially in those children who fail to respond
appropriately to routine treatment for
pneumonia

31. Pneumonia - investigations
 Pulse oximetry
 Chest x-ray, especially in:
– Severe pneumonia
– Severe pneumonia not responding to treatment or with
complications
– HIV infection
 To consider:
– Full blood picture
• Increased WBC with neutrophilia suggests bacterial process
– Blood cultures
– Induced sputums or gastric aspirates for AFB smear and
culture if not responding to treatment

32. MANAGEMENT

33. Indications for Admission
Age Group Indications for Admission to Hospital
Infants Oxygen Saturation <= 92%, cyanosis
RR > 70 breaths /min
Difficulty in breathing
Intermittent apnea, grunting
Not feeding
Family not able to provide appropriate observation or supervision
Older Children Oxygen Saturation <= 92%, cyanosis
RR > 50 breaths /min
Difficulty in breathing
Grunting
Signs of Dehydration
Family not able to provide appropriate observation or supervision
From: British Thoracic Society (BTS) of Standards of Care Committee.
BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002;57: i1-i24.

34. In-Patient Management
• Consideration must be given to the provision of
adequate hydration, oxygenation, nutrition,
antipyretics and pain control.
• Monitoring should include:
• Respiratory rate
• Work of breathing
• Temperature
• Heart rate
• Oxygen saturation (if available)
• Findings on auscultation.

35. Management of Respiratory Distress and
Respiratory Failure: ABC’s and Intubation

36. Airway
• Support the airway (position of comfort
for the child) or open the airway (chin lift
or jaw thrust)
• Clear the airway (suction nose and mouth,
remove any foreign body)
• Insert an oropharyngeal or
nasopharyngeal airway as indicated

37. Breathing
• Assist ventilation (e.g., bag-mask
ventilation) as needed
• Provide oxygen
• Continuously monitor oxygen saturation
• Consider use of CPAP
• Prepare for endotracheal intubation as
needed
• Administer medications as needed

38. Circulation
• Monitor heart rate and rhythm
• Establish vascular access as indicated (for
fluid therapy and medications)

39. Indications for Intubation
• Inadequate oxygenation or ventilation
• Inability to maintain and/or protect the airway
• Potential for clinical deterioration
• Prolonged patient transport or diagnostic studies

40. Chest X-ray
Consider if available and:
• Infection is severe
• Diagnosis is otherwise inconclusive
• To exclude other causes of shortness of breath
(e.g.. foreign body, heart failure)
• To look for complications of pneumonia
unresponsive to treatment (e.g.. empyema,
pleural effusion)
• To exclude pneumonia in an infant less than
three months with fever

41. Normal Chest x ray

42. Right Upper Lobe Pneumonia

43. Right Middle Lobe Pneumonia

44. Laboratory Investigations
• Routine blood work is not required in children
with uncomplicated lower respiratory tract
infections who will be treated as outpatients
• Tests to consider if available:
• CBC, particularly WBC
• Electrolytes
• Consider blood cultures, sputum cultures
• HIV and TB testing as appropriate

45. Complications

46. Complications of Pneumonia
Pleural effusion – fluid in the pleural space as
the result of inflammation.
Empyema – bacterial infection in the pleural
space.
Parapneumonic effusions develop in
approximately 40% of patients admitted to
hospital with bacterial pneumonia
If an effusion is present and the patient is
persistently febrile, the pleural space should be
drained

47. Complications of Pneumonia
• Pneumatocele – thin walled, air filled cysts of the lung, often
occurs with empyema.
• Pneumatoceles often resolve spontaneously, but may lead to
pneumothorax.

48. Supportive Treatment – IMCI
Guidelines
• Oxygen therapy
• If fever (=>39o
C) causing distress, give paracetamol
• If wheeze is present, give a rapid-acting broncho-dilator
• Gentle suction any thick secretions in the throat, which
the child cannot clear.

49. Supportive Treatment – IMCI
Guidelines
• Ensure that the child receives daily maintenance fluids for the child's age -
avoid overhydration.
• Encourage breastfeeding and oral fluids.
• If the child cannot drink, insert a NG tube and give maintenance fluids in
frequent small amounts.
• If the child is taking fluids adequately by mouth, do not use a NG tube as it
increases the risk of aspiration pneumonia.
• If oxygen is given by nasopharyngeal catheter at the same time as NG
fluids, pass both tubes through the same nostril.
• Encourage the child to eat as soon as food can be taken.

50. Severe pneumonia - antibiotics
Give intravenous ampicillin( or benzyl penicillin) and
gentamycin
 Ampicillin (50 mg/kg every 6 hours) or benzyl penicillin 50
000 U/kg IM or IV every 6 hours for at least 5 days
 gentamicin (7.5 mg/kg daily) for 5 days
• Can change ampicillin to PO amoxicillin after 5 days if
improving
Alternatively
Use Ceftriaxone (80 mg/kg IM or IV once daily) in cases of
failure of first line treatment
If no improvement within 48 hours, consider complications and
change to cloxacillin (50 mg/kg every 6 hours) + gentamicin

51. Pneumonia - management
Amoxicillin (40 mg/kg BD for 3 days)
Amoxillin 25mg/kg tds for 5 days
Amoxicillin preferred if pneumonia develops in an HIV-
positive child using CTX for PCP prophylaxis

52. ‘Atypical’ pathogens
Mycoplasma pneumoniae and Chlamydia
pneumoniae
Generally more common in older children >5
years
Treat with macrolides
• Erythromycin 12.5 mg/kg QDS
(30-50mg/kg/day divided q6-8hr)
OR
• Azithromycin 10 mg/kg OD day 1, 5 mg/kg OD
days 2-5

53. Aspiration pneumonia – predisposing
conditions
Altered consciousness
Dysphagia
Neurologic disorder
Mechanical disruption of usual defenses
• NG tube
Other
• Protracted vomiting
• Gastric outlet obstruction
• Large volume NG tube feedings
• Recumbent positioning

54. Aspiration pneumonia treatment
Coverage of oral anaerobes important
Treat with
• (cephalosporin) AND metronidazole 7.5 mg/kg
IV/PO TDS
• Alternatives if available
• Clindamycin 10 mg/kg IV/PO TDS
• Amoxicillin/ clavulanate (Augmentin) 10
mg/kg PO TDS

55. Prevention Strategies
• Vaccination against measles, Streptococcus pneumoniae, and
Haemophilus influenzae type b
• Breasfeeding
• Zinc supplementation
• Prevention of HIV in Children
• Co-trimoxazole prophylaxis for HIV-infected children

56. RECUP QUIZ
©
2007
Baylor
College
of
Medicine

57. Quiz question 1
What illness is the number one killer of
children?
• A. Diarrheal Disease
• B. HIV/AIDS
• C. Malaria
• D. Pneumonia

58. Quiz Question 2
What is the most sensitive and specific sign of
pneumonia in children?
• A. Difficulty breathing
• B. Fever
• C. Tachypnea
• D. Tachycardia

59. Quiz Question 3
If available, a chest x-ray should be done for
children with possible pneumonia:
• A. When a diagnosis is made
• B. When a history of tachypnea is present
• C. When antibiotics are started
• D. When complications are suspected

60. Quiz Question 4
Which of the following immunization
effectively reduce pneumonia mortality in
children?
• A. Haemophilus influenzae b Vaccine
• B. Pneumococcal Conjugate Vaccine
• C. Measles Vaccine
• D. All of the above

62. Summary
 Pneumonia is a common, deadly condition in childhood
 Pneumonia is a clinical diagnosis
 Antibiotics and other therapies are given according to clinical assessment of
severity
– Be aggressive with antibiotics when necessary (hypoxemia, severe tachypnea,
HIV, malnutrition, etc.)
– Be more judicious when children are less sick and without significant
comorbidities
 HIV, TB, and malnutrition complicate the management of pneumonia
significantly in our setting
 Children with HIV need to be managed more aggressively with special attention
to PCP in infants <1 year
 In HIV-negative children with severe pneumonia, outpatient therapy with high-
dose amoxicillin may be as effective as hospitalization and IV antibiotics

63. References
• Nelson Textbook of Pediatrics, 17th edition.
• WHO pocket book of Hospital care for children