This document provides information on evaluating and diagnosing recurrent or chronic pneumonia in children. It discusses obtaining a thorough medical history including details of pneumonia episodes, risk factors, and associated symptoms. A complete physical exam focuses on the respiratory system, lymph nodes, growth, and other organ systems. Diagnostic tests include complete blood count, chest x-ray, pulmonary function tests, bronchoscopy, sweat test, and genetic testing to identify potential causes like cystic fibrosis, immunodeficiencies, structural lung abnormalities, or gastroesophageal reflux. The goal is to determine if episodes are due to infectious, anatomical, immune, or aspiration-related factors.

1. Dr seema rai
Assistant professor
Guru Gobind singh medical college Faridkot

2.  Pneumonia is an acute
infection of the pulmonary parenchyma

4.  Two episodes of pneumonia within the same
year or 3 or more episodes over any period of
time but with complete resolution of clinical
and radiological findings between acute
episodes.

5.  When there is clinical and radiological
evidence of pneumonia for more than a
month despite a course of adequate and
appropriate antibiotic therapy for 10 days.

6.  Congenital Malformations
a. Airways Cleft Palate, Pierre Robin syndrome
Tracheoesophageal fistulae,Tracheomalacia
b. Lungs Pulmonary hypoplasia, Pulmonary
sequestration, Congenital adenomatoid
malformation of the lung,Bronchogenic cyst
c. Cardiovascular Congenital heart disease,
especially L-R shunts, Vascular ring

7.  Aspirations Gastro-esophageal reflux
Foreign body, Anomalies of the upper airways
Swallowing abnormalities
 Defects in the clearance of airway secretions
Cystic fibrosis, Abnormalities of the ciliary
structure function, Abnormal clearance
secondary to infections, repair of congenital
defects, Airway compression
(intrinsic/extrinsic) e.g., mediastinal
tubercular lymphadenopathy

8.  Disorders of local/systemic immunity
 Primary immunodeficiency
 Acquired immunodeficiency
- HIV infection
- Immunosuppressive therapy
- Malnutrition

9.  Intraluminal obstruction
Foreign body
Bronchial tumor,
Adenoma, lipoma, papilloma
 Extraluminal obstruction
1 INFECTIOUS LAP(lymphadenopathy)
Tuberculosis, histoplasmosis.
2 Non-infectious lymphadenopathy
Tumors, sarcoidosis.
Vascular rings and slings
 Structural abnormalities
Bronchial stenosis or atresia,
Bronchomalacia, localized bronchiectasis,
pulmonary sequestration or congnital cystic adenoid
malformation, bronchogenic cyst

11.  Recurrent microaspiration
 Asthma
 Immunodeficiency
 Mucociliary dysfunction
 Structural Abnormality
 Congenital heart disease
 Bronchopulmonary dysplasia

13.  Age of onset: Onset of symptoms soon after
birth or in early infancy indicates hereditary/
congenital disorder. History of possible foreign
body aspiration followed by recurrent
episodes of pneumonia tends to occur in the
1-3 year age.

14.  Details of the episodes: Details of first
episode and subsequent episodes should be
obtained.
 Onset, nature and duration of cough,
 History of fever, and documentation of signs of
pneumonia and radiological evaluation
 Type and duration of antimicrobial therapy
(adequate/appropriate), response to
therapy and need for hospitalization also should
be recorded. It is important to differentiate these
episodes from recurrent wheezing episodes

15.  Ask about the timing of the symptoms in
relation to feeding and the change in
position.
 vomiting, irritability, and nocturnal symptoms
of coughing and wheezing.
 Sleep disturbances may be seen in gastro-
esophageal reflux and obstructive lesions,
especially of upper respiratory tract.

16.  Past history/associated complaints:
 History suggestive of systemic
immunodeficiency.
 Past history of tuberculosis and history of foreign
body inhalation is important.
 Symptoms of malabsorption, recurrent otitis
media and sinusitis and failure to thrive suggest
cystic fibrosis.
 Presence or absence of symptoms when the child
is well eg. intercurrent wheeze may suggest
poorly controlled asthma.

17.  Patient with congenital heart disease with
failure exhibit easy fatiguability, sweating
over the forehead on feeding.
 Swallowing dysfunction can present as
recurrent regurgitation of feeds and child
may develop cyanosis during these episodes

18.  Perinatal history:
 Prematurity, history of prolonged exposure to
oxygen and blood transfusions should be
looked for.
 History of ileus or delayed passage of
meconium should arouse suspicion of cystic
fibrosis.
 History of maternal infections such as HIV,
Chlamydia or other viral illnesses should be
sought

19.  history of allergic disorders, asthma, cystic
fibrosis, and congenital anomalies.
Occurrence of early or unexplained deaths or
recurrent infections in other family members
may suggest immunologic disorder.
 High risk behavior or history of blood
transfusion in parents is essential, to rule out
exposure to maternal HIV infection, in a child
where immunodeficiency is suspected.

20.  Crowded and polluted living environment
predispose to recurrent respiratory
infections.
 Daycare attendance, exposure to inhaled
pollutants, irritants and passive tobacco
smoking may provide important clues to the
aetiology, as well as the presence of siblings
with similar problems.

21.  Many medications also may cause pulmonary
problems (ACE inhibitors cough, aspirin-
induced wheeze, leukotriene antagonist
associated infiltrates) and hence, a
comprehensive drug history should be also
be taken
 Vaccination history as pertussis can present
with prolonged cough

22.  Obstructive upper respiratory tract lesions
present with sleep disturbances or even sleep
apnoea.
 Gastro-esophageal reflux also can have
similar presentation.

23.  If two or more of the following warning signs are present,
there is possibility of an underlying primary
immunodeficiency.
1. Four or more new ear infections within 1 year.
2. Two or more serious sinus infection within 1 year.
3. Two or more months on antibiotics with little effect.
4. Two or more pneumonia within 1 year.
5. Failure of an infant to gain weight or grow normally.
6. Recurrent, deep skin or organ abscesses.
7. Persistent thrush in mouth or fungal infection on skin.
8. Need for intravenous antibiotics to clear infection.
9. Two or more deep seated infection including septicemia.
10. A family history of primary immunodeficiency.

24.  Head and neck
 Signs of chronic otitis media or sinusitis. Chronic
otitis media is associated with ciliary dysmotility
syndromes or in boys with Wiscott-Aldrich
syndrome.
 Conjunctivitis, allergic shiners, Dennie morgan’s
lines and transverse creases over nose may
accompany dermatitits in atopic patients, who
have an increased frequency of asthma and
associated pneumonia.
 Presence of purulent conjunctivitis may suggest
a B cell immune deficiency.

25.  Phylectenular conjunctivitis may be seen in
several conditions having hyperactive immune
response including tuberculosis.
 Look for presence/ absence of
tonsillar/adenoidal tissue. Tonsils may be absent
in hypo/agammaglobulinemia.
2. Periodontal disease: indicates phagocytic
cell dysfunction, while oral candidiasis may
suggest T-cell abnormalities. Abnormal dentition
has been reported as a finding in hyper IgE
Syndrome.

26.  GROWTH AND DEVELOPMENT
 Normal growth is a reassuring sign, though
children may grow normally during the early
stages of serious systemic diseases.
 Malnutrition impose delay in clearing
infection

27.  Clubbing may be present in chronic disorders
like bronchiectasis, cystic fibrosis, and
bronchiolitis obliterans.
 Lymphadenopathy: Generalized
lymphadenopathy may be present
intuberculosis, HIV infection and histiocytosis

28.  Morphologic features: May point towards
specific disorders e.g., presence of “fish
mouth” with hypertelorism in DiGeorge’s
syndrome, telangiectasia of eyes/ears in
ataxia telangiectasia.
 Skin: Examined for evidence of infective foci
rash or for features of atopic dermatitis. Fine
and sparse hair is seen in severe combined
immunedeficiency. Multiple recurrent
pustules indicate immunodeficiency

29.  Observation during feeding: Nasopharyngeal
regurgitation, difficulty in sucking/swallowing
and associated coughing/choking should be
looked for. The palate, tongue and oro-
pharynx should be inspected for any
anomalies.

30.  Respiratory system: A meticulous
examination of respiratroy sytem including
assessment of :
 respiratory rate, evidence of distress, thoracic
deformities, wheezing, stridor,
 The dimensions of the chest
 Auscultation of the chest to localize the
infection should be done.

31.  1. A complete blood count: Anemia may
suggest chronic disease. Thrombocytopenia
can be seen in Wiskott-Aldrich syndrome.
 2. Xray chest: It helps to make the distinction
between recurrent and persistent pneumonia
and whether consolidation is localized to a
single lobe or multiple lobes.

32.  Mantoux test: Should be done on any child
with focal changes in chest x-ray and
consideration should be given to tests for
fungal infection in endemic areas.

33.  Computed tomography: Useful in diagnosing
structural anomalies and also helps in defining the
extent of involvement of the lung, especially in
diseases like bronchiectasis, cystic fibrosis and
interstitial lung disease.
 CT is the preferred method for investigating
perilaryngeal or mediastinal compressive masses
affecting the airway and has largely replaced
conventional angiography for investigation of
suspected vascular rings.
 High resolution CT(HRCT) needs to be done
when interstial lung disease is suspected.

34.  Pulmonary function tests (PFT), commonly
performed using spirometer, usually feasible
only in children >5 years age. It helps to
evaluate the airway hyper-reactivity.

35.  Bronchoscopy is indicated if abnormality of
bronchial anatomy or foreign body aspiration is
suspected. In addition, bronchoalveolar lavage
(BAL) can be performed to identify the etiologic
agent. Isolation of mucoid Pseudomonas
aeruginosa is a strong pointer to the diagnosis
of cystic fibrosis. Demonstration of
Pneumocystis jiroveci suggests underlying
immunodeficiency.

36.  Barium study: Barium swallow or cine
esophagogram may help in identifying the
disorders of swallowing. Radionuclide scans,
esophageal pH monitoring may be done to
confirm GER.
Presence of lipid laden macrophages in
bronchial washings has been
found to be of value in confirming recurrent or
chronic aspiration.

37.  Sweat chloride estimation should be
performed in all children with recurrent
pneumonia even in patients without evidence
of malabsorption or growth failure, because
20% of children with CF may have adequate
pancreatic function.

38.  Electron microscopy: Morphologic studies
are performed on nasal mucosal
scrapping/biopsy when ciliary abnormalities
are suspected in patients with bronchiectasis
or chronic sinobronchial disease.

39. i) Complete and differential blood counts
ii) Quantitative serum immunoglobulin G/M/A
including IgE.
iii) HIV screen by ELISA.
iv) T and B cell subset quantification.
If phagocytic defects are suspected,
screening tests include neutrophil count and
nitro blue tetrazolium test.

40.  Therapy for specific illness associated with
recurrent pulmonary infections
including asthma, chronic aspiration, GERD
and immunodeficiency should follow the
standard guidelines.
 Nutritional support chest physiotherapy
allergens are all important. Those with
congenital anatomic abnormalities or
acquired focal disease involving a single lobe
or segment may benefit from surgical
resection of that part.