Pneumonia is a common lung infection in children characterized by fever, respiratory symptoms, and evidence of lung involvement on physical exam or chest imaging. It can be caused by bacteria, viruses, or other pathogens. Clinical features include tachypnea, cough, hypoxemia, and abnormal breath sounds. Chest x-ray is used to confirm the diagnosis. Treatment involves antibiotics, oxygen, and hospitalization for severe cases. Prevention strategies include vaccination, hand hygiene, and reducing hospital-acquired infections.

1. Pneumonia in Children
Dr Anand Singh
Consultant Neonatologist

2. • Lower respiratory tract infection (LRTI) is frequently used interchangeably to include
bronchitis, bronchiolitis and pneumonia or any combination of the three.
• Terms pneumonia and pneumonitis strictly represent any inflammatory condition involving
the lungs, which include the visceral pleura, connective tissue, airways, alveoli, and vascular
structures.
• Pneumonia will be defined as a condition typically associated with fever, respiratory
symptoms and evidence of parenchymal involvement, either by physical examination or the
presence of involvement on chest radiography (consolidation).
• Pneumonitis is general term for lung inflammation that may or may not be associated with
consolidation.

3. Incidence

5. • Between 2000 and 2015, the estimated number of pneumonia cases in Indian HIV -uninfected children
younger than 5 years decreased from 83·8 million cases to 49·8 million cases, representing a 41%
reduction in pneumonia cases.
• The incidence of pneumonia in children younger than 5 years in India was 657 cases per 1000 children
in 2000 and 403 cases per 1000 children in 2015.
• In 2015, the estimated number of pneumonia cases was highest in Uttar Pradesh 12·4 million, Bihar 7·3
million, and Madhya Pradesh 4·6 million.
• In 2015, pneumonia incidence was greater than 500 cases per 1000 children in two states: UP 565 cases
per 1000 children and MP 563 cases per 1000 children.
• Between 2000 and 2015, the greatest reduction in pneumonia cases was observed in Kerala (82%
reduction).
Lancet Child Adolesc Health 2020; 4: 678–87

6. Risk factors

8. PATHOGENESIS

11. Pathologic patterns & Type of pneumonia

12. • There are five pathologic patterns of bacterial pneumonia---
1. Lobar pneumonia – single lobe or segment of a lobe (S. pneumonia) pneumonia.
2. Bronchopneumonia – Primary involvement of airways and surrounding interstitium
(Streptococcus pyogenes and Staphylococcus aureus pneumonia).
3. Necrotizing pneumonia- Associated with aspiration pneumonia and pneumonia resulting
from S. pneumoniae, S. pyogenes, and S. aureus
4. Caseating granuloma (as in tuberculous pneumonia).
5. Interstitial with secondary parenchymal infiltration – when a severe viral pneumonia is
complicated by bacterial pneumonia.
• There are two major pathologic patterns of viral pneumonia
● Interstitial pneumonia ● Parenchymal infection

13. Classification by Site of Acquisition
Community-acquired pneumonia (CAP)
Acute infection of lung parenchyma in
- Previously healthy child
- Acquired outside of the hospital settings
- Not hospitalized within 14 days prior to onset of
symptoms.
- (This excludes children with immunodeficiency, severe
malnutrition and post measles state)
Nosocomial pneumonia
An acute infection of the pulmonary parenchyma acquired in
hospital settings, which encompasses hospital-acquired
pneumonia and ventilator-associated pneumonia
Hospital-acquired pneumonia (HAP)
Pneumonia acquired ≥48 hours after hospital admission;
includes both HAP and VAP
Ventilator-associated pneumonia (VAP) Pneumonia acquired ≥48 hours after endotracheal intubation

14. Classification by Etiology
Atypical pneumonia
Pneumonia caused by ”Atypical"
¶
bacterial pathogens
including Legionella spp, Mycoplasma
pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci,
and Coxiella burnetii
Aspiration pneumonia
Adverse pulmonary consequences due to entry of gastric or
oropharyngeal fluids, which may contain bacteria and/or be
of low pH, or exogenous substances (eg, ingested food
particles or liquids, mineral oil, salt or fresh water) into the
lower airways
Chemical pneumonitis
Aspiration of substances (eg, acidic gastric fluid) that cause
an inflammatory reaction in the lower airways, independent
of bacterial infection

15. ETIOLOGIC AGENTS

18. CLINICAL PRESENTATION

19. • The presenting signs and symptoms are nonspecific.
• Symptoms and signs of pneumonia may be subtle, particularly in infants and young children.
• The combination of fever and cough is suggestive of pneumonia, other respiratory findings (Ex -
tachypnea, increased work of breathing) may precede the cough.
• The longer fever, cough, and respiratory findings are present, the greater the likelihood of pneumonia.
• Neonates and young infants - difficulty feeding, restlessness, or fussiness rather than with cough and/or
abnormal breath sounds.
• Older children and adolescents may complain of pleuritic chest pain (pain with respiration), Abdominal
pain (because of referred pain from the lower lobes) or Nuchal rigidity (because of referred pain from
the upper lobes).
• Walking pneumonia" is a term that is sometimes used to describe pneumonia in which the respiratory
symptoms do not interfere with normal activity.

20. • Persistent single cardinal clinical sign which is very sensitive and specific to
diagnose pneumonia is rapid breathing or tachypnea. - IAP 2022
• Tachypnea with accessory muscles working = severe pneumonia
Sensitivity and Specificity (74% and 67% respectively) IAP

21. CLINICAL EVALUATION
(HISTORY & EXAMINATION)

22. • Objectives-
1. Identification of the clinical syndrome (eg, pneumonia, bronchiolitis,
asthma)
2. Consideration of the etiologic agent (eg, bacteria, virus)
3. Assessment of the severity
• The severity of illness determines the need for additional evaluation.

23. • HISTORY

24. Age of the child
Recent viral upper respiratory tract infection
May predispose to bacterial superinfection with Streptococcus
pneumoniae or Staphylococcus aureus
Associated symptoms
Mycoplasma pneumoniae is often associated with
extrapulmonary manifestations (eg, headache, photophobia,
rash)
Cough, chest pain, shortness of breath, difficulty breathing "Classic" features of pneumonia, but nonspecific
Increased work of breathing in the absence of stridor or
wheezing
Suggestive of severe pneumonia
Fluid and nutrition intake Difficulty or inability to feed suggests severe illness
Choking episode May indicate foreign body aspiration
Duration of symptoms
Chronic cough (> 4 weeks) suggests etiology other than acute
pneumonia
Previous episodes
Recurrent episodes may indicate aspiration, congenital or
acquired anatomic abnormality, cystic fibrosis,
immunodeficiency, asthma, missed foreign body
Immunization status
Completion of the primary series of immunizations
for Haemophilus influenzae type b, S. pneumoniae, Bordetella
pertussis, and seasonal influenza decreases, but does not
eliminate, the risk of infection with these organisms

25. Previous antibiotic therapy Increases the likelihood of antibiotic-resistant bacteria
Maternal history of chlamydia during pregnancy (for
infants <4 months of age)
May indicate Chlamydia trachomatis infection
Exposure to tuberculosis May indicate Mycobacterium tuberculosis infection
Ill contacts More common with viral etiologies
Travel to or residence in certain areas that suggest
endemic pathogens
Animal exposure May indicate histoplasmosis, psittacosis, Q fever
Day care center attendance Exposure to viruses and antibiotic-resistant bacteria
Pyoderma, Measles May indicate Staphylococcus Pneumonia

26. EXAMINATION

27. • General appearance -
• Ability to attend to the environment, to feed, to vocalize and to be consoled.
• State of awareness and cyanosis should be assessed in all children, although
children may be hypoxemic without cyanosis.
• Fever – Fever is a common manifestation of pneumonia in children.
• However, it is nonspecific and young infants may have afebrile pneumonia related
to Chlamydia trachomatis or other pathogens.

29. • Respiratory distress –
 Tachypnea,
 SPO2 < 92 % @ RA
 Increased work of breathing (intercostal/subcostal/suprasternal retractions/nasal
flaring/grunting)
 Altered mental status.
• Oxygen saturation should be measured in children with increased work of breathing,
particularly if they have a decreased level of activity or are agitated.
• Infants and children with hypoxemia may not appear cyanotic.
• Hypoxemia is a sign of severe disease and an indication for admission.
• In a systematic review, retractions, nasal flaring, and grunting were two to three times
more frequent in children with radiographically confirmed pneumonia than without.
• When present, Grunting is a sign of severe disease and impending respiratory failure.

30. • Lung examination –
• Auscultation is an important component of the examination of the child who presents with
findings suggestive of pneumonia.
• Auscultation of all lung fields should be performed.
• Examination findings consistent with radiographically confirmed pneumonia include -
Crackles
Decreased breath sounds
Bronchial breath sounds
Tactile fremitus (eg, when the patient says "ninety-nine")
Dullness to percussion
Wheezing is more common in pneumonia caused by atypical bacteria and viruses than
bacteria, it is also a characteristic feature of bronchiolitis.

31. Severity Assessment

33. Clues to Etiology

34. Extrapulmonary Features in
Mycoplasma – SJS,
Polyarthritis, Hemolytic
Anemia, Pancreatitis,
Hepatitis, Myocarditis

35. • INVESTIGATIONS

36. • Radiographs- In children > 4 years, PA upright chest view is usually obtained to minimize the cardiac
shadow.
• In younger children, position does not affect the size of the cardiothoracic shadow, and AP supine
view is preferred because immobilization is easier and the likelihood of a better inspiration is
improved.
• Indications — Indications for radiographs in children with clinical evidence of pneumonia include -
1. Severe disease (to confirm the diagnosis and assess for complications)
2. Confirmation/exclusion of the diagnosis when clinical findings are inconclusive
3. Hospitalization (to document the presence, size, and character of parenchymal infiltrates and
evaluate potential complications)
4. History of recurrent pneumonia
5. Exclusion of alternate explanations for respiratory distress (eg, foreign body aspiration, heart
failure)
6. Assessment of complications, particularly in children whose pneumonia is prolonged and
unresponsive to antimicrobial therapy.

39. Other imaging techniques — HRCT/USG are available for patients who require more extensive imaging or clarification of
radiographic findings.

40. TLC- <4000
OR > 16000
S/O ACUTE
INFECTION

41. DIAGNOSIS

42. • Clinical diagnosis-
• Radiographic confirmation — An infiltrate on chest radiograph confirms the
diagnosis of pneumonia in children with compatible clinical findings, although
chest radiographs must be interpreted with caution in children with asthma
and comorbid viral infection.

43. • Etiologic diagnosis -
Blood cultures, particularly in children with complications
Sputum Gram stain and culture in children who are able to produce sputum
Pleural fluid examination
Gram stain and culture in children with pleural effusion
Rapid diagnostic tests (eg PCR based assays)
Required in children with severe disease, complications, require hospitalization, unusual
pathogen is suspected, fail to respond to initial therapy
• Other test which can help in etiological diagnosis is Mantoux test.

45. • Invasive studies — Invasive procedures may be necessary to obtain lower
respiratory tract specimens for culture and other studies in children in whom an
etiologic diagnosis is necessary and has not been established by other means.
• Bronchoscopy with bronchoalveolar lavage (BAL) – to differentiate true infection
from upper airway contamination.
• Percutaneous needle aspiration guided by USG or CT – Microbiologic specimens
may be obtained by USG/CT guided needle aspiration.
• USG is preferred because of the lack of radiation exposure.
• Lung biopsy either by a thoracoscopic or thoracotomy approach – Samples
obtained by lung biopsy often yield diagnostic information in children who had
nondiagnostic BAL.

46. DIFFERENTIAL DIAGNOSIS

47. Bronchiolitis
WALRI
Foreign body
Asthma
Metabolic acidosis (DKA, CRF)
Congestive heart failure

48. TREATMENT

51. INDICATIONS FOR ADMISSION

57. PROGNOSIS

58. • Most children recover from pneumonia rapidly and completely.
• The radiographic abnormalities may take 6 to 8 weeks to return to normal.
• In a few children, pneumonia may persist longer than 1 month or may be
recurrent.
• In such cases, the possibility of underlying disease must be investigated
further, such as with TST, sweat chloride determination for cystic fibrosis,
serum immunoglobulin and IgG subclass determinations, bronchoscopy to
identify anatomic abnormalities or foreign body, and barium swallow for
gastroesophageal reflux.

59. PREVENTION

60. • Immunizations have had a great impact on reducing the incidence of vaccine-
preventable causes of pneumonia.
• Zinc supplementation
• RSV infections can be reduced in severity by use of palivizumab .
• Reducing the length of mechanical ventilation and using antibiotic treatment
only when necessary can reduce ventilator-associated pneumonias.
• Hand washing before and after every patient contact and use of gloves for
invasive procedures are important measures to prevent nosocomial transmission
of infections.
• Hospital staff with respiratory illnesses or who are carriers of certain organisms,
such as MRSA, should use masks or be reassigned to non-patient care duties.

61. SUMMARY