Pneumonia in children can be caused by viral or bacterial infections that lead to lung inflammation and fluid-filled alveoli. It is a common cause of death in children under 5 years old. Common bacteria that cause pneumonia include Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. Clinically, pneumonia can be diagnosed by symptoms like fast breathing, chest indrawing, and coarse lung sounds. Chest x-rays can reveal lung infiltrates. Treatment involves antibiotics, oxygen, and managing symptoms. Vaccines help prevent acute respiratory infections that can lead to pneumonia.

1. Pneumonia in Children
Classification, Epidemiology, Etiology, Pathology
Clinical Features, Complications, Management
Prognosis and Prevention
Prof. Imran Iqbal
Fellowship in Pediatric Neurology (Australia)
Prof of Paediatrics (2003-2018)
Prof of Pediatrics Emeritus, CHICH
Prof of Pediatrics, CIMS
Multan, Pakistan

2. (God speaking to Prophet Muhammad (PBUH)
And HE (Allah) raised the heavens and imposed the balance.
So that you do not transgress in the balance.
Keep the balance with justice and do not reduce the measure
Al Quran surah Al-Rehman 55:7-9

3. Case scenario
• A 12 months old baby presents in emergency with cough
and fever for the last 2 days. Mother says, he is having wet
cough which comes many times a day. Baby is feeding much
less than before.
• On examination, On examination, his temperature is 102.5
F. His respiration is 55 per minute and chest indrawing is
present. On auscultation of chest, and coarse inspiratory
crepitations are bilaterally audible.
• How will you classify this child in IMNCI ?
• What is your most likely diagnosis ?

4. IMNCI – Cough or Difficult Breathing
Classification at first level of care

5. IMNCI
Treat Cough or Difficult Breathing
• Severe Pneumonia or Very Severe Disease –
Referral / Admit
• Pneumonia -- Amoxycillin (oral)
-- Paracetamol (if fever)
-- Salbutamol (if wheezing)
• Cough and Cold -- Salbutamol (if wheezing)
-- safe, soothing remedies for cough

6. Causes of Fast Breathing or Chest Indrawing
• Pneumonia
• Bronchiolitis
• Asthma
• Airway obstruction (causes stridor)
• Pleural effusion / empyema
• Congestive heart failure
• Renal failure
• Metabolic acidosis

7. Case scenario
• A 12 months old baby presents in emergency with cough
and fever for the last 2 days. Mother says, he is having wet
cough which comes many times a day. Baby is feeding much
less than before.
• On examination, On examination, his temperature is 102.5
F. His respiration is 55 per minute and chest indrawing is
present. On auscultation of chest, and coarse inspiratory
crepitations are bilaterally audible.
• What is your most likely diagnosis ?
• BRONCHOPNEUMONIA

8. Case Scenario
• A 9 years old child presents to OPD with cough and fever for
the last 3 days.
• On examination, child is having wet cough. His temperature
is 103 F. His respiration is 35 per minute.
• Examination of chest shows dull percussion note at left
infra-scapular region. On auscultation of chest, at the same
area, intensity of breath sounds is decreased and breathing
is bronchial. His temperature is 103 F.
• What is your most likely diagnosis ?

9. Case Scenario
• A 9 years old child presents to OPD with cough and fever for
the last 3 days.
• On examination, child is having wet cough. His temperature
is 103 F. His respiration is 35 per minute.
• Examination of chest shows dull percussion note at left
infra-scapular region. On auscultation of chest, at the same
area, intensity of breath sounds is decreased and breathing
is bronchial. His temperature is 103 F.
• What is your most likely diagnosis ?
• LOBAR PNEUMONIA

10. Pneumonia
• Pneumonia is inflammation of lung parenchyma
• Common cause of Pneumonia is a VIRAL or BACTERIAL
infection
• Pathologically, there is consolidation of alveolar spaces with
fluid filled alveoli

11. Epidemiology
• It is the most common cause of deaths in children
less than 5 years of age
• Pneumonia is a common terminal illness before
death in many childhood diseases
• Respiratory tract contains many non-pathogenic
and few pathogenic bacteria even in healthy
children

12. Causes of death among children under 5 years,
globally, 2016
• Neonatal deaths
• Prematurity 18 %
• Asphyxia 12 %
• Cong anomalies 9 %
• Neonatal sepsis 7 %
• Infant & child deaths
• Pneumonia 16 %
• Other infection 10 %
• Diarrhea 9 %
• Injuries 6 %
• NCD 5 %
• Measles 1 %

13. Etiology – Micro-organisms
• Newborn
• Klebsiella Pneumoniae
• Pseudomonas
• E. coli
• Staph aureus
• Viruses – RSV, Human
metapneumo virus
• Child
• Streptococcus
pneumoniae
• Haemophilus influenzae
• Staphylococcus aureus
• Mycoplasma pneumonia
• Viruses – measles, RSV,
influenza
• Mycobacterium
tuberculosis

14. Etiology – most common infections
• Streptococcus pneumoniae
• Haemophilus influenzae
• Staphylococcus aureus

15. Etiology –
Other types / causes of Pneumonia
• Aspiration Pneumonia – inhalation of food contents,
common in preterm newborns
• Chemical Pneumonia – inhalation of hydrocarbons in
poisoning
• Eosinophilic pneumonia – due to allergy to bird or animal
antigens or worm infestations
• Nosocomial Pneumonia / Health-care associated pneumonia
– develops as a complication in sick admitted patients
• Interstitial Pneumonia – inflammation of interstitial tissues
associated with fibrosis usually due to non-infective causes

16. Pathogenesis
• Commonly, viral and bacterial Infections causing
pneumonia spread from infected individuals by
droplet infection
• Micro-organisms present in patient airways can
cause pneumonia when the immune mechanisms
are impaired
• Pneumonia can develop as a result of blood stream
infections

17. Pathology

18. Pathology
Gross and Microscopic picture

19. Recurrent pneumonia – causes
COMMON CAUSES
• Asthma
• Recurrent aspiration (in
neurological disorders)
• Bronchiectasis
• Tuberculosis
RARE CAUSES
• Immunodeficiency
• Heart failure
• Cystic fibrosis
• Ciliary dyskinesia
• GERD
• Congenital lobar
emphysema

20. Pneumonia - Clinical Features
• Symptoms
• Runny nose (viral infections)
• Cough – dry (viral infections), wet (bacterial infection)
• Wheeze (allergy)
• Fever (low to high)
• Chest / abdominal pains (pleural involvement)
• Signs on Examination
• Fast breathing
• Chest indrawing
• Nasal flaring, use of accessory muscles of respiration
• Crepitations on auscultation
• Bronchial breath sounds

21. Clinical DIAGNOSIS
PNEUMONIA can be clinically diagnosed in children
on the presence of
any of these clinical findings
• Fast breathing
• Lower Chest wall indrawing
• Inspiratory coarse crepitations
• Bronchial breath sounds

22. Investigations
• CBC
• CRP
• Chest X-ray
• HRCT chest
• USG chest
• Blood culture
• Lung aspirate cultures
• Pleural fluid examination

23. Chest radiology – lung infiltrates

24. Chest X - ray
Bronchopneumonia Lobar Pneumonia

25. Complications
• Para-pneumonic Pleural Effusion
• Empyema
• Pneumothorax
• Lung abscess
• Bronchiectasis
• Respiratory failure
• Meningitis
• Septic shock

26. Complications
Paraneumonic Pleural Effusion (Empyema)

27. MANAGEMENT
• Supportive management –
• Hydration - extra fluids / IV fluids
• Nutrition – small frequent feeds
• Symptomatic management –
• Antipyretics – Paracetamol / Ibuprofen
• Specific management – Antibiotics
• Danger signs – Hospitalization
• Hypoxia – Oxygen / Artificial Ventilation
• Empyema – chest tube drainage

28. Choice of antibiotics in PNEUMONIA
• OPD / INITIAL / UNCOMPLICATED
= Amoxicillin (high dose),
= Co-amoxiclav
--- Azithromycin (in older children)
--- Moxifloxacin (in adolescents)
• HOSPITALIZED / UNRESPONSIVE / SEVERE
• 1st Line : Ampicillin + Gentamicin / Ceftriaxone
• 2nd Line : Co-amoxiclav and / or Moxifloxacin
• 3rd Line : Linezolid / Vancomycin (MRSA) and /or
Meropenem / Imipenem (newborns and infants)

29. PREVENTION

31. Prevention of
Acute Respiratory Infections
• Vaccination –
Penta (DPT, Hib, Hep B),
Pneumococcal, Measles,
Influenza, Covid 19
• Breastfeeding, Nutrition, Micronutrients
• Masks and Social Distancing
• Hand washing,
• Control of smoking, air pollution, cold air

32. Thank You