ADDIS ABABA UNIVERSITY

COLLAGE OF HEALTH SCIENCE

PEDIATRICS AND NEONATOLOGY ON
PNEUMONIA
 PNEUMONIA IN CHILDREN

 Pneumonia • Pneumonia is an infection of the lower respiratory tract that

involves the airways and parenchyma with consolidation of the alveolar
spaces
 The term lower respiratory tract infection is often used to encompass
bronchitis, bronchiolitis, or pneumonia or any combination of the three,
which may be difficult to distinguish clinically.
 Pneumonitis is a general term for lung inflammation that may or may not
be associated with consolidation
 Important notes
 Lobar pneumonia describes "typical" pneumonia localized to one or more lobes of the
lung in which the affected lobe or lobes are completely consolidated.
 Bronchopneumonia refers to inflammation of the lung that is centered in the
bronchioles and leads to the production of a mucopurulent exudate that obstructs some
of these small airways and causes patchy consolidation of the adjacent lobules.
 Interstitial pneumonitis refers to inflammation of the interstitium, which is composed of
the walls of the alveoli, the alveolar sacs and ducts, and the bronchioles. Interstitial
pneumonitis is characteristic of acute viral infections, but also may be a chronic process.
 Defense mechanism

 Lower airways and secretions are sterile as a result of a multicomponent cleansing

system.
 Airway contaminants are caught in the mucus secreted by the goblet cells.
 Cilia on epithelial surfaces, composing the ciliary elevator system, beat synchronously
to move particles upward toward the central airways and into the throat, where they are
swallowed or expectorated.
 Polymorph nuclear neutrophils from the blood and tissue macrophages ingest and kill
microorganisms.
 IgA secreted into the upper airway fluid protects against invasive infections and
facilitates viral neutralization.
 Epidemiology
 Pneumonia is a substantial cause of morbidity and mortality in childhood
throughout the world,
 Immunizations have had a great impact on the incidence of pneumonia
caused by peruses, diphtheria, measles, Hib, and S. pneumonia.
 Where used, bacilli Calmette-Guérin (BCG) for tuberculosis also has had a
significant impact.
 More than 4 million deaths each year in developing countries are due to
acute respiratory tract infections.
 The incidence of pneumonia is more than 10-fold higher and the number
of childhood-related deaths due to pneumonia ≈2000-fold higher, in
developing than in developed countries
 Risk factors
 Risk factors for lower respiratory tract infections include:
 gastroesophageal reflux,
 neurologic impairment (aspiration),
 immunocompromised states,
 anatomic abnormalities of the respiratory tract,
 residence in residential care facilities for handicapped children, and
 hospitalization, especially in an ICU or requiring invasive procedures
 Etiology

 Although most cases of pneumonia are caused by microorganisms,

(infectious)
 noninfectious causes include:
 aspiration of food or gastric acid,
 foreign bodies,
 hydrocarbons, and lipoid substances,
 hypersensitivity reactions, and
 drug- or radiation-induced pneumonitis.
 Etiology

  The infectious agents that commonly cause community-acquired

pneumonia vary by age
 The most common causes are RSV in infants ,
 respiratory viruses (RSV, parain-fluenza viruses, influenza viruses,
adenoviruses) in children younger than 5 years old, and
 M. pneumonia and S. pneumonia in children older than age 5.
 M. pneumonia and C. pneumonia are the principal causes of atypical
pneumonia.
 Additional agents occasionally or rarely cause pneumonia as hospital-
acquired pneumonia, as zoonotic infections, in endemic areas, or among
immunocompromised persons.
  Causes
of pneumonia in immunocompromised persons include:
 gram-negative enteric bacteria,

 mycobacteria (M. valium complex),

 fungi (aspergillosis, histoplasmosis),

 viruses (CMV), and

 Pneumocystis jirovecii (carinii).

 Pneumonia in patients with cystic fibrosis usually is caused by:

 S. aureus in infancy and

 P. aeruginosa or Burkholderia cepacia in older patients.

CLINICAL MANIFESTATIONS
 Age is a determinant in the clinical manifestations of pneumonia.
 Neonates may have fever only with subtle or no physical findings of pneumonia.
 The typical clinical patterns of viral and bacterial pneumonias usually differ between older
infants and children, although the distinction is not always clear for a particular patient.
 Fever, chills,
 tachypnea,
 cough,
 malaise,
 pleuritic chest pain,
 retractions, and
 apprehension, because of difficulty breathing or shortness of breath.
Viral pneumonias are associated more often with cough, wheezing, or
stridor; fever is less prominent than with bacterial pneumonia.
The chest radiograph in viral pneumonia shows diffuse, streaky
infiltrates of bronchopneumonia, and
the WBC count often is normal or mildly elevated, with a predominance
of lymphocytes.
 Bacterial pneumonias typically are associated with higher fever, chills,
cough, dyspnea, and auscultatory findings of lung consolidation.
 The chest radiograph often shows lobar consolidation (or a round
pneumonia) and pleural effusion (10% to 30%).
 The WBC count is elevated (>20,000/mm3) with a predominance of
neutrophils. Afebrile pneumonia in young infants is characterized
by tachypnea, cough, crackles on auscultation, and often
concomitant chlamydial conjunctivitis.
 The WBC count typically shows mild eosinophilia
 and there is hyperinflation on chest radiograph
 Pneumonia History
 Age
 Presence of cough,
 difficulty breathing,
 shortness of breath, chest pain
 Fever
 Recent upper respiratory tract infections
 Associated symptoms
 Duration of symptoms
 Immunizations status
 TB exposure
 Maternal Chlamydia,
 Group B Strep status during pregnancy
 Choking episodes
 Previous episodes
 Previous antibiotics
 DIFFERENTIAL DIAGNOSIS
 The various types of pneumonia-lobar pneumonia, bronchopneumonia, interstitial and
alveolar pneumonias-need to be differentiated on the basis of radiologic or pathologic
diagnosis.
 Pneumonia must be differentiated from other acute lung diseases, including:
 lung edema caused by heart failure,
 allergic pneumonitis, and
 aspiration, and
 autoimmune diseases, such as rheumatoid disease and systemic lupus erythematosus.
 Radiographically, pneumonia must be differentiated from lung trauma and contusion,
hemorrhage, foreign body obstruction, and irritation from subdiaphragmatic
inflammation.
 TREATMENT
 Therapy for pneumonia includes :
 supportive and specific treatment.
 The appropriate treatment plan depends on the degree of illness, complications, and
knowledge of the infectious agent or of the agent that is likely causing the pneumonia.
 Age, severity of the illness, complications noted on the chest radiograph, degree of
respiratory distress, and ability of the family to care for the child and to assess the
progression of the symptoms all must be taken into consideration in the choice of
ambulatory treatment over hospitalization.
 Most cases of pneumonia in healthy children can be managed on an outpatient basis.

Although viruses cause most community-acquired pneumonias in young children, in most
 

situations experts recommend empirical treatment for the most probable treatable causes.
 Treatment recommendations are based on the age of the child, severity of the pneumonia,

and antimicrobial activity of agents against the expected pathogens that cause pneumonia
at different ages.
 High-dose amoxicillin is used as a first-line agent for children with uncomplicated

community-acquired pneumonia. third-generation cephalosporin and macrolide antibiotics

such as azithromycin are acceptable alternatives. Combination therapy (ampicillin and
either gentamicin or cefotaxime) is typically used in the initial treatment of newborns and
young infants.
 Hospitalized patients can also usually be treated with ampicillin. The choice of agent and

dosing may vary based on local resistance rates. In areas where resistance is very high, a
third-generation cephalosporin might be indicated instead. Older children, in addition, may
receive a macrolide to cover for atypical infections.
  Pneumonia caused by S. pneumonia presents a problem because of
increasing antibiotic resistance.
 In contrast to pneumococcal meningitis, presumed pneumococcal
pneumonia can be treated with high-dose penicillin or cephalosporin
therapy, even with high-level penicillin resistance. Vancomycin can
be used if the isolate shows high-level resistance and the patient is
severely ill.
 Empirical antibiotic treatment is sufficient for management of pneumonia in
children, unless there is an exceptional need to know the pathogen to guide
management.
 Such exceptional situations include:
 lack of response to empirical therapy,
 unusually severe presentations,
 nosocomial pneumonia, and
 immunocompromised children susceptible to infections with opportunistic
pathogens.
 Infants 4 to 18 weeks old with afebrile pneumonia most likely have infection
with C. trachomatis, and erythromycin is the recommended treatment.
 COMPLICATIONS
 Pleural effusion
 Empyema
 Parapneumonic effusions
 Lung abscess
 Pneumothorax
 Pneumatocele
 Delayed Resolution
 Respiratory Failure
 Metastatic Septic lesions  Activation of latent TB
  PROGNOSIS
 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, bronchoscope to identify
anatomic abnormalities or foreign body, and barium swallow for
gastroesophageal reflux.
 PREVENTION

 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 methicillin-resistant S. aureus, should use masks or be reassigned to non-
patient care duties