Pneumonia

Updated September 2016

Key facts
 Pneumonia accounts for 16% of all deaths of children under 5 years old, killing 920 136 children in 2015.
 Pneumonia can be caused by viruses, bacteria, or fungi.
 Pneumonia can be prevented by immunization, adequate nutrition, and by addressing environmental factors.
 Pneumonia caused by bacteria can be treated with antibiotics, but only one third of children with pneumonia
receive the antibiotics they need.

Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are made up of small sacs
called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli
are filled with pus and fluid, which makes breathing painful and limits oxygen intake.
Pneumonia is the single largest infectious cause of death in children worldwide. Pneumonia killed 920 136
children under the age of 5 in 2015, accounting for 16% of all deaths of children under five years old. Pneumonia
affects children and families everywhere, but is most prevalent in South Asia and sub-Saharan Africa. Children
can be protected from pneumonia, it can be prevented with simple interventions, and treated with low-cost, low-
tech medication and care.
Causes
Pneumonia is caused by a number of infectious agents, including viruses, bacteria and fungi. The most common
are:
 Streptococcus pneumoniae – the most common cause of bacterial pneumonia in children;
 Haemophilus influenzae type b (Hib) – the second most common cause of bacterial pneumonia;
 respiratory syncytial virus is the most common viral cause of pneumonia;
 in infants infected with HIV, Pneumocystis jiroveci is one of the most common causes of pneumonia, responsible
for at least one quarter of all pneumonia deaths in HIV-infected infants.
Transmission
Pneumonia can be spread in a number of ways. The viruses and bacteria that are commonly found in a child's
nose or throat, can infect the lungs if they are inhaled. They may also spread via air-borne droplets from a cough
or sneeze. In addition, pneumonia may spread through blood, especially during and shortly after birth. More
research needs to be done on the different pathogens causing pneumonia and the ways they are transmitted, as
this is of critical importance for treatment and prevention.
Presenting features
The presenting features of viral and bacterial pneumonia are similar. However, the symptoms of viral pneumonia
may be more numerous than the symptoms of bacterial pneumonia. In children under 5 years of age, who have
cough and/or difficult breathing, with or without fever, pneumonia is diagnosed by the presence of either fast
breathing or lower chest wall indrawing where their chest moves in or retracts during inhalation (in a healthy
person, the chest expands during inhalation). Wheezing is more common in viral infections.
Very severely ill infants may be unable to feed or drink and may also experience unconsciousness, hypothermia
and convulsions.
Risk factors
While most healthy children can fight the infection with their natural defences, children whose immune systems
are compromised are at higher risk of developing pneumonia. A child's immune system may be weakened by
malnutrition or undernourishment, especially in infants who are not exclusively breastfed.
Pre-existing illnesses, such as symptomatic HIV infections and measles, also increase a child's risk of contracting
pneumonia.
The following environmental factors also increase a child's susceptibility to pneumonia:
 indoor air pollution caused by cooking and heating with biomass fuels (such as wood or dung)
 living in crowded homes
 parental smoking.
Treatment
Pneumonia should be treated with antibiotics. The antibiotic of choice is amoxicillin dispersable tablets. Most
cases of pneumonia require oral antibiotics, which are often prescribed at a health centre. These cases can also be
diagnosed and treated with inexpensive oral antibiotics at the community level by trained community health
workers. Hospitalization is recommended only for severe cases of pneumonia.
Prevention
Preventing pneumonia in children is an essential component of a strategy to reduce child mortality.
Immunization against Hib, pneumococcus, measles and whooping cough (pertussis) is the most effective way to
prevent pneumonia.
Adequate nutrition is key to improving children's natural defences, starting with exclusive breastfeeding for the
first 6 months of life. In addition to being effective in preventing pneumonia, it also helps to reduce the length of
the illness if a child does become ill.
Addressing environmental factors such as indoor air pollution (by providing affordable clean indoor stoves, for
example) and encouraging good hygiene in crowded homes also reduces the number of children who fall ill with
pneumonia.
In children infected with HIV, the antibiotic cotrimoxazole is given daily to decrease the risk of contracting
pneumonia.
Economic costs
The cost of antibiotic treatment for all children with pneumonia in 66 of the countdown to 2015 countries for
maternal, newborn and child survival is estimated at around US$ 109 million per year. The price includes the
antibiotics and diagnostics for pneumonia management.
WHO response
The WHO and UNICEF integrated Global action plan for pneumonia and diarrhoea (GAPPD) aims to accelerate
pneumonia control with a combination of interventions to protect, prevent, and treat pneumonia in children with
actions to:
 protect children from pneumonia including promoting exclusive breastfeeding and adequate complementary
feeding;
 prevent pneumonia with vaccinations, hand washing with soap, reducing household air pollution, HIV
prevention and cotrimoxazole prophylaxis for HIV-infected and exposed children;
 treat pneumonia focusing on making sure that every sick child has access to the right kind of care -- either from
a community-based health worker, or in a health facility if the disease is severe -- and can get the antibiotics and
oxygen they need to get well;
A number of countries including Bangladesh, India, Kenya, Uganda and Zambia have developed district, state
and national plans to intensify actions for the control of pneumonia and diarrhoea. Many more have integrated
diarrhoea and pneumonia specific action into their national child health and child survival strategies. For many
countries the post Millenium Development Goal agenda has explicitly included ending preventable diarrhoea and
pneumonia deaths as a priority action.

Pediatric Pneumonia Differential Diagnoses

Updated: Mar 14, 2017
 Author: Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP; Chief Editor: Russell W Steele, MD more...
Diagnostic Considerations
Pneumonia can occur at any age, although it is more common in younger children. Different age groups tend to be
infected by different pathogens, which affects diagnostic and therapeutic decisions.
patients referred for evaluation for recurrent pneumonia are diagnosed with asthma. In emergency Many department
studies, 35% of children with an asthma exacerbation have abnormalities visible on chest radiographs. In a child not
yet diagnosed with asthma, these abnormalities are frequently interpreted as pneumonia. Inflammation, often
triggered by viral infection, is part of the asthmatic response. Wheezing responsive to bronchodilators, a history of
atopy, a family history of asthma, and a history of cough or wheeze with exercise may be helpful in identifying these
patients.
Consider any other diseases that may present with respiratory dysfunction in the first 24 hours of life. Keep in mind
that any of the conditions listed below may also have superimposed pneumonia:
 Alveolar-capillary dysplasia
 Arrhythmia
 Asphyxia
 Bronchial duplication
 Chest wall injury or anomaly
 Choanal atresia
 Chylothorax
 Diaphragmatic eventration
 Heart block
 Intracranial hemorrhage
 Laryngeal cleft
 Laryngeal nerve injury
 Mutation of ABCA3 gene (for surfactant phospholipid transport)
 Neuromuscular disorders
 Phrenic nerve injury
 Pulmonary hemorrhage
 Pulmonary hypoplasia
 Pulmonary lymphangiectasia
 Spinal injury
 Surfactant-related protein B deficiency
 Tachycardia syndromes
 Tracheoesophageal fistula
 Transplacental medications
 Vascular catheter accident
 Other causes of airway obstruction
 Other congenital heart diseases
 Other inborn errors of metabolism
 Other neuromuscular diseases
A careful history and examination in patients with recurrent pneumonia are helpful to further narrow the differential
diagnosis. However, more testing is often needed to confirm most of these diagnoses and is generally outside the
scope of a primary care provider.
Differential Diagnoses
 Acidosis, Metabolic
 Acute Anemia
 Acute Hypoglycemia
 Afebrile Pneumonia Syndrome
 Agammaglobulinemia
 Alveolar Proteinosis
 Aortic Stenosis
 Aortic Stenosis, Subaortic
 Aortic Stenosis, Valvar
 Aseptic Meningitis
 Asphyxiating Thoracic Dystrophy (Jeune Syndrome)
 Aspiration Syndromes
 Asthma
 Atelectasis, Pulmonary
 Atrioventricular Septal Defect, Complete
 Atrioventricular Septal Defect, Unbalanced
 Bacteremia
 Birth Trauma
 Bowel Obstruction in the Newborn
 Bronchiectasis
 Bronchiolitis
 Bronchitis
 Bronchitis, Acute and Chronic
 Bronchogenic Cyst
 Cardiomyopathy, Hypertrophic
 Chronic Anemia
 Chronic Granulomatous Disease
 Coarctation of the Aorta
 Coccidioidomycosis and Valley Fever
 Combined B-Cell and T-Cell Disorders
 Common Variable Immunodeficiency
 Complement Deficiency
 Complement Receptor Deficiency
 Congenital Diaphragmatic Hernia
 Congenital Pneumonia
 Congenital Stridor
 Cystic Adenomatoid Malformation
 Cystic Fibrosis
 Double Outlet Right Ventricle, Normally Related Great Arteries
 Double Outlet Right Ventricle, With Transposition
 Ebstein Anomaly
 Emergent Management of Atrial Flutter
 Empyema
 Esophageal Atresia With or Without Tracheoesophageal Fistula
 Foreign Body Aspiration
 Gastroesophageal Reflux
 Goodpasture Syndrome
 Head Trauma
 Hemosiderosis
 Hemothorax
 Human Immunodeficiency Virus Infection
 Hypersensitivity Pneumonitis
 Hypocalcemia
 Hypoplastic Left Heart Syndrome
 IgA and IgG Subclass Deficiencies
 Inhalation Injury
 Interrupted Aortic Arch
 Legionella Infection
 Meningitis, Bacterial
 Neural Tube Defects
 Patent Ductus Arteriosus (PDA)
 Pediatric Acute Respiratory Distress Syndrome
 Pediatric Airway Foreign Body
 Pediatric Histoplasmosis
 Pediatric Pleural Effusion
 Pediatric Pneumococcal Infections
 Pediatric Pulmonary Hypoplasia
 Pertussis
 Pneumococcal Infections
 Pneumonia, Aspiration
 Pneumonia, Bacterial
 Pneumonia, Empyema and Abscess
 Pneumonia, Immunocompromised
 Pneumonia, Mycoplasma
 Pneumothorax
 Pulmonary Atresia With Intact Ventricular Septum
 Pulmonary Atresia With Ventricular Septal Defect
 Pulmonary Hypertension, Persistent-Newborn
 Pulmonary Sequestration
 Q Fever
 Respiratory Distress Syndrome
 Respiratory Distress Syndrome
 Smoke Inhalation Injury
 Total Anomalous Pulmonary Venous Connection
 Transient Tachypnea of the Newborn
 Transposition of the Great Arteries
 Tricuspid Atresia
 Truncus Arteriosus
 Vascular Ring, Double Aortic Arch
 Vascular Ring, Right Aortic Arch