Infectious Pediatric Pneumonia

Author: Roberta D. Hood, HBSc, MD, CCFP

Lecturer, University of Toronto
Date Created: December 2011


Global Health Emergency Medicine Teachi ng Modules by GHEM is licensed under
a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.
Learning Objectives
To describe the presentation of pediatric
pneumonia
To outline the management of pediatric
pneumonia
To summarize the complications of pediatric
pneumonia
To highlight interventions to prevent and
protect against pediatric pneumonia
Outline
Quiz
Epidemiology and Pathophysiology
Patient History
Presentation and Diagnosis
Management and Disposition
Further Testing
Complications
Treatment
Interventions to Protect
Interventions to Prevent
Summary Key Points
Case
Quiz Results

Quiz Question 1
What illness is the number one killer of
children?
A. Diarrheal Disease
B. HIV/AIDS
C. Malaria
D. Pneumonia
Quiz Question 2
What is the most sensitive and specific sign of
pneumonia in children?
A. Difficulty breathing
B. Fever
C. Tachypnea
D. Tachycardia
Quiz Question 3
If available, a chest x-ray should be done for
children with possible pneumonia:
A. When a diagnosis is made
B. When a history of tachypnea is present
C. When antibiotics are started
D. When complications are suspected

Quiz Question 4
Which of the following immunization
effectively reduce pneumonia mortality in
children?
A. Haemophilus influenzae b Vaccine
B. Pneumococcal Conjugate Vaccine
C. Measles Vaccine
D. All of the above
What is Pneumonia?
Pneumonia: an acute infection of the
pulmonary parenchyma

The term Lower Respiratory Tract
Infection (LRTI) may include pneumonia,
bronchiolitis and/or bronchitis
Epidemiology and Pathophysiology
Epidemiology
Pneumonia kills more children under the
age of five than any other illness in every
region of the world.
It is estimated that of the 9 million child
deaths in 2007, 20% (1.8 million) were due
to pneumonia
Approximately 98% of children who die of
pneumonia are in developing countries.



Epidemiology Dadaab and Kakuma
Refugee Camps (Kenya)
Data collected from 2007-2011 revealed
that acute respiratory infections are the
leading cause of morbidity and mortality in
the camps.
In Dadaab camp acute respiratory
infections were associated with 30% to
40% of deaths of children less than 5 years
of age and up to 45% of morbidity in the
same age group.

Millennium Development Goal
In 2000, the United Nations Member States
committed to Millennium Development
Goal 4 to reduce the under five
mortality rate by two thirds by 2015,
compared to 1990.
Millennium Development Goal 4 can only
be achieved by an intensified effort to
reduce pneumonia deaths.

Question:
Is reducing the incidence, morbidity, and
mortality of pneumonia in children a high
priority in the region where you practice?

What is being done in your area?
Basic Pathophysiology
Most cases of pneumonia are caused by
the aspiration of infective particles into the
lower respiratory tract.
Organisms that colonize a childs upper
airway can cause pneumonia.
Pneumonia can be caused by person to
person transmission via airborne droplets.


Etiology
The common pathogens are a function of the
patients age.
The specific agent causing pneumonia can be
determined in 1/3 to 2/3 of cases when
cultures, antigen detection and serologic
techniques are available.
It is helpful to be aware of local outbreaks as
clustering of cases is common.

Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
Newborn Group B Streptococci
Gram-negative bacilli
Listeria monocytogenes
Herpes Simplex
Cytomegalovirus
Rubella
1-3 months Chlamydia trachomatis
Respiratory Syncytial virus
Other respiratory viruses
3-12 months Respiratory Syncytial virus
Other respiratory viruses
Streptococcus pneumoniae
Haemophilus influenzae
Chlamydia trachomatis
Mycoplasma pneumoniae
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
Pneumonia - Common Pathogens
Age Group Common Pathogens (in Order of Frequency)
2-5 years Respiratory Viruses
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae
Chlamydia pneumoniae
5-18 years Mycoplasma pneumoniae
Streptococcus pneumoniae
Chlamydia pneumoniae
Haemophilus influenzae
Influenza viruses A and B
Adenoviruses
Other respiratory viruses
From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition.
American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.
Pneumonia History
Pneumonia History Fundamentals
Age
Presence of cough, difficulty breathing,
shortness of breath, chest pain
Fever
Recent upper respiratory tract infections
Associated symptoms (e.g.. headache,
lethargy, pharyngitis, nausea, vomiting,
diarrhea, abdominal pain, rash)
Duration of symptoms


Pneumonia History
Immunizations status
TB exposure
Maternal Chlamydia, Group B Strep status
during pregnancy
Choking episodes
Previous episodes
Previous antibiotics
Pneumonia History
Ill contacts
Travel history
Day care attendance
Animal exposure

Dehydration is a sign of severe infection that
may require hospitalization. Inquire about:
Fluid and nutrition intake
Urine output



History Fundamentals
Past Medical History
Birth History
Medications
Allergies
Immunization Status
Home Environment
Social History
Family History
Diagnosis
Diagnosis Objectives
Recognition of the signs of pneumonia
Diagnosis in a community setting
Diagnosis in a health care setting
Differential Diagnosis RSV and TB
Diagnosis in the context of malnutrition,
and considering HIV
Recognition of Signs of Pneumonia
Tachypnea is the most sensitive and
specific sign of pneumonia

Tachypnea had a Sensitivity of 61% and
79% and Specificity of 79% and 65% for
pneumonia in malnourished and well-
nourished Gambian children respectively




WHO Definition of Tachypnea
Age Respiratory
Rate
(breaths/min)
Indication of
severe
infection
(breaths/min)
< 2 months > 60 >70
2 to 12 months > 50
12 months to 5
years
> 40 >50
Greater than 5
years
> 20
Other signs of pneumonia -
Indrawing
out---breathing---in
Lower chest wall indrawing: with inspiration,
the lower chest wall moves in
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
Other signs of pneumonia -
Nasal Flare
Nasal flaring: with inspiration, the side of the
nostrils flares outwards
From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000
https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012
Diagnosis in Community Setting
SIGNS
Classify AS Treatment
Tachypnea
Lower chest wall
indrawing
Stridor in a calm child
Severe Pneumonia Refer urgently to hospital for
injectable antibiotics and oxygen
if needed
Give first dose of appropriate
antibiotic
Tachypnea Non-Severe
Pneumonia
Prescribe appropriate antibiotic
Advise caregiver of other
supportive measure and when to
return for a follow-up visit
Normal respiratory rate Other respiratory
illness
Advise caregiver on other
supportive measures and when to
return if symptoms persist or
worsen
From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Childrens Fund (UNICEF), 2006.
Infants at Risk of Pneumonia
Infants less than 3 months old with signs of
pneumonia should be referred immediately
to the nearest health facility because they
are at high risk of severe illness and death.

Infants who were premature, and those
with congenital heart disease or chronic
lung disease are also at increased risk.

Diagnosis in a Health Care Setting
Vital signs that should routinely be taken in an
Emergency Care setting include:
Respiratory Rate
Heart Rate
Temperature
Oxygen saturation (if available)

Any child with an increased respiratory
rate should be immediately identified as
having possible pneumonia.
Vital Signs
Both heart rate and respiratory rate are
influenced by the presence of fever.
Heart rate increases by approximately 10
beats per minute for each 1 degree
Celsius.
Respiratory Rate has been estimated to
vary by 0.5-2 breath per minute to 5-11
breaths per minute for each 1 degree
Celsius.
Does this infant child have pneumonia?
The Rational Clinical Exam, Journal of the
American Medical Association
Observation of the infant is the most
important part of the examination does the
child look sick?
Respiratory rate should be calculated over
two thirty second intervals, or one minute due
to moment to moment variability.
Auscultation is unreliable when examining
infants.

Does this infant child have pneumonia?
Absence of tachypnea is the best individual
finding for ruling out pneumonia.
Chest indrawing, other signs of increased
work of breathing and abnormal findings
on auscultation can be used toward ruling in
pneumonia.
If clinical signs are negative (respiratory rate,
auscultation, and work of breathing), it is
unlikely that there will be chest x-ray findings.
Pneumonia Severity Assessment
Mild Severe
Infants Temperature <38.5 C
RR < 50 breaths/min
Mild recession
Taking full feeds
Temperature >38.5 C
RR > 70 breaths/min
Moderate to severe recession
Nasal Flaring
Cyanosis
Intermittent Apnea
Grunting Respirations
Not feeding
Older Children Temperature <38.5 C
RR < 50 breaths/min
Mild breathlessness
No vomiting

Temperature >38.5 C
RR > 50 breaths/min
Severe difficulty in breathing
Nasal Flaring
Cyanosis
Grunting Respirations
Signs of dehydration
From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Childrens Fund (UNICEF), 2006.
Differential Diagnosis:
A Focus on Respiratory Syncytial Virus
(RSV)
Respiratory Syncytial Virus (RSV)
RSV is the most common cause of LRTIs in
children less than 1.
Infants and young children typically present
with pneumonia or bronchiolitis.
Older children may have upper respiratory
tract infection symptoms.
RSV is associated with apnea in infants.
Wheezing is common.


RSV Seasonality
Seasonal outbreaks occur throughout the
world.
In the northern hemisphere outbreaks peak in
January and February.
In the southern hemisphere outbreaks peak in
May, June and July.
In tropical climates outbreaks are often
associated with the rainy season.
Differential Diagnosis:
Consider Tuberculosis
Tuberculosis
Common symptoms of tuberculosis include:
Chronic cough that has been present for
more than 3 weeks and is not improving
Fever greater than 38C for at least two
weeks, not attributable to other common
causes
Weight loss or failure to thrive
Tuberculosis
Physical exam findings of children with
pulmonary tuberculosis are similar to
those of a lower respiratory tract infection.
In children less than age five tuberculosis can
progress rapidly from latent infection to active
disease and serve as a sentinel case in the
community.
Consider the diagnosis of tuberculosis,
especially in those children who fail to
respond appropriately to routine treatment for
pneumonia.


Pneumonia in Malnourished
Children
Pneumonia in Malnourished Children
History of cough, fast breathing and difficulty breathing
were significant predictors of pneumonia in
malnourished children.
Only difficulty breathing was a significant predictor of
pneumonia in well-nourished children.
As malnourished children are a high risk group, those
who present with a history of cough, fast breathing, or
difficulty breathing should be treated with antibiotics.
Fast breathing and lower chest wall indrawing are not
specific predictors of pneumonia in malnourished
children.

Pneumonia and HIV infected
Children
Pneumonia and HIV infected Children
The prevalence of HIV-1 in children admitted with
severe pneumonia (by WHO criteria) in Africa is 55-
65%.
The case fatality rate is 20-34%.
This case fatality rate is 3-6 times higher for children
infected with HIV compared to those not infected with
HIV.
Pneumonia caused by Pneumocystis jiroveci may be
the first indicator of HIV infection, and lead to HIV
testing and diagnosis.
Question:
How are children who may have pulmonary
tuberculosis identified and treated?

Malnourished children, and children with
HIV are at high-risk for complications
associated with pneumonia. How are these
children managed where you practice?


Management and Disposition
Disposition
The decision whether the patient would be best
managed at home or in a heath care setting is
based on many factors, including the resources
available.

Admission Considerations
If caregivers are unable to care for the child,
or to commit to following a treatment plan, the
child should be admitted to a health care
facility.
Any child less than three months of age.
Failure of outpatient treatment (worsening or
no response to treatment after 24 to 72
hours).
Family lives in a remote area.

Indications for Admission - IMCI
All Children with Very Severe Pneumonia
need admission
Very Severe Pneumonia includes any of:
Cough or difficult breathing plus at least one of the following:
Central cyanosis
Inability to breastfeed or drink, or vomiting everything
Convulsions, lethargy or unconsciousness
Severe respiratory distress (e.g. head nodding)
Some or all of the other signs of pneumonia (tachypnea,
grunting, nasal flare, indrawing, changes in auscultation)

Indications for Admission
Age Group Indications for Admission to Hospital
Infants Oxygen Saturation <= 92%, cyanosis
RR > 70 breaths /min
Difficulty in breathing
Intermittent apnea, grunting
Not feeding
Family not able to provide appropriate observation or supervision
Older Children Oxygen Saturation <= 92%, cyanosis
RR > 50 breaths /min
Difficulty in breathing
Grunting
Signs of Dehydration
Family not able to provide appropriate observation or supervision
From: British Thoracic Society (BTS) of Standards of Care Committee.
BTS Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax. 2002;57: i1-i24.
In-Patient Management
Consideration must be given to the provision
of adequate hydration, oxygenation, nutrition,
antipyretics and pain control.
Monitoring should include:
Respiratory rate
Work of breathing
Temperature
Heart rate
Oxygen saturation (if available)
Findings on auscultation.
In-Patient Considerations
Due to the risk of transmission, a child
suspected of having pneumonia should be
cared for in an area that is isolated from
others to who are at risk of becoming infected.
Contact precautions by health care workers
such as hand washing, gloves, gowns and
masks to prevent transmission between
patients are often appropriate.
Criteria for Intensive Care
If intensive care is available consider the following:
The patient is failing to maintain an oxygen
saturation of > 92% in FiO2 of > 0.6.
The patient is in shock.
There is a rising respiratory rate and rising pulse
rate with clinical evidence of severe respiratory
distress and exhaustion, with or without a raised
arterial carbon dioxide tension (PaCO2).
There is recurrent apnea or slow irregular
breathing.
Management of Respiratory Distress
and Respiratory Failure: ABCs and
Intubation
Airway
Support the airway (position of comfort for
the child) or open the airway (chin lift or jaw
thrust).
Clear the airway (suction nose and mouth,
remove any foreign body).
Insert an oropharyngeal or nasopharyngeal
airway as indicated.

Breathing
Assist ventilation (e.g., bag-mask
ventilation) as needed
Provide oxygen
Continuously monitor oxygen saturation
Consider use of CPAP or BIPAP
Prepare for endotracheal intubation as
needed
Administer medications as needed

Circulation
Monitor heart rate and rhythm
Establish vascular access as indicated (for
fluid therapy and medications)
Indications for Intubation
Inadequate oxygenation or ventilation
Inability to maintain and/or protect the
airway
Potential for clinical deterioration
Prolonged patient transport or diagnostic
studies



Indications for Intubation
Respiratory failure is the most common indication for
intubation in children with pneumonia

Clinical evidence of respiratory failure:
Poor or absent respiratory effort
Poor colour
Obtunded mental status

Oxygen saturation and end-tidal carbon dioxide can be
used to support the decision to intubate, but intubation
should not be delayed if there is clinical evidence of
respiratory failure


Relative Contraindications to Intubation
No absolute contraindications

Caution using rapid sequence intubation with
neuromuscular blockade in a child difficult to
bag and mask
High-risk intubation (e.g.. suspected
epiglottitis)
Airway trauma that may require a surgical
airway
Intubation Pointers
Detailed Pediatric Airway management is
beyond the scope of this module

Endotracheal tube size calculations:
Uncuffed tube = 4 + (age in years/4)
Cuffed tube = 3.5 + (age in years/4)

Ventilation: begin with 8-10 breaths per
minute
Question:
What resources do you have available to
care for children with pneumonia?

What are the criteria for hospital admission/
transfer to another facility/intensive care
where you practice?
Further Testing
Chest X-ray
Confirmation of pneumonia by chest x-ray
is not indicated in children with mild,
uncomplicated lower respiratory tract
infections who will be treated at
outpatients.

Chest X-ray
A study in South Africa randomized children
age 2-59 months who met the WHO case
definition of pneumonia to have a chest x-ray,
or not.
There was no clinically identifiable subgroup of
children within the WHO case definition who
were found to benefit from a chest x-ray.
It was concluded that there was no benefit in
routine chest x-ray of ambulatory children with
lower respiratory-tract infection over two
months of age.

Chest X-ray
Consider if available and:
Infection is severe
Diagnosis is otherwise inconclusive
To exclude other causes of shortness of
breath (e.g.. foreign body, heart failure)
To look for complications of pneumonia
unresponsive to treatment (e.g.. empyema,
pleural effusion)
To exclude pneumonia in an infant less than
three months with fever


Right Upper Lobe Pneumonia
Right Middle Lobe Pneumonia


Laboratory Investigations
Routine blood work is not required in children
with uncomplicated lower respiratory tract
infections who will be treated as outpatients
Tests to consider if available:
CBC, particularly WBC
Electrolytes, particularly Sodium
Consider blood cultures, sputum cultures
HIV and TB testing as appropriate


Question:
What tests do you have readily available to
assist in the management of a child with
complications of pneumonia?

What other testing could reasonably be
arranged?
Complications
Complications of Pneumonia
Pleural effusion fluid in the pleural space
as the result of inflammation.
Empyema bacterial infection in the pleural
space.
Parapneumonic effusions develop in
approximately 40% of patients admitted to
hospital with bacterial pneumonia.
If an effusion is present and the patient is
persistently febrile, the pleural space should
be drained.

Complications of Pneumonia
Necrotizing Pneumonia necrosis or
liquefaction of lung parenchyma.
Lung Abscess A collection of inflammatory
cells leading to tissue destruction resulting in one
or more cavities in the lungs. A rare complication.
Treatment of both Necrotizing Pneumonia and
Lung Abscess involves long term parenteral
antibiotics for 2-4 weeks, or 2 weeks after the
patient is afebrile, and has clinically improved.

Complications of Pneumonia
Pneumatocele thin walled, air filled cysts
of the lung, often occurs with empyema.

Pneumatoceles often resolve
spontaneously, but may lead to
pneumothorax.

Complications of Pneumonia
Hyponatremia:
Serum sodium <135 mmol/L.
Studies in India (1992) revealed that in children
hospitalized with pneumonia, 27% had
hyponatremia and 4% had hypernatremia.
SIADH was the most common cause of
hyponatremia.
Hyponatremia is associated with increased
hospital stay, complications and increased
mortality, however most cases were found to be
mild.

Treatment
Treatment - Epidemiology
Antibiotics serve an essential role in reducing
child deaths from pneumonia.

Limited data suggest that in the early 1990s
less than one in five children with pneumonia
received antibiotics.

Children in urban areas, and those with well
educated mothers were more likely to receive
antibiotics.
Treatment Oral Antibiotics
Common medications for treating pneumonia:
Penicillins: Amoxicillin, Amoxicillin-
Clavulanate
Sulfonamides: Co-trimoxazole
Macrolides: Azithromycin, Clarithromycin,
Erythromycin
2
nd
generation Cephalosporins: Cefaclor
Dose according to childs weight

Treatment IV Antibiotics
Common medications for treating pneumonia:
Penicillins: Amoxicillin, Ampicillin, Benzyl
Penicillin
2
nd
generation Cephalosporins: Cefuroxime
3
rd
generation Cephalosporins: Cefotaxime
Dose according to childs weight

Treatment IMCI Guidelines
Antibiotic therapy
Chloramphenicol (25 mg/kg IM or IV every 8
hours) until the child has improved. Then continue
orally 3 x/ day for a total course of 10 days.
If chloramphenicol is not available, give
benzylpenicillin (50 000 units/kg IM or IV every 6
hours) and gentamicin (7.5 mg/kg IM once a day)
for 10 days.


Treatment IMCI Guidelines
If the child does not improve within 48
hours,
Switch to gentamicin (7.5 mg/kg IM once a
day) and cloxacillin (50 mg/kg IM or IV every
6 hours), for staphylococcal pneumonia.
When the child improves, continue cloxacillin
(or dicloxacillin) orally 4 times a day for a total
course of 3 weeks.
Outpatient Antibiotic Choice
The British Thoracic Society suggests amoxicillin
as the first line outpatient antibiotic for community
acquired pneumonia in children of all ages.
For children age 5 and older who can be
managed as outpatients, atypical bacteria
mycoplasma pneumoniae and chlamydia
pneumoniae are the most common cause. A
macrolide can be considered as the first line
treatment in these children.
Treatment
In a study conducted in areas of Pakistan
with high levels of Streptococcus
pneumoniae and Haemophilus Influenzae b
resistance to co-trimoxazole, co-
trimoxazole was found to be over 90%
effective in treating cases of non-severe
pneumonia.
In cases of severe pneumonia, amoxicillin
was more effective than co-trimoxazole.
Inpatient Antibiotic Choice
Consider IV 3
rd
Generation Cephalosporin
in a child less than 1 year of age, or who is
not fully immunized, or with severe illness.

Consider IV Ampicillin or Penicillin in a
child over 1 year of age in areas that do not
have a high prevalence of penicillin-
resistant Streptococcus Pneumoniae.
Oral vs. IV Antibiotics
A non-blinded randomized controlled trial in
England found that oral amoxicillin was equivalent
to IV benzyl penicillin for children admitted to
hospital, although the sickest children were
excluded from the study.

Patients were excluded for: wheezing,
hypotension, chronic pulmonary conditions (other
than asthma), immunodeficiency, pleural effusion
requiring drainage, oxygen saturation <85% on
room air.
Treatment
Three studies (two in Gambia, one in
Turkey) published between 1988 and 1995
comparing co-trimoxazole treatment with
parenteral procaine penicillin G, ampicillin,
or chloramphenicol showed no significant
improvement in efficacy with the alternative
antibiotic regimens.

Antibiotic Resistance
Expanded and continued use of antibiotics
to treat pneumonia could make antibiotic
resistance an increasing challenge in the
future.

Increased treatment of pneumonia with
antibiotics must be accompanied by
appropriate training of health care workers
to ensure proper diagnosis and treatment
of pneumonia.
Question:
What antibiotics are commonly used and/or
readily available where you practice?

What are the costs?

What is the antibiotic resistance in your
local area?
Supportive Treatment IMCI
Guidelines
Oxygen therapy

If fever (=>39
o
C) causing distress, give
paracetamol

If wheeze is present, give a rapid-acting broncho-
dilator

Gentle suction any thick secretions in the throat,
which the child cannot clear.
Supportive Treatment IMCI
Guidelines
Ensure that the child receives daily maintenance fluids for
the child's age - avoid overhydration.
Encourage breastfeeding and oral fluids.
If the child cannot drink, insert a NG tube and give
maintenance fluids in frequent small amounts.
If the child is taking fluids adequately by mouth, do not use a
NG tube as it increases the risk of aspiration pneumonia.
If oxygen is given by nasopharyngeal catheter at the same time
as NG fluids, pass both tubes through the same nostril.
Encourage the child to eat as soon as food can be taken.


Interventions to Protect Against
Pneumonia
Interventions to Protect Against
Pneumonia
It is estimated that hand washing, when
combined with improved water and
sanitation could lead to a 3% reduction in
all child deaths.

Promote exclusive breast feeding for 6
months. Impact 15-23% reduction in
pneumonia incidence. 13% reduction in all
child deaths. Shown to be cost effective.



Interventions to Protect Against
Pneumonia
Adequate nutrition throughout the first
five years of life, including adequate
micronutrient intake. Impact 6% reduction
in all child deaths for adequate
complementary feeding (age 6-23 months).

Reduce incidence of low birth weight.
Public Awareness
Tachypnea and respiratory distress are
considered the most important signs in the
diagnosis of pneumonia.

Only 1 in 5 caregivers know that fast
breathing and respiratory distress are a
reason to seek care immediately.

Care Seeking Behaviour
In developing countries only half of the
children with pneumonia are taken to an
appropriate health care provider.
Rates are similar between boys and girls.
Children who are rural, poorer, and those
with less educated mothers are less likely
to be taken to an appropriate health care
provider.
Question:
Are parents and/or caregivers in your area
aware of the signs that indicate their child
should see a health care provider?
Intervention to Protect Against
Pneumonia
Reducing indoor air pollution, by
changing to cleaner gas or liquid fuels or
high-quality, well maintained biomass
stoves, may reduce the incidence of
pneumonia by 22 to 46% in appropriate
settings. This intervention may be cost-
effective in low-income settings.



Intervention to Protect Against
Pneumonia
Reduce Exposure to Second-Hand
Tobacco Smoke.

Both maternal and paternal smoking cause
lower respiratory tract illnesses such as
pneumonia and bronchitis, particularly
during the first year of life.
Question:
Would changing to cleaner cooking options
be helpful in the region where you
practice? Are there cultural barriers to
change?

Would education on smoking cessation be
helpful in your area?


Interventions to Prevent
Pneumonia
Prevention Strategies
Vaccination against measles, Streptococcus
pneumoniae, and Haemophilus influenzae
type b
Zinc supplementation
Prevention of HIV in Children
Co-trimoxazole prophylaxis for HIV-infected
children

Prevention - Vaccination
Three vaccinations have the potential to
significantly reduce childhood deaths from
pneumonia
Haemophilus Influenzae type B (Hib) vaccine and
Pneumococcal conjugate vaccine prevent
infections that directly cause pneumonia
Pneumonia is a possible complication of Measles,
thus prevention of measles would decrease the
incidence of pneumonia.

Prevention - Vaccination
The implementation of Haemophilus
influenzae type b (Hib) and Streptococcus
pneumoniae immunization through an
existing immunization program has been
shown to be cost effective in reducing
pneumonia mortality.
Measles immunization coverage is high
(making cost effectiveness estimates
difficult).
Measles Vaccine 2010
From: WHO. Immunization Surveillance Assessment and Monitoring.
[http://www.who.int/immunization_monitoring/diseases/measles/en/index.html]. Accessed on December 9,2011.
HIB Vaccine 2008
From: GAPP. Geneva: WHO/UNICEF, 2009.
Pneumococcal Conjugate Vaccine 2008
From: GAPP. Geneva: WHO/UNICEF, 2009.
Question:
What immunizations are given in your
area?

Are there plans to expand immunization
programs in your area?
Prevention Zinc Supplementation
Zinc supplementation in Bangladesh has
been shown to reduce pneumonia mortality
in children in children less than 2 years.
Zinc supplementation was also shown to
reduce the incidence of pneumonia, other
upper and lower respiratory tract infections
and diarrhea.
Doses of 70 mg per week have been found
to be effective.
Prevention Zinc Supplementation
Zinc supplementation had been shown to
be cost-effective in reducing pneumonia
mortality.
Prevention of HIV in Children
It is estimated that prevention of HIV in
children would lead to a 2% reduction in all
child deaths.
Prevention Co-trimoxazole
Prophylaxis for HIV-infected Children
Children with features of HIV should receive
daily Co-trimoxazole even in areas of high
bacterial resistance this medicine.

Daily Co-trimoxazole prophylaxis has been
shown to decrease mortality in HIV infected
children.


Co-trimoxazole Prophylaxis
In the CHAP study in Zambia (Lancet, 2004),
a double-blind, randomized placebo controlled
trial, at 19 months the mortality rate for
enrolled children was 28% in the Co-
trimoxazole group and 42% in the placebo
group.
The study was stopped early with the
conclusion that all HIV infected children in
resource poor areas should receive Co-
trimoxazole prophylaxis.

Summary
Key Points
Pneumonia is an acute infection of the
pulmonary parenchyma
Pneumonia kills more children under the age
of five than any other illness.
A diagnosis of pneumonia should be
considered in all children with tachypnea and
difficulty breathing.
Common first-line antibiotics include
amoxicillin and co-trimoxazole .


A Complicated Case from Gambia
Based on a true story
Case Chief Complaints
A 1 year old child is brought in for fever,
cough, lethargy, and mild respiratory
distress increasing over 2 weeks.

You take a focused medical history from
the childs mother.

What are the patients vital signs?



Vital Signs
Vital signs are as follows: Temperature
38.7, Pulse 150, Respiratory Rate 54,
Oxygen Saturation 94% on room air.


What is observed on physical examination?

Physical Examination
On observation the patient clearly appears
septic. Mild respiratory distress is present.
Skin is mottled.


What is the likely diagnosis?
Diagnosis
It is reasonable to make a presumptive
diagnosis of pneumonia based on the
history and vital signs.


What other physical examination
information is immediately relevant to
forming an initial treatment plan for this
patient?



Weight and Hydration Status
The childs weight is z score was minus 2
(but 1 lb more and would have been minus
3 i.e.. severe malnutrition)

The patient appears mildly dehydrated.

What interventions should be started?







Initial Treatment
A presumptive diagnosis of pneumonia is
made. The patient is admitted to the
hospital and started on broad spectrum IV
antibiotics and appropriate hydration and
re-feeding.
The patient does not seem to improve
initially.
What is your differential diagnosis?
Differential Diagnosis
Differential Diagnosis includes:
Pneumonia +/- complications (e.g. Empyema)
Pneumonia in a patient with HIV
Tuberculosis

What is the first investigation you would
order? (assume first choice investigation is
available).

Actual Case Chest X-ray
Chest X-ray Interpretation
The chest x-ray reveals a right sided lobar
infiltrate.



What is the clinical correlation?
Clinical Course
The patient begins to improve clinically.
Fever, cough and respiratory distress resolve.
However, over the next few weeks of
appropriate re-feeding, the patient fails to gain
weight despite remaining on broad spectrum
antibiotics.

What other investigations would you consider?


Other Investigations
HIV test negative
TB skin test unreactive
Sputum culture unable to induce sputum

*Important Note: The mother is no longer
with the patient. Another family member
reports that she is sick with a cough, fever,
and weight loss.*

What other courses of treatment should be
considered in this case?



Treatment and Outcome
The patient was started on treatment for
tuberculosis and began to improve and
gain weight.


This patient did well. The mother and other
close contacts were also treated for
tuberculosis.
Learning Point
This patients x-ray revealed a lobar infiltrate.
Pneumonia commonly presents as a lobar
infiltrate.
Reactivation of TB tends to be apical, but
acute TB can present as a lobar infiltrate.
TB should remain as a differential diagnosis
and be reconsidered if there is a poor
response to treatment, or a possible exposure
history.
Post-Test
Quiz Question 1
What illness is the number one killer of
children?
A. Diarrheal Disease
B. HIV/AIDS
C. Malaria
D. Pneumonia
Quiz Question 2
What is the most sensitive and specific sign of
pneumonia in children?
A. Difficulty breathing
B. Fever
C. Tachypnea
D. Tachycardia
Quiz Question 3
If available, a chest x-ray should be done for
children with possible pneumonia
A. When a diagnosis is made
B. When a history of tachypnea is present
C. When antibiotics are started
D. When complications are suspected

Quiz Question 4
Which of the following immunizations
effectively reduce pneumonia mortality in
children?
A. Haemophilus influenzae b Vaccine
B. Pneumococcal Conjugate Vaccine
C. Measles Vaccine
D. All of the above
Quiz Answers:
1. D. Pneumonia
2. C. Tachypnea
3. D. When complications are suspected
4. D. All of the above


Millennium Development Goal
Please use the information in this presentation
to help achieve Millennium Development Goal
4 to reduce the under five mortality rate
by two thirds by 2015, compared to 1990.

Millennium Development Goal 4 can only be
achieved by an intensified effort to reduce
pneumonia deaths

Further Reading
Considerable content and structure for this presentation
is based on the following reports, which are
recommended for further reading:

Global Action Plan for Prevention and Control of Pneumonia
(GAPP). Geneva: World Health Organization (WHO)/United
Nations Childrens Fund (UNICEF), 2009.

Pneumonia The Forgotten Killer of Children. Geneva: World
Health Organization (WHO)/United Nations Childrens Fund
(UNICEF), 2006.