Pneumonia in children

Definition
• Pneumonia is defined as an acute infectious
inflammatory disease of various nature with
involving of lower respiratory tract into pathologic
process and intra-alveolar inflammatory
exudation.
• Upper panel shows a
normal lung under a
microscope. The white
spaces are alveoli that
contain air.
• Lower panel shows a
lung with pneumonia
under a microscope.
The alveoli are filled
with inflammation
 Вставка рисунка
Pneumonia fills the
lung's alveoli with fluid,
hindering oxygenation.
The alveolus on the left is
normal, whereas the one
on the right is full of fluid
from pneumonia.
Epidemiology
• Globally the incidence of pneumonia in children <
5 years in developing countries is 0.28 episodes
per child - year (150 ml/year), compared to 0.05
episodes per child - year in developed countries.
• Pneumonia is responsible for 18% of death (2
ml/year) in young children worldwide, mostly
occurring in developing countries with a limited
access to the healthcare system.
 Сlassification
By location acquired:
• Community Acqiured Pneumonia (CAP)
• Hospital Acquired Pneumonia (HAP)

Вy area of lung affected:

• Focal
• Segmental
• Polysegmental
• Lobar
• Interstitial

By the presence of complications:

• Сomplicated
• Uncomplicated

By severity:
• Non-severe
Сlassification: by location acquired
• Community Acqiured Pneumonia (CAP)
• Hospital Acquired Pneumonia (HAP)

• CAP can be defined as pneumonia in previously healthy

children caused by an infectious agent contacted outside
the hospital.
• Hospital-acquired pneumonia, also called nosocomial
pneumonia, is pneumonia acquired during or after
hospitalization for another illness or procedure with onset
at least 72 hrs after admission.
Сlassification: by area of lung affected

• Focal pneumonia
• Lobar pneumonia
• Interstitial pneumonia
• Segmental
• Polysegmental
Lobar pneumonia
• A lobar pneumonia is an infection that only
involves a single lobe, or a section of a lung.
• Lobar pneumonia is often due to Streptococcus
pneumoniae (Klebsiella pneumoniae is also
possible).
Right upper lobe
pneumonia
Right upper lobe
consolidation in a
patient with bacterial
pneumonia
 Right lower
lobe
pneumonia

Right lower lobe

consolidation in a
patient with
bacterial
pneumonia
Right upper
lobe
pneumonia
 -

Lobar
pneumonia
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Focal pneumonia

• Focal pneumonia affects the lungs in patches

around the bronchi or bronchioles.
Focal pneumonia
Focal pneumonia
of the lower lobe
of the right lung
Focal pneumonia
Focal pneumonia
Segmental pneumonia

• Segmental pneumonia - pneumonia limited to

one anatomic segment of lung tissue
Interstitial pneumonia

• Interstitial pneumonia involves the areas in

between the alveoli, and it may be called
"interstitial pneumonitis».
• It is more likely to be caused by viruses or by
atypical bacteria.
Interstitial pneumonia
Interstitial pneumonia
Сlassification: by the presence of
complications
• Uncomplicated
• Сomplicated
Pulmonary complications
- pleural empyema (pleurisy exudative)
- pyopneumothorax
- lung abscess
- necrotising pneumonia
- Acute respiratory distress
Systemic complications
- sepsis
- hemolytic uremic syndrome
Pleural effusion
• Pleural effusion refers to a pathologic accumulation of
pleural fluid in the pleural cavity that has been caused by
either inflammation (pleuritis) or other diseases.
• If the pleural effusion is the result of pneumonia, it is
called a parapneumonic effusion. These effusions, in
particular, tend to become infected and are then further
classified, by using various parameters,
as uncomplicated (= not infected), complicated (=
infected), or pleural empyema (= infected).
A left-sided
pleurisy
exudative
A right-sided Вставка рисунка
pleurisy
exudative
A left-sided
pleurisy
exudative
A right-sided
Вставка рисунка
pyopneumothora
x
A right-sided Вставка рисунка
pyopneumothora
x
Lung
abscess
Necrotisin
g
pneumoni
a
Congenital pneumonia
• Congenital pneumonia is called such because infection
and inflammation occur during pregnancy or childbirth.
• The cause of this pneumonia is an infectious agent that is
in the body of a woman and can become more active
during pregnancy, or the pathogen is activated during
labor.
• Therefore, all congenital pneumonia can be divided into
antenatal (those that develop in utero to the time of
delivery) and intranatal (develop during childbirth).
Etiology
Organisms causing pneumonia
• bacteria
• viruses
• fungi
• protozoans
Etiology

• Most cases of pneumonia are preceded by acute

viral bronchitis.
• Viruses facilitate infections with pathogenic
microorganisms colonizing nasopharynx.
• These pathogens include Streptococcus
pneumoniae, Haemophilus influenzae and
Moraxella catarrhalis.
Etiology
• Etiological factor of pneumonia can be identified
in no more than 65-86% patients combining
multiple diagnostic tools including culture,
serology and PCR .
• In everyday clinical practice these methods are
rarely used and treatment remains empiric based
on national and international guidelines.
Viruses
Viruses are responsible for 30-67% cases of CAP, and are
the most common in children <2
• respiratory syncytial virus (13-29%)
• rhinovirus (3-45%)
• adenovirus (1-13%)
• influenza (4-22%)
• parainfluenza virus (3-10%)
• human metapneumovirus (5-12%)
• coronavirus

Viruses are identified either in combination with bacteria or

alone.
Bacteria
In older children bacterial infections are more
frequent
• Streptococcus pneumoniae (30-44% of CAP)
• Mycoplasma pneumoniae (22-36%)
• Chlamydophila pneumoniae (5-27%)
• Haemophilus influenzae type B (5-9%)
• Staphylococcus aureus, Moraxella catarrhalis (1.5-4%)
• Bordatella pertussis, Streptococcus pyogenes (1-7%)
 The most common bacterial
causative agent of pneumonia,
depending on age
 Streptococcus pneumoniae
• Streptococcus pneumoniae is the
most common pathogen in CAP in
children and the most common cause
of pneumonia mortality in children
worldwide.
• There are 92 known pneumococcal
serotypes that differ by
polysaccharide capsule. It was found
that serotypes are correlated with
different pneumonia outcomes.
• In pediatric patients serotypes 7F,
23F and 3 were correlated with the
highest risk of death in the course of
invasive pneumococcal disease.
Etiology
• 8-40% of cases represent a mixed viral - bacterial or
bacterial - bacterial infection
• Primary viral infection predisposes to bacterial
pneumonia: influenza epidemics in developed countries
coincide with epidemics of Streptococcus pneumoniae
and Staphylococcus aureus pneumonias.
Signs and symptoms
Pneumonia is typically diagnosed based on a combination
of physical signs and a chest X-ray.
• fever (present in 88-96% of children with radiologically
confirmed pneumonia)
• toxic appearance
• сough
• signs of respiratory distress: tachypnoe, history of
breathlessness or difficulty in breathing – chest
retractions, nasal flaring, use of accessory muscles of
respiration
• chest pain
• abdominal pain (referred pain from the diaphragmatic
pleura might be the first sign of pneumonia in little
 Tachypnoe defined according to
WHO criteria
• Tachypnoe is a very
Age Respiratory
sensitive marker of rate/minute
pneumonia. 0-2 months >60
• 50-80% of children with
2-12 months >50
WHO defined tachypnoe
had radiological signs of 1-4 years >40
pneumonia, and the
≥ 5 years >20
absence of tachypnoe is
the best single finding for
ruling out the disease
Severity of pneumonia
• Based on clinical symptoms pneumonia
can be divided into severe pneumonia that
requires hospitalization and non-severe.

Signs of severe pneumonia:

- Cough or shortness of breath + at least
one of the following symptoms:
- central cyanosis or SpO2 < 90% (according
to pulse oximetry);
- respiratory failure II or more degree;
- systemic danger signs (inability to
Physical examination
• Dullness to percussion.
• Diminished breath sounds over affected site,
bronchial breath sounds (specific for lobar
consolidation).
• Crackles (present in 33-90% of children with
pneumonia).
Physical examination

• Presence of wheeze, especially in the absence of

fever, makes the diagnosis of typical bacterial
pneumonia unlikely.
• It is, however, a common sign in viral and
Mycoplasma pneumonia (up to 30%) infection.
Additional tests

• Blood test
• Pulsoximetry
• Chest X-ray
Blood test
• ↑ WBC > than 18×109/l
- suggests bacterial
process
• ↑ ESR
Pulsoximetry
• Pulsoximetry should be performed in all children
with pneumonia since its results facilitate
assessment of severity.
• Pulsoximetry should be performed in all children
admitted to hospital.
CT scan
• A CT scan can give
additional information
in indeterminate cases.
• CT scans can also
provide more details in
those with an unclear
chest radiograph.
• However, CT scans
are more expensive,
have a higher dose of
radiation, and cannot
 Microbiological investigations
• Determining the specific pathogen in children with CAP is
difficult, not cost-effective and typically does not alter
management.
• Little children do not expectorate sputum, nasopharyngeal
swabs are not reliable since bacteria present in the upper
airways are not necessarily the same as those causing
pneumonia.
• British Thoracic Society (BTS) standards, Pediatric
Infectious Diseases Society guidelines as well as
American Academy of Pediatrics Policy statements do not
recommend microbiological investigation of the child with
pneumonia treated as an outpatient.
• For patients admitted to the hospital, especially those
Microbiological investigations
• Blood cultures are positive in <10% of patients with
pneumonia and < 2% of patients treated in the outpatient
setting.
• They should, nevertheless, be performed since if positive,
they provide information on CAP etiology and antibiotic
resistance.
• In children with complicated pneumonia prevalence of
bacteremia vary from 7.8% to 26.5% in pneumonia with
parapneumonic effusion.
Microbiological investigations
• Sputum is difficult to obtain in small children. Sputum
induced by inhalation with 5% hypertonic saline has much
higher bacterial yield and seems to be a valuable tool in
microbiological diagnosis in children with CAP.
• Aspirated pleural fluid should be sent for microscopy,
culture and antigen detection.
• Cultures are positive in 9% - 18% of cases (sensitivity
23%, specificity 100%). Pneumococcal antigen detection
in pleural fluid has sensitivity of 90% and specificity of
95%. Pleural fluid should be checked for Mycobacteria.
Pleural empyema (pleurisy exudative)
• Empyema is defined as the accumulation of purulent fluid
in the pleural cavity.
• Empyema should be suspected in every child with
pneumonia with a history of prolonged fever, tachypnoe,
pain on abdominal palpation, pleuritic chest pain, splinting
of the affected side and persistence of high serum C-
reactive protein levels.
• The clinical examination can reveal an asymmetric chest
expansion, with delayed expansion on the side of the
effusion, dullness on percussion, auscultation presents as
decreased or inaudible breath sounds over the effusion.
Pleural empyema (pleurisy
exudative)
• Chest X-ray shows homogenous opacity over the entire
lung (large effusion).
• A method of choice for radiologic evaluation of patients
with empyema is ultrasonography.
• It helps estimate the amount of fluid, its echogenicity,
detects loculations and fibrin strands and is used to guide
invasive procedures.
 Management
Indications for hospital referral
• clinical signs of severe pneumonia
• signs of sepsis or septic shock
• young age – < 6 months of life
• hypoxemia – oxygen saturation < 93%
• underlying conditions eg. congenital heart defect, cystic
fibrosis, bronchopulmonary dysplasia, immune
deficiencies
• diffuse radiological changes: multilobar pneumonia,
pleural effusion
• outpatient treatment failure
• parents’ inability to manage the illness at home
Management
• All children treated for pneumonia should be reassessed
in 48 hours if there is no clinical improvement or
deterioration and persistence of fever.
• A child should improve as evaluated by clinical symptoms
and laboratory inflammatory markers in 48-72 hours after
initiation of adequate treatment.
• Failure to improve warrants further investigation for
possible complications, resistant microorganisms or
alternative diagnosis.
Antibiotic treatment

• The first dose of antibiotics should be given as

soon as possible.
• Antibiotic choice depends initially on the
characteristics of the person affected, such as
age, underlying health, and the location the
infection was acquired.
Antibiotic treatment for CAP

• Amoxicillin (the first line for community-acquired

pneumonia)
• Amoxicillin/clavulanic acid
• Cephalosporins (second or third-generation)
• Macrolides (such as azithromycin)
Antibiotic treatment for HAP
• Cephalosporins (third and fourth generation)
• Carbapenems
• Aminoglycosides
• Vancomycin
Antibiotic treatment
• Children with non-severe pneumonia can be treated with
oral antibiotics.
• Intravenous route of antibiotic administration is necessary
for children with severe, complicated pneumonia or sepsis
for whom intravenous amoxicillin, amoxicillin/clavulanic
acid, cefuroxime, cefotaxime or ceftriaxone are
recommended.
• Duration of antibiotic therapy is 7-10 days (3-4 days after
temperature normalization)
 Antibiotic treatment
• For Streptococcus pneumoniae resistant to penicillin
preferred treatment consists in vancomycin, linezolid.
• PIDS recommends levofloxacin for children from 6 months
of age as preferred choice for oral therapy.
• Macrolide antibiotics may be added if Mycoplasma
pneumoniae or Chlamydophila pneumonia are suspected
when the child is not improving after 24 - 48 hours or in
very severe cases.
• They are not recommended as first choice antibiotics
because up to 40% of currently isolated in strains of S.
pneumoniae are resistant to macrolides.
Antibiotic treatment
• According to PIDS guidelines, however, all children
treated in hospital should receive antibiotics intravenously
to provide reliable blood and tissue concentrations.
• In hospitalized children suspected of S. aureus infection
vancomycin or clindamycin should be added to beta-
lactam therapy.
• For children with penicillin allergy recommended drugs
are cephalosporins and in case of type-I allergic reactions
macrolides, vancomycin or clindamycin are suggested.
• In children who do not tolerate vancomycin or
clindamycin, linezolid may be administered.
• Antibiotic should be changed according to results of
culture and sensitivity if these tests are positive.
Other methods of therapies
• Hospitalized hypoxemic children should be given oxygen
to maintain oxygen saturation > 92%.
• Dehydrated children should be provided adequate amount
of oral fluids and if unable to drink should receive
intravenous fluids.
• Up to date there have been no studies proving beneficial
effects of chest physiotherapy in children with pneumonia
and therefore chest physiotherapy should not be
performed.
Treatment of pleural empyema
• Conservative treatment with antibiotics is recommended
for small effusions (Many patients improve with
conservative treatment alone).
• Management of moderate effusions depends on child’s
degree of respiratory compromise: if clinical condition is
good, treatment with antibiotics is appropriate and if the
child presents signs of respiratory distress, treatment is
the same as for large effusions: fluid should be removed
either by tube thoracocentesis (for not loculated fluid) or
chest tube with fibrinolytics.
• Once the chest tube is inserted, no more than 10 ml/kg of
fluid in little children and 1.5 liters of fluid in older children
and adolescents should be removed in order to avoid re-
expansion pulmonary edema.
Prevention
Non-specific prevention measures
• improving nourishment
• reducing tobacco smoke exposure
• promoting breast-feeding for the first 6 months of age
• specific infection control measures (hand-washing,
avoiding individuals with signs of respiratory tract
infections).
Prevention
Specific prevention measures - Vaccinations
• Influenza virus
• Streptococcus pneumoniae
• Haemophilus influenzae
• Measles virus
• Varicella virus
• Bordatella pertussiss
• Mycobacterium tuberculosis
• Since introduction of conjugate pneumococcal vaccine
(PCV7) to national immunization programs in the USA
and Europe the incidence of pneumococcal pneumonia
has decreased (by 65% in the USA) and rates of CAP
hospitalizations have decreased for children <1 but seem
to be increasing for children > 5.
• At the same time the incidence of severe pneumonia
requiring hospital management as well as complicated
pneumonia seems to be increasing.
IMMUNIZATION SCHEDULE IN INDIA 2020
Conclusion: COVID-19 has distinct features in children. The disease severity is mild.
Current diagnosis is based mainly on typical ground glass opacities on chest CT,
epidemiological suspicion and contact tracing.
• A 3-year-old boy was admitted to hospital with the
complaints about body temperature rise up to 38.1С,
sickness, loss of appetite, productive cough.
• Anamnesis of the disease: The child has been ill for a
week. The disease began acutely with body temperature
rise up to 37.6С, dry cough, nasal catarrh. Expected
treatment was provided. On the fifth day of the disease
the body temperature ran up to 38.3С, cough
intensified, the child became weak. A Primary care
pediatrician referred the child to hospital treatment.
• Life history: The child is first born, the first term vaginal
labor. Birth weight is 3700 g, length is 52 cm. Apgar score
is 8. Formula-feeding was from 6 months. No chronic
diseases. The child suffer from acute respiratory infection
6-8 times per year. The child visits nursary school.
• Objective status: Moderately grave condition, the child is