Pediatric Department Pneumonias in pediatric Age groups Dr.

Kawes Zangana

Pneumonias
Definition: Inflammation of the parenchyma of the lungs.
Etiology: The cause of pneumonia is often difficult to determine because culture of the lung tissue
is invasive and rarely performed. Cultures performed on sputum do not accurately reflect the cause.

1. Infections:
Etiologic Agents Grouped by Age of the Patient
Neonates (<3 wk) Same as sepsis
Frequent Pathogens (In Order of Frequency)
Group B streptococcus, Escherichia coli, other Gram-negative bacilli, Streptococcus pneumonia,
Haemophilus influenzae.
3 wk-3 mo Underlined are atypicals
Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza
viruses, human metapneumovirus, adenovirus), S. pneumonia, H. influenza (type b*, nontypeable); if
patient is febrile, consider Chlamydia trachomatis
4 mo-4 yr
Respiratory syncytial virus, other respiratory viruses (rhinoviruses, parainfluenza viruses, influenza
viruses, human metapneumovirus, adenovirus), S. pneumonia, H. influenza (type b*, nontypeable),
Mycoplasma pneumonia, group A streptococcus
>5 yr
M. pneumonia, S. pneumonia, Chlamydophila pneumoniae, H. influenza (type b*, nontypeable),
influenza viruses, adenovirus, other respiratory viruses,

Recurrent pneumonia: Recurrent pneumonia is defined as 2 or more episodes in a single year or 3

or more episodes ever, with radiographic clearing between occurrences.

Differential Diagnosis of Recurrent Pneumonia

Hereditary Disorders: Cystic fibrosis, Sickle cell disease
Disorders of Immunity
HIV/AIDS, Selective immunoglobulin G subclass deficiencies, Severe combined immunodeficiency
syndrome, Chronic granulomatous disease
Disorders of Cilia
Primary ciliary dyskinesia, Kartagener syndrome
Anatomic Disorders: Pulmonary sequestration, Gastroesophageal reflux, Tracheoesophageal
fistula (H type), Aspiration (oropharyngeal incoordination)
Foreign bodis
Bronchiectasis
Aberrant bronchus
Congenital cystic adenomatoid malformation

Pathogenesis
The lower respiratory tract is normally kept sterile by physiologic defense mechanisms, including
mucociliary clearance, macrophages, secretory immunoglobulin (1g) A, and clearing of the airway
by coughing.

TYPICAL ATYPICAL 1
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 Pediatric Department Pneumonias in pediatric Age groups Dr. Kawes Zangana

Viral pneumonia usually results from spread of infection along the airways, accompanied by direct
injury of the respiratory epithelium, which results in airway obstruction from swelling, abnormal
secretions, and cellular debris. Atelectasis, interstitial edema, and hypoxemia from ventilation-
perfusion mismatch often accompany airway obstruction.
Viral infection of the respiratory tract can also predispose to secondary bacterial infection by
disturbing normal host defense mechanisms, altering secretions, and through disruptions in the
respiratory microbiota.
Bacterial pneumonia most often occurs when respiratory tract organisms colonize the trachea and
subsequently gain access to the lungs, but pneumonia may also result from direct seeding of lung
tissue after bacteremia.

Risk factors: 1. Lung disease (cystic fibrosis. 2. Aspiration (tracheoesophageal fistula and GERD).
3. Neurologic disorders that interfere with protection of the airway or 4. Diseases that alter the
immune system, compromise clearing of the airway.
(immunodeficiency diseases or hemoglobinopathies). 5. Trauma and anesthesia.
Mainly clinically diagnosed
Clinical manifestations Cardinal features are fever, cough and SoB.🔺 Crepit in
1. Non-specific symptoms of an upper respiratory tract infection (rhinitis and cough): severe form
They frequently precede pneumonia by several days.
1. Viral pneumonia in infants: Fever is usually present, but temperatures are generally lower than
in bacterial pneumonia. Tachypnea is the most consistent clinical manifestation of pneumonia.
Increased work of breathing accompanied by intercostal, subcostal, and suprasternal retractions,
nasal flaring, and use of accessory muscles is common. Severe infection may be accompanied by
cyanosis and lethargy, especially in infants.
2.Bacterial and pneumococcal pneumonia in young children and infants: In infants, there may be
a prodrome of upper respiratory tract infection and diminished appetite, leading to the abrupt onset
of fever, restlessness and respiratory distress.
These infants appear ill, with respiratory distress manifested as grunting; nasal flaring; retractions of
the supraclavicular, intercostal, and subcostal areas; tachypnea; tachycardia; air hunger; and often
cyanosis. Results of physical examination may be misleading, particularly in young infants, with
meager findings disproportionate to the degree of tachypnea.
Some infants may have associated gastrointestinal disturbances characterized by vomiting,
anorexia, diarrhea, and abdominal distention secondary to a paralytic ileus.

3. Bacterial pneumonia in older children: It typically begins suddenly with high fever, cough, and
chest pain. Other symptoms that may be seen include drowsiness with intermittent periods of
restlessness; rapid respirations; anxiety; and, occasionally, delirium. In many children, splinting on
the affected side to minimize pleuritic pain and improve ventilation is noted; such children may lie
on one side with the knees drawn up to the chest.
Rapid progression of symptoms is characteristic in the most severe cases of bacterial pneumonia
4. Physical findings: They depend on the stage of pneumonia. Early in the course of illness,
diminished breath sounds, scattered crackles, and rhonchi are commonly heard over the affected
lung field. With the development of increasing consolidation or complications of pneumonia such as
pleural effusion or empyema, dullness on percussion is noted and diminished breath sounds.
Abdominal distention may be prominent because of gastric dilation from swallowed air or ileus.

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 Pediatric Department Pneumonias in pediatric Age groups Dr. Kawes Zangana

Abdominal pain is common in lower-lobe pneumonia. The liver may seem enlarged because of
downward displacement of the diaphragm secondary to hyperinflation of the lungs or
superimposed congestive heart failure.

Diagnosis
1. Chest radiograph (postero-anterior and lateral views): An infiltrate on supports the diagnosis of
pneumonia; the film may also indicate a complication such as a pleural effusion or empyema.
Viral pneumonia is usually characterized by hyperinflation with bilateral interstitial infiltrates and
peribronchial cuffing. Confluent lobar consolidation is typically seen with pneumococcal
pneumonia. A large pleural effusion, lobar consolidation, and a high fever at the onset of the
illness are also suggestive of a bacterial etiology.
2. The peripheral white blood cell (WBC) count: It can be useful in differentiating viral from
bacterial pneumonia. In viral pneumonia, the WBC count can be normal or elevated but is
usually not higher than 20,000/ mm, with a lymphocyte predominance. Bacterial pneumonia is
often associated with an elevated WBC count, in the range of 15,000-40,000/ mm, and a
predominance of granulocytes.
4. Diagnosis of viral pneumonia CBC-ESR-CRP-culture
Viral culture for isolation of a virus.
Serologic techniques:
Polymerase chain reaction is an emerging technology that may help differentiate viral from bacterial
causes of pneumonia.

Diagnosis of bacterial pneumonia: The definitive diagnosis of a bacterial infection requires

isolation of an organism from the blood, pleural fluid, or lung. Culture of sputum is of little value in
the diagnosis of pneumonia in young children, while percutaneous lung aspiration is invasive and
not routinely performed.
Blood culture results are positive in only 10% of children with pneumococcal pneumonia and are
not recommended for nontoxic appearing children treated as an outpatient.
Group A streptococcal pneumonia: Serologic evidence, such as the antistreptolysin O titer, may be
useful in the diagnosis.
Diagnosis of atypical pneumonia caused by C. pneumoniae or M. pneumonia: It is difficult to
distinguish from pneumococcal pneumonia on the basis of radiographic and laboratory findings.
Cold agglutinins at titers >1: 64 are found in the blood in -50% of patients with M. pneumonia
infections Acute infection caused by M. pneumonia can be diagnosed on the basis of a positive
polymerase chain reaction test result or seroconversion in an IgG assay.

Factors Suggesting Need for Hospitalization of Children with Pneumonia

• Age <6 mo
• Sickle cell anemia with acute chest syndrome
• Immunocompromised state
• Toxic appearance
• Moderate to severe respiratory distress
• Hypoxemia (oxygen saturation <90% breathing room air, sea level)
• Complicated pneumonia

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 Pediatric Department Pneumonias in pediatric Age groups Dr. Kawes Zangana

• Severe dehydration
• Vomiting or inability to tolerate oral fluids or medications
• No response to appropriate oral antibiotic therapy
• Social factors (e.g., inability of caregivers to administer medications at home or follow-up

Treatment of suspected bacterial pneumonia: It is based on the presumptive cause, the age, and
clinical appearance of the child. The empirie antibiotic therapy for mildly ill children who do not
require hospitalization may include the following drugs:
Amoxicillin is recommended (high doses of amoxicillin; 90 mg/ kg/ 24 hr because of the emergence
of penicillin-resistant pneumococci).
Therapeutic alternatives include cefuroxime and amoxicillin/clavulanate.
A macrolide antibiotic such as azithromycin is an appropriate choice for school-age children and in
children in whom infection with M. pneumonia or C. pneumoniae is suggested.
Antimicrobial therapy for specific pathogens. Hospitalized children should receive supportive care
and may require intravenous fluids; respiratory support, including supplemental oxygen, continuous
positive airway pressure (CAP), or mechanical ventilation; or vasoactive medications for
hypotension or sepsis
Streptococcus pneumonia: Parenteral therapy: Preferred: ampicillin (150-200 mg per kg/ day every
6 hr), or penicillin (200,000-250,000 U/ kg/ day every 4-6 hr).
Alternatives: ceftriaxone, clindamycin, or vancomycin. Oral therapy (step-down therapy or mild
infection outside the hospital): Preferred: amoxicillin. Alternatives:
second- or third-generation cephalosporin (cefpodoxime, cefixime, cefprozil)

Group A streptococeus: Parenteral therapy: Preferred: intravenous penicillin

(100,000-250,000 U/ kg/ day every 4-6 hr) or ampicillin (200 mg/ kg/ day every 6 hr).
Alternatives: cefriaxone, clindamycin, or vancomycin. Oral therapy (step-down therapy or mild
infection outside the hospital): Preferred: amoxicillin (50-75 mg/ kg per day in 2 doses), or penicillin
V (50-75 mg/kg/day in 3 or 4 doses). Alternative: Oral
clindamycin.
Staphylococcus aureus (methicillin susceptible): Parenteral therapy: Preferred: cefazolin (150 mg/
kg/ day every 8 hr) or semisynthetic penicillin, oxacillin (150-200 mg kg day every 6-8 hr).
Alternatives: clindamycin or vancomycin. Oral therapy (step. down therapy or mild infection outside
the hospital): Preferred: oral cephalexin (75-100 mg/kg/ day in 3 or 4 doses). Alternative: oral
clindamycin.
S. aureus (methicillin resistant, susceptible to clindamycin): Parenteral therapy:
Preferred: vancomycin or clindamycin . Alternatives: linezolid. Oral therapy (step-down therapy or
mild infection outside the hospital): Preferred: oral clindamycin.
Alternatives: oral linezolid.

Haemophilus influenza Parenteral therapy: Preferred: intravenous ampicillin (150-200 mg/ kg day
every 6 hr) if B-lactamase negative, ceftriaxone if B-lactamase producing. Alternatives: intravenous
ciprofloxacin (30 mg/ kg/ day every 12 hr) or intravenous levofloxacin. Oral therapy (step-down
therapy or mild infection outside the hospital: Preferred: amoxicillin if B-lactamase negative, or
amoxicillin clavulanate if B-lactamase producing. Alternatives: cefdinir, cefixime, cefpodoxime, or
ceftibuten.

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 Pediatric Department Pneumonias in pediatric Age groups Dr. Kawes Zangana

Mycoplasma pneumonia: Parenteral therapy: Preferred: intravenous azithromycin (10 mg/ kg on

days 1 and 2 of therapy; transition to oral therapy if possible).
Alternatives: intravenous erythromycin lactobionate (20 mg/ kg/ day every 6 hr) or levofloxacin. Oral
therapy (step-down therapy or mild infection outside the hospital):
Preferred: azithromycin (10 mg/ kg on day 1, followed by 5 mg/ kg/ day once daily on days 2-5).
Alternatives: clarithromycin (15 mg/ kg/ day in 2 doses) or oral erythromycin (40 mg/ kg/ day in 4
doses); for children >7 vr old: doxycycline (2-4 mg per kg/ day in 2 doses; and for adolescents with
skeletal maturity, levofloxacin (500 mg once daily) or moxifloxacin (400 mg once daily).

9. Chlamydia trachomatis or Chlamydophila pneumonia: Parenteral therapy:

Preferred: intravenous azithromyein (as in Mycoplasma preumonia). Alternatives: intravenous
erythromycin lactobionate (as in Mycoplasma pneumonia) or levofloxacin.
Oral therapy (step-down therapy or mild infection outside the hospital): as in
Mycoplasma pneumonia.

Oral zinc
in developing countries, oral zine (10 mg/ day for <12 mo of age and 20 mg/ day for >12 no of age)
reduces mortality among children with clinically defined severe pneumonia.

Prognosis
Response to therapy: Patients with uncomplicated community-acquired bacterial pneumonia show
improvement in clinical symptoms (fever, cough, tachypnea, chest pain), within 48-96 hours of
initiation of antibiotics.
The possibilities of failure of improvement with appropriate antibiotic therapy: (1) complications,
such as empyema ; (2) bacterial resistance; (3) nonbacterial etiologies such as viruses or fungi and
aspiration of foreign bodies or food; (4) bronchial obstruction from endobronchial lesions, foreign
body, or mucous plugs; (5) preexisting diseases such as immunodeficiencies, ciliary dyskinesia,
cystic fibrosis, pulmonary sequestration, or congenital pulmonary airway malformation; and (6)
other noninfectious causes (including bronchiolitis obliterans, hypersensitivity pneumonitis,
eosinophilic pneumonia, aspiration, and granulomatosis with polyangitis

A repeat chest radiograph is the first step in determining the reason for delay in response to
treatment.
Bronchoalveolar lavage may be indicated in children with respiratory failure.
High-resolution CT scans may better identify complications or an anatomic reason for a poor
response to therapy.
Mortality from community-acquired pneumonia in developed nations is rare.
Pneumonia causes one-third of all under-5 year deaths from infection annually

Bronchial asthma: Up to 45% of children have symptoms of asthma 5 yr after hospitalization for
pneumonia; this finding may reflect either undiagnosed asthma at the time of presentation or a
propensity for development of asthma after pneumonia.
Prevention
1. Vaccination: It has reduced the incidence of pneumonia hospitalizations.

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 Pediatric Department Pneumonias in pediatric Age groups Dr. Kawes Zangana

a. Pneumococcal vaccine: The 7-valent pneumococcal conjugate vaccine (PCV7) and later the 13-
valent pneumococcal conjugate vaccine (PCVI3) have reduced the pneumonia hospitalization rate;
a 35% decrease from the prevaccine rate.
Influenza vaccine: Influenza vaccine may also prevent pneumonia hospitalizations among children
and should be administered to all children >6 mo of age. For infants <6 mo of age, household
contacts and other primary caregivers should be immunized.
Other vaccinations: Maintaining high rates of vaccination for H. influenza type b, pertussis, and
measles are important for the prevention of pneumonia from these causes.
Several RSV vaccines are currently under development.
Improving the socioeconomic standard of living.