CHAPTER I

INTRODUCTION
1.1 Introduction
Pneumonia is a respiratory infection characterized by inflammation of the alveolar space
and/or interstitial tissue of the lungs.
Pneumonia can occur at any age, although it is more common in younger children. Pneumonia
accounts for 13% of all infectious illnesses in infants younger than 2 years of age. In a large
community-based study conducted by Denny and Clyde, the annual incidence rate of
pneumonia was 4 cases per 100 children in the preschool-aged group, 2 cases per 100 children
aged 5-9 years, and 1 case per 100 children aged 9-15 years (Medscape). Pneumonia is more
common in children younger than five years of age than in older Risk factors for pneumonia
include environmental crowding, having school-age siblings, and underlying cardiopulmonary
and other medical disorders (M. William J Barson, 2020). Pneumonia is the single largest
infectious cause of death in children worldwide. Pneumonia killed 808 694 children under the
age of 5 in 2017, accounting for 15% of all deaths of children under five years old (WHO,
2019).

Many people associate pneumonia with the elderly, but it is actually the biggest infectious
killer of children worldwide. Every year, it claims the lives of more than 700,000 children
under the age of 5, including over 153,000 newborns, who are particularly vulnerable to
infection (UNICEF).
Pneumonia is caused by noninfectious causes include aspiration (of food or gastric acid,
foreign bodies, hydrocarbons, and lipoid substances), hypersensitivity reactions, and drug- or
radiation-induced pneumonitis. (Matthew S. Kelly, Thomas J. Sandora, 2020). Pneumonia
also caused by a number of infectious agents commonly responsible vary according to the age
of the child and the setting in which the infection is acquired, including viruses ( Haemophilus
influenzae type b), bacteria (Streptococcus pneumonia) and fungi (Pneumocystis jiroveci)
(WHO, 2019).

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.

1
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 (WHO, 2019).

Diagnosis in most of milder cases of community acquired pneumonia is based on clinical

judgement alone, since laboratory tests and radiologic examination do not provide clues
concerning etiology. Children with severe pneumonia, hospital acquired pneumonia and
immunocompromised children require invasive diagnostic approach (Zihan, 2019).

Treatment of mild and moderate cases consists in supportive care and antibiotic treatment
(Zihan, 2019). The antibiotic of choice is amoxicillin dispersible 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.

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 (WHO, 2019).

1.2 Objective

1.2.1 General Objective

To demonstrate the clinical characteristic of pneumonia in children at NPH in 2021.

1.2.2 Specific Objective
- Sex
- Age
- Geography
- Clinical feature
- Laboratory investigation
1.3 Research questions
- How old was the child?
- What is gender of the child?

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- Where did the child come from?
- When was the child admitted to the hospital?
- What was the vaccination status of the child?
- What was the main reason for admission?
- What was the temperature at admission?
- What were the most common signs and symptoms of the child?
- Did the child admit to the intensive care unit?
- Did the child have a chest X-ray done?
- What was the result of the chest X-ray?
- What type and result of blood tests were done for the child?

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 CHAPTER II
LITERATURE REVIEW
2.1 Definition
Pneumonia is an infection of the pulmonary parenchyma. Despite being the cause of
significant morbidity and mortality, pneumonia is often misdiagnosed, mistreated, and
underestimated. In the past, pneumonia was typically classified as community-acquired
(CAP), hospital-acquired (HAP), or ventilator-associated (VAP) (Harrison, 2012).
Community‐acquired pneumonia (CAP) is defined as pneumonia acquired outside hospital or
healthcare facilities. Clinical diagnosis is based on a group of signs and symptoms related to
lower respiratory tract infection with presence of fever > 38 0C, cough, mucopurulent sputum,
pleuritic chest pain, dyspnea, and new focal chest signs on examination such as crackles or
bronchial breathing (Lim WS, Baudouin SV, Geoge RC, et al, 2009).
2.2 Epidemiology
Incidence and hospitalization: The incidence of childhood pneumonia varies
geographically.
Resource-rich countries: In resource-rich countries, the annual incidence of pneumonia is
estimated to be 3.3 per 1000 in children younger than 5 years and 1.45 per 1000 in children 0
to 16 years (Harris M, Clark J, Coote N, et al, 2011). Approximately one-half of children
younger than five years of age with community-acquired pneumonia require hospitalization.
Resource-limited countries: In a systematic review, the annual incidence of pneumonia in
children younger than five years from resource-limited countries in 2015 was estimated to be
231 per 1000; 50 to 80 percent of children with severe pneumonia required hospitalization
(McAllister DA, Liu L, Shi T, et al, 2019).
Mortality: In 2015, lower respiratory tract infections (LRTIs) accounted for nearly 800,000
deaths among children ≤19 years worldwide (31.1 per 100,000 population), second only to
neonatal/preterm birth complications (Kassebaum N, Kyu HH, et al, 2017).
In observational studies in resource-rich countries, the case fatality rate among hospitalized
children <5 years of age was <1 percent (Jain S, Williams DJ, Arnold SR, et al, 2015).
In a systematic review, the case fatality rate among hospitalized children <5 years in resource-
limited countries ranged from 0.3 to 15 percent (McAllister DA, Liu L, Shi T, et al, 2019).
Risk factors: Lower socioeconomic groups have a higher prevalence of LRTIs, which
correlates best with family size, a reflection of environmental crowding. School-age children

4
often introduce respiratory viral agents into households, resulting in secondary infections in
their parents and siblings (Glezen P, Denny FW, 1973).
Underlying cardiopulmonary disorders and other medical conditions predispose to pneumonia
and contribute to increasing severity. These include:
● Congenital heart disease
● Bronchopulmonary dysplasia
● Cystic fibrosis
● Asthma
● Sickle cell disease
● Neuromuscular disorders, especially those associated with a depressed consciousness
● Some gastrointestinal disorders (eg, gastroesophageal reflux, tracheoesophageal
fistula)
● Congenital and acquired immunodeficiency disorders (Pelton SI, Hammerschlag MR,
2005).
Seasonality: Although both viral and bacterial pneumonia occur throughout the year, they are
more prevalent during the colder months, presumably because direct transmission of infected
droplets is enhanced by indoor crowding. For reasons that are unknown, different viruses
cause peaks of infection at different times during the respiratory virus season, and these peaks
seldom occur simultaneously (Glezen P, Denny FW, 1973).
Effect of vaccines: Immunization with the Hemophilus influenzae type b (Hib) and
pneumococcal conjugate vaccines protects children from invasive disease caused by these
organisms. Hib was once a common cause of pneumonia in young children in the United
States.
The universal immunization of infants in the United States with the PCV has effectively
decreased the incidence of pneumonia requiring hospitalization and other
invasive Streptococcus pneumoniae infections in children (Olarte L, Barson WJ, Barson RM,
et al, 2017).
2.3 Pathogenesis
Pneumonia occurs because of an impairment of host defenses, invasion by a virulent
organism, and/or invasion by an overwhelming inoculum. In the typical scenario, pneumonia
follows an upper respiratory tract illness that permits invasion of the lower respiratory tract by
bacteria, viruses, or other pathogens that trigger the immune response and produce
inflammation (Mani CS, 2018).

5
The lower respiratory tract air spaces fill with white blood cells, fluid, and cellular debris.
This process reduces lung compliance, increases resistance, obstructs smaller airways, and
may result in collapse of distal air spaces, air trapping, and altered ventilation-perfusion
relationships (Margolis P, Gadomski A, 1998).
Severe infection is associated with necrosis of bronchial or bronchiolar epithelium (Aherne
W, Bird T, Court SD, et al, 1970) and/or pulmonary parenchyma (Lemaître C, Angoulvant F,
Gabor F, et al, 2013).
The viral agents that cause pneumonia proliferate and spread by contiguity to involve lower
and more distal portions of the respiratory tract.
Normal host defense: The pulmonary host defense system is complex and includes anatomic
and mechanical barriers, humoral immunity, phagocytic activity, and cell-mediated immunity
(Shah SS, Bradley JS, 2018), as discussed below, with a focus on bacterial infection.
 Anatomic and mechanical barriers- Anatomic and mechanical barriers in the upper
airway from an important part of the host defense. Particles greater than 1o microns
are efficiently filtered by the hairs in the anterior nares or trapped on mucosa surfaces.
An intact epiglottic reflex helps to prevent aspiration of infected secretions, and the
cough reflex help to expel materials that may be aspirated.
 Humoral immunity- Secretory IgA is the major immunoglobulin produced in the
upper airways and accounts for 10 percent of the total protein concentration of nasal
secretions. IgG and IgM enter the airways and alveolar spaces predominantly via
transudation from the blood and act to opsonize bacteria, activate complement, and
neutralize toxin.
 Phagocytic cell- There are two populations of phagocytic cells in the lung:
polymorphonuclear leukocytes from the blood and macrophages. There are several
distinct populations of macrophages, which vary in their location and function:
o The alveolar macrophage is located in the alveolar fluid and is the first
phagocyte encountered by inert particles and potential pathogens entering the
lung. If this cell is overwhelmed, it has the capacity to become a mediator of
inflammation and produce cytokines that recruit neutrophils.
o Interstitial macrophages are located in the lung connective tissue and serve
both as phagocytic cells and antigen-processing cells.

6
 o The intravascular macrophage is located in located in capillary endothelial
cells and phagocytizes and removes foreign material entering the lungs via the
bloodstream.
 Cell-mediated immunity – Cell-mediated immunity is especially important against
certain pathogens, including viruses and intracellular microorganisms that can survive
within pulmonary macrophages. Although relatively few in number (5 to 10 percent
of the total lung parenchyma cell population), lymphocytes play three critical roles:
the production of antibody, cytotoxic activity, and the production of cytokines.
Pathologic patterns of pneumonia
There are five pathologic patterns of bacterial pneumonia (Mani CS, 2018):
 Lobar pneumonia- Involvement of a single lobe or segment of a lobe. This is the
classic pattern of S. pneumoniae pneumonia.
 Bronchopneumonia- Primary involvement of airways and surrounding interstitial.
This pattern is sometimes seen in Streptococcus pyogenes and Staphylococcus aureus
pneumonia.
 Necrotizing pneumonia (associated with aspiration pneumonia and pneumonia
resulting from S. pneumoniae, S. pyrogens, and S. aureus).
 Caseating granuloma (as in tuberculous pneumonia)
 Interstitial and peribronchiolar with secondary parenchymal infiltration- This pattern
typically occurs when a severe viral pneumonia is complicated by bacterial
pneumonia.
There are two major pathologic patterns of viral pneumonia (Mani CS, 2018) :
 Interstitial pneumonia
 Parenchymal infection
2.4 Etiology agents
A large number of microorganisms have been implicated as etiologic agents of pneumonia in
children. The agents commonly responsible vary according to the age of the child and the
setting in which the infection is acquired.
Community-acquired pneumonia: Community-acquired pneumonia (CAP) is an acute
infection of the pulmonary parenchyma that is acquired in the community (Jain S, Williams
DJ, Arnold SR, et al, 2015).
The most common causes of CAP in children vary with age.

7
In neonates: Bacterial pathogens are the most common cause of early- and late-onset
pneumonia, although the specific organisms may differ.
In infants: Viruses are the most common cause of CAP in infants younger than one year.
They account for >80 percent of CAP in children younger than two years (Jain S, Williams
DJ, Arnold SR, et al, 2015).It is classically caused by Chlamydia trachomatis, but other
agents, such as cytomegalovirus (CMV), Mycoplasma hominis, and Ureaplasma urealyticum,
also are implicated. Infants with severe Bordetella pertussis infection also may develop
pneumonia.
In children < 5 years
 Viruses: Viruses are the most common etiology of CAP in older infants and children
younger than five years of age. They account for up to 50 percent of cases in young
children (Jain S, Williams DJ, Arnold SR, et al, 2015). Other viral causes of
pneumonia in children younger than five years, in decreasing order of likelihood,
include (Self WH, Williams DJ, Zhu Y, et al, 2016):
- Influenza A and B viruses
- Human metapneumovirus is a common cause of lower respiratory tract infections
(LRTIs) in children; most children have been infected by five years of age.
- A number of adenovirus serotypes (eg, 1, 2, 3, 4, 5, 7, 14, 21, and 35) have been
reported to cause pneumonia; serotypes 3, 7, and 21 have been associated with
severe and complicated pneumonia (Chen TK, Cherry JD, 2018).
- Parainfluenza viruses, usually type 3.
- Enterovirus D68 emerged as a significant pathogen of lower respiratory tract
disease among American children in 2014 (Bosis S, Esposito S, 2017).
- Coronaviruses (229E, OC43, NL63, HKU1) as well as SARS-CoV (responsible
for severe acute respiratory syndrome), MERS-CoV (responsible for Middle East
respiratory syndrome), and SARS-CoV-2 (responsible for coronavirus disease-
2019) may also cause respiratory tract infections in children younger than five
years (Dong Y, Mo X, Hu Y, et al, 2020).
- Rhinovirus has been implicated as a cause of pneumonia using PCR assays on
specimens from the upper respiratory tract (Juvén T, Mertsola J, Waris M, et al,
2000).
- Human bocavirus and human parechovirus types 1, 2, and 3 also have been
implicated as causes of LRTIs in children (Schlaberg R, Ampofo K, Tardif KD, et
al, 2017).

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  Bacteria: Important bacterial causes of pneumonia in preschool children include S.
pneumoniae, H. influenzae type b (Hib), nontypeable H. influenzae, Moraxella
catarrhalis, S. aureus, S. pyogenes, and atypical bacteria. S. pneumoniae, S. aureus,
and S. pyogenes are associated with increased morbidity and mortality.

In children ≥5 years
 S. pneumoniae is the most common typical bacteria cause of pneumonia in children
older than five years.
 M. pneumoniae is more common among children ≥5 years than among younger
children (Jain S, Williams DJ, Arnold SR, et al, 2015).
 C. pneumoniae also is emerging as a frequent cause of pneumonia in older children
and young adults (Kurz H, Göpfrich H, Wabnegger L, Apfalter P, 2009).
Aspiration pneumonia: When there is a predisposition to aspiration, pneumonia may be
caused by anaerobic oral flora, including:
 Anaerobic streptococci (eg, Peptostreptococcus)
 Fusobacterium spp
 Bacteroides spp
 Prevotella melaninogenica
Risk factors for aspiration include a history of seizure, anesthesia, or other episode of reduced
level of consciousness, neurologic disease, dysphagia, gastroesophageal reflux, alcohol or
substance abuse, use of a nasogastric tube, or foreign body aspiration.
Hospital-acquired pneumonia: Hospital-acquired pneumonia occurs ≥48 hours after
admission and does not appear to be incubating at the time of admission. Hospital-acquired
bacterial pneumonia is usually caused by gram-negative bacilli or S. aureus. Hospital-
acquired pneumonia frequently occurs in intensive care units where mechanical ventilation,
indwelling catheters, and administration of broad-spectrum antibiotics are common.
Special populations
Immunocompromised
The cause of pneumonia in immunocompromised hosts include all of the pathogens
mentioned above, as well as a variety of other organisms, as discussed below. Gram-negative
bacilli and S. aureus are common etiologies in neutropenic patients or in those with white
blood cell defects. One of the more common pneumonia pathogens diagnosed in HIV-infected

9
patients is Pneumocystis jirovecii, which was formerly called Pneumocystis carinii (Stringer
JR, Beard CB, Miller RF, Wakefield AE, 2002).
Viral causes of pneumonia, which may be life-threatening in the immunocompromised host,
including the post-solid organ and stem cell transplant populations, include:
 RSV: Respiratory syncytial virus
 Adenovirus
 Influenza
 Parainfluenza
 Rhinovirus
 Human metapneumovirus
Sickle cell anemia: The prevalence of pneumonia is increased in children with sickle cell
anemia (De Ceulaer K, McMullen KW, Maude GH, et al, 1985). Atypical bacterial pathogens
(eg, M. pneumoniae, C. pneumoniae) appear to be most frequent and are more commonly
associated with the acute chest syndrome.
Environmental Consideration
Geography: Residence in or travel to specific geographic areas should suggest endemic
pathogens:
 Tuberculosis is most common in immigrants from countries with a high prevalence of
infection (eg, countries throughout Asia, Africa, Latin America, and Eastern Europe)
 Measle pneumonia is common in the resource-limited countries.
 Coccidioides immitis is endemic to the southwestern United States, northern Mexico,
and parts of Central and South America.
Animal exposures: Histoplasmosis is associated with exposure to bird droppings and bat
guano, and hantavirus infection is associated with exposure to an infected deer mouse. Other
causes of pneumonia that are associated with animal exposure include:
 Chlamydia psittaci (psittacosis), which is transmitted to humans predominantly from
domestic and wild birds.
 Coxiella burnetii (Q fever), which is associated with exposure to parturient sheep,
goats, cattle, and cats (or exposure to dust/soil contaminated by these animals).
Other exposures: Exposure to individuals at high risk for tuberculosis is a risk factor for the
development of tuberculosis in children. High-risk individuals include the homeless, recent
immigrants from endemic regions, incarcerated individuals, and HIV-infected patients.
2.5 Clinical Presentation

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The clinical presentation of childhood pneumonia varies depending upon the responsible
pathogen, the particular host, and the severity. The presenting signs and symptoms are
nonspecific; no single symptom or sign is pathognomonic for pneumonia in children (Bradley
JS, Byington CL, Shah SS, et al, 2011).
Symptoms and signs of pneumonia may be subtle, particularly in infants and young children.
The combination of fever and cough is suggestive of pneumonia; other respiratory findings
(eg, tachypnea, increased work of breathing) may precede the cough (Murphy CG, van de Pol
AC, Harper MB, Bachur RG, 2007).
Neonates and young infants may present with difficulty feeding, restlessness, or fussiness
rather than with cough and/or abnormal breath sounds. Neonates, young infants, and young
children (ie, <5 to 10 years of age) may present only with fever and leukocytosis (Murphy
CG, van de Pol AC, Harper MB, Bachur RG, 2007).
Older children and adolescents may complain of pleuritic chest pain (pain with respiration),
but this is an inconsistent finding (Bradley JS, Byington CL, Shah SS, et al, 2011).
In a multicenter population-based study that included 2358 children <18 years hospitalized
with radiographic evidence of pneumonia, 95 percent had cough, 90 percent had fever, 75
percent had anorexia, 70 percent had dyspnea, and 55 percent had chest wall retractions
(Bachur R, Perry H, Harper MB, 1999).
2.6 Clinical Evaluation
Objectives: The evaluation of the child with cough and potential lower respiratory tract
disease has three goals: the identification of the clinical syndrome (eg, pneumonia,
bronchiolitis, asthma), consideration of the etiologic agent (eg, bacteria, virus), and an
assessment of the severity of the illness (Margolis P, Gadomski A, 1998).
History and examination: Historical features can be helpful in determining the
etiologic agent, the likelihood of infection with an organism that is resistant to antibiotics, and
the severity of illness.
 General appearance: In the young infant, assessment of general appearance includes
the ability to attend to the environment, to feed, to vocalize, and to be consoled. State
of awareness and cyanosis should be assessed in all children, although children may
be hypoxemic without cyanosis. Most children with radiographically confirmed
pneumonia appear ill (Pereira JC, Escuder MM, 1998).

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  Fever: Fever is a common manifestation of pneumonia in children (K, McIntosh,
2002). However, it is nonspecific and variably present. Young infants may have
afebrile pneumonia related to Chlamydia trachomatis or other pathogens.
 Tachypnea: Children with pneumonia often have tachypnea, but tachypnea is less
predictive of radiographically confirmed pneumonia than hypoxia or increased work
of breathing (Shah SN, Bachur RG, Simel DL, Neuman MI, 2017) . Lack of tachypnea
is helpful in excluding pneumonia.
 Respiratory distress: Signs of respiratory distress include tachypnea, hypoxemia
(peripheral arterial oxygen saturation [SpO2] <90 percent on room air at sea level),
increased work of breathing (intercostal, subcostal, or suprasternal retractions; nasal
flaring; grunting; use of accessory muscles), apnea, and altered mental status (Bradley
JS, Byington CL, Shah SS, et al, 2011).
 Lung examination: Examination of the lungs may provide clues to the diagnosis of
pneumonia and/or potential complications.
Auscultation is an important component of the examination of the child who presents
with findings suggestive of pneumonia.
Examination findings consistent with radiographically confirmed pneumonia include (Lynch
T, Platt R, Gouin S, et al, 2004):
o Crackles
o Findings consistent with consolidated lung parenchyma, including:
- Decreased breath sounds
- Bronchial breath sounds (louder than normal, with short inspiratory
and long expiratory phases, and higher-pitched during expiration),
egophony (E to A change)
- Bronchophony (the distinct transmission of sounds such as the
syllables of "ninety-nine")
- Whispered pectoriloquy (transmission of whispered syllables)
- Tactile fremitus (eg, when the patient says "ninety-nine")
- Dullness to percussion
 Wheezing is more common in pneumonia caused by atypical bacteria and viruses
(Nascimento-Carvalho AC, Ruuskanen O, Nascimento-Carvalho CM, 2019) than
bacteria; it is also a characteristic feature of bronchiolitis and asthma.

12
  Findings suggestive of pleural effusion include chest pain with splinting, dullness to
percussion, distant breath sounds, and a pleural friction rub.
2.7 Diagnosis
Clinical diagnosis: The diagnosis of pneumonia should be considered in infants and
children with respiratory complaints, particularly cough, tachypnea, retractions, and abnormal
lung examination (Harris M, Clark J, Coote N, et al, 2011).
The diagnosis of pneumonia can be made clinically in children with fever and historical or
physical examination evidence of an infectious process with symptoms or signs of respiratory
distress (JM, Leventhal, 1982). Tachypnea, nasal flaring, grunting, retractions, and hypoxia
increase the likelihood of pneumonia (Shah SN, Bachur RG, Simel DL, Neuman MI, 2017).
The absence of tachypnea is helpful in excluding pneumonia; the absence of the other signs is
not.
In resource-limited countries where there is a high prevalence of pneumonia, a single positive
respiratory sign increases the certainty of pneumonia (Margolis P, Gadomski A, 1998).
The World Health Organization uses tachypnea (>60 breaths/min in infants <2 months; >50
breaths/min in infants 2 to 12 months; >40 breaths/min in children 1 to 5 years; and >20
breaths/min in children ≥5 years) as the sole criterion to define pneumonia in children with
cough or difficulty breathing (World Health Organization, 1995).
In developed countries with a lower prevalence of pneumonia, multiple respiratory signs (eg,
hypoxia, grunting, nasal flaring, retractions) are necessary to increase the certainty of
pneumonia (Shah SN, Bachur RG, Simel DL, Neuman MI, 2017).
Radiographic confirmation — An infiltrate on chest radiograph confirms the diagnosis of
pneumonia in children with compatible clinical findings, although chest radiographs must be
interpreted with caution in children with asthma and comorbid viral infection.
Radiographs should be obtained in children who require hospitalization, those in whom the
diagnosis is uncertain, and in those with severe, complicated, or recurrent pneumonia
(Bradley JS, Byington CL, Shah SS, et al, 2011).
Approach to microbiologic testing — Microbiologic diagnosis can be established with
culture or rapid diagnostic testing (enzyme immunoassay [EIA], immunofluorescence, or
polymerase chain reaction [PCR]).
 Cultures
 Blood Cultures: We suggest that blood cultures be performed in children
with CAP who require hospital admission, particularly those with

13
 complications. The majority of isolates were susceptible to penicillin; the most
frequently isolated pathogens were S. pneumoniae (46 percent), S. aureus (6
percent), and Streptococcus. pyogenes (9 percent).
 Sputum culture: We suggest that sputum samples for Gram stain and culture
be obtained in children who require hospital admission if they are able to
produce sputum (Bradley JS, Byington CL, Shah SS, et al, 2011). Children
younger than five years usually swallow sputum, so it is rarely available for
examination.
As a general guide, an appropriate sputum specimen for examination is one
with ≤10 epithelial cells and ≥25 polymorphonuclear leukocytes under low
power (x100) (Murray PR, Washington JA, 1975). A predominant
microorganism and/or intracellular organisms suggest the etiologic agent.
 Pleural fluid cultures: Diagnostic (and possibly therapeutic) thoracentesis
generally is warranted for children with more than minimal pleural effusion.
 Rapid diagnostic tests: Rapid diagnostic tests include molecular tests that use PCR
techniques (including multiplex PCR panels) and immunofluorescence. They can be
performed on samples from the NP, pleural fluid, or throat (for M.
pneumoniae (Kakuya F, Kinebuchi T, Okubo H, Matsuo K, 2017)).
 Serology: We do not suggest routine serologic testing for specific pathogens (eg, S.
pneumoniae, M. pneumoniae, C. pneumoniae) because the results usually do not
influence management (Honda J, Yano T, Kusaba M, et al, 2000).
2.8 Differential Diagnosis
Although pneumonia is highly probable in a child with fever, tachypnea, cough, and
infiltrate(s) on chest radiograph, alternate diagnoses and coincident conditions must be
considered in children who fail to respond to therapy or have an unusual presentation/course.
 Noninfectious mimics of pneumonia
 Others cause tachypnea: Other causes of tachypnea, with or without fever and
cough, in infants and young children include (Pneumonia., Gaston B, 2002):
 Bronchiolitis
 Heart failure
 Sepsis
 Metabolic acidosis
 Other considerations

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  Comorbid asthma and viral respiratory infection – CAP can be
misdiagnosed in young children with asthma who have viral respiratory
infections (Clark CE, Coote JM, Silver DA, Halpin DM, 2000).
 Comorbid noninfectious lung disease – Rare, noninfectious lung diseases
may present with an intercurrent infectious illness.
- Pulmonary alveolar proteinosis
- Eosinophilic pneumonitis
- Cryptogenic organizing pneumonia

2.9 Treatment
Clinically, it is difficult to distinguish patients with bacterial pneumonia from those with viral
illnesses. Therefore, decisions concerning antibiotic prescription for children suspected of
having community-acquired pneumonia (CAP) can be challenging. Although pneumonia is
commonly caused by viral organisms in children, many children diagnosed with pneumonia
are treated empirically with antibiotics (Handy LK, Bryn M, Gerber JS, Zaoutis T, Feemster
KA, 2017).
Treatment decisions for children with pneumonia are dictated on the basis of the likely
etiology of the infectious organism and the age and clinical status of the patient. Antibiotic
administration must be targeted to the likely organism, bearing in mind the age of the patient,
the history of exposure, the possibility of resistance (which may vary, depending on local
resistance patterns), and other pertinent history.
2.9.1 Hospitalization
Indications: The decision to hospitalize a child with community-acquired pneumonia
(CAP) is individualized based upon age, underlying medical problems, and clinical factors
including severity of illness (Bradley JS, Byington CL, Shah SS, et al, 2011).
Additional indications for hospitalization include (Bradley JS, Byington CL, Shah SS, et al,
2011):
 Hypoxemia (peripheral capillary oxygen saturation [SpO 2] <90 percent in room air at
sea level)
 Dehydration, or inability to maintain hydration orally; inability to feed in an infant

15
  Moderate to severe respiratory distress: Respiratory rate >70 breaths/minute for
infants <12 months of age and >50 breaths per minute for older children; retractions;
nasal flaring; difficulty breathing; apnea; grunting
 Toxic appearance (more common in bacterial pneumonia and may suggest a more
severe course)
 Underlying conditions that may predispose to a more serious course of pneumonia (eg,
cardiopulmonary disease, genetic syndromes, neurocognitive disorders), may be
worsened by pneumonia (eg, metabolic disorder) or may adversely affect response to
treatment (eg, immunocompromised host)
 Complications (eg, effusion/empyema, necrotizing process, abscess)
 Suspicion or confirmation that CAP is due to a pathogen with increased virulence,
such as Staphylococcus aureus or group A Streptococcus (GAS)
 Failure of outpatient therapy (worsening or no response in 48 to 72 hours)
Indications for intensive care: The decision to treat a child with pneumonia in an intensive
care setting is individualized, based upon clinical, laboratory, and radiologic findings.
Care in the ICU also may be warranted for children with two or more of the following
(Bradley JS, Byington CL, Shah SS, et al, 2011):
 Respiratory rate>70 breaths/minute for infants<12 months of age and >50
breaths/minute for older children
 Apnea
 Increased work of breathing (retractions, dyspnea, nasal flaring, grunting)
 Partial pressure of oxygen in arterial blood (PaO2): FiO2 ratio <250
 Multilobar infiltrates
 Altered mental status
 Hypotension
 Pleural effusion
 Comorbid condition (eg, sickle cell disease, immune deficiency, immunosuppression)
 Unexplained metabolic acidosis
 Pediatric Early Warning Score >5 (Duncan H, Hutchison J, Parshuram CS, 2006).
2.9.2 Supportive Care
Antipyresis and analgesia: Children hospitalized with pneumonia usually have fever and
may have pleuritic chest pain, which can lead to shallow breathing and impaired ability to

16
cough. Administration of antipyretics and/or analgesics (eg, acetaminophen, ibuprofen) can be
used to keep the child comfortable.
Adequate pain control may promote coughing, which facilitates airway
clearance. Antitussives should be avoided as none have been found to be effective in
pneumonia (Chan CC, Chen AC, Chang AB, 2014).
Respiratory support: Children hospitalized with pneumonia should receive ventilatory
support as indicated by their clinical condition. A supported sitting position may help to
expand the lungs and improve respiratory symptoms.
We suggest that children with oxygen saturation [SpO 2] <95 percent in room air be treated
with supplemental oxygen to maintain oxygen saturation ≥95 percent while they are in
respiratory distress. Different thresholds for supplemental oxygen are suggested by other
experts (eg, the British Thoracic Society guidelines suggest supplemental oxygenation to
maintain oxygenation saturation >92 percent) (Harris M, Clark J, Coote N, et al, 2011).
Fluid management: Children who cannot maintain adequate fluid intake because of
breathlessness, fatigue, or risk of aspiration (Khoshoo V, Edell D, 1999) may require
intravenous (IV) fluid therapy.
Chest physiotherapy: Chest physiotherapy is not beneficial for children with uncomplicated
community-acquired pneumonia (CAP) (Harris M, Clark J, Coote N, et al, 2011). In
randomized and observational studies in children and adults, chest physiotherapy had no
conclusive effect on length of hospital stay, duration of fever, or radiographic resolution
(Chaves GS, Freitas DA, Santino TA, Nogueira PAM, Fregonezi GA, Mendonca KM, 2019).
Adjunctive glucocorticoid therapy: Although a systematic review and meta-analysis of two
small heterogeneous trials suggested that glucocorticoids reduce clinical failure (defined as
death from any cause, radiographic progression, or clinical instability at day 5 to 8) and time
to clinical cure, additional studies in children are necessary before glucocorticoids can be
routinely recommended (Stern A, Skalsky K, Avni T, Carrara E, Leibovici L, Paul M, 2017).
2.9.3 Medications
2.9.3.1 Recommendation 1
Children with fast breathing pneumonia with no chest indrawing or general danger sign
should be treated with oral amoxicillin: at least 40mg/kg/dose twice daily (80mg/kg/day) for
five days. In areas with low HIV prevalence, give amoxicillin for three days.
Children with fast-breathing pneumonia who fail on first-line treatment with amoxicillin
should have the option of referral to a facility where there is appropriate second-line
treatment.

17
2.9.3.2 Recommendation 2
Children age 2-59 months with chest indrawing pneumonia should be treated with oral
amoxicillin: at least 40mg/kg/dose twice daily (80mg/kg/day) for five days.
2.9.3.3 Recommendation 3
Children aged 2-59 months with severe pneumonia should be treated with parenteral
ampicillin (or penicillin) and gentamicin as a first-line treatment.
- Ampicillin: 50mg/kg, or benzyl penicillin: 50 000 units per kg IM/IV every six hours
for at least five days
- Gentamicin: 7.5 mg/kg IM/IV once a day for at least five days
- Ceftriaxone should be used as a second-line treatment in children with severe
pneumonia having failed on the first-line treatment.

2.9.3.4 Recommendation 4
Ampicillin (or penicillin when ampicillin is not available) plus gentamicin or ceftriaxone are
recommended as a first-line antibiotic regimen for HIV-infected and exposed infants and for
children under 5 years of age with chest indrawing pneumonia or severe pneumonia.
For HIV-infected and -exposed infants and for children with chest indrawing pneumonia or
severe pneumonia, who do not respond to treatment with ampicillin or penicillin plus
gentamicin, ceftriaxone alone is recommended for use as second-line treatment.
2.9.3.5 Recommendation 5
Empiric cotrimoxazole treatment for suspected pneumocystis jirovecii (previously
pneumocystis carinii) pneumonia (PCP) is recommended as an additional treatment for HIV-
infected and exposed infants age from 2 months up to 1 year with severe or very severe
pneumonia.
Empirical cotrimoxazole treatment for pneumocystis jirovecii pneumonia (PCP) is not
recommended for HIV-infected and-exposed children over 1 year with chest indrawing or
severe pneumonia (World Health Organization, 2014).
2.10 Prognosis
Typically, patients with uncomplicated community-acquired bacterial pneumonia show
response to therapy, with improvement in clinical symptoms (fever, cough, tachypnea, chest
pain), within 48-72 hours of initiation of antibiotics. Radiographic evidence of improvement
lags substantially behind clinical improvement. A chest radiograph is the first step in

18
determining the reason for a lack of response to initial 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 countries is rare, and most
children with pneumonia do not experience long-term pulmonary sequelae. Some data suggest
chat up to 45% of children have symptoms of asthma 5 years 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 (Matthew S.Kelly, Tomas J.Sandora).
2.11 Complications
Complications of pneumonia are usually the result of direct spread of bacterial infection
within the thoracic cavity (pleural effusion, empyema, and pericarditis) or bacteremia and
hematologic spread.
Meningitis, endocarditis, suppurative arthritis, and osteomyelitis are rare complications of
hematologic spread of pneumococcal or H. influenzae type b infection.
S. aureus, S. pneumoniae, and S. pyogenes are the most common causes of parapneumonic
effusions and empyema. Nonetheless many effusions that complicate bacterial pneumonia is
sterile. Analysis of pleural fluid parameters, including pH, glucose, protein, and lactate
dehydrogenase, can differentiate transudative from exudative effusions. However, current
PIDSIDSA guideline do not recommend that these tests be performed because this distinction
rarely changes management. Pleural fluid should be sent for Gram stain, and bacterial culture
as this may identify the bacterial cause of pneumonia. A pleural fluid WBC count with
differential may be helpful if there is suspicion for pulmonary tuberculosis or a noninfectious
etiology for the pleural effusion, such as malignancy (Matthew S, Kelly, Tomas J.Sandora).
2.12 Prevention
Influenza vaccine may also prevent pneumonia hospitalizations among children and should be
administered to all children>6 months of age. For infants <6 months of age, household
contacts and other primary caregivers should be immunized. Maintaining high rates of
vaccination for H. influenzae type b, pertussis, and measles remains important for the
prevention of pneumonia from these causes. Several RSV vaccines are currently under
development; introduction of an effective vaccine against RSV would be anticipated to
substantially reduce pneumonia incidence among children, particularly young infants
(Matthew S. Kelly, Tomas J. Sandora).

19
 CHAPTER III
MATERIAL AND METHOD
3.1 Study Design
It was a retrospective descriptive study.
3.2 Location of Study
This study was conducted at the National Pediatric Hospital, Phnom Penh, Cambodia
3.3 Study Population and Study Period
This study was conducted in children with diagnosis of Pneumonia admitted at the National
Pediatric Hospital Cambodia in 2021.
3.4 Sample Size
All children who fulfilled the inclusion criteria were selected for the study.
3.5 Data Collection Method
3.5.1 Inclusion Criteria
-Hospitalized children with discharged diagnosis of pneumonia
- Age ≤ 15 years
- Complete medical record
3.5.2 Exclusion Criteria
-Age > 15 years
- Incomplete medical record

20
 - Associated with other serious/ chronic disease such as HIV, congenital heart
disease.
3.6 Data Collection
Medical records will be obtained from the medical storage at the National Pediatric Hospital.
The check list has been developed and used for data collection containing as following:
- Patient identification
- Epidemiological data
- Vaccination History
- Clinical data
- Laboratory data

3.7 Data Entry and Analysis

All data was recorded using Microsoft Office-Excel-365 Pro Plus and analyzed using Epi Info
7. The results were obtained as percentage (%) and presented as tables and graphs.

3.8 Ethic Consideration

This study was approved by the Health Science Institute of RCAF and the National Pediatric
Hospital. All patient identification was not showed to public. All the results were anonymous
for viewers. Patient identification was known only to researchers and their supervisor. This
study was not affected to either patient or his/her care giver.

21
 CHAPTER IV

RESULTS

There were 100 patients with pneumonia during period from 01 January 2021 to 31 December
2021 for study.

4.1 Epidemiology Characteristics

4.1.1 Sex Distribution

Among our patients, male represented 59 cases (59%) while female represented 41 cases
(41%). The male to female sex ratio was 1.43:1.

Figure 4.1 Sex Distribution

4.1.2 Age Distribution

The mean of age of our children was 2.08 years (SD 2.57) with minimum was 0.3 month and
maximum age was 15 years.
The under 2 years age group represented 78 cases (78%). The 2 - < 5 years age group
represented 15 cases (15%) while the older group 5-15 years old occupied 7 cases (7%).

22
 Female
41
41%)

Male59
(59%)

90

80 78 (78%)

70

60
Number of Cases (%)

50

40

30

20 15 (15%)

10 7 (7%)

0
< 2 Years 2-< 5 Years 5- 15 Years

Figure 4.2 Age Distribution

4.1.3 Month Distribution

The case was range from 0 to 30 cases. The highest cases were found in March (28 cases) and
February (24 cases), meanwhile there was no cases of pneumonia in November.

23
 30 28 (28%)

25 24 (24%)

20
18 (18%)
Number of cases (%)

15

10 8 (8%)
6 (6%)
5 4 (4%)
3 (3%)
3 (3%)
2 (2%) 2 (2%) 2 (2%) 0(0%)

r
ry

r
y

t
il

ne
ch

ay

ly

be

be

be
us

be
ar

pr

Ju
ua

ar

Ju

ug

em

em

em
o
nu

A
M

ct
br

A
Ja

ec
pt

ov
O
Fe

D
Se

N
Figure 4.3 Months Distribution

4.1.4 Geographic Distribution

Nearly half of children (54 cases or 54%) were from capital city (Phnom Penh), followed by
Kandal (13 cases or 13%), Kampong Speu (8 cases or 8%). The other provinces had less
number of patients that ranged from 1 case (1%) to 7 cases (7%).
60
54
50
Number of Cases (%)

40

30

20
13
9
10 7
5 4
2 1 1 1 1 1 1
0
nh al er ng m g
sa
t tie ng po
t o
om
Pe
d sp ve ha an ra bo om ke
an ng y c n Po K m th Ta
hm
m K o Pr
e ng hh m K
o g K
no p po gc atta po
n
ng
Ph om om po
n B m o
K K om K
o Tb
K

Figure 4.4 Geographic Distribution

24
4.2 Clinical Characteristics

4.2.1 Vaccination
Among the 100 cases of our patients, 34 cases (34%) received complete vaccination and 66
children (66 %) got up to date vaccination according to National Vaccination Program. No
children (0 %) did not receive complete vaccination.

70
66 (66%)

60

50
Number of Cases (%)

40
34 (34%)

30

20

10

0
Up to date Complete

Figure 4.5 Vaccination

4.2.2 Temperature at Admission

Related to temperature at admission, we found that 68 patients (68%) had fever while the rest
(32 cases or 32 %) had normal temperature. Our mean of temperature at admission was
37.5oC. The minimum temperature was 36.5 oC and maximum was 40 oC.

25
 80

68 (68%)
70

60
Number of Cases (%)

50

40
32 (32%)
30

20

10

0
Fever No Fever

Figure 4.6 Temperature of Admission

4.2.3 Reason of Admission

According to chief complaint, just over half of our children had fever, cough and dyspnea (33
patients or 33%), only dyspnea in 20 patients (20%), dyspnea, fever and cough was noted in
18 children (18%), cough and fever was documented in 9 patients (9%) and fever and dyspnea
in 7 patients (7%) and other reasons was noted in 13 children.

Dyspnea, Cyanose 2%

Fever, Rhinorrhea 3%

Cough 4%

Cough, Rhinorrhea 4%

Dyspnea, Fever 7%

Cough, Fever 9%

Fever, Cough, Dyspnea 18 %

Dyspnea 20 %

Cough, Dyspnea 33 %

0 5 10 15 20 25 30 35

Number of Cases (%)

Figure 4.7 Reason of Admission

4.2.4 Respiratory Rate (RR)

26
Among our 100 patients of our study, the mean of respiratory rate was 38.40 rates per minute
(SD 10.2). However, the mean of RR varied with age group. The mean RR of children less
than 2 years was 39.68 per minute, 2 to less than 5 years was 32.8 per minute and 5 to 15
years was 36.28 per minute.
45

39.68 %
40
36.28%
Mean of Respiratory Rate(/min)

35 32.8%

30

25

20

15

10

0
< 2 Years 2-< 5 Years 5< 15 Years

Figure 4.8 Respiratory Rate

4.2.5 Cough

Cough is the main symptom of respiratory tract infection, was found in 84 cases (84%) while
the rest have (16 cases or 16%) had no cough.

90 84 (84%)
80

70

60
Number of Cases (%)

50

40

30

20 16 (16%)

10

0
Cough No Cough

Figure 4.9 Cough

27
4.2.6 Type of Cough

Among 100 children with cough, 64 children (64%) had productive cough and 36 patients
(36%) had dry cough.

70
64 (64%)

60
Number of Cases (%)

50

40 36 (36%)

30

20

10

0
Productive Cough Dry Cough

Figure 4.10 Type of Cough

4.2.7 Dyspnea

Dyspnea was reported in 68 patients (68%).

80

70 68 (68%)

60
Number of Cases (%)

50

40
32 (32%)
30

20

10

0
Dyspnea No Dyspnea

Figure 4.11 Dyspnea

28
 4.2.8 Chest Retraction
With regard to chest retraction, 59 patients (59%) were found with chest retraction. The
common location of retraction was noted as intercostal (18 cases or 18%), Subcostal (16 cases
or 16%), Intercostal and substernal (11 cases or 11%), Substernal (6 cases or 6%) and
subcostal and substernal (5 cases or 5%) and Intercostal and subcostal (3 cases or 3%).

20
18 (18%)
18
16 (16%)
16

14
Number of Cases (%)

12 11 (11%)

10

8
6 (6%)
6 5 (5%)

4 3 (3%)

0
Intercostal Subcostal Intercostal and Substernal Subcostal and Intercostal and
Substernal Substernal Subcostal

Figure 4.12 Chest Retraction

4.2.9 Crackle
Crackle was main symptoms of pneumonia. This sing was documented in 77 patients (77 %)
among our pneumonia patients.

90

80 77 (77%)

70

60
Number of Cases (%)

50

40

30
23 (23%)
20

10

0
Crackle No Crackle

29
 Figure 4.13 Crackle

4.2.10 Wheezing
Wheezing was reported in 57 patients (57%) while the majority did not have this sign (43
cases or 43%).

60 57 (57%)

50

43 (43%)

40
Number of Cases (%)

30

20

10

0
Wheezing No Wheezing

Figure 4.14 Wheezing

4.2.11 Rhonchi
Our study also found that 44 children (44%) had rhonchi on lung auscultation.

60
56 (56%)

50
44 (44%)
Number of Cases (%)

40

30

20

10

0
Rhonchi No Rhonchi

30
 Figure 4.15 Ronchi

4.2.12 Runny Nose

Runny nose was reported 34 patients (34%) while the majority (66 cases or 66%) had
no rhinorrhea.
70
66 (66%)

60

50
Number of Cases (%)

40
34 (34%)

30

20

10

0
Runny Nose No Runny nose

Figure 4.16 Runny Nose

4.2.13 Anorexia
Anorexia was reported 30 patients (30%) and 70 children 70%) had normal appetite.
80

70 (70%)
70

60
Number of Cases (%)

50

40

30 (30%)
30

20

10

0
Anorexia No Anorexia

31
 Figure 4.17 Anorexia

4.2.14 Other Signs and Symptoms

Below table were the list of other signs and symptoms that we collected.
Table 4.1 Other Signs and Symptoms

Sign and Symptom Number Percentage (%)

Decrease Feeding 45 45%

Fatigue 21 21%

Nasal Congestion 13 13%

Diarrhea 12 12%

Vomiting 9 9%

Nasal Flaring 6 6%

Cyanosis 4 4%

Apnea 2 2%

4.2.15 ICU Admission

Among 100 patients with pneumonia, 3 patients (3%) needed to admit in intensive care unit
(ICU) while the majority (97 or 97%) needed to treat in the normal ward.

32
 120

100 97 (97%)
Number of Cases (%)

80

60

40

20

3 (3%)
0
Need ICU admission No Need ICU admission

Figure 4.18 ICU Admission

4.3 Investigations
4.3.1 Chest X-Ray
We found that 87 (87%) of our patients had chest x-ray done.
100

90 87 (87%)

80

70
Number of Cases (%)

60

50

40

30

20
13 (13%)
10

0
Yes No

Figure 4.19 Chest X-Ray

4.3.2 Complete Blood Counts
All children had their complete blood count checked with the results were demonstrated in
below table.

33
 Table 4.2 Complete Blood Counts

Result Mean Minimum Minimum

White Blood Cell 14.88 x 109/L 5.0 x 109/L 32.3 x 109/L

(WBC) (5.92)

Hemoglobin 11.02 g/dL (1.7) 5.8 g/dL 16.1 g/dL

Platelet 431.39 x 109/L 126 x 109/L 9.03 x 109/L

(158.37)

Neutrophil 7.24 x 109/L 1.5 x 109/L 18.48 x 109/L

Lymphocyte 6.96 x 109/L 1.01 x 109/L 8.7 x 109/L

4.3.3 C-Reactive Protein (CRP)

34
Our study also found that among 100 patients had C-reactive protein test checked. Among
100 cases with CRP check, 39 (39%) of patients have positive result, while other 61 (61 %) of
patients have negative result. The results of CRP were shown in the below table.
70

61 (61%)
60
Number of Cases (%)

50

40

30
24 (24%)

20

9 (9%)
10
4 (4%)
2 (2%)
0
CRP Negative CRP 12 CRP 24 CRP 48 CRP 96

Figure 4.20 C-reactive protein (CRP)

4.3.4 Blood Culture

The majority of our patients did not have blood culture check (94 cases or 94%). Only 6
patients (6%) had blood culture done but the result was negative for bacteria.
100
94 (94%)
90

80

70
Number of Cases (%)

60

50

40

30

20

10 6 (6%)

0
Blood Culture No Blood Culture

Figure 4.21 Blood Culture

35
 CHAPTER V
DISCUSSION
5.1 Epidemiology
5.1.1 Age
The mean age of our children was 20.81 years (SD 25.78) with minimum age was 0.2 months
and maximum age was 130 months. This mean age was consistent with other studies which mean
age ranged from 2 years to 3.51 years (Seema Jain 2015, Chang Hyu Lee 2012, Guergana
Petrova 2018, Maria Hartiala 2014). However, David Aguilera-Alonso 2015 report the older
mean age was 6 years.

Table 5.1 Comparison of Age

Studies Countries Years Mean Age (Years)

Our Study Cambodia (NPH) 2021 20.81

Data from seniors Cambodia (NPH) 2019 2.35

David Aguilera-Alonso, et al. Spanish 2015 6

Maria Hartiala, et al. Finland 2014 3.51

Guergana Petrova, et al. Bulgaria 2018 3.08

36
 Chang Hyu Lee et al. Korea 2012
2.9

Seema Jain et al. USA 2015

2

5.1.2 Age Group

In our study we found that the burden of pneumonia related hospitalization was highest among
children younger than 2 years (78%), decrease among those 2 -<5 years of age (15%), and
decrease further among those with increasing ages 5-15 years (7%).
Other hand, studies from Seema Jain (2015) also reported higher incidence of pneumonia among
children younger than 2 years, decrease among those 2 -<5 years of age, and slightly increase
among those 5-15 years of ages. However, when we compared to Maria Hartiala (2014) study,
we found that the incidence of pneumonia was highest in the age group over 5 year olds.

Table 5.2 Comparison of Age Group

Studies Countries Years Age Group (%)

<2Y 2 - < 5Y 5-15Y

Our Study Cambodia 2021 78 15 7

(NPH)
Data from seniors Cambodia
2019 64.77 18.23 17
(NPH)

Maria Hartiala, et al Finland 2014 33 24 43

Seema Jain, et al USA 2015 45 25 30

37
 5.1.3 Sex
The majority of our patients were male 59% compared to female 41%. Three other reports
conducted by Jian Gao (2015), Joseph L. Mathew (2013) and Maria Hartiala (2014) also found
that the higher rate of patients were males in 56.28%, 71.68% and 52.81% respectively. On the
otherhand, other 3 studies by Guergana Petrova (2018), David Aguilera Alonso (2015) and Mia
Johanna Sondergaard (2012) showed the higher rate of female patients in 52.63%, 51.9% and
58.20% respectively.
Table 5.3 Comparison of Sex

Sex Ratio
Studies Countries Years Sex (%)
(M:F)

Cambodia Male: 59
Our Study 2021 1.44:1
(NPH) Female: 41
Data from seniors Cambodia Male: 57.86
(NPH) 2019 1.37:1
Female: 42.14

Male: 48
Joseph L.Mathew et al. India 2013 2.53:1
Female: 52

Male: 52.82
Jian Gao et al. China 2015 1.28:1
Female: 47.18

Male: 47.4
Maria Hartiala et al. Finland 2014 1.11:1
Female: 52.6

Guergana Petrova et al. Male: 71.70

Bulgaria 2018 0.9:1
Female: 28.30
Male: 56.28
David Aguilera-Alonso et al. Spanish 2015 0.92:1
Female: 43.72

38
 Male: 41.80
Mia Johanna Søndergaard et al. Denmark 2012 0.71:1
Female: 58.20

5.2 Clinical Characteristics

5.2.1 Fever
Our study result showed 68% of our patients had fever. This finding was consistent to other
studies that was over 68% of patients with pneumonia had fever (Table below).
Likewise, our mean temperature was 37.9oC which was the same figure as Mia Johanna
Søndergaard et al. (2012) in Denmark.
Table 5.4 Comparison of Fever

Studies Countries Years Fever Mean of

(%) Temperature
(0C)
Our Study
Cambodia 2021 68 37.5
(NPH)
Maria Hartiala et al
Finland 2014 97 NA

Seema Jain et al
USA 2015 91 NA
Mia Johanna Søndergaard et
al Denmark 2012 91 37.9
Jian Gao et al
China 2015 90.20 NA
David Aguilera-Alonso et al
Spain 2015 85.80 NA
Joseph L. Mathew et al
India 2013 79.81 NA

5.2.2 Cough
Cough in our studied children was found in 84%. This finding was consistent with other studies
such as Yanhong Lu (2013), Mia Johanna Søndergaard (2012), Seema Jain (2015), Joseph L.

39
Mathew (2013), David Aguilera-Alonso (2015), Maria Hartiala (2014) in which cough was
documented in 99.43%, 99%, 95%, 93.68%, 92.60% and 80% respectively.

Table 5.5 Comparison of Cough

Studies Countries Years Cough (%)

Our Study Cambodia (NPH) 2021 84

Data from seniors Cambodia (NPH) 2019 96.86

Yanhong Lu et al. China 2013 99.43

Mia Johanna Søndergaard et al. Denmark 2012 99

Joseph L. Mathew et al. India 2013 93.68

Seema Jain et al. USA 2015 95

David Aguilera-Alonso et al. Spanish 2015 92.60

Maria Hartiala et al. Finland 2014 80

5.2.3 Dyspnea
Dyspnea was discovered in 68% of our patients. This study was higher than Joseph L.Mathew,
Seema Jain and Maria Hartiala studies that were in (75.18%, 70%, 28%). In additionally, our
study was the highest rate when we compared to another 2 studies by Yanhong Lu and Chang
Hyu Lee which dyspnea rate were (3.7%, 2.1%).
Table 5.6 Comparison of Dyspnea

Studies Countries Years Dyspnea (%)

Our Study Cambodia (NPH) 2021 68

Data from seniors Cambodia (NPH) 93.71
2019

Joseph L.Mathew et al. India 2013 75.18

Seema Jain et al. USA 2015 70

40
 Maria Hartiala et al. Finland 2014 28

Yanhong Lu et al. China 2013 3.7

5.2.4 Crackle
Crackle was found in 77% among our patients. This finding was similar with other studies by
Joseph L. Mathew (2013) and David Aguilera-Alonso (2015) which crackle was noticed in
72.53% and 64.2% respectively. However, our study showed higher rate of crackle sign than the
previous studies by Maria Hartiala (2014), Todd A. Florin (2013) and Jian Gao (2016) that
crackle was shown in 43%, 38% and 37.42% respectively.
Table 5.7 Comparison of Crackle

Studies Countries Years Crackle (%)

Our Study Cambodia (NPH) 2021 77

Data from seniors Cambodia (NPH) 2019 76.10

Joseph L.Mathew et al. India 2013 72.53

David Aguilera-Alonso et al. Spanish 2015 64.2

Mia Johanna Søndergaard Denmark 2012 56

Maria Hartiala et al. Finland 2014 43

Todd A.Florin et al. USA 2016 38

Jian Gao et al. China 2015 37.42

5.2.5 Wheezing
Wheezing was found nearly a haft of our children (57%). This rate was much higher than the
others such as Joseph L. Mathew (35.90%), David Aguilera-Alonso (32.7%), Todd A. Florin
(32%), Yanhong Lu (31.50%) and Maria Hartiala (11%).

Table 5.8 Comparison of Wheezing

41
 Studies Countries Years Wheezing (%)

Our Study Cambodia (NPH) 2021 57

Data from seniors Cambodia (NPH) 40.25
2019

Joseph L.Mathew, et al India 2013 35.90

David Aguilera-Alonso, et al Spanish 2015 32.7

Todd A. Florin, et al USA 2016 32

Yanhong Lu, et al China 2013 31.50

Mia Johanna Søndergaard, et al Denmark 2012 24

Maria Hartiala, et al Finland 2014 11

5.2.6 Rhonchi
More than half of our children (44%) was found to have rhonchi on examination. This finding
was higher than the report of David Aguilera-Alonso (2015) and Todd A. Florin (2016) that were
in 34% and 3.7% respectively.
Table 5.9 Comparison of Rhonchi

Studies Countries Years Rhonchi (%)

Our Study Cambodia (NPH) 2021 44

Data from seniors Cambodia (NPH) 56.60
2019

Todd A.Florin et al. USA 2016 34

David Aguilera-Alonso et al. Spanish 2015 3.7

42
 Studies Countries Years Chest Retraction
(%)

Our Study Cambodia (NPH) 2021 59

Data from seniors Cambodia (NPH) 2019 59.75

Joseph L.Mathew et al. India 2013 58.46

Todd A.Florin et al. USA 2016 57

5.2.7 Respiratory Rate

The mean respiratory rate in our children was 38.40 per minute. This number was similar to the
study of Todd A. Florin that found respiratory rate in their children was 46 per minute.
Table 5.10 Comparison of Respiratory Rate

Studies Countries Years Mean Respiratory Rate

(Minutes)

Our Study Cambodia 2021 38.40

(NPH)
Data from seniors Cambodia 42.22
(NPH) 2019

Todd A.Florin, et al USA 2016 46

5.2.8 Chest Retraction

The chest retraction, the sign of sever pneumonia, was found in 59% of our patients. This finding
was concordant with other studies such as Joseph L. Mathew (2013) in India and Todd A. Florin
(2016) in USA that chest retraction was reported in 58.46% and 57% respectively.
Table 5.11 Comparison of Chest Retraction

5.2.9 Cyanosis

43
Cyanosis was discovered in 4% of our children. This was similar to Joseph L. Mathew in India
(4.56%), but higher than previous study by Yanhong Lu (1.70%). Cyanosis is the sign of very
severe pneumonia and should be treated with supplemental oxygen.
Table 5.12 Comparison of Cyanosis

Studies Countries Years Cyanosis (%)

Our Study Cambodia (NPH) 2021 4

Data from seniors Cambodia (NPH) 2019 5.4

Joseph L.Mathew et al. India 2013 4.56

Yanhong Lu et al. China 2013 1.70

5.2.10 Vomiting
Vomiting was found in 9% of our children which was lower than previous studies such as David
Aguilera-Alonso in Spain (26.5%), Maria Hartiala in Finland (30%), Alexander J. Millman in
USA (56.9%) and Mia Johanna Søndergaard in Denmark (31%).

Table 5.13 Comparison of Vomiting

Studies Countries Years Vomiting (%)

Our Study Cambodia (NPH) 2021 9

Data from seniors Cambodia (NPH) 16.3
2019

Alexander J.Millman et al. USA 2012 56.9

Mia Johanna Søndergaard et al. Denmark 2012 31

Maria Hartiala et al. Finland 2014 30

44
 David Aguilera-Alonso et al. Spain 2015 26.50

5.2.11 Diarrhea
Diarrhea was discovered in 12% of our children. This figure was lower than the previous studies
by Alexander J. Millman (2012) that was 35.1%.

Table 5.14 Comparison of Diarrhea

Studies Countries Years Diarrhea (%)

Our Study Cambodia (NPH) 2021 12

Data from seniors Cambodia (NPH) 2019 20.75

Alexander J. Millman et al. USA 2012 35.1

5.2.12 Runny Nose

Runny nose was discovered in 34% of our patients. This rate was higher than all other studies by
David Aguilera-Alonso in Spain (45.10%), Maria Hartiala in Denmark in Finland (36%),
Yanhong Lu in China (27.18%) and Mia Johanna Søndergaard in Denmark (15%).

Table 5.15 Comparison of Runny Nose

Studies Countries Years Runny Nose (%)

Our Study Cambodia (NPH) 2021 34

45
 Data from seniors Cambodia (NPH) 56.60
2019

David Aguilera-Alonso, et al Spain 2015 45.10

Maria Hartiala, et al Finland 2014 36

Yanhong Lu, et al China 2013 27.18

Mia Johanna Søndergaard, Denmark 2012 15

et al

5.2.13 Nasal Congestion

In our study we found that our children had nasal congestion 13% this rate was lower than
previous studied by Maria Hartiala in Finland that was in 36%.
Table 5.16 Comparison of Nasal Congestion

Studies Countries Years Nasal Congestion

(%)

Our Study Cambodia (NPH) 2021 13

Data from seniors Cambodia (NPH) 2019
21.38

Maria Hartiala, et al Finland 2014 36

5.2.14 Tachypnea
Tachypnea was discovered in 32% of our children. This figure was lower than the previous
studies by Joseph L. Mathew in India (96.11%) and Todd A. Florin in USA (70%). Nevertheless,
our figure was higher than previous studied by Mia Johanna Søndergaard in Denmark (52%),
Maria Hartiala in in Finland (29%) and Yanhong Lu in China (8.18%).

46
 Table 5.17 Comparison of Tachypnea

Studies Countries Years Tachypnea (%)

Our Study Cambodia (NPH) 2021 32

Data from seniors Cambodia (NPH) 53.80
2019

Joseph L.Mathew et al. India 2013 96.11

Todd A.Florin et al. USA 2016 70

Mia Johanna Søndergaard et Denmark 2012 52

al.

Maria Hartiala et al. Finland 2014 29

Yanhong Lu et al. China 2013 8.18

5.2.15 ICU Admission

Among hospitalized children with pneumonia, we noticed that 3% of our patients was admitted
to intensive care unit (ICU). This finding was lower than study by Seema Jain (2015) in USA
(21%), but higher than study by Chang Hyu Lee (2012) in Korea (2.6%).

Table 5.18 Comparison of ICU Admission

Studies Countries Years ICU Admission (%)

Our Study Cambodia (NPH) 2021 3

Data from seniors Cambodia (NPH) 8.17
2019

47
 Seema Jain et al. USA 2015 21

Chang Hyu Lee et al. Korea 2012 2.6

5.2.16 Anorexia
Anorexia in our children was found in 30% of cases. This figure was consistent with study of
Seema Jain et al. (2015) that was 75%. However, our rate was higher than previous studies by
David Aguilera-Alonso et al. (2015) in 19.80% and Joseph L. Mathew et al. (2013) in 16.12%.

Table 5.19 Comparison of Anorexia

Studies Countries Years Anorexia (%)

Our Study Cambodia (NPH) 2021 30

Data from seniors Cambodia (NPH) 71.07
2019

Seema Jain et al. USA 2015 75

David Aguilera-Alonso et al. Spanish 2015 19.80

Joseph L. Mathew et al. India 2013 16.12

5.3 Investigation
5.3.1 White Blood Cell (WBC)
The mean WBC in our study was 14.88 x 10 3/mm3. This result was consistent with the study of
Maria Hartiala et al. which the mean WBC was 14.8 x 10 3 /mm3, Rujipat Samransamruajkit (14 x
103/mm3) and Medjo, et al. (16.8 x 103 /mm3). However, this rate was higher than previous

48
studies by David Aguilera-Alonso et al. (10.2 x 10 3 /mm3) and Mia Johanna Søndergaard et al.
(9.3 x 103/mm3).

Table 5.21 Comparison of White Blood Cells

Studies Countries Years Mean WBC/mm3

Our Study Cambodia (NPH) 2021 14.88

Data from seniors Cambodia (NPH) 14.78
2019

Biljana Medjo et al. Italy 2014 16.81

Maria Hartiala et al. Finland 2014 14.8

Rujipat Samransamruajkit et al. Thailand 2007 14

David Aguilera-Alonso et al. Spanish 2015 10.2

Mia Johanna Søndergaard et al. Denmark 2012 9.3

5.3.2 Neutrophil
In our study found the mean neutrophil was 47.69%. This rate was similar to other studies such
as Mia Johanna Søndergaard et al. (54%) and Rujipat Samransamruajkit et al. (51.8%).
However, the mean eutrophil in this current study was lower than report by Biljana Medjo et al.
that was 68.96% and David Aguilera-Alonso, et al that was 65%
Table 5.22 Comparison of Neutrophil

Studies Countries Years Means Neutrophil

(%)

Our Study Cambodia 2021 47.69

49
 (NPH)
Data from seniors Cambodia (NPH) 52.75
2019

Biljana Medjo et al. Italy 2014 68.96

David Aguilera-Alonso et al. Spain 2015 65

Mia Johanna Søndergaard et al. Denmark 2012 54

Rujipat Samransamruajkit et al. Thailand 2007 51.8

5.3.3 Lymphocyte
The mean lymphocyte in our study was 43.56% that was the highest rate when we compared to
other studies such as Biljana Medjo et al. in Italy (24.88%) and Rujipat Samransamruajkit et al.
in Thailand (16.20%).
Table 5.23 Comparison of Lymphocyte

Studies Countries Years Means Lymphocyte

(%)

Our Study Cambodia (NPH) 2021 43.56

Data from seniors Cambodia (NPH)
2019
51.75

Biljana Medjo, et al Italy 2014 24.88

Rujipat Samransamruajkit, Thailand 2007 16.20

et al

5.3.4 C-reactive protein

In our study the mean C-reactive protein was 45 mg/l. This result was higher than two previous
studies such as David Aguilera-Alonso in Spain (30mg/l) and Mia Johanna Søndergaard in

50
Denmark (28mg/l). Nevertheless, this rate was lower than two other studies by Biljana Medjo in
in Italy (90 mg/L) and Maria Hartiala in Finland (87 mg/L).

Table 5.24 Comparison of C-reactive Protein (CRP)

Studies Countries Years Mean CRP (mg/l)

Our Study Cambodia (NPH) 2021 45

Data from seniors Cambodia (NPH) 54.86
2019

Biljana Medjo et al. Italy 2014 90.97

Maria Hartiala et al. Finland 2014 87

David Aguilera-Alonso et al. Spanish 2015 30

Mia Johanna Søndergaard et al. Denmark 2012 28

5.3.5 Platelet

51
The mean platelet in our study was 431.39 x 10 9/L. This rate was similar to study of Rujipat
Samransamruajkit et al. (2007) in Thailand which was 437.600 10 9/L. However, our rate was
higher than previous studies of Yanhong Lu et al. (2013) in China (397.000 x 10 9/L) and Biljana
Medjo et al. (2014) in Italy (273.830 x 109/L).

Table 5.25 Comparison of Platelet

Studies Countries Years Means Platelet (x

109/L)

Our Study Cambodia (NPH) 2021 431.39

Data from seniors Cambodia (NPH) 463.020

2019

Rujipat Samransamruajkit et al. Thailand 2007 437.600

Yanhong Lu et al. China 2013 397.000

Biljana Medjo et al. Italy 2014 273.830

52
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