Pneumonia In Children - Pediatric Oncall

PNEUMONIAS IN CHILDREN

Dr Ira Shah
M.D, DCH(Gold Medalist), FCPS, DNB

Pneumonia is infection of the lungs. Other lower respiratory tract infections seen in children are croup (laryngotracheobronchitis), bronchitis, and bronchiolitis.

Pneumonia results from direct inflammation of the lung tissue. Most commonly, it is the result of infections (bacterial, viral or fungal), but it can occur as a result of chemical injury (gastric acid/ aspiration of food/ hydrocarbon and lipoid pneumonia/ radiation induced pneumonia). The causative agent may reach the lung via the blood stream or from direct inhalation

The incidence of pneumonia in developing countries in children less than 5 years old is almost 30% with a high mortality rate.

Clinical features:

Neonates: Refusal of feeds, lethargy. Tachypnea, grunting, retractions, cyanosis.

Infants: Cough, fever, Refusal of feeds, lethargy.Tachypnea, grunting, retractions, cyanosis, wheezing, noisy breathing.

Preschoolers: cough, post tussive vomiting, fever, chest pain, abdominal pain.In severe cases: Tachypnea, grunting, retractions, cyanosis,

Older Children: fever, cough, chest pain, dysnea. Pharyngitis and otalgia/otitis are other common symptoms.

The pathognomic sign of pneumonia is the presence of crackles (also called as crepitations). Localized crepts in a febrile child without underlying lung disease is pneumonia until proven otherwise. However, not all children with pneumonia have crepitations. Decreased breath sounds with dull note on percussion and presence of bronchial breathing are also suggestive of pneumonia.

Common causes of pneumonia:

Newborns:group B Streptococcus (GBS), respiratory syncytial virus (RSV).

Infants:
Viruses: parainfluenza viruses, influenza virus, adenovirus, and respiratory syncytial virus (RSV). cytomegalovirus
Atypical organisms: Chlamydia trachomatis, Ureaplasma urealyticum, and Pneumocystis carinii (PCP). PCP is especially seen in children with immunodeficiencies.
Bacterial: B. pertussis, Streptococcus pneumoniae, Haemophilus influenzae, Haemophilus influenzae, mycobaterial tuberculosis.

Young children:
Viruses: parainfluenza viruses, influenza virus, adenovirus, and respiratory syncytial virus (RSV).
Atypical organisms: Mycoplasma pneumoniae.
Bacterial: Pneumococcus, mycobaterial tuberculosis.

Older children and adolescents:
Atypical organisms: Mycoplasma pneumoniae, Chlamydia trachomatis.
Bacterial: Pneumococcus, B. pertussis, mycobaterial tuberculosis.

Other rare causes of pneumonia:

Histoplasma capsulatum: It is found in nitrate rich soil from bird droppings and decaying wood. It is usually acquired as a result of inhalation of spores. The infection is usually asymptomatic; however, in infants and young children it may cause respiratory distress and hypoxemia.
Cryptococcus neoformans is a common among pigeon breeders, seen in immunocompromised patients.
In older children, pneumonia may complicate common varicella infections.

Diagnosis of pneumonia:

Complete blood count: WBC count is often increased with a polymorphic predominance in bacterial infections. Lymphocytic predominance may be seen in viral pneumonias, pertussis and atypical infections.
Cultures: In the cooperative older child with a productive cough, a sputum Gram stain is useful. Sputum cultures and immunofluorescent antibody testing may be useful. Bactec cultures (sputum or blood) are useful to isolate the organisms).
Imaging Studies: Chest x-ray PA view is the diagnostic test for pneumonias. Sometimes to differentiate from a sine-pneumonic effusion, a USG chest may be required. In rare cases of children who have an effusion or an empyema identified on CXR, a CT scan may be needed to further define the scope of the problem.
Mantoux Test: To diagnose pneumonia due to mycobaterial tuberculosis.
Cold agglutinin test: A bedside cold agglutinins test may help confirm the clinical suspicion of mycoplasmal infection. This test is performed by placing a small amount of blood in a specimen tube containing anticoagulant and inserting this into a cup filled with ice water. After a few minutes in the cold water the tube is held up to the light, tilted slightly, and slowly rotated. Small clumps of red blood cells coating the tube are indicative of a positive test result. This test is positive only in about one half of the cases of mycoplasmal infection and has high chances of false positive reactions.
Other tests: If there is presence of pleural fluid, pleural fluid aspiration and culture and microscopy.

Differentiation between bacterial and viral pneumonia:

Bacterial pneumonia: Usually associated with a fever more than 103 degree F. It is often a lobar, segmental or rounded well-defined pneumonia affecting a single lobe or multiple lobes. There may associated pleural effusion with abscess, bullae or pneumatoceles.

Viral pneumonia: The fever is usually lower than 103 degree F. The pneumonia is poorly defined, interstitial or peribronchial affecting multiple sites predominantly in multiple sites and poorly defined. There may be subsegmental atelectasis.

Treatment of pneumonia:

Oxygen is required if there is grunting, flaring, severe tachypnea, and retractions.
Bacterial Pneumonia: Antibiotics: oral or intravenous :

Penicillins: They are appropriate first-line agents in children in whom pneumococcal disease is strongly suspected. They have limited activity against gram-negative bacteria due to resistance.

Amoxicillin: 40 mg/kg/day PO divided tid/ 100 mg/kg/day IV qds
Penicillin V: 40 mg/kg/d PO divided qid
Crystalline Penicillin: 1,00,000 units/kg/day IV in 6 divided doses.
Ampicillin/sublactum: 40mg/kg/day PO divided tid, 100 mg/kg/day IV qds
Amoxicillin/clavulanic acid: 40mg/kg/day PO divided tid, 100 mg/kg/day IV qds

Cephalosporins:

First generation cephalosporins: They are useful against gram positive organisms and Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis.

Cephalexin: 50 mg/kg/day PO bid
Cefadur : 30-50 mg/kg/day PO bid.
Cefuroxime: 30 mg/kg/d PO bid, IV: 150-200 mg/kg/d IV divided q8h.
Cefalothin: 50 mg/kg/day PO qds / 100 mg/kg/day IV qds.

Second generation cephalosporin: They are useful against gram positive organisms and have limited activity against gram negative organisms.

Cefaclor: 20-40 mg/kg/day PO tds.

Third generation cephalosporins: They are broad-spectrum antibiotics having good gram-negative activity.

Cefixime: 8 mg/kg/day PO bid.
Ceftriaxone: 50-100 mg/kg/d IV/IM bd not to exceed 1 g.
Cefotaxime: 100-200 mg/kg/d IV/IM divided q6-8h.
Cefpodoxime: 10 mg/kg/d PO divided bid
Cefprozil: 30 mg/kg/d PO divided bid

Chloramphenicol: It is a bacteriostastic drug having good gram positive and gram negative coverage. It is given along with penicillin and is especially useful in patients with H. influenza infections. Dose: 100mg/kg/day IV/IM.

Septran : 21 mg/kg/day PO/IV for 21 days. Useful for PCP pneumonia.

Macrolides: They are used for treatment of staphylococcal and streptococcal infections. Also used in the treatment of atypical pneumonias due to mycoplasma, chlamydias.

Vancomycin is used in children with penicillin resistant streptococci and methicillin resistant staphylococci. Dose: 45-50 mg/kg/day IV qds

Viral pneumonia:

RSV: Serious infections with this organism usually occur in infants with underlying lung disease. Aerosolized ribavirin can be given to severely affected infants.
Herpes virus: Acyclovir is available for treatment of these pneumonias. Dose: 10 mg/kg/dose IV q8h; infuse over 1 h
Influenza A pneumonia, which is particularly severe or when it occurs in a high-risk patient, may be treated with amantadine.
Children who are toxic: Antibiotic therapy should include vancomycin (particularly in areas where penicillin resistant streptococci have been identified) and a cephalosporin.

Erythromycin: 30-50 mg/kg/d PO divided q6-8h.
Clarithromycin: 15 mg/kg/d PO divided q12h.
Azithromycin: Day 1: 10 mg/kg PO once; not to exceed 500 mg/d Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d.

Vancomycin is used in children with penicillin resistant streptococci and methicillin resistant staphylococci. Dose: 45-50 mg/kg/day IV qds

Viral pneumonia:

RSV: Serious infections with this organism usually occur in infants with underlying lung disease. Aerosolized ribavirin can be given to severely affected infants.
Herpes virus: Acyclovir is available for treatment of these pneumonias. Dose: 10 mg/kg/dose IV q8h; infuse over 1 h
Influenza A pneumonia, which is particularly severe or when it occurs in a high-risk patient, may be treated with amantadine.
Children who are toxic: Antibiotic therapy should include vancomycin (particularly in areas where penicillin resistant streptococci have been identified) and a cephalosporin.

Sequelae:

Most children with uncomplicated pneumonia recover without sequelae. Persistent effusions and empyemas are the most common serious complications of bacterial pneumonia.
Pulmonary abscess
Respiratory distress
Sepsis
Pneumatoceles especially with staphylococcal infections
In children who have recurrent or chronic symptoms, further testing including skin testing to identify fungal pathogens, sweat chloride estimation to identify cystic fibrosis, titers against rare organisms, and bronchoscopy may be required.

Prevention: Several vaccines exist that may prevent certain types of pneumonia.

Pneumococcal vaccine should be given to children with asplenia or sickle cell disease or have undergone splenectomy. A new conjugated pneumococcal vaccine has been developed and is recommended as a part of the routine childhood immunization schedule.

Conjugated Haemophilus influenzae type B vaccine is recommended as a part of the routine childhood immunization schedule and has reduced the incidence of infections caused by this organism.

Varicella vaccine is especially recommended in children who are immunocompromised or adults who are unprotected.

Influenza vaccines usually are given only to chronically ill children.

Prognosis:

The prognosis for most forms of pneumonia is excellent.
Most cases of viral pneumonia resolve without treatment; common bacterial pathogens and atypical organisms respond to antimicrobial therapy.
The prognosis for varicella pneumonia is somewhat more guarded.
Staphylococcal pneumonia, although rare, can be very serious despite treatment.
Immunocompromised children, those with underlying lung disease, and neonates are at high risk for severe sequelae.
Some forms of viral pneumonia, particularly adenoviral disease, tend to cause bronchiolitis obliterans and hyperlucent lung syndrome.

Last created on 23-02-2001
Last updated on 24-05-2007


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