Childhood Pneumonia- Causes, Symptoms, and Treatment

Pneumonia is the most common death in children below 5 years of age. It is the most common cause of under 5 mortality rate It is due to infections, such as infectious pneumonia, hypersensitivity reactions (rare), aspiration, radiation, and drug-induced diseases.

Risk Factors for Childhood Pneumonia

Most child deaths in developing countries occur due to pneumonia.

Risk Factors

Low birth weight, Severe acute malnutrition,  Vitamin A deficiency, associated with measles and staph aureus, Lack of breastfeeding, Large family size and overcrowding.

Indoor air pollution, places where cooking gas is not there, ventilation system is not proper,  Advanced birth order, History of bronchitis, immunodeficiency.

Etiology of Pneumonia 

1. Based  upon Age
2. Based upon Exposure

Based Up On Age

In neonates < 3 weeks of age:

• Bacteria is the most common cause of pneumonia. 

B. Streptococcus (Streptococcus agalactiae).

• The second most common cause is E. coli.
• In India, the most common cause is Klebsiella > E. coli.

 In children 3 weeks to 4 years of age: viral > bacterial causes.

• India/World: RSV is the most common in the first two years of the child, followed by rhinovirus.
• India/World: The most common bacterial cause is Streptococcus pneumoniae > H. influenzae.
• In children of five years or older, the most common cause is Mycoplasma pneumoniae > Streptococcus pneumoniae > Chlamydophila pneumoniae.

Also read: About Neonatology for NEET  Pediatrics

Based Upon Exposure

• Contaminated aerosols: Legionella pneumoniae
  • In air-conditioned campuses and hospital water supply, bat droppings or soil enriched with bird droppings—Histoplasma capsulatum.
• Water contaminated with animal urine—Leptospira.
• Unpasteurized milk—Brucella.
• Droppings, urine, or saliva of rodents—Hantavirus.
• Cattle or goat hair or hides—Anthrax.
• If there is an outbreak in a school dormitory, Mycoplasma pneumoniae or N.meningitides
• Parrots and pigeons: Chlamydia psittaci. (Psittacosis)

What is Recurrent Pneumonia in Children? 

• ≥ 2 episodes of pneumonia in one year (OR)
• ≥3 episodes of pneumonia at any time are called recurrent pneumonia in children.
• With radiological evidence of the clearing of lesions between the episodes.

Pathogenesis

There are four factors that maintain the integrity of the lower respiratory tract and prevent pathogenic bacteria from causing pneumonia.

The factors are cough reflex and mucociliary clearance.

• Presence of antibodies called secretory IgA; the pattern of spread is viral and bacterial.

4 Patterns of Bacterial Pneumonia

Also read : Staphylococcus Infections in Children: Signs and Treatment

Clinical Features

1. Tachypnea, or rapid breathing, is the most consistent feature clinically seen in childhood pneumonia.
2. It has an age-dependent respiratory rate.
   • If the age of the child is < 2 months, the respiratory rate is ≥ 60/minute.
   • If the age of the child is 1-5 years: respiratory rate: ≥ 40/minute.

If the age of the child is 2–12 months, respiratory rate: ≥ 50/minute. 

• In infants with pneumonia:
  • Tachypnea
  • Fever (moderate-grade fever—viral cause and high-grade—bacterial cause)
  • Cough, respiratory distress, irritability, poor feeding.
• GIT symptoms (20-25%): diarrhea, vomiting, abdominal distension.

In older children with pneumonia, fever, cough, chest pain, and Tachypnea, with a tendency to lie on one side with knees pulled close to the chest (in case of unilateral pneumonia), can be seen. Abdominal pain is present in children with lower lobe pneumonia.

• Meningismus may be present in pneumococcal pneumonia, causing apex of lung involvement. 

Also read : Phenylalanine Metabolism & PKU: Symptoms, Diagnosis, Treatment 

On Physical Examination

Ronchi, scattered crackles/crepitations

• Localized consolidation or complication—decreased breath sounds on affected side.

Diagnosis of Pneumonia

• In children above 2 months of age, the diagnosis is primarily clinical, and investigations like CXR and blood tests are only ancillary or supportive in nature.
• For children below 2 months of age, most suspected of pneumonia may need some form of investigation.
• In an Indian setting, the World Health Organization and IMNCI guidelines are favoured wholly or in principle for the evaluation of suspected pneumonia.

Danger Signs

• Severe protein energy malnutrition.
• Persistent vomiting: >3 vomiting/hour.
• Lethargic with abnormally sleepy or difficult to awaken.
• Convulsions or seizures.
• Inability to feed and drink.
• Stridor at rest/Stridor in a calm child.

Investigations

1. Chest X-Ray
2. Portable or hand-held USG

Complications

1. The most common complication is parapneumonic effusion.
   • Adjacent to the pneumonic patch in the overlying pleura, collection of fluid occurs.
     • Reactive fluid, sterile in nature.
     • Fluid gets absorbed on antibiotic therapy.
2. Empyema, or pus in the pleural cavity
   • In children<2 years of age, caused by Staphylococcus aureus.
   • In children above 2 years, caused by group A streptococcus, staphylococcus aureus.
   • In both cases, a chest X-ray was performed, followed by a diagnostic paracentesis. Total leukocyte count, LDH levels, Gram stain, and culture of the pleural fluid are done and sent for analysis.
3. Pneumatocele: air-filled cystic carities seen in necrotizing pneumonias.

MC-Staph. Aureus, Sometimes-Klebsiella & Kerosene Poisoning

• Well-defined circular cystic cavities in the lung parenchyma, filled with air.

• Appear intensely black in colour.
• Boundary seen as granulation tissue.
• Due to necrosis, there is liquefaction and loss of lung tissue. where necrosis has taken place will communicate with the bronchus, or it's a small segment. Air will move inside and get trapped, developing a zone of inflammation around the area.
• Lesions are seen on a radiograph and called pneumatoceles.

4. Pneumothorax, Lung Abscess
5. Complications related to bacteria spread systemically:
   • Septicemia, meningitis, pyelonephritis, brain abscess, osteomyelitis.
6. Extensive alveolar involvement with the collapse of alveoli producing ARDS.
7. Septic shock and MOD

Also read: Autoimmune Encephalitis in Pediatrics: Symptoms & Treatments 

Treatment+

A. Empirical therapy

• Pneumonia: Treated on an OPD basis.
  • Drug of choice: oral amoxicillin in 80 mg/kg/day in 2 divided doses x 5 days.
  • Reviewed in 48 hours.+ SUPPORTIVE THERAPY continued.
  • If complications are seen, then switch to parenteral antibiotics and advise higher center referral.
• Severe pneumonia

• According to IMNCI, in Primary Health Centre.
• The first dose of antibiotic should be given and then referred to a higher centre. 
• Hospital admission
  • Parenteral antibiotics started—a combination of ampicillin + gentamycin.
  • Parenteral antibiotics continued for 10 days.
  • Antibiotics can be stopped if the patient is afebrile for at least 72 hours.
• Specific therapy—etiological agent—is known.

B. Specific therapy—etiological agent—is known.

1. Streptococcus pneumonia with MIC for Penicillin ≤ 2 micrograms/ml,
   • The parenteral agent is ampicillin/penicillin/Ceftriaxone.
   • Oral/step-down age: Amoxicillin>second/third generation cephalosporines.

2. Streptococcus pneumonia with MIC for penicillin ≥4 micrograms per ml,
   • Parenteral agent of choice: Ceftriaxone (100 mg/kg/day) every 12-24 hrs.
   • Oral or step-down agent: levofloxacin > clindamycin.
3. Group A Streptococcus,
   • Parenteral agent: ampicillin/penicillin > ceftriaxone.
   • Oral or step-down agent: amoxicillin.
4. Staphylococcus aureus-MSSA.
   • Parenteral agent: cefazoline or cloxacillin.
   • Oral or step-down agent Cephalexin > Clonamycin.
5. Staphylococcus aureus-MRSA
   • Parenteral agent: Vancomycin or Clindamycin.
   • Oral or step-down agent: Clindamycin or Linezolid.
6. Mycoplasma or chlamydophila
   • Parenteral agent: IV Azithromycin > Erythromycin or levofloxacin.
   • Oral or step-down agent: Oral Azithromycin > Clarithromycin, Erythromycin or Levofloxacin, or Doxycycline (doxycycline given to children above 8 years of age).

For empirical therapy of pneumonia for children > 5 years: (OPD basis)

• Drug of choice: oral azithromycin X 10 mg/kg on day 1, followed by 5 mg/kg per day from D2 to D5.

Also read : Expert Pediatric Pulmonology Care for Your Child's Respiratory Health 

Supportive therapy in hospitalized children

IV fluid, oxygen supply, bubble CPAP therapy, ventilation.

FAQ’S

Q. What prognosis do children have with pneumonia present? 

Ans. Most children recover fully with appropriate treatment. Recovery time may differ due to the underlying cause and appropriate treatment monitoring.

Q. Can pneumonia be prevented? 

Ans. Yes, prevention is possible with some vaccinations & health hygiene.

Hope you found this blog helpful for your NEET SS Pediatrics Pulmonology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.