Overview
Definition:
Pneumonia in children is an acute inflammation of the lung parenchyma, primarily affecting the alveoli and interstitium, leading to impaired gas exchange
It is a major cause of morbidity and mortality in children globally.
Epidemiology:
It is the leading cause of death in children under five years of age, with an estimated 15% of all deaths in this age group attributable to pneumonia
Incidence varies by age, socioeconomic status, and geographic location, with higher rates in low-resource settings
Bacterial pneumonia is more common in infants and young children, while viral pneumonia is prevalent in younger infants.
Clinical Significance:
Understanding pediatric pneumonia is critical for accurate diagnosis, appropriate management, and prevention of severe outcomes
Timely recognition of severity, appropriate antibiotic selection, and judicious IV-to-PO switch are key to optimizing patient care and resource utilization, particularly relevant for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Fever
Cough, which may be dry or productive
Tachypnea or difficulty breathing
Grunting or nasal flaring
Lethargy or irritability
Poor feeding or vomiting
Chest pain (reported as abdominal pain in younger children)
Cyanosis in severe cases.
Signs:
Increased respiratory rate (tachypnea) is a key indicator
Decreased oxygen saturation
Auscultation may reveal crackles (rales), bronchial breath sounds, or diminished breath sounds
Palpable signs of consolidation like dullness to percussion
Retractions (supraclavicular, intercostal, subcostal)
Nasal flaring
Grunting respirations.
Diagnostic Criteria:
Diagnosis is primarily clinical, supported by radiography
WHO defines pneumonia based on age-specific respiratory rates: 2-12 months: >= 50 breaths/min
1-5 years: >= 40 breaths/min
Chest X-ray (CXR) typically shows infiltrates, consolidation, or interstitial opacities
Presence of fever, cough, and tachypnea are cardinal signs
Severity can be graded based on respiratory distress and oxygen saturation.
Diagnostic Approach
History Taking:
Duration and character of cough and fever
Presence of dyspnea or feeding difficulties
History of recent viral illness
Immunization status (pertussis, pneumococcal)
Exposure to sick contacts or environmental irritants
Underlying medical conditions (asthma, congenital heart disease)
Red flags include high fever, severe respiratory distress, cyanosis, lethargy, and inability to feed.
Physical Examination:
Assess general appearance (alertness, comfort)
Measure vital signs: temperature, heart rate, respiratory rate, oxygen saturation
Perform thorough respiratory examination: inspect for retractions, grunting, nasal flaring
palpate for tactile fremitus
percuss for dullness
auscultate for breath sounds, crackles, wheezes
Assess hydration status and perfusion.
Investigations:
Chest X-ray (PA and lateral views) is crucial, showing lobar consolidation (bacterial) or interstitial infiltrates (viral)
Complete blood count (CBC) may show leukocytosis with neutrophilia in bacterial pneumonia
C-reactive protein (CRP) can be elevated
Blood cultures are indicated for severe pneumonia or suspected sepsis to identify pathogens
Sputum Gram stain and culture are rarely useful in young children due to difficulty in obtaining a good sample, but may be considered in older children or if specific pathogens are suspected
Nasopharyngeal aspirates for viral PCR panels can identify common respiratory viruses (RSV, influenza, parainfluenza, adenovirus)
Procalcitonin can help differentiate bacterial from viral etiology.
Differential Diagnosis:
Bronchiolitis
Asthma exacerbation
Foreign body aspiration
Pulmonary edema
Allergic alveolitis
Meconium aspiration
Sepsis
Congenital anomalies of the lung.
Admission Criteria
Indicators Of Severity:
Hypoxemia (SpO2 < 90% on room air)
Significant respiratory distress (retractions, grunting, nasal flaring, tachypnea > 70 breaths/min in infants, > 50 breaths/min in older children)
Altered mental status (lethargy, irritability, unresponsiveness)
Inability to maintain adequate oral hydration or feeding
Signs of systemic illness: hemodynamic instability, poor perfusion, or sepsis
Age less than 3 months with fever or respiratory symptoms
Presence of significant comorbidities (congenital heart disease, immunosuppression, chronic lung disease)
Persistent high fever despite appropriate antipyretics.
Radiographic Findings:
Extensive bilateral infiltrates, lobar consolidation, or presence of parapneumonic effusion/empyema on CXR may warrant admission for closer monitoring and treatment
Pneumothorax or abscess formation also indicates severe disease.
Social Factors:
Inadequate home support or resources for care
Inability of caregivers to manage child at home
Concern for child abuse or neglect
These factors, in conjunction with clinical assessment, may influence the decision for admission.
Management
Initial Management:
Supplemental oxygen to maintain SpO2 > 92%
Airway support if necessary
Intravenous fluid resuscitation for dehydration
Antipyretics for fever control (paracetamol, ibuprofen)
Chest physiotherapy is generally not recommended and may be harmful.
Medical Management:
Antibiotic therapy is guided by likely pathogen and severity
For community-acquired pneumonia (CAP) in outpatient settings or mild inpatient cases: Amoxicillin is first-line for suspected bacterial pneumonia (e.g., 90 mg/kg/day divided bid for 5-7 days)
Alternatives include azithromycin (for suspected atypical pathogens or penicillin allergy), or ceftriaxone
For severe pneumonia or hospital-acquired pneumonia: Intravenous antibiotics are started empirically
Broad-spectrum coverage is often used initially, covering typical and atypical bacteria (e.g., ceftriaxone plus azithromycin or a respiratory fluoroquinolone in specific circumstances)
Duration of therapy depends on clinical response and pathogen, typically 7-10 days for bacterial pneumonia.
Supportive Care:
Close monitoring of respiratory status, vital signs, and oxygen saturation
Adequate pain and fever management
Nutritional support, including encouraging oral intake or providing IV fluids as needed
Nebulized bronchodilators are generally not indicated unless there is a clear history of wheezing or bronchospasm
Mechanical ventilation may be required for severe respiratory failure.
Iv To Po Switch
Criteria For Switch:
Clinical improvement: Resolution of fever (afebrile for 24-48 hours)
Significant reduction in respiratory rate and distress
Improvement in oxygenation (SpO2 > 92% on room air or minimal supplemental oxygen)
Ability to tolerate oral intake and medications
Hemodynamically stable
Absence of complications like empyema or sepsis
The child should be clinically stable and showing sustained improvement for at least 24-48 hours prior to considering the switch.
Medication Selection:
The oral antibiotic chosen should have good bioavailability and adequate coverage for the likely pathogen
Common choices include amoxicillin, amoxicillin-clavulanate, azithromycin, clarithromycin, or cefuroxime axetil
The switch should ideally be to a drug from the same class or with similar spectrum of activity to ensure continued effective treatment.
Timing And Duration:
The switch can typically occur once the patient meets clinical improvement criteria, usually within 48-72 hours of starting IV antibiotics
The total duration of antibiotic therapy (IV + PO) is usually 7-10 days for bacterial pneumonia, but may be extended based on pathogen, severity, and clinical response
The duration of oral therapy should complete a full course as prescribed.
Complications
Early Complications:
Parapneumonic effusion and empyema
Lung abscess
Bacteremia and sepsis
Respiratory failure requiring mechanical ventilation
Pneumothorax
Necrotizing pneumonia.
Late Complications:
Bronchiolitis obliterans
Chronic lung disease or bronchiectasis (rare)
Recurrent pneumonia
Post-pneumonic reactive airway disease.
Prevention Strategies:
Vaccination (pneumococcal, influenza, pertussis)
Early recognition and prompt treatment
Adequate hydration and nutrition
Avoiding exposure to secondhand smoke
Hand hygiene
Addressing underlying host factors like immunosuppression.
Prognosis
Factors Affecting Prognosis:
Age (younger age has poorer prognosis)
Severity of illness at presentation
Presence of comorbidities
Promptness and adequacy of treatment
Identification of causative pathogen
Development of complications.
Outcomes:
With appropriate treatment, most children recover fully from pneumonia
Mortality rates have significantly decreased with advances in medical care, antibiotics, and supportive management
However, severe pneumonia, especially in infants and immunocompromised individuals, can still carry a significant risk of mortality and long-term sequelae.
Follow Up:
Children who have had severe pneumonia or empyema may require follow-up to monitor for residual lung damage or functional impairment
Routine follow-up is generally not needed for uncomplicated CAP
Education for caregivers on recognizing early signs of recurrence or worsening is essential.
Key Points
Exam Focus:
Remember age-specific tachypnea criteria for diagnosis
Amoxicillin is first-line for typical bacterial CAP
Criteria for IV-to-PO switch are crucial: clinical improvement, afebrile, tolerating PO intake
Recognize red flags for admission: SpO2 < 90%, severe distress, altered mental status, age < 3 months.
Clinical Pearls:
Always assess oxygen saturation in any child with respiratory distress
Consider atypical pathogens (Mycoplasma, Chlamydia) in older children and those with prolonged symptoms
Don't forget vaccination status as a preventive measure
Monitor for empyema, especially in persistent fever or worsening symptoms.
Common Mistakes:
Overuse of antibiotics for viral pneumonia
Delaying admission in critically ill children
Incorrectly switching from IV to PO without meeting clinical improvement criteria
Not considering atypical pathogens or resistant organisms
Inadequate oxygen supplementation.