Overview/Definition
Definition:
• Community-acquired pneumonia (CAP) in children is acute infection of lung parenchyma occurring in previously healthy children outside healthcare settings
Represents leading cause of morbidity and mortality in children under 5 years globally
Major cause of hospitalization in pediatric age group accounting for 15-20% of all pediatric admissions in India.
Epidemiology:
• In India, pneumonia affects 43 million children annually with case fatality rate of 4-5%
Peak incidence occurs in children 6 months to 2 years age group
Seasonal variation with higher incidence during winter months (November-February)
Rural areas show higher prevalence due to indoor air pollution, malnutrition, and delayed healthcare access.
Age Distribution:
• Neonates: Hospital-acquired pneumonia more common than CAP
Infants (1-24 months): Highest incidence and mortality rates
Children (2-12 years): Most common cause of antibiotic prescription
Adolescents (12-18 years): Atypical pneumonia organisms more prevalent including Mycoplasma pneumoniae.
Clinical Significance:
• Essential topic for DNB Pediatrics and NEET SS examinations with high-yield questions on antibiotic selection, severity assessment, and management protocols
Understanding regional antibiotic resistance patterns crucial for clinical practice
Knowledge of WHO/IAP guidelines mandatory for board preparation.
Age-Specific Considerations
Newborn:
• Neonates (0-28 days): Early-onset pneumonia typically nosocomial
Group B Streptococcus, E
coli, and Klebsiella common pathogens
Empirical therapy with ampicillin plus gentamicin or third-generation cephalosporin
Consider MRSA coverage in NICU settings
Surfactant deficiency may coexist requiring supportive care.
Infant:
• Infants (1 month-2 years): Respiratory syncytial virus (RSV) most common viral cause
Streptococcus pneumoniae and Haemophilus influenzae type b important bacterial pathogens
Wheezing component common due to small airway involvement
Higher risk for severe disease requiring hospitalization
Breastfeeding provides protective immunity.
Child:
• Children (2-12 years): Classic bacterial pneumonia presentation more common
Streptococcus pneumoniae predominant pathogen
Mycoplasma pneumoniae emerges after 5 years age
Walking pneumonia with atypical features
Better clinical response to appropriate antibiotic therapy
Immunization status affects pathogen likelihood.
Adolescent:
• Adolescents (12-18 years): Atypical pneumonia patterns increase
Mycoplasma pneumoniae, Chlamydia pneumoniae common
Risk factors include smoking, immunosuppression
Healthcare-associated pneumonia risk in chronic conditions
Adult-like presentations with systemic symptoms.
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Clinical Presentation
Symptoms:
• Fever (>38.5°C) present in 85-90% cases across all age groups
Cough initially dry progressing to productive in older children
Dyspnea and tachypnea universal in bacterial pneumonia
Chest pain more common in children >2 years, pleuritic in nature
Systemic symptoms include malaise, anorexia, and irritability in infants.
Physical Signs:
• Tachypnea (respiratory rate >60/min in infants, >50/min in children 1-5 years, >40/min in older children)
Chest indrawing indicating severe pneumonia in children 2-59 months
Focal signs include dullness to percussion, decreased breath sounds, bronchial breathing
Wheeze suggests viral etiology or Mycoplasma infection.
Severity Assessment:
• WHO classification: Fast breathing pneumonia (tachypnea only)
Severe pneumonia (chest indrawing, nasal flaring, grunting)
Very severe pneumonia (danger signs: inability to feed, lethargy, unconsciousness, convulsions)
PIRO scoring system for severity stratification in hospital settings.
Differential Diagnosis:
• Viral bronchiolitis: Wheeze prominent, seasonal pattern, gradual onset
Tuberculosis: Chronic symptoms, weight loss, family history
Asthma exacerbation: Previous episodes, trigger identification
Foreign body aspiration: Sudden onset, unilateral signs
Pulmonary edema: Cardiac history, bilateral involvement.
Diagnostic Approach
History Taking:
• Detailed immunization history including pneumococcal and Hib vaccines
Recent antibiotic use affecting pathogen selection
Contact with tuberculosis patients
Day care attendance increasing bacterial exposure
Indoor air pollution from biomass fuel use
Nutritional status assessment including vitamin D deficiency.
Investigations:
• Chest X-ray: Consolidation patterns, pleural effusion, complications assessment
Complete blood count with differential: Leukocytosis with left shift in bacterial pneumonia
C-reactive protein: Elevated >40 mg/L suggests bacterial etiology
Blood culture: Low yield (2-10%) but important for antibiotic selection
Rapid antigen tests for RSV in infants.
Normal Values:
• Normal respiratory rates by age: 0-2 months: 30-60/min
2-12 months: 25-50/min
1-5 years: 20-40/min
6-12 years: 16-30/min
>12 years: 12-20/min
Normal oxygen saturation >95% at sea level
CRP normal <10 mg/L, procalcitonin <0.25 ng/ml suggests viral etiology.
Interpretation:
• Lobar consolidation suggests bacterial pneumonia (typically Streptococcus pneumoniae)
Interstitial patterns favor viral or atypical bacterial pathogens
Bilateral involvement common in viral pneumonia
Pleural effusion in 20-40% of pneumococcal pneumonia cases
Cavitation rare in pediatric CAP, suggests Staphylococcus aureus or tuberculosis.
Management/Treatment
Acute Management:
• Oxygen therapy for SpO2 <90% or signs of respiratory distress
IV fluids for dehydration maintaining 80% of maintenance requirements
Antipyretics: Paracetamol 10-15 mg/kg every 6 hours or ibuprofen 5-10 mg/kg every 8 hours
Bronchodilators for wheeze component
Chest physiotherapy contraindicated in acute phase.
Chronic Management:
• Outpatient management for non-severe cases with oral antibiotics
Hospital admission criteria: Age <6 months, severe pneumonia, complications, social factors
ICU admission for mechanical ventilation requirements, shock, or multiorgan failure
Follow-up chest X-ray only if clinical deterioration or complications suspected.
Lifestyle Modifications:
• Adequate nutrition with continued breastfeeding in infants
Zinc supplementation 20 mg/day during acute illness
Smoking cessation counseling for adolescents
Environmental modifications including reduced indoor air pollution
Hand hygiene education for family members
School/daycare attendance restrictions during acute phase.
Follow Up:
• Clinical improvement expected within 48-72 hours of appropriate antibiotic therapy
Complete resolution of symptoms typically within 7-10 days
Follow-up visit at 48-72 hours for outpatients
Return visit instructions for worsening symptoms
Complete immunization as per national schedule.
Age-Specific Dosing
Medications:
• First-line empirical therapy (oral): Amoxicillin 90 mg/kg/day divided 8-12 hourly for 5-7 days
Severe pneumonia (IV): Ampicillin 200 mg/kg/day divided 6 hourly plus gentamicin 7.5 mg/kg/day once daily
Alternative: Ceftriaxone 100 mg/kg/day once daily
Atypical coverage: Azithromycin 10 mg/kg once daily for 3-5 days.
Formulations:
• Amoxicillin: 125 mg/5 ml, 250 mg/5 ml suspensions for children
Dispersible tablets (125 mg, 250 mg) for easy administration
Injectable ampicillin: 500 mg, 1 g vials for IV use
Azithromycin: 200 mg/5 ml suspension, tablets for older children
Age-appropriate formulation selection based on taste and compliance.
Safety Considerations:
• Monitor for allergic reactions especially penicillin allergy history
Nephrotoxicity with aminoglycosides requiring renal function monitoring
QT prolongation with macrolides in predisposed patients
Clostridioides difficile-associated diarrhea with broad-spectrum antibiotics
Hepatotoxicity rare with standard doses.
Monitoring:
• Clinical response assessment at 48-72 hours
Temperature charting and oxygen saturation monitoring
Signs of complications: Pleural effusion, pneumathorax, septic shock
Antibiotic-associated diarrhea monitoring
Growth parameters in prolonged illness
Hearing assessment with aminoglycoside use.
Prevention & Follow-up
Prevention Strategies:
• Primary prevention through pneumococcal conjugate vaccine (PCV13) and Haemophilus influenzae type b vaccine as per national immunization schedule
Exclusive breastfeeding for first 6 months
Adequate nutrition and micronutrient supplementation
Reduction of indoor air pollution from biomass fuels.
Vaccination Considerations:
• PCV13 schedule in India: 6, 10, 14 weeks with booster at 15 months
Additional high-risk groups: Children with chronic conditions (asthma, congenital heart disease)
Influenza vaccine annually for children >6 months age
Catch-up vaccination for incomplete primary series.
Follow Up Schedule:
• Outpatient follow-up: 48-72 hours initially, then weekly until symptom resolution
Hospital discharge when stable for 24 hours, tolerating oral feeds, oxygen saturation >90% on room air
Post-discharge follow-up within 48-72 hours
Annual health maintenance visits for risk assessment.
Monitoring Parameters:
• Growth parameters: Weight, height, head circumference in infants
Respiratory function assessment in chronic/recurrent cases
Immunization status review and catch-up if needed
Nutritional assessment and supplementation
Developmental milestone evaluation in young children.
Complications
Acute Complications:
• Pleural effusion in 20-40% of pneumococcal pneumonia cases requiring drainage if significant
Pneumathorax rare but life-threatening
Septic shock in 5-10% requiring intensive care management
Acute respiratory distress syndrome (ARDS) in severe cases
Meningoencephalitis with pneumococcal pneumonia.
Chronic Complications:
• Bronchiectasis following severe pneumonia or inadequate treatment
Lung abscess more common with Staphylococcus aureus pneumonia
Empyema requiring prolonged antibiotic therapy and possible surgical intervention
Chronic pulmonary insufficiency in severe cases
Recurrent pneumonia suggesting underlying immune deficiency.
Warning Signs:
• Persistent fever beyond 72 hours of appropriate antibiotic therapy
Worsening respiratory distress or oxygen requirements
Signs of septic shock: poor perfusion, altered mental status
Inability to maintain oral hydration
New onset seizures or altered consciousness
Chest pain suggesting pleural involvement.
Emergency Referral:
• Immediate referral for age <2 months, severe pneumonia with danger signs
ICU consultation for mechanical ventilation requirements, inotrope support
Surgical consultation for complicated pleural effusion or empyema
Infectious disease consultation for antibiotic-resistant organisms or recurrent infections.
Parent Education Points
Counseling Points:
• Pneumonia is treatable bacterial infection requiring complete antibiotic course
Viral pneumonia supportive care with symptom monitoring
Importance of vaccination in prevention especially pneumococcal vaccine
Environmental modifications to reduce risk factors
Recognition of danger signs requiring immediate medical attention.
Home Care:
• Maintain adequate fluid intake with frequent small feeds
Continue breastfeeding in infants unless contraindicated
Positioning: Semi-upright position to ease breathing
Gentle suctioning of nasal secretions in infants
Avoid cough suppressants in productive cough
Rest and avoid strenuous activities during recovery.
Medication Administration:
• Complete prescribed antibiotic course even if child feels better
Administer antibiotics at regular intervals for optimal efficacy
Paracetamol/ibuprofen for fever and discomfort as needed
Proper dosing based on child's weight
Store medications as per manufacturer instructions
Report adverse drug reactions promptly.
When To Seek Help:
• Immediate medical attention for difficulty breathing, chest pain, high fever >39°C
Inability to feed or drink, lethargy, or altered consciousness
Worsening symptoms after 48-72 hours of treatment
New symptoms: Vomiting, diarrhea, rash
Emergency signs: Blue lips/fingernails, severe respiratory distress.