ACUTE PNEUMONIA IN CHILDREN Department of pediatrics

ACUTE PNEUMONIA IN CHILDREN Pneumonia is an inflammation of the parenchyma of the lung,Incidence 0.026 episodes per child/year in USA,0.28 episodes per child/year in developed countries

SYMPTOMS AND SIGNS Raised respiratory rate - 50 per minute or more if child 2mo up to 12mo;- 40 per minute or more if child 12 mo up to 5 yr- 30 per minute or more if child above 5 yrStridor in calm child or wheezingFever >37.5oDry cough or production of sputumWorse signs:the child is not able to drink or feeding wall, vomit everything, is lethargic or had convulsionsFocal chest signs- chest indrawing- decreased expansion- dullness on percussion- bronchial breathing- pleural chest pain in older children

ETIOLOGY Viruses: influenza A and B, RS, adenovirus, parainfluenzaGram + bacteria: Str.pneumoniae, Str.pyogenes, Staph.aureusGram- bacteria: H.influenzae, Kl.pneumoniae, Ps.aeruginosa, Morax. catarrhalis, Neis. meningitides, E.coli, Proteus, Enterobacter.Atypical nonbacterial bacilli: Mycoplasma or Chlamydia pneumoniae,Legionella (acquired by breathing droplets or contaminated water)Specific pneumonia in infants: aspiration (diminished gag reflex), gastroesophagal reflux, heart defects, genetic disorders, asthma, impaired immune system.

CLINICAL MANIFESTATIONS History- recent respiratory infection, exposure to people with pneumonia, fever, acute or persistent cough, dry/productive, related to feeding (aspiration), choking/ staccato/paroxysmal (foreign body aspiration, pertussis).Worse signs: not able to drink or feeding, vomit everything, is lethargic or had convulsions Physical examination-confusions, abnormally sleepy, cyanosis, fast breathing, nasal flaring, respiratory distress, grunting, stridor, wheezing;- vomiting, diarrhea, abdominal pain in paralytic ileus; - dullness on percussion: -consolidation or pleural effusion, empyema;- auscultation- rales, crackles, crepitations, rhonchi (rumblings).- clinical signs that predict death in children:worse signs, prolonged illness, severe X-ray changes, cyanosis, leukocytosis, hepatomegaly.

PNEUMONIA- DIAGNOSIS Chest X-ray confirms pneumonia and pleural effusion or empyema - Confluent lobar consolidation is typically in pneumococcal causes - Viral pneumonia- hyperinflation with bilateral interstitial infiltratesBronchoscopy, USG, CT scan in malformation or tumorsWBC in viral pneumonia are normal or 20,000/ml, granulocyte risesAtypical pneumonia: a higher WBC, ESR and C-reactive proteinDNA, RNA, antibodies tests for the rapid detection of virusesPCR test or seroconversion in an IgG assaySerologic evidence of the ASL-OSerum IgE in recurrent wheezingIsolation of the bacteria from the blood, pleural fluid or lungCulture of sputum and susceptibility of the antibioticsUrinary antigen test positive

PNEUMONIA -TREATMENTANTIBIOTIS:1.Penicillins and betalactams: Amoxycillin, Amoxi/Clav, Sulbactam2.Cephalosporines- Cefazolin, Cefuroxim, Ceftriaxon, Ceftazidizime3.Penems- Imipenem/Cilastatin, Meropenem, Ertapenem4.Quinolones-Ciprofloxacin, Levofloxacin, Moxifloxacin, Gatifloxacin- more effective in Gram- bacteria5.In atypical pneumonia macrolides: Clarithromycin, Roxithromycin, Azithromycin (7.5-15mg/kg/day)6.Aminoglycosides- dosage according to age, weight and kidney function (Gentamicin, Tobramycin, Amikacin)7.In viral pneumonia treatment withhold antibiotics

SUPPORTIVE TREATMENTgood hydration, cough remedies, antipyretics, oxygen in the central cyanosis or worse signsFor children with wheeze- rapid acting bronchodilator(Salbutamol)Drainage with tube in empyema, fibrinolytic therapy: urokinase, streptokinase, alteplaseIndications for hospitalization: age

RESPONSE TO TREATMENTThe factors then patients leads to Slowly resolving pneumonia: 1. complications such as empyema2 .bacterial resistance 3.viral causes, foreign bodies or food aspiration4. bronchial obstruction 5.pre-existing immunodeficiencies6. cyliary dyskinesia, cystic fibrosis, other noninfectious causes. The first step- repeat chest X-ray

COMPLICATIONS The result of direct spread in the thoracic cavity: pleural effusion, empyema, pneumothorax, pericarditis Hematologic spread:sepsis, meningitis, arthritis, osteomyelitis

PREVENTION OF PNEUMONIA Immunization against H. influenzae type b Influenza vaccine Heptavalent pneumococcal conjugate vaccine Health education of the community Messages for mothers to recognize the signs of pneumonia

REFERENCES1.Nelson textbook of pediatrics, 18-th edition, 2007, p.1795-18002.Dr Herman Laferi-Community acquired pneumonia, diagnosis, treatment, Satellite Symposium Update in Infectious Pathology, 2006, Chisinau3.Technical bases for WHO recommendations on the management of pneumonia in children at first-level health facilities, Geneva, 2001