Paediatrics chapters
Pneumonia in children
How pneumonia in children is classified, which organisms cause it at each age, how IMNCI sorts a coughing child, and how to treat and follow up.
- Pneumonia is inflammation of the lung parenchyma; in Pakistan most severe childhood pneumonia is bacterial, led by Streptococcus pneumoniae.
- IMNCI uses fast breathing (60, 50 and 40 per minute by age) and chest indrawing to diagnose pneumonia, and danger signs or stridor in a calm child to label severe pneumonia.
- Simple pneumonia is treated with oral amoxicillin for 5 days; severe pneumonia needs a first dose of antibiotic and urgent referral.
On this page
Overview
Pneumonia is inflammation of the lung parenchyma (respiratory bronchioles, alveolar ducts, sacs and alveoli), usually with filling of the alveoli (consolidation).
Pneumonia is a common problem, accounting for 10-20% of children's hospital admissions (Akbar). Most acute respiratory infections (ARI) are upper respiratory and self-limiting; nearly 20% spread to the lower tract, and most of these are pneumonia. Pakistan loses roughly 250,000 under-fives to pneumonia each year, which is why the national ARI programme and IMNCI focus on it.
In Pakistan and other low-income settings bacterial pneumonia predominates; in rich countries most childhood pneumonia is viral.
Classification
Anatomical
| Type | Pattern |
|---|---|
| Lobar pneumonia | Consolidation of one or more whole lobes; classic for pneumococcus |
| Bronchopneumonia | Patchy consolidation around the bronchioles, often both lungs |
| Pneumonitis | Patchy lung inflammation with or without consolidation |
| Interstitial pneumonitis | Inflammation of alveolar walls and interstitium; typical of viruses and Mycoplasma |
Aetiological
- Bacterial (pneumococcus, Haemophilus influenzae type b, Staphylococcus aureus, group A streptococcus, Gram-negatives).
- Viral (RSV, influenza, parainfluenza, adenovirus, measles).
- Atypical: Mycoplasma.
- Aspiration (poor swallowing, reflux, H-type tracheo-oesophageal fistula), hypostatic, fungal, Pneumocystis (immunosuppressed).
- Loeffler pneumonia: passing lung shadows with eosinophilia (larval migration of worms).
- Chemical: hydrocarbon (kerosene) aspiration, smoke, dusts.
- Inflammatory: SLE, sarcoidosis, histiocytosis.
It is often impossible to separate viral from bacterial pneumonia at the bedside, and bacterial cultures are frequently negative. Treat by the IMNCI classification, not by guessing the organism.
Pathogenesis
The airway below the vocal cords is normally sterile. Defences are the mucus layer, ciliary clearance, the cough reflex, secretory IgA, alveolar macrophages, lymphatic drainage and systemic immunity. Bacteria usually reach the lung by aspiration from the nasopharynx, often after a viral infection (RSV, measles, influenza) has damaged the airway lining. Less often they arrive through the blood from a distant focus, and then meninges, bones or joints may also be infected.
IMNCI classification (child aged 2 months to 5 years)
First check for general danger signs: not able to drink or breastfeed, vomits everything, has had convulsions, is lethargic or unconscious, or is convulsing now.
Then for any child with cough or difficult breathing: ask for how long, count the breaths for one full minute in a calm child, look for chest indrawing, and listen for stridor and wheeze.
Fast-breathing cut-offs
| Age | Fast breathing if |
|---|---|
| Under 2 months | 60 or more per minute |
| 2 months up to 12 months | 50 or more per minute |
| 12 months up to 5 years | 40 or more per minute |
Classification and action
| Signs | Classification | Action |
|---|---|---|
| Any general danger sign or stridor in a calm child | Severe pneumonia or very severe disease | First dose of an appropriate antibiotic; refer urgently to hospital |
| Chest indrawing or fast breathing | Pneumonia | Oral amoxicillin for 5 days; inhaled bronchodilator for 5 days if wheezing; soothe the throat; advise when to return; follow up in 3 days |
| None of the above | Cough or cold | No antibiotic; safe home remedy for the throat; advise when to return; review after 5 days if there is no improvement |
- In both the "pneumonia" and "cough or cold" boxes, a cough lasting more than 14 days or recurrent wheeze means referral to assess for TB or asthma.
- If a pulse oximeter is available, refer when oxygen saturation is below 90%.
- Amoxicillin is now the first-line drug because cotrimoxazole resistance is high. It is given twice daily for 5 days in age or weight bands (Akbar's IMNCI chart): one 250 mg tablet per dose at 2 to 12 months (under 10 kg), two at 12 months to 3 years (10 to under 14 kg; syrup 10 mL), three at 3 to 5 years (14 to 19 kg; syrup 15 mL).
In the current IMNCI chart, chest indrawing alone (without danger signs) is classified as pneumonia and treated at home with oral amoxicillin. Severe pneumonia needs a danger sign or stridor in a calm child.
Young infant (under 2 months)
A young infant with fast breathing (60 or more), severe chest indrawing, poor feeding, convulsions, fever (37.5°C or more), low temperature (below 35.5°C) or reduced movement is classified as very severe disease: give the first dose of intramuscular antibiotics, prevent low blood sugar, keep warm and refer urgently.
Below 2 months the chart asks for severe chest indrawing, and the breath count is repeated if it is 60 or more.
"60-50-40": the fast-breathing thresholds fall by ten as the child grows (newborn, infant, toddler to preschool).
Rational use of drugs
More than 80% of ARI cases are cough or cold and do not need antibiotics. Cough syrups add nothing and some contain harmful ingredients; a simple soothing home remedy (green tea with honey, for example) is enough.
Organisms by age
| Age | Usual bacteria |
|---|---|
| Newborn | E. coli, group B streptococcus, Staphylococcus aureus, Klebsiella, Pseudomonas |
| Infants and young children | Pneumococcus, Haemophilus influenzae type b, Staphylococcus aureus, group A streptococcus, Mycoplasma, E. coli, Klebsiella |
| Older children | Pneumococcus, H. influenzae type b, group A streptococcus, Staphylococcus, Mycoplasma, Mycobacterium tuberculosis |
Nelson adds that RSV is the commonest cause in infants and other respiratory viruses are common under 5 years, with Mycoplasma the leading cause over 5 years (a high-income pattern; Akbar stresses that bacterial pneumonia predominates in Pakistan).
Organism-specific clues
| Organism | Clues |
|---|---|
| Pneumococcus | Over 90% of childhood bacterial pneumonia (Akbar); classic lobar pneumonia; complications uncommon; high neutrophil count |
| Staphylococcus aureus | Mostly in the first year of life; may follow staphylococcal skin lesions; abrupt high fever and rapid worsening; bronchopneumonia spreading to a whole lobe or side; pneumatoceles, empyema, pyopneumothorax |
| H. influenzae type b | Slower (insidious) onset; lobar; effusion or empyema; often with bacteraemia, meningitis, cellulitis or arthritis |
| Group A streptococcus | Diffuse bronchopneumonia with large effusions; empyema in about a quarter; more likely after measles; ASO titre helps |
| Mycoplasma | Leading cause over 5 years (Nelson); a cause of atypical pneumonia; severe or persistent cough after a sore throat is a clue (Akbar) |
A rapidly worsening infant whose X-ray shows thin-walled air cysts (pneumatoceles) has staphylococcal pneumonia until proved otherwise.
Clinical features
- Often a preceding cold, then sudden high fever, chills, poor feeding, drowsiness or restlessness.
- Tachypnoea: the respiratory rate rises out of proportion to the heart rate (ratio near 1:2 or 1:3 instead of the usual 1:4).
- Dry cough at first, later productive and sometimes blood-tinged.
- Nasal flaring, expiratory grunting, intercostal and subcostal recession, cyanosis in severe cases.
- Infants: vomiting, diarrhoea, convulsions, and neck stiffness (meningism) with right upper lobe pneumonia.
- Older children: pleuritic chest pain; abdominal pain with lower lobe pneumonia (can mimic appendicitis).
- The liver may be felt lower because hyperinflation pushes the diaphragm down, or because of heart failure.
Signs of consolidation (from day 2 or 3)
| Sign | Finding |
|---|---|
| Chest movement | Reduced on the affected side |
| Percussion | Dull |
| Vocal fremitus and resonance | Increased |
| Breath sounds | Bronchial breathing |
| Added sounds | Crackles; pleural rub; crackles return during resolution |
In young children the physical signs are often slight compared with the X-ray. Do not rule out pneumonia because the chest sounds clear; count the breathing rate.
Investigations
| Test | Findings |
|---|---|
| Chest X-ray | Extent of consolidation; lobar (pneumococcus), diffuse bronchopneumonia with big effusion (streptococcus), rapid lobar or whole-side spread with pneumatoceles (staphylococcus); shows effusion |
| Full blood count | Leucocytosis (15,000 to 40,000 per mm3) with neutrophilia in bacterial disease; white count below 5,000 is a bad sign |
| Blood culture | Positive in a minority; guides therapy |
| Sputum Gram stain | Only in older children who can produce sputum |
| Pleural fluid | Tap any effusion: Gram stain, culture, cells |
| ASO titre | Streptococcal pneumonia |
| Tuberculin test | When TB is possible (contact, poor response, long cough) |
| Pulse oximetry | Saturation below 90% needs oxygen and admission |
Management
Supportive
- Oxygen (about 2 to 4 L/min) for hypoxia or severe distress.
- Antipyretics; tepid sponging for very high fever.
- Adequate fluids, since fast breathing increases insensible loss; bed rest and good diet.
- Breathing exercises during recovery.
Antibiotics
Give for 7 to 10 days (2 to 3 weeks for staphylococcal pneumonia); adjust to culture results.
| Organism | Drug |
|---|---|
| Pneumococcus | Benzylpenicillin; first-generation cephalosporin |
| Group A streptococcus | Benzylpenicillin; erythromycin |
| Staphylococcus aureus | Cloxacillin or a first-generation cephalosporin |
| H. influenzae | Second- or third-generation cephalosporin; chloramphenicol |
| Mycoplasma | Erythromycin or clarithromycin |
| E. coli | Aminoglycoside (gentamicin, amikacin) |
| Hospital-acquired Pseudomonas or Klebsiella | Meropenem or piperacillin-tazobactam, or cefepime, with or without gentamicin and vancomycin |
| Tuberculosis | Anti-tuberculous treatment |
Children classified as severe pneumonia are treated in hospital with injectable antibiotics, oxygen and fluids; follow the current national (WHO-based) hospital guideline, which can change.
Complications
| Complication | Notes and treatment |
|---|---|
| Pleural effusion and empyema | Most often with S. aureus, S. pneumoniae and S. pyogenes; drain by aspiration or chest tube |
| Lung abscess | Postural drainage, physiotherapy, prolonged antibiotics |
| Pneumatocele | Thin-walled air cavities from air dissecting in the lung, mostly staphylococcal |
| Pneumothorax / pyopneumothorax | Chest drain |
| Delayed resolution | Pneumonia lasting over 1 month or recurring: tuberculin test, sweat chloride, immunoglobulins, bronchoscopy for a foreign body or anatomical lesion, and barium swallow for reflux (Nelson) |
| Respiratory failure | Oxygen, ventilation |
| Spread of infection | Meningitis, otitis media, sinusitis, septicaemia (pneumococcus, Hib) |
Recurrent pneumonia
Defined as two or more episodes in one year, or three or more ever, with X-ray clearing in between. Look for:
- Hereditary: cystic fibrosis, sickle cell disease.
- Immune defects: agammaglobulinaemia, severe combined immunodeficiency, chronic granulomatous disease, hyper-IgE syndrome, leucocyte adhesion defect.
- Cilia: immotile cilia, Kartagener syndrome.
- Aspiration: reflux, swallowing problems, H-type fistula, cleft palate, foreign body.
- Structural: sequestration, lobar emphysema, bronchiectasis.
- Heart disease with high pulmonary blood flow (VSD, AV canal).
A child with recurrent pneumonia plus diarrhoea or poor growth should have a sweat test for cystic fibrosis.
Prognosis and prevention
- With early recognition and correct antibiotics, survival from bacterial pneumonia is high.
- Clinical signs usually settle within 48 hours of effective treatment; X-ray shadows may persist up to 4 weeks (Akbar; Nelson says 6 to 8 weeks), so a repeat film is not needed early in a child who is improving.
- A white count below 5,000 per mm3 is associated with a grave prognosis (Akbar).
- Prevention: pneumococcal conjugate vaccine (reduces pneumonia admissions) and influenza vaccine (Akbar); universal Hib and pneumococcal vaccination has greatly reduced these pneumonias (Nelson); the ARI programme adds standard case management, immunisation and breastfeeding.
Expect: the IMNCI fast-breathing cut-offs (60, 50, 40 by age); the general danger signs; classifying a child with chest indrawing or fast breathing as pneumonia (oral amoxicillin for 5 days, review in 3 days) and a child with a danger sign or stridor at rest as severe pneumonia (first antibiotic dose and urgent referral); very severe disease in a young infant; pneumococcus as the commonest bacterial cause; staphylococcal pneumonia with pneumatoceles and empyema in infancy; Hib with meningitis; signs of consolidation (dullness, increased vocal fremitus, bronchial breathing); slow X-ray clearing; and causes of recurrent pneumonia such as cystic fibrosis.
Quick revision
- Pneumonia = inflammation of the lung parenchyma; lobar, bronchopneumonia, interstitial.
- WHO's key signs: fast breathing and lower chest indrawing.
- Cut-offs: 60 (under 2 months), 50 (2 to 12 months), 40 (1 to 5 years).
- Danger sign or stridor in a calm child: severe pneumonia, refer after first antibiotic dose.
- Fast breathing or chest indrawing: pneumonia, oral amoxicillin 5 days, review day 3.
- Pneumococcus commonest; staphylococcus gives pneumatoceles and empyema in infants.
- Consolidation: dull, increased fremitus, bronchial breathing.
- Antibiotics 7 to 10 days (2 to 3 weeks for staphylococcus).
- X-ray may lag clinical recovery by up to 4 weeks.
Written by The House Job from standard references (Basis of Paediatrics by Pervez Akbar; Nelson Essentials of Paediatrics).
FAQ
Which two signs does IMNCI rely on to diagnose pneumonia?
Fast breathing for the child's age and lower chest indrawing, counted and looked for in a calm child.
Is a child with chest indrawing always referred?
No. In the current IMNCI chart, chest indrawing without any danger sign is classed as pneumonia and treated with oral amoxicillin for 5 days with review in 3 days.
Which organism should you suspect when an infant's X-ray shows pneumatoceles?
Staphylococcus aureus, which also commonly causes empyema and pyopneumothorax and needs a longer antibiotic course.
When does a child with pneumonia need investigation for an underlying disease?
When pneumonia recurs (two episodes in a year or three in total with clearing between), or when it comes with poor growth, chronic diarrhoea or a long cough.