Pneumonia

exp date isn't null, but text field is

Introduction

  • Pneumonia accounts for 15% of all under-five deaths (including neonatal death due to pneumonia) in Nigeria, the highest in Africa.
  • Burden of disease mainly in the younger age groups;
    • 81% of deaths from pneumonia in children less than 2 years.
  • Male to female ratio is 1.5:1.
  • Classified clinically as lobar pneumonia or bronchopneumonia

Clinical Features

  • Cough
  • Fast breathing.
  • Fever is very common in childhood pneumonia.
  • Vomiting
  • Poor feeding
  • Diarrhea
  • Convulsion
  • Chest pain (due to pleuritis) in older children.
  • Tachypnoea is a sensitive marker of pneumonia and is commonly present
  • and/or difficult breathing
  • Dull or resonant percussion note on percussion
  • Bronchial breath sounds and or crepitations on auscultation

For neonates:

  • Fever or hypothermia
  • Poor feeding
  • Vomiting
  • Lethargy or irritability
  • Abdominal distension
  • Convulsion
  • Jaundice
  • Tachypnoea (≥ 60 breaths/min)
  • Tachycardia etc

Complications

Complications can be acute or chronic.

Acute:

  • Heart failure
  • Pleural effusion
  • Empyema
  • 3 Ps: Pneumatocoele, pneumothorax, pyopneumothorax, pyopneumothorax
  • Atelectasis
  • Septicaemia
  • Acute respiratory failure

Chronic:

  • Lung abscess
  • Bronchiectasis

Diagnostic Criteria

Gold standard for diagnosis is chest radiography,(although does not reveal the aetiology)

Investigations

  • Chest radiography
  • Blood culture to determine the bacterial aetiology
  • Full blood count will determine anaemia and suggest a bacterial (polymorphonuclear leukocytosis) or viral aetiology (lymphocytosis).
  • Electroltye and urea, may show hyponatraemia and azotaemia especially in those children with accompanying diarrhea and vomiting, and poor feeding.

Treatment

  • Clear the airway using gentle suction
  • Supplemental oxygen if oxygen saturation is less than 90% in room air or signs of severe respiratory distress are present. If pulse oximetry is not available give oxygen if signs of respiratory distress and or cyanosis are present.
    • Give oxygen via nasal prongs or nasal catheters: 0.5-1L/min for children 0-2months, 2-3L/min for children 3 months to 5 years; maximum of 4L/min for older children)
  • Allow small frequent feeds if tolerated; feeding may also be done using nasogastric tube
  • If feeds are not tolerated give intravenous isotonic fluid. Ensure it contains at least 5% glucose (e.g. 5% dextrose in 0.9% saline or Ringer’s lactate with added glucose)
  • Nursing care should be provided at least every 3 hours: check vital signs including oxygen saturation
  • The doctor should review the child at least twice each day
  • For high grade fever (temperature ≥39oC), give paracetamol 10-15mg/kg 4-6 hourly or ibuprofen 6 mg/kg.  If widespread wheeze is present (high-pitch musical sound during expiration only or during both phases of respiration) give first dose of short acting bronchodilator such as salbutamol or albuterol and re-assess.

The National Guideline on the antibiotic treatment of community-acquired pneumonia in under-5s is summarised below:

Category of children

Outpatients

Inpatients
 

First line

Alternatives*

First line

Alternatives*

<2 months

Admit and treat as neonatal sepsis

≥2 months

High dose Oral amoxicillin (45mg/kg per dose 12 hrly) for at least 5 days

Oral amoxicillin-clavulanic acid (amoxicillin component 45mg/kg per dose 12 hrly) OR oral cefpodoxime (5mg/kg per dose 12 hrly) OR oral cefuroxime (10-15mg/kg per dose 12 hrly) for at least 5 days

IV amoxicillin (50mg/kg every 8 hrs) AND IV/IM genticin (5-7.5mg/kg once daily)

IV cefuroxime (50mg/kg 8 hrly)

AND

IV/IMgenticin (5-7.5mg/kg once daily) for at least 5 days

OR

IV ceftriaxone (50-100mg/kg/day every 12-24hours),

OR

IV cefotaxime (25-50mg/kg 6 hrly),

OR

IV/IM genticin (5 -7.5mg/kg once daily)

AND

IV cloxacillin (25-50mg/kg 6 hrly) for at least 5 days.

HIV-infected children

High dose Oral amoxicillin (45mg/kg per dose 12 hrly) for 10 days

Oral amoxicillin-clavulanic acid (amoxicillin component 45mg/kg per dose 12 hrly) OR oral cefpodoxime (5mg/kg per dose 12 hrly) OR oral cefuroxime (10-15mg/kg per dose 12 hrly)for at least 10 days

IV amoxicillin (50mg/kg every 8 hrs) AND IV/IM genticin (5-7.5mg/kg once daily) PLUS high dose co-trimoxazole (5mg/kg 6 hrly of trimethoprim) for at least 10 days

IV cefuroxime (50mg/kg 8 hrly)

AND

IV/IM genticin (5-7.5mg/kg once daily) for at least 5 days

OR

IV ceftriaxone (50-100mg/kg/day every 12-24hours),

OR

IV cefotaxime(25-50mg/kg 6 hrly),

OR

IV/IM genticin(5 -7.5mg/kg once daily)

AND

IV cloxacillin (25-50mg/kg 6 hrly)

AND

high dose co-trimoxazole (5mg/kg 6 hrly of trimethoprim) for at least 10 days

Children with sickle cell disease

High dose Oral amoxicillin (45mg/kg per dose 12 hrly) for at least 5 days

Oral amoxicillin-clavulanic acid (amoxicillin component 45mg/kg per dose 12 hrly) OR oral cefpodoxime (5mg/kg per dose 12 hrly) OR oral cefuroxime (10-15mg/kg per dose 12 hrly) for at least 5 days

IV amoxicillin (50mg/kg per dose 8 hrly) AND IV/IM genticin (5- 7.5mg/kg once daily) for at least 5 days PLUS oral erythromycin (15-25mg/kg per dose 6 hrly)

IV cefuroxime (50mg/kg per dose 8 hrly)

AND

IV/IM genticin (5-7.5mg/kg once daily)

OR

IV ceftriaxone (50-100mg/kg/day every 12-24hours),

OR

IV cefotaxime (25-50mg/kg 6 hrly)

AND

oral azithromycin (10 mg /kg) daily dose for 3 days

Notes:

  1. Step down to appropriate oral antibiotics when improvement is sustained. For instance, cefpodoxime after ceftriaxone.
  2. Target pathogens in outpatients’ treatment are Streptococcus pneumoniae and Haemophilus influenzae type B; whereas in cases on admission, these as well as Staphylococcus aureus and other bacilli are included.
  3. Maximum dose of gentamicin should not exceed 120mg.

*Alternatives: Consider alternatives when first line drugs are not available or applicable or child has not responded to the first line drugs.