pediatric pneumonia

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Slide 1 :

Pneumonia: Past and Present Dr. Pushpa Raj Sharma Professor of Child Health Institute of Medicine

Slide 2 :

Disease Pattern

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Epidemiology Each year, acute respiratory infections cause approximately 2-3 million deaths among children <5 years old and are the leading cause of death in this age group. About 1% of pneumonia cases result in sequelae (e.g., bronchiectasis) Identifying the cause of community-acquired pneumonia is more difficult in children

Slide 4 :

Children with ARI presenting in OPD Place % of children London (UK) 35.0 Herston (Australia) 34 Ethiopia (Whole country) 25.5 Sau aulo (Brazil) 41.8 India 38.9 Nepal 37.6

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Number of Pneumonia Episodes Per Year in Childeren Under 5 Years Place Annual Incidence per 100 Seattle (USA) 3.0 Gadchiorili (India) 13.0 Basse, (Gambia) 17.0 Bankok (Thailand) 7.0 Nepal 16.5

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Epidemiology A lower respiratory tract infection (LRI) develops in one in three children in the first year of life. Twenty-nine percent of these children develop pneumonia Approximately 10-20% of all children <5 years old in developing countries develop pneumonia each year

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Risk Factors Significant risk factors were younger age (2-6 months), low parental education, smoking at home, prematurity, weaning from breast milk at < 6 months, a negative history of diphtheria, pertussis and tetanus vaccination, anaemia and malnutrition. Trop Doct 2001 Jul;31(3):139-41

Slide 8 :

Pathology

Slide 9 :

Pathology

Slide 10 :

Types of Pneumonia

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Aetiological agents

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Diagnosis Clinical evaluation of pneumonia Cough, Grunting, Chest pain, Tachypnea. Retractions, Signs of consolidation, Crackles Wheezing , Cyanosis, Abdominal pain , Drooping of shoulder.

Slide 13 :

Mechanism of cough Bronchioles and Respiratory bronchiole alveolus

Slide 14 :

Signs of Pneumonia

Slide 15 :

Symptoms and Signs in Pneumonia

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Comparison of Methods for the Detection of Pneumonia in Children Method Sensitivity Specificity Stethoscope 53% 59% (crepetations) Simple clinical signs 77% 58% (fast breathing or chest indrawing) Note: Pneumonia diagnosis confirmed by Chest X-ray

Slide 17 :

Diagnosis Diagnostic evaluation of lower respiratory infections: WBC count Blood cultures C-reactive protein Chest radiograph. Bacterial antigen assays Nasopharyngeal cultures

Slide 18 :

Diagnosis

Slide 19 :

Clinical Diagnosis Tachypnoea according to the usual WHO criteria. Auscultatory signs have lower specificity. Acute phase reactants cannot be relied for aetiological diagnosis. Blood culture positivity in only <10% Viral antigen detection not available.

Slide 20 :

Pneumonia and Vitamin A Weekly low-dose (10 000 IU) vitamin A supplementation in a region of subclinical deficiency protected underweight children from ALRI and paradoxically increased ALRI in normal children with body weight over -1 SD in Ecuadorian Children . Large doses of vitamin A had no protective effect on the course of pneumonia in hospitalized Tanzanian children.

Slide 21 :

Pneumonia and Zinc Reduction in all respiratory diseases. (Indian J Pediatr 1995; 62,181-93 2.5 fold decrease in respiratory infection. (Am J Clin Nutr; 1996; 63; 514-9 Significant reduction in upper respiratory tract disease. (Am J Clin. Nutr. 1996; 63;514-9) Reduction of 45% incidence of lower respiratory tract infection. (PEDIATRICS 1998; 102 ;1-5)

Slide 22 :

Compositions of cough mixtures available Category A - Only Antitussive F - Expectorant + Antitussive B - Only expectorant G - Expectorant + Bronchodilator C - Only mucolytics H - Expectorant + Mucolytics D - Only bronchodilator I - Expectorant + Antihistamines E - Only Antihistamine J - Having more than 2 of the A,B,C,D,E. K - Bronchodilator + Antihistamine

Slide 23 :

Formulations available Type of Formulation

Slide 24 :

Role of cough mixtures in pneumonia

Slide 25 :

Over the counter cough mixtures No well-controlled studies supporting the use of codeine or dextromethorphan as antitussives for children have been published, and indications for their use have not been established. Cough due to URTI can often be treated with non-drug measures (fluids and humidity). Pediatric dosages of antitussives are extrapolated from adult data and thus are imprecise for children. Significant adverse effects of their use have been documented. Clinicians should tell parents and patients about these concerns.

Slide 26 :

Systematic review of randomised controlled trials of over the counter cough medicines for acute cough in adults BMJ 2002;324:329 ( 9 February ) Conclusion: Over the counter cough medicines for acute cough cannot be recommended because there is no good evidence for their effectiveness. Even when trials had significant results, the effect sizes were small and of doubtful clinical relevance. Because of the small number of trials in each category, the results have to be interpreted cautiously.

Slide 27 :

Treatment must assess the severity of the illness, appropriate setting for treatment (outpatient vs. inpatient), socioeconomic conditions, and local susceptibility patterns of common pathogens. Treatment

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Causative Agents In Africa and South America (8 studies), bacteria were recovered from 56% (range 32%-68%) of severely ill children studied by lung aspirate. The most often isolated bacteria were Streptococcus pneumoniae (33%) and Haemophilus influenzae (21%) Braz J Infect Dis 2001 Apr;5(2):87-97

Slide 29 :

Haemophilus influenzae

Slide 30 :

Streptococcus pneumoniae

Slide 31 :

Mycoplasma pneumoniae

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Integrated Management of Childhood Illnesses Does the child have cough or difficulty in breathing? If Yes Ask: Signs Clsssify as For How Long? Any general danger sign or Severe Chest indrawing or pneumonia Stridor Look, Listen Fast breathing Pneumonia Count the breaths Chest indrawing No signs of pneumonia No Pneumonia: Stridor or very severe disease cough or cold

Slide 33 :

Suggested Drug Treatment Birth to 20 days: Admission 3 weeks to 3 months: Afebrile: oral erythromycin Febrile: add cefotaxime 4 months to 5 years: Amoxycillin 80mg/kg/dose 6-14 years: Erythromycin NEJM

Slide 34 :

Prevention Within two years of the introduction of routine Hib vaccination of infants in the UK, the risk of serious Hib infection had fallen from 1:600 to 1:30,000 by 5 years of age Eur J Clin Microbiol Infect Dis 1995 Nov;14(11):935-48 It is important that these highly effective vaccines should be made available to children in the developing countries. Acta Paediatr 2001 May;90(5):473-6

Slide 35 :

Summary Pneumonia in children in the age group of 2 months to 5 years Pneumonia is the commonest cause of mortality Fast breathing in a child with cough or difficulty breathing is highly sensitive and specific for diagnosis Co-trimoxazole is the effective treatment for community pneumonia in children Cough mixtures are not useful but harmful. Cough persists for few weeks.

Slide 36 :

Haemophilus influenzae

Slide 37 :

Haemophilus influenzae

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Mycoplasma pneumoniae

Slide 39 :

Structure, Virulence Factors and Pathogenesis

Slide 40 :

Mycoplasma pneumoniae

Slide 41 :

Structure, Virulence Factors and Pathogenesis

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