pneumonia in children (1)

8/12/2019 Pneumonia in Children (1)

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Pneumonia: Past and Present

Dr. Pushpa Raj Sharma

Professor of Child Health

Institute of Medicine


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Disease Pattern


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Epidemiology

Each year, acute respiratory infections

cause approximately 2-3 million deaths

among children


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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) 17.0Bankok (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


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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 milkat < 6 months, a negative history of

diphtheria, pertussis and tetanus

vaccination, anaemia and malnutrition. Trop Doct 2001 Jul;31(3):139-41


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Pathology
http://axon.sote.hu/KKK/PICTURES/0339/0339010.JPGhttp://axon.sote.hu/KKK/PICTURES/0339/0339009.JPG


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Pathology


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Types of Pneumonia

Currently pneumonias aredefined as either community-

acquired (CAP) or nosocomial or

hospital-acquired.CAP is defined as an infection

acquired in the community

setting; the definition varies andit may or may not include

infections acquired in a nursing

home or long-term care facility


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Aetiological agents

The exact incidence varies but

in a meta-analysis of 122 cases

of CAP, it accounted for 66% ofcases in which a microbiological

diagnosis was made.

Exact incidences of thevarious aetiologic organisms

are not known.


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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.


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Mechanism of cough

Bronchioles and Respiratory bronchiole

alveolus


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Signs of Pneumonia


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Symptoms and Signs in Pneumonia

0

10

20

30

40

50

60

70

80

90

100

Cough

Indrawing

Convulsion

Cyanosis

Abdominal pain

crepitations

Fast breathing

Wheeze


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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


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Diagnosis

Diagnostic evaluation of lower respiratory

infections:

WBC count Blood cultures

C-reactive proteinChest radiograph.

Bacterial antigen assays

Nasopharyngeal cultures

Di i


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Diagnosis

Recent studies have concluded

that generally radiology is not

helpful for determining the

aetiology of the infection.

The diagnosis of pneumonia is

based on a history of respiratory

tract infection and theradiological finding of new

pulmonary infiltrates


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Clinical Diagnosis

Tachypnoea according to the usual

WHO criteria.

Auscultatory signs have lowerspecificity.

Acute phase reactants cannot be relied

for aetiological diagnosis. Blood culture positivity in only


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Pneumonia and Vitamin A

Weekly low-dose (10 000 IU) vitamin Asupplementation in a region of

subclinical deficiency protected

underweight childrenfrom ALRI and

paradoxically increased ALRI innormal childrenwith body weight

over -1 SD in Ecuadorian Children .

Large doses of vitamin A had noprotectiveeffect on the course of

pneumonia in hospitalized Tanzanian

children.


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Pneumonia and ZincReduction 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)


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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 theA,B,C,D,E.

K - Bronchodilator + Antihistamine


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Formulations available

Type of Formulation

Tablets/capsules 19 23.75%

Liquid/Syrups 56 70.00%

Other forms 5 6.25%

TOTAL 80 100%


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Role of cough mixtures in

pneumonia


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Over the counter cough mixtures

No well-controlled studies supporting the use ofcodeine or dextromethorphan as antitussives forchildren have been published, and indications fortheir 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 extrapolatedfrom adult data and thus are imprecise for children.

Significant adverse effects of their use have beendocumented.

Clinicians should tell parents and patients aboutthese concerns.

Systematic review of randomised controlled trials of over the


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Systematic review of randomised controlled trials of over thecounter cough medicines for acute cough in adults

BMJ2002;324:329 ( 9 February )

Conclusion:Over the counter coughmedicines for acute cough cannot berecommended because there is no good

evidence for their effectiveness. Evenwhen trials had significant results, theeffect sizes were small and of doubtfulclinical relevance. Because of the small

number of trials in each category, theresults have to be interpreted cautiously.

T t t


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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

Various guidelineshave been developed.

Once treatment has begun, no change

in medication is indicated within the 1st72 hours unless a specific organism is

identified and is not covered by the

current medication .


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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 isolatedbacteria were Streptococcus pneumoniae

(33%) and Haemophilus influenzae (21%)

Braz J Infect Dis 2001 Apr;5(2):87-97

H hil i fl


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Haemophilus influenzae

polyribosyl ribitol phosphate (PRP) capsule

is an important virulence factor whichrenders type b H. influenzaeresistant to

phagocytosis by PMNs in the absence of

specific anticapsular antibody .produce IgA protease which may

facilitate attachment to mucosal surfaces

treatment with a combination of

amoxicillin and clavulanic acid

(Augmentin) or TMP/SMX is effective

against -lactamase-producing strains


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Streptococcus pneumon iae

Ccapsular polysaccharide is mostimportant virulence factor;

approximately 85 capsular types

Penicillin is drug of choice for

susceptible organisms (MIC =

0.06 g/mL) .

Vaccine contains 23 most

common capsular serotypes

Mycoplasma pneumon iae


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special attachment organelle; attach to

epithelium via protein adhesins on theattachment organelle; major adhesin is a

170-kilodalton (kDa) protein, named P1

bacteria injure mucosa by producing

oxidants (hydrogen peroxide &

superoxide radicals) which cause

ciliostasis and epithelial necrosis thusinhibiting normal clearance mechanisms

Integrated Management of


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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


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Suggested Drug Treatment

Birth to 20 days:

Admission

3 weeks to 3 months:

Afebrile: oralerythromycin

Febrile: add

cefotaxime

4 months to 5 years:

Amoxycillin

80mg/kg/dose

6-14 years:

Erythromycin

NEJM Volume 346:429-437


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Prevention

Within two years of the introduction of routineHib vaccination of infants in the UK, the risk ofserious Hib infection had fallen from 1:600 to

1:30,000 by 5 years of ageEur J Clin Microbiol Infect Dis 1995Nov;14(11):935-48

It is important that these highly effectivevaccines should be made available to children inthe developing countries.

Acta Paediatr 2001 May;90(5):473-6

Summary


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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 difficultybreathing is highly sensitive and specific for diagnosis

Co-trimoxazole is the effective treatment for

community pneumonia in childrenCough mixtures are not useful but harmful.

Cough persists for few weeks.


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Haemoph i lus in f luenzae

Strains are classified as eitherserotypable (if they display a capsular

polysaccharide antigen) or nontypable

(no capsule); seven generallyrecognized serotypes: a, b, c, d, e, e'

and f; H. in f luenzaetype b (Hib) is the

most virulent

Nontypable H. in fluenzaestrains

colonize the nasopharynx of most

normal children.


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Haemoph i lus inf luenzae

Approximately 20-30% of isolates

are beta-lactamse positive.

Treatment with either

amoxicillin/clavulanic acid or

TMP/SMX is effective against -

lactamase-producing strains.


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Data suggest that repeated infections

are required before symptomatic

disease occurs - antibodies to M.

pneumoniaecan be found in most

children age 2 - 5 years while illnessoccurs with greater frequency among

older children and young adults .

Resistant to antibiotics that inhibit

bacterial cell wall synthesis (e.g.,

penicillin, cephalosporins, vancomycin)

S Vi l F d


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Structure, Virulence Factors and

Pathogenesis

encapsulated organisms can

penetrate the epithelium of the

nasopharynx and invade bloodcapillaries directly; nontypable strains

are less invasive, but they, as well as

typable strains, induce an

inflammatory response that causes

disease


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M. pneumoniaeacts as a superantigen

(macrophage activation, cytokine

induction) and stimulates inflammation;

pneumonia is induced largely by localimmunologic and phagocytic responses

to the parasites.

some children may develop coldagglutininsas a result of infection.

Structure Virulence Factors and


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Structure, Virulence Factors and

Pathogenesis

Secretory IgA protease - inhibits

function of secretory IgA which

normally binds bacteria to mucin to

facilitate clearance from the

respiratory tract

Pneumolysin - creates pores in and

destroys ciliated epithelial cellsHydrogen peroxide - reactive 02

intermediate causes tissue damage

pneumonia in children (1)

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