Community-Acquired Pneumonia in Children

Community acquired pneumonia in children is infection of the lung parenchyma acquired outside hospital, and it is the leading infectious cause of death in children under 5 years worldwide.

• Viruses cause most cases in preschool children (respiratory syncytial virus, rhinovirus, influenza, parainfluenza). Bacteria cause a larger share in older children and in severe disease.
• Streptococcus pneumoniae is the commonest bacterial cause. Others include Haemophilus influenzae type b, Staphylococcus aureus, Mycoplasma pneumoniae, Chlamydia pneumoniae, Group A Streptococcus and Mycobacterium tuberculosis.
• Risk factors include malnutrition, HIV, incomplete immunisation, indoor air pollution, overcrowding, prematurity, lack of breastfeeding and sickle cell disease.
• In resource-limited settings, diagnosis relies on respiratory rate and chest indrawing.

Cough with fast breathing is the cardinal feature.

• Cough, fever, rapid breathing (respiratory rate 50 or more per minute in infants 2 to 11 months, 40 or more in children 1 to 5 years, above 30 in children over 5 years), and difficulty breathing.
• Lower chest indrawing, nasal flaring and grunting.
• Crackles, bronchial breathing, reduced air entry, dullness on percussion (effusion).
• Abdominal pain and vomiting in older children; lower lobe pneumonia may mimic appendicitis.
• Severe pneumonia: central cyanosis, saturation below 90 percent, inability to drink, convulsions, lethargy or reduced consciousness.
• Differential diagnosis: bronchiolitis, asthma, tuberculosis, pertussis, foreign body, heart failure, pulmonary oedema, malaria with respiratory distress, pneumocystis pneumonia, empyema and lung abscess.
• Complications: pleural effusion, empyema, lung abscess, pneumothorax, respiratory failure, sepsis, meningitis, pericarditis, necrotising pneumonia and bronchiectasis.

Diagnosis is clinical, with limited investigation.

• Respiratory rate counted for a full minute, saturation by pulse oximetry, and signs of severity.
• Chest X-ray not routine for outpatient mild cases; indicated for severe disease, failure to improve, effusion suspicion or diagnostic uncertainty.
• Full blood count, C-reactive protein, blood culture for hospitalised children.
• Pleural fluid analysis and culture for effusion.
• Malaria test, HIV test, Xpert MTB/RIF and tuberculosis assessment in at-risk children or persistent illness.
• Nasopharyngeal polymerase chain reaction for respiratory viruses.

Antibiotics and oxygen are given by severity.

• Supportive: oxygen if saturation below 90 percent (or below 92 percent in hospital settings), fluids, antipyretics, nutrition, and nasal suction.
• Pharmacological, non-severe (fast breathing only) outpatient: amoxicillin 40 to 45 mg/kg twice daily (or 25 mg/kg three times daily) for 3 to 5 days.
• Severe pneumonia (chest indrawing or danger signs): admit and give intravenous benzylpenicillin 50,000 units/kg every 6 hours or ampicillin 50 mg/kg every 6 hours, with gentamicin 7.5 mg/kg once daily, for at least 5 days, then change to oral amoxicillin. Ceftriaxone 80 mg/kg once daily if there is no response to first-line therapy.
• Suspected Staphylococcus aureus: add cloxacillin 50 mg/kg every 6 hours or flucloxacillin, or vancomycin 15 mg/kg every 6 to 8 hours where methicillin-resistant strains are suspected.
• Atypical pathogens (children over 5 years or poor response): azithromycin 10 mg/kg on day 1, then 5 mg/kg for 4 more days, or clarithromycin 7.5 mg/kg twice daily for 7 to 10 days.
• Children with HIV and suspected pneumocystis pneumonia: add cotrimoxazole 20 mg/kg of trimethoprim per day (trimethoprim 5 mg/kg per dose and sulfamethoxazole 25 mg/kg per dose) every 6 hours for 21 days, with prednisolone 2 mg/kg daily for 7 days then tapering.
• Procedures: pleural drainage for large effusion or empyema. Intubation for respiratory failure.
• Special groups: malnourished children need extended treatment, broad-spectrum antibiotics and careful fluid management. Infants under 2 months with fast breathing need admission.
• Red flags: central cyanosis, inability to drink, convulsions, lethargy, severe chest indrawing, saturation below 90 percent, grunting, and no response in 48 to 72 hours.
• Follow-up: review at 48 hours for outpatients. Follow-up chest X-ray at 4 to 6 weeks for complicated pneumonia or slow recovery. Complete immunisation.