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Infectious Pediatric Pneumonia

Infectious Pediatric Pneumonia. Author: Roberta D. Hood, HBSc, MD, CCFP Lecturer, University of Toronto Date Created: December 2011. Learning Objectives. To describe the presentation of pediatric pneumonia To outline the management of pediatric pneumonia

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Infectious Pediatric Pneumonia

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  1. Infectious Pediatric Pneumonia Author: Roberta D. Hood, HBSc, MD, CCFP Lecturer, University of Toronto Date Created: December 2011

  2. Learning Objectives To describe the presentation of pediatric pneumonia To outline the management of pediatric pneumonia To summarize the complications of pediatric pneumonia To highlight interventions to prevent and protect against pediatric pneumonia

  3. Outline • Quiz • Epidemiology and Pathophysiology • Patient History • Presentation and Diagnosis • Management and Disposition • Further Testing • Complications • Treatment • Interventions to Protect • Interventions to Prevent • Summary Key Points • Case • Quiz Results

  4. Quiz Question 1 What illness is the number one killer of children? A. Diarrheal Disease B. HIV/AIDS C. Malaria D. Pneumonia

  5. Quiz Question 2 What is the most sensitive and specific sign of pneumonia in children? A. Difficulty breathing B. Fever C. Tachypnea D. Tachycardia

  6. Quiz Question 3 If available, a chest x-ray should be done for children with possible pneumonia: A. When a diagnosis is made B. When a history of tachypnea is present C. When antibiotics are started D. When complications are suspected

  7. Quiz Question 4 Which of the following immunization effectively reduce pneumonia mortality in children? A. Haemophilus influenzae b Vaccine B. Pneumococcal Conjugate Vaccine C. Measles Vaccine D. All of the above

  8. What is Pneumonia? Pneumonia: an acute infection of the pulmonary parenchyma The term “Lower Respiratory Tract Infection” (LRTI) may include pneumonia, bronchiolitis and/or bronchitis

  9. Epidemiology and Pathophysiology

  10. Epidemiology Pneumonia kills more children under the age of five than any other illness in every region of the world. It is estimated that of the 9 million child deaths in 2007, 20% (1.8 million) were due to pneumonia Approximately 98% of children who die of pneumonia are in developing countries.

  11. Epidemiology – Dadaab and Kakuma Refugee Camps (Kenya) Data collected from 2007-2011 revealed that acute respiratory infections are the leading cause of morbidity and mortality in the camps. In Dadaab camp acute respiratory infections were associated with 30% to 40% of deaths of children less than 5 years of age and up to 45% of morbidity in the same age group.

  12. Millennium Development Goal In 2000, the United Nations Member States committed to Millennium Development Goal 4 – to reduce the under five mortality rate by two thirds by 2015, compared to 1990. Millennium Development Goal 4 can only be achieved by an intensified effort to reduce pneumonia deaths.

  13. Question: Is reducing the incidence, morbidity, and mortality of pneumonia in children a high priority in the region where you practice? What is being done in your area?

  14. Basic Pathophysiology Most cases of pneumonia are caused by the aspiration of infective particles into the lower respiratory tract. Organisms that colonize a child’s upper airway can cause pneumonia. Pneumonia can be caused by person to person transmission via airborne droplets.

  15. Etiology The common pathogens are a function of the patient’s age. The specific agent causing pneumonia can be determined in 1/3 to 2/3 of cases when cultures, antigen detection and serologic techniques are available. It is helpful to be aware of local outbreaks as clustering of cases is common.

  16. Pneumonia - Common Pathogens From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

  17. Pneumonia - Common Pathogens From: Tintinalli JE et al. (2004). Emergency Medicine, A Comprehensive Study Guide, Sixth Edition. American College of Emergency Physicians. (pp. 784-789). McGraw-Hill. Toronto, ON.

  18. Pneumonia History

  19. Pneumonia History Fundamentals Age Presence of cough, difficulty breathing, shortness of breath, chest pain Fever Recent upper respiratory tract infections Associated symptoms (e.g.. headache, lethargy, pharyngitis, nausea, vomiting, diarrhea, abdominal pain, rash) Duration of symptoms

  20. Pneumonia History Immunizations status TB exposure Maternal Chlamydia, Group B Strep status during pregnancy Choking episodes Previous episodes Previous antibiotics

  21. Pneumonia History Ill contacts Travel history Day care attendance Animal exposure Dehydration is a sign of severe infection that may require hospitalization. Inquire about: Fluid and nutrition intake Urine output

  22. History Fundamentals Past Medical History Birth History Medications Allergies Immunization Status Home Environment Social History Family History

  23. Diagnosis

  24. Diagnosis Objectives Recognition of the signs of pneumonia Diagnosis in a community setting Diagnosis in a health care setting Differential Diagnosis RSV and TB Diagnosis in the context of malnutrition, and considering HIV

  25. Recognition of Signs of Pneumonia Tachypnea is the most sensitive and specific sign of pneumonia Tachypnea had a Sensitivity of 61% and 79% and Specificity of 79% and 65% for pneumonia in malnourished and well-nourished Gambian children respectively

  26. WHO Definition of Tachypnea

  27. Other signs of pneumonia -Indrawing out---breathing---in Lower chest wall indrawing: with inspiration, the lower chest wall moves in From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000 ”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

  28. Other signs of pneumonia - Nasal Flare Nasal flaring: with inspiration, the side of the nostrils flares outwards From: Integrated Management of Childhood Illness. Chapter Three: Cough or difficulty breathing. World Health Organization. 2000 ”https://apps.who.int/chd/publications/referral_care/chap3/chap31.htm. Accessed February 2, 2012

  29. Diagnosis in Community Setting From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Children’s Fund (UNICEF), 2006.

  30. Infants at Risk of Pneumonia Infants less than 3 months old with signs of pneumonia should be referred immediately to the nearest health facility because they are at high risk of severe illness and death. Infants who were premature, and those with congenital heart disease or chronic lung disease are also at increased risk.

  31. Diagnosis in a Health Care Setting Vital signs that should routinely be taken in an Emergency Care setting include: Respiratory Rate Heart Rate Temperature Oxygen saturation (if available) Any child with an increased respiratory rate should be immediately identified as having possible pneumonia.

  32. Vital Signs Both heart rate and respiratory rate are influenced by the presence of fever. Heart rate increases by approximately 10 beats per minute for each 1 degree Celsius. Respiratory Rate has been estimated to vary by 0.5-2 breath per minute to 5-11 breaths per minute for each 1 degree Celsius.

  33. Does this infant child have pneumonia? The Rational Clinical Exam, Journal of the American Medical Association Observation of the infant is the most important part of the examination – does the child look sick? Respiratory rate should be calculated over two thirty second intervals, or one minute due to moment to moment variability. Auscultation is unreliable when examining infants.

  34. Does this infant child have pneumonia? Absence of tachypnea is the best individual finding for ruling out pneumonia. Chest indrawing, other signs of increased work of breathing and abnormal findings on auscultation can be used toward ruling in pneumonia. If clinical signs are negative (respiratory rate, auscultation, and work of breathing), it is unlikely that there will be chest x-ray findings.

  35. Pneumonia Severity Assessment From: Pneumonia The Forgotten Killer of Children. Geneva: World Health Organization (WHO)/United Nations Children’s Fund (UNICEF), 2006.

  36. Differential Diagnosis: A Focus on Respiratory Syncytial Virus (RSV)

  37. Respiratory Syncytial Virus (RSV) RSV is the most common cause of LRTIs in children less than 1. Infants and young children typically present with pneumonia or bronchiolitis. Older children may have upper respiratory tract infection symptoms. RSV is associated with apnea in infants. Wheezing is common.

  38. RSV Seasonality Seasonal outbreaks occur throughout the world. In the northern hemisphere outbreaks peak in January and February. In the southern hemisphere outbreaks peak in May, June and July. In tropical climates outbreaks are often associated with the rainy season.

  39. Differential Diagnosis: Consider Tuberculosis

  40. Tuberculosis Common symptoms of tuberculosis include: Chronic cough that has been present for more than 3 weeks and is not improving Fever greater than 38°C for at least two weeks, not attributable to other common causes Weight loss or failure to thrive

  41. Tuberculosis Physical exam findings of children with pulmonary tuberculosis are similar to those of a lower respiratory tract infection. In children less than age five tuberculosis can progress rapidly from latent infection to active disease and serve as a sentinel case in the community. Consider the diagnosis of tuberculosis, especially in those children who fail to respond appropriately to routine treatment for pneumonia.

  42. Pneumonia in Malnourished Children

  43. Pneumonia in Malnourished Children History of cough, fast breathing and difficulty breathing were significant predictors of pneumonia in malnourished children. Only difficulty breathing was a significant predictor of pneumonia in well-nourished children. As malnourished children are a high risk group, those who present with a history of cough, fast breathing, or difficulty breathing should be treated with antibiotics. Fast breathing and lower chest wall indrawing are not specific predictors of pneumonia in malnourished children.

  44. Pneumonia and HIV infected Children

  45. Pneumonia and HIV infected Children The prevalence of HIV-1 in children admitted with severe pneumonia (by WHO criteria) in Africa is 55-65%. The case fatality rate is 20-34%. This case fatality rate is 3-6 times higher for children infected with HIV compared to those not infected with HIV. Pneumonia caused by Pneumocystis jiroveci may be the first indicator of HIV infection, and lead to HIV testing and diagnosis.

  46. Question: How are children who may have pulmonary tuberculosis identified and treated? Malnourished children, and children with HIV are at high-risk for complications associated with pneumonia. How are these children managed where you practice?

  47. Management and Disposition

  48. Disposition The decision whether the patient would be best managed at home or in a heath care setting is based on many factors, including the resources available.

  49. Admission Considerations If caregivers are unable to care for the child, or to commit to following a treatment plan, the child should be admitted to a health care facility. Any child less than three months of age. Failure of outpatient treatment (worsening or no response to treatment after 24 to 72 hours). Family lives in a remote area.

  50. Indications for Admission - IMCI All Children with Very Severe Pneumonia need admission Very Severe Pneumonia includes any of: Cough or difficult breathing plus at least one of the following: Central cyanosis Inability to breastfeed or drink, or vomiting everything Convulsions, lethargy or unconsciousness Severe respiratory distress (e.g. head nodding) Some or all of the other signs of pneumonia (tachypnea, grunting, nasal flare, indrawing, changes in auscultation)

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