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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.JPG8/12/2019 Pneumonia in Children (1)
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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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Mycoplasma pneumon iae
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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Mycoplasma pneumon iae
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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Mycoplasma pneumon iae
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
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