Infection of the pulmonary alveolar viral, bacterial (pneumococci, Haemophilus influenzae, Mycoplasma pneumoniae)or parasitic (Pneumocystis carinii in HIV infection).
Pneumonia in children under 5 years
Clinical signs:
The most common causes are viruses, pneumococci, Haemophilus influenzae.
Should be suspected pneumonia in any child with a cough or has difficulty breathing.
– Often high fever (higher than 39ºC) but perhaps moderate and sometimes absent (often a sign of seriousness).
– Clinical examination should be performed on a quiet child in order to correctly measure the respiratory rate and look for signs of severity.
– Often difficult pulmonary Review: dullness with decreased breath sounds, crackles and sometimes tubal breath (inspiratory and intense) or normal lung auscultation.
– Respiratory rate: because of its variability, measurement of respiratory rate (RR) must be calculated on a minute.WHO can use the timer or a watch with a second hand.
The child has tachypnea (rapid breathing rate) if:
EN> 60 / min in children under 2 months
EN> 50 / min in a 2 to 11 months
EN> 40 / min in children 12 months to 5 years
Signs of gravity to search (on a quiet child to rest or asleep) are:
– Indrawing: the lower chest wall is depressed inspiration while the upper part of the abdomen rises (thoracoabdominal swing).
– EN> 60 / min in less than 2 months of infant
– Cyanosis (to look at the lips, oral mucosa and nails)
– Beats the nostrils
– Refusal to drink or breastfeed
– Impaired consciousness (child sleepy or difficult to wake)
– Stridor (harsh sound on inspiration)
– Grunting (his short, repetitive produced by the partial closure of the vocal cords to expiration)
– Severe malnutrition
remarks:
– In children, fever may increase the FR 10 / min per degree centigrade.
– In children malnourished must decrease the thresholds of 5 / min.
– The indrawing has meaning only if there permanently and it is visible. If one observes that when the child is upset, he eats, not at rest, it is considered that there is no draw.
– In infants under 2 months a moderate draw subcostal is normal because the chest wall is soft.
– If only the soft tissue between the ribs and / or above the collarbone is depressed, there is no indrawing.
– Eliminate severe malaria who can also provide respiratory symptoms with cough and tachypnea.
The presence of clinical anemia, splenomegaly, a deep and labored breathing are in favor of severe malaria.
Unilateral signs on auscultation, the presence of crackles, a indrawing are more in favor of pneumonia.
– In case of diarrhea and painful abdominal bloating, think as a Staphylococcal pneumonia.
Pneumonia diagnosis in children under 5 years with cough or breathing difficulties:
Treatment:
Serious pneumonia (hospital):
In infants less than 2 months:
The treatment of choice is:
ceftriaxone IM or slow IV “The solvent of ceftriaxone for IM injection contains lidocaine. Reconstituted with the solvent, ceftriaxone should never be administered IV. For IV administration, use only water ppi. “
Newborn: 50 mg / kg / day as an infusion to go in 60 minutes
Infant over a month: 50 mg / kg / day by IM injection or slow IV (3 minutes) for at least 3 days and take the oral treatment with amoxicillin PO:
100 mg / kg / day in 3 divided doses to complete 7 to 10 days of treatment.
in the absence of :
ampicillin IV or IM: 100 mg / kg / day in 3 divided in 4 injections and take the oral treatment with amoxicillin at the same dose after resolution of fever or signs of severity, to complete 7 to 10 days of treatment .
+ Gentamicin IM: 3 to 6 mg / kg / once daily for 7 days
In the absence of improvement or if deterioration after 48 hours of treatment behaved well, think of a staphylococcal lung.
In children 2 months to 5 years:
ampicillin IV or IM + gentamicin IM, same dosage as for the infant (see above).
or
Chloramphenicol IV or IM: 100 mg / kg / day in 3 injections for 5 days minimum, then take oral treatment, the same doses to complete 7 to 10 days of treatment
In the absence of improvement or if deterioration after 48 hours of treatment behaved well, think of a staphylococcal lung.
When the administration of injectable chloramphenicol or ampicillin 3 times a day can not be guaranteed, the antibiotic of choice is ceftriaxone IV or IM, followed by amoxicillin PO, same dosage as for the infant (see above) .
Adjuvant therapy for all cases:
– Fever: paracetamol PO.
– Clearing the nasopharynx by washing with sodium chloride 0.9% or Ringer’s lactate.
– Oxygen at a rate of 1 liter / min.
– Ensure proper hydration and good nutrition: in children under 12 months, milk (possibly using a breast pump) and water at will, with a spoon.
In children over 12 months, food, milk, water, at will.
– If the child refuses to eat, use a stomach tube.
In children under 12 months: 5 ml / kg / hour; in children over 12 months: 3-4 ml / kg / hour; alternating, milk, water and ORS if needed.
– Child less than two months: keep warm.
Pneumonia minor signs (outpatient, except infants):
In infants less than 2 months:
Treated in hospital as severe pneumonia (see above).
In children 2 months to 5 years:
Haemophilus influenzae is common at this age, but also pneumococcal perhaps
worse :
amoxicillin PO: 100 mg / kg / day in 3 divided doses for 5 days
Review the patient after 48 hours or so before aggravation:
– Improving: continue with the same antibiotic to complete treatment.
– Lack of improvement despite correct treatment, change antibiotics:
chloramphenicol PO: 100 mg / kg / day in 3 divided doses for 5 days
– Deteriorating: hospitalise and treat as severe pneumonia.
Pneumonia in children over 5 years and adults
Clinical signs:
The most common causes are viruses, pneumococci, Mycoplasma pneumoniae.
– Cough, more or less purulent sputum, fever, chest pain, tachypnea
– Pulmonary examination: decreased breath sounds, dullness, crackling fireplace, sometimes tubal breath.
Sudden onset with high fever (above 39 ° C), chest pain, presence of herpes labialis, are in favor of a pneumococcus.Sometimes the symptoms can be misleading, especially in children with abdominal pain, meningeal syndrome, etc.
Signs of gravity to look for (severe pneumonia) are:
– Cyanosis (to look at the lips, oral mucosa and nails)
– Beats the nostrils
– Intercostal or supraclavicular draw
– EN> 30 / min
– Heart rate> 125 / min
– Impaired consciousness (drowsiness, confusion)
Patients at risk are the elderly or those with heart failure, sickle cell anemia, bronchitis severe chronic immune deficiency (severe malnutrition, HIV infection with CD4 <200, splenectomy).
Treatment:
Serious pneumonia (hospital):
benzylpenicillin high procaine (PPF) IM
Children: 100 000 IU / kg / once daily for 2 to 3 days and then take oral treatment after resolution of fever or signs of severity, with amoxicillin
PO: 100 mg / kg / day in 3 divided doses to complete 7 days of treatment.
Adult: 3-4 MIU / once daily for 2 to 3 days and then take oral treatment after resolution of fever or signs of severity, with amoxicillin PO: 3 g / day in 3 divided doses to complete 7 days of treatment.
or
ampicillin IV or IM
Children: 100 mg / kg / day in 3 injections
Adults: 3 g / day in 3 injections
Take the oral treatment after resolution of fever or signs of severity, the same doses to complete 7 days of treatment.
In the absence of improvement after 48 hours of treatment behaved well, change antibiotics:
Chloramphenicol IV or IM
Children: 100 mg / kg / day in 3 injections for 2 to 3 days
Adult: 3-4 g / day in 3 injections for 2 to 3 days
Take the oral route at the same doses to complete 7 days of treatment.
When the administration of ampicillin or chloramphenicol injection 3 times a day can not be guaranteed, the antibiotic of choice is ceftriaxone IV or IM followed by amoxicillin PO:
Child: same dose as for infants
Adult: ceftriaxone IM or slow IV (3 minutes): 1 g / once daily for 3 days minimum, followed by amoxicillin PO: 3 g / day in 3 divided doses to complete 7 to 10 days of treatment.
Adjuvant therapy for all cases:
– Fever.
– Clearing the nasopharynx by washing with sodium chloride 0.9% or Ringer’s Lactate.
– Oxygen by nasal tube at the rate of 1 liter / min.
– Ensure proper hydration and good nutrition. Use a feeding tube if necessary.
Pneumonia minor signs (outpatient):
Typical pneumonia (acute lobar pneumonia):
The pneumococcus is the most common germ.
benzylpenicillin high procaine (PPF) IM
Children: 100 000 IU / kg / once daily for 5 days
Adult: 3-4 MIU / once daily for 5 days or amoxicillin PO
Children: 100 mg / kg / day in 3 divided doses for 5 days
Adults: 3 g / day in 3 divided doses for 5 days.
Review the patient after 48 hours or so before aggravation:
– Improving: continue with the same antibiotic to complete treatment.
– Deteriorating: hospitalise and treat as severe pneumonia.
Pneumonia drawling:
It can be a atypical pneumonia (Mycoplasma pneumoniae, Chlamydia pneumoniae).
erythromycin PO
Children: 50 mg / kg / day divided into 2 or 3 doses for 10 days
Adults: 2 to 3 g / day in 2 or 3 doses for 10 days or, failing that, doxycycline PO (against-indicated in children under 8 years old, pregnant or breastfeeding)
Children: 4 mg / kg / day in 2 divided doses for 10 days
Adult: 200 mg / day in 2 divided doses for 10 days
If signs persist after two successive treatments, think of tuberculosis, Pneumocystis pneumonia.
