Even if this question is not posed to them, they themselves should try to answer this

HOW SEVERE IT IS?

All pneumonia in children less than two months of age are considered severe irrespective of findings / presentation.

If the child has one or more of the following presentation/ findings, with or without increased respiratory rate he/she should be labeled severe pneumonia

*Marked irritability / drowsiness * inability to take feed * grunting * recession of subcostal / intercostal spaces *Cyanosis or marked pallor * associated moderate / severe malnutrition

Out of these altered sensorium, grunting, and color changes (Cyanosis or marked pallor) are indicative of serious illness and may be life threatening.

At the primary care settings, there is no need for the confirmation. All the suspected cases are managed as proved patients.

USE OF LABORATORY AND X-RAY

Laboratory and x-ray facilities are neither available nor needed for the majority of the patients at primary care settings.

investigations discussed in standard text books are

TLC,DLC, blood culture, laryngeal swab for microscopy , culture, advanced immunological tests lung puncture, x-ray chest and ABG

Bacterial pneumonia can only be confirmed by the demonstration of bacteria or its products in various specimens (sputum, blood, lung tissue obtained by lung puncture) bacteria are demonstrated by microscopy or culture. Bacterial products are identified by various immunological techniques such as ELISA test or immuno electrophoresis

Severity of pneumonia is judged better, clinically not with the help of conventional laboratory tests and x-ray.

For the diagnosis and management of pneumonia x-ray chest is most commonly used investigation.

X-ray chest is not required for all the suspected cases of pneumonia.

At the community level majority of the patients can be diagnosed (label the patients as pneumonia if the respiratory rate is increased for the age) and managed effectively without this help.

Though very unlikely x-ray chest may be normal in Pneumonia patients.

X-ray findings are not much helpful and conclusive for differentiating bacterial and non bacterial pneumonia.

Findings or x-ray chest may be disproportionate to the severity of Pneumonia for this reason, assess the severity of pneumonia on the basis of clinical condition of the patient.

Persistence of x-ray findings upto 4-6 weeks if the child has improved clinically should not be considered as "Failure to resolve" or "failure of treatment".

In the patients who have not improved clinically persistence of x-ray chest findings should lead to the suspicion of Tuberculosis. Foreign body inhalation, Lung abscess and very rarely cancer lung.

DECISION ABOUT ADMISSION OR O.P.D MANAGEMENT?

All sever pneumonia, and pneumonia in high-risk children irrespective of severity should preferably be managed in hospital. This means only mild to moderate pneumonia should be managed on OPD basis

IN WHICH PNEUMONIC CHILDREN SHOULD WE USE ANTIBIOTICS?

The answer is simple use them in bacterial pneumonias not in non-bacterial. The problem faced by pediatricians (physicians) is distinction between bacterial and non-bacterial pneumonia

HOW TO DIFFERENTIATE BETWEEN BACTERIAL AND NON-BACTERIAL PNEUMONIA?

In the majority of pneumonia it is very difficult and at times impossible to differentiate between bacterial and non-bacterial pneumonia, clinically, radiologically, or with the help of laboratory. Bacterial pneumonia can only be confirmed by the demonstration of bacteria or its products in various specimens (sputum, blood, lung tissue obtained by lung puncture) bacteria are demonstrated by microscopy or culture. Bacterial products are identified by various immunological techniques such as ELISA test or immuno electrophoresis. All the above mentioned tests are not practicable in primary care settings either because of cost or unavailability or both. Because of these reasons physicians are left with two options

1-consider and treat all pneumonia as bacterial this approach is advocated by some of the authorities and adopted by some physicians. This approach is safer than the other option but causes economic burden and increases the chance of unjustified drug toxicity. This approach is advised for all the pneumonia/ suspected pneumonia patients who can afford the cost of drugs.

2-selective use of antibiotics in patients in whom chances of bacterial infection are more or the child is high risk

This approach is not fail-safe and should be reserved only for non affording patients. These patients should clearly be explained about the possible risk

Increased possibility of bacterial pneumonia  High fever, toxic look, findings in chest confined  to one lobe or side   (this does not mean bacterial  pneumonia may not be diffused and bilateral)  rapidly progressive pneumonia , all severe  pneumonias  on x-ray chest localized patch, or cavitation(single or multiple and /or effusion  or pneumothorax)  TLC >15000

High risk children first half of infancy immunodeficiency states--- including moderate to severe malnutrition children with congenital defects, specially cardiac and neurological

HOW TO CHOOSE THE ANTIBIOTIC?

The antibiotics are chosen on the basis of age (the main decisive factor ) as organisms identification is not practicable for the majority of the patients at primary care level

FOR INFANTS

Pneumonia patients in the first half of infancy should be advised admission in the hospital. If it is possible use second or third generation cephalosporins and one of the aminoglycosides (amikacin or gentamyciene). The injectable form is preferred till the patient starts improving.

Cephalosporins are quiet costly but the advantage is they are effective against all most all organisms and are effective 12 hourly. This 12 hourly schedule is practicable and acceptable to the majority of the patients.

If the patient is non-affording use ampiclox and one of the aminoglycoside.

FOR CHILDREN OLDER THAN ONE YEAR FOLLOWING DRUGS CAN BE USED

Amoxycillin 40-50mg/kg/day divided 8 hourly orally Ampicillin 40-50mg/kg/day divided 6 hourly orally

Erythromycin 40-50mg/kg/day divided 6 hourly orally Cotimoxazole 8-10 mg of trimethoprim/kg/day divided 12 hourly . it is cheap also

CEPHALOSPORINS

Cephalexin (KEFLEX) 25-50 mg/kg/day divided 6-8 hrly PO Cephradine(VELOSEF) 25-50mg/kg/day divided 6-8 hrlyPO

Cefaclor (CECLOR) 20-40mg/kg/day divided 8 hrly PO

Cefuroxime—30-100mg/kg/day IMI Cefotaxime—100-150mg/kg/day divided 12 hourly IMI

Ceftizozoxime—30-60mg/kg/day divided 12 hourl Ceftriaxone—80-150mg/kg/day IMI divided 12 hourly

Malaria in children may present similar to pneumonia, for this reason antimalarial drugs in addition to antibiotics may be tried in pneumonic children.

For the treatment of simple (uncomplicated) malaria, use oral chloroquin. 10mg / kg stat and 5mg /kg 6-8 hours later from next day 5mg /kg /day for three days

Following drugs may be used

Fansidar---single dose 25 mg sulfadoxine/kg PO Mefloquine----15mg/kg single dose PO

SUPPORTIVE TREATMENT

Do not give symptomatic treatment. Is it true?

NO. It the professional and moral duty of the physician to relieve the sufferings of the patients. But definitely it should not be the only treatment.

All efforts should be made to eradicate or at least counteract the disease process.

¨ Diet continue soft pasty high calorie diet. Give small amount at a time to avoid choking.

¨ Fever control-- paracetamol or brufen . Do not give aspirin

¨ Cough remedies Cough sedatives should not be used in young children until and unless cough is disturbing feeding, sleep, and routines of the child or causing exhaustion or vomiting. Even in these children preparations containing narcotics are not advised.

Cough expectorants are not recommended below the age of 6 years. ¨ Chest physiotherapy ¨ Hypoxia

FOLLOW UP AND DECISION ABOUT CONTINUATION / DISCONTINUATION OR CHANGING THE ANTIBIOTICS

In the majority of the patients improvement starts after 48 hours of antibiotic therapy. Settling down of temperature, respiratory rate and other signs of distress are indication of clinical improvement. Radiological findings may persist for weeks and should be ignored if there is clinical improvement.

Continue using the same antibiotics for 5-7 days if patient is improving. Consider addition of another antibiotic or change in case patient is not improving.

Follow up x-ray is not required in all the patients, though it is commonly demanded.

CONSIDER FOLLOWING POSSIBILITIES IF IMPROVEMENT DOES NOT OCCUR IN 48 HOURS

• Wrong diagnosis(patient is suffering from some other problem, not the pneumonia)
• Inappropriate drug(consider addition of another antibiotic or change of antibiotic)
• Use of sub-optimal dose
• Noncompliance on the part of patient’s attendants
• Development of complications such as pneumothorax or empyema or lung abscess

SOME IMPORTANT DO NOTS ABOUT PNEUMONIA IN CHILDREN

¨ Do not rely too heavily on the laboratory for the confirmation of pneumonia, detection of etiology or severity

¨ Do not delay the referral / admission in severe pneumonia

¨ Do not hesitate to use antibiotics on slightest suspicion

¨ Do not use aspirin

¨ Do not neglect the supportive treatment

¨ Do not forget to educate the mothers to identify advancing illness / severe pneumonia.

¨ Do not forget to remove the misconceptions

COMMON MISCONCEPTIONS ABOUT PNEUMONIA
Pneumonia is caused by the exposure to cold, this thinking is a misconception. Undueexposure to cold is to be avoided but it should be explained that almost all pneumonia cases in primary care are infections and need treatment with germ killers. Warming up of babies and giving them so called hot foods without germ killers is not recommended and may harm the baby
--Denying the diagnosis of pneumonia and stopping treatment in the absence of abnormal findings on x-ray chest / laboratory tests is a misconception

 

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