Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
Guideline for the management of Pneumonia
Title of Guideline (must include the word “Guideline” (not protocol, policy,
procedure etc)
Guideline for
Contact Name and Job Title (author)
Dr. Colin Gilhooley
Dr. Jess Morgan
Dr. Nayasopo
Directorate & Speciality
Paediatrics
Date of submission
Date on which guideline must be reviewed (this should be one to three
years)
Explicit definition of patient group to which it applies (e.g. inclusion and
exclusion criteria, diagnosis)
March 2013
March 2016
Abstract
This guideline describes the causes, assessment
and management of pneumonia in children
Key Words
Statement of the evidence base of the guideline – has the guideline been
peer reviewed by colleagues?
Fever, chest infection, pneumonia
All children and young people
Evidence base: (1-5)
1a
meta analysis of randomised controlled trials
1b
at least one randomised controlled trial
2a
at least one well-designed controlled study without randomisation
2b
at least one other type of well-designed quasi-experimental study
3
well –designed non-experimental descriptive studies (ie comparative /
correlation and case studies)
4
expert committee reports or opinions and / or clinical experiences of
respected authorities
5
recommended best practise based on the clinical experience of the
guideline developer
Consultation Process
Paediatric Clinical Staff
Target audience
All paediatric staff involved in treating pneumonia
Clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised
when using guidelines after the review date.
Gilhooley
Page 1 of 8
March 2013
Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
Management of Pneumonia in children
Summary
Pneumonia is an inflammatory condition of the lung—affecting primarily the microscopic air sacs known
as alveoli.1 It is usually caused by infection with viruses or bacteria.
In 2008, pneumonia occurred in approximately 156 million children worldwide(151 million in the developing
world and 5 million in the developed world).2 It resulted in 1.6 million deaths, or 28–34% of all deaths in
those under five years, of which 95% occurred in the developing world.2,3 It is the leading cause of death
among children in low income countries.2,4 Many of these deaths occur in the newborn period. The World
Health Organization estimates that one in three newborn infant deaths is due to pneumonia.5
Due to the extremely high morbidity and mortality associated with pneumonia this guideline has been
designed to ensure that all children presenting with signs of pneumonia have a effective standardised
approach.
Gilhooley
Page 2 of 8
March 2013
Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
Acute Treatment algorithm for
Pneumonia
Cough and or difficulty in breathing in any infant over 2 months of age
Airway –grunting
Breathing – cyanosis
Circulation- not breast feeding or drinking
Disability – AVPU = V, P, U
Yes
No
Airway – no concerns
Breathing – No cyanosis, but chest wall
indrawing
Circulation - tolerating some fluids
Disability – AVPU = A
Yes
No
Airway –no concerns
Breathing – No cyanosis or chest wall
indrawing but:
RR> 50 aged 2-11 months
RR>40 aged 12 -59months
RR>30 aged >5 years
Circulation – tolerating fluids
Disability – AVPU = A
No
VERY SEVERE PNEUMONIA
Airway
Ensure airway open, use airway manoeuvres if needed
Breathing
Oxygen
Circulation
IV access
Start intravenous maintenance fluids
Disability
IF AVPU = V,P,U ensure airway is safe
IF not available start benzylpenicillin 50mg/kg 6 hourly
and gentamicin 5mg/kg OD
Vitamin A (6-11m 100,000 IUOD , 12-59m 200,000 IU
OD)
Severe pneumonia
Airway – safe
Breathing – monitor for cyanosis and
worsening distress
Circulation – assess for dehydration.
Encourage oral intake. Needs IV fluid?
Disability – monitor for deterioration
Start benzylpenicillin 50,000 IU/kg 6 hourly
and gentamicin 5mg/kg OD
Vitamin A (6-11m 100,000 IU, 12-59m
200,000 IU)
Pneumonia
Cotrimoxazole 24mg/kg 8 hourly
If has had cotrimoxazole during THIS illness
or for prophylaxis give amoxicillin 25mg/kg
8 hourly
Ceftriaxone
100mg/kg
OD if
worsens at
any point or
fails to
improve
after 48
hours.
IF HIV POSITIVE
Always start penicillin, gentamicin and cotrimoxazole.
Yes
If wheeze present consider possibility of asthma and treat.
Once tolerating oral fluids aim to switch to oral antibiotics
No pneumonia. Probable URTI
Gilhooley
Page 3 of 8
March 2013
Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
Introduction
Annually, pneumonia affects approximately 450 million people, seven percent of the world's total, and
results in about 4 million deaths.
In 2008, pneumonia occurred in approximately 156 million children (151 million in the developing world and
5 million in the developed world). It resulted in 1.6 million deaths, or 28–34% of all deaths in those under
five years, of which 95% occurred in the developing world.
WHO 2004 data shows that pneumonia accounts for 34.3 deaths/1000 people aged under 14. This
equates to over 474,000 children dying in Uganda each year due to pneumonia.6
Whilst antibiotics have been shown to be very effective in treating children with pneumonia the delay in
presentation to healthcare services and comorbidities and the time of treatment make treating pneumonia a
huge challenge.
Causes of Pneumonia
Pneumonia is primarily due to infections caused by bacteria or viruses and less commonly
by fungi and parasites. Although there are more than 100 strains of infectious agents
identified, only a few are responsible for the majority of the cases. Mixed infections with both
viruses and bacteria may occur in up to 45% of infections in children.2
The two most common bacteria responsible for pneumonia are Streptoccus pneumonia and
haemophilus influenze. In total they account for approximately ¾ of cases.7
Clinical presentation
History
Children with infectious pneumonia often have a productive cough and fever and an increased respiratory rate. This
may be accompanies by differing degrees of shortness of breath and aton taking a deep breath (pleuritic pain). 8
Fever is not very specific, as it occurs in many other common illnesses, and may be absent in those with severe
disease or malnutrition. More severe symptoms may include: decreased thirst, convulsions, persistent vomiting,
extremes of temperature, or a decreased level of consciousness.3
Specific bacterial infections can sometimes present with specific symptoms for instance:
Pneumonia caused by Legionella may occur with abdominal pain, diarrhoea, or confusion.9
Pneumonia caused by Streptococcus pneumoniae is associated with rusty colored sputum.10
Pneumonia caused by Klebsiella may have bloody sputum often described as "currant jelly".7
Gilhooley
Page 4 of 8
March 2013
Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
Examination
Patients with suspected pneumonia should be carefully examined to ascertain the presence and
severity of pneumonia. A systematic approach should be employed to ensure no important signs are
missed. This should begin with assessing the airway for signs of grunting or stridor indicating severe
respiratory distress and the need for immediate intervention. A blue colour around the lips and
tongue would indicate cyanosis and the child should immediately be given oxygen. Any of the above
signs represent an EMERGENCY and the child should be admitted and seen IMMEDIATELY.
Following on from this the Childs breathing should be assessed paying particular attention to the
respiratory rate and indrawing of the chest. This would indicate significant respiratory distress and
severe pneumonia requiring urgent care. Auscultation of the chest should also be performed to look
for focal chest signs (reduced air entry, crackles, dullness to percussion)
The child’s circulation should be assessed next to look for signs of dehydration and shock. Any signs
of severe dehydration or shock should be taken serious and the child should receive emergency fluid
resuscitation in line with WHO guidelines.
Next the Child’s conscious level should be assessed. If the child is not alert then this would represent
an Emergency and the child should be immediately admitted and have prompt treatment and
assessment.
Table 1: Severity of pneumonia
Airway
Breathing
Circulation
Disability
Emergency
Grunting,
stridor
Cyanosis
Weak fast
pulse, CRT
>3
AVPU = V,
P, U
Urgent
No
concerns
Indrawing
of chest
No
concerns
No
concerns
Increased
RR
No
concerns
No
concerns
AVPU =A
No
concerns
AVPU = A
First line investigations and interpretation
CBC – review Hb and need for further support (blood transfusion or iron supplements)
CXR – review for focal area of change, likelihood of staphylococcal infection (if CXR
suggestive of staph infection switch antibiotics to cloxacillin 50mg/kg 6 hourly and
gentamicin 2.5mg/kg 12 hourly)
Assess for malnutrition – if present manage according to WHO protocol
Initial management
Emergency management
Airway
Assess for signs of grunting or stridor indicating severe respiratory distress and the need for
immediate intervention. IF present the airway should be positioned appropriately and if necessary
airway manoeuvres used (e.g. jaw thrust). Oxygen should also be applied.
Breathing
A blue colour around the lips and tongue would indicate cyanosis and the child should immediately be
Gilhooley
Page 5 of 8
March 2013
Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
admitted and given oxygen. Following on from this the Childs
breathing should be assessed paying particular attention to the respiratory rate and indrawing of the
chest. This would indicate significant respiratory distress and severe pneumonia requiring urgent
care. Auscultation of the chest should also be performed to look for focal chest signs (reduced air
entry, crackles, dullness to percussion). A long time should not be wasted auscultating the chest. If
signs of cyanosis or indrawing of the chest are present the child needs urgent care and the rest of the
emergency assessment takes priority over auscultation which can be repeated following the
emergency assessment
Circulation
The child’s circulation should be assessed next to look for signs of dehydration and shock. Any signs
of severe dehydration or shock (weak, fast pulse, CRT >3 seconds) should be taken serious and the
child should receive emergency fluid resuscitation in line with MOH & WHO guidelines.
Disability
Next the Child’s conscious level should be assessed. If the child is not alert then this would represent
an Emergency and the child should be immediately admitted and have prompt treatment and
assessment.
Treatment
Pneumonia – aim to discharge home
Cotrimoxazole 24mg/kg every 12 hrs for 5 days - once clinical improvement occurs, amoxicillin 25mg/kg may be
used to complete the course of at least 5 days
or
Amoxicillin 15-25mg/kg every 8 hrs for 5 days
Severe pneumonia
benzylpenicillin 50,000 IU/kg IV or IM every 6 hours for 48 hours and reassess.
If improving consider oral antibiotics.
If worsening consider switching to ceftriaxone and gentamicin
Very Severe Pneumonia
Benzylpenicillin 50,000 IU/kg IV or IM every 6 hours for 48 hours and reassess,
and
Gentamicin 2.5mg/kg 12 hourly for 48 hours and reassess.
If improving consider oral antibiotics.
If worsening consider switching to ceftriaxone and gentamicin
Special circumstances
Patient with known or suspected HIV - Always start benzylpenicillin 50,000IU/kg, gentamicin
2.5mg 12 hourly and cotrimoxazole 24mg/kg 8 hourly
Patient with malnutrition – malnutrition should be assessed according to MOH and WHO guidelines
and treat commenced according to these guidelines. Ensure that antibiotic choices will provide cover
against Strep. Pneumonia and H. Influenza
Gilhooley
Page 6 of 8
March 2013
Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
Monitoring
All children admitted with pneumonia should have their respiratory rate, work of breathing and pulse documented at
least twice daily. If saturations are possible these should be performed daily. Fluid intake should be monitored and
urine output should be documented, especially for children on gentamicin.
Complications
Pleural Effusion
A pleural effusion is a collection of that forms in the space that surrounds the lung. The size of the effusion should be
assessed clinically by chest expansion, percussion and auscultation. If significant clinically a chest x-ray should be
ordered to review the possible size of effusion. If a significant effusion is present and the child has ongoing respiratory
distress a pleural tab can be performed and a specimen sent for MC&S & AFB. The child with significant effusion is
likely to need surgical intervention in order to drain the fluid.
ALL children with a pleural effusion should be investigated for TB.
Seizures
If seizures develop initially management should be with diazepam 500 micrograms (0.5mg)/kg orally or rectally,
repeated prn after 10 mins (rectal) or 30 mins (oral) or 50-200 micrograms (0.05-0.2mg)/kg IV or IM. This can be
repeated after 10 minutes if necessary and then prn for a maximum of 3 doses in 24 hours. If seizures are continuing
then phenobarbitone 10-15mg/kg IM as a loading dose then depending on response repeat this dose
after 12 hours or switch to oral maintenance dose of 3-5mg/kg every 8-12 hours.
It is important to ensure that the signs of the pneumonia started before any seizures and that the seizures did not predate the starting of the pneumonia as this may indicate the patient has a seizure disorder and subsequent aspiration
pneumonia.
Failed therapy
Treatment has failed if:
1. The patient worsens at any stage during treatment
2. The patient has failed to improve following 48 hours of treatment
In these instances ensure that the patient is re-assessed using an ABCD approach. After ensuring the patient is
stable a review of the history and examination should be conducted to ensure the diagnosis is correct. If a CXR has
not been performed it should be requested now. The antibiotics should then be reviewed:
If at any point the patient deteriorates to very severe pneumonia gentamicin should be added to treatment.
If a patient with any degree of pneumonia fails to improve after 48 hours of treatment gentamicin should be added to
treatment. At this point consideration should also be given to the possibility of a Staphlococcal infection, TB and HIV.
Education
Parents and carers should be educated on the signs and symptoms of pneumonia and the need to seek medical
assistance. They should also be made aware of the danger signs and when to seek immediate medical support.
Gilhooley
Page 7 of 8
March 2013
Jinja Regional Referral Hospital
Department of Paediatrics
Nalufenya Road
Jinja
Uganda
Bibliography
1
McLuckie, [editor] A. (2009). Respiratory disease and its management. New York: Springer. p. 51.
2
Ruuskanen, O; Lahti, E; Jennings, LC; Murdoch, DR (2011-04-09). "Viral pneumonia". Lancet 377 (9773): 1264–75.
3
Singh, V; Aneja, S (March 2011). "Pneumonia-management in the developing world". Paediatric respiratory reviews 12 (1): 52-9.
4
Kabra SK; Lodha, R; Pandey, RM (2010). Kabra, Sushil K. ed. "Antibiotics for community-acquired pneumonia in
children". Cochrane Database Syst Rev 3 (3): CD004874.
5
Garenne M; Ronsmans, C; Campbell, H (1992). "The magnitude of mortality from acute respiratory infections in children under 5
years in developing countries". World Health Stat Q 45 (2–3): 180–91.
6
WHO. Measurement and Health Information. Burden of Disease 2008. WHO.
7
Lecture notes Tropical Medicine 6th edition
8
Hoare Z; Lim WS (2006). "Pneumonia: update on diagnosis and management" (PDF). BMJ 332 (7549): 1077–9
9
Darby, J; Buising, K (October 2008). "Could it be Legionella?". Australian family physician 37 (10): 812–5.
10
Ortqvist, A; Hedlund, J; Kalin, M (December 2005). "Streptococcus pneumoniae: epidemiology, risk factors, and clinical
features". Seminars in respiratory and critical care medicine 26 (6): 563–74.
Gilhooley
Page 8 of 8
March 2013