PEDIATRIC PATIENT MANAGEMENT ALGORITHM ---- PNEUMONIA

Suspect Pneumonia Point of entry: Healthcare facility Fever Clinic. OPD & Emergency Danger/Warning Signs:*

Pneumonia should be Suspected in Patients with fever, cough, flu like illness and difficulty in breathing • Sub-costal Inter-cos-
➢ Pneumonia: In a child with history of cough and/or fever, it is defined as fast breathing** and/or chest tal recessions
in drawings that do not resolve after a trial of inhaled bronchodilator (salbutamol) given thrice at 15 – • Drowsy, abnormally
20-minute intervals sleepy, lethargic,
➢ Severe Pneumonia/Very Severe disease: In a child with history of cough and/or fever with respiratory • Unable to take feed
distress and presence of any of the general danger signs*, (i.e. inability to feed, persistent vomiting, • Stridor
• Central cyanosis
stridor, convulsions, lethargy, unconsciousness)
• Convulsions
➢ Impending Respiratory Failure: Cyanosis, gasping breathing, rising CO 2
The severity of pneumonia is defined on the basis of clinical symptoms mainly along with low oxygen sat- Cut-off Fast Breathing**
uration (<92%) supported by X-ray chest and laboratory tests including CBC, CRP, arterial blood gases,
1. 0-2 months
blood culture (for septicemia) and nasopharyngeal swab for PCR (for viral etiology) = 60 breaths/min
2. 2- 12 months
CLASSIFICATION OF PNEUMONIA = 50 breaths/min
3. 13 to 59 months
A) Source of the organism: B) Type of the organism: C) Radiological findings: D) Severity of symptoms /signs:
= 40 breaths/min
1. Community acquired 1. Bacterial 1. Lobar pneumonia 1. No pneumonia cough & cold
2. Pneumonia 4. Beyond 60 months
2. Hospital acquired 2. Viral 2. Bronchopneumonia
3. Severe Pneumonia = 30 breaths/min
3. Ventilator acquired 3. Fungal 3. Interstitial pneumonia
4. Very Severe disease

MANAGEMENT OF PNEUMONIA
Danger O2 Satu-
Diagnosis General Signs Actions Advice
Signs ration
No Pneumo- Cough & Flu with or without No O2 Oral Paracetamol 10 • Mandatory counseling
nia: Cough Fever Satura- mg/kg/dose not more than 4 about danger signs.
or Common tion times a day • Continue feeding
Cold / URTI >94% at • Ask for follow up if there
room is Fast breathing
air / Respiratory distress or
general danger signs
Bronchiolitis• Cough with or without fever Child is O2 • O2 Inhalation Discharge when there is
(in children • Wheezing usually ac- satura-• Saline nasal drops no respiratory distress,
below 2 • Fast breathing / respiratory dis- tive and tion • Nebulize with Hypertonic or tolerating feed & main-
years of age) tress comforta- may • normal saline 6-8 hourly taining O2 >94% satura-
ble drop • Bronchodilators: usually less tion at room air
<92% • effective
Pneumonia Fast breathing or chest indraw- No O2 Sats• Oral or I.V Co- amoxiclav Follow up if there is per-
ing with or without crepita- >94% • Oseltamivir (if influenza PCR is sistent fast breathing
tions/bronchial breathing positive) / Respiratory distress or
• Encourage oral intake any of the general danger
signs
Severe Pneu- Fast Breathing & signs of respir- Yes O2 • O2 Inhalation NPO Paracetamol Admit to pediatric
monia / Very atory Distress with stridor or Satura- IV maintenance fluids HDU/ICU
Severe Dis- any general danger sign (i.e. tion • IV Ceftriaxone &
ease inability to drink or breastfeed, <92% • IV Co-amoxiclav
persistent vomiting, convul- • IV Vancomycin (if Staph pneu-
sions, lethargy, unconscious- monia is suspected)
ness) • Oseltamivir (if influenza PCR is
positive)
• CPAP/High flow Oxygen
Type 2 Res-• Severe respiratory distress with Yes O2 sats• ICU care, NPO, I.V fluids ICU Care
piratory fail- nasal flaring, chest indrawing, <92% • IV Ceftriaxone &
ure stridor • IV Co-amoxiclav
• Decreasing respiratory rate ABGs • IV Vancomycin (if Staph pneu-
with increase in distress/central PO2 < monia is suspected)
cyanosis/Gasping respiration 60 • Oseltamivir (if influenza PCR is
with or without signs of circula- mm Hg positive)
tory collapse Prolonged CRT & PCO•2 Ventilatory & circulatory sup-
(Capillary refill > 55 port
time > 3 sec) mm Hg
EMPIRICAL ANTIBIOTICS DOSAGE & DURATION
Co-amoxiclav: Ceftriaxone: Vancomycin: Oseltamivir:
Oral: 45mg/kg/day IV: 50mg/kg/day: IV: 40mg/kg/day: Children (2 weeks to 12 Months)
3 divided doses for 7-10 days As single or 2 divided doses 12~24 3-4 divided doses for 10 days 3mg/kg/dose for 12 hourly for 5 days
hourly for 10-14 days In septicemia with CNS involvement Children (Older than 12 Months)
IV: 90mg/kg/day: IV: 60mg/kg/day: <15kg: 30mg/kg/dose twice a day
3 divided doses for 10-14 days In septicemia with CNS involvement 3-4 divided doses for 10-14 days <15-23kg: 45mg/kg/dose twice a day
IV: 100mg/kg/day: Note: Vancomycin should be given in infusion di- 23-40kg: 60mg/kg/dose twice a day
2 divided doses for 10-14 days luted in normal saline over at least one hour for 7 days

➢ In patients allergic to penicillin: Alternatives: Levofloxacin, Clindamycin, Linezolid