Pediatric Community

Acquired Pneumonia
Group 1
UV -Gullas and SWU Pediatric Clerks

UV-GULLAS CLERKS
Ligan, Janmarl Mae
Ahmad, Hanna Gwen
Kumar, Swetha Kumar
Sounderraj, Roshini
Devapiram, Angela Karen
Palani, Ajay Kumar

SWU CLERKS
Abdul-azis, Mohammad
Bacaraman, Aliya
Belongilot, Glaiza
Bordios, Steven
 PATIENT HISTORY
General Data
● Name: R.P.
● Age/Sex: 1 year/ Male
● Birthdate: November 2, 2022
● Birthplace : Maribojoc, Bohol
● Residing address: Maribojoc, Bohol
● Nationality: Filipino
● Religion: Roman Catholic
● Admission: 1st in GCGMMC

Chief complaint: Cough

History of Present Illness:

I WEEK PTA
● Onset of coryza.
● Sought consult at their Local Health Center and was prescribed Disudrin and Ambroxol.
● Mother gave patient 1.2 ml of Disudrin and Ambroxol.
● No relief of symptom.

5 DAYS PTA
● Persistence of coryza, now associated with undocumented fever and cough.
● Mother gave Paracetamol (Tempra).
○ Provided temporary relief.
● Mother continued to give Disudrin + Ambroxol
● Tolerated condition, no consult done

3 DAYS PTA
● Persistence of coryza, fever and cough.
● Worsening of cough.
● Mother continued to give the same medications.

Day of Admission:
● Persistence of symptoms now associated with dyspnea.
● Patient’s mother sought consult at Maribojoc Community Hospital.
● Was nebulized 2 times with Salbutamol.
○ No relief of symptoms.
● Patient was subsequently referred to our institution for further management and
treatment.
● Referring vital signs from Maribojoc Community Hospital:
○ Temperature: 38.6 C
○ HR: 168 bpm
○ RR: 58 cpm
○ O2 saturation 89%
■ Patient then placed on nasal cannula at 3 LPM.
 ■ O2 increased to 98%

PRENATAL HISTORY

● Born to a 32-year-old G1P1 (1001) mother

● Prenatal consults: First prenatal checkup at 3 months AOG with first ultrasound at 4
months AOG
● Laboratory examinations: completely done as claimed but unrecalled details
● Supplements taken: Folic acid 1 tab/day, iron 1 tab/day), Calcium 1 tab/day, and
Multivitamins 1 tab/day

INTRANATAL HISTORY

● Delivered full term via 40 weeks AOG at Evasco Memorial Health Centre by NSD with
no comorbidities
● Duration of labour was 8 hours
● Birthweight: 3070 grams
● Complication: None
● APGAR score : 8,9
● Vaccinations at birth: Hepatitis B vaccine and BCG
● Expanded newborn screening and hearing test done & unremarkable

FEEDING HISTORY

● Exclusive breastfeeding: for 2 weeks

● Formula Milk: started by 2 weeks
● Complementary feeding: solid foods such as Cerelac and mashed vegetables introduced
at 7 months.
● Feeding problems: None

VACCINATION HISTORY

VACCINATION DOSES

BCG 1 dose

HEP B 1 dose

PENTAVALENT VACCINE 3 doses

OPV 3 doses

IPV 1 dose
MMR 2 doses

Flu 3 doses

PERSONAL AND SOCIAL HISTORY

● Lives in a house, with his mother and father and his two sisters.
● House is made up of concrete and wood.
● Mother claims there is proper ventilation.
● Primary care giver: Mother
● Father is a tobacco smoker.
● Drinking water: purified water
● Water for cleaning and bathing: Tap water
● Garbage collected weekly.
● No pets.
● No history of recent travel.

FAMILY HISTORY

● Mother is 33 years old, housewife, completed high school level, and is healthy with no
known comorbidities.
● Father is 49 years old, retired, completed high school level, and is healthy with no known
comorbidities.
● Siblings:
● 1 of 3: From Paternal side: 27 years old, female, healthy.
● 2 of 3: From Paternal side: 24 years old, female, healthy.
● 3 of 3. Patient.
●
● Maternal side: Diabetes Mellitus
● Paternal side: None

PHYSICAL EXAMINATION

● Skin: (-) cyanosis, (-) pallor, warm to touch, good skin turgor
● HEENT: Anicteric sclerae, pink palpebral conjunctiva, (-) cervical
lymphadenopathy, (+) alar flaring
● Chest and Lungs: Symmetric, Equal chest expansion, (+) wheezing and rales in
bilateral lung fields,
● CVS: Adynamic precordium, distinct heart sound, (-) murmur
● GIT: Flat, Normoactive bowel sound, soft, non-distended, non-tender in all
 quadrants
● Genitalia: Grossly Male
● Extremities: (-) edema, strong peripheral pulses, capillary refill time <2 secs

GROWTH CHART

Weight: 10 kg: 50th - 85th percentile

Interpretation

Normal weight for age

Length: 89 cm 50th - 85th percentile

Interpretation:

Normal length for age

REVIEW OF SYSTEMS

General: (-) recent weight changes, (+) febrile episodes, (-) weakness
Eyes: (-) discharges, (-) yellow sclera, (-) visual loss
Ears: (-) hearing loss, (-) ear discharges
Nose/Throat: (-) sneezing, (+) coryza
Skin: (-) pallor (-) rashes
Cardiovascular: (-) chest pain, (-) chest pressure, (-) chest discomfort, (-) palpitations, (-)
edema
Respiratory: (+) dyspnea, (+) cough
GIT: (-) anorexia, (-) nausea, (-) vomiting, (-) diarrhea, (-) abdominal pain, (-) bloody stool
GUT: (-) dysuria, (-) polyuria, (-) nocturia
Neuro: (-) dizziness, (-) syncope, (-) numbness/tingling
Musculoskeletal: (-) muscle pain, (-) joint pain, (-) stiffness
Hematology: (-) anemia, (-) bleeding, (-) bruising
Lymphatics: (-) enlarged lymph nodes, (-) history of splenectomy
Endocrine: (-) excessive sweating, (-) cold tolerance, (-) heat tolerance
Allergies: (-) history of asthma, (-) hives, (-) eczema, (-) rhinitis

DEVELOPMENTAL MILESTONE
2 months - Coos and started social smiling
3 months - hold the head up and supported
5 months - Roll-over
6 months - starts to babble
7 months - learn to sit with support
9 months - says “ma”
12 months - walks independently

SALIENT FEATURES

● Fever
● Coryza
● Cough
● Dyspnea
● Alar flaring
● Rales in bilateral lung fields

INITIAL IMPRESSION

Pediatric Community Acquired Pneumonia - C Vs. SARS Covid -19 infection

DIFFERENTIAL DIAGNOSES

Differential Rule In Rule Out

Pulmonary Tuberculosis ● (+) Cough ● Should be at least 2

● (+) Fever weeks of symptoms
● (+)Tachypnic ● (-) Scrofula
● (+) Retractions ● Good feeding
● (-)exposure to infected
with TB
● No night sweats

SARS-COVID19 ● (+) Cough ● Cannot be ruled out at

● (+) Fever this point.
 ● (+)Tachypnic
● (+) Retractions

Asthma ● (+) Cough ● (-) Wheezing

● (+) Dyspnea ● Triggers for
symptoms (e.g.,
allergens, exercise,
irritants etc.)

COURSE IN THE ER

● Admit under Pulmo service

● Secure consent to care
● Insert Heplock
● DAT with SAP
● Start D5LR 1 liter at 40 cc/hr
● Hook to O2 at 1 lpm
● Labs: CBC, CRP, Blood GS/CS, CXR APL, RAT
● Meds:
○ Ceftriaxone 375mg via IV now then q 12H (AD: 75mkD)
○ Salbutamol + Ipratropium neb, 1 neb q 15 mins for 3 doses
○ Salbutamol plain, 1 neb every 8h
○ Budesonide 1 neb q 12h
○ Zinc sulfate drops 2 ml once daily
○ Monitor vital signs q4h
○ I&O qshift
○ Refer for chest indrawing, alar flaring, desaturations, and unusualties
● Diagnostic Work-up

CBC (12/11/23) Results

WBC 6.7

RBC 4.01 (L)

Hemoglobin 10.4 (L)

Hematocrit 31.80 (L)

MCV 79
MCH 26

MCHC 33

Platelet 229

Neutrophil 51.0 (L)

Lymphocytes 41.0 (H)

Monocytes 4.0

Eosinophils 4.0 (H)

Basophils 0.0

CRP (12/11/23) 5.00

SARS-CoV-2 Negative
Antigen testing
(12/11/23)
 ○ There are reticular densities seen in both lungs. The heart is not enlarged. The
tracheal air column is at the midline. Both hemidiaphragms and costophrenic sulci
are intact. The bony structures are unremarkable.
○ Impression
■ Bilateral pneumonia

COURSE IN THE WARDS

● Day 0 (12/11)

Subjective Objective Assessment Plan

(+) cough Awake, comfortable, not Pediatric Community DAT with SAP
(+) episodes of in respiratory distress Acquired Pneumonia- ● Venoclysis: D5LR
dyspnea Severe (C ) 1L at 40cc/hr (Mx)
(+) fever HR: 78 ● O2 at 1lpm
(+)urine output RR: 60 ● Meds:
T: 37.7 ○ Ceftriaxone
O2sat: 97% 375mg IV q
12H (AD:
Skin: (-)pallor,
75mkD) -
(-)cyanosis, warm to
touch D0
HEENT: Anicteric ○ Salbutamol
sclerae, pink palpebral plain, 1 neb
conjunctivae, no q 8h
nasoaural discharge, no ○ Budesonide
alar flaring 1 neb q 12h
C/L: Equal chest
○ Zinc sulfate
expansion, (-)chest
retractions, (+) rales on drops 2ml
bilateral lung fields once daily
CVS: Adynamic ● Monitor vital signs
precordium, distinct heart q 4hr
sound, no murmurs ● I&O qshift
Abdomen: NABS, soft,
● Refer for chest
nondistended
Ext: (-) edema, SPP, CRT indrawing, alar
<2secs flaring,
desaturation, and
alter unusualities

● Day 1 (12/12)
Subjective Objective Assessment Plan
(+) cough Awake, comfortable, not in Pediatric DAT with SAP
(-) dyspnea respiratory distress Community ● To consume IVF
(-) fever Acquired then shift to
(+) bowel HR: 130 Pneumonia- Severe heplock
movement RR: 40 (C ) ● On room air trial
(+) urine output T: 37.7 ● Meds:
O2sat: 97% ○ Ceftriaxone
375mg IV q
Skin: (-)pallor, (-)cyanosis, 12H-D1
warm to touch
○ Salbutamol
HEENT: Anicteric sclerae,
pink palpebral plain, 1 neb
conjunctivae, no nasoaural q 8h
discharge, no alar flaring ○ Budesonide
C/L: Equal chest 1 neb q 12h
expansion, (-)chest ○ Zinc sulfate
retractions, (+) rales on drops 2ml
bilateral lung fields
once daily
CVS: Adynamic
precordium, distinct heart
sound, no murmurs ● Monitor vital signs
Abdomen: NABS, soft, q 4hr
nondistended ● I&O qshift
Ext: (-) edema, SPP, CRT ● Refer for chest
<2secs indrawing, alar
flaring,
desaturation, and
alter unusualities

● Day 2 (12/13)

Subjective Objective Assessment Plan

(+) cough Awake, comfortable, not in Pediatric DAT with SAP
(-) dyspnea respiratory distress Community ● To consume IVF
(-) fever Acquired then shift to
(+) bowel HR: 130 Pneumonia- heplock
movement RR: 30 Severe ( C ) ● On room air trial
(+) urine output T: 37.7 ● Meds:
O2sat: 97% ○ Ceftriaxon
e 375mg
Skin: (-)pallor, (-)cyanosis, IV q
warm to touch
12H-D2
HEENT: Anicteric sclerae,
pink palpebral conjunctivae, no ○ Salbutamol
nasoaural discharge, no alar plain, 1
flaring neb q 8h
C/L: Equal chest expansion, ○ Budesonid
(-)chest retractions, (+) rales e 1 neb q
on bilateral lung fields 12h
CVS: Adynamic precordium,
○ Zinc
distinct heart sound, no
murmurs sulfate
Abdomen: NABS, soft, drops 2ml
nondistended once daily
Ext: (-) edema, SPP, CRT
<2secs ● Monitor vital signs
q 4hr
● I&O qshift
● Refer for chest
indrawing, alar
flaring,
desaturation, and
alter unusualities

● Day 3 (12/14)
Subjective Objective Assessment Plan
(+) cough Awake, comfortable, not in Pediatric DAT with SAP
(-) dyspnea respiratory distress Community Maintain on heplock
(-) fever Acquired On room air trial
(+) bowel HR: 128 Pneumonia- Continue medications
movement RR: 24 Severe ( C ) - Ceftriaxone D3
(+) urine output T: 36.4 - Salbutamol
O2sat: 98% nebule
- Budesonide
Skin: (-)pallor, (-)cyanosis, (-) - Zinc sulfate
Jaundice Monitor vital
HEENT: Anicteric sclerae, signs q 4hr
pink palpebral conjunctivae, no I&O qshift
nasoaural discharge
Refer for chest
C/L: Equal chest expansion, (-)
chest retractions, (+) rales indrawing, alar flaring,
bilateral lung field desaturation, and alter
CVS: Adynamic precordium, unusualities
distinct heart sound, no
murmurs
Abdomen: NABS, soft,
nondistended
Ext: (-) edema, SPP, CRT
<2secs

● Day 4 (12/15)
Subjective Objective Assessment Plan
(-) cough Awake, comfortable, not Pediatric Community May go Home
(-) dyspnea in respiratory distress Acquired Pneumonia-C - Take home
(-) fever resolved medications
(+) bowel Vital Signs 1. Cefixime 100
movement HR: 148 mg/ 5 mL
(+) urine output RR: 32 - Give 2 mL PO
T: 36.4 2x a day for 4
O2sat: 98% more days
2. Zinc sulfate
Skin: (-)pallor, 55mg/mL
(-)cyanosis, (-)jaundice - Give 2 mL PO
HEENT: Anicteric once a day
sclerae, pink palpebral
conjunctivae, no nasoaural
discharge
C/L: Equal chest
expansion, (-)chest
retractions, clear breath
sounds
CVS: Adynamic
precordium, distinct heart
sound, no murmurs
Abdomen: NABS, soft,
nondistended
Ext: (-) edema, SPP, CRT
<2secs

CASE DISCUSSION

PNEUMONIA

● Inflammation of the lung parenchyma.

● Leading infectious cause of death globally among children younger than 5 years old.
Epidemiology
Pathogenesis

[Link] pneumonia
● Due to spread of infection along the airways, direct injury of the respiratory epithelium,
which causing airway obstruction from swelling, abnormal secretions, and cellular debris

[Link] pneumonia
 ● Occurs when respiratory tract organisms colonize the trachea and subsequently gain
access to the lungs, or may also result from direct seeding of lung tissue after bacteremia

[Link] pneumonia
● 2 or more episodes in a single year or 3 or more episodes ever, with radiographic clearing
between occurrences.

Clinical Manifestation of Pediatric community-acquired pneumonia (PCAP)

● Cough or fever,
● PLUS any of the following positive predictors of radiographically-confirmed pneumonia
[Link]
● 3 months to 12 months old: ≥50 breaths per minute
● >1 year old to 5 years old: ≥40 breaths per minute
● >5 years to 12 years old: ≥30 breaths per minute
● >12 years old: ≥20 breaths per minute
[Link] or chest indrawing
[Link] flaring
4.O2 saturation <95% at room air
[Link]

DIAGNOSIS

DIAGNOSTICS BACTERIAL VIRAL

Confluent lobar Hyperinflation with

consolidation with bilateral interstitial
CHEST X-RAY pleural effusion infiltrates and
peribronchial cuffing

Elevated Normal / Elevated < or =

15,000-40,000 with to 20,000/mm3, with
PERIPHERAL polymorphonuclear lymphocytic predominance
WBC
predominance
 Culture and Viral genome or
Isolation (Blood, antigen detection
DEFINITIVE pleural fluid or
DIAGNOSIS
Sputum)

MANAGEMENT

● Empiric antibiotic therapy is considered to be started in patients with clinical signs and
symptoms of PCAP with any of the following parameters:
○ Elevated white blood cell count
○ Elevated C-reactive protein
○ Elevated procalcitonin
● Imaging finding:
○ Alvelolar infiltrates in chest X-ray
○ Unilateral, solitary lung consolidation in lung ultrasound

MANAGEMENT - NON SEVERE PCAP

● Regardless of immunization status against Streptococcus pneumoniae or Hemophilus
influenza type b (Hib)
○ Start Amoxicillin trihydrate at 40-50mg/kg/day Q8 for 7 days OR at
80-90mg/kg/day Q12 for 5 to 7days.
○ Start Amoxicillin-clavulanate at 80-90mg/kg/day Q12 for 5 to 7 days or
Cefuroxime at 20-30mg/kg/day Q12 for 7 days with documented high-level
penicillin resistant pneumococci or beta-lactamase-producing H. influenza

MANAGEMENT - SEVERE PCAP

Regardless of immunization status against Streptococcus pneumoniae,

● Start Penicillin G at 200,000 units/kg/day Q6 if with complete Hemophilus influenza
type b (Hib) vaccination or Ampicillin at 200mg/kg/day Q6 if with no or incomplete or
unknown Hemophilus influenza type b (Hib) vaccination
● Start Cefuroxime at 100-150mg/kg/day Q8 OR Ceftriaxone at 75-100mg/kg/day Q12 to
Q24 OR Ampicillin-sulbactam at 200mg/kg/day Q6 with documented high-level
penicillin resistant pneumococci orbeta-lactamase-producing H. influenzae
● Add Clindamycin at 20-40mg/kg/day Q6 to Q8 when Staphylococcal pneumonia is
highly suspected , In cases of sepsis and shock, Vancomycin at 40-60 mg/kg/day Q6 to
Q8 is preferred.
MANAGEMENT FOR PATIENTS WITH KNOWN HYPERSENSITIVITY TO PENICILLIN

● Non-type 1 hypersensitivity to Penicillin, cephalosporins such as :

Cefuroxime PO 20-30mg/kg/day Q12 or IV 100-150mg/kg/day
Q8 OR Ceftriaxone at 75-100mg/kg/day Q12 to Q24
● Type 1 hypersensitivity to Penicillin (immediate, anaphylactic-type)
Azithromycin at 10mg/kg/day PO or IV Q24 for 3 days OR 10mg/kg/day on day 1 followed by 5
mg/kg/day Q24 for 2 to 5 Days
Clarithromycin at 15mg/kg/day Q12 for 7 days Clindamycin at 10-40mg/kg/day PO or
20-40mg/kg/day IV Q6 to Q8 for 7 days

MANAGEMENT - ATYPICAL PATHOGENS

● When an atypical pathogen is highly suspected, starting a macrolide is considered:

○ Azithromycin at 10 mg/kg/day PO or IV Q24 for 5 days, particularly in infants
less than 6 months old whom pertussis is entertained,
■ OR 10mg/kg/day Q24 for 3-5 days OR 10mg/kg/day on day 1 followed by
5 mg/kg/day Q24 for 2 to 5 days
○ Clarithromycin at 15 mg/kg/day Q12 for 7 to 14 days

PROGNOSIS :
● For patients having non-severe PCAP
○ Good clinical response to current therapeutic management is considered by
improvement of cough and normalization of core body temperature in Celsius in
the absence of antipyretics within 24-72 hours after initiation of treatment.
● For patients having severe PCAP
○ Good clinical response to current therapeutic management is considered as
evidenced by resolution of hypoxia, tachypnea, fever, tachycardia, improving
radiologic pneumonia findings, normal or decreasing CRP and procalcitonin
observed within 24-72 hours after initiation of treatment.

PREVENTION:
● Vaccination against Streptococcus pneumoniae (pneumococcus), Haemophilus
influenzae type b (Hib), Bordetella pertussis (pertussis), Rubeola virus (measles) and
Influenza virus
● Breastfeeding for the first six months of life plays a major role by boosting immunity
against causative organisms of pneumonia. Breastfeeding decrease the incidence of
pneumonia in young children upto 32%.
● Avoidance of environmental tobacco smoke or indoor biomass fuel exposure .
● Zinc plays an important role in cell regeneration, immunity and growth. Daily
supplementation with 10mg of Zinc (as gluconate or sulfate) for at least 4 to 6 months
 can prevent pneumonia in children aged 2 to 59 months. Zinc supplementation in children
increases levels of complement in the blood that modulate the function of T-lymphocytes,
T-helper, macrophages and neutrophils and hence improves the ability to fight infection.

References:
1. Nelson, W.E. (2019) Nelson Textbook of Pediatrics. 21st Edition
2. 2021 Clinical Practice Guidelines in the Evaluation and Management of Pediatric
Community Acquired Pneumonia