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  This is the first line of treatment in bronchopneumonia.

  Along with the above treatment additionally proper food supplementation, hydration by

giving adequate water, vegetable juices made up of carrot, and spinach can be given.

  Pneumococcal vactionation is advised in children.

Related Topics 

  Bronchopneumonia Treatment | Symptoms, Causes of Broncho Pneumonia

  Iga Deficiency In Children: Symptoms And Treatment For Low IgA In Kids

  Children with Cystic Fibrosis: Causes, Symptoms, Remedies, Treatment

  Pneumonia In Children Under 5: Symptoms And Treatment For Pneumonia

  Enlarged Heart In Children: Symptoms, Causes And Treatment

Etiology

Pneumonia can be caused by a myriad of microorganisms. Clinical suspicion of a particular

offending agent is derived from clues obtained during the history and physical examination.While virtually any microorganism can lead to pneumonia, specific bacterial, viral, fungal, and

mycobacterial infections are most common in previously healthy children. The age of infection,

exposure history, risk factors for unusual pathogens, and immunization history all provide clues

to the infecting agent.

In a prospective multicenter study of 154 hospitalized children with acute community-acquiredpneumonia (CAP) in whom a comprehensive search for an etiology was sought, a pathogen was

identified in 79% of children. Pyogenic bacteria accounted for 60% of cases, of which 73% were

due to Streptococcus pneumoniae, while the atypical bacteria Mycoplasma pneumoniae and

Chlamydophila pneumoniae were detected in 14% and 9%, respectively. Viruses weredocumented in 45% of children. Notably, 23% of the children had concurrent acute viral and

bacterial disease. In the study, preschool-aged children had as many episodes of atypical

bacterial lower respiratory infections as older children. Multivariable analyses revealed that high

temperature (38.4°C) within 72 hours after admission and the presence of pleural effusion weresignificantly associated with bacterial pneumonia.[4]

Specific etiologic agents vary based on age groups (ie, newborns, young infants, infants and

toddlers, 5-year-olds, school-aged children and young adolescents, older adolescents).

Newborns

In newborns (age 0-30 d), organisms responsible for infectious pneumonia typically mirror those

responsible for early onset neonatal sepsis. This is not surprising in view of the role that maternal

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genitourinary and gastrointestinal tract flora play in both processes. Infections with group B

Streptococcus, Listeria monocytogenes, or gram-negative rods (eg, Escherichia coli, Klebsiella

 pneumoniae) are common causes of bacterial pneumonia. These pathogens can be acquired in

utero, via aspiration of organisms present in the birth canal, or by postnatal contact with other

people or contaminated equipment.

Group B Streptococcus (GBS) was the most common bacterial isolate in most locales from the

late 1960s to the late 1990s, when the impact of intrapartum chemoprophylaxis in reducingneonatal and maternal infection by this organism became evident. E coli has become the most

common bacterial isolate among VLBW infants (1500 g or less) since that time.[5]

Other potential

bacterial organisms include the following:

  Nontypeable Haemophilus influenzae (NTHi)

  Other gram-negative bacilli

  Enterococci

  Staphylococcus aureus 

Some organisms acquired perinatally may not cause illness until later in infancy, including

Chlamydia trachomatis, U urealyticum, Mycoplasma hominis, CMV, and Pneumocystis carinii.

C trachomatis organisms are presumably transmitted at birth during passage through an infected

birth canal, although most infants are asymptomatic during the first 24 hours and developpneumonia only after the first 2 weeks of life.

Group B streptococci infections are most often transmitted to the fetus in utero, usually as a

result of colonization of the mother's vagina and cervix by the organism. Agents of chronic

congenital infection, such as CMV, Treponema pallidum (the cause of pneumonia alba),

Toxoplasma gondii, and others, may cause pneumonia in the first 24 hours of life. The clinical

presentation usually involves other organ systems as well.

Community-acquired viral infections occur in newborns, although less commonly than in olderinfants. The most commonly isolated virus is respiratory syncytial virus (RSV). The transfer of 

maternal antibodies is important in protecting newborns and young infants from such infections,

making premature infants (who may not have benefited from sufficient transfer of transplacentalimmunoglobulin [Ig] G]) especially vulnerable to lower-tract disease. In addition, premature

infants may have chronic lung disease of prematurity, with associated hyperreactive airways,

fewer functional alveoli, and baseline increased oxygen requirements.

Newborns may also be affected by the bacteria and viruses that commonly cause infections in

older infants and children. Risk factors for infection include older siblings, group daycare, and

lack of immunization.

Young infants

In the young infant (aged 1-3 mo), continued concern about the perinatally acquired pathogens

mentioned above remains. However, most bacterial pneumonia in this age group is community

acquired and involves S pneumoniae, S aureus, and nontypeable H influenzae. S pneumoniae is

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by far the most common bacterial pathogen in this age group. Infection with any of these

pyogenic bacteria may be complicated by lung abscess, parapneumonic effusions, and empyema,although S aureus is notorious for such complications.[6]

At this age, infants are incompletely immunized and remain at higher risk for  H influenzae type

B and pneumococcal disease, although herd immunity gained from widespread immunization of the population has been broadly protective. It is important to note that the current conjugate

pneumococcal vaccine provides protection against 13 common pneumococcal types, butnonvaccine types remain problematic.

Most lower respiratory tract disease in young infants occurs during the respiratory virus seasonand is viral in origin, particularly in the patient with clinical bronchiolitis. The most common

viral agents include RSV, parainfluenza viruses, influenza virus, adenovirus, and human

metapneumovirus (hMPV).

Atypical organisms may rarely cause infection in infants. Of these, C trachomatis, U 

urealyticum, CMV, and P carinii are described.

 Bordetella pertussis infection leads to pneumonia in as many as 20% of infected infants (as a

complication of the whooping cough infection).

Among other potential atypical bacterial pathogens, U urealyticum and U parvum have been

recovered from endotracheal aspirates shortly after birth in very low birth weight (VLBW)infants and have been variably associated with various adverse pulmonary outcomes, including

bronchopulmonary dysplasia (BPD).[7, 8, 9, 10]

Whether these organisms are causal or simply a

marker of increased risk is unclear.

Infants, toddlers, and preschool-aged children

Viruses remain the most common cause of pneumonia in this age group, accounting forapproximately 90% of all lower respiratory tract infections. Tsolia et al identified a viral

infection among 65% of hospitalized children with community-acquired pneumonia.[11]

RSV is the most common viral pathogen, followed by parainfluenza types 1, 2, and 3 and

influenza A or B. RSV infection occurs in the winter and early spring. Parainfluenza type 3

infection occurs in the spring, and types 1 and 2 occur in the fall. Influenza occurs in the winter.

Other viruses that cause pneumonia less frequently in infants and young children include

adenovirus, enterovirus, rhinovirus, and coronavirus. A recent addition to this list is hMPV,which causes an illness similar to RSV and may be responsible for one third to one half of non-

RSV bronchiolitis. The herpesviruses (HSV, VZV, and CMV) may rarely cause pneumonia,

particularly in children with impaired immune systems.

Bacterial infections in this age group are seen on a regular basis. S pneumoniae is by far the most

common bacterial cause of pneumonia. Among hospitalized children with bacterial pneumonia, S

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 pneumoniae accounts for 21-44% of disease.[4, 12, 13]

Other agents to consider include H 

influenzae type B (HiB) (very uncommon in immunized children[14]

), S pyogenes, and S aureus.

Children younger than 5 years, children enrolled in daycare, or those with frequent ear infections

are at increased risk for invasive pneumococcal disease and infection with resistant

pneumococcal strains. Evidence suggests that breastfeeding has a protective effect againstinvasive pneumococcal infection.

School-aged children and young adolescents

 M pneumoniae is the most frequent cause of pneumonia among older children and adolescents.

 Mycoplasma accounts for 14-35% of pneumonia hospitalizations in this age group.[4, 11, 15]

Children in homeless shelters and group homes and those with household contacts are at

particular risk. Similarly, the diagnosis must be considered in immunocompromised children.

In this age group, pyogenic bacterial pneumonia remains a concern, usually caused by S

 pneumoniae. Other pyogenic bacterial pathogens to consider include S aureus and S pyogenes.

Chlamydophila pneumoniae also causes pneumonia. The related organism, C psittaci, is an

unusual cause of pneumonia that occurs in people who work with and handle birds.

In immunosuppressed individuals, opportunistic infections with organisms such as  Aspergillus 

species, Pneumocystis jirovecii, and CMV can occur.

Viral pneumonia remains common in this age group. Influenza pneumonia is a particular concern

because ongoing infection with this virus predisposes to the development of bacterialsuperinfection, usually with S pneumoniae or S aureus.

Older adolescents

 M pneumoniae is the most common cause of community-acquired pneumonia during the teenage

and young adult years. Atypical pneumonia caused by C pneumoniae can present with identical

signs and symptoms. Bacterial pneumonia caused by S pneumoniae is also seen.

Pulmonary infections caused by dimorphic fungi are also seen in this age group.  Histoplasma

capsulatum, which is found in nitrate-rich soil, is usually acquired as a result of inhalation of 

spores. Chicken coops and other bird roosts and decaying wood are often-cited sources.

Cryptococcus neoformans is a common infection among pigeon breeders, but it is unusual in

other immunocompetent individuals.

 Blastomyces dermatitides, another dimorphic fungus, is found in certain geographic locations,

most notably the Ohio and Mississippi River valleys. As with histoplasmosis, blastomycosis isacquired by inhalation of spores. Although 3 distinct forms of infection exist, the most common

is acute pneumonia, which, in previously healthy individuals, most often resolves without

treatment.

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Viral pneumonias are common in this age group are usually mild and self-limited, but influenza

pneumonia can be severe or protracted, particularly when a bacterial infection follows.

TB pneumonia in children warrants special mention. It can occur in any age group, and it is

important to remember that children with TB usually do not present with symptoms until 1-6

months after primary infection. Any child with pneumonia who has a history of TB exposure, orwho has traveled to a TB-endemic area of the world needs to be fully evaluated for the

possibility of tuberculosis.

 Legionella pneumophila, the agent of Legionnaires disease, can also cause pneumonia, although

it is uncommon in the pediatric age group.

Not all pneumonia is caused by infectious agents. Children who have severe gastroesophageal

reflux (GERD) may develop chemical pneumonitis secondary to recurrent aspiration. Inhalationof certain chemicals or smoke may cause pulmonary inflammation. Additionally, aspiration

pneumonia is more common in children with neurologic impairment, swallowing abnormalities,

gastrointestinal motility, or a gastrostomy tube. Oral anaerobic flora, with or without aerobes, isthe most common etiologic agent.

Immunocompromised children

Some children who are immunocompromised, whether secondary to HIV infection/AIDS, an

immune disorder, or chemotherapy for a malignancy, are at risk for pneumonias with

opportunistic agents. Virtually any bacteria, virus, fungus, or even parasite can invade and infectthe lungs if the immune system is sufficiently impaired. Carefully obtained samples for

appropriate microbiologic testing are paramount in such patients so that therapy can be

optimized.

Children with cystic fibrosis are especially prone to develop infections with S aureus,

Pseudomonas aeruginosa, Burkholderia cepacia, and other multidrug-resistant organisms.

P jirovecii pneumonia (PCP) is common in the most severely compromised children and can lead

to respiratory failure and death in those who are profoundly immunocompromised. Adenovirusinfections can be severe in these children as well, leading to bronchiolitis obliterans or

hyperlucent lung syndrome. In addition, CMV poses a great risk to immunocompromised

patients.

Fungal pneumonia, caused by Aspergillus, Zygomycetes, or other related fungi, occur in

immunocompromised patients who undergo prolonged hospitalization, have prolongedneutropenia, and/or have received broad-spectrum antibiotics. Patients with underlyinghematologic malignancies are at the highest risk.

Patients with sickle cell disease have problems with their complement system as well as

functional asplenia, which predisposes them to infection with encapsulated organisms such as S

 pneumoniae and H influenzae type B. M pneumoniae is also a common agent of pneumonia isthis group of patients.

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Epidemiology

United States statistics

Pneumonia can occur at any age, although it is more common in younger children. Pneumonia

accounts for 13% of all infectious illnesses in infants younger than 2 years. In a largecommunity-based study conducted by Denny and Clyde, the annual incidence rate of pneumonia

was 4 cases per 100 children in the preschool-aged group, 2 cases per 100 children aged 5-9

years, and 1 case per 100 children aged 9-15 years.[16]

Thompson et al reported that, after elderly persons, the second highest rates of influenza-

associated hospitalizations in the United States were in children younger than 5 years.[17]

The

investigators evaluated annual influenza-associated hospitalizations by hospital dischargecategory, discharge type, and age group.

In a randomized double-blind trial, the heptavalent pneumococcal vaccine reduced the incidence

of clinically diagnosed and radiographically diagnosed pneumonia among children younger than5 years by 4% and 20%, respectively.

[18]Although the overall rate of pneumonia has decreased in

the United States with the use of the 7-valent vaccine, the rate of empyema and complicatedpneumonia has increased.[19] With the use of the 13-valent conjugated pneumococcal

polysaccharide vaccine, the overall rates of pneumonia are anticipated to drop further. The new

vaccine includes serotypes that have become associated with complicated or antibiotic-resistantdisease (19A and 6A, for example).

In school-aged children and adolescents, bronchopneumonia occurs in 0.8-2% of all pertussiscases and 16-20% of hospitalized cases. M pneumoniae accounts for 14-35% of pneumonia

hospitalizations in this age group,[4, 11, 15] and mycobacterial pneumonia has recently been noted

with increasing frequency in some inner-city areas, particularly children in homeless shelters andgroup homes and those with household contacts.

International statistics

Pneumonia and other lower respiratory tract infections are the leading cause of death worldwide.

The WHO Child Health Epidemiology Reference Group estimated the median global incidence

of clinical pneumonia to be 0.28 episodes per child-year.[20]

This equates to an annual incidenceof 150.7 million new cases, of which 11-20 million (7-13%) are severe enough to require

hospital admission. Ninety-five percent of all episodes of clinical pneumonia in young children

worldwide occur in developing countries.

Approximately 150 million new cases of pneumonia occur annually among children younger

than 5 years worldwide, accounting for approximately 10-20 million hospitalizations.[16]

A WHO

Child Health Epidemiology Reference Group publication cited the incidence of community-acquired pneumonia among children younger than 5 years in developed countries as

approximately 0.026 episodes per child-year,[20]

and a study conducted in the United Kingdom

showed that 59% of deaths from pertussis are associated with pneumonia.

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Prognosis

Overall, the prognosis is good. Most cases of viral pneumonia resolve without treatment;common bacterial pathogens and atypical organisms respond to antimicrobial therapy (see

Treatment and Management). Long-term alteration of pulmonary function is rare, even in

children with pneumonia that has been complicated by empyema or lung abscess.

Patients placed on a protocol-driven pneumonia clinical pathway are more likely to havefavorable outcomes. The prognosis for varicella pneumonia is somewhat more guarded.

Staphylococcal pneumonia, although rare, can be very serious despite treatment.

Morbidity

Although viral pneumonias are common in school-aged children and adolescents and are usually

mild and self-limited, these pneumonias are occasionally severe and can rapidly progress to

respiratory failure, either as a primary manifestation of viral infection or as a consequence of 

subsequent bacterial infection.

Morbidity and mortality from RSV and other viral infections is higher among premature infants

and infants with underlying lung disease. Significant sequelae occur with adenoviral disease,

including bronchiolitis obliterans and necrotizing bronchiolitis. With neonatal pneumonia, even

if the infection is eradicated, many hosts develop long-lasting or permanent pulmonary changesthat affect lung function, the quality of life, and susceptibility to later infections.

Infants and postpubertal adolescents with TB pneumonia are at increased risk of diseaseprogression. If TB is not treated during the early stages of infection, approximately 25% of 

children younger than 15 years develop extrapulmonary disease.

Bronchopneumonia occurs in 0.8-2% of all pertussis cases and 16-20% of hospitalized cases; the

survival rate of these patients is much lower than in those with pneumonia that is attributed to

other causes.

Immunocompromised children, those with underlying lung disease, and neonates are at high risk for severe sequelae, and they are also susceptible to various comorbidities. Cryptococcosis may

occur in as many as 5-10% of patients with AIDS, and acute chest syndrome occurs in 15-43%

of patients with sickle cell disease. Individuals with sickle cell disease not only have problems

with their complement system, but they also have functional asplenia, which predisposes them toinfection with encapsulated organisms such as S pneumoniae and H influenzae type B.

Mortality

The United Nations Children's Fund (UNICEF) estimates that 3 million children die worldwide

from pneumonia each year; these deaths almost exclusively occur in children with underlying

conditions, such as chronic lung disease of prematurity, congenital heart disease, andimmunosuppression. Although most fatalities occur in developing countries, pneumonia remains

a significant cause of morbidity in industrialized nations.

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According to the WHO’s Global Burden of Disease 2000 Project, lower respiratory infections

were the second leading cause of death in children younger than 5 years (about 2.1 million[19.6%]).[20] Most children are treated as outpatients and fully recover. However, in young

infants and immunocompromised individuals, mortality is much higher. In studies of adults with

pneumonia, a higher mortality rate is associated with abnormal vital signs, immunodeficiency,

and certain pathogens.

Patient Education project

Counsel parents regarding the need to prevent exposure of infants to tobacco smoke, and, as part

of anticipatory primary care, educate parents regarding later infectious exposures in daycare

centers, schools, and similar settings as well as the importance of hand washing. In addition,discuss the benefit infants may receive from pneumococcal immunization and annual influenza

immunization and the potential benefits and costs of RSV immune globulin (see Prevention).

Emphasize careful longitudinal surveillance for long-term problems with growth, development,

otitis, reactive airway disease, and other complications.

Most children treated with outpatient antibiotics are much improved within 48 hours after the

initiation of treatment. Educate parents about and caution them to look for the signs of increasingrespiratory distress and to seek medical attention immediately should any of these signs appear.

For excellent patient education resources, visit eMedicine's Procedures Center and Pneumonia

Center. Also, see eMedicine's patient education articles Bronchoscopy, Viral Pneumonia, and

Bacterial Pneumonia. 

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literature

Conclusions

About 156 million new episodes of childhood clinical pneumonia occurred globally in 2000,

more than 95% of them in developing countries. Of all the pneumonia cases occurring in thosecountries, 8.7% are severe enough to be life-threatening and require hospital admission. About 2

million pneumonia deaths occur each year in children aged less than 5 years, mainly in the

African and South-East Asia Regions. The main bacterial causes of clinical pneumonia in

developing countries are S. pneumoniae and Hib, and the main viral cause is respiratory syncytial

virus, but estimates of their relative importance vary in different settings. The only vaccines forthe prevention of bacterial pneumonia (excluding pertussis) are Hib and pneumococcal vaccines.

Future studies, with new molecular techniques to better detect infections due to the wide range of pathogens, will broaden our understanding of the cause of pneumonia and may highlight which

pathogens should be the targets for new vaccines. Despite the lack of data, mainly for the

developing regions of the world, morbidity and mortality estimates and the main risk factors

presented in this review could contribute to an understanding of the burden of acute lowerrespiratory infections in children aged less than 5 years in developing countries and to informed

care and vaccine policy.

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