Management of community acquired pneumonia CAP in children Clinical practice guidelines by the Paediatrics Association of Nigeria PAN

Niger J Paed 2015; 42 (4):283 – 292

CLINICAL PROTOCOL

Management of community acquired pneumonia (CAP) in

children: Clinical practice guidelines by the Paediatrics

Association of Nigeria (PAN)

1 Olowu A,² Elusiyan JBE,³ Esangbedo D,⁴ Ekure EN,⁴ Esezobor C,⁵ Falade AG

Osinusi K, Mukhtar-Yola M, Meremikwu M, Ibe B, Johnson WBR

Oviawe O, Bastos I

1 Department of Paediatrics, Ogun State Uuniversity, Ago-iwoye,² Department of Paediatrics and Child Health, Obafemi Awolowo

University, Ile-Ife, Osun-State, Providence Hospital, Lagos, Nigeria, Department of Paediatrics, Lagos University Teaching

Hospital, Lagos, Department of Paediatrics, University College Hospital, Ibadan, Department of Paediatrics, National Hospital,

Abuja, Department of Paediatrics, University of Calabar, Calabar, Department of Paediatrics, University of Nigeria Teaching

Hospital, Enugu, Department of Paediatrics, University of Ilorin, Ilorin, Department of Paediatrics, University of Benin, Benin

City, Nursing services, Lagos University Teaching Hospital, Lagos,

DOI:http://dx.doi.org/10.4314/njp.v42i4.1

Accepted: 4th June 2015

sub-Saharan Africa, pneumonia

population) has become impera-

remains a common cause of under

tive. This was the logic that in-

Preamble

-five mortality, accounting for

formed the current initiative of the

17% of deaths in this age-group.

Paediatric Association of Nigeria,

Against the background of the sub-

Indeed, it has been estimated that

aimed at formulating diagnostic,

sisting high childhood mortality

globally,

treatment and control policies with

indices in Nigeria, vis-a-vis the

a child dies from pneumonia

respect to paediatric community

global efforts in the last 10 years to

every 20 seconds. With these in

acquired pneumonia (CAP). This

stem the tide (as articulated in the

mind, and indeed the laudable

document is targeted primarily at

Millennium Development Goals),

goal of a 66% reduction of the

health care providers working in

there has been a corresponding need

national under-five deaths by the

Nigeria in centres with limited

to address the common causes of

year 2015, a prompt recognition

facilities as well as those working

deaths in under- fives. In Nigeria,

and management of pneumonia

in tertiary hospitals.

as is the case in many countries in

(in this vulnerable paediatric

Definition

facility.

Duration of Pneumonia: Pneumonia can be classi-

Pneumonia is the inflammation of lung parenchyma due

fied as "acute" (less than two weeks duration) and

to pathogenic micro-organisms such as bacteria, viruses

"chronic". Chronic pneumonias tend to be either

and fungi. Clinically, it is also defined as a condition

mycobacterial or fungal. A microbiological classifi-

typically associated with fever, respiratory symptoms,

cation involves knowledge of the aetiological

and evidence of parenchymal involvement, either by

agents.

physical examination or the presence of infiltrates on

Anatomical area(s) of involvement: Usually rec-

chest radiograph. In order to facilitate early recognition,

ognized based on chest radiographic parameters:

prompt treatment and referral of children with pneumo-

Lobar pneumonia: characterized by the presence

nia, the World Health Organization (WHO) definition of

of a smooth, dense homogenous opacity of a single

pneumonia relies on simple clinical signs, such as

lobe, or a segment of a lobe, of a lung. The aetio-

tachypnoea and lower chest in-drawing (Table 1). Ac-

logical agent is often Streptococcus pneumoniae .

cording to this definition, severity classification of pneu-

Multilobar pneumonia involves more than one lobe,

monia in under-fives is non-severe and severe (Table 1).

often causing a more severe illness.

Bronchopneumonia: there are patchy changes in

Classification of pneumonia

the lung around the bronchi or bronchioles.

Pneumonia can be classified using several parameters:

Interstitial pneumonia: this involves the areas in

between the alveoli. It is more likely to be caused

Source of infection: Community-acquired pneumo-

by viruses or by atypical bacteria

nia

(CAP)

and

hospital

acquired

infection

Microbiologial classification: This is based on the

(nosocomial) pneumonia. CAP is defined as pneu-

organism isolated/identified. This is exemplified by

monia in a previously healthy child who acquired

viral, bacterial, fungal, mycoplasmal and

the infection outside a health facility or develops the

chlamydial pneumonia.

illness within 48 hours of admission into a health

284

Epidemiology

General population of children

Pneumonia is the leading cause of death in children un-

The two commonest bacteria are Streptococcus pneumo-

der five years around the world, accounting for ~ 20% of

niae (30 – 50% of pneumonia cases) and H. influenzae

all under-five mortality globally. Indeed, more than 155

type b (Hib; 10-30% of cases) , and the main viral cause

million new episodes of clinical pneumonia occur in

is RSV, but estimates of their relative importance vary

children under 5 years of age annually with about 10%

in different settings.

of these being of sufficient severity to be life-threatening

requiring hospitalization. In 2011, for example, an esti-

HIV-infected children

mated 1.3 million children under five years died from

pneumonia. Nigeria ranked fifth among the countries

Pneumocystis jiroveci and Mycobacterium tuberculosis

with the highest absolute number of new cases of clini-

are important causes of pneumonia, though bacterial

cal pneumonia in 2008 with an estimated 6.1 million

causes remain the major cause of pneumonia mortality.

new cases.

By 2010, the estimated number of under-

five children dying from pneumonia in Nigeria was

Severely malnourished children

more than 120,000, a disease burden that constitutes the

highest in Africa. The burden of disease is mainly in the

Klebsiella pneumoniae, S. aureus, S. pneumoniae, E.

younger age groups. Furthermore, while 81% of deaths

coli, and H. influenzae are the major aetiological agents

from pneumonia happen in children younger than 2

with very few data on the role of respiratory viruses and

years, disease incidence has been shown to fall less rap-

M.tuberculosis.

idly with age than does mortality from the disease. Also,

the global pneumonia incidence shows a higher preva-

Neonates

lence among boys than girls with the largest differences

recorded in South Asia regions. Indeed the recent series

The organisms responsible for pneumonia in this age

by Abdulkarim in Ilorin reported a male to female ratio

group are essentially similar to those causing neonatal

of 1.5:1.

sepsis and include gram-negative enteric organisms such

as E.. coli, Klebsiella spp, and gram-positive organisms,

Aetiological Agents

mainly S. pneumoniae, S. aureus and group B Strepto-

The aetiological agents of CAP could be divided into

coccus.

bacterial, viral and fungal.

School-aged children

a. Bacteria

Common bacterial agents

Mycoplasma pneumoniae is an important cause of pneu-

Streptococcus pneumoniae

monia in school-aged children.

Haemophilus influenzae

However, in Nigeria pathogens causing CAP in the un-

Staphylococcus aureus

der-fives are as shown in the table below:

Less common bacterial agents

Klebsiella pneumoniae

Table 1: Aetiological agents of childhood pneumonia in

Mycoplasma pneumoniae

Nigeria

Chlamydophilia pneumoniae

Studies

Isolated organisms

Non-typhoidal salmonella

Non-typeable Haemophilus influenza

Abdulkarim et

Staphylococcus aureus (23.9%), Klebsiellaspp

al 2013

(17.4%), coliforms and coagulase negative

Staphylococcus(15.2%) each; micrococcus and

b. Viruses

non-haemolytic Streptococcus(6.5%) each

Common Viral agents

Falade et al 2009

S. pneumoniae (9), Hib (2), and others- Klebsiel-

Respiratory syncytial virus (RSV)

laspp (14 cases), Salmonella spp (11), Pseudo-

Influenza A & B virus

monas. aeruginosa (6 ), Enterococcus. faecalis

Parainfluenza

(2 ), E. coli (2), and possible S. aureus (44) but

only 1 of the 44 isolates was confirmed

Less common viral agents

Johnson et

Bacteria: S. aureus (37.3%), Klebsiella spp.

Adenovirus (ADV)

al 2008

(15.3%) and S. pneumoniae (5.1%). 92 viruses:

Human metapneumovirus

RSV (30.4%), PIV-3 (19.5%) Flu-A (17.3%)

Measles virus

Tagbo et al 2005

S.pneumoniae (3), S . aureus (2), coliforms (2),

H. influenzae (1), Proteus mirabilis (1), P.

Others

aeruginosa (1)

Mycobacterium spp

Pneumocystis jiroveci

Results of aetiology of pneumonia studies in Nigeria are at

variance with the global trend due to a) high pre-consultation

antibiotic use; b) use of human blood to prepare blood agar;

Globally, the common pathogens of CAP and the corre-

and c) lack of current method to distinguish coagulase

sponding paediatric population are:

negative Staphylococcus from S. aureus.

285

Predisposing/Risk Factors

findings are suggestive of CAP.

Risk factors for CAP include the following:

Clinical Assessment

Table 2: Risk Categories of Community Acquired Pneumonia

Relevant history questions :

(modified from Rudan et al Bull WHO 2008)

Definite Risk

Likely Risk

Possible Risk

Risk Factors



Host-related factors: Age, immunization status, lack

Factors

for neonate

of exclusive breastfeeding, low birth weight, severe

Malnutrition

Parental smoking

Mother’s

Premature

malnutrition

(WAZ score <-

education

rupture of



Environmental Factors: household air pollution e.g.

membranes

Low birth

Zinc deficiency

Day care

Low birth

firewood burning, passive tobacco smoking , season

weight

attendance

weight

of the year, overcrowding and poor ventilation

Non-exclusive

Mother’s experi-

Outdoor air

Preterm deliv-



Co-morbidities: heart disease, sickle cell disease,

breastfeeding

ence as a care-

pollution

ery

HIV infection, gastro-esophageal reflux disease

giver

Lack of mea-

Concomitant

Lack of exclu-

sles immuniza-

disease, e.g.

sive breast-

An initial physical examination should be per-

tion

heart disease,

feeding

formed for signs of respiratory illness and for fever.

Household air

sickle cell dis-

Concomitant

These signs include tachypnoea, evidence of in-

pollution

ease, immunode-

disease, e.g.

Overcrowding

ficiency states

heart disease

creased work of breathing, cyanosis, auscultatory

signs such as decreased breath sounds, crepitations

and bronchial breath sounds. Other features to be

Pathophysiology and Pathogenesis of Pneumonia

looked for include evidence of other organ involve-

ment such as heart failure (tachycardia, tender hepa-

The respiratory tract is replete with both specific and

tomegaly), acute osteomyelitis, septic arthritis and

non-specific protective mechanisms which act in concert

meningitis

to keep the airways and alveoli free of both particulate

materials and microbes.

The following points should be noted, however:

The non-specific defense mechanisms include the nasal

hair and nasal turbinates, the vocal cord, glottis, muco-

Respiratory rates are best determined over a full 60-

ciliary clearance and the cough reflex. Others include

second period and inconsistencies require repeated

humidification, neutrophils, resident alveolar macro-

observations. This is required in view of the effects

phages, airway secretions including lysozymes, iron

of the peculiar behavioral and physiologic factors in

binding proteins, complements and surfactant.

children.

The specific defense system involves the coordinated

No single clinical finding is sufficient in determin-

activities of B and T lymphocytes resulting in activation

ing the presence or absence of pneumonia; combi-

of cytotoxic T cells and specific antibodies

nations of clinical findings are more useful.

Microbes are introduced to the airway via inhalational or

The best individual examination measures in chil-

haematogenous route. When microbes evade the non-

dren less than 5 years are:nasal flaring (age < 12

specific defense system they provoke an inflammatory

months); oxygen saturation 90% or less in room air;

response leading to exudates of plasma, neutrophils,

tachypnoea; and retractions. The absence of tachyp-

lymphocytes, macrophages and inflammatory debris.

noea alone or of all other signs of respiratory illness

The inflammatory debris narrows the airway and in-

is highly suggestive of the absence of pneumonia.

creases airway resistance. The debris also causes partial

Among children less than 5 years, especially in neo-

or total occlusion of the smaller airways with resultant

nates and those with severe malnutrition pneumonia

atelectasis and hyperinflation of some alveoli leading to

may be present without signs of respiratory illness.

increased work of breathing and wheezing. Furthermore,

the increased alveolar diffusion barrier causes signifi-

Table 3: Respiratory Rate Cut-offs for Children According to

cant ventilation-perfusion mismatch and intrapulmonary

Age Groups

shunt.

Age groups

Approximate normal

Tachypnoea

These pathophysiological events are responsible for (1)

respiratory rates

threshold (bpm)

tachypnoea (2) increased work of breathing (3) crepita-

(bpm)

tions (4) reduced air entry (5) dull percussion note (6)

Less than 2 months

40 to 60

≥60

wheeze/rhonchi and (7) fever

2 up to 12 months

25 to 40

≥50

Seeding of bacteria to the blood and other organs could

1 up to5 years

20 to 30

≥40

also occur causing organ-specific manifestations,(such

≥ 5 years

15 to 25

≥30

as meningitis, septic arthritis, acute ostemyelitis), while

the inevitable increase in pulmonary vascular resistance

Classification of severity of pneumonia

coupled with increased myocardial oxygen requirement

may cause heart failure.

Children with pneumonia usually present with cough

and/ or difficult breathing, fast breathing and fever.

Clinical Features

These children may either have severe or non-severe

pneumonia, as defined below. This classification forms

The main objective of the initial clinical assessment is to

the basis of subsequent management:

decide if the child’s history and physical examination

286

a. Pneumonia (non-severe)

health workers as part of capacity building for recogni-

tion of varying severity of the disease and appropriate



Mild chest indrawing: (i.e. lower chest wall goes in

referral option. Also recommended is the knowledge of

when the child breathes in)

the haemoglobin genotype of the child.



chest auscultation signs: decreased breath sounds,

At hospital setting, aims of management include aetio-

bronchial breath sounds, crackles or crepitations

logical diagnosis, anatomical/pathological diagnosis and

determination/correction of effects of the CAP on the

b. Severe pneumonia

child.

These children will have, in addition to the features of

Supportive Investigations

non-severe pneumonia, at least one or more of the fol-

lowing:



Anthropometry – weight, height, mid upper arm



Central cyanosis, or oxygen saturation 90% or less

circumference

on pulse oximetry in room air



Bedside determination of respiratory rate and pulse



Severe respiratory distress (e.g. grunting, very se-

rate

vere chest indrawing)



Pulse oximetry for oxygen saturation: Helpful in



chest auscultatory signs: decreased/absent breath

monitoring response to therapy and detection of

sounds or vocal resonance as in pleural effusion,

cyanosis. Acceptable cut-off value for discontinuing

pleural rub

oxygen therapy is is SPO 2 90% or more.



Signs of pneumonia with a general danger sign:



Acute phase reactants (APR), C-reactive protein

Inability to breastfeed or drink, lethargy or uncon-

(CRP), erythrocyte sedimentation rate (ESR), pro-

scious, convulsions.

calcitonin (PCT). While these non-specific inflam-



Presence of complications or co-morbidities: e.g.

matory markers may be of clinical benefit, their

congestive heart failure, severe malnutrition and

usefulness in differentiating the cause or indeed the

sickle cell disease

severity of the CAP is doubtful.

Clinical chest examination is useful in providing ana-

tomical diagnosis (Table 4):

Diagnostic Imaging

Table 4: Chest Signs of Lobar and Bronchopneumonia

Diagnosis of CAP is commonly achieved by carefully

considering the symptoms and signs, and in the majority

Signs

Lobar pneumonia

Broncho-

pneumonia

of cases, further investigations are uncalled for, espe-

cially in resource-poor countries.

Chest deformity

None

Chest movement

Diminished or absent

Normal

Plain chest radiograph is the commonest ancillary inves-

tigation for confirmation of CAP. Its main value is the

Mediastinal shift

None

identification of opacities in the chest radiograph.

Indications for chest radiograph in CAP include:

Vocal fremitus

Increased

Normal

Presence of significant chest retractions

Percussion note

Dull

Resonant

Failure to respond to initial course of antibiotic ther-

apy at 48 hours

Breath sound

Bronchial or vesicular

Vesicular

Suspected CAP with complications, e.g. pleural

Added sound

Crepitations (crackles)

Crepitations

effusion, pneumothorax

(crackles)

Progressive symptoms despite antibiotic therapy

Vocal resonance

Increased

Normal

In general CAP requiring hospitalization is an indication

for requesting a chest radiograph. There is controversy

Diagnostic Evaluation

regarding the timing and the specific views of the chest

radiograph required. The majority of clinicians favour

Management of CAP can be in a community or hospital

chest radiograph for severe pneumonia at presentation,

settings. Community setting includes: the home, health

while others favour chest radiograph as a pre-discharge

centres, community pharmacy shops/stores; as against

recommendation. Follow-up chest radiographs are un-

hospital setting, i.e. emergency departments, out-patient

necessary in children who recover uneventfully from

and in-patient departments.. Emphasis on community

CAP. Commonly, anteroposterior (AP) view is all that is

setting is on treatment of symptoms and prevention of

required. In the Nigeria situation, simultaneous AP and

progression to severe cases of pneumonia in order to

lateral views are preferred in order to assess additionally

avoid hospitalization.

the hilum, paratracheal and paravertebral structures.

For a child with suspected CAP in the community, there

Where massive effusion is suspected, lateral views

are no indicators for any general investigations. Investi-

should also be obtained following a substantial drainage

gation of any sort is not necessary and where this has

of the effusion.

been done, it has not contributed to outcome of manage-

ment. We recommend instruction on respiratory rate

Possible chest radiograph findings indicative of CAP

count for mothers, pharmacy assistants and community

include: lobar infiltrates, interstitial infiltrates (bacterial,

287

viral, atypical pneumonia), lobar consolidation, atelecta-

Step 4: Palpate for the position of the trachea

sis, nodular infiltration, hilar adenopathy, pneumato-

Step 5: Percuss the chest for dullness, or hyper-

coeles, etc.

resonance

Step 6: Auscultate for bronchial breath sounds, crepita-

However, the ‘gold standard’ for the diagnosis of pneu-

tions or rhonchi.

monia is chest radiography. Nevertheless, some of the

Step 7: Look for complications such as heart failure

limitations of chest radiography include:

(tachycardia, tender hepatomegaly), pleural effusion

(stony dull percussion note, reduced/absent breath sound

Interpretation of the chest radiographs in pneumonia

over the region of either or both chest regions), pneu-

varies as some studies classify only cases with al-

mothorax (hyper-resonance and reduced/absent breath

veolar consolidation as pneumonia, others include

sound over the upper and lateral region of the involved

the presence of any pulmonary parenchymal infil-

lung field).

trates

Step 8: Look for signs of other organ involvement. Ask/

Poor agreement between radiologists on the pres-

determine if convulsion, lethargy, inability to drink or

ence or absence of infiltrates in paediatric chest

feed or not responding to calls is present. Presence of

radiographs even when standard reporting formats

these features or any of the complications listed above

are used.

indicates severe pneumonia.

Chest radiographs predict the post-mortem diagno-

Step 9: Classify the severity of pneumonia (using WHO

sis of pneumonia in severely malnourished children

classification; see above)

with 100% specificity but only 50% sensitivity.

Step 10: Decide on who needs hospitalization. Criteria

Facility for chest radiography is not available in

for management in the hospital are:

most health facilities in developing countries



Age less than 2 months

There is no sufficient evidence to recommend the rou-



Severe pneumonia

tine use of ultrasound and computerized tomography



Presence of complications or co-morbidities

scan in CAP.



SpO 2 90% or less in room air.

Isolation of Microbiologic Agents

Step 11: Decide on relevant investigations:



Chest radiography is NOT required in children with

This is a desirable investigation in children with CAP in

pneumonia to be managed as outpatient

order to avoid antibiotics misuse and development of



Do chest radiography in children with pneumonia

bacterial resistance. Available methods include blood

needing hospitalization, more so in those children

culture, pleural fluid culture, nasopharyngeal culture,

suspected of having complications such as parap-

sputum (induced using 5% normal saline) culture, etc.

neumonic effusion (pleural effusion, empyema) or

However, the gold standard for sample recovery is lung

pneumothorax

puncture aspirate from infected region of the lung. Em-



Routine full blood count is NOT required for chil-

phasis should be on the less invasive sampling methods

dren suspected of having pneumonia to be managed

Although new molecular diagnostic tests are available,

in the outpatient

e.g., polymerase chain reaction (PCR), their usefulness

in our hospital setting is limited.



A full blood count should be obtained for all chil-

dren with severe pneumonia or sick enough to be

Recommendations for Management of Community

hospitalized.

Acquired Pneumonia



Because malaria is a common co-morbidity in this

Introduction

environment, screen for malaria parasite



Blood culture should be obtained in sick children

Results of aetiological studies of CAP in Nigeria, as

requiring hospitalization

well as its complications are essential to formulate its

Serum electrolytes, urea and creatinine, and random

management. It is paramount to consider the manage-

blood sugar should be obtained in children with severe

ment as first/alternative and second lines, which will fit

pneumonia.

into management at primary, secondary and tertiary lev-

els.

A stepwise approach to management is preferred: In

children with a history of fever, cough, and/or difficult

breathing:

Step 1: Count the respiratory rate for one full minute

when the child is awake and calm, or asleep. If the

breathing is fast, consider pneumonia.

Step 2: Look for evidence of increased work of breath-

ing (difficult breathing): in-drawing of the lower chest

wall when the child breathes in and nasal flaring

Step 3: Check for cyanosis (bluish discolouration) by

looking at the tongue and buccal mucosa. Document the

oxygen saturation using a pulse oximeter.

288

Step 12: Give systemic antibiotics to all children with pneumonia

Category

of children

Outpatients

Inpatients

Alternatives

First line

<2 months

Admit and treat as neonatal sepsis

≥2 months

High doseOral

Oral amoxicillin-clavulanic

IV amoxicillin

IV ceftriaxone (50-100mg/kg/day every

amoxicillin

acid (amoxicillin compo-

(150mg/kg/day in 3

12-24hours), OR

(90mg/kg/day in

nent 90mg/kg/dayin 2 di-

divided doses) AND

IV cefotaxime (100-200mg/kg/day in 4

2 divided doses)

vided doses) OR oralcefpo-

IV/IM genticin (5-

divided doses), OR

for at least 5

doxime (10mg/kg/day in 2

7.5mg/kg once

IV/IM genticin (5 -7.5mg/kg once daily)

days

divided doses) OR oral

daily) for at least 5

AND IV cloxacillin (100-200mg/kg in 4

cefuroxime (20-30mg/kg/

days

divided doses)OR

day in 2 divided doses) for

IV cefuroxime (150mg/kg/day in 3 di-

at least 5 days

vided doses)AND IV/IM genticin (5-

7.5mg/kg once daily) for at least 5 days.

HIV-

High doseOral

Oral amoxicillin-clavulanic

IV amoxicillin

IV ceftriaxone (50-100mg/kg/day every

infected

amoxicillin

acid (amoxicillin compo-

(150mg/kg/day in 3

12-24hours), OR

children

(90mg/kg/day in

nent 90mg/kg/dayin 2 di-

divided doses) AND

IV cefotaxime (100-200mg/kg/day in 4

2 divided doses)

vided doses) OR oralcefpo-

IV/IM genticin (5-

divided doses) OR

for 10 days

doxime (10mg/kg/day in 2

7.5mg/kg once

IV cefuroxime (150mg/kg/day in 3 di-

divided doses) OR oral

daily) PLUS high

vided doses)AND IV/IM genticin (5-

cefuroxime (20-30mg/kg/

dose co-trimoxazole

7.5mg/kg once daily)

day in 2 divided doses) for

(20mg/kg/day of

at least 10 days

trimethoprim) for at

PLUShigh dose co-trimoxazole (20mg/

least 10 days

kg/day of trimethoprim in 4 divided

doses)for at least 10 days

Children

High doseOral

Oral amoxicillin-clavulanic

IV amoxicillin

IV ceftriaxone (50-100mg/kg/day every

with sickle

amoxicillin

acid (amoxicillin compo-

(150mg/kg/day in 3

12-24hours), OR

cell disease

(90mg/kg/day in

nent 90mg/kg/dayin 2 di-

divided doses) AND

IV cefotaxime (100-200mg/kg/day in 4

2 divided doses)

vided doses) OR oralcefpo-

IV/IM genticin (5-

divided doses) OR

for at least 5

doxime (10mg/kg/day in 2

7.5mg/kg once

IV cefuroxime (150mg/kg/day in 3 di-

days

divided doses) OR oral

daily) PLUS

vided doses) AND IV/IM genticin (5-

cefuroxime (20-30mg/kg/

oralerythromycin

7.5mg/kg once daily) for at least 5 days

day in 2 divided doses) for

(60-100mg/kg/day

PLUS oral azithromycin ( 10 mg /kg)

at least 5 days

in 4 divided doses))

daily dose for 3 days

for at least 5 days

Notes:

Step down to appropriate oral antibiotics when improvement is sustained. For instance, cefpodoxime after ceftriaxone; Target

pathogens in outpatients’ treatment are S. pneumoniae and Hib; whereas in cases on admission, these as well as S. aureus and other

bacilli are included; Maximum dose of gentamicin should not exceed 120mg; Chloramphenicol is not included in the antibiotic

protocol because of its toxicity in the face of effective alternative antibiotics;

Alternatives: Consider alternatives when first line drugs are not available or applicable or child has not responded to the first line

drugs

Other Supportive Measures

fluid. Ensure it contains at least 5% glucose (e.g.

5% dextrose in 0.9% saline or ringer’s lactate with



Clear the airway using gentle suction as needed,

added glucose)

always mouth before nose

For high grade fever (temperature ≥39 C), give



Give supplemental oxygen if oxygen saturation is

paracetamol 10-15mg/kg 4-6 hourly, and ibuprofen

90% or less, in room air or signs of severe respira-

if required.

tory distress are present. If pulse oximetry is not



If widespread rhonchi is present (high-pitch con-

available give oxygen if signs of respiratory distress

tinuous sound during expiration only or during both

and or cyanosis are present.

phases of respiration) give first dose of short acting



Give oxygen via nasal prongs or nasal catheters: 0.5

bronchodilator such as salbutamol or albuterol and

-1L/min for children 0-2months, 2-3L/min for chil-

re-assess

dren 3months to 5 years; maximum of 4L/min for



Nursing care should be provided at least every 3

older children)

hours: check vital signs including oxygen saturation



Allow small frequent feeds/fluids if tolerated; feed-



The doctor should review the child at least twice

ing may also be done using appropriate size na-

daily

sogastric tube



If feeds are not tolerated give intravenous isotonic

289

When to Consider Referring a Child with Pneumonia to

should be ongoing from admission to discharge with

a Tertiary Centre/Getting a Specialist’s Review

family regularly updated on progress of management.

Information on what the caregiver should observe in the



If child’s clinical state does not improve after 48

child and report to the health facility should be commu-

hours or worsens within this period

nicated.



When the child requires mechanical ventilation at

The education should include:

presentation

The fact that CAP is caused by micro-organisms.



If oxygen saturation is persistently <90% despite

Environmental factors that predispose to CAP and

supplemental oxygen

CAP-related deaths such as indoor air pollution



If blood pressure remains low If the child has al-

including passive parental smoking, overcrowding,

tered mental status

poor ventilation, poor personal and environmental

hygiene. Good hand washing practices should be

When to consider transfers to a Critical Care Unit

emphasized.

Education about the presenting features with em-



When the child requires mechanical ventilation

phasis on the need for early recognition of fast



If blood pressure remains low or child requires ino-

breathing.

tropic agent(s) to maintain normal blood pressure

Immunization against the childhood diseases. Vac-



If the child has altered mental status

cines that protect against pneumonia such as Pneu-

mococcal conjugate vaccine (PCV), Haemophilus



If oxygen saturation is persistently <90% despite

influenzae type B vaccine (Hib), pertussis, and mea-

supplemental oxygen

sles vaccines should be communicated.



Presence of other organ failure

The importance of Exclusive breastfeeding in the

first 6 months of life and adequate nutrition should

When to Consider Discharge

be explained to the caregiver.

Opportunities should be given for the caregivers to



When clinical features such as fast breathing, respi-

express his/her fears, so that cultural and religious

ratory distress and fever have resolved for at least

beliefs that are detrimental to achieving optimal

24 hours

health and development of the child should be dis-



Child is feeding by mouth and tolerates oral medi-

cussed.

cations and

The need to avoid self-medications including the



Caregiver is comfortable about discharge from hos-

use of cough mixtures

pital and capable of administering oral medication

(s) if any

Prevention

At Discharge

There are proven strategies for the prevention of com-

munity acquired pneumonia in children. These include:



Plan to review the child two days after discharge



Review immunization record and make plans to get

Specific Vaccines

the child fully immunized if vaccines have been

missed. In addition, children under 2 years should

Conjugate vaccine for S. pneumoniae

get recommended doses of pneumococcal conjugate

Conjugate vaccine for H. influenzae type b

vaccines (PCV) or H. influenzae Type b conjugate

Influenza vaccine

vaccines(Hib vaccine) if not already immunized



Instruct caregiver to bring child to the hospital when

Other vaccines

child with cough and catarrh develops fast breathing



Instruct caregiver to increase frequency of feeding

Measles containing vaccine (including booster doses)

for the next 2 weeks after treatment for pneumonia.

BCG vaccine

Children with moderate to severe malnutrition

Pertussis vaccine (now in pentavalent vaccine used na-

should receive treatment advice according to stan-

tionwide; including booster doses)

dard guidelines

Measures to reduce risk factors

Drugs to Avoid in the Management of Pneumonia

Improved housing: improved ventilation, reduce over-

Cough syrups containing antihistamines or opioids

crowding and indoor air pollution

such as codeine, hydrocodeine, because they add little to

Improved nutrition

the management of pneumonia and may be toxic in

Exclusive breastfeeding for the first 6 months

some children

Micronutrients supplementation, including vitamin A

and zinc

Counselling/Health Education For CAP

HIV prevention – prevention of mother-to-child trans-

mission of HIV

Health education and guidance play important roles in

the management of children with CAP. Counselling

290

Future Research

Appendices

Appendix I: Lung Sound Nomenclature

Paucity or absence of recent data on various aspects of

Lung Sound Nomenclature Description

Term

childhood community acquired pneumonia in Nigeria

Discontinu-

Fine (high pitched, low

Fine crackles

makes it imperative for research strategies directed at

ous

amplitude, short dura-

(crepitations/Rhales)

filling the knowledge gaps in:

tion)

Coarse crackles

Viral contribution to aetiology of CAP

(crepitations/Rhales)

Bacterial super-imposition following an initial viral

Coarse(low pitched,

Coarse crackles

infection

high amplitude, long

(crepitations/Rhales)

Seasonal variations in the contribution of various

duration)

organisms to childhood community acquired pneu-

Continuous

Continuous, musical

Rhonchi

monia

sound heard during

expiration only or dur-

Contribution of Mycoplasma pneumoniae to child-

ing both phases of res-

hood community acquired pneumonia

piration

Severity grading of childhood community acquired

pneumonia

NB: Wheezes and Rhonchi may be heard in severe Pneumonia

Antibiotic resistance/sensitivity pattern of common

organisms causing community acquired pneumonia

Appendix II: Methods of Oxygen Delivery

Appropriate and relevant clinical scoring tool for

pneumonia

Usefulness of procalcitonin and C-reactive protein

in the diagnosis of CAP

Surveillance study on the prevalent pneumococcal

serotypes in CAP

10. Surveillance study on the prevalence and the role of

non-typeable Haemophilus influenzae in CAP

Acknowledgement

We wish to acknowledge the support received from San-

ofi and Roche Pharmaceuticals in facilitating the meet-

ings of the drafting committee and for organizing train-

ings for general practitioners across the country.

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