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CRISBERT I. CUALTEROS, M.D. Family and Medicine
Content of the new page

Clinical Practice Guidelines on

Pneumonia and

Respiratory Tract Infections

in Children



List of committee members 3

Foreword 4

Common Cold 5

Sore throat 6

Croup 10

Viral bronchiolitis 16

Pneumonia 21

References 29

Acknowledgment 36

List of Tables and Algorithms 37

Appendix 38




Dr. Azizi Hj Omar

Consultant Paediatrician and Paediatric Chest Physician

Damansara Specialist Hospital

Kuala Lumpur


Dr. Norzila Mohamed Zainudin

Consultant Paediatrician and Paediatric Chest Physician

Institut Pediatrik

Kuala Lumpur

Members (in alphabetical order)

Dr. Bilkis Banu Abd Aziz Dr. Koh Chong Tuan

Associate Professor Consultant Paediatrician

Department of Paediatrics Island Hospital

Hospital Universiti Kebangsaan Malaysia Penang

Kuala Lumpur

Dr. Mazidah Abdul Rasid Dr. M Paramjothy

Lecturer Consultant Paediatrician

Department of Paediatrics Assunta Hospital

Hospital Universiti Sains Malaysia Kuala Lumpur

Kubang Kerian, Kelantan

Dr. Noor Khatijah Nurani Dr. Wong Swee Lan

Consultant Paediatrician Consultant Paediatrician

Paediatric Unit Institut Pediatrik

Hospital Ipoh Kuala Lumpur

Dr. Patrick Chan Wai Kiong

Associate Professor

Department of Paediatrics

Pusat Perubatan Universiti Malaya

Kuala Lumpur



Pneumonia and other respiratory infections are the main causes of morbidity and

mortality among children worldwide. They occupy most of the consultation time at the

primary care as well as in the hospital setting. Managing these ailments imposes

enormous burdens on our resources. It is fitting that the most appropriate and costeffective

approaches are employed.

There are many controversial issues in the management of respiratory infections.

The use of antibiotics, cough suppressants, antihistamines, nasal decongestants, chest

physiotherapy, inhaled and systemic steroids, bronchodilators, adrenaline and oxygen are

the most important issues to be addressed. Issues regarding diagnosis and investigations

also require clarification. These guidelines attempt to address these issues by looking at

the evidence in the world literature and proposing evidence-based practices in the local

context. The epidemiology of respiratory infections and their sequelae in this part of the

world do certainly influence some aspects of these guidelines.

Five different syndromes are discussed, namely the common cold, sore throat, croup,

acute viral bronchiolitis and pneumonia. These are distinct syndromes that need to be

identified confidently by the attending clinician. The management of each of these

conditions is different and a misdiagnosis should be avoided.

The committee hopes that these guidelines will be used extensively at all levels of care.

Dr. Azizi Haji Omar

Dr. Norzila Zainudin



Key points

1. Correct identification of the common cold syndrome is important i n ensuring

appropriate treatment

2. Antibiotic therapy is not useful


The common cold is a highly infectious viral upper respiratory illness caused by over 100

different virus types

syndrome in children and treat appropriately.

1. It is important that clinicians correctly identify the common cold


The minimal symptoms that define the common cold syndrome are nasal discharge, nasal

stuffiness and throat irritation resulting in a cough. A purulent nasal discharge does not

necessarily indicate bacterial infection.

Infants are more likely to have an associated fever (38

and sleep difficulties. There is usually little or no fever in older children but they may

complain of myalgia, lethargy and anorexia.

The uncomplicated cold has a uniformly excellent outcome with illness duration of about

7 days. A persistent fever with worsening symptoms beyond 7 days may indicate

secondary bacterial infection. A lingering clear nasal discharge may persist fo r up to 2


0C or more) and experience feeding


None are required.


Antibiotic therapy is not useful. The common cold is usually a self- limiting illness and

no specific therapy is indicated. Common cold remedies often prescribed have not been

shown to provide any significant benefit and are generally not recommended

general measures that may help include

1. fever relief

2. nasal obstruction/stuffiness relief

3. frequent fluid intake/small frequent feeds

4. avoidance of environmental tobacco smoke

2,3. However,



Key points

1. Viruses remain the most common cause for sore throat. Group A

Streptococcus (GABHS) is responsible for 1 or 2 of 10 children with sore


2. Both throat culture and rapid antigen testing should not be routinely


3. A constellation of clinical features that allows presumptive treatment of a high

proportion of people with GABHS pharyngitis is recommended.

4. A 10-day course of penicillin is the drug of choice for the treatment of GABSH


5. The use of codeine preparation for the treatment of cough is strongly

discouraged in children and young infants. The sedative effects, potential for

serious toxicity and uncertain efficacy make anti-histamines an unsuitable

cold remedy for young infants

? -hemolytic


Sore throat encompasses the following clinical descriptions: acute pharyngitis, tonsillitis,

acute exudative tonsillitis and pharyngotonsillitis. These terms are treated as synonymous

for the purpose of this guideline.

Sore throat is uncommon in children le ss than 1 year of age. The incidence increases to a

peak at 4-7 years but continues throughout later childhood and adult life

Viruses remain the most common cause for sore throat

Streptococcus (GABHS), the most important bacterial cause of sore throat is accountable

for only 1 or 2 of 10 children with sore throat

1.1. Group A ? -hemolytic2.


Viral and bacterial (GABHS) pharyngitis have many similar signs and symptoms.

Conjunctivitis, rhinitis, cough, hoarseness, coryza, anterior stomatitis, discrete ulcerative

lesions, viral exanthem and diarrhoea strongly suggest a viral aetiology.


Table 1: Clinical features strongly suggestive of streptococcal pharyngitis





diffuse redness of the tonsils and pharyngeal exudates



tender, enlarged anterior cervical lymph nodes


conjunctivitis, cough.

absence of symptoms or signs suggesting viral pharyngitis eg. rhinorrhoea,


When a membranous exudate is present on the tonsils, consider diphtheria especially in

the under-immunized child, and infectious mononucleosis.

A syndrome of purulent nasal discharge, pharyngitis and persistent fever may be

associated with secondary infection with

complication of viral pharyngitis

S. pneumococcus or H. influenzae, a possible1.


Both throat culture and rapid antigen testing should not be carried out routinely in

patients with a sorethroat

Throat swabs are neither sensitive nor specific for serologically confirmed infections. The

sensitivity of Rapid Antigen Testing (RAT) measured against throat culture is wide and

varies between 61% - 95%, although specificity may be better at 88%-100%. Both

considerably increase cost and alter few management decisions.

The Center for Disease Control and American Academy of Pediatrics recommended that

the diagnosis of GABHS pharyngitis should be based on results of appropriate laboratory

tests in conjunction with clinical and epidemiological findings. Anti- microbial therapy

should not be given to a child with pharyngitis in the absence of evidence for GABHS or

other bacterial infection. Specific identification of GABHS infection before antibiotic

treatment of pharyngitis is however not practical in Malaysia. A constellation of clinical

features that allows presumptive treatment of a high proportion of people with GABHS

pharyngitis is therefore recommended



The complication rate is low in viral infection but secondary purulent bacterial otitis

media may occur.

With bacterial disease, suppurative complications are uncommon in young children and

include the following:

a. sinusitis

b. otitis media


c. cervical adenitis

d. peritonsillar abscess (quinsy)

e. retropharyngeal abscess

f. pneumonia.

Acute glomerulonephritis and rheumatic fever may follow streptococcal infections. It is

important to treat suspected GABHS pharyngitis with adequate dose and duration of the

appropriate antibiotics as acute rheumatic fever and rheumatic valvular heart disease are

still major health problems in Malaysia



General measures

1. Provide a full explanation of the likely course of the illness to the parents. The child

can be treated at home unless he/she is unable to drink, has stridor, or develops


2. Ensure adequate oral hydration.

3. Adequate analgesia is usually all that is required ie paracetamol.

Antibiotic therapy

Antibiotic therapy is not routinely required in all children with sore throat

antibiotics should not be withheld if the clinical condition is severe or GASBH is


early administration of appropriate antibiotic therapy

If GABSH pharyngitis is suspected, a 10 day course of penicillin is the treatment of


Infectious mononucleosis may present with severe sore throat, tonsillar exudates and

anterior cervical lymphadenopathy,. Ampicillin-based antibiotics, including coamoxiclavulanic

acid should be avoided as first line treatment

Table 2: Recommended antibiotic therapy in GABHS pharyngitis

Oral penicillin V 10-15mg/kg every 8 hours daily for 10 days or

Oral amoxicillin 25mg/kg every 8 hours daily for 10 days or

Oral ampicillin 25mg/kg every 6 hours daily for 10 days

1. However,5. Complications like rheumatic fever, otitis media and quinsy benefit from8.1,2,3,5,.5.



If compliance cannot be assured, give:

IM benzathine penicillin 600 000 units for children < 5 years

1.2 mega unit for children > 5 years


If patient is allergic to penicillin, use oral erythromycin succinate 15-25mg/kg every

12 hours for 10 days.

Other antibiotics namely macrolides and cepahalosporins have also been shown to be

effective and may be given for a shorter duration.

Adjunctive therapy

Relieve nasal congestion when it interferes with feeding. Saline nose drops may be tried.

Use of intranasal anti-decongestants in young infants less than 3 months of age are not


Oral antihistamines have been shown to provide a modest degree of symptomatic relief of

nasal congestion in adults. However, their sedative effects, potential for serious toxicity

and uncertain efficacy make anti- histamines an unsuitable cold remedy for young infants

The use of codeine preparation for the treatment of cough is strongly discouraged in

children and young infants.



Key points

1. Croup refers to a clinical syndrome characterized by barking cough,

inspiratory stridor, hoarse voice and respiratory distress of varying severity.

2. A routine neck radiograph is not necessary, unless the diagnosis is in doubt.

3. Steroid therapy is effective and should be routinely used in moderate - severe

viral croup.

4. Nebulised adrenaline may be used to provide rapid relief but its effect is



Croup affects children between 6 months to 6 years with the peak incidence between the

age of 1-2 years; usually involving twice as many boys than girls

vary between 3% to 50%, worldwide. About 15% of patients have a family history of


The most common aetiological agent is parainfluenza virus (74%) followed by

respiratory syncytial virus, influenza virus, adenovirus, enterovirus, measles, mumps and


cause the croup syndrome

Viral invasion of the laryngeal, tracheal and bronchial mucosa leads to inflammation,

hyperemia, edema, epithelial necrosis and shedding of this region. This leads to irritation

(cough), airway obstruction due to subglottic narrowing (biphasic stridor), collapse

supraglottic region (inspiratory stridor), and respiratory distress.

1, 2. Hospitalization rates3.Mycoplasma pneumoniae and Corynebacterium Diptheriae may rarely4.


The illness begins with a low- grade fever and a prodrome of cough and coryza for 12-72

hours followed by


increasingly bark-like cough and hoarseness


stridor that may occur when excited, at rest or both


respiratory distress of varying degree




iral croup is the commonest cause of acute onset stridor. However other conditions have

to be considered in the differential diagnosis (see algorithm 1)

Acute epiglotitis and bacterial tracheitis though very rare have occurred in Malaysian

children. Foreign body aspiration is a universal problem. Fatal cases of diphtheria have

recently been reported among un-immunised children in Selangor.

safe to visualise the pharynx to exclude acute epiglotitis, retropharyngeal abscess etc

5 Studies show that it is6.


Though essentially a benign self–limiting disease, complications occur in about 15% of

patients and include:


otitis media


secondary bacterial tracheitis




respiratory failure


The diagnosis is most importantly made on clinical grounds.

A routine neck radiograph is not necessary, unless the diagnosis is in doubt, such as in

the exclusion of a foreign body

Although not essential for diagnosis or management, the virus responsible can be isolated

from nasopharyngeal secretions with the isolation rate reported to be between 22% and


7.3 .


Assessment of severity

1. Clinical Assessment of Croup


a. Mild: Stridor with excitement or at rest, with no respiratory distress.

b. Moderate: Stridor at rest with intercostal, subcostal or sternal recession.

c. Severe: Stridor at rest with marked recession, decreased air entry and

altered level of consciousness.

2. Pulse oxymetry: This is helpful but not essential


3. Arterial blood gas is not helpful as the blood parameters may remain normal until the

late stage. The process of blood taking may distress the child.


Treatment of viral croup

The management of croup requires a calm and reassuring approach.


I Indications for hospital admission

1. Moderate and severe viral croup.

2. Toxic looking

3. Poor oral intake

4. Age less than six months

5. Unreliable caregivers at home

6. Family that lives a long distance from the hospital and lacks reliable transport

II Corticosteroid therapy


namely dexamethasone and nebulised budesonide in viral croup. There is significant

improvement in the following outcomes:

1. severity of symptoms

2. need for co- intervention with nebulised adrenaline

3. the number of patients admitted to hospital after treatment in emergency department

4. the number of patients requiring PICU care

5. number of children requiring intubation

6. duration of hospitalization .

Steroid therapy acts by both the anti-inflammatory and vasoconstrictive mechanisms.

Both oral dexamethasone and nebulised budesonide are equally effective and may even

be additive in their efficacy when given together. However oral dexamethasone is easier

and cheaper to administer

Budesonide is a synthetic glucocorticoid that is deposited in the upper airway; the point

of maximal inflammation in croup. It is effective within 1-2 hours of administration and

lasts as long as 24 hours

11 of several clinical studies have proven the efficacy of steroid therapy12 ,13.14.

III. Nebulised Adrenaline

While nebulised racemic adrenaline has been in use for the last 30 years, recent

randomised controlled trials have proven L- adrenaline to be equally effective

(known commonly as adrenaline) is available in Malaysia and many parts of

Asia. The recommended dose is 0.5 mg/ kg, to a maximum of 5mg of 1:1000


on within 30 minutes and lasts for about 2 hours. The recurrence of symptoms after 2

hours have on occasion been described as the “rebound phenomenon”; that will most

likely be less severe with the concomitant administration of steroid therapy. Nebulised

15. Only Ladrenaline16,17,18. Normal saline can be used as a diluent, if necessary. The effect comes


adrenaline should generally not be given to children with congenital cyanotic heart

disease especially those with right outflow obstruction.

IV Endotracheal Intubation

The use of steroid therapy and nebulised adrenaline in severe croup, where the sustained

action of steroids is combined with the quick action of adrenaline have reduced the rate

of intubation from about 3% to nil.

criteria and should be done under controlled conditions ie Operation Theatre or Paediatric

Intensive Care Unit, with anaesthesiologist and otolarnygologist in attendance.

11,18 The decision to intubate is made on clinical

V Oxygen Therapy

The indications for oxygen therapy include:

1. severe viral croup

2. percutaneous SpO

2 < 93%

Caution: With oxygen therapy, the SaO2 may be normal despite progressive

respiratory failure and a high PaCO2. Clinical assessment and vigilance remain

important in monitoring children with viral croup.

VI Antibiotic

It is not recommended unless secondary bacterial infection is strongly suspected or if the

patient is very ill and toxic- looking.

VII Intravenous fluids

They are not usually necessary except for those unable to drink.

VIII Mist Therapy

There is no evidence to support its use.

*Algorithm 2 is a summary of the treatment for viral croup.




Acute Stridor

Fever No Fever

Mild Fever

High Fever (>38.5)

Throat Normal Throat: bulging pharynx

Viral croup

Bacterial Tracheitis Diphteriae

Throat swollen epiglottis

Retrophryngeal abscess Acute Epiglotitis

History of choking History of Allergy

Normal throat

Foreign Body Angioneurotic edema

Age 6 mths-2


Age 1 -2 years

complicates LTB

Age <3 years


Bull neck

Age < 2years

Neck hyperextended


Age 3-7 years

Sudden onset


Prefers sitting

Age 6 mth - 4 years


Any age



Throat: grey exudate





Outpatient In patient Inpatient


Oral (1st choice)/Parenteral

0.15 kg/single dose

May repeat at 12 and 24 hours

Prednisolone 1-2 mg / kg/stat

or if vomiting

Nebulised Budesonide

2 mg single dose only



0.3-0.6 mg/kg single dose

and/ or

Nebulised Budesonide

2mg stat and 1 mg 12 hrly

Nebulised adrenaline

0.5 mg/kg 1:1000




0.3-0.6 mg/kg


Nebulised Budesonide

2mg stat, 1 mg 12 hrly



Nebulised adrenaline

No improvement/deteriorate

Intubate and ventilate



No improvement/deteriorate



Key Points

1. Respiratory syncytial virus is the most common cause of bronchiolitis in


2. Severe respiratory distress is more likely to develop in infants who have risk

factors namely prematurity, chronic lung disease, a very young age (less

than six weeks old) and congenital heart disease.

3. Supportive therapy and oxygen supplementation if necessary remain the

cornerstones of treatment.

4. A trial of nebulised bronchodilator therapy may be given but regular

assessment and vigilance during treatment is essential.

5. Chest physiotherapy, routine antibiotic and ribavarin therapy are not



Viral bronchiolitis is a common respiratory illness especially in infants between 1 to 6


bronchiolitis in Malaysia

periodicity with annual peaks occur, in the months of November, December and


1. Respiratory syncytial virus (RSV) remains the commonest cause of acute2,3,4. Although it is endemic throughout the year, cyclical5.


Viral bronchiolitis typically presents with a mild coryza, low grade fever and cough.

Tachypnoea, chest wall recession, whe eze and respiratory distress subsequently

develop. Parents usually report that the infant may sound “chesty” especially at night

and may appear breathless after feeding. The chest may be hyperinflated and

auscultation usually reveals fine crepitations and sometimes rhonchi.

The majority of children with viral bronchiolitis has mild illness and about 1% of these

children require hospital admission. Several categories of infants are at high risk of

developing severe disease (Table 4.1). Severe respiratory distress requiring paediatric

intensive care occurs in 5% of hospitalized children and 2% develop respiratory failure

requiring ventilatory support; overall mortality however remains low

Table 3: Categories of infants at high risk for severe respirator y distress


? ?

History of prematurity less than 36 weeks gestation

? ?

Congenital heart disease

? ?

Chronic lung disease


Underlying immunodeficiency


Age less than six weeks



A chest x-ray is not routinely required but recommended for children with severe

respiratory distress, unusual clinical features, an underlying cardiac or chronic

respiratory disorder and if intensive care is required. There is a wide range of

radiological changes seen in viral bronchiolitis; hyperinflation is most commonly seen,

segmental or lobar collapse/consolidation may be found.

Although not essential for diagnosis or management, respiratory viruses can be isolated

from nasopharyngeal secretions.


The decision to determine hospitalization in viral bronchiolitis is essentially clinical and

outlined in Table 4.

Table 4: Guideline for Hospital Admission in Viral Bronchiolitis

Home Management Hospital management

Age < than 3 months No Yes

Toxic – looking No Yes

Chest recession Mild Moderate/Severe

Central cyanosis No Yes

Wheeze Yes Yes

Crepitations on auscultation Yes Yes

Feeding Well Difficult

Apnoea No Yes

Oxygen saturation >95% <93%

High risk group No Yes

The distance between the home and primary health care facility, parental anxiety and

social circumstances should be taken into consideration when evaluating the child’s

need for hospital admission

The foundation of managing infants with acute bronchiolitis include vital physiological

monitoring (heart rate, respiratory rate, cutaneous oxygenation, level of consciousness),

adequate hydration, minimal handling and early recognition of complications especially

respiratory failure and its prompt treatment.


I Oxygen Therapy

Careful assessment of the respiratory status and oxygenation are the most critical

aspects of caring for children with viral bronchiolitis. Arterial oxygenation as

ascertained by pulse oxymetry (Sa0

and maintained above 93%; with the administration of supplemental humidified oxygen

if necessary

Clinicians must monitor for signs of impending respiratory failure including inability to

maintain satisfactory SpO

young infants are at risk of apnoea and require greater vigilance

2) should be performed for all infants at presentation11.2 on inspired oxygen of more than 40% or a rising PCO2. Very12.


Table 5: Modes of Oxygen Delivery to Infants

Intranasal oxygen 0.1 – 3 Liters/minute

Headbox oxygen 5 – 15 Litres/minute

Ventimask 5-8 Litres/ minute

High flow mask 5 – 15 Litres/minute

Positive pressure ventilation FiO

2 0.21 –1.0 %

II Nutrition and Fluid Therapy

Infants admitted with viral bronchiolitis frequently have poor feeding, are at risk of


children with moderate respiratory distress. Naso-gastric feeding, although not

universally practiced, may be useful in these children who refuse to feed and also to

empty the dilated stomach.

Intravenous fluids are given to children with severe respiratory distress, cyanosis and

apnoea. Fluid therapy should be restricted to maintenance requirement of 100 ml/kg/day

for infants, in the absence of dehydration.

13 and may be dehydrated. Small frequent feeds as tolerated can be allowed in

III Nebulised Bronchodilators

There is no definitive evidence to support the routine use of nebulised bronchodilators in

the treatment of viral bronchiolitis.

Data concerning the efficacy of

bronchiolitis remains inconclusive

adrenaline, which has both


bronchiolitis has been disappointing

Nonetheless, in view that pooled data have indicated a modest clinical improvement

with its use

infants with viral bronchiolitis. Vigilant and regular assessment of the child should be

carried out if such a treatment is provided.

ß2 agonist i.e. salbutamol in the treatment of viral14. Limited studies using nebulised racemica and ß2 agonist effects, appears superior to salbutamol or15, 16. The efficacy of anticholinergic agents i.e. ipratropium bromide in viral17, 18 .19, a trial of nebulised ß2-agonist, given in oxygen, may be considered in

IV Corticosteroid therapy

The role of corticosteroid therapy in acute bronchiolitis remains unresolved.

Randomised controlled trials of the use of inhaled steroids for treatment of viral

bronchiolitis demonstrated no meaningful benefit

of systemic corticosteroid showed possible benefits in infants with severe bronchiolitis

resulting in a reduction in the clinical scores and length of hospital stay

20. However a meta-analysis of the use21.


V Ribavirin therapy

Ribavirin is the only anti-viral agent approved for RSV bronchiolitis. However,

systematic review of the evidence of its efficacy does not support its use as


22. Ribavirin is not a registered drug in Malaysia.

VI Antibiotic therapy

Acute bronchiolitis is usually viral in origin. The risk of secondary bacterial infection in

children who has no underlying pulmonary or immune disorder is less than 2%

Although secondary infection is uncommon, dual infection with RSV and bacteria or

other organisms should be considered in the presence of atypical clinical or radiological

features. Antibiotic therapy is recommended for all infants with


? ?

recurrent apnoea and circulatory impairment,

? ?

possibility of septicaemia

? ?

acute clinical deterioration

? ?

high white cell count

? ?

progressive infiltrative changes on chest radiography.

VII Prevention

There is no effective RSV vaccine available.

Humanised RSV specific monoclonal antibody prophylaxis

Humanised RSV specific monoclonal antibody (Palivizumab

USA) prophylaxis when given during the expected annual RSV outbreak period has

been shown to be effective in reducing the incidence of hospitalization and severe

respiratory disease in infants in the “high risk” categories

administered at a dose of 15 mg/kg monthly during the RSV season namely from

November to January.

The recommended groups of children that will most benefit from prophylaxis include

1. Chronic lung disease

Children or infants less than 24 months of age who required medical treatment in the

last 6 months before the anticipated RSV season. Medical treatment includes

supplementary oxygen, corticosteroids, bronchodilators and diuretics.

2. Premature infants less than 32 weeks gestation without chronic lung disease

Infants less than 28 weeks gestation up to 12 months of age at the

start of the RSV season

Infants between 28 – 32 weeks gestation up to 6 months of age at the

start of the RSV season

Its use is generally not recommended in children with congenital heart disease.

@, Abbott Laboratories,25, 26. Prophylaxis is27:


Side effects are uncommon. Fever and discomfort at the site of administration may be

encountered. Routine immunization can be given as scheduled.

Prophylaxis is costly and there is no evidence to demonstrate cost -effectiveness with its

use as recommended in Malaysia.

VIII Sedation

It should not be used unless the infants is intubated and receiving positive pressure


IX Chest Physiotherapy

Infants with respiratory distress often show a fall in SaO

Minimal handling is an important aspect of care. Physiotherapy is not only of no benefit,

but may cause unnecessary and more importantly, acute deterioration resulting in


2 when handled or upset.28.



Key Points

1. Tachypnoea is the best single predictor of pneumonia in children of all ages.

2. Bacterial pneumonia cannot be reliably distinguished from viral pneumonia

on the basis of any single parameter; clinical, laboratory or chest radiograph


3. The age of the child, local epidemiology of respiratory pathogens and

sensitivity of these pathogens to particular microbial agents and the

emergence of anti-microbial resistance determine the choice of antibiotic


4. Anti-tussive remedies and chest physiotherapy should NOT be routinely

prescribed for children with pneumonia.


Acute respiratory infections namely pneumonia cause up to 5 million deaths

annually among children less than 5 years old in developing nations. Of the estimated

total of 12.9 million deaths globally in 1990 in children under 5 years of age, over 3.6

million were attributed to acute respiratory infections mostly due to pneumonia. This

represents 28% of all deaths in young children and places pneumonia as the largest

single cause of childhood mortality. In Malaysia the prevalence of ARI in children

below the age of five years is estimated to be 28% - 39.3%


Low birth weight, malnutrition, nasopharyngeal colonization, poor environmental

factors and tobacco smoke are risk factors for developing pneumonia. Two local studies

conducted in hospitalized children with acute lower respiratory tract infections

identified the following factors as risks for developing pneumonia

1.low weight for age

2.lack of breast feeding

3.failure to complete immunization

4.presence of coughing sibling (s) at home

5.overcrowding in bedroom


Clinical definition of pneumonia

There is no single definition for pneumonia. It is a clinical illness defined in terms of

symptoms and signs, and its course. WHO defines pneumonia in terms of febrile illness

with tachypnoea for which there is no apparent cause



There are two clinical definitions of pneumonia:

1. bronchopneumonia which is a febrile illness with cough, respiratory distress with

evidence of localised or generalised patchy infiltrates on chest x-ray

2. lobar pneumonia which is similar to bronchopneumonia except that the physical

findings and radiographs indicate lobar consolidation.


A specific aetiological agent cannot be identified in 40% to 60% of cases

pneumonia cannot be distinguished from bacterial pneumonia based on a combination of

clinical findings. The majority of lower respiratory tract infections that present for

medical attention in young children are viral in origin such as respiratory syncytial

virus, influenza, adenovirus and parainfluenza virus. One helpful indicator in predicting

aetiological agents is the age group as shown in Table 6.

Table 6: Pathogens causing pneumonia

6,7. Viral

Age Bacterial Pathogens

Newborns Group B streptococcus,

Escherichia coli, Klebsiella species,


1- 3 months

Chlamydia trachomatis


Streptococcus pneumoniae, Haemophilus influenzae type b,

Staphylococcal aureus

Less common: group A streptococcus,

Pseudomonas aeruginosa

,Moraxella catarrhalis,


Mycoplasma pneumoniae, Chlamydia pneumoniae


The clinical diagnosis of pneumonia has traditionally been made using auscultatory

findings such as bronchial breath sounds and crepitations in children with cough.

However, the sensitivity of auscultation has been shown to be poor and varies between

33 %- 60% with an average of 50 % in children.


Tachypnoea is the best single predictor in children of all ages.

tachypnoea is better compared with observations of retractions or auscultatory findings

10 Measurement of11

It is nonetheless important to measure respiratory rate accurately

should be counted by inspection for 60 seconds. However in the young infants,

pneumonia may present with irregular breathing and hypopnea.

12. Respiratory rate



Children with bacterial pneumonia cannot be reliably distinguished from those with

viral disease on the basis of any single parameter; clinical, laboratory or chest

radiograph findings.

1. Chest radiograph

Chest radiograph is indicated when clinical criteria suggests pneumonia. It will not

identify the aetiological agent. However the chest radiograph is not always necessary if

facilities are not available or the pneumonia is mild


2. Complete white blood cell and differential count

This test may be helpful as an increased white blood count with predominance of

polymorphonuclear cells may suggest bacterial cause. However, leucopenia can either

suggest a viral cause or severe overwhelming infection.


3. Blood culture

Blood culture remains the non-invasive gold standard for determining the precise

aetiology of pneumonia. However the sensitivity of this test is very low. Positive blood

cultures are found only in 10% to 30% of patients with pneumonia

patients with radiographic findings consistent with pneumonia, only 2.7% were positive

for pathogenic bacteria.

when there is poor response to the first line antibiotics.

4. Culture from respiratory secretions

It should be noted that bacteria isolates from throat swabs and upper respiratory tract

secretions are not representative of pathogens present in the lower respiratory tract.

Samples from the nasopharynx and throat have no predictive values.

should not be routinely done.

5. Other tests

Bronchoalveolar lavage is usually necessary for the diagnosis of

15. Even in 44% of16 Blood culture should be performed in severe pneumonia or6 This investigationPneumocystis carini

infections primarily in immunosuppressed children

and expertise are available.

If there is significant pleural effusion diagnostic, pleural tap will be helpful.

. It is only to be done when facilities

Mycoplasma pneumoniae, Chlamydia, Legio nella and Moxarella catarrhalis

difficult organisms to culture, and thus serological studies should be performed in

children with suspected atypical pneumonia. An acute phase serum titre of more than

1:160 or paired samples taken 2-4 weeks apart showing four fold rise is a good indicator


aged five years or older with pneumonia.

areMycoplasma pneumoniae infection. 17 This test should be considered for children



I Assessment of severity of pneumonia

The predictive value of respiratory rate fo r the diagnosis of pneumonia is age specific

(Table 7)

Table 7: Definition of Tachypnoea

Less than 2 months > 60 /min

2- 12 months > 50 /min

12 months – 5 years > 40/ min

Assessment of severity is essential for optimal management of pneumonia. Pneumonia

may be categorized according to mild, severe, very severe based on the respiratory signs

and symptoms (Table 8 and Table 9)


Table 8: Assessment of severity of pneumonia in infants below two months old.

Severe pneumonia Severe chest indrawing or fast breathing

Very severe pneumonia Not feeding


Abnormally sleepy or difficult to wake

Fever/ low body temperature

Hypopnea with slow irregular breathing

Table 9: Assessment of severity of pneumonia in children age 2 months to 5 years old

Mild Pneumonia Fast breathing

Severe pneumonia Chest indrawing

Very severe pneumonia Not able to drink




Adapted from WHO


II Assessment of oxygenation

The best objective measurement of hypoxia is by pulse oximetry which avoids the need

for arterial blood gases. It is a good indicator of the severity of pneumonia


III Criteria for hospitalization

Community acquired pneumonia can be treated at home. It is crucial to identify

indicators of severity in children who may need admission as failure to do so may result

in death. The following indicators can be used as a guide for admission.


1. Children aged <3 months whatever the severity of pneumonia.

2. Fever (>38.5

3. Rapid breathing with or without cyanosis

4. Systemic manifestation

5. Failure of previous antibiotic therapy

6. Recurrent pneumonia

7. Severe underlying disorders ( i.e. immunodeficiency, chronic lung disease )

0 C), refusal to feed and vomiting

IV Antibiotic therapy

When treating pneumonia clinical, laboratory and radiographic findings should be

considered. The age of the child, local epidemiology of respiratory pathogens and

sensitivity of these pathogens to particular microbial agents and the emergence of

antimicrobial resistance also determine the choice of antibiotic therapy (Table 10 and

Table 11) The severity of the pneumonia and drug costs have also a great impact on the

selection of therapy (Table 5.7).

The majority of childhood infections are caused by viruses and do not require any

antibiotic. However, it is also very important to remember that we should be vigilant to

choose appropriate antibiotics especially in the initial treatment to reduce further

mortality and morbidity.

Table 10: Susceptibility (%) pattern of

Streptococcus pneumoniae found in Malaysia 20

Antibio tic Susceptible Intermediate Resistance

Azithromycin 98.1 1.9

Cefuroxime 99.6 0.4

Chloramphenicol 95.1 1.5 3.4

Chlindamycin 9.2 0.4 0.4

Cotrimoxazole 86.4 3.9 9.7

Erythromycin 98.4 0.4 1.1

Penicillin 93.0 7.0

Tetracycline 78.2 0.8 21.0

Table 11: Predominant bacterial pathogens of children and the recommended

antimicrobial agents to be used.

Pathogens Antimicrobial agent

Beta- lactam susceptible

Streptococcus pneumonia

Penicillin, Cephalosporins

Haemophilus influenzae type b



Staphylococcus aureus



Group A Sreptococcus


Mycoplasma pneumonia


e Macrolides such as erythromycin and

Chlamydia pneumoniae


Macrolides such as erythromycin and

Bordetella pertussis


Table 12: Commonly used antibiotics and their dosages

Macrolides such as erythromycin and

Intravenous Antibiotics Dosages

Amoxycillin-Clavulanate Acid 10-25mg/kg/dose 8 hrly

Ampicillin -sulbactam 10-25 mg/kg/dose 8 hrly

Ampicillin 100mg/kg/day 6 hrly

C. Penicillin 25,000-50,000U/kg/dose 6 hourly

Cefuroxime 10-25 mg/kg/dose 8 hrly

Cefotaxime 25-50mg/kg/dose 8 hrly

Cloxacillin 25-50mg/kg/dose 6hrly

Co-trimoxazole (trimethoprim ) 4 mg/kg/dose 12 hrly

Erythromycin 7.5mg kg/dose 6 hrly

Oral Antibiotis Dosages

Azithromycin 10-15 mg/kg/day daily dose

Augmentin 114 mg 12 hourly (less than 2 years)

228 mg 12 hourly (more than 2 years)

Cefuroxime 125 mg 12 hourly (less than 2 years)

250 mg 12 hourly (more than 2 years)

Cotrimoxazole 4 mg/kg/dose 12 hourly

Cloxacillin 50mg/kg /dose 6 hourly

Erythromycin Estolate 7.5 mg/kg/dose 12 hour ly

Penicillin V 7.5 - 15 mg/kg/dose 6 hourly


I Antibiotic therapy

For inpatient management of children with severe pneumonia, the following antibiotic

therapy is recommended.

1st line


2nd line Cephalosporins : Cefotaxime, Cefuroxime, Ceftazidime,

? lactams drugs: Benzlypenicillin, Amoxycillin, Ampicillin,


3rd line Carbapenem: Imepenam

Others Aminoglycosides: Gentamicin, Amikacin

If there are no signs of recovery; especially if the patient remains toxic and ill with

spiking temperature for 48-72 hours, a 2

considered. If

is the appropriate choice

A child admitted to hospital with severe community acquired pneumonia must receive

parenteral antibiotics. As a rule, in severe cases of pneumonia, combination therapy

using a second or third generation cephalasporins and macrolide should be given.

nd of 3rd line antibiotic therapy need to beMycoplasma or Chlamydia species are the causative agents, a macrolide


infections and infection caused by Gram negative organisms such as

Klebsiella sp

are more frequently reported in malnourished children.

Staphyloccoccal infection

Staphylococcus aureus

infections in children. Nevertheless a high index of suspicion is required because of the

potential for rapid deterioration.

mortality rate

the presence of multilobar consolidation, cavitation, pneumatocoeles, spontaneous

pneumothorax, empyema and pleural effusion

intravenous cloxacillin (200mg/ for a longer duration and drainage of empyema

will result in good outcome in the majority of cases.

is responsible for a small proportion of acute respiratory21 It is chiefly a disease of infants with a significant22 Radiological features suggestive of Staphylococcal pneumonia include21,23. Treatment with high dose

II Supportive treatment

1. Fluid therapy

Oral intake should cease when a child is in severe respiratory distress. In severe

pneumonia, inappropriate secretion of anti-diuretic hormone is increased

is therefore uncommon. It is important that the child should not be overhydrated.

2. Oxygen therapy

Oxygen reduces mortality associated with severe pneumonia. It should be given

especially to children who are restless, tachypnoea with severe chest indrawing,

cyanosed or not tolerating feeds. The SpO

3. Anti-tussive remedies

It is not recommended as it causes suppression of cough and may interfere with airway

clearance. Adverse effects and overdosa ge have been reported

24, dehydration2 should be maintained above 95%.25


4. Chest physiotherapy

The function of chest physiotherapy is to assist in the removal of tracheobronchial

secretions resulting in an increase gas exchange and reduction in the work of breathing.

However, trials have found no clinically discernible benefit or impact of chest

physiotherapy on the course of illness in bronchiectasis, cystic fibrosis, pneumonia,

bronchiolitis, asthma, acute atelectasis, inhaled foreign body and post extubation


performed in pneumonia

26 There is no evidence to suggest that chest physiotherapy should be routinely


In children with mild pneumonia, their breathing is fast but there is no chest indrawing.

Oral antibiotics at an appropriate dose for an adequate duration is effective for treatment

27, 28, 29, 30, 31.

the child appears to deteriorate.

The mother is advised to return in two days for reassessment or earlier if



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We thank the following for their support:



Astra Zeneca



Table 1 Clinical features strongly suggestive of streptococcal pharyngitis

Table 2 Recommended antibiotic therapy in GABHS pharyngitis

Table 3 Categories of infants at high risk for sever respiratory distress

Table 4 Guideline for hospital admission in viral bronchiolitis

Table 5 Modes of oxygen delivery to infants

Table 6 Pathogens causing pneumonia

Table 7 Definition of tachypnoea

Table 8 Assessment of pneumonia in infants below 2 months

Table 9 Assessment of pneumonia in children aged 2 months to 5 years

Table 10 Susceptibility (%) pattern of

Table 11 Predominant bacterial pathogens of children and the recommended antimicrobial

agents to be used.

Table 12 Commonly used antibiotics and their dosages

Streptococcus pneumoniae found in Malaysia


Algorithm 1 Approach to differential diagnosis of acute onset stridor

Algorithm 2 Management of viral croup


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