CLINICAL PROTOCOL Niger J Paed 2015; 42 (4):283 –292 Management of community acquired (CAP) in children: Clinical practice guidelines by the Paediatrics Association of Nigeria (PAN)

1Olowu A, 2Elusiyan JBE, 3Esangbedo D, 4Ekure EN, 4Esezobor C, 5Falade AG 5Osinusi K, 6Mukhtar-Yola M, 7Meremikwu M, 8Ibe B, 9Johnson WBR 10Oviawe O, 11Bastos I

1Department of Paediatrics, Ogun State Uuniversity, Ago-iwoye, 2Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Osun-State, 3Providence Hospital, Lagos, Nigeria, 4Department of Paediatrics, Lagos University Teaching Hospital, Lagos, 5Department of Paediatrics, University College Hospital, Ibadan, 6Department of Paediatrics, National Hospital, Abuja, 7Department of Paediatrics, University of Calabar, Calabar, 8Department of Paediatrics, University of Nigeria Teaching Hospital, Enugu, 9Department of Paediatrics, University of Ilorin, Ilorin, 10Department of Paediatrics, University of Benin, Benin City, 11Nursing 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. b. Duration of Pneumonia: Pneumonia can be classi- Pneumonia is the of parenchyma due fied as "acute" (less than two weeks duration) and to pathogenic micro-organisms such as bacteria, viruses "chronic". Chronic 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 c. 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- d. : 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 . 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. e. Bronchopneumonia: there are patchy changes in Classification of pneumonia the lung around the bronchi or . Pneumonia can be classified using several parameters: f. Interstitial pneumonia: this involves the areas in between the alveoli. It is more likely to be caused a. Source of infection: Community-acquired pneumo- by viruses or by atypical bacteria nia (CAP) and hospital acquired infection g. 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- areimportant 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 , S. aureus, S. pneumoniae, E. younger age groups. Furthermore, while 81% of deaths coli, and H. influenzaeare 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- 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 Abdulkarim et Staphylococcus aureus (23.9%), Klebsiellaspp al2013 (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) al2008 (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 al2005 S.pneumoniae (3), S. aureus (2), coliforms (2), H. influenzae (1), Proteus mirabilis (1), P. c. 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 1. 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 Factors 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. 2) membranes firewood burning, passive tobacco smoking , season Low birth Zinc deficiency Day care Low birth 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- 2. 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. creased work of breathing, cyanosis, auscultatory Overcrowding ficiency states heart disease 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 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- 1. Respiratory rates are best determined over a full 60- ciliary clearance and the cough reflex. Others include second period and inconsistencies require repeated humidification, , 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 2. 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 3. 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 4. 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 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 , cyanosis. Acceptable cut-off value for discontinuing pleural rub oxygen therapy is is SPO2 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- of cases, further investigations are uncalled for, espe- pneumonia cially in resource-poor countries. Chest deformity None None Plain chest radiograph is the commonest ancillary inves- Chest movement Diminished or absent Normal tigation for confirmation of CAP. Its main value is the Mediastinal shift None None identification of opacities in the chest radiograph. Indications for chest radiograph in CAP include: Vocal fremitus Increased Normal a. Presence of significant chest retractions Percussion note Dull Resonant b. Failure to respond to initial course of antibiotic ther- apy at 48 hours Breath sound Bronchial or vesicular Vesicular c. Suspected CAP with complications, e.g. pleural Added sound Crepitations (crackles) Crepitations effusion, (crackles) d. 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, ), lobar consolidation, atelecta- Step 4: Palpate for the position of the 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 1. 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/ 2. 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. 3. 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 4. 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.  SpO2 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- (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  A full blood count should be obtained for all chil- in our hospital setting is limited. dren with severe pneumonia or sick enough to be hospitalized. Recommendations for Management of Community  Because malaria is a common co-morbidity in this Acquired Pneumonia 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 Outpatients of children Inpatients

First line Alternatives* First line Alternatives*

<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 o  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 1. The fact that CAP is caused by micro-organisms.  If oxygen saturation is persistently <90% despite 2. 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. 3. 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 4. Immunization against the childhood diseases. Vac- cines that protect against pneumonia such as Pneu-  If the child has altered mental status 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 5. 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. 6. 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 7. 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 1. Viral contribution to aetiology of CAP (crepitations/Rhales) 2. Bacterial super-imposition following an initial viral Coarse(low pitched, Coarse crackles infection high amplitude, long (crepitations/Rhales) 3. 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- 4. Contribution of Mycoplasma pneumoniae to child- ing both phases of res- hood community acquired pneumonia piration 5. Severity grading of childhood community acquired pneumonia NB: Wheezes and Rhonchi may be heard in severe Pneumonia 6. Antibiotic resistance/sensitivity pattern of common organisms causing community acquired pneumonia Appendix II: Methods of Oxygen Delivery 7. Appropriate and relevant clinical scoring tool for pneumonia 8. Usefulness of procalcitonin and C-reactive protein in the diagnosis of CAP 9. 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.

References

1. Bachur R, Perry H, Harper MB. 4. Bradley JS, Byington CL, Shah 6. Falade AG, Ayede AI. Epidemiol- Occult pneumonias: empiric chest SS, Alverson B, Carter ER, Harri- ogy, aetiology and management of radiographs in febrile children son C, et al. The management of childhood acute community- with leukocytosis. Annals Emerg community-acquired pneumonia in acquired pneumonia in developing Med. 1999;33(2):166-73. Pub Med infants and children older than 3 countries--a review. Afr J Med PMID: 9922412. months of age: clinical practice Med sc. 2011;40(4):293-308. Pub- 2. Berman S, Simoes EA, Lanata C. guidelines by the Pediatric Infec- Med PMID: 22783679. Respiratory rate and pneumonia in tious Diseases Society and the 7. Falade AG, Lagunju IA, Bakare infancy. Arch Dis. Childhood. Infectious Diseases Society of RA, Odekanmi AA, Adegbola RA. 1991;66(1):81-4. PubMed PMID: America. Clin Infect Diseases Invasive pneumococcal disease in 1994857. Pubmed Central 2011;53(7):e25-76. PubMed children aged <5 years admitted to PMCID: 1793190. PMID: 21880587. 3 urban hospitals in Ibadan, Nige- 3. Black RE, Cousens S, Johnson 5. Community Acquired Pneumonia ria. Clin Infect Disease. 2009 HL, Lawn JE, Rudan I, Bassani Guideline Team, Cincinnati Chil- 1;48 Suppl 2:S190-6. PubMed DG, et al. Global, regional, and dren's Hospital Medical Center: PMID: 19191615. national causes of child mortality Evidence-based care guideline for 8. Fox B, Bull TB, Guz A. Innerva- in 2008: a systematic analysis. medical management of Commu- tion of alveolar walls in the human Lancet. 2010;375(9730):1969-87. nity Acquired Pneumonia in chil- lung: an electron microscopic PubMed PMID: 20466419. dren 60 days to 17 years of age. study. J. Anat 1980;131(Pt 4):683- Guideline 14, pp 1-16, December 92. PubMed PMID: 7216905. 22, 2005. Pubmed Central PMCID: 1233220. 291

9. Harari M, Shann F, Spooner V, 18. Leventhal JM. Clinical predictors 28. Rudan I, Boschi-Pinto C, Biloglav Meisner S, Carney M, de Campo J. of pneumonia as a guide to order- Z, Mulholland K, Campbell H. Clinical signs of pneumonia in ing chest roentgenograms. Clinical Epidemiology and etiology of children. Lancet. 1991 Oct 12;338 Pediatrics. 1982;21(12):730-4. childhood pneumonia. Bulletin (8772):928-30. PubMed PMID: PubMed PMID: 7140124. WHO. 2008; 86(5):408-16. Pub- 1681277. 19. Lodha R, Kabra SK, Pandey RM. Med PMID: 18545744. Pubmed 10. Harper SA, Fukuda K, Uyeki TM, Antibiotics for community- Central PMCID: 2647437. Cox NJ, Bridges CB, Advisory acquired pneumonia in children. 29. Rudan I, Nair H, Marusic A, Committee on Immunization Prac- The Cochrane database of system- Campbell H. Reducing mortality tices CDC, et al. Prevention and atic reviews. 2013;6:CD004874. from childhood pneumonia and control of influenza. Recommen- PubMed PMID: 23733365. diarrhoea: The leading priority is dations of the Advisory Committee 20. Mahabee-Gittens EM, Grupp- also the greatest opportunity. J. on Immunization Practices Phelan J, Brody AS, Donnelly LF, Global Hlth. 2013; 3(1):010101. (ACIP). MMWR Recommenda- Bracey SE, Duma EM, et al. Iden- PubMed PMID: 23826497. Pub- tions and reports : Morbidity and tifying children with pneumonia in med Central PMCID: 3700027. mortality weekly report Recom- the emergency department. Clini- 30. Rudan I, O'Brien KL, Nair H, Liu mendations and reports / Centers cal Pediatrics. 2005; 44(5):427- L, Theodoratou E, Qazi S, et al. for Disease Control. 2005 Jul 35. PubMed PMID: 15965550. Epidemiology and etiology of 29;54(RR-8):1-40. PubMed 21. Margolis P, Gadomski A. The childhood pneumonia in 2010: PMID: 16086456. rational clinical examination. Does estimates of incidence, severe 11. Harris M, Clark J, Coote N, this infant have pneumonia? JAMA morbidity, mortality, underlying Fletcher P, Harnden A, McKean 1998 28;279(4):308-13. PubMed risk factors and causative patho- M, et al. British Thoracic Society PMID: 9450716. gens for 192 countries. J. Global guidelines for the management of 22. McIntosh K. Community-acquired Hlth. 2013; 3(1):010401. PubMed community acquired pneumonia in pneumonia in children. The New PMID: 23826505. Pubmed Cen- children: update 2011. Thorax. England journal of medicine. 2002 tral PMCID: 3700032. 2011 Oct;66 Suppl 2:ii1-23. Pub- 7;346(6):429-37. PubMed PMID: 31. Singhi S, Dhawan A, Kataria S, Med PMID: 21903691. 11832532. Walia BN. Validity of clinical 12. Izadnegahdar R, Cohen AL, Klug- 23. Morley CJ, Thornton AJ, Fowler signs for the identification of pneu- man KP, Qazi SA. Childhood MA, Cole TJ, Hewson PH. Respi- monia in children. Annal Trop pneumonia in developing coun- ratory rate and severity of illness Paediatrics. 1994;14(1):53-8. tries. Lancet Respiratory Med. in babies under 6 months old. Arch PubMed PMID: 7516135. 2013 Sep;1(7):574-84. PubMed Dis. Childhood. 1990; 65(8):834- 32. Tagbo O, Uchenna O, Anthony H. PMID: 24461618. 7. PubMed PMID: 2400218. Pub- Childhood parapneumonic pleural 13. Johnson WBR AA. Childhood med Central PMCID: 1792484. effusion in Enugu. Niger Post- pneumonia in developing coun- 24. Nair H, Simoes EA, Rudan I, graduate Med J. 2005;12(1):28- tries. Afr J Resp Med. 2013;8(2):4- Gessner BD, Azziz-Baumgartner 32. PubMed PMID: 15827593. 9. E, Zhang JS, et al. Global and 33. Taylor JA, Del Beccaro M, Done 14. Johnson AW, Osinusi K, Aderele regional burden of hospital admis- S, Winters W. Establishing clini- WI, Gbadero DA, Olaleye OD, sions for severe acute lower respi- cally relevant standards for tachyp- Adeyemi-Doro FA. Etiologic ratory infections in young children nea in febrile children younger agents and outcome determinants in 2010: a systematic analysis. than 2 years. Arch Ped. Adolesc of community-acquired pneumonia Lancet. 2013: 20;381(9875):1380- Med. 1995;149(3):283-7. PubMed in urban children: a hospital-based 90. PubMed PMID: 23369797. PMID: 7858688. study. J National Med Assoc. Pubmed Central PMCID: 34. United Nations Children’s Fund/ 2008;100(4):370-85. PubMed 3986472. World Health Organization. Pneu- PMID: 18481475. 25. Oviawe O OH. Respiratory rate monia: The forgotten killer of 15. Jona JZ, Belin RP. Basilar pneu- thresholds in children with varying children. A publication of UNI- monia simulating acute appendici- severity of pneumonia. Int Child CEF/WHO 2006. Date accessed tis in children. Arch Surg. Hlth. 1993;4:67-70. 09/08/2013. 1976;111(5):552-3. PubMed 26. Redd SC, Patrick E, Vreuls R, 35. Walker CL, Rudan I, Liu L, Nair PMID: 1267602. Metsing M, Moteetee M. Compari- H, Theodoratou E, Bhutta ZA, et 16. Juven T, Mertsola J, Waris M, son of the clinical and radiographic al. Global burden of childhood Leinonen M, Meurman O, diagnosis of paediatric pneumonia. pneumonia and diarrhoea. Lancet. Roivainen M, et al. Etiology of Trans Royal Soc Trop Med Hyg. 2013: 20;381(9875):1405-16. community-acquired pneumonia in 1994;88(3):307-10. PubMed PubMed PMID: 23582727. 254 hospitalized children. Ped PMID: 7974671. 36. World Health Organization pocket Infect Disease J. 2000;19(4):293- 27. Rudan I, Tomaskovic L, Boschi- book for hospital care for children. 8. PubMed PMID: 10783017. Pinto C, Campbell H, Group Second edition. 2013. 17. Kim PE, Musher DM, Glezen WP, WHOCHER. Global estimate of Rodriguez-Barradas MC, Nahm the incidence of clinical pneumo- WK, Wright CE. Association of nia among children under five invasive pneumococcal disease years of age. Bulletin WHO 2004; with season, atmospheric condi- 82(12):895-903. PubMed PMID: tions, air pollution, and the isola- 15654403. Pubmed Central tion of respiratory viruses. Clin PMCID: 2623105. Infect Diseases. 1996; 22(1):100- 6. PubMed PMID: 8824973. 292

37. Zukin DD, Hoffman JR, Cleveland 38. Abdulkarim AA, Ibraheem RM, RH, Kushner DC, Herman TE. Adegboye AO, Johnson WBR, Correlation of pulmonary signs Adeboye MAN. Childhood pneu- and symptoms with chest radio- monia at the University of Ilorin graphs in the pediatric age group. Teaching Hospital, Ilorin Nigeria. Annal Emerg Med. 1986;15 Niger. J. Paed 2013; 40(3): 284- (7):792-6. PubMed PMID: 289 3729100.