Indian J Pediatr 1987; 54 : 199-204 Pneumonia in the newborn O.N. Bhakoo Department of Pediatrics, Postgraduate Institute of Medical Education and Researeh, Chandigarh The studies reviewed in this paper have been made in India on babies looked after in hospital as indoor patients during the first four weeks of life. Some of the studies on hospital-born babies have the advantage of availability of detailed and accurate peri- natal history, closer observation and more definitive diagnosis. An attempt has been made to highlight the results of prospective studies. Understandably, this report is based on relatively more serious cases, who possibly couM not be looked after at home. Key words : Neonatal pneumonia Pneumonia during the neonatal period were most frequently encountered. In can be broadly classified under the follow- the only study in which congenital pne- ing headings. umonia was separately analysed, it was Congenital pneumonia. Most of them found to be commoner than pneumonia present during the first 72 hours of life. due to cross infection. 8 Since in these studies all the babies had not been followed Asph'ation pneumonia. It is mostly till the age of four weeks, the incidence due to aspiration of meconium-stained of pneumonia due to cross infection has liquor at birth or of feeds later on. probably been underestimated. Cross infection pneumonia. This is related to inadequate asepsis. Epidemiology Incidence The common predisposing factors asso- Aatopsy analysis among Indian studies ciated with neonatal pneumonia are showed that 26-0 to 34-6~o of all neonatal low birth weight (LBW), prematurity; deaths in the hospital were associated birth asphyxia, meconeum stained liquor; with pneumonia. 1-4 Reports on clinical duration of labour more than 24 hours; incidence of pneumonia during the neo- maternal fever during labour and delivery; natal period among hospital born babies prolonged rupture of membranes (PROM); have been summarised in Table I. foul smelling liquor; unclean vaginal Pneumonia occurred among 1.5-4.6% examinations (UVE) and baby on assisted of all live births. Aspiration pneumonias ventilation. Lower the weight of the baby, higher are his chances to develop infection. Reprint requests : Dr. O.N. Bhakoo, Professor of Pediatrics, Postgraduate Institute of Medical This vulnerability further increases in Education and Research, Chandigarh 160012. preterm or small-for-dates babies due to 199 200 THE INDIAN JOURNAL OF PEDIATRICS Vol. 54, No. 2 their poor immunological status. Pro- foul smelling liquor, unclean vaginal exa- longed rupture of membranes especially minations and prolonged labour have not if associated with prolonged labour and/ been evaluated in majority of the studies. or birth asphyxia leads to fetal infection Pneumonia may also occur during the and pneumonia. Vaginal examinations, course of septicemia any time during the without the use of gloves and other aseptic neonatal period. It may complicate hyaline measures, are frequently done by the membrane diseases. Infants requiring traditional birth attendants. Babies born endotracheal intubation and IPPR or to such mothers have been found to have ventilator care are at risk to develop higher incidence of infection and pneu- secondary pneumonia. However, of all monia during early neonatal period. 9 The predisposing factors, aspiration is the most relative incidence of different predis- common initiating pathogenetic mecha- posing factors as reportedin studies from nism. Infants vulnerable to aspiration our country has been described in Table II. are those having difficulty in swallowing It is surprising to note that some of the due to prematurity, birth asphyxia, illness important factors like maternal pyrexia, or congenital malformations like cleft Table 1. Incidence of neonatal pneumonia (%of live births) Place of study Chandigarh5 Lucknow6 New Delhi r Rourkela s (1984) (1985) (1981) (1980) Overall incidence 1" 7 1" 8 4" 6 1" 5 Meconium aspiration 1" 1 0" 6 I. 0 Excluded Other types of aspiration 0" 2 0" 5 ? 0" 1 Congenital pneumonia 0" 4 0" 7 3" 6 1" 1 Cross infection pneumonia 0.3 Table II. Epidemiology of neonatal pneumonia (~ of cases in whom factor was operating) Rourekela8 Chandigarh '~ New Delhi7 Lucknow6 Hydera- badt0 LBW (~.~2.5 kg) 37* 81 -- -- 70 Preterm 32 67 45 -- -- PROM 30 -- 26 -- -- Birth asphyxia 48 46 -- -- -- Mec. st. liquor Excluded 64 23 33 -- *Birth weight below 2.0 kg PROM=Premature rupture of membranes, Mec. st.--Meconium stained BHAKO0 : PNEUMONIA IN NEWBORN 2oi palate, macroglossia, glossoptosis eso- were encountered in a sizeable number of phageal atresia etc. cases. Late diagnosis leads to delay in treat- Bacteriology ment, resulting in high mortality. This can be reduced by early diagnosis, which There is only one study on the bacterio- is possible through anticipation and the logy of neonatal pneumonias from our use of rapid diagnostic techniques inclu- country. In this study of lung puncture ding radiology. aspirate of 50 cases of neonatal pneumonia, bacteria were grown from 29 cases. 10 The Anticipation or screening. Neonatal common bacteria grown during the first pneumonia can possibly be anticipated by week were staphylococcus aureus and the use of perinatal risk score 9 and gas- streptococcus while pneumococci were tric aspirates polymorph count at birth.n grown from 14 out of 16 positive cases Perinatal risk score was described by later during neonatal period. Such a us largely to anticipate infection during the preponderance of pneumococcal pneu - first few days of life. 9 Most of the serious monia during neonatal period is an unusual infection thus identified had pneumonia finding and needs confirmation from other as a prominent feature. This score needs centres. The common bacteria grown in to be evaluated for anticipating pneu- the blood culture of cases of neonatal monias occurring during the first three pneumonia at our hospital has been staphy- days of life and may be further simplified lococcus aureus, klebsiella aeruginosa for use by health workers in rural areas. and E coll. 5 No systematic viral studies The score has been described in the on neonatal pneumonia are available appendix. from our country. Table IH. Signs and symptoms in neo- natal pneumonia. ~ Diagnosis Syrup toms Signs and symptoms of neonatal pneu- Lethargy 72 monia are non-specific and vague in a Refusal of feed 46 large number of cases especially in con- Abdominal distension 46 genital pneumonia and among low birth Vomiting 18 Paralytic ileus 16 weight babies. Table III describes the Diarrhea 8 frequency distribution of various signs Umbilical sepsis 32 and symptoms as seen in 50 cases of pneu- Conjunctivitis 10 monia during the neonatal period.10 Signs Tachypnea was seen among only 60~o Taehypnea 60 cases and cough and retractions in only Cyanosis 40 36~o each. Apneic spells were encountered Cough 36 in 28~0. Many signs and symptoms seen Retractions 36 Apneac spells 28 were of non-respiratory nature e.g. lethargy Pulmonary hemorrhage 20 in 72~o, abdominal distension in 46~ and Convulsions 16 refusal to feed in 46~o etc. Again, compli- Meningitis 12 cations like paralytic ileus, pulmonary Note figures denote percentage of cases hemorrhage, convulsions and meningitis 202 THE INDIAN JOURNAL OF PEDIATRICS Vol. 54, No. 2 Gastric aspirate polymorph count done near the four corners and an area at the at birth is a good screening test for diag- centre of the smear. At least 200 cells are nosis of contaminated liquor and possibly counted and the polymorph cells (pus for congenital pneumonia. Lall et al cells) as a percentage of the total cell count have shown it to have a good correlation estimated. A polymorph count of above with early neonatal sepsis.lt The procedure 75~ is indicative of pneumonia and is carried out as follows. below 35~o is considered normal. Poly- The gastric contents should be aspira- morph count between 35-75~o is indeter- ted with sterile catheter and syringe within minate and may suggest possibility of in- one hour of birth. One drop of it fection. This is a quick and a reliable test is taken on a glass slide and mixed with and may be of particular value in our a drop of heparin. The material is spread country where good portable X-ray faci- out and stained with Leishman's stain. lities are not available at many places. The slide is studied under high power Difficulties in diagnosis of pneumonia magnification for polymorph cell count. during the neonatal period are three fold. These cells are counted in ten high power 1. Respiratory symptoms may be present fields and a mean count derived. A mean in the absence of pneumonia. E.g. Hyaline polymorph count of 6 or above is con- membrane disease, transient tachypnea sidered abnormal. Higher the count, more of the newborn, recovery period after is the risk for infection. Gram stain of a perinatal asphyxia, pneumothorax, con- similar smear can give some clue about the genital malformations etc. Differentiation offending bacteria. is possible with the help of history, clini- cal examination and radiology. 2. Differen- Earl), diagnosis of neonatal pneumonia tiation of infectious bronchopneumonia can be made by radiology, gastric aspirate from non infective aspiration pneumonia cytology1: and by some rapid diagnostic can be done from history, gastric aspirate tests like micro ESR, absolute neutrophil cytology and rapid diagnostic tests and count, Band count/Neutrophil count 3. Pneumonia associated with septicemia. ratio and C reactive protein.13,14 More In these cases signs and symptoms are definitive bacteriological diagnosis, which more general and non specific rather than may take 24-48 hours, can be made from related to respiratory tract. Radiology the culture of lung aspirate, blood and and gastric aspirate cytology may help tracheal laryngeal/nesopharangeal secre- in diagnosing pneumonia in such situa- tions. tions.12 It is important to state that the gastric aspirate cytology for diagnosis of neonatal Management pneumonia has to be done differently from that done as a screening test at birth Supportive care is as important as (vide supra)J 2 Here the gastric contents are specific care in determining the outcome aspirated after at least four hours fasting.