- Bhawya Banga

    Pneumonia is one of the dreadful acute respiratory infections. If not treated in time, Pneumonia can prove fatal for children. Acute respiratory infections (ARI) are one of the major causes of death of infants and children under the age of five years. Majority of the respiratory infections are self-limiting. However, pneumonia is a serious life threatening illness with high fatality rate unless treatment is started early. This is generally not well understood by the parents and episodes of cough and cold among children are taken as usual occurrences which will cure with time. At times parents remain busy in their routine daily activities and tend to postpone taking the child to the health worker or a doctor. This results in serious consequences because the time between onset of pneumonia in a young infant and development of complications and death may be as little as 2-3 days. It has to be understood that all episodes of cough and difficulty in breathing in a small child should be taken seriously and the child should be taken for treatment immediately. At the health centres also, it is the duty of health workers to treat such cases or refer them to the hospitals promptly.

    ARI is often classified by clinical syndromes depending on the site of the infection and is referred to as ARI of the upper (AURI) or lower (ALRI) respiratory tract. Upper respiratory tract infections (AURI) include common cold, pharyngitis and otitis media. Lower respiratory tract infections (ALRI) include epiglottitis, laryngitis, bronchitis, bronchiolitis and pneumonia. Majority of ARI deaths in children are due to pneumonia. Children with pneumonia are generally present with symptoms of cough or/and difficult breathing.

    Timely and correct treatment and referral can save most cases of pneumonia in young children. Deaths due to pneumonia generally occur because of three reasons -

i) Children come for treatment, but come too late;

ii) Children do not come for treatments;

iii)Children come for treatment but receive poor treatment.

    ARI is an acute infection of any part of the respiratory tract and related structures including paranasal sinuses, middle ear and the pleura cavity. Majority of the ARI episodes are self-limiting. However, pneumonia is a serious life-threatening illness with high case fatality rates. In a child with cough or difficulty in breathing, pneumonia is indicated by fast breathing. Fast breathing and chest in-drawing or chest in-drawing alone are the signs of severe pneumonia. These signs have been found to be reliable and more sensitive than auscultation with a stethoscope for the purposes of diagnosis of pneumonia.

    Fast breathing is present when the respiratory rate is 60 or more in a child less than 2 months old, 50 or more in a child 2 to 12 months old and 40 or more in a child 12 months to 5 years old.

    Chest in-drawing is defined as a definite inward movement of the lower chest wall while breathing in (inspiration). For observing chest in-drawing, the child should be made to lie flat in the bed or in the mother’s lap. A child is said to have a definite chest in-drawing only if it is persistent. Whenever there is chest in-drawing (with or without fast breathing), severe Pneumonia should be inferred.

    Malnutrition when present is a high risk factor and case fatality rates are higher in such children. In severely malnourished children with pneumonia, fast breathing and chest in-drawing may not be as evident as in other children. A severely malnourished child may have an impaired or absent response to hypoxia and a weak or absent cough reflex. These children need careful management.

    Catrimoxazole is the drug of choice for the treatment of pneumonia. Studies carried out in India have confirmed the efficacy of catrimoxazole to be similar to ampicillin and procaine penicillin and cure rates up to 95 per cent have been recorded. Cotrimoxazole is less expensive with few side effects and can be used safely by health workers at the peripheral health facilities and at home by mothers. Cotrimoxazole has been included as one of the drugs provided to the sub-centres in the drug kit ‘A’ under the RCH Programme and health workers have been trained under the CSSM Programme for recognition of signs of pneumonia and treatment of simple cases and referral of severe cases.

    Children who have pneumonia should be treated with cotrimoxazole. The condition of the child should be assessed after 48 hours. Cotrimoxazole should be continued for another 3 days in children who show improvement in the clinical condition. If there is no significant change in condition (neither improvement nor worsening), cotrimoxazole should be continued for another 48 hours and condition reassessed. If the condition worsens during these 48 hours and chest in-drawing or other signs of severe illness ( inability to drink, excessive drowsiness, convulsions or cyanosis) appear, the child should be hospitalised immediately.

    Although, commercially available drugs are expensive, these are still widely used. Such drugs generally do not have clinical efficacy and some are even harmful and may give false sense of security to parents. Many commercial drugs contain mixtures of antihistamine, cough suppressant, oral decongestant and expectorants. These may sedate the child or interfere with her feeding and her ability to clear secretions. Medicated nose drops can cause systemic toxic affects (because the medication is absorbed) and when stopped the child can have nasal discharge again (rebound rhinorrhoea). These drugs should not be used.

Majority of the cases of pneumonia do not need in-patient care and can be treated at home. Even children who may be hospitalised have to be taken care of by the mothers at home after discharge. The mother plays a key role in the treatment of the child with cough and cold. It is, therefore, very important that the mother understands the basic principles of home treatment.

    Therefore the mother should learn to handle the patient child. As a part of treatment of a child it is the duty of health workers and medical officers to advise mothers on mangement at home. Mothers must be advised on how to give the antibiotic in proper dosage and give adequate feeding including breastfeeding in younger children. Since the child may not take food willingly, small and frequent feeds should be advised. The moment she is able to recognise the danger signs, she must bring the child for treatment. Failure to recognise the signs may cost the child its life. She should be explained the danger signs which include difficult and rapid breathing, chest in-drawing, refusal of feeds (in infants), eating or drinking poorly, excessive sleepiness and convulsions. In such cases, the treatment must be started immediately with a doctor or the child should be taken to a hospital.

    The infants do not contact pneumonia, for this some basic precautions must be observed. Mothers should keep infants warm and away from draught. As far as possible, excessive breast-feeding should be given to child up to four months age. DPT and measles vaccination should be administered to children at appropriate age. Washing hands before touching and feeding the child is also important. Also remind the mother of the immunization schedule and the prophylactic doses of Vitamin A so that these are completed in time. If mothers are educated along the points, the health of children is better taken care of.

    The feature is based on the material provided by Ministry of Health & Family Welfare.