9.2 Cough, Fast Breathing & Pediatric Pneumonia

Cough, Fast Breathing & Pediatric Pneumonia

Pneumonia remains the single largest infectious cause of death among children under five years of age in Kenya and across sub-Saharan Africa. The vast majority of these deaths occur due to late clinical presentation, failure to recognize fast breathing and chest indrawing, inappropriate antimicrobial selection, and lack of oxygen therapy in primary health settings.

The IMCI guidelines and the Kenya Basic Paediatric Protocols provide a streamlined, highly sensitive syndromic framework designed to detect pneumonia early and distinguish between mild viral upper respiratory infections, outpatient-manageable bacterial pneumonia, and life-threatening severe lower respiratory disease requiring urgent inpatient hospitalization.

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1. Etiology & Risk Factors in Kenya

Pediatric community-acquired pneumonia (CAP) in sub-Saharan Africa involves both bacterial and viral pathogens, often occurring as polymicrobial co-infections:

• Bacterial Pathogens: Streptococcus pneumoniae (pneumococcus) remains the predominant bacterial pathogen across all post-neonatal age groups, despite the significant success of the 10-valent pneumococcal conjugate vaccine (PCV-10 / PCV-13) introduced into Kenya's routine schedule at 6, 10, and 14 weeks. Non-typeable Haemophilus influenzae and Haemophilus influenzae type b (Hib, dramatically reduced by the pentavalent vaccine) are also significant. Staphylococcus aureus (often causing necrotizing pneumonia, pneumatoceles, and pyopneumothorax) and Klebsiella pneumoniae are frequently encountered in young infants, severely malnourished children, and hospital-acquired infections.
• Viral Pathogens: Respiratory Syncytial Virus (RSV, the primary cause of infant bronchiolitis), Human Rhinovirus, Parainfluenza viruses, Influenza A and B, and Adenovirus.
• Atypical / Immunocompromised Pathogens: Pneumocystis jirovecii (PJP/PCP) and Mycobacterium tuberculosis (TB) are critical considerations in HIV-exposed, HIV-infected, or severely malnourished children.
• Key Vulnerability Factors: Lack of exclusive breastfeeding in the first 6 months, indoor air pollution from household biomass fuels (wood, charcoal, kerosene), incomplete routine vaccinations, household overcrowding, prematurity, and zinc/vitamin A deficiencies.

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2. Clinical Assessment of the Child with Cough

A sick child presenting with cough or difficulty breathing must undergo a systematic physical examination adhering to three critical rules:

1. Count the Respiratory Rate for a Full 60 Seconds

• Pre-requisite: The child MUST be calm and resting quietly (ideally resting on the caregiver's lap or asleep). Crying, agitation, feeding, or acute fever significantly elevate the respiratory rate and lead to false-positive diagnoses.
• Technique: Uncover the child's chest and observe the respiratory excursions (upward and downward movements of the abdomen and lower ribs). You must count for a full 60 seconds (one complete minute) using a timer or wristwatch. Do not count for 15 or 30 seconds and multiply, as periodic breathing and irregular respiratory patterns are common in young infants.
• Age-Specific Cut-Offs for Fast Breathing:

2. Look for Lower Chest Wall Indrawing

• Technique: Lower chest wall indrawing is present when the lower bony rib cage moves inward (retracts) as the child breathes in (inspiration), while the abdomen expands outward.
• Clinical Significance: Indrawing indicates significant loss of lung compliance (stiff lungs) and marked work of breathing. It signifies severe lower respiratory tract disease (alveolar consolidation or severe bronchiolar obstruction).
• Diagnostic Trap: Do not confuse lower chest wall indrawing with soft-tissue intercostal recession (indrawing between the ribs) or subcostal skin movement seen during crying or deep respiration in healthy thin infants. True lower chest wall indrawing involves the bony ribs moving inward and is present consistently in a calm, resting child.

3. Listen for Stridor and Wheezing

• Stridor: A harsh, high-pitched, vibrating sound heard predominantly on inspiration. It originates from extrathoracic upper airway narrowing at the laryngeal, subglottic, or tracheal level (e.g., viral croup, foreign body aspiration, retropharyngeal abscess, or diphtheria). The clinician must distinguish between stridor heard only when the child is crying/agitated versus stridor at rest in a calm child (a sign of critical airway compromise).
• Wheezing: A musical, continuous, whistling or polyphonic sound heard predominantly on expiration, resulting from intrathoracic lower airway narrowing (bronchospasm, mucosal edema, or luminal secretions in bronchiolitis or reactive airway disease/asthma).
• IMCI Wheeze Protocol: If a child has fast breathing or chest indrawing accompanied by audible wheezing, administer a rapid-acting inhaled bronchodilator (Salbutamol 100 μg MDI via spacer, 2 to 4 puffs, repeated up to 3 times at 15-minute intervals). Reassess the child after bronchodilation:
  • If fast breathing and indrawing disappear -> classify as Wheezing / Asthma / Bronchiolitis.
  • If fast breathing or chest indrawing persists despite bronchodilation -> classify and treat as Pneumonia or Severe Pneumonia.

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3. IMCI Pneumonia Classification & Treatment Algorithm

IMCI CLASSIFICATION FOR COUGH OR DIFFICULTY BREATHING:

[Any General Danger Sign?]
  OR [Lower Chest Wall Indrawing?]
  OR [Stridor at Rest in Calm Child?]
  OR [Oxygen Saturation SpO2 < 90%?]
        ├── YES ──► PINK: SEVERE PNEUMONIA OR VERY SEVERE DISEASE
        │           • Emergency hospitalization
        │           • Parenteral antibiotic (Ampicillin + Gentamicin or Ceftriaxone)
        │           • Oxygen therapy if SpO2 < 90%
        │           • Prevent hypoglycemia and hypothermia
        │
        └── NO
             │
             ▼
      [Fast Breathing?]
      (≥50/min if 2–11 months; ≥40/min if 12–59 months)
        ├── YES ──► YELLOW: PNEUMONIA
        │           • Outpatient oral Amoxicillin dispersible tablets
        │           • 40–45 mg/kg/dose twice daily for 5 days
        │           • Home fluids and continued feeding
        │           • Mandatory follow-up in 3 days
        │
        └── NO ───► GREEN: NO PNEUMONIA (COUGH OR COLD)
                    • NO antibiotics
                    • Soothing home fluids (warm water, breastmilk, honey if >1 year)
                    • Clear blocked nose with saline drops
                    • Counsel mother on danger signs; review in 5 days if not improving

Detailed Management Protocols

1. Severe Pneumonia or Very Severe Disease (Pink Category)

• Inpatient Admission: Mandatory urgent admission to a hospital with pediatric inpatient beds and reliable oxygen delivery.
• Parenteral Antimicrobial Therapy (Kenya Basic Paediatric Protocols):
  • First-line Inpatient Regimen: IV/IM Ampicillin (50 mg/kg every 6 hours) combined with IV/IM Gentamicin (7.5 mg/kg once daily) for 5 to 7 days.
  • Alternative / Pre-Referral Regimen: IV/IM Ceftriaxone (80–100 mg/kg once daily), particularly if the child cannot be admitted immediately or is referred from a Level 2/3 facility.
  • Suspected Staphylococcal Pneumonia (severe illness, rapid deterioration, pneumatoceles, skin pustules): Add IV Cloxacillin (50 mg/kg every 6 hours) to Gentamicin.
• Oxygen Therapy:
  • Indicated immediately for any child with SpO2 < 90%, central cyanosis, severe chest indrawing, respiratory rate ≥ 70/min, or grunting.
  • Delivered via nasal prongs at 0.5–1.0 L/min for infants and 1.0–2.0 L/min for older children (titrated to maintain SpO2 ≥ 92%).
• Supportive Fluid Balance: Restrict maintenance intravenous fluids to two-thirds (60–70%) of normal daily requirements during the acute phase. Severe pneumonia causes high circulating antidiuretic hormone (ADH) levels (SIADH), predisposing the child to fluid overload and pulmonary edema.

2. Pneumonia (Yellow Category - Outpatient)

• First-Line Oral Antibiotic: Oral Amoxicillin Dispersible Tablets (DT).
  • Dosage: 40 to 45 mg/kg per dose twice daily (total daily dose = 80 to 90 mg/kg/day) for 5 full days.
  • High-dose amoxicillin is mandatory to overcome intermediate penicillin resistance in Streptococcus pneumoniae.
  • Dispersible tablets dissolve rapidly (within 60 seconds) in 5–10 mL of clean water or breastmilk, ensuring accurate dosing without refrigeration.

• Caregiver Counseling & Home Care:
  • Demonstrate how to dissolve the tablet in clean water or breastmilk; supervise the administration of the first dose in the clinic.
  • Emphasize finishing the complete 5-day course, even if the child appears fully recovered after 2 days.
  • Provide supportive home care: offer small, frequent nutritious meals, increase fluid intake, and clear nasal secretions.
• Mandatory Follow-Up Review in 3 Days (72 Hours):
  • Reassess: Count respiratory rate, check temperature, and assess for danger signs.
  • If improved (slower breathing, fever resolved, eating well): Congratulate caregiver; ensure completion of the 5-day course.
  • If unchanged or worse (fast breathing persists, new chest indrawing, general danger sign appears): Classify as treatment failure / Severe Pneumonia; immediately administer parenteral ceftriaxone and refer to hospital.

3. Cough or Cold / No Pneumonia (Green Category)

• NO ANTIBIOTICS: Simple viral upper respiratory tract infections (common cold, pharyngitis, viral bronchitis) must never be treated with antibiotics. Indiscriminate antibiotic prescribing accelerates community antimicrobial resistance, causes diarrhea, and offers zero therapeutic benefit.
• Soothing Home Remedies:
  • Encourage warm, safe fluids: warm water, light soup, or continued frequent breastfeeding.
  • Honey: Highly effective for relieving night cough and soothing irritated pharyngeal mucosa in children older than 12 months (1 teaspoon [2.5–5 mL] as needed).
  • Absolute Safety Contraindication: Honey is strictly contraindicated in infants under 12 months of age due to the fatal risk of infant botulism caused by ingestion of Clostridium botulinum endospores colonizing the infant's immature gastrointestinal tract.
  • Avoid over-the-counter (OTC) commercial cough syrups, antihistamines, and decongestants (no proven efficacy, risk of sedation and respiratory depression).
• Caregiver Education on Danger Signs:
  • Advise the mother to bring the child back immediately if the child develops fast breathing, difficult breathing, inability to drink, vomiting everything, or convulsions.
  • Scheduled follow-up in 5 days if the cough has not improved.