Name: ADDIELOU FIDELFIO E. ABAD Cluster No.

Institution: Mariano Marcos Memorial Hospital and Medical Center

Case Vignette

Ruel, a 2-year-old male child came in due to fast breathing. 5 days prior to admission, the
patient was noted with cough and colds. 3 days prior to admission, he developed
undocumented intermittent high-grade fever and was given Paracetamol 100mg/ml 1.2ml
every 4 hours with no relief. Patient was also started with Ambroxol syrup 2.5ml 2x a day
and Phenylephrine/Chlorpheniramine syrup 2.5ml 3x day by the mother. 1 day prior to
admission, the patient was noted with poor appetite with fast breathing.

Patient received primary immunization from the health center but missed the 3rd dose of
DPT/HIB/HEP B, OPV and PCV 13. Breastfed until 1year old. Had pneumonia at 6 months
old. Growth and developmental milestones are at par with age. Environmental exposure
includes smoking from both parents.

The patient was examined awake, irritable, weak-looking, in respiratory distress with the
following vital signs:
RR 58 bpm BP 90/60 mmHg
Temp 39.8C HR 120 bpm
CRT 4 seconds sO2 92% room air
Weight: 9 kg
Height: 80cm

Pertinent PE findings were pale palpebral conjunctivae, sunken eyeballs, alar flaring, dry
lips and buccal mucosa, with intercostal and subcostal retractions and crackles on both
lung fields. Other PE findings were unremarkable.

Chest X-ray: Infiltrates noted at the right lower lobe. Impression: Pneumonia

Complete Blood Count

Hemoglobin- 108
WBC- 16.11
Neutrophil- 9.43
Lymphocytes-2.0
Monocytes- 0.2
Eosinophils- 0.08
Platelet- 390
 Task 1. Patient- Centered Care

Based on the case given, provide the following information:

1. Criteria for the diagnosis of PCAP to include risk classification
Be able to identify applicable clinical variables in the case

Pediatric community-acquired pneumonia (PCAP) is considered in a patient who

presents with cough or fever, PLUS any of the following positive predictors of
radiographically-confirmed pneumonia:
1.1 3 months to 12 months old: ≥50 breaths per minute
1.2 >1 year old to 5 years old: ≥40 breaths per minute
1.3 >5 years to 12 years old: ≥30 breaths per minute
1.4 >12 years old: ≥20 breaths per minute
2. Retractions or chest indrawing
3. Nasal flaring
4. O2 saturation <95% at room air
5. Grunting

Pediatric community-acquired pneumonia (PCAP) is highly likely for the above case
due to the clinical signs and symptoms present in the patient as evident with the variables
being highlighted as bold.

The clinical case vignette that the patient was noted with cough and colds 5 days
prior to admission, developed undocumented intermittent high-grade fever 3 days prior to
admission and was noted with poor appetite with fast breathing 1 day prior to admission
supports the diagnosis of PCAP. The patient’s vital signs particularly the respiratory rate of
58 bpm, temperature of 39.8C, capillary refill time of 4 seconds and oxygen saturation
at 92% in room air substantiate the diagnosis. Moreover, pertinent PE findings which are
pale palpebral conjunctivae, sunken eyeballs, alar flaring, dry lips and buccal mucosa, with
intercostal and subcostal retractions and crackles on both lung fields are applicable
clinical variables to be considered in the case.

2. Action Plan. Provide clinical and ancillary parameters that will determine site of care
for this case.
 Patient is classified as having severe PCAP or high-risk for pneumonia-related
mortality based on the following clinical parameters and/or ancillary features highlighted in
the red boxes.

3. Treatment
A. Clinical and ancillary parameters that will determine the need for antibiotic
treatment
i. Elevated white blood cell count (WBC)
ii. Elevated C-reactive protein (CRP)
iii. Elevated procalcitonin (PCT)
iv. Imaging findings such as:
a. Alveolar infiltrates in chest radiograph;
b. Unilateral, solitary lung consolidation and/or air bronchograms
and/or pleural effusion in lung ultrasound

In our case, the clinical and ancillary parameters of elevated WBC (16.11) and the
presence of infiltrates noted at the right lower lobe determine the need for antibiotic
treatment.

B. Empiric Treatment if a bacterial etiology is considered

For patients classified as having severe PCAP, regardless of immunization status
against Streptococcus pneumoniae, any of the following is considered:
i. start Penicillin G at 200,000 units/kg/day Q6 if with complete Haemophilus
influenzae type b (Hib) vaccination OR Ampicillin at 200mg/kg/day Q6 if with no
or incomplete or unknown Haemophilus influenzae type b (Hib) vaccination
ii. start Cefuroxime at 100-150mg/kg/day Q8 OR Ceftriaxone at 75-100mg/kg/day
Q12 to Q24 OR Ampicillin-sulbactam at 200mg/kg/day Q6 (based on ampicillin
content) in settings with documented high-level penicillin-resistant
pneumococci or betalactamase-producing H. influenzae based on local
resistance data or hospital antibiogram
iii. add Clindamycin at 20-40mg/kg/day Q6 to Q8 when Staphylococcal
pneumonia is highly suspected based on clinical and chest radiograph
features. However, in cases of severe and life-threatening conditions such as
sepsis and shock, vancomycin at 40-60 mg/kg/day Q6 to Q8 is preferred.

In our case, Ruel will be started on Ampicillin at 200mg/kg/day Q6 since he missed the
3rd dose of DPT/HIB/HEP B.

4. Monitoring
A. Clinical and ancillary parameters that will determine good response to current
therapeutic management
Ruel, classified as having severe PCAP, good clinical response to current therapeutic
management is considered when clinical stability is sustained for the immediate past 24
hours as evidenced by any one of the following physiologic and ancillary parameters
observed within 24-72 hours after initiation of treatment:
i. Absence or resolution of hypoxia
ii. Absence or resolution of danger signs
iii. Absence or resolution of tachypnea
iv. Absence or resolution of fever
v. Absence or resolution of tachycardia
vi. Resolving or improving radiologic pneumonia
vii. Resolving or absent chest ultrasound findings
viii. Normal or decreasing CRP
ix. Normal or decreasing PCT

B. Clinical decision if patient is not responding to current therapeutic

 management
Ruel, classified as having severe PCAP and is not improving or clinically worsening,
within 24-72 hours after initiating a therapeutic management, diagnostic evaluation is
considered to determine if any of the following is present:
i. Coexisting or other etiologic agents
ii. Etiologic agent resistant to current antibiotic, if being given
iii. Other diagnosis
a. Pneumonia-related complication
a.1. Pleural effusion
a.2. Pneumothorax
a.3. Necrotizing pneumonia
a.4. Lung abscess
b. Asthma
c. Pulmonary tuberculosis
d. Sepsis

C. Clinical parameters for consideration of switch therapy in this case

Switch therapy is considered in this case when all of the following clinical parameters
are present:
i. Current parenteral antibiotic has been given for at least 24 hours
ii. Afebrile for at least 8 hours without the use of any antipyretic drug
iii. Able to feed and without vomiting or diarrhea
iv. Presence of clinical improvement as defined by ALL of the following:
a. Absence of hypoxia
b. Absence of danger signs
c. Absence of tachypnea
d. Absence of fever
e. Absence of tachycardia

5. Others
A. Adjunctive treatment for PCAP
i. Vitamin A is strongly recommended as adjunctive treatment for measles
pneumonia.
ii. Zinc is not considered as adjunctive treatment for severe PCAP as it does
not have any effect in shortening recovery time.
iii. Vitamin D is not considered as adjunctive treatment for severe PCAP as it
does not reduce the length of hospital stay.
iv. Bronchodilators are considered as adjunctive treatment for PCAP in the
presence of wheezing.
v. Mucokinetic, secretolytic, and mucolytic agents are not considered as
adjunctive treatment for PCAP.

B. Effective interventions for the prevention of PCAP

The following strategies are recommended to prevent PCAP:
a. Vaccination against Streptococcus pneumoniae (pneumococcus),
Haemophilus influenzae type b (Hib), Bordetella pertussis (pertussis), Rubeola
virus (measles) and Influenza virus
b. Breastfeeding
c. Avoidance of environmental tobacco smoke or indoor biomass fuel exposure
d. Zinc supplementation

C. Vaccinations applicable for this patient

Family Genogram
Task 2. Family- Focused Care

Looking at the genogram and the family life cycle stage, what are the possible problems this
family might have in caring for a patient with pneumonia? How can we help the family?

Family life cycle stage: Family with young children

Anticipated Problems Guidance and/or Interventions

Additional financial burden and increased Finding of other work opportunities
financial resources for medical needs, that can be a source of additional family
making it difficult for the family to meet income, but not compromising health
monetary demands of the medical condition of the main caregiver
condition especially antibiotic regimen for
pneumonia is somewhat costly
Risk of transmission since the family is Keep vaccination up-to-date
composed of 7 children
Coordination with Department of Education
for simple lecture and demonstration of
proper handwashing and cough etiquette
among elementary pupils
Lack of knowledge on the disease
progression and complication
Resistance in taking medications since the
index patient is a child
Overloaded mother’s role (Caregiver strain) Conduct psychosocial interventions
(e.g. psychoeducation interventions,
support groups and counselling) to
improve well-being and coping skills of
family carers and promote emotional
support
Task 3. Community-Oriented care

List down measures that can be implemented in your area with regards to diagnosis,
management and prevention among pediatric patients with pneumonia using the table
below.

Alternatives and/or
Area Barriers
Enhancers
 Lack of laboratory and  Conduct of consultative meeting
diagnostic services in the with the Local Chief Executive
RHU such as chest X-ray and other officials such as the
and complete blood count Sangguniang Bayan Member,
Chair of the Committee on
 Some patients opted to be Health on the re-alignment and
Diagnosis treated with medications re-allocation of the health budget
right away without to purchase laboratory facilities
laboratory examination
verbalized as “Bigyan mo
nalang ako ng gamot, Doc,
Sayang lang yung pang-
laboratory.”
 Non-adherence to treatment  Intensified education and
regimen or failure to counselling on the importance of
complete the antibiotic drug compliance for better health
regimen outcome
 Re-alignment and re-allocation of
the health budget to cover
antimicrobial drugs
 Referral to Department of Social
Welfare and Development for
financial and medical assistance
Management
 Presence of cultural health  Enhanced awareness campaign and
beliefs in the treatment of information dissemination (signs
diseases and symptoms, risk factors,
treatment, prevention and
 Lack of medical care complications) via IEC materials,
knowledge, impaired social media platform through
comprehension of medical infographics
information, lack of
knowledge about medical
conditions
Prevention  Scarcity of catch-up vaccines  Re-alignment and re-allocation of
in the health facility the health budget to cover catch-up
immunization doses and flu
vaccination

 Unhygienic practices among  Involvement of community workers

households on the barangay level and
coordination and partnership with
the Sanitary Inspector to facilitate
community health programs on
disease prevention such holding
lectures on handwashing and cough
etiquettes

 Coordination with the Municipal

 Inadequate nutrition to Nutrition Action Officer for the
improve children’s natural provision of vitamin supplements
defenses to children
 Conduct of lectures on exclusive
breastfeeding especially to first-
time moms

 Conduct counselling among

  Prevalence of large parents on smoking cessation
proportion of smokers in the using multi-behavioral and
area evidence-based interventions,
including avoidance of
secondhand and environmental
(passive) tobacco smoke
 Conduct of consultative meeting
with the Local Chief Executive
and other officials such as the
Sangguniang Bayan Member,
Chair of the Committee on
Health on the reinforced
implementation of smoking
cessation practices in the
locality
 Initiation of community dialogue
and community-based lectures on
the reduction of common risk
factors such as tobacco use
 Referral to smoking cessation
clinics

References:
1. 2021 Clinical Practice Guidelines in the Evaluation and Management of Pediatric
Community Acquired Pneumonia
2. Child and Adolescent Immunization Schedule. Available from
https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html
3. Growth Charts. Available from https://www.who.int/tools/child-growth
standards/standards/length-height-for-age