Childhood Pneumonia — WHO IMCI Classification & Management
Pneumonia is the single largest infectious cause of under-5 mortality worldwide, killing over 7 lakh children annually. India carries approximately 20% of the global under-5 pneumonia burden. The WHO Integrated Management of Childhood Illness (IMCI) protocol standardises classification and treatment based on clinical signs — primarily fast breathing and chest indrawing — enabling even ANMs and ASHAs to identify and refer severe cases.
Pneumonia is inflammation of the lung parenchyma caused by infection — bacterial (Streptococcus pneumoniae, Haemophilus influenzae type b, Staphylococcus aureus), viral (RSV, influenza, parainfluenza, adenovirus, SARS-CoV-2), or atypical (Mycoplasma, Chlamydia). In India, bacterial pneumonia is more common in under-2 children, while viral and atypical pneumonia rise with age. Pneumonia kills more under-5 children than malaria, measles, and HIV combined.
Risk factors: malnutrition (especially severe acute malnutrition), indoor air pollution (biomass fuel), incomplete immunisation (no Hib, no PCV, no measles), low birth weight, exclusive breastfeeding not practised, overcrowding, parental smoking. Addressing these risk factors through NHM programmes (Hib in pentavalent vaccine, PCV since 2017, Mission Indradhanush, IFA supplementation) has reduced India's under-5 pneumonia mortality substantially.
| Category | Clinical Signs | Treatment Setting |
|---|---|---|
| No pneumonia (cough/cold) | No fast breathing, no chest indrawing | Home — symptomatic, follow up if worsening |
| Pneumonia | Fast breathing (age-specific cutoffs), NO chest indrawing | Oral Amoxicillin DT at home for 5 days |
| Severe pneumonia | Chest indrawing | Referral to hospital — injectable Ampicillin + Gentamicin |
| Very severe pneumonia | Any general danger sign (unable to drink, convulsions, lethargy, vomiting everything, stridor in calm child, SpO2 < 90%, severe malnutrition) | Urgent referral to hospital — IV antibiotics, oxygen |
Fast breathing cutoffs (WHO):
- Age < 2 months: ≥ 60 breaths/min
- Age 2-11 months: ≥ 50 breaths/min
- Age 12-59 months: ≥ 40 breaths/min
Assess every child with cough/difficulty breathing for:
- General danger signs: Unable to drink/breastfeed, vomiting everything, convulsions, lethargic/unconscious — if present, classify as very severe disease and refer urgently
- Chest indrawing: Lower chest wall moves IN during inspiration (suction). Note: Nasal flaring, grunting, head bobbing are additional signs of severe respiratory distress
- Fast breathing: Count for full 60 seconds when child is calm. Apply age-specific cutoff.
- Stridor: Harsh sound on inspiration — indicates upper airway obstruction (croup, epiglottitis, foreign body). If present in calm child, classify as very severe.
- Wheezing: Musical sound on expiration — indicates bronchospasm (asthma, bronchiolitis). Trial of rapid-acting bronchodilator may help.
- Cyanosis, grunting, nasal flaring: Signs of severe distress.
- SpO2 (if pulse oximeter available): < 90% on room air = severe hypoxaemia, oxygen required
- Chest X-ray: Not required for IMCI classification. Useful for complicated cases — lobar consolidation suggests bacterial; interstitial pattern suggests viral; pleural effusion, pneumatocele suggest staphylococcal.
Pneumonia (no severe signs):
- Oral Amoxicillin dispersible tablet (DT) — 25 mg/kg/day in 2 divided doses for 5 days (or 3 days in some countries). DT formulation preferred — easier administration, better absorption.
- Dose: age 2-11 months: 125 mg BD; age 12-59 months: 250 mg BD
- Paracetamol for fever; ensure feeding and fluids; advise mother to return immediately if danger signs develop
- Follow-up at 48 hours — if no improvement, reclassify and refer
Severe pneumonia (chest indrawing):
- Refer urgently to hospital. Pre-referral dose: IM/IV Ampicillin 50 mg/kg 6-hourly + Gentamicin 7.5 mg/kg OD
- Continue Ampicillin + Gentamicin for at least 5 days IV/IM, then switch to oral Amoxicillin to complete 7-10 days total
- Oxygen via nasal prongs or mask to maintain SpO2 ≥ 90%
- IV fluids if unable to feed — Dextrose 5% + Normal Saline, 100 ml/kg/day
Very severe pneumonia:
- IV Ampicillin (or Ceftriaxone 75 mg/kg OD if meningitis suspected) + Gentamicin
- If staphylococcal suspected (pneumatocele, empyema): add Cloxacillin or Vancomycin
- Oxygen, IV fluids, NG tube feeding if cannot eat
- Manage complications: pleural effusion (chest tube if empyema), pneumothorax (chest drain), ARDS (mechanical ventilation)
Treatment failure at 48 hours: Worsening signs, new signs, persistent fever — switch to second-line (Ceftriaxone) and investigate for complications (effusion, empyema, pneumothorax, TB, foreign body).
- Immunisation: Pentavalent vaccine (Hib) at 6, 10, 14 weeks; Pneumococcal Conjugate Vaccine (PCV) at 6, 14 weeks + booster at 9 months; Measles-Rubella at 9 and 15-18 months; Influenza vaccine annually for high-risk children
- Exclusive breastfeeding for first 6 months — reduces pneumonia risk by 50%
- Complementary feeding from 6 months, adequate calories and protein
- Vitamin A supplementation as per NIS — reduces pneumonia mortality
- Reduce indoor air pollution: LPG instead of biomass, ventilation, no smoking indoors
- Zinc supplementation for 10-14 days during diarrhoea — reduces future pneumonia episodes
- HIV-positive mothers: PJP prophylaxis with Cotrimoxazole from 6 weeks of age
Childhood pneumonia remains a leading killer despite cheap, effective interventions. For UPSC CMS aspirants, WHO IMCI classification, fast breathing cutoffs, and Amoxicillin DT dosing are essential clinical topics.