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Pneumonia in Children
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Pneumonia in Children
, Pediatric Pneumonia, Community Acquired Pneumonia in Children
See Also
Pneumonia
Pneumonia Management in Children
Respiratory Distress in Children with Pneumonia
Pediatric Early Warning Score
(
PEWS Score
)
Epidemiology
Incidence
Worldwide: 155 million cases annually (and 2 million deaths under age 5 years)
Pneumonia
is the most common cause of hospitalization in children
Immunization
(esp.
Prevnar
,
Hib Vaccine
) has dramatically cut the number of childhood
Pneumonia
hospitalizations
Pneumococcal Pneumonia
hospitalization cases dropped by half after
Prevnar
Vaccine
introduced
Olarte (2017) Clin Infect Dis 64(12): 1699-1704 [PubMed]
Causes
See
Pneumonia Causes in Children
Viral Pneumonia
accounts for 80% of cases in under age 2 year old children
Hospitalized Children
Viral Pneumonia
(66%)
Respiratory Syncytial Virus
(esp. under age 4 years)
Human
Rhinovirus
Adenovirus
(esp. age <2 years)
Human
Metapneumovirus
(esp. age <10 years)
Coronaviruses (includes
Covid19
)
Influenza Virus
Parainfluenza
Virus
Bacterial Pneumonia
(8%)
Atypical Pneumonia
(>3%)
Mycoplasma pneumonia
(esp. age >4 years old)
Chlamydia pneumoniae
(infants)
Streptococcus Pneumoniae
Staphylococcus aureus
Streptococcus Pyogenes
History
Age suggests cause and management
Immunization
s deficient
Streptococcus Pneumoniae
Haemophilus
Influenza
e
Pertussis
Recent hospitalizations
Nosocomial Pneumonia
Day care attendance
Viral Pneumonia
Contagious contacts
Viral Pneumonia
Mycoplasma pneumonia
Tuberculosis
Travel
Influenza
Severe Acute Respiratory Syndrome
(Asia)
Fungal Infection
Blastomycosis
Coccidioidomycosis
(Southwestern U.S.)
Histoplasmosis
(Ohio and Mississippi River Valleys)
Recent
Antibiotic
s
Consider
Antibiotic Resistance
(e.g. PRP)
Comorbid conditions
Cardiopulmonary disease (e.g.
Cystic Fibrosis
)
Immunodeficiency
(e.g.
Asplenic
)
Neuromuscular Disease
Possible Ingestion
Foreign Body Aspiration
Toxin Ingestion
Risk Factors
Young age
Male gender
Tobacco
exposure
Pollution exposure
Child care attendance
Malnutrition
Immunodeficiency
Anatomical airway anomalies
Underlying metabolic disorders
Precautions
Occult
Pneumonia
should be considered in the following cases
Fever
for more than 5 days (especially if over 39 C)
Leukocytosis
with
White Blood Cell Count
over 20,000
Abdominal Pain
Presenting complaint in 8.5% of patients, age 3 to 14 years old (esp age <5 years)
Vomiting
or
Diarrhea
is present in 27% of cases
Broder (2022) Crit Dec Emerg Med 36(1):11-2
Symptoms
Fever
Respiratory symptoms (see signs below)
Cough
Tachpnea
Dyspnea
Lethargy
Irritability
Decreased oral intake
Dehydration
(e.g. decreased
Urine Output
)
Vomiting
Diarrhea
Abdominal Pain
Signs
Pneumonia
unlikely without fever and
Tachypnea
Consider
Chlamydia trachomatis
Pneumonia
in under age 3 weeks if affebrile with
Staccato Cough
Consider
Mycoplasma pneumonia
in older children with malaise,
Sore Throat
, fever and indolent course
Findings highly suggestive of
Pneumonia
Fever
More commonly >101.3 F in
Bacterial Pneumonia
Cyanosis
Respiratory distress (one or more of the following)
Respiratory Distress in Children with Pneumonia
Tachypnea
Absence of tachpnea when fever is present has strong
Negative Predictive Value
Tachypnea
is common with fever and therefore has poor
Positive Predictive Value
Cough
Nasal flaring
Intercostal retractions
Grunting
Rales
Decreased breath sounds
Differential Diagnosis
See
Pneumonia
Head and neck disorders
Otitis Media
Rhinorrhea
Nasal Polyp
s
Pharyngitis
Upper Respiratory Infection
Respiratory conditions
Asthma
Bronchiolitis
Bronchitis
Labs
Efficacy
Tests that are helpful
Rapid viral
Antigen
s
Influenza Immunoassay
Covid19
PCR
RSV Test
Not indicated in classic presentations (obtain if unclear diagnosis)
Oxygen Saturation
(if respiratory distress)
Tests helpful in severe cases (low yield if moderate infection)
Gram Stain
Blood Culture
Tests possibly useful in retrospect (identify outbreak)
Mycoplasma pneumoniae
titer
Chlamydia pneumoniae
titer
Tests which are usually not helpful for diagnosis (but may be used for trending in the inpatient setting)
Complete Blood Count
(CBC)
C-Reactive Protein
(CRP)
Erythrocyte Sedimentation Rate
(ESR)
Labs
Inpatient
Rapid viral
Antigen
s
Influenza
test
RSV test
Covid19
PCR
Respiratory Panel
(consider)
Sputum Culture
and
Gram Stain
Difficult to obtain in children
Low yield
Blood Culture
and
Gram Stain
Identifies pathogen in 2 to 7% of hospitalized cases
Complete Blood Count
C-Reactive Protein
(CRP)
Erythrocyte Sedimentation Rate
(ESR)
Procalcitonin
Procalcitonin
<0.25 ng/ml suggests non-
Bacterial Pneumonia
(may reduce
Antibiotic
use)
Tsou (2020) Infect Dis 52(10): 683-97 [PubMed]
Stockmann (2018) J Pediatric Infect Dis Soc 7(1): 46-53 [PubMed]
Imaging
Chest XRay
Indications
Inpatient
Unclear diagnosis
Prolonged
Pneumonia
or not responding to
Antibiotic
s after 48 to 72 hours of treatment
Pneumonia
complications
Hypoxia
Findings
Lobar consolidation
More common in
Bacterial Pneumonia
May be seen in viral pneumona
Interstitial Infiltrate
s
More common in
Viral Pneumonia
May be seen in
Bacterial Pneumonia
Precautions
Chest XRay
is not needed to confirm
Pneumonia
in the outpatient setting
History and exam may be sufficient to make a
Pneumonia
diagnosis
Chest XRay
does not differentiate virus from
Bacteria
Significant overlap of xray findings in cases of
Pneumonia
,
Bronchiolitis
,
Asthma Exacerbation
Chest XRay
may be normal in early
Pneumonia
Chest XRay
may be abnormal for 3-6 weeks after diagnosis
Imaging
Other
Lung Ultrasound
(
POCUS
)
Detects lung consolidation,
Parapneumonic Effusion
, empyema
Sufficient to diagnose
Pneumonia
with good
Test Sensitivity
Jones (2016) Chest 150(1): 131-8 [PubMed]
Management
See
Pneumonia Management in Children
Disposition
See
Pneumonia Management in Children
Complications
Parapneumonic Effusion
See
Pneumonia
for other complications
Indications for drainage
Symptomatic
Pleural Effusion
s >10 mm on lateral XRay
Pleural Effusion
>1/4 of hemithorax
Prevention
Immunization
Primary Series
Rubeola
(
MMR Vaccine
)
Varicella Zoster Virus
Pertussis
(DTP
Vaccine
)
Haemophilus
Influenza
e
Vaccine
(Hib)
Pneumococcal Conjugate Vaccine
(
Prevnar
)
Booster and periodic
Vaccination
s
Influenza Vaccine
yearly
Pertussis
(
DTaP Vaccine
)
High risk infants
Palivizumab
(
Synagis
)
Pregnancy
Diphtheria
and
Pertussis
Vaccine
(
Tdap Vaccine
)
Given at 27 to 36 weeks in each pregnancy
Allows for passive
Immunity
for newborns
(2017) Obstet Gynecol 130(3): e153-7 [PubMed]
References
Bradley (2011) Clin Infect Dis 53(7): e1-52 [PubMed]
McIntosh (2002) N Engl J Med 346:429-37 [PubMed]
Nelson (2000) Pediatr Infect Dis 19:251-3 [PubMed]
Ostapchuk (2004) Am Fam Physician 70(5):899-908 [PubMed]
Smith (2021) Am Fam Physician 104(6): 618-25 [PubMed]
Stuckey-Schrock (2012) Am Fam Physician 86(7): 661-7 [PubMed]
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