Pneumonia (peds)

This page is for pediatric patients. For adult patients, see: pneumonia

Background

Death rates from pneumonia in children under 5 (2017).

Lobes of the lung with related anatomy.

• Most common site of infection in neonates

Bugs by Age Group

• Newborn
  • Group B streptococci
  • Gram-negative bacilli
  • Listeria monocytogenes
• 1-3 months
  • Streptococcus pneumoniae
  • Chlamydia trachomatis
  • Haemophilus influenzae
  • Bordetella pertussis
  • Staphylococcus aureus
• 3 months-5 years
  • S. pneumoniae
  • S. aureus
  • H. influenzae type b
  • Nontypeable H. influenzae
  • C. trachomatis
  • Mycoplasma pneumoniae
• 5–18 years
  • M. pneumoniae
  • S. pneumoniae
  • C. pneumoniae
  • H. influenzae type b
  • S. aureus

Clinical Features

Fever and tachypnea are sensitive but not specific

• Fever
• Cough
  • Productive cough is rarely seen before late childhood

Differential Diagnosis

Pediatric fever

• Upper respiratory infection (URI)
• UTI
• Sepsis
• Meningitis
• Febrile seizure
• Juvenile rheumatoid arthritis
• Pneumonia
• Acute otitis media
• Whooping cough
• Unclear source
• Kawasaki disease
• Neonatal HSV
• Specific virus
  • COVID-19 (peds)
    • MIS-C

Pediatric Shortness of Breath

Pulmonary/airway

• Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspirated foreign body
  • Asthma exacerbation

• Structural
  • Bronchopulmonary dysplasia
  • Choanal atresia
  • Neoplasm
  • Subglottic stenosis
  • Tracheoesophageal fistula
  • Tracheomalacia
  • Spontaneous pneumothorax

• Infectious
  • Bacterial tracheitis
  • Bronchiolitis (peds), URI
  • Croup
  • Epiglottitis
  • Pertussis
  • Pneumonia
  • Cystic fibrosis exacerbation

• Trauma
  • Rib fractures
  • Flail chest
  • Traumatic pneumothorax
  • Pulmonary contusion

• Other
  • Inhalation exposure
  • Meconium aspiration syndrome
  • Pulmonary edema
  • Pulmonary hypertension, cor pulmonale
  • Respiratory distress syndrome

Cardiac

• Congenital heart disease
• Vascular ring
• Cardiac tamponade
• Congestive Heart Failure (peds)
• Myocarditis (peds)

Other diseases with abnormal respiration

• Normal neonatal periodic breathing (misinterpreted by caregivers as abnormal)
• Brief resolved unexplained event
• Anemia
• Abdominal distension (e.g. SBO, liver failure
• Neonatal abstinence syndrome
• Decreased perfusion states
  • Pediatric shock
  • Sepsis (peds)
  • Dehydration (peds)
• Metabolic acidosis
  • Diabetic ketoacidosis (peds)
  • Inborn errors of metabolism
  • Salicylate toxicity
• CO Poisoning
• Diaphragm injury
• Renal Failure
• Electrolyte abnormalities
• Organophosphate toxicity
• Tick paralysis
• Fever (Peds)
• Panic attack
• Porphyria

Evaluation

CXR showing prominent wedge-shape area of airspace consolidation in the right lung, characteristic of bacterial pneumonia.

CT chest showing right sided pneumonia

Hepatization of the lung and dynamic air bronchograms present in patient with LLL pneumonia. Source: POCUS Atlas

Workup

Likely Outpatient

• Imaging
  • CXR, consider for:
    • Age 0-3mo (as part of sepsis workup)
    • <5yr with temperature >102.2, WBC >20K and no clear source of infection
    • Ambiguous clinical findings
    • Pneumonia that is prolonged or not responsive to antibiotics
• Consider rapid assays:
  • Covid-19
  • RSV
  • Influenza

Sick/Likely Inpatient

Above plus:

• CBC
• Chemistry
• Blood/nasal culture are low yield
  • In prospective study, 91 blood cultures needed for one positive result for CAP; but in ICU one child had bacteremia for every 24 cultures obtained, one for every 12 with parapneumonic effusion
  • consider for sicker ones, those with effusions
• IDSA does not support using initial serum procalcitonin levels to determine whether empiric antibiotics should be initiated.
  • Clinical judgement plus radiographic evidence alone should guide therapy (strong recommendation, moderate quality of evidence)

Diagnosis

• Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
• CXR
  • Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
  • May have negative CXR early in disease or in cases of dehydration; infiltrate may "blossom" after providing rehydration and repeat imaging
  • Well-circumscribed round/oval opacity (“round pneumonia”), usually in a posterior lower-lobe segment of children < 8 y; mimics a mass but clears with antibiotics
  • Absence of CXR findings does not preclude diagnosis; high clinical suspicion with adventitious breath sounds can be consistent with pneumonia despite negative imaging
  • Immunocompromised patients may not manifest radiographic evidence of pneumonia despite suggestive clinical findings
  • Clinical and radiographic findings do not necessarily correspond: the patient may be improving clinically despite having a worsening appearance on the CXR
• Ultrasound
  • Can be considered as an alternative to CXR
  • Sensitivity 82% and specificity 94% (adults)

Management

Newborn

• Hospitalized
  • Ampicillin (80-90mg/kg/day) + gentamicin +/- cefotaxime
    • Add vancomycin if MRSA a concern
    • Add erythromycin (12.g mg/kg QID) if concern for chlamydia
• Outpatient
  • Initial outpatient management not recommended

1-3 Month

• Hospitalized
  • Afebrile pneumonitis
    • Erythromycin (10 mg/kg q6) or Azithromycin (2.5 mg/kg q12)
  • Febrile pneumonia
    • Add Cefotaxime (200mg/kg per day divided q8h)
• Outpatient
  • Erythromycin OR Azithromycin PO

>3mo - 18 years

• Hospitalized (PICU/severely ill)
  • Cefepime (50 mg/kg/DOSE q8h) IV, AND
  • Vancomycin (15 mg/kg/DOSE q6h) IV, AND
  • Consider coverage for anaerobes if strong concern for aspiration
• Hospitalized (moderately ill)
  • Fully immunized: Ampicillin (50mg/kg/DOSE q6) IV (max: 2 g/DOSE)
  • Not fully immunized: Ceftriaxone (50 mg/kg/day q24h) IV (max: 2 g/DOSE)
• Outpatient
  • Amoxicillin (45 mg/kg/DOSE BID) x 5-7 days PO
    • Some studies have shown that 5 day course may also be adequate treatment
  • Alternative: Clindamycin OR Azithromycin OR Amoxicillin-clavulanate

Disposition

All Children less than 2 months should be hospitalized

Consider Admission For

• Age: <2-3 months old
• History of severe or relevant congenital disorders
• Immune suppression (HIV, SCD, malignancy)
• Toxic appearance/respiratory distress
• SpO2 <90-93%
• Vomiting/dehydration
• Unstable social environment

See Also

• Pneumonia (Main)
• Pediatric fever