Pneumonia (Children)

Original article by Tom Leach | Last updated on 28/5/2014
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Introduction

Pneumonia is an infection of the lungs, characterised by inflammation of the lung parenchyma and production of fluid in the alveoli.
 

It is technically a type of bronchitis (infection of the bronchi). The highest incidence of pneumonia is during infancy. This gradually decline with age, before rising again in older age groups.

  • In ½ of cases, no causatory organism is identified
  • Viral causes are more common in young infants
  • Bacterial causes are more common in older children
  • It is difficult to differentiate viral and bacterial pneumonia clinically
  • Viral disease fluctuates with the seasons (more common in winter), whilst bacterial disease is fairly constant all year round.
 

Pathogens tend to depend upon the age of the child:
Newborns

  • Organisms from mother’s genital tract: Streptococcus B, Gram-negative enterococci

Infants and young children

  • Viral – RSV is especially common
  • Bacterial –less common, but can include streptococcus pneumoniae, and haemophilus influenzae. Bordetella pertussis and chlamydia trachomatis are also sometimes seen.

Children over 5

  • Usually bacterial – mycoplasma pneumoniae, streptococcus pneumoniae, and chlamydia pneumoniae are the most common.

All ages – TUBERCULOSIS (Myobacterium Tuberculosis)

 

Risk Factors

  • Low birthweight
  • Vit A defiency
  • Non-breast fed
 

Clinical Features

Usually there is a preceding URTI, followed by :
  • Fever
  • SOB
  • Cough (may or may not be present)
  • Lethargy
  • Localised pain. Can be neck, chest or abdominal, and is particularly suggestive of pneumonia.
  • Tachypnoea
  • Nasal flaring
  • Chest hyperinflation
  • Wheeze
  • Consolidation – with associated dullness to percussion – a classic sign in adults, is not usually present in paediatric cases.
 
Although it is difficult to distinguish clinically between bacterial and viral infection, wheeze and hyperinflation are more typical of viral infection. Nasal aspirate samples may be taken to confirm or rule out any causatory organisms.
 
WHO guidelines for diagnosis
  • Cough
  • Fever
  • Tachypnoea
  • Head nodding
  • Chest recession
 

Investigations

CXRmay help to confirm the diagnosis, but cannot differentiate bacterial and viral causes.
  • CXR with cavities, fluid and air is usually caused by staphylococcus
  • Bluting of costophrenic recess – is a rare sign of effusion, known as parapneumonic effusion. This can be drained if needed. In some cases however, this can become an empyema, which is much more difficult to drain.
  • Most cases of parapneumonic effusion will resolve themselves. In cases that become empyemous, then a pigtail catheter, may be inserted, and urokinase administered through it to help break down any septic ‘lumps’. In some cases, surgery may be required.
 

Management

Most cases can be managed at home! This might include analgesia and careful monitoring.
Indications for admission:
  • O2 <93%
  • Tachypnoea
  • Grunting
  • Apnoea
  • Poor feeding
 
In hospital, additional management step may include:
  • O2 therapy
  • IV fluids - Be careful not to give too much, or you can end up with Inappropriate ADH secretion.
  • Physiotherapy is not useful
 
Dependent on the age of the child, severity of illness, and appearance of x-ray.
  • Newborns - Wide spectrum, IV antibiotics
  • Older Children - Often amoxicillin is the first line. Co-amoxiclav is used as second line, as well as in complicated, or special cases.
  • Age >5 - Amoxicillin first line. Erythromycin second line.
 

Prognosis

Prognosis is usually very good.
Most cases, even those with consolidation on x-ray will recover will no long term effects, and will not require follow up.
Cases that require follow up:
  • Any with empyema
  • Any with collapse
These should have a repeat x-ray at 4-6 weeks. However, even usually those with empyema will make a full recovery.