Pediatric Pneumonia


Article Author:
Chiemelie Ebeledike


Article Editor:
Thaer Ahmad


Editors In Chief:
Allison Castro


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
1/7/2019 11:54:00 AM

Introduction

Globally, pneumonia is a leading cause of morbidity and mortality in children younger than the age of 5 years.[1] Although the majority of deaths attributed to pneumonia in children are mostly in the developing world, the burden of disease is substantial, and there are significant healthcare-associated costs related to pneumonia in the developed world.[2]

Etiology

The etiology of pneumonia in the pediatric population can be classified by age-specific versus pathogen-specific organisms.[3] Neonates are at risk for bacterial pathogens present in the birth canal, this includes organisms such as group B streptococci, Klebsiella, Escherichia coli, and Listeria monocytogenes.[4][5][6] Streptococcus pneumonia, Streptococcus pyogenes, and Staphylococcus aureus can be identified in late onset neonatal pneumonia.[4] Viruses are the main cause of pneumonia in older infants and toddlers between 30 days and 2 years old.[7] In children 2 to 5 years old, respiratory viruses are also the most common.[8][9] The rise of cases related to S. pneumoniae and H. influenza type B is observed in this age group.[10][11] Mycoplasma pneumonia occurs frequently in children in the range from 5 to 13 years old[12][13]; however, S. pneumoniae is still the most common identified organism.[8] Adolescents usually have the same infectious risks as adults. It is important to consider tuberculosis (TB) in immigrants from high prevalence areas, and children with known exposures. Children with chronic diseases are also at risk for specific pathogens. In cystic fibrosis, pneumonia secondary to S. aureus and Pseudomonas aeruginosa are ubiquitous.[14] Patients with sickle cell disease are at risk of infection from encapsulated organisms.[15] Children who are immunocompromised should be evaluated for Pneumocystis jirovecci, cytomegalovirus, and fungal species if no other organism is identified.[16] Unvaccinated children are at risk for vaccine-preventable pathogens.

Epidemiology

There are an estimated 120 million cases of pneumonia annually worldwide, resulting in as many as 1.3 million deaths.[3] Younger children under the age of 2 in the developing world, account for nearly 80% of pediatric deaths secondary to pneumonia.[17] Prognosis of pneumonia is better in the developed world, with fewer lives claimed, but the burden of disease is extreme with roughly 2.5 million cases yearly.[18] Approximately a third to half of these cases lead to hospitalizations.[18]

Pathophysiology

Pneumonia is an invasion of the lower respiratory tract, below the larynx by pathogens either by inhalation, aspiration, respiratory epithelium invasion, or hematogenous spread.[19] There are barriers to infection that include anatomical structures (nasal hairs, turbinates, epiglottis, cilia), and humoral and cellular immunity.[19] Once these barriers are breached, infection, either by fomite/droplet spread (mostly viruses) or nasopharyngeal colonization (mostly bacterial) results in inflammation and injury or death of surrounding epithelium and alveoli. This is ultimately accompanied by a migration of inflammatory cells to the site of infection, causing an exudative process which in turn impairs oxygenation.[20] In the majority of cases, the microbe is not identified and the most common cause is of viral etiology.

History and Physical

In many cases, complaints associated with Pneumonia are non-specific, including cough, fever, tachypnea, and difficulty breathing.[21] Young children may present with abdominal pain. Important history to obtain includes the duration of symptoms, exposures/travel, sick contacts, baseline health of the child, chronic diseases, recurrent symptoms, choking, immunization history, maternal health or birth complications in neonates.[22]

Physical exam should include observation for signs of respiratory distress including tachypnea, nasal flaring, lower chest in-drawing, or hypoxia on room air.[21] Note that infants may present with reported inability to tolerate feeds, grunting or apnea. Auscultation for rales or rhonchi in all lung fields with the appropriately sized stethoscope can also aid in diagnosis. In the developed world, other adjuncts like laboratory testing and imaging can be a helpful part of the physical exam. No isolated physical exam finding can accurately diagnose pneumonia.[23] However, the combination of symptoms including fever, tachypnea, focal crackles, and decreased breath sounds together raises the sensitivity for finding pneumonia on x-ray.[23] Pneumonia is a clinical diagnosis that should take into consideration the history of present illness, physical exam findings, adjunct testing, and imaging modalities.

Evaluation

Laboratory evaluation in children suspected of having pneumonia should ideally start with non-invasive, rapid bedside testing including nasopharyngeal swab assays for influenza, respiratory syncytial virus and human metapneumovirus when available and appropriate. This can help minimize unnecessary imaging and antibiotic treatment in children with influenza or bronchiolitis. Children who present with severe disease and appear toxic should have complete blood count (CBC), electrolytes, renal/hepatic function testing, and blood cultures performed.[24] These tests are generally not required in children who present with mild disease. Inflammatory markers do not help distinguish between viral and bacterial pneumonia in the pediatric population.[24][25] However, these tests may be obtained to trend disease progression and serve as prognostic indicators. Children who have been in areas endemic to TB, or have exposure history, and present with signs and symptoms suspicious for pneumonia should have sputum samples or gastric aspirates collected for culture.

There are no clear guidelines for, routine use of chest x-ray in the pediatric population.[24] Although the chest x-ray can be helpful in diagnosis/confirmation of pneumonia,[26] it carries with it risks including radiation exposure, healthcare-associated costs, and false-negative results increasing the use of unwarranted antibiotics. Imaging should be restricted to children who appear toxic, those with the recurrent or prolonged course of illness despite treatment, infants age 0 to 3 months with a fever, suspected foreign body aspiration, or congenital lung malformation. Imaging can also be considered in children younger than 5 years old, who present with fever, leukocytosis, and no identifiable source of infection.[26] Imaging may also be useful in those with acute worsening of upper respiratory infections or to rule out underlying mass in children who have "round pneumonia."[27][28]

Treatment / Management

Treatment should be targeted to a specific pathogen that is suspected based on information obtained from history and physical exam. Supportive and symptomatic management are key and include supplemental oxygen for hypoxia, antipyretics for fever, and fluids for dehydration. This is especially important for non-infectious pneumonitis and viral pneumonia for which antibiotics are not indicated.[21][29] Cough suppressants are not recommended.

If bacterial pneumonia is suspected, treat empirically with antibiotics, keeping in mind significant history and bacterial pathogens that are common to specific age groups.

Neonates should receive ampicillin plus an aminoglycoside or third-generation cephalosporin[21][30], however, not ceftriaxone, as it can displace bound bilirubin and lead to kernicterus.

Atypical pneumonia is common in infants 1 to 3 months old, and this group should have additional antibiotic coverage with erythromycin or clarithromycin.[21][30]

For infants and children over 3 months old, S. pneumoniae is the most common, for which the drug of choice is high-dose oral amoxicillin[21][30] or another beta-lactam antibiotic.

In children older than 5 years old, atypical agents have a more important role, and macrolide antibiotics are usually first-line therapy.[21]

Special attention should be given to children with chronic illnesses as these might alter choices for antibiotics[21]. Children with sickle cell anemia will need cefotaxime, macrolide, vancomycin if severely ill. Children with cystic fibrosis will require piperacillin or ceftazidime plus tobramycin. Treat fulminant viral pneumonia as indicated depending on the virus identified. ForVaricella, use acyclovir and for respiratory syncytial virus (RSV), use ribavirin for high-risk patients. Patients with HIV should be treated with sulfamethoxazole/trimethoprim and prednisone, and for Cytomegalovirus, ganciclovir and gamma globulin are the preferred agents. If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, clindamycin or vancomycin may be given.

It is important to have a high index of suspicion for complications, especially in patients returning for repeat evaluation. For patients sent home with symptomatic or supportive management for suspected viral pneumonia, consider a secondary bacterial infection or other diagnosis upon re-evaluation.[31] Children with uncomplicated bacterial infections who fail to respond to treatment within 72 hours should be assessed for complications including pneumothorax, empyema, or pleural effusion.[32] Other systemic complications of pneumonia include sepsis, dehydration, arthritis, meningitis, and hemolytic uremic syndrome.

Neonates and infants younger than 90 days old should be hospitalized for treatment, in addition to children who are immunocompromised or have other underlying chronic diseases like sickle cell anemia or cystic fibrosis.[21] Children with social factors that preclude access to care, have failed outpatient therapy, or present with presumed tuberculosis, should also be hospitalized.[33]

It is essential to ensure that clear discharge instructions and return precautions are given to parents or caregivers of children being discharged home in addition to close pediatrician follow-up.

Enhancing Healthcare Team Outcomes

Healthcare professionals including physicians, nurses, PAs/NPs, pharmacists ideally work together in close environments for optimum patient care. When caring for children with pneumonia, pharmacists can be of significant help with geographic resistance patterns for better treatment outcomes with selected antibiotic choices.


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Pediatric Pneumonia - Questions

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What is the most common cause of pneumonia in immunocompetent infants of 2 to 12 months of age?



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An infant of an unremarkable pregnancy presents at 4 days of age with a fever, tachypnea at 72 breaths per minute, jaundice, and poor feeding. The cardiac exam is normal. Pulmonary exam shows crackles. Chest x-ray shows a right lower lobe infiltrate. What is the most appropriate treatment?



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An 18-month previously healthy male is diagnosed with pneumonia with a parapneumonic effusion. The patient is hypoxic and appears toxic. Thoracentesis is done and blood cultures are drawn. Which of the following antibiotics should be started?



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An 18-month-old is admitted for pneumonia with empyema. Which of the following would be the most appropriate treatment?



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An 18-month-old African American child is brought in with a 3-day history of cough and fever. He has been taking fluids but is not hungry. The only medication his parents have given him is acetaminophen. He has no significant past medical or travel history. Exam shows temperature of 38.5 degrees Celsius, clear mucosa, dullness to percussion over the left lung with rhonchi, but no rashes or cardiac findings. Chest x-ray shows a left lower lobe infiltrate and opacification of the left lower half of the lung. What comorbidity should be considered?



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What are the most common causes of bacterial pneumonia in neonates?



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What is the expected presentation of a child with atypical pneumonia due to Mycoplasma pneumoniae infection?



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A 4-year-old child presents to triage in the emergency department with fever, chills, and a cough. On physical exam, fine crackles are heard at the left base. The nurse suspects pneumonia. Which of the following is associated with pneumonia in children?



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A 5-year old child is hospitalized on a medical unit for pneumonia. The child had an oxygen saturation of 88% on admission prior to the administration of oxygen at 1 L/min per nasal cannula. The child seems to be improving. The nurse should do which of the following (select all that apply):



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Pediatric Pneumonia - References

References

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