Pneumonia (peds)

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

Background

• 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
• Pneumonia
• Acute otitis media
• Whooping cough
• Unclear source
• Kawasaki disease
• Neonatal HSV
• Specific virus
  • COVID-19 (peds)

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

• Absence of tachypnea, respiratory distress, and rales/decreased breath sounds rules-out with 100% sensitivity
• Imaging
  • CXR is not the gold standard!
  • Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
  • 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 for RSV, influenza
• 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

Treatment

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 azithro (2.5 mg/kg q12)
  • Febrile pneumonia
    • Add cefoTAXime (200mg/kg per day divided q8h)
• Outpatient
  • erythromycin OR azithro PO

>3mo - 18 years

• Hospitalized (PICU/severely ill)
  • Ceftriaxone IV AND vancomycin AND consider azithromycin
• Hospitalized (moderately ill)
  • Fully immunized: Ampicillin (50mg/kg q6) IV
  • Not fully immunized: Ceftriaxone IV
• Outpatient
  • Amoxicillin (90 mg/kg divided BID) x 5 days PO
  • 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