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Pneumonia in Children

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Overview

Community-acquired pneumonia (CAP) is an infection of the lung tissue caused by bacteria or viruses. This can lead to consolidation and collapse of the alveoli, resulting in impaired gas exchange, which can cause hypoxia and breathlessness.

Causes

  • The most common viral cause is respiratory syncytial virus (RSV)
  • The most common bacterial cause is Streptococcus pneumoniae

Epidemiology

  • CAP has an incidence of around 14 per 10,000 in children >5 years
  • CAP has an incidence of around 33.8 per 10,000 in children <5 years

Presentation

A diagnosis of pneumonia should be considered in children with a high fever (>39°C) and/or:

  • Increased respiratory rate:
    • 0-5 months: >60 /min 
    • 6-12 months: >50 /min
    • > 12 months: >40 /min
  • Increased work of breathing:
    • Grunting
    • Chest indrawing
    • Nasal flaring
    • Tracheal tugging
    • Head bobbing
  • Persistent focal crackles – usually coarse crackles
  • Cyanosis
  • Oxygen saturations <95% on room air
  • Dull percussion and absent breath sounds – suggests effusion

Referral

Overview

Immediately refer to hospital via 999 ambulance if any of the following apply:

  • Persistent oxygen saturations <92% when breathing air
  • Grunting, marked chest recession, or respiratory rate >60 /min
  • Cyanosis
  • Features of effusion are present
  • Child looks seriously unwell, does not wake, or if roused does not stay awake, or does not respond to normal social cues
  • Temperature of 38°C or higher in a child 3 aged 3 months or less

Consider an immediate referral to hospital if any of the following apply:

  • Temperature of 39°C or higher in a child aged 3-6 months
  • Tachycardia:
    • <1 year: >160 bpm
    • 1-2 years: >150 bpm
    • 2-5 years: >140 bpm
  • Reduced oral intake – 50-75% of the usual volume of fluid intake
  • Pallor of the skin, lips or tongue reported by the carer
  • Difficult to rouse – waking only with prolonged stimulation
  • Abnormal response to social cues
  • Decreased activity
  • Nasal flaring
  • Clinical dehydration – reduced skin turgor, capillary refill time >3 seconds, dry mucous membranes, reduced urine output
  • Features of an underlying disorder (e.g. <3 months, chronic lung disease such as bronchopulmonary dysplasia, congenital heart disease, neuromuscular disorders, immunodeficiency, premature infant)
  • Factors affecting a carer’s ability to look after the child (e.g. adverse social circumstances)
  • Longer distance to healthcare in case of deterioration

Differential Diagnoses

Bronchiolitis

  • Usually seen in children <2 years with peaks of aged 3-6 months
  • Characterised by a prodrome of coryza/fever lasting 1-3 days followed by cough and tachypnoea, chest recession, wheeze, or crackles
  • If present, fine crackles are present throughout the lung fields

Viral-induced wheeze

  • Usually seen in children aged 6 months – 5 years
  • Wheezing present that only occurs in the presence of a viral infection
  • Crackles are not seen

Acute asthma

  • Wheezing present that occurs after a predictable trigger (e.g. pollen exposure)
  • There may be a personal or family history of atopy
  • Fever is not present, unless it is an infective exacerbation of asthma
  • Crackles are not seen

Bronchiectasis

  • There may be a history of childhood pneumonia or serious lung infection
  • Patients cough up copious amounts of sputum
  • There may be a history of recurrent lung infections
  • Coarse crackles may be present

Primary ciliary dyskinesia

  • Recurrent respiratory tract infections
  • Persistent productive cough from birth
  • There may be a history of consanguinity in the parents

Cystic fibrosis

  • Persistent productive cough from birth
  • History of failure to thrive
  • Malabsorption and steatorrhoea
  • Recurrent chest infections

Foreign body aspiration

  • Sudden-onset stridor
  • Focal diminished breath sounds

Pertussis (whooping cough)

  • Coughing bouts that increase in severity leading to vomiting
  • There may be inspiratory whoops before coughing
  • The cough may persist for several months

Management

Overview

If the patient is being managed in the community, prescribe antibiotics to all children with a clinical diagnosis of CAP. This is because viral and bacterial pneumonia cannot reliably be distinguished from each other clinically.

  • 1st-line: amoxicillin
    • Alternatives include: co-amoxiclav, cefaclor, or macrolides (e.g. clarithromycin)
    • If amoxicillin is not effective: add macrolide
  • If atypical pneumonia is present (e.g. Mycoplasma or Chlamydia species): prescribe macrolide
  • If pneumonia is associated with influenza: prescribe co-amoxiclav

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