The most common symptoms of pneumonia are fever, cough and tachypnoea.
However, the most common cause of a cough in a child is an acute viral respiratory infection.
A chest x-ray is normally unnecessary if a child in good clinical condition is diagnosed with pneumonia based on symptoms and clinical findings and treated in outpatient care.
The antimicrobial therapy must provide coverage for pneumococci, and the first choice outpatient medication is amoxicillin for 5 days.
Antimicrobials are not always necessary for young children with pneumonia, provided that findings are consistent with viral infection.
If the condition of a patient with serious pneumonia does not improve clearly within 48 hours from the beginning of antimicrobial treatment, if suspicion of a complication of pneumonia arises or if the patient is less than 6 months old, they should be referred to hospital for assessment by a paediatrician.
No follow-up visit or x-ray is usually necessary for children with pneumonia.
Causative organisms
The causative organisms of pneumonia in children are either viruses or bacteria or the infection may be mixed. In young children, in particular, the role of viruses is significant.
The most common causative microbes are pneumococci in children of any age and mycoplasma particularly in school children, and the most common causative viruses are RSV, metapneumovirus, rhinovirus, adenovirus, influenza and parainfluenza viruses.
SARS-CoV-2 causes respiratory symptoms in children, but in basically healthy children, severe viral pneumonia is rare.
The prevalence of pulmonary tuberculosis in children varies across countries, but even if it would be rare, it has to be borne in mind as one possibility.
Rare causative agents include Staphylococcus aureus, Streptococcus pyogenes and Chlamydophila pneumoniae.
Signs and symptoms
Fever
Cough
Tachypnoea
Respiratory distress
Sharp pain in the chest or abdominal pain (school-age children)
Worsening general condition; this may manifest in young children as fatigue, apathy, poor eating, crying and dislike of being handled.
Findings
Tachypnoea
Respiratory distress signified by the use of auxiliary breathing muscles, grunting, nasal flaring in young children, and hypoxia (oxygen saturation < 95%) are signs of severe pneumonia.
Prolonged expiratory phase and/or expiratory wheeze is possible but not a typical finding in bacterial pneumonia.
Tachycardia
Diagnosis
It is challenging to hear fine crackles, particularly in a crying and constantly moving child. This emphasises the importance of overall assessment of the child's status and the degree of respiratory distress.
If the child is clearly unwell with an acute disease, pneumonia must be kept in mind in differential diagnosis even if the auscultation finding is normal.
It is important to measure oxygen saturation at least in children with respiratory distress.
Laboratory tests
High CRP concentration or high blood leukocyte counts increase the probability of bacterial pneumonia but low CRP or low leukocyte levels do not exclude bacterial infection particularly at the initial stage of the disease.
Measuring blood count and CRP is not absolutely necessary, however, in a child with suspected pneumonia who is in good general condition and whose treatment takes place at home.
Aetiological investigations
A rapid test for influenza is warranted during an epidemic.
Other aetiological investigations are not usually necessary in outpatient care.
The urinary pneumococcal antigen test is unreliable in children and should therefore not be used.
If mycoplasma is suspected, the nucleic acid test is useful.
Interpretation of a single IgM antibody determination for the diagnosis of an acute disease is challenging because IgM antibodies may remain positive for a long time after a preceding infection.
Measuring elevated IgG antibodies in paired serum samples is a reliable but laborious and slow method.
Blood culture is usually performed in inpatients before starting antimicrobial treatment.
Radiological diagnosis
A chest x-ray is normally unnecessary if a child in good clinical condition is diagnosed with pneumonia based on typical symptoms and fine crackles heard on auscultation and treated in outpatient care.
A chest x-ray is necessary if the patient's general condition has deteriorated and pneumonia is suspected, if the focus of infection is unclear or if breath sounds are clearly diminished.
A chest x-ray is also necessary if the patient's condition does not improve in 48 hours from the beginning of treatment.
In children, primarily just an AP projection is obtained.
It is not possible to reliably determine the aetiology of pneumonia from an x-ray.
Alveolar opacities may be seen in both viral and bacterial pneumonias but are more commonly seen in the case of bacterial than viral pneumonia.
On the other hand, pneumococcal pneumonia with an abrupt onset does not always show up as dense shadowing on a chest x-ray but nevertheless requires the commencement of antimicrobial therapy.
Most interpretation problems are caused by accentuated or dense peribronchial/peribronchovascular structures seen in association with viral infections and easily interpreted as pneumonia.
Choice and dosing of antimicrobial therapy
The first choice drug for pneumonia treated in an outpatient setting is amoxicillin 50-80 mg/kg/day, in three divided doses (maximum dose 750 mg 3 times daily) for 5 days. It is effective against penicillin-sensitive pneumococci.
Patients with penicillin allergy who are in a good clinical condition can be treated with a macrolide.
Macrolides alone may not be sufficiently effective for the treatment of severe pneumonia in the outpatient setting.
The first-line treatment is azithromycin 10 mg/kg once daily for 3 days or 10 mg/kg for 1 day, followed by 5 mg/kg for 4 days (the maximum for the whole course being 2 500 mg)
Alternatively, clarithromycin 15 mg/kg divided into 2 daily doses for 5 days (no more than 1 000 mg/day)
In a child aged over 8 years, doxycycline may also be considered (2.2-4.4 mg/kg/day in two divided doses for 5 days (no more than 200 mg/day).
If there is a justified suspicion of a mycoplasma infection
a patient who is in a good clinical condition can be treated with a macrolide or doxycycline or,
Oseltamivir can be used in the treatment of pneumonia caused by influenza virus .
Indications for hospital treatment
Worsening general condition or clear respiratory distress
Reliably measured oxygen saturation < 95%
Known or suspected complication of pneumonia (pleural effusion, empyema or pulmonary abscess)
Patient deteriorating
No improvement in 48 hours
Problems with administration of oral medication
Children aged less than 6 months as well as children with a significant underlying disease should be referred to specialized care for evaluation.
Monitoring treatment
If the child starts to improve within 48 hours and no complications develop, check-up appointments or follow-up x-rays are not indicated.
References
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