Pediatric Pneumonia

Article Author:
Chiemelie Ebeledike
Article Editor:
Thaer Ahmad
Updated:
11/27/2019 12:11:24 AM
PubMed Link:
Pediatric Pneumonia

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, and this includes organisms such as group B streptococci, Klebsiella, Escherichia coli, and Listeria monocytogenes.[4][5][6] Streptococcus pneumoniae, 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. influenzae type B is observed in this age group.[10][11] Mycoplasma pneumonia frequently occurs in children in the range from 5 to 13 years old[12][13]; however, S. pneumoniae is still the most commonly 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 is 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 jirovecii, 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. Approximately a third to half of these cases lead to hospitalizations.[18]

The introduction of the pneumococcal vaccine has significantly lowered the risk of pneumonia in the United States.

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.

There are four stages of lobar pneumonia. The first stage occurs within 24 hours and is characterized by alveolar edema and vascular congestion. Both bacteria and neutrophils are present.

Red hepatization is the second stage, and it has the consistency of the liver. The stage is characterized by neutrophils, red blood cells, and desquamated epithelial cells. Fibrin deposits in the alveoli are common.

The third of gray hepatization stage occurs 2-3 days later, and the lung appears dark brown. There is an accumulation of hemosiderin and hemolysis of red cells.

The fourth stage is the resolution stage, where the cellula infiltrates is resorbed, and the pulmonary architecture is restored. If the healing is not ideal, then it may lead to parapneumonic effusions and pleural adhesions.

In bronchopneumonia, there is often patch consolidation of one or more lobes. The neutrophilic infiltrate is chiefly around the center of the bronchi.

History and Physical

In many cases, complaints associated with pneumonia are nonspecific, 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, with 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.

Sputum gram stain and culture are not productive as the samples are often contaminated by oral flora. Blood cultures can be done but are often negative. Today, serology is being used to determine the presence of mycoplasma, legionella, and chlamydia species. PCR is becoming available in most hospitals, but still, the results take 24-48 hours.

There are no clear guidelines for the routine use of chest x-ray in the pediatric population.[24] Although the chest x-ray can be helpful in diagnosis and 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 is key and includes 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. For Varicella, use acyclovir and for the 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 diagnoses 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]

Admission is often required for patients with respiratory distress and low oxygenation. In most cases, the presence of a parapneumonic effusion requires admission. Children with severe respiratory distress may require chest therapy, CPAP, or even mechanical ventilation. A large pleural effusion requires drainage for diagnostic and therapeutic purposes.

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.

Prognosis

For most children, the prognosis is good. Viral pneumonia tends to resolve without treatment. Long term sequelae are rare. However, both staphylococcal and varicella pneumonia have guarded outcomes in children. 

Children with tuberculosis are at high risk for disease progression if the condition is not treated Immunocompromized children have the worst prognosis. Each year, roughly 3 million children die from pneumonia and the majority of these children also have other comorbidities like congenital heart disease, immunosuppression or chronic lung disease of prematurity.

Complications

  • Empyema
  • Pleural effusion
  • Lung abscess
  • Necrotizing pneumonia
  • Sepsis

Enhancing Healthcare Team Outcomes

Pediatric pneumonia is often undertreated or missed, leading to high morbidity and mortality. The condition is best managed by an interprofessional team to improve outcomes. The majority of patients are managed by the pediatrician, nurse practitioner, or primary care provider.  Patient and caregiver education is vital. Parents need to be told to avoid smoking, and the importance of handwashing cannot be overstated. In addition, all clinicians looking after children should emphasize vaccination against pneumococcus and influenza.

Healthcare professionals, including physicians, nurses, physician assistants, nurse practitioners, 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.

Caregivers should be educated about signs of respiratory difficulty and when to seek medical assistance. Only through a team approach can pneumonia in children be treated promptly with minimal morbidity.


References

[1] Gupta GR, Tackling pneumonia and diarrhoea: the deadliest diseases for the world's poorest children. Lancet (London, England). 2012 Jun 9     [PubMed PMID: 22682449]
[2] Rudan I,Nair H,Marušić A,Campbell H, Reducing mortality from childhood pneumonia and diarrhoea: The leading priority is also the greatest opportunity. Journal of global health. 2013 Jun     [PubMed PMID: 23826497]
[3] Rudan I,O'Brien KL,Nair H,Liu L,Theodoratou E,Qazi S,Lukšić I,Fischer Walker CL,Black RE,Campbell H, Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. Journal of global health. 2013 Jun     [PubMed PMID: 23826505]
[4] Arif F, Updated Recommendations Of Rcog On Prevention Of Early Onset Neonatal Group B Streptococcus Infection. Journal of Ayub Medical College, Abbottabad : JAMC. 2018 Jul-Sep     [PubMed PMID: 30465394]
[5] Chen JC,Jenkins-Marsh S,Flenady V,Ireland S,May M,Grimwood K,Liley HG, Early-onset group B streptococcal disease in a risk factor-based prevention setting: A 15-year population-based study. The Australian     [PubMed PMID: 30203834]
[6] Al Hazzani AA,Bawazeer RAB,Shehata AI, Epidemiological characterization of serotype group B Streptococci neonatal infections associated with interleukin-6 level as a sensitive parameter for the early diagnosis. Saudi journal of biological sciences. 2018 Nov     [PubMed PMID: 30505181]
[7] Verhoeven D, Influence of Immunological Maturity on Respiratory Syncytial Virus-Induced Morbidity in Young Children. Viral immunology. 2018 Nov 30     [PubMed PMID: 30499759]
[8] Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet. Infectious diseases. 2018 Sep 19     [PubMed PMID: 30243584]
[9] Omer SB,Sutanto A,Sarwo H,Linehan M,Djelantik IG,Mercer D,Moniaga V,Moulton LH,Widjaya A,Muljati P,Gessner BD,Steinhoff MC, Climatic, temporal, and geographic characteristics of respiratory syncytial virus disease in a tropical island population. Epidemiology and infection. 2008 Oct     [PubMed PMID: 18177515]
[10] Gessner BD,Sutanto A,Linehan M,Djelantik IG,Fletcher T,Gerudug IK,Ingerani,Mercer D,Moniaga V,Moulton LH,Moulton LH,Mulholland K,Nelson C,Soemohardjo S,Steinhoff M,Widjaya A,Stoeckel P,Maynard J,Arjoso S, Incidences of vaccine-preventable Haemophilus influenzae type b pneumonia and meningitis in Indonesian children: hamlet-randomised vaccine-probe trial. Lancet (London, England). 2005 Jan 1-7     [PubMed PMID: 15643700]
[11] Cutts FT,Zaman SM,Enwere G,Jaffar S,Levine OS,Okoko JB,Oluwalana C,Vaughan A,Obaro SK,Leach A,McAdam KP,Biney E,Saaka M,Onwuchekwa U,Yallop F,Pierce NF,Greenwood BM,Adegbola RA, Efficacy of nine-valent pneumococcal conjugate vaccine against pneumonia and invasive pneumococcal disease in The Gambia: randomised, double-blind, placebo-controlled trial. Lancet (London, England). 2005 Mar 26-Apr 1     [PubMed PMID: 15794968]
[12] Saraya T, {i}Mycoplasma pneumoniae{/i} infection: Basics. Journal of general and family medicine. 2017 Jun     [PubMed PMID: 29264006]
[13] Akashi Y,Hayashi D,Suzuki H,Shiigai M,Kanemoto K,Notake S,Ishiodori T,Ishikawa H,Imai H, Clinical features and seasonal variations in the prevalence of macrolide-resistant {i}Mycoplasma pneumoniae{/i}. Journal of general and family medicine. 2018 Nov     [PubMed PMID: 30464865]
[14] Dryahina K,Sovová K,Nemec A,Španěl P, Differentiation of pulmonary bacterial pathogens in cystic fibrosis by volatile metabolites emitted by their in vitro cultures: Pseudomonas aeruginosa, Staphylococcus aureus, Stenotrophomonas maltophilia and the Burkholderia cepacia complex. Journal of breath research. 2016 Aug 10     [PubMed PMID: 27506232]
[15] Martí-Carvajal AJ,Conterno LO, Antibiotics for treating community-acquired pneumonia in people with sickle cell disease. The Cochrane database of systematic reviews. 2016 Nov 14     [PubMed PMID: 27841444]
[16] Stagno S,Brasfield DM,Brown MB,Cassell GH,Pifer LL,Whitley RJ,Tiller RE, Infant pneumonitis associated with cytomegalovirus, Chlamydia, Pneumocystis, and Ureaplasma: a prospective study. Pediatrics. 1981 Sep     [PubMed PMID: 6269042]
[17] Garenne M,Ronsmans C,Campbell H, The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries. World health statistics quarterly. Rapport trimestriel de statistiques sanitaires mondiales. 1992     [PubMed PMID: 1462653]
[18] Howie SRC,Murdoch DR, Global childhood pneumonia: the good news, the bad news, and the way ahead. The Lancet. Global health. 2018 Nov 26     [PubMed PMID: 30497987]
[19] Bengoechea JA,Pessoa JS, Klebsiella pneumoniae infection biology: living to counteract host defences. FEMS microbiology reviews. 2018 Nov 18     [PubMed PMID: 30452654]
[20] Zar HJ, Bacterial and viral pneumonia: New insights from the Drakenstein Child Health Study. Paediatric respiratory reviews. 2017 Sep     [PubMed PMID: 28687247]
[21] Jadavji T,Law B,Lebel MH,Kennedy WA,Gold R,Wang EE, A practical guide for the diagnosis and treatment of pediatric pneumonia. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 1997 Mar 1     [PubMed PMID: 9068582]
[22] Don M, Risk factors of paediatric community-acquired pneumonia. The European respiratory journal. 2011 Mar     [PubMed PMID: 21357931]
[23] Neuman MI,Monuteaux MC,Scully KJ,Bachur RG, Prediction of pneumonia in a pediatric emergency department. Pediatrics. 2011 Aug     [PubMed PMID: 21746723]
[24] McIntosh K, Community-acquired pneumonia in children. The New England journal of medicine. 2002 Feb 7     [PubMed PMID: 11832532]
[25] Nohynek H,Valkeila E,Leinonen M,Eskola J, Erythrocyte sedimentation rate, white blood cell count and serum C-reactive protein in assessing etiologic diagnosis of acute lower respiratory infections in children. The Pediatric infectious disease journal. 1995 Jun     [PubMed PMID: 7667052]
[26] Markowitz RI,Ruchelli E, Pneumonia in infants and children: radiological-pathological correlation. Seminars in roentgenology. 1998 Apr     [PubMed PMID: 9583110]
[27] Kim YW,Donnelly LF, Round pneumonia: imaging findings in a large series of children. Pediatric radiology. 2007 Dec     [PubMed PMID: 17952428]
[28] McLennan MK, Radiology rounds. Round pneumonia. Canadian family physician Medecin de famille canadien. 1998 Apr     [PubMed PMID: 9585845]
[29] Hall CB,Powell KR,Schnabel KC,Gala CL,Pincus PH, Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection. The Journal of pediatrics. 1988 Aug     [PubMed PMID: 3397789]
[30] Matera MG,Rogliani P,Ora J,Cazzola M, Current pharmacotherapeutic options for pediatric lower respiratory tract infections with a focus on antimicrobial agents. Expert opinion on pharmacotherapy. 2018 Oct 25     [PubMed PMID: 30359143]
[31] Wald ER, Recurrent and nonresolving pneumonia in children. Seminars in respiratory infections. 1993 Mar     [PubMed PMID: 8372275]
[32] Freij BJ,Kusmiesz H,Nelson JD,McCracken GH Jr, Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatric infectious disease. 1984 Nov-Dec     [PubMed PMID: 6514596]
[33] Jain S,Williams DJ,Arnold SR,Ampofo K,Bramley AM,Reed C,Stockmann C,Anderson EJ,Grijalva CG,Self WH,Zhu Y,Patel A,Hymas W,Chappell JD,Kaufman RA,Kan JH,Dansie D,Lenny N,Hillyard DR,Haynes LM,Levine M,Lindstrom S,Winchell JM,Katz JM,Erdman D,Schneider E,Hicks LA,Wunderink RG,Edwards KM,Pavia AT,McCullers JA,Finelli L, Community-acquired pneumonia requiring hospitalization among U.S. children. The New England journal of medicine. 2015 Feb 26     [PubMed PMID: 25714161]