Pneumonia

Question 1

What is pneumonia?

Answer 1

Pneumonia is an infection which causes inflammation of the pulmonary tissue and is associated with consolidation of the alveolar spaces.

Question 2

Are bacteria or viruses more common causes of pneumonia in children

Answer 2

Viral cause of pneumonia is the most common cause in children between 1 month and 5 years of age

Question 3

In 4 different age groups (neonates, 1-3 months, 3 months – 5 years, >5 years) what are the bacteria and viruses that can cause pneumonia?

Answer 3

Neonates (bacterial cause is more common in neonates)
Bacteria: GBS, E. coli, Listeria
Viral: CMV, Herpes Virus, Enterovirus

1-3 months (until 5 years of age, viral causes become more common)
Viral: CMV, RSV, Influenza, Parainfluenza
Bacteria: S. aureus, H. influenzae, S. pneumonia, B. pertussis

3 months – 5 years
Viral: RSV, Adenovirus, Influenza
Bacteria: S. pneumonia, S. aureus, H. influenzae, GAS

> 5 years (Bacterial causes become more common)
Bacteria: S. pneumoniae, H. influenzae, S. aureus + atypical bacteria: Mycoplasma pneumonia (most common)
Viral: Influenza, Varicella, Adenovirus

Question 4

What is the clinical picture of child with pneumonia?

Answer 4

Fever and cough or difficulty breathing. Sometimes the cough may not be present initially e.g S. pneumoniae.

Tachypnoea, nasal flaring, lower chest indrawing or recession, consolidation or effusion. Tachypnoea is an important sign as it is associated with severity and with the increased likelihood of underlying consolidation.

Persistent fever

Fever and upper abdominal pain -> lower lobe pneumonia

Wheeze (#wheezybaby) – presence of viral or mycoplasma infection

Headaches – one of the initial presenting complaints in pneumonia caused by Mycoplasma pneumonia

Question 5

What are the differences between bacterial and viral pneumonia?

Answer 5

Bacterial causes may present with cough, fever, chills, dyspnoea and more dramatic CXR changes with lobar consolidation and pleural effusion.

On auscultation if you have localised signs then it is more likely going to be bacterial while generalised signs could mean it is more viral or due to mycoplasma.

Question 6

What are the investigations that are required in the context of a child with potential pneumonia?

Answer 6

In paediatric pneumonia is important to minimise tests if possible. It is possible to make a clinical diagnosis in most cases.

CXR if considering a LRTI or unsure of the diagnosis or if the child is not responding to therapy

Other than that, blood tests and swabs and all other types of investigations are not required as pneumonia is largely a clinical diagnosis in the paediatric population.

Question 7

What is seen on the X-ray of a child with pneumonia?

Answer 7

Since a viral cause of pneumonia is more common in children, you will see diffuse, streaky infiltrates bilaterally.

If you have a bacterial cause, you will see unilateral patchy or lobar consolidation.

Question 8

What are the principles of management of a child with pneumonia?

Answer 8

Basic management includes supportive therapy including hydration, antipyretics and humidified o2

ABx therapy is important in the neonatal and greater than 5 year age groups because in these age groups, bacterial causes of pneumonia are more common.

Question 9

What are the antibiotics used in each of the 4 age groups mentioned previously? (neonates, 1 -3 months, 3 months – 5 years, >5years)

Answer 9

Neonates
Since pneumonia is caused by maternally acquired pathogens (GBS, E.coli): benzylpenicillin + gentamicin

1 month – 3 months
If bacterial pneumonia is diagnosed clinically or on CXR and acute bronchiolitis is not present then start ABx.
Use azithromycin if afebrile and only mildly unwell because C. trachomatis could be the cause
If febrile or unwell (moderate disease) use benzylpenicillin.
If severe disease use cefotaxime or ceftriaxone plus flucoxacillin.

3 months – 5 years
Pneumonia in children 3 months – 5 years is usually caused by viruses but if a bacterial infection is suspected clinically or on CXR then begin ABx.
Mild disease: amoxicillin
Severe Disease: cefotaxime or ceftriaxone plus flucloxacillin

> 5 years
S. pneumoniae is the most common cause in this age group and Mycoplasma pneumoniae is also prominent.
Mild disease and Mycoplasma pneumoniae is not suspected use amoxicillin
If Mycoplasma pneumoniae is suspected use doxycycline or roxithromycin
If severe disease, again use cefotxime or ceftriaxone plus flucloxacillin