Pneumonia (pediatrics): Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:32

Pneumonia is an infection of the lower respiratory tract that involves the airways and surrounding lung tissue. In all age groups, one of the most common causes of pneumonia is Streptococcus pneumoniae.
Other common causes include viruses in young infants, and atypical organisms such as Mycoplasma pneumoniae and Chlamydophila pneumoniae in children ages 5 and older.

Unstable patient0:32–1:11

When a pediatric patient presents with a chief concern suggesting pneumonia, first, perform an ABCDE assessment to determine if the patient is unstable or stable.
If unstable, stabilize their airway, breathing, and circulation, and you may even need to intubate your patient. Next, obtain IV access, and consider starting IV fluids.
Begin continuous vital sign monitoring, including respiratory rate, pulse oximetry, and cardiac monitoring, and administer supplemental oxygen as needed.
Finally, administer empiric antibiotics early on.Now, let’s go back to the ABCDE assessment and take a look at stable patients.

Stable Patient1:11–2:35

In this case, first, obtain a focused history and physical exam, and measure your patient’s oxygen saturation using pulse oximetry.
Infants and children with pneumonia commonly present with fever and a cough. The physical exam usually reveals an elevated respiratory rate and an increased work of breathing, with nasal flaring or grunting commonly seen in young infants, as well as intercostal or subcostal retractions in all age groups.
Meanwhile, auscultatory findings may include crackles, rhonchi, or decreased breath sounds, and pulse oximetry might show an oxygen saturation below 90%.
A combination of these findings should make you suspect pneumonia. The next step is to assess the criteria for hospitalization, which include an age less than 6 months, oxygen saturation below 90%, respiratory distress or signs of dehydration, an ill or toxic appearance, if the patient is unable to maintain oral hydration, if they’ve already received and failed outpatient treatment, or social factors which might prevent effective outpatient treatment.If criteria for hospitalization are met, you should suspect moderate to severe pneumonia, and begin a diagnostic workup, starting with labs.

Hospitalized patients2:35–3:05

Order a CBC, CRP, and procalcitonin, as well as a blood culture, and consider ordering a respiratory viral PCR. In addition, order an AP and lateral chest X-ray.
To determine the next steps, first assess your patient’s age.Patients younger than 3 months of age frequently present with vague symptoms such as apnea, lethargy, or isolated fever, so you have to evaluate your patient for sepsis, which includes ordering additional testing, such as a urinalysis, urine culture, as well as CSF analysis and culture.

Age less than 3 months3:05–5:28

Next, admit your patient to the hospital, start supportive care with IV fluids, and begin empiric parenteral antibiotics, such as ampicillin and cefotaxime.
Let's now look at lab and imaging findings. Viral PCR could be positive, while CRP and procalcitonin could be elevated or normal, depending on the underlying cause of pneumonia.
Additionally, you might get positive blood culture results, but keep in mind that urinalysis, urine cultures, CSF analysis, and cultures are typically negative.
Finally, imaging may reveal findings associated with bacterial pneumonia, which typically appears as a round or fluffy consolidation with a lobar distribution; or viral pneumonia, which typically lacks a round appearance and often appears as increased peribronchial markings near the hilum.
At this point, you can diagnose pneumonia, so continue supportive care, and don’t forget to tailor antibiotics if the patient’s cultures are positive for growth!Here’s a high-yield fact!
If your patient is between 2 weeks and 3 months of age and presents with a staccato cough and conjunctivitis, the absence of fever, and scattered crackles on physical exam, consider Chlamydia trachomatis or other atypical bacterial pneumonia.
Lab findings may include elevated WBCs with eosinophilia, and the chest X-ray typically demonstrates bilateral diffuse interstitial infiltrates with hyperinflation.
If these findings are present, make a clinical diagnosis of afebrile pneumonia, and treat your patient with a macrolide antibiotic like azithromycin, with supportive care and close follow up.On the other hand, let’s look at patients 3 months or older.

Age more than 3 months5:28–5:49

You should admit your patient to the hospital and begin IV ampicillin, and then assess the lab and imaging results to determine the type of pneumonia; viral, typical bacterial or MRSA.First, let’s discuss patients with viral pneumonia.

Viral5:49–6:36

The viral PCR might identify a virus, while the CBC results typically reveal normal or slightly elevated WBCs with a predominance of lymphocytes.
The CRP and procalcitonin are usually normal, while the blood culture is negative. Typical chest X-ray findings include diffuse interstitial infiltrates with or without hyperinflation.
These findings are highly suggestive of viral pneumonia. Treatment includes supportive care, and if the influenza PCR is positive, a neuraminidase inhibitor.
You may also decide to continue antibiotics if you suspect viral pneumonitis with a superimposed bacterial pneumonia.Now let’s switch gears and discuss hospitalized patients with typical bacterial pneumonia.

Typical bacterial6:36–7:39

These patients will have a negative viral PCR, and the CBC will typically reveal elevated WBCs with a predominance of neutrophils.
The CRP and procalcitonin are usually elevated, blood cultures might be positive, while the chest X-ray will demonstrate lobar consolidation.
These findings are highly suggestive of typical bacterial pneumonia, which is most commonly caused by Streptococcus pneumoniae in all age groups beyond the newborn period.
For treatment, you can continue IV ampicillin, but if your patient isn’t fully immunized, or if there’s high-level penicillin resistance locally, switch to a third-generation cephalosporin.
Additionally, if your patient is over 5 years of age and you suspect a co-infection with Mycoplasma pneumoniae, you can consider adding a macrolide for coverage of atypical bacteria.Finally, let’s discuss methicillin-resistant Staphylococcus aureus pneumonia, or MRSA pneumonia for short.

MRSA pneumonia7:39–9:04

Affected patients often have a history of recent hospitalization or influenza infection, in which case the viral PCR might be positive for influenza.
The CBC will show elevated WBCs with a predominance of neutrophils, CRP and procalcitonin will be elevated, with or without positive blood cultures.
Typical chest X-ray findings include cavitary lesions or unilateral nodular infiltrates. These findings are highly suggestive of MRSA pneumonia, so treat your patient with a beta-lactam antibiotic, and add vancomycin or clindamycin for Staph coverage.Now here’s a clinical pearl to keep in mind!
If your patient’s lung exam reveals dullness to percussion, distant breath sounds, or a friction rub, consider complications of pneumonia, such as parapneumonic effusion or empyema.
If imaging confirms a moderate- to large effusion or empyema, or if your patient has any respiratory compromise, consult the surgical team for diagnostic thoracentesis and consideration of thoracoscopy tube placement or surgical drainage.Alright, now let’s turn our attention to patients who don’t meet criteria for hospitalization.

Outpatients9:04–9:42

In this case, suspect mild pneumonia, so as a first step, consider ordering a respiratory viral PCR. Patients who don’t need hospitalization usually don’t need additional labs, and unless their physical exam findings are unclear, most patients won’t need a chest X-ray to make a diagnosis of uncomplicated mild pneumonia.
You will then assess for possible types of mild pneumonia; viral pneumonia, typical bacterial pneumonia, and atypical bacterial pneumonia.First let’s consider viral pneumonia.
Typically, patients are under 5 years of age and present with a subacute onset of symptoms, which may include cough and nasal congestion.

Viral9:42–10:26

Physical exam typically reveals diffuse wheezing, rhonchi, or crackles, while a viral PCR, if you obtain one, may identify a virus, such as RSV or influenza.
With these findings, you can make a clinical diagnosis of viral pneumonia. Most children with mild viral pneumonia can be treated as outpatients with supportive care, but if your patient tests positive for influenza, you should consider starting a neuraminidase inhibitor, such as oseltamivir.Next, let’s focus on outpatients with typical bacterial pneumonia.
Affected children usually present with a more rapid onset of respiratory symptoms, often after an upper respiratory infection.

Typical bacterial10:26–11:12

If the lower lobes of the lungs are affected, they may also report abdominal pain or vomiting. Physical exam usually reveals localized crackles or a focal decrease in breath sounds, while the viral PCR is negative.
These findings are highly suggestive of typical bacterial pneumonia. Begin treatment with amoxicillin for coverage of Streptococcus pneumoniae, but if your patient hasn’t been fully immunized, treat with a third-generation cephalosporin instead.Finally, let’s discuss atypical bacterial pneumonia, which is usually caused by Mycoplasma pneumoniae.
Patients are usually over 5 years old and, in addition to cough, they usually report symptoms such as headache, sore throat, myalgia, and chest pain.

Atypical bacterial11:12–12:23

Physical exam often demonstrates pharyngeal erythema and cervical lymphadenopathy, while auscultation of the chest reveals diffuse wheezing and crackles.
Finally, viral PCR is negative. Based on these findings you can make a clinical diagnosis of atypical bacterial pneumonia, Atypical Bacterial Pneumonia is also known as “walking pneumonia”, because symptoms are typically mild.
Atypical bacterial pneumonia is most often caused by Mycoplasma pneumoniae, and is diagnosed clinically. If the diagnosis is unclear, you could order a Mycoplasma PCR to identify the organism.
For medical management, treat with a macrolide antibiotic, such as azithromycin, although most patients improve with supportive care alone.Alright, as a quick recap… If you suspect pneumonia, first assess the criteria for hospitalization, and if the criteria are met, assess your patient’s age.

Review12:23–13:15

For infants under 3 months, consider a full sepsis workup and administer parenteral ampicillin and cefotaxime. For patients older than 3 months, start IV ampicillin, and after assessing labs and imaging, determine whether your patient has viral, typical bacterial, or MRSA pneumonia.
However, if hospitalization criteria are not met, consider viral testing and assess the type of pneumonia. Treat mild viral pneumonia with supportive care plus neuraminidase inhibitors if your patient is influenza-positive, and treat mild typical bacterial pneumonia with amoxicillin.
Finally, treat atypical bacterial pneumonia with a macrolide. influenza positive and treat mild typical bacterial pneumonia with