• We are sorry, but NCBI web applications do not support your browser and may not function properly. More information
Logo of pchealthPaediatrics and Child Health HomepageCurrent IssueSubscription PageSubmissions Pagewww.pulsus.comPaediatrics and Child Health
Paediatr Child Health. 2011 Aug-Sep; 16(7): 417–420.
PMCID: PMC3200392

Language: English | French

Pneumonia in healthy Canadian children and youth: Practice points for management

N Le Saux and JL Robinson, Canadian Paediatric Society, Infectious Diseases and Immunization Committee

Abstract

Although immunization has decreased the incidence of bacterial pneumonia in vaccinated children, pneumonia remains common in healthy children. Unless it is totally impractical, a chest radiograph should be performed to confirm the diagnosis of pneumonia. Factors such as age, vital signs and other measures of illness severity are critical in the decision regarding whether to admit a patient to hospital. Because Streptococcus pneumoniae continues to be the most common cause of bacterial pneumonia in children, prescribing amoxicillin or ampicillin for seven to 10 days remains the mainstay of empirical therapy for non-severe pneumonia. If improvement does not occur, consideration should be given to searching for complications (empyema or lung abscess). Routine chest radiographs at the end of therapy are not recommended unless clinically indicated.

Keywords: Antimicrobial therapy, Bacterial pneumonia, Viral pneumonia

Résumé

La vaccination a réduit l’incidence de pneumonie bactérienne chez les enfants vaccinés, mais la pneumonie demeure courante chez les enfants en santé. À moins que ce soit tout à fait irréalisable, il faudrait effectuer une radiographie pulmonaire pour confirmer le diagnostic de pneumonie. Des facteurs comme l’âge, les signes vitaux et d’autres mesures de gravité de la maladie sont essentiels dans la décision d’hospitaliser ou non un patient. Puisque le Streptococcus pneumoniae continue d’être la principale cause de pneumonie bactérienne chez les enfants, la prescription d’amoxicilline ou d’ampicilline pendant sept à dix jours constitue le principal traitement empirique d’une forme non sévère de la pneumonie. Si on n’observe pas d’amélioration, il faut envisager des complications (empyème ou abcès pulmonaire). Il n’est pas recommandé de procéder à une radiographie pulmonaire systématique à la fin du traitement, à moins d’une indication clinique.

Français en page 421

Most physicians who care for children and youth have had experience in managing acute pneumonia. The WHO has estimated that in developed countries, one in 20 children younger than five years of age will contract pneumonia each year (1,2). Pneumococcal conjugate vaccines have been shown to decrease radiologically proven pneumonia admission rates by an average of 27% (36).

The present practice point focuses on the current diagnosis and management of uncomplicated acute community-acquired pneumonia in healthy immunized children with no underlying pulmonary pathology aside from mild reactive airways disease. The practice point does not apply to persistent (chronic) pneumonia syndromes (with symptoms for more than two weeks), aspiration pneumonia or recurrent pneumonias, or those associated with chronic medical problems such as immunodeficiency, because these pneumonias may be caused by different pathogens or require more extensive investigation.

DEFINITION AND HOST RISK FACTORS

Pneumonia is an acute inflammation of the parenchyma of the lower respiratory tract caused by a microbial pathogen. Bacterial infections are usually primary but, occasionally, viral respiratory tract infections such as influenza can increase the subsequent risk of bacterial pneumonias (7). In uncomplicated pneumonia, there is no evidence of empyema (pus in the pleural space), a lung abscess or a necrotic lung.

ETIOLOGY

The most common causes of pneumonia in infants and preschool children are viruses that usually, but not exclusively, circulate in winter (eg, respiratory syncytial virus, influenza, parainfluenza virus and human metapneumovirus). Viruses as a sole cause of pneumonia are less common in older children with the exception of influenza (8).

Among bacteria, Streptococcus pneumoniae continues to be the most significant pathogen in children of all ages (9). Group A streptococcal pneumonia is much less common. Although Staphylococcus aureus is not a common cause of paediatric pneumonia, it has been increasingly encountered in communities where methicillin-resistant Staphylococcus aureus is prevalent. Haemophilus influenzae type b has almost disappeared because of vaccination. Mycoplasma pneumoniae and Chlamydophila pneumoniae are more common causes of pneumonia among school-age children, but they occasionally cause pneumonia in younger children (10,11).

SYMPTOMS AND SIGNS OF ACUTE PNEUMONIA

The symptoms of pneumonia may be nonspecific, especially in infants and younger children. Acute onset of fever, cough, difficulty breathing, poor feeding or vomiting, and lack of interest in normal activities are common. Chest or abdominal pain may be a prominent feature. Abrupt onset of rigors favours a bacterial cause. A significant, persistent cough may predominate in pneumonia caused by M pneumoniae. During influenza season, consider influenza, with or without a secondary bacterial component, as a cause of pneumonia.

Children typically experience fever and tachypnea (determined by counting the respiratory rate for 60 s in a calm state; see Table 1). Indrawing, retractions and/or a tracheal tug will indicate respiratory distress (dyspnea) (12). Decreased oxygen saturation indicates hypoxemia and should be measured in all hospital settings. Cyanosis will only be evident with very severe hypoxemia. Normal oxygen saturation does not exclude pneumonia, especially early in the course of the illness.

TABLE 1
Age-specific criteria for tachypnea

Physical signs suggesting consolidation include dullness to percussion, increased tactile fremitus, reduced normal vesicular breath sounds and increased bronchial breath sounds – all of which can be difficult to detect in young children. The presence of wheezing should suggest the possibility that radiographic changes may be due to atelectasis and mucous plugging from asthma or bronchiolitis rather than pneumonia. Signs of an effusion are dullness to percussion, decreased tactile fremitus, and decreased or absent breath sounds. There may be associated signs of dehydration and/or sepsis (12).

INVESTIGATIONS

Imaging

Pneumonia is overdiagnosed in the absence of radiological confirmation. Radiological confirmation is encouraged whenever possible to support the clinical diagnosis and may be useful if the child subsequently deteriorates. Poorly defined nodules and patchy areas of opacity with variable hyperinflation and without effusion are more indicative of a viral etiology (13). Lobar or segmental consolidation with or without pleural effusions is suggestive of bacterial pneumonia due to S pneumoniae, group A streptococcus and, less commonly, S aureus. The atypical pathogens, M pneumoniae or C pneumoniae, classically produce focal infiltrates that appear to be more extensive than the clinical findings would suggest.

Detection of the pathogen

Determining the etiology of pneumonia is difficult in children because few children are bacteremic, and most cannot provide a sputum sample. If adequate sputum is available, it should be sent for Gram staining and subsequent culture (14). Culture of pleural fluid is suggested if it can be sampled. Additional invasive or molecular testing should be pursued if the child fails to improve or worsens on therapy.

Routine viral testing of nasopharyngeal secretions is usually not indicated for outpatients with mild or moderate illness. Admitted children who have possible viral pneumonia should undergo viral testing of nasopharyngeal secretions because this will also assist in cohorting patients (15,16).

Bloodwork

Typical bacterial pneumonias usually show higher peripheral white blood cell counts than atypical bacterial or viral pneumonias. A complete blood count with differential testing and blood cultures are indicated for children who are hospitalized or worsening (9,17).

GUIDELINES FOR REFERRAL TO HOSPITAL OR HOSPITAL ADMISSION

Most children can be managed as outpatients. Specific criteria for admission are not available for children. Hospitalization is generally indicated if the child is unable to eat or drink, has an inability to comply with oral therapy, has a concerning social situation, dehydration, hypotension, sepsis, oxygen saturations of lower than 92%, vomiting, tachypnea (Table 1), chest retractions, or any evidence of an empyema or lung abscess (14). There should be a low threshold for admitting children younger than six months of age because it can be difficult for caregivers to recognize deterioration.

MANAGEMENT

If the clinical picture and chest radiograph (CXR) are compatible with bacterial pneumonia, provide supportive care and choose empirical antimicrobials as shown in Table 2, following all steps in the algorithm. This algorithm places less emphasis on macrolides than previous recommendations did because there is increasing evidence that pneumonia due to M pneumoniae often resolves without therapy (18).

TABLE 2
Guidelines for empirical antimicrobial therapy for previously healthy children three months to 17 years of age with community-acquired, radiologically proven pneumonia of suspected bacterial etiology

Suggested doses of antibiotics are listed in Table 3. In all situations, if a bacterium is detected in blood or pleural fluid, antimicrobial therapy should be modified to the narrowest spectrum agent based on susceptibility results.

TABLE 3
Doses of antimicrobials for suspected or proven bacterial pneumonia

In Canada, it is still standard to treat uncomplicated pneumonia for seven to 10 days (five days with azithromycin) (19). Pneumonia complicated by empyema or abscess formation requires a longer duration of therapy as determined by the clinical course. Oral step-down therapy is usually appropriate when patients are improved and afebrile.

If a virus is detected in a nasopharyngeal sample and/or CXR is most compatible with viral pneumonia, manage with supportive care (oxygen and rehydration if required) without antibiotics. Consider antivirals if influenza is suspected or proven, and the child has risk factors for severe disease (20) or requires admission, especially if symptoms have been present for less than 48 h.

PENICILLIN ALLERGY

If the previous suspected allergic reaction included an urticarial rash, hypotension or bronchospasm, the reaction may have been immunoglobulin E (IgE) mediated and all beta lactams should be avoided. For children with nonsevere pneumonia who are treated as outpatients, clarithromycin and azithromycin are reasonable choices, while keeping in mind that pneumococcal resistance to antimicrobials is increasingly common. For more severe pneumonias with suspected IgE-mediated penicillin allergy, options should be discussed with a paediatric infectious diseases physician. If the previous suspected allergic reaction did not appear to be IgE mediated, cephalosporins can be used. Cefuroxime axetil can be used in place of amoxicillin, while recognizing that pneumococcal coverage is inferior with these drugs.

EXPECTED CLINICAL COURSE AND FOLLOW-UP FOR UNCOMPLICATED PNEUMONIA

Clinical improvement (improved appetite, decreasing fever, resolution of tachypnea and decreasing oxygen requirements) should be evident within 48 h with bacterial pneumonia; however, improvement often takes longer with viral pneumonia. If the patient does not improve within the expected time frame, repeat the CXR to search for evidence of a complication (ie, empyema or abscess). Foreign body aspiration, reactive airways disease with atelectasis, congenital pulmonary anomaly, tuberculosis or unrecognized immunodeficiency with an opportunistic infection are also possible (Table 2).

Because radiographic resolution can take up to four to six weeks, repeat radiographs are not indicated for children with clinical improvement (21).

Acknowledgments

The authors acknowledge Dr Thomas Kovesi, Paediatric Respirologist, Children’s Hospital of Eastern Ontario (Ottawa, Ontario), for his thoughtful review of the physical examination portion of the document. This practice point was also reviewed by the Canadian Paediatric Society’s Community Paediatrics and Acute Care committees.

Footnotes

INFECTIOUS DISEASES AND IMMUNIZATION COMMITTEE

Members: Drs Robert Bortolussi, IWK Health Centre, Halifax, Nova Scotia (Chair); Jane Finlay, Richmond, British Columbia; Susanna Martin, Royal University Hospital, Saskatoon, Saskatchewan (Board Representative); Jane C McDonald, The Montreal Children’s Hospital, Montreal, Quebec; Heather Onyett, Queen’s University, Kingston, Ontario; Joan L Robinson, Edmonton, Alberta

Liaisons: Drs Upton D Allen, The Hospital for Sick Children, Toronto, Ontario (Canadian Pediatric AIDS Research Group); Janet Dollin, University of Ottawa, Ottawa, Ontario (College of Family Physicians of Canada); Charles PS Hui, Children’s Hospital of Eastern Ontario, Ottawa, Ontario (Health Canada, Committee to Advise on Tropical Medicine and Travel); Nicole Le Saux, Children’s Hospital of Eastern Ontario, Ottawa, Ontario (Canadian Immunization Monitoring Program, ACTive); Larry Pickering, Elk Grove, Illinois (American Academy of Pediatrics, Committee on Infectious Diseases); Marina I Salvadori, Children’s Hospital of Western Ontario, London, Ontario (Health Canada, National Advisory Committee on Immunization); John Spika, Ottawa, Ontario (Public Health Agency of Canada)

Consultants: Drs James D Kellner, Alberta Children’s Hospital, Calgary, Alberta; Noni E MacDonald, IWK Health Centre, Halifax, Nova Scotia; Dorothy L Moore, The Montreal Children’s Hospital, Montreal, Quebec

Principal authors: Drs Nicole Le Saux, Ottawa, Ontario; Joan L Robinson, Edmonton, Alberta

The recommendations in this document do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate. All Canadian Paediatric Society position statements and practice points are reviewed on a regular basis. Please consult the Position Statements section of the CPS website (www.cps.ca/english/publications/statementsindex.htm) for the full-text, current version.

REFERENCES

1. Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008;86:408–16. [PMC free article] [PubMed]
2. Farha T, Thomson AH. The burden of pneumonia in children in the developed world. Paediatr Respir Rev. 2005;6:76–82. [PubMed]
3. Grijalva CG. Recognising pneumonia burden through prevention. Vaccine. 2009;27(Suppl 3):C6–8. [PubMed]
4. Hansen J, Black S, Shinefield H, et al. Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than 5 years of age for prevention of pneumonia: Updated analysis using World Health Organization standardized interpretation of chest radiographs. Pediatr Infect Dis J. 2006;25:779–81. [PubMed]
5. Lucero MG, Dulalia VE, Nillos LT, et al. Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and X-ray defined pneumonia in children less than two years of age. Cochrane Database Syst Rev. 2009;(4):CD004977. [PubMed]
6. Mulholland K, Hilton S, Adegbola R, et al. Randomised trial of Haemophilus influenzae type-b tetanus protein conjugate vaccine [corrected] for prevention of pneumonia and meningitis in Gambian infants. Lancet. 1997;349:1191–7. [PubMed]
7. McCullers JA. Insights into the interaction between influenza virus and pneumococcus. Clin Microbiol Rev. 2006;19:571–82. [PMC free article] [PubMed]
8. Klugman KP, Chien YW, Madhi SA. Pneumococcal pneumonia and influenza: A deadly combination. Vaccine. 2009;27(Suppl 3):C9–14. [PubMed]
9. Wubbel L, Muniz L, Ahmed A, et al. Etiology and treatment of community-acquired pneumonia in ambulatory children. Pediatr Infect Dis J. 1999;18:98–104. [PubMed]
10. McCracken GH., Jr Diagnosis and management of pneumonia in children. Pediatr Infect Dis J. 2000;19:924–8. [PubMed]
11. Michelow IC, Olsen K, Lozano J, Duffy LB, McCracken GH, Hardy RD. Diagnostic utility and clinical significance of naso- and oropharyngeal samples used in a PCR assay to diagnose Mycoplasma pneumoniae infection in children with community-acquired pneumonia. J Clin Microbiol. 2004;42:3339–41. [PMC free article] [PubMed]
12. Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med. 2005;6:2–8. [PubMed]
13. Tew J, Calenoff L, Berlin BS. Bacterial or nonbacterial pneumonia: Accuracy of radiographic diagnosis. Radiology. 1977;124:607–12. [PubMed]
14. Low DE, Kellner JD, Allen U, et al. Community-acquired pneumonia in children: A multidisciplinary consensus review. Can J Infect Dis. 2003;14(Suppl B):3B–11B.
15. Hamano-Hasegawa K, Morozumi M, Nakayama E, et al. Comprehensive detection of causative pathogens using real-time PCR to diagnose pediatric community-acquired pneumonia. J Infect Chemother. 2008;14:424–32. [PubMed]
16. Cilla G, Oñate E, Perez-Yarza EG, Montes M, Vicente D, Perez-Trallero E. Viruses in community-acquired pneumonia in children aged less than 3 years old: High rate of viral coinfection. J Med Virol. 2008;80:1843–9. [PubMed]
17. Waterer GW, Wunderink RG. The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures. Respir Med. 2001;95:78–82. [PubMed]
18. Mulholland S, Gavranich JB, Chang AB. Antibiotics for community-acquired lower respiratory tract infections secondary to Mycoplasma pneumoniae in children. Cochrane Database Syst Rev. 2010;(7):CD004875. [PubMed]
19. Haider BA, Saeed MA, Bhutta ZA. Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months. Cochrane Database Syst Rev. 2008;(2):CD005976. [PubMed]
20. MacDonald N, Onyett H, Bortolussi R, Canadian Paediatric Society, Infectious Diseases and Immunization Committee Managing Seasonal and Pandemic Influenza in Infants, Children and Youth. < www.cps.ca/english/publications/SeasonalPandemicFlu.pdf> (Accessed on June 15, 2011).
21. Virkki R, Juven T, Mertsola J, Ruuskanen O. Radiographic follow-up of pneumonia in children. Pediatr Pulmonol. 2005;40:223–7. [PubMed]
22. Chibuk TK, Cohen E, Robinson JL, Mahant S, Hartfield DS, Canadian Paediatric Society, Hospital Paediatrics Section Paediatric complicated pneumonia: Diagnosis and management of empyema. Paediatr Child Health. 2011;16:425–7. [PMC free article] [PubMed]

Articles from Paediatrics & Child Health are provided here courtesy of Pulsus Group
PubReader format: click here to try

Formats:

Related citations in PubMed

See reviews...See all...

Cited by other articles in PMC

See all...

Links

Recent Activity

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...