Pneumonia (kids)

[display-posts category=”paediatrics”]

1. Epidemiology
   1. common condition
      1. 40 per 1,000 in children < 5 years of age
      2. 15 per 1,000 in children 514 years of age
   2. males more commonly affected than females
   3. presents with fever, cough, tachypnoea and possibly grunting
   4. can present as
      1. fever without source
      2. abdominal pain
      3. meningism
   5. tachypnoea by itself does not discriminate children with or without pneumonia
   6. auscultation unreliable
2. Causes
   1. viral more common than bacterial
   2. differentiation best done clinically as XR, WCC, neutrophils, CRP all unreliable for differentiation
   3. viruses
      1. responsible for the majority of cases, especially in infants
      2. RSV responsible for approximately 30% of cases
      3. influenza
      4. parainfluenza
      5. adenovirus
      6. often causes a neutrophilia
   4. bacteria
      1. Strep. pneumoniae (especially in children < 5years of age)
      2. Staph aureus
      3. Mycoplasma pneumoniae
         1. up to 30% of community pneumonias
         2. mean age 6.3 +/ 3.5 yrs
         3. associated nonrespiratory symptoms include Kawasaki syndrome, Erythema multiforme, cold urticaria, Guillain Barre
   5. Chlamydia trachomatis

3. Clinical

• fever, cough, tachypnoea
• Diagnose clinically if signs of lower respiratory tract infection – and wheezing syndrome, foreign body have been ruled out
• Only need CXR if suspect severe or complicated
• Red flags
  • Respiratory distress
  • Apnoeas
  • Hypoxaemia/cyanosis
  • Marked tachycardia
  • Altered mental state
  • empyema

4. Assessment
   1. Clinical features
      1. difficult to differentiate bacterial from viral infection on clinical grounds
      2. wheeze in preschooler makes bacterial cause unlikely
      3. bilateral signs make viral more likely
      4. Mycoplasma has indolent course with variable signs such as crackles, wheeze diffuse or focal
      5. XR changes of lobar or segmental consolidation makes bacterial more likely
      6. cavitations and pleural effusions are more likely bacterial esp Staph Aureus
   2. Investigation
      1. CXR
         1. useful with isolated signs
         2. less helpful with widespread wheeze and/or crackles
         3. ‘round’ pneumonia associated with Staph aureus infection
      2. blood culture – in patients with likely bacterial pneumonia needing admission
      3. nasopharyngeal aspirate for PCR
         1. can be useful in young children to identify virus, older children for mycoplasma
         2. not useful for bacterial culture
      4. WCC, CRP and ESR unhelpful in determining cause
5. Management
   1. most managed at home with early community review
   2. Antibiotics
      1. First line – amoxicillin 30mg/kg up to 1g TDS for 3 -5 days
      2. 2nd line – cefuroxime
      3. Anaphylaxis – azithromycin 10mg/kg up to 500mg PO for 3 days ( or doxycycline)
   3. admission indicated if
      1. age < 6-12 months
      2. toxic appearance
      3. significant respiratory distress
      4. hypoxia
      5. extensive consolidation, effusion or cavitations on XR
      6. dehydration
      7. not tolerating oral antibiotics
      8. failure to respond to 48 hours of oral antibiotics
      9. previous cardiorespiratory compromise, congenital heart disease, prematurity, immunodeficiency, trisomy 21
      10. geographic location, access to travel, other social issues
   4. more severe pneumonia
      1. IV flucloxacillin and 3rd generation cephalosporin
      2. suspected Mycoplasma or Chlamydia pneumonia, or failure to improve with amoxycillin/penicillin monotherapy by 48 hours requires erythromycin or roxithromycin or azithromycin
   5. Follow up CXR in 4-6 weeks only if complciated/severe

Protracted bacterial bronchitis

1. Criteria
   1. Wet sounding cough
   2. Present > 4 weeks
   3. Isolated symptom and child otherwise well
   4. Wet and moist in nature, with rattly sound sometimes present on chest exam
   5. Present day and night, worse with changing posture
   6. Not SOB – aside from coughing fits
2. Treatment
   1. Augmentin for 2 weeks
   2. If helpful but not fully resolved can extend to 4 weeks