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Emergency And Acute Medicine – Pneumonia in Pediatric Patients
Pneumonia in children is an infection of the lung parenchyma most commonly resulting from oropharyngeal aspiration, although hematogenous spread may occur. The radiographic distribution often depends on the organism involved: interstitial patterns are typically seen with viral infections and Mycoplasma pneumoniae, lobar consolidation with Streptococcus pneumoniae, abscess formation with Staphylococcus aureus, and diffuse disease with Pneumocystis jirovecii. Clinical presentation and likely pathogens vary significantly with age.
In neonates younger than 2 weeks, common pathogens include group B Streptococcus, enteric gram-negative organisms, respiratory syncytial virus (RSV), herpes simplex virus, and S. aureus. Between 2 weeks and 3 months, pathogens include Chlamydia trachomatis, parainfluenza virus, RSV, S. pneumoniae, S. aureus, Haemophilus influenzae, and Bordetella pertussis. From 3 months to 8 years, viral etiologies predominate (RSV, parainfluenza, influenza, adenovirus), along with S. pneumoniae, H. influenzae in unimmunized children, group A streptococcus, S. aureus, and B. pertussis. In children older than 8 years, Mycoplasma pneumoniae is most common, followed by viral pathogens and S. pneumoniae. Recent immigrants may be at risk for Mycobacterium tuberculosis. Immunocompromised children are susceptible to organisms such as Pneumocystis jirovecii, Mycobacterium avium complex, M. tuberculosis, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Less common causes include fungal infections and rickettsial organisms.
Common symptoms across all pediatric age groups include cough, fever, tachypnea, tachycardia, hypoxia, rales, and signs of respiratory distress such as retractions or grunting. A maculopapular rash may occur in up to 10% of cases. Infants younger than 6 months may present atypically with irritability, lethargy, apnea (especially RSV in premature infants), cyanosis, poor feeding, temperature instability, vomiting with coughing, nasal congestion, nasal flaring, or wheezing. A staccato cough in infants suggests Chlamydia trachomatis. Older children, particularly those over 5 years, are more likely to report pleuritic chest pain, productive cough, rigors, and chills. A thorough history should include immunization status, immune function, exposures, and progression of symptoms.
Pulse oximetry is essential in all suspected cases. Chest radiography remains the gold standard for diagnosis and should be obtained in children with signs of lower respiratory tract infection and in those younger than 36 months with marked leukocytosis (WBC >15,000 or absolute neutrophil count >9,000). Viral and Mycoplasma infections often produce interstitial, perihilar, or peribronchial infiltrates, whereas bacterial infections may demonstrate focal lobar consolidation, alveolar infiltrates, pleural effusion, or pneumatocele. Round pneumonia is considered pathognomonic for S. pneumoniae. Lateral decubitus films can help identify pleural effusions.
Laboratory studies may include a complete blood count, although sensitivity and specificity are limited. Marked leukocytosis (WBC ≥20,000 or ANC >9,000) increases the risk of pneumococcal bacteremia. Bordetella pertussis typically presents with leukocytosis and lymphocytosis. Blood cultures are recommended in children younger than 36 months and in toxic-appearing or hospitalized patients, though yield is low. Arterial blood gas analysis may be necessary in critically ill patients to assess respiratory insufficiency. Electrolytes should be checked in hypotensive children or when syndrome of inappropriate antidiuretic hormone secretion is suspected. Sputum cultures may be obtained in older children, and nasopharyngeal testing can identify RSV, C. trachomatis, and B. pertussis.
Initial management focuses on airway, breathing, and circulation. Children with moderate to severe illness may require aggressive airway management and intubation. High-flow oxygen should be administered for hypoxia. Intravenous fluid resuscitation with 0.9% normal saline (20 mL/kg bolus) is indicated for hypovolemia or shock. Bedside glucose should be checked in severely ill infants and toddlers, with prompt treatment of hypoglycemia. Ongoing monitoring with pulse oximetry is essential.
Empiric antibiotic therapy depends on age and clinical severity. Most well-appearing children aged 6 months and older can be treated as outpatients with oral antibiotics. For children aged 3 months to 5 years, amoxicillin is first-line therapy, with alternatives including amoxicillin–clavulanate or macrolides when atypical pathogens are suspected. For children aged 5 to 18 years, macrolides such as azithromycin or clarithromycin are commonly used for suspected Mycoplasma pneumoniae. Neonates requiring hospitalization should receive ampicillin plus cefotaxime or gentamicin, with azithromycin added if Chlamydia trachomatis or Bordetella pertussis is suspected. Infants 1–2 months old should receive ampicillin plus cefotaxime. Children older than 3 months requiring admission may receive cefotaxime, cefuroxime, or ceftriaxone, with vancomycin added for suspected penicillin-resistant S. pneumoniae, macrolides for atypical pathogens, and clindamycin for suspected group A streptococcal infection. Bronchodilators such as albuterol may be beneficial in children with concurrent reactive airway disease. Thoracentesis is indicated for significant pleural effusion.
Admission is warranted for toxic appearance, respiratory distress or failure, dehydration, apnea, infants younger than 2 months, infants younger than 6 months with lobar pneumonia, hypoxia (oxygen saturation <92% on room air at sea level), pleural effusion, poor outpatient response, immunocompromised status, or concerns about caregiver reliability. most mild cases can be discharged if there is no hypoxia, significant work of breathing, dehydration, vomiting, compliance concern, with follow-up ensured within 1–2 days.< />pan>
Early recognition and aggressive airway management are critical in children with severe sepsis or septic shock. Delays in antibiotic therapy should be avoided. Knowledge of local antimicrobial resistance patterns is essential to guide empiric therapy. Clear discharge instructions, reliable follow-up, and caregiver education are vital to ensure safe outpatient management.
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