Who is most affected:

males
children aged < 5 years and children born between
24-28 weeks gestation more likely to have severe
disease

Incidence/Prevalence:

incidence in developed world about 30-40 cases per
1,000 for children < 5 years old



Age Bacterial Viral
20 days Common causes Escherichia coli
Group B streptococci
Listeria monocytogenes
Less common causes Anaerobic
organisms
Group D streptococci
Haemophilus influenzae
Streptococcus pneumoniae
Ureaplasma urealyticum

Less common
causes
Cytomegalovirus
Herpes simplex
virus

3 weeks to 3
months
Common causes Chlamydia
trachomatis
S. pneumoniae
Less common causes Bordetella
pertussis
H. influenzae type b and
nontypeable
Moraxella catarrhalis
Staphylococcus aureus
U. urealyticum

Common causes
Adenovirus
Influenza virus
Parainfluenza virus
1, 2, and 3
Respiratory
syncytial virus
Less common
causes
Cytomegalovirus
Age Bacterial Viral
4 months to 5 years Common causes Chlamydia
pneumoniae
Mycoplasma pneumoniae
S. pneumoniae
Less common causes H.
influenzae type b
M. catarrhalis
Mycobacterium tuberculosis
Neisseria meningitis
S. aureus
Common causes
Adenovirus
Influenza virus
Parainfluenza virus
Rhinovirus
Respiratory syncytial
virus
Less common causes
Varicella-zoster virus

5 years Common causes C.
pneumoniae
M. pneumoniae
S. pneumoniae
Less common causes H.
influenzae
Legionella species
M. tuberculosis
S. aureus

Less common causes
Adenovirus
Epstein-Barr virus
Influenza virus
Parainfluenza virus
Rhinovirus
Respiratory syncytial
virus
Varicella-zoster virus

bacterial infection likely in hospitalized children with
pneumonia
based on prospective cohort study
154 immunocompetent children aged 2 months to 17 years
(median 33 months) hospitalized with radiographically
confirmed lower respiratory infection were evaluated
identified pathogens
typical respiratory bacteria in 60% (73% of which were S.
pneumoniae)
viruses in 45%
mixed bacterial/viral infections in 23%
M. pneumoniae in 14%
C. pneumoniae in 9%
bacterial pneumonia significantly associated with
temperature 38.4 degrees C within 72 hours after admission .
presence of pleural effusion.

atypical pathogens account for 25%-28% of community-
acquired pneumonia worldwide
based on retrospective analysis of 4,337 patients
28% of community-acquired (CAP) cases in Europe and 20%-22% in
North America, Latin America, Asia, and Africa were due to atypical
pathogens
12% due to M. pneumoniae
7% due to C. pneumoniae
5% due to L. pneumophila
most common atypical pathogen appears to be M.
pneumoniae in young children hospitalized with CAP
based on prospective cohort study in India
243 children aged 1-59 months hospitalized for CAP were assessed
for C. pneumoniae, M. pneumoniae, and L. pneumophila by
immunofluorescence, enzyme-linked immunoadsorbent assay,
bacterial culture, and polymerase chain reaction
M. pneumoniae detected in 9.9% (24 children); no infections due to
C. pneumoniae or L. pneumophila
no significant differences in symptoms, signs, complete blood count,
and chest x-ray findings in patients with M. pneumoniae compared
to children without M. pneumoniae infection
Pathogenesis:
pneumonia usually follows upper respiratory tract
illness
(5)

bacteria, viruses, or other pathogens invade lower
respiratory tract and trigger immune response and
produce inflammation
histamines, leukotrienes, and chemotactic factors
released that recruit white blood cells to area
air spaces of lower respiratory tract fill with white blood
cells, fluid, and cellular debris resulting in
reduced lung compliance
increased resistance
obstruction of smaller airways
possible collapse of distal air spaces

Likely risk factors:

male gender
age < 5 years, birth at 24-28 weeks gestation associated with higher risk of severe disease
in developing countries
based on subgroup analysis of database from Child Health Epidemiology Reference Group (CHERG)
working group on pneumonia
malnutrition
low birth weight ( 2,500 g)
nonexclusive breastfeeding during first 4 months of life
no measles immunization within first 12 months of life
indoor air pollution
crowding
parental smoking
zinc deficiency
maternal inexperience as caregiver
concomitant disease (such as diarrhea, heart disease, asthma)

most cases of recurrent pneumonia in children related to underlying illnesses including
aspiration syndrome
immune disorder (including HIV)
congenital heart disease
asthma
pulmonary anomalies
gastroesophageal reflus disease (GERD)
sickle cell disease

incidence of empyema and lung abscess appears to be increasing and may be
associated with preadmission ibuprofen use in children hospitalized for
pneumonia
based on retrospective cohort study in 1995-2003 in France
767 children aged 28 days to 15 years hospitalized with uncomplicated vs. complicated
primary community-acquired pneumonia were assessed
complicated pneumonia defined as pleural effusion > 1 cm thick on ultrasound, or
presence of lung abscess or cavitation
90 children (11.7%) had complicated pneumonia during study period
pleural empyema in 70 children (78%)
pleural empyema with lung abscess in 13 children (14%)
lung abscess without pleural involvement in 7 children (8%)
pathogen isolated in 19 children (21%)
prevalence was 2.8% in 1995-1998 compared to 23.1% in 2003 (p < 0.001)
comparing uncomplicated vs. complicated pneumonia
median age 3 vs. 4.1 years (p = 0.02)
hospitalization after 1998 in 59.4% vs. 88.9% (p < 0.001)
median preadmission fever duration 3 vs. 6 days (p < 0.001)
number of preadmission medical exams 1-2 vs. 2-3 (p < 0.001)
preadmission medication use adjusted for demographic and contextual variables
ibuprofen in 14.3% vs. 36.7% (odds ratio 2.57, 95% CI 1.51-4.35)
no significant differences in antibiotics or other anti-inflammatory medication use
pathogen isolated in blood or effusion in 1.9% vs. 21%
Streptococcus pneumoniae in 12 vs. 14 children
Streptococcus pyogenes in 1 vs. 2 children
Fusobacterium species in 0 vs. 2 children
Staphylococcus aureus in 0 vs. 1 child

pediatric parapneumonic empyema may be associated with ibuprofen use
based on cohort of 540 children hospitalized with community-acquired bacterial
pneumonia in Utah 1993-1999
153 (28%) had empyema
risk factors for empyema were
age > 3 years
fever 7 days
varicella
antibiotic use before hospital admission
ibuprofen use before hospital admission
mild hyponatremia common in children with pneumonia
based on prospective cohort study
108 children aged 4 months to 16 years (mean age 4.6 years) with community-
acquired pneumonia (based on chest x-ray) were assessed for serum sodium
concentration
97 children with serologic evidence of causative agent of pneumonia were
analyzed
hyponatremia (defined as serum sodium < 135 mmol/L [135 mEq/L]) in 49
children (45%)
severe (< 125 mmol/L [125 mEq/L]) in 2 children
moderate (125-129 mmol/L [125-129 mEq/L]) in 2 children
mild (130-134 mmol/L [130-134 mEq/L]) in 45 children
hyponatremia not associated with x-ray findings or causative agent

many children with pneumonia have unrecognized
asthma or subsequently develop asthma

based on prospective cohort study
78 children < 16 years old admitted for pneumonia
(confirmed by x-ray) were followed for median 68
months (range 61-91 months)
diagnosis of asthma at time of admission in 19%
diagnosis of asthma at time of follow-up in 45%

Making the diagnosis:
chest x-ray often used as diagnostic standard, but not needed in patients
well enough to be treated as outpatients
clinical prediction of pneumonia in children
no single sign could definitively rule in or rule out pneumonia in infants
clinical features suggestive of pneumonia include
tachypnea
retractions
grunting
fever
crepitations
wheezes
in children aged 2-12 months - nasal flaring
in children aged 12-59 months - respiratory rate > 50 breaths/minute and oxygen
saturation < 96%
absence of all of respiratory distress, tachypnea, crackles, and decreased
breath sounds may exclude pneumonia .
best negative predictor for pneumonia is absence of tachypnea alone or
absence of all other signs of respiratory illness
fever, tachypnea, and chest signs in preschool children have poor interobserver
agreement
definitive diagnosis of pneumonia would require lower respiratory tract
aspirate by lung puncture or bronchoalveolar lavage, but not appropriate
except in refractory or complicated pneumonia

Differential diagnosis:
other acute infections
upper respiratory tract
common cold
otitis media
pharyngitis (including streptococcal pharyngitis)
lower respiratory tract (defined as at or below the larynx)
asthma exacerbation (see Asthma exacerbation in children or Asthma
exacerbation in adults or adolescents)
epiglottitis
laryngitis
croup
bronchitis
bronchiolitis
noninfectious disorders
inhaled foreign body (see also Foreign body aspiration)
pulmonary edema (see also Heart failure)
pulmonary emboli
fibrosing alveolitis (see also Idiopathic pulmonary fibrosis)
cancer

Treatment overview:
pediatric outpatients
for children < 5 years old with nonsevere pneumonia
oral amoxicillin usually recommended as first-line empiric treatment for presumed
bacterial pneumonia
recommended amoxicillin regimens range from 50 mg/kg/day orally in 2 divided
doses for 3 days (by World Health Organization [WHO]) to 90 mg/kg/day orally in 2
divided doses for up to 10 days (by IDSA)
consider single dose of ceftriaxone before starting oral antibiotics if unable to
tolerate liquids.
for children 5 years old - recommendations for first-line therapy vary
between amoxicillin and macrolides
consider amoxicillin for presumed bacterial pneumonia and/or macrolide for
presumed atypical pneumonia .
macrolide antibiotics (erythromycin, clarithromycin and azithromycin) appear to
have similar efficacy for community-acquired pneumonia .
dosing
amoxicillin 90 mg/kg/day in 2 divided doses (maximum 4 g/day)
azithromycin 10 mg/kg/day for 1 day (maximum 500 mg/day), then 5
mg/kg/day orally (maximum 250 mg/day) for 4 days
clarithromycin 15 mg/kg/day in 2 divided doses (maximum 1,000 mg/day) for
7-10 days
erythromycin 40 mg/kg/day in 4 divided doses (maximum 2,000 mg/day) for
7-10 days
alternative in children > 8 years old - doxycycline 4 mg/kg/day in 2 divided
doses (maximum 200 mg/day) for 7-10 days


pediatric inpatients
oral antibiotics appear safe and effective for hospitalized children < 5 years old with
severe pneumonia .
recommended IV antibiotics for children hospitalized for community-acquired
pneumonia include
ampicillin or penicillin G for fully immunized children in areas with minimal penicillin resistance in
invasive pneumococcus strains .
ceftriaxone or cefotaxime for children who are severely ill, not fully immunized, or in areas with
penicillin-resistant pneumococcus .
add macrolide (oral or parenteral) when Mycoplasma pneumoniae and Chlamydophila pneumoniae
are significant considerations .
adjunctive treatments
zinc supplementation may not improve clinical recovery in children with
pneumonia, but evidence inconsistent
vitamin A supplementation not associated with significant reduction in
morbidity, mortality, or clinical course of nonmeasles pneumonia in children.
noninvasive positive pressure ventilation (NPPV) associated with reduced
risk for intubation in children with acute respiratory failure but may be less
successful for acute respiratory distress syndrome than for other causes .

follow-up and consider additional testing or change in management if no
improvement 48 hours after starting treatment

Indications for hospitalization:
hospitalization recommended for pneumonia in
infants 20 days old
infants aged 3 weeks to 3 months with fever
all children with toxic appearance
Pediatric Infectious Diseases Society/Infectious Diseases Society of America
(PIDS/IDSA) recommend hospitalization for community-acquired
pneumonia (CAP) in children with any of
moderate-to-severe CAP, defined as any of the following :
tachypnea
retractions (suprasternal, intercostals, or subcostal)
grunting
nasal flaring
apnea
altered mental status
pulse oximetry measurement < 90% on room air
suspected or documented CAP caused by pathogen with increased virulence,
such as community-associated methicillin-resistant Staphylococcus aureus (CA-
MRSA).
concern about careful observation at home, inability to comply with therapy, or
inability to be followed up .
infants < 3-6 months old with suspected bacterial CAP .


British Thoracic Society (BTS) recommendations
(3)

evaluation and management at hospital should occur if
oxygen saturation < 92% .
auscultation reveals absent breath sounds with dullness to percussion; raises
suspicion of pneumonia complicated by effusion.
decision on whether to admit a child should be based on clinical
severity, underlying risk factors for severe disease and ability of parents
to manage illness in the community
features of severe disease that likely require hospital admission include
oxygen saturation < 92%, cyanosis
respiratory rate > 70 breaths/minute in infants or > 50 breaths/minute in older
child
significant tachycardia for level of fever
prolonged central capillary refill time > 2 seconds
difficulty breathing
grunting
intermittent apnea in infant
not feeding in infant, signs of dehydration in older child
chronic conditions, such as
congenital heart disease
chronic lung disease of prematurity
chronic respiratory conditions leading to infection such as cystic fibrosis, bronchiectasis,
immune deficiency
family unable to provide appropriate observation or supervision

home-based treatment with high-dose oral
amoxicillin appears at least as effective as
hospitalization with parenteral ampicillin for
children < 5 years old with severe pneumonia .

day treatment for children < 5 years old with
severe pneumonia may have higher referral and
readmission rates compared to hospital care,
especially for infants with hypoxemia.
Antibiotics:
antibacterial therapy not necessary for children with positive
test for influenza virus in absence of clinical, laboratory, or
radiographic findings that suggests bacterial coinfection in
the outpatient or inpatient setting .
Antibiotics for pediatric outpatients:
various antibiotics may have similar efficacy for pneumonia in
children .
guideline recommendations regarding the need for antibiotic
therapy differ between organizations
Pediatric Infectious Diseases Society (PIDS) and Infectious
Diseases Society of America (IDSA) recommend that antimicrobial
therapy not routinely required for preschool-aged children
because viral pathogens are responsible in most cases .
British Thoracic Society (BTS) recommends all children with clear
clinical diagnosis of pneumonia should receive antibiotics


for children < 5 years old with nonsevere
pneumonia
for presumed bacterial pneumonia -- oral amoxicillin
usually recommended as first-line empiric treatment
amoxicillin for 3 days may have limited efficacy for
children < 5 years old with nonsevere pneumonia in
developing countries .
amoxicillin and co-trimoxazole appear to have similar
efficacy in children aged 2-59 months treated as
outpatients .
3-day course of antibiotics is as effective as 5-day course
for children aged 2-59 months with nonsevere
pneumonia .
double-dose amoxicillin appears no more effective than
standard dose in children < 5 years old with nonsevere
pneumonia
for children 5 years old
recommendations for first-line therapy vary between
amoxicillin and macrolides
macrolide antibiotics (erythromycin, clarithromycin, and
azithromycin) appear to have similar efficacy for
community-acquired pneumonia .
systemic corticosteroids associated with shorter
hospital stay for children with pneumonia and
wheezing but longer hospital stay for children without
wheezing .
insufficient evidence to evaluate benefit of
nonprescription medications for treatment of cough
associated with acute pneumonia .

Prevention:
Pediatric Infectious Diseases Society/Infectious
Diseases Society of America (PIDS/IDSA)
recommendations to prevent community-acquired
pneumonia in children
immunize children with vaccines for bacterial pathogens
including
Streptococcus pneumoniae
Haemophilus influenzae type b
pertussis
immunize all children and adolescents 6 months old
annually with influenza virus vaccine .
immunize parents and caretakers of infants < 6 months old,
including pregnant adolescents, with vaccines for influenza
virus and pertussis to protect infants from exposure .
give high-risk infants immune prophylaxis with palivizumab
to decrease risk of severe pneumonia and hospitalization
caused by respiratory syncytial virus (RSV).





The End