Paediatric Pneumonia
Pneumonia is an infection of the lower respiratory tract leading to inflammation and consolidation of the lung tissue. It’s a leading cause of paediatric hospitalisation and mortality worldwide. UK guidelines, particularly those from the National Institute for Health and Care Excellence (NICE) and the British Thoracic Society (BTS), focus on a risk-stratified approach to management, emphasising correct antibiotic choice and identifying children who need hospital admission.
Aetiology and Clinical Presentation
Causative Organisms
The most common cause of community-acquired pneumonia (CAP) in children is viral, particularly in infants and toddlers.
Viruses: Respiratory Syncytial Virus (RSV), Adenovirus, Influenza, Parainfluenza.
Typical Bacteria:
Streptococcus pneumoniae: The most common bacterial cause across all paediatric age groups.
Haemophilus influenzae.
Atypical Bacteria:
Mycoplasma pneumoniae and Chlamydophila pneumoniae: More common in school-aged children and adolescents.
Specific Risk Groups:
Cystic Fibrosis: Staphylococcus aureus in infants, and Pseudomonas aeruginosa in older children.
Immunocompromised: A broader range of organisms, including Gram-negative bacteria and fungi.
Clinical Presentation
The classic triad of symptoms is fever, cough, and tachypnoea.
Infants: Tachypnoea is the most consistent sign. Other signs are often non-specific, such as poor feeding, irritability, and grunting.
Older Children: Symptoms include fever (often high), productive cough, pleuritic chest pain, and increased work of breathing.
Examination: On chest auscultation, there may be bronchial breath sounds over an area of consolidation and fine crackles.
UK Management and Guidelines
The majority of children with mild to moderate pneumonia can be safely managed at home with oral antibiotics.
Admission Criteria
NICE guidelines recommend hospital admission for children with any of the following:
Age: Infants under 3 months old.
Risk Factors: Underlying cardiorespiratory disease, neuromuscular condition, or immunodeficiency.
Clinical Signs:
Hypoxia: Oxygen saturation (SpO2) of less than 92% in air.
Significant Respiratory Distress: Marked subcostal and intercostal recession, grunting, or a very high respiratory rate.
Apnoeas.
Dehydration or inability to tolerate oral fluids and antibiotics.
Signs of severe disease: A toxic-looking or very unwell child.
Investigations
Not needed for a well child who is able to be managed at home.
For admitted patients:
Blood tests: Full blood count, urea & electrolytes, and C-reactive protein (CRP).
Chest X-ray: Indicated for all hospitalised patients to confirm the diagnosis and check for complications like a pleural effusion.
Microbiology: Blood culture and nasopharyngeal swabs are taken to identify the causative organism.
Antibiotic Therapy
Community-Managed Pneumonia: Oral amoxicillin is the first-line antibiotic. If an atypical organism is suspected, or for children with a penicillin allergy, a macrolide such as clarithromycin is used.
Hospital-Admitted Pneumonia:
Mild/Moderate CAP: IV amoxicillin or benzylpenicillin.
Severe CAP: Co-amoxiclav may be considered, often with the addition of a macrolide if an atypical pathogen is suspected.
Special Cases:
Aspiration Pneumonia: Often managed with co-amoxiclav.
Suspected Staphylococcal Pneumonia: Consider adding flucloxacillin.
Key Principles
Monitoring: All admitted children require frequent monitoring of their vital signs, including oxygen saturation.
Hydration: Ensure adequate hydration either orally or with intravenous fluids.
Discharge: The child can be discharged once they are clinically stable, their SpO2 is consistently over 92% in air, they are tolerating oral antibiotics, and the family is confident in providing care at home.
Safety-Netting: Parents must be given clear instructions on when to seek medical help again.