Pediatric Pneumonia in the ED

Jadavji T (2011). An Evidence-Based Review Of Pediatric Pneumonia In The ED. Pediatric Emergency Medicine Practice, 8(2).

Let’s not muck around — here are 8 Q-and-As to test whether you’re a (wo)man or an amoeba when it comes to childhood pneumonia…

Questions

Q1. From a global perspective, how important is childhood pneumonia?

Answer and interpretation

Pneumonia is the no. 1 killer of children worldwide.

There are over 2 million deaths per year from pneumonia, accounting for 1 in 5 deaths of children under 5 years of age. This is more than AIDS, malaria and measles combined.


Q2. How is pneumonia diagnosed?

Answer and interpretation

Definitions of pneumonia are hard to pin down!

In the simplest clinical terms, pneumonia is simply an infection resulting in lower respiratory tract dysfunction in the presence of radiographic abnormalities on chest x-ray.

A chest radiograph should be considered in children with prolonged cough, high or prolonged fever and in the presence of focal respiratory signs other than wheeze (especially if there are multiple signs and symptoms).

In resource poor settings, WHO guidelines for pneumonia in children aged 2 months to 5 years states that a clinical diagnosis can be made if the child has a cough and fast or difficult breathing. Tachypnea according to age is defined as:

  • RR>60 if <2 months, RR>50 if 2 months to 12 months, and RR>40 if 12 months or older.

Q3. How should respiratory rate be measured?

Answer and interpretation

Respiratory rate should be measured by observation of an awake child who is not crying over 60 seconds.

Measurement of respiratory rate will vary according to:

  • method of measurement: lower respiratory rate for observation than electronic measurement, which are both less than for measurement by auscultation.
  • duration of measurement: increased RR if measured over 15 seconds rather than 60 seconds.
  • child activity: respiratory rate is increased if crying or active, decreased if asleep.

Q4. What is occult pneumonia?

Answer and interpretation

Occult pneumonia refers to the presence of CXR abnormalities consistent with pneumonia in a febrile child with no evidence of tachypnea or focal respiratory signs. In the current post-vaccination age, about 5-7% of cases of diagnosed pneumonia are occult.


Q5. How can viral pneumonia be distinguished from bacterial pneumonia?

Answer and interpretation

Viral and bacterial causation cannot be reliably distinguished in usual clinical practice.

In modern times, even with a comprehensive search for a cause, the underlying etiology of pneumonia remains unknown in over 20% of cases. Furthermore, viral and bacterial causes may coexist.

Traditionally the appearance of the chest radiograph was felt to help distinguish between viral and bacterial causation:

  • Viral pneumonias classically show perihilar bronchial thickening, interstitial opacities and hyperinflation.
  • Bacterial pneumonias classically cause lobar consolidation.

In reality, either radiographic appearance may be seen in viral or bacterial causes.

Age is the best predictor of the likely cause of pneumonia in children.


Q6. What is the likely cause of pneumonia in the following age groups (in order!):

Neonates

Group B streptococci, Escherischia coli, Listeria monocytogenes, Staphylococcus aureus

1 month to 2 years

Respiratory syncytial virus, parainfluenza virus, metapneumovirus, influenza virus, adenovirus, Streptococcuspneumoniae

(NB. 3 weeks to 3 years: pneumonitis syndrome may be caused by: Chlamydiapneumoniae, RSV, parainfluenza virus, Bordetellapertussis)

2 – 5 years

Respiratory syncytial virus (RSV), Streptococcus pneumoniae, non-typeable Haemophilus influenzae, Group A Streptococcci, Mycoplasma pneumoniae, Chlamydia pneumoniae

6-18 years

Mycoplasma pneumoniae, Chlamydiapneumoniae, Streptococcuspneumoniae, non-typeable Haemophilus influenzae, influenza A, other respiratory viruses

The choice of antibiotics depends on the likely cause, and the severity of illness, and should be guided by local practice guidelines and sensitivity patterns.

Q7. Which children with pneumonia require admission?

Answer and interpretation

There is little evidence to guide us in deciding who to admit to hospital.

Hospitalisation should be considered when:

  • age < 6months (more likely to rapidly deteriorate)
  • hypoxemia (Sp02 <92% OA)
  • toxic appearance or severe respiratory distress
  • suspected complications (e.g. empyema)
  • immunocompromise
  • vomiting, dehydration or not tolerating oral intake
  • social circumstances

Q8. How has the epidemiology of pneumonia in children changed since the introduction of pneumococcal vaccination?

Answer and interpretation

The introduction of pneumococcal vaccination has decreased the rates of pneumonia, and in particular has reduced rates of pneumococcal hospitalisations. However, the rates of empyema complicating pneumonia have increased, although pneumococcal disease is now less likely to be the cause. MRSA should be considered in this setting, along with the administration of vancomycin.


More pediatric perplexity

CLINICAL CASES

Pediatric Perplexity

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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