Paediatric pneumonia

Pneumonia is an acute infection of the respiratory system that can occur in one or both lungs causing inflammation of the lung tissue. The inflammation interferes with the body’s ability to deliver oxygen and remove carbon dioxide from the blood. Children can develop pneumonia at any age, but it is more common in babies and younger children.

Worldwide, pneumonia is responsible for nearly 20% of child deaths and is the leading cause of death due to infectious diseases for this age group (UNICEF, 2020). Pneumonia is associated with poverty and is a marker of inequities such as poor nutrition, overcrowded households, lack of clean water and basic sanitation and high levels of indoor and outdoor air pollution (United Nations International Children's Emergency Fund (UNICEF), 2020).

The symptoms of pneumonia will vary depending on the age of the child and the cause of the infection. The most common symptoms are cough, pyrexia and rapid respiratory rate (tachypnoea). Newborns and babies under 1 month old rarely cough as a direct consequence of pneumonia and instead may grunt.

Children have pliable rib cages. When respiratory effort is increased the muscles between the ribs may be drawn in (intercostal recession) and along the costal margins where the diaphragm attaches (subcostal recession). In newborns, even the sternum itself may draw in (sternal recession). With older children, where the ribs are less pliable, there may instead be use of accessory muscles, such as the sternomastoid in the neck, rather than recession. This may be accompanied by nostril flaring (University of Warwick, 2006).

In newborns under 1 month, observe for:

• struggling to breathe - they may be grunting or moving their head

Pneumonia can be caused by bacteria or by a virus. Less commonly, pneumonia can also be caused by fungal infection and aspiration. It is normally classified according to whether it is community acquired pneumonia or hospital acquired pneumonia. The latter is an acute lower respiratory tract infection (usually bacterial) that is acquired after at least 48 hours of admission to hospital and is not incubating at the time of admission (Kalil et al, 2016). It is the most frequent hospital-acquired infection in critically ill patients (Mansour and Bendry, 2012).

Viruses are a common cause of pneumonia in young children, particularly premature babies. The most common viral cause is usually respiratory syncytial virus (RSV) or influenza (flu) type A or B. These viruses do not respond to antibiotics, but a child’s immune system can usually fight them off. The COVID-19 virus is less serious in children and rarely causes pneumonia

COVID-19 can precipitate pneumonia. Please consult the latest guidelines (see resources section) for the specific diagnosis and management guidance.

Be alert for signs of sepsis (see resources section): blotchy skin or a rash that does not fade when you roll a glass over it.

Diagnosis in children can be difficult and is made by a comprehensive assessment:

• physical examination for abnormal breathing patterns
• auscultation of the chest for breath sounds
• assess the child's hydration status by measuring capillary refill time, examining skin turgor and dryness of mucous membranes, and ascertaining urine output.
• pyrexia, tachycardia and tachypnoea, relevant to the age of the child (Table 1)
• chest X-ray is not routinely done with community acquired infections
• pulse oximetry to look for low oxygen saturation levels of 93% or less on room air
• blood tests such as full blood count, white cell count and urea and electrolytes
• microbiological methods to identify the

Bacterial pneumonia can be treated with antibiotics. However, all children with a clear clinical diagnosis of pneumonia should receive antibiotics as bacterial and viral pneumonia cannot reliably be distinguished from each other (Harris et al, 2011). In most cases, pneumonia can be treated at home with oral antibiotics. The type of antibiotic used depends on the type of pneumonia. Viral pneumonia usually resolves on its own without the need for medication.

If the child does not improve after 48 hours of treatment at home, hospital treatment may be needed. For example if there is:

• persistent pyrexia
• auscultation revealing absent breath sounds with a dull percussion note should raise the possibility of a pneumonia complicated by effusion 
• oxygen saturations <92%
• the child’s breathing worsens and if verbal, they cannot speak a full sentence
• problems with feeding or urinary output (Harris et al, 2011)

Hospital management might involve the administration of intravenous antibiotics and supplementary

Conservative management of paediatric pneumonia includes:

• paracetamol syrup to manage pyrexia
• maintain fluid intake by offering drinks
• encourage the child (depending upon age) to cough up phlegm
• younger children can be helped when coughing by lying the child across the knees and patting the back
• assist breathing by raising the head of the child’s cot or by putting a pillow or blanket beneath the mattress
• applying a warm compress to the chest if the child complains of chest pain
• regularly checking blood oxygenation by observing that the child’s nail bed and lip colour remains pink (Great Ormond Street Hospital, 2020)