Pneumonia, bronchiolitis and asthma are all common illnesses that result in children presenting with acute lower respiratory symptoms and signs. Antibiotics should be given to children with bacterial pneumonia but not to children with bronchiolitis or asthma.
Most children with pneumonia present with cough or difficulty breathing, but only the minority of children with these symptoms have pneumonia. Bacterial pneumonia should be considered in children <3 years of age who present with fever > 38.5, chest recession and increased respiratory rate >50 breaths/minute. Older children with bacterial pneumonia often present with difficultly
breathing in combination with tachypnoea. If wheeze is present in a preschool child, primary bacterial pneumonia is unlikely however in school age children it may suggest Mycoplasma pneumonia.
Pneumonia Complications
Health professionals caring for children with pneumonia should be aware of the range of potential complications, how to recognise them and their management. The following serves to highlight these complications but is not intended as a full list nor a comprehensive guide to their management.
(a) Syndrome of inappropriate anti-diuretic hormone (SIADH): Inappropriate secretion of anti-diuretic hormone leads to retention of water and hyponatraemia. This is recognised frequently in paediatric respiratory illness. Most children should be managed with ¾ maintenance (see Intravenous Fluids guideline). Consider symptomatic hyponatraemia if there is irritability, an altered level of consciousness. Initial test is serum electrolytes. Seek
expert advice on management.
(b) Lung necrosis: Necrosis and liquefaction of lung tissue. Suspicion may be raised by poor response to treatment, including persisting fever. Definitive diagnosis requires contrast chest CT . Additional therapy or surgical intervention is not necessarily required and outcome with conservative management in childhood is usually good. Careful follow up is required as long term sequelae may follow.
(c) Pneumatocoele: These are thin-walled air-filled cysts that develop within the parenchyma. They are particularly associated with Staphylococcus aureus and will usually resolve over time without specific intervention. Careful follow up is recommended to ensure full recovery and resolution. Family should be notified that it may be unsafe for the child to fly while the pneumatocoele(s) are present.
(d) Atelectasis / Lobar collapse: This is not uncommon. Chest physiotherapy (airway clearance techniques) may be indicated. Follow up should be arranged to ensure resolution as may be associated with long term sequelae. Children with persistent lobar collapse should be referred to a respiratory paediatrician for review and potentially a flexible bronchoscopy.
(e) Lung abscess: The symptoms and signs of lung abscess are the same as for pneumonia and they may be difficult to distinguish on clinical grounds alone. Diagnosis is usually made by chest x-ray supported by contrast CT chest. The presence of underlying lung disease or malformation, foreign body, aspiration, or immunodeficiency should be carefully considered. Blood cultures, full blood count and inflammatory markers should be obtained at diagnosis. Therapy is a prolonged course of antibiotics, usually a minimum of 4 weeks. Management
of lung abscess should be guided by a respiratory paediatrician.
(f) Chronic bronchitis / bronchiectasis (sequelae): Children with persistent symptoms and/or signs including chronic productive cough, persistent crackles, clubbing and/or x-ray findings should be evaluated further for possible underlying bronchitis/bronchiectasis.
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Most children with pneumonia present with cough or difficulty breathing, but only the minority of children with these symptoms have pneumonia. Bacterial pneumonia should be considered in children <3 years of age who present with fever > 38.5, chest recession and increased respiratory rate >50 breaths/minute. Older children with bacterial pneumonia often present with difficultly
breathing in combination with tachypnoea. If wheeze is present in a preschool child, primary bacterial pneumonia is unlikely however in school age children it may suggest Mycoplasma pneumonia.
Pneumonia Complications
Health professionals caring for children with pneumonia should be aware of the range of potential complications, how to recognise them and their management. The following serves to highlight these complications but is not intended as a full list nor a comprehensive guide to their management.
(a) Syndrome of inappropriate anti-diuretic hormone (SIADH): Inappropriate secretion of anti-diuretic hormone leads to retention of water and hyponatraemia. This is recognised frequently in paediatric respiratory illness. Most children should be managed with ¾ maintenance (see Intravenous Fluids guideline). Consider symptomatic hyponatraemia if there is irritability, an altered level of consciousness. Initial test is serum electrolytes. Seek
expert advice on management.
(b) Lung necrosis: Necrosis and liquefaction of lung tissue. Suspicion may be raised by poor response to treatment, including persisting fever. Definitive diagnosis requires contrast chest CT . Additional therapy or surgical intervention is not necessarily required and outcome with conservative management in childhood is usually good. Careful follow up is required as long term sequelae may follow.
(c) Pneumatocoele: These are thin-walled air-filled cysts that develop within the parenchyma. They are particularly associated with Staphylococcus aureus and will usually resolve over time without specific intervention. Careful follow up is recommended to ensure full recovery and resolution. Family should be notified that it may be unsafe for the child to fly while the pneumatocoele(s) are present.
(d) Atelectasis / Lobar collapse: This is not uncommon. Chest physiotherapy (airway clearance techniques) may be indicated. Follow up should be arranged to ensure resolution as may be associated with long term sequelae. Children with persistent lobar collapse should be referred to a respiratory paediatrician for review and potentially a flexible bronchoscopy.
(e) Lung abscess: The symptoms and signs of lung abscess are the same as for pneumonia and they may be difficult to distinguish on clinical grounds alone. Diagnosis is usually made by chest x-ray supported by contrast CT chest. The presence of underlying lung disease or malformation, foreign body, aspiration, or immunodeficiency should be carefully considered. Blood cultures, full blood count and inflammatory markers should be obtained at diagnosis. Therapy is a prolonged course of antibiotics, usually a minimum of 4 weeks. Management
of lung abscess should be guided by a respiratory paediatrician.
(f) Chronic bronchitis / bronchiectasis (sequelae): Children with persistent symptoms and/or signs including chronic productive cough, persistent crackles, clubbing and/or x-ray findings should be evaluated further for possible underlying bronchitis/bronchiectasis.
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