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Child Health Guideline Identifier

Pneumonia

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Exclusions

These guidelines may not be appropriate for immunocompromised children or those with chronic lung disease (e.g. cystic fibrosis, bronchiectasis, neonatal chronic lung disease). Seek senior medical advice.

Clinical features 

NOTE: not all the features below may be present.

History

  • persistent fever
  • tachypnoea at rest
  • cough
  • increased work of breathing/respiratory distress
  • lethargy/ unwell appearance  

Examination

  • hypoxaemia (especially <93%) on pulse oximetry
  • crackles and bronchial breathing on auscultation
  • elevated respiratory rate for age
  • chest wall indrawing, retractions, grunting, nasal flaring
  • apnoea
  • absent breath sounds and a dull percussion note suggest a pleural effusion  
Tachypnoea by age (World Health Organisation)
< 2 months age > 60 breaths per minute
2- 12 months age > 50  breaths per minute
12 months to 5 years age > 40 breaths per minute

Occasionally children present with atypical symtpoms, such as abdominal pain (from referred pain)  and vomiting.

Indications of severe pneumonia

Consider severe pneumonia if there are clinical features of pneumonia and 2 or more of the following:

  • Severe respiratory distress
  • Severe hypoxaemia or cyanosis
  • Marked tachycardia
  • Altered mental state

OR

There are clinical features of complicated pneumonia (including empyema, parapneumonic effusion, lung abscess, or necrotising pneumonia). See Empyema guideline

Staphylococcus aureus is a cause of severe pneumonia. If suspected, discuss with senior staff. Features:

  • Lung abscess or pneumatocoeles
  • Empyema
  • Multisystem infection
  • Very unwell
  • Pneumonia as a consequence of chickenpox, influenza or measles

Consider MRSA coverage (clindamycin or vancomycin) if the child is very unwell (eg requiring PICU admission) or has positive blood cultures indicating Staphylococcus (pending sensitivity).

Investigations

Investigations are guided by clinical features.   Many children with pneumonia may be diagnosed and managed on clinical grounds alone and do not require a chest x-ray (especially if mild, and expected to be managed as an outpatient).

Chest x-ray if:

  • Presentation not typical
  • Diagnostic uncertainty
  • Infants <3 months of age
  • Severely unwell
  • History suggesting underlying respiratory disease
  • Suspected complications (such as effusion) based on clinical signs
  • Not making expected clinical progress.

Other investigations are usually only needed in patients requiring admission:

  • Blood cultures if febrile and unwell, or septic, or complicated pneumonia
  • Serum electrolytes for any child receiving intravenous fluids (risk of hyponatraemia due to SIADH)
  • Full blood count does not differentiate between viral and bacterial causes, but may help identify other issues such as anaemia.
  • Nasopharyngeal swab not always needed, however:
    • Consider viral PCR panel if diagnostic uncertainty, or during influenza season to assist with treatment choice such as antiviral medication in selected cases.
    • Consider atypical pneumonia PCR panel for severe or persistent illness.

Admission 

Indications for admission:

  • Ill or toxic appearance
  • Age < 3 months
  • Oxygen saturation less than 93% on air
  • Respiratory distress interfering significantly with feeding
  • Significant dehydration
  • Complicated pneumonia
  • Deterioration despite appropriate oral antibiotics
  • Significant co-morbidity
  • Social concerns (eg transport or communication barriers)
  • Signs of severe pneumonia can include:
    • Shock or toxic appearance
    • Oxygen saturations < 85%, or diifficulty maintaining oxygenation > 92% with supplemental oxygen.
    • Severe tachycardia
    • Severe respiratory distress

Antibiotic treatment 

Treat suspected bacterial pneumonia with antibiotics. Likely viral pneumonia does not require antibiotic treatment.

Oral antibiotics can be used for most mild to moderate episodes of pneumonia. This may include some of those requiring admission.  

Age/Clinical features   Antibiotic
< 1 month

Oral antibiotics not appropriate in this age group

< 7 days old:
Cefotaxime 50 mg/kg/dose IV 12 hourly PLUS
Amoxicillin 50 mg/kg/dose IV 12 hourly

7 days - 1 month old:
Cefotaxime 50 mg/kg/dose (max 2g) IV 8 hourly PLUS
Amoxicillin 50 mg/kg/dose (max 1g) IV 8 hourly

> 1 month
Mild to moderate pneumonia

Oral antibiotics not appropriate in < 3 month olds

Mild/moderate pneumonia > 3 months old
Oral high dose amoxicillin 30 mg/kg/dose PO 3 times a day (max 500mg/dose)
3 - 5 days (5 days if admitted or radiologically proven) duration

Moderate/Uncomplicated pneumonia needing admission and IV therapy:
Amoxicillin 50 mg/kg/dose (max 1g) IV 6 hourly 5-7 days

1-3 months
Severe pneumonia

Cefotaxime 50 mg/kg/dose (max 2g) IV 6 hourly PLUS
Flucloxacillin 50 mg/kg/dose (max 1g) IV 6 hourly

> 3 months
Severe pneumonia

Cefuroxime 30 mg/kg/dose (max 1.5g) IV 6-8 hourly 

OR

Amoxicillin + clavulanic acid 30 mg/kg/dose (combined dosing, max 1.2g) IV 6-8 hourly

Severe pneumonia possibly due to MRSA

Add Clindamycin (requires ID approval) or
Vancomycin for life threatening sepsis and/or requiring ICU care

Possible Bordetella pertussis or Chlamydia trachomatis

Consider pertussis in younger age group or unimmunised children. Presents with apnoea in the very young, or paroxysmal coughing

Chlamydia usually presents at 3-8 weeks of age with prominent coughing

Send nasopharyngeal swab for PCR testing

Treat with Azithromycin - see NZFC dosing https://nzfchildren.org.nz/nzf_3150

Possible Mycoplasma pneumonia Consider ADDING a macrolide if Mycoplasma suspected clinically, and failed beta-lactam in community
NOTE - no evidence that empiric treatment affects outcome compared to beta-lactam alone
Erythromycin 12.5mg/kg/dose (max 400mg/dose) PO 4 times a day 7-10 days  OR
Roxithromycin (tablets only) 4mg/kg  (max 150mg/dose) PO twice a day 7 days  
Severe pneumonia possibly due to influenza

Consider ADDING oseltamivir and send urgent viral nasopharyngeal specimen - see NZFC for dosing https://nzfchildren.org.nz/nzf_3472 

Also see: Influenza guideline

History of penicillin/amoxicillin
allergy (urticarial rash or delayed type hypersensitivity)
Mild/moderate pneumonia not requiring intravenous therapy
Roxithromycin (tablets only) 4mg/kg (max 150mg/dose) PO twice a day for 7 days
If >10 years and weight >35kg Doxycyline 100mg PO twice a day for 7 days

If intravenous therapy required and/or severe pneumonia
Cefuroxime 30mg/kg IV 8 hourly (if anaphylactic or delayed type hypersensitivity to beta-lactams - discuss with Infectious diseases)

Duration of intravenous therapy

  • Determined by clinical response
  • Usually intravenous treatment until afebrile
  • Total duration of treatment for radiologically confirmed pneumonia is usually 5-7 days.
  • Intravenous treatment can be switched to oral treatment to complete course when appropriate (cephalexin can be used to follow cefuroxime).
  • Rationalise if bacterial identification and/or sensitivity is available (eg from a positive blood culture). For example, penicillin or amoxicillin for proven susceptible Streptococcus pneumoniae or Flucloxacillin for proven MSSA.

Progression of pneumonia while on treatment

  • Undertake nasopharyngeal swab for viral and atypical pneumonia panel (if not done already).
  • Consider broader antibiotic cover to cover severe pneumonia +/- empiric addition of macrolide
  • Consider repeat chest x-ray 

Follow up

Most children with pneumonia respond to quickly to treatment and make full recovery.

  • Cough usually resolves within 6 weeks
  • Review by the child's General Practitioner (GP) if cough persists, or other concerns.
  • Follow up chest x-ray is not needed for uncomplicated pneumonia, but may be required in those with complicated pneumonia or chronic/recurrent symptoms.

Children with recurrent pneumonia or persistent symptoms

A history of recurrent pneumonia or chronic cough / respiratory symptoms at admission. This may be a sign of underlying vulnerabilities, chronic lung disease or environmental factors (see table below). History and clinical examination is the best starting point to investigate further.

See Guideline on Cough

Consider referral to General Paediatric outpatient clinic if the child has recurrent pneumonia or persistent symptoms.

Predisposing factors associated with pneumonia

Environmental factors Underlying conditions

Tobacco smoke exposure

Poor nutrition

Poor housing

Over-crowding

Not immunised

Chronic lung diseases (chronic bronchitis/bronchiectasis)

Cystic fibrosis

Primary immunodeficiency

Chronic aspiration

Congenital lung malformation

Airway malformation

Family information

Factsheet on pneumonia at Kidshealth.org.nz

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Document Control

  • Date last published: 16 April 2019
  • Document type: Clinical Guideline
  • Services responsible: General Paediatrics, Paediatric Infectious Diseases, Children’s Emergency Department
  • Author(s): Mike Shepherd, Emma Best
  • Editor: Greg Williams
  • Review frequency: 2 years

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