Background to pneumonia

Pneumonia in childhood is still responsible for over 130 deaths each year in England and Wales. Infants, and children with congenital abnormalities or chronic illnesses are at particular risk. In adults, two-thirds of cases of pneumonia are caused by either Streptococcus pneumoniae or Haemophilus influenzae. A much wider spectrum of pathogens causes pneumonia in childhood, and different organisms are important in different age groups.

In the newborn, organisms from the mother's genital tract, such as Escherichia coli and other Gram-negative bacilli, group B beta-haemolytic Streptococcus and increasingly, Chlamydia trachomatis, are the most common pathogens. In infancy respiratory viruses, particularly respiratory syncytial virus, are the most frequent cause, but Pneumococcus, Haemophilus and, less commonly, Staphylococcus aureus are also important. In older children, viruses become less frequent pathogens and bacterial infection is more important. Mycoplasma pneumonia is a common cause of pneumonia in the school-age child. Bordatella pertussis can present with pneumonia as well as with classical whooping cough, even in children who have been fully immunised.

Fever, cough, breathlessness, and lethargy following an upper respiratory infection are the usual presenting symptoms. The cough is often dry initially but then becomes loose. Older children may produce purulent sputum but in those below the age of 5 years it is usually swallowed. Pleuritic chest pain, neck stiffness and abdominal pain may be present if there is pleural inflammation. Classical signs of consolidation such as impaired percussion, decreased breath sounds and bronchial breathing are often absent, particularly in infants, and a chest radiograph is needed. This may show lobar consolidation, widespread bronchopneumonia or less commonly, cavitation of the lung. Pleural effusions are quite common, particularly in bacterial pneumonia. An ultrasound of the chest will delineate a pleural effusion and be helpful in the placing of a chest drain. Blood cultures, swabs for viral isolation, and a full blood count should also be performed.

As it is not possible to differentiate reliably between bacterial or viral infection on clinical or radiological grounds, all children diagnosed as having pneumonia should receive antibiotics. The initial choice of antibiotics depends on the age of the child. Antibiotics should be given for 7-10 days, except in staphylococcal pneumonia, where a flucloxacillin course of 4-6 weeks duration is needed. Many older children have no respiratory difficulty and can be treated at home with penicillin, a cephalosporin or erythromycin. Infants, and children who look toxic or have definite dyspnoea should be admitted and usually require intravenous treatment initially. Local antibiotic policies should be followed. Physiotherapy, an adequate fluid intake and oxygen (in severe pneumonia), are also required. Mechanical ventilation is rarely required unless there is serious underlying condition. If a child has recurrent or persistent pneumonia, investigations to exclude underlying conditions such as cystic fibrosis or immunodeficiency should be performed.

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