Paediatric Protocol
Respiratory: 3.5
September 2004
PNEUMONIA – INVESTIGATION AND MANAGEMENT
GUIDELINES
First distributed 1996- Revised Sept 2000 (Helena Clements), September 2004 (Maria Atkinson).
Background
This guideline is based on the following 3 documents: 1. Evidence Based Guideline – Management of Community Acquired
Pneumonia in Children drawn up by the British Thoracic Society (BTS)
2002 [1].
2. A Prospective Study of the Aetiology of Community Acquired Pneumonia
completed in Nottingham in 1997 [2]. The Nottingham study showed that in
89 children a diagnosis was achieved in 48. Seven children had Streptococcus
pneumoniae, 14 had Mycoplasma, 6 had Pertussis and 1 had Chlamydia.
Twenty-three children had a viral cause of which respiratory syncytial virus
(RSV) was commonest. Three children had dual infections. Chest radiographs
and acute phase reactants did not help distinguish between different bacterial
and viral aetiologies. This study led to use of benzyl penicillin as first line
antibiotic treatment in children with pneumonia.
3. A Multicentre RCT Comparing Oral Amoxicillin and IV Benzyl penicillin for
Community Acquired Pneumonia (CAP) PIVOT Trial (submitted for
publication). Lead centre Nottingham, completed June 2004. This study
involving over 250 children from 8 different centres demonstrated that oral
and IV treatment are equivalent for CAP in previously well children who were
unwell enough to require admission to hospital. Complications such as
empyema were not increased in the oral arm. Time to resolution of symptoms
was the same in both groups (median 9 days).
CLINICAL PRESENTATION
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

Some features such as wheeze and hyperinflation on CXR make a diagnosis of
viral pneumonia more likely. However, studies have consistently shown [3]
that it is not possible to distinguish viral and bacterial pneumonia by
presenting symptoms, signs or radiological changes. Therefore, all children
with pneumonia should be treated with antibiotics.
Clinical presentation varies, pneumonia can sometimes be difficult to
diagnose. Many children present with classical symptoms such as cough,
difficulty breathing, fever and tachynoea. However some children with
pneumonia have a normal respiratory rate and clear chest. It should be
remembered that pneumonia is a differential for PUO and can also present
with referred pain to the abdomen.
If you are faced with a child with breathing difficulty and are unsure whether
they have pneumonia or another respiratory disorder please refer to the
“Nottingham Evidence Based Guideline on Management of Breathing
Difficulty in Children”.
Author: Dr Maria Atkinson
1
Does the child need admission to hospital ?
Any child with 1 or more of the features below
should be admitted to hospital for further
management
Infants
SaO2 <92%, cyanosis
RR> 70/min
Difficulty breathing
Intermittent apnoea, grunting
Not feeding
Family not able to provide appropriate
observation or supervision
Older Children
SaO2 <92%, cyanosis
RR >50/min
Difficulty breathing
Grunting
Signs of dehydration
Family not able to provide appropriate
observation or supervision
Admission required?
No
Yes
Are any of the following features
present ?
 Oxygen saturations <85% air
 Still shocked following
20mls/kg fluid resuscitation
 Chronic lung disease such as
cystic fibrosis
 Definite penicillin allergy
 Large pleural effusion
 Established diagnosis of
immunodeficiency
 < 6 months
Management
 Investigations – CXR is not necessary to
confirm the diagnosis in children with mild
disease well enough to be discharged home
[4]. Blood tests are not indicated.
 Discharge with a 7 day course of amoxicillin
(doses from Medicines For Children).
 Calpol and ibuprofen for pain relief and
temperature control
 Advise the parents to seek further medical
attention if the temperatures are not settling
in 48 hours, the child is unable to tolerate
oral antibiotics or they become more unwell.
See page 3
Author: Dr Maria Atkinson
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No



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Yes

Treat with oral amoxicillin,
erythromycin if penicillin
allergic (doses Medicines
Children)
CXR
NO indication for FBC,
CRP, B/C or serology
NPA or viral throat swab for
viral immunofluoresence
and culture



Treat with IV antibiotics see
Table below (doses
Medicines Children)
CXR
FBC, CRP, B/C, serology
(1-2mls clotted blood for
respiratory pathogens)
NPA or viral throat swab for
viral immunofluoresence
and culture
General inpatient Care
 Adequate fluid intake orally, NG or IV fluids
at 80% maintenance (watch for SIADH).
 Oxygen to keep saturations >92%
 Chest physiotherapy is not beneficial
 Antipyretics and analgesics
Choice of antibiotic in those requiring IV treatment
< 6 months
Cefuroxime
Pathogens include gram negatives e.g. E.
coli and gram positives e.g. Group B
Streptococci therefore a broad spectrum
antibiotic is needed until culture and
sensitivities are known.
Also consider pertussis
> 6 months
Benzyl penicillin
Clarithromycin if penicillin allergic
Aspiration pneumonia
Metronidazole + Benzyl penicillin.
Usually suggested by history. ‘At risk’
groups are children with neurological
problems such as cerebral palsy, or acute
problems such as febrile convulsions or
head injury. Need to cover anaerobic
organisms.
Coexisting disease such as cystic fibrosis, Refer to appropriate protocol or discuss
immunodeficiency, oncology patients.
with microbiology if unsure
All doses should be taken from Medicines For Children
Author: Dr Maria Atkinson
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Failure to respond to first line treatment
The majority of children with pneumonia will respond to treatment within 48 hours.
If the child remains unwell with high temperatures at 48 hours consider the following.
1. Mycoplasma pneumoniae infection
Historically this was thought to be far more common in older children but it is
increasing being recognised as a cause of pneumonia in the < 5 year age group [5,
6]. It may present with patchy infiltrates or consolidation on the CXR.
Add erythromycin (PO) or clarithromycin IV if oral medication not tolerated.
2. Empyema
Repeat CXR. If pleural effusion or empyema is present discuss with the paediatric
surgical registrar on call. Further imaging such as chest USS may be indicated
prior to surgery or drainage.
3. Antibiotic cover
If addition of a macrolide fails to confer improvement, consider a change to a
broader spectrum antibiotic such as cefuroxime IV, examine for empyema and
repeat CXR.
4. Rare causes to consider – lung abscess, coexisting disease that may be
undiagnosed such as immunodeficiency.
5. Take blood for FBC, CRP, B/C and acute serology for respiratory pathogens if
not already sent.
Follow Up

Outpatient follow up – not routine
if complicated, prolonged recovery (i.e. more than 5 days in
hospital) or empyema
if parents call re. continuing concerns or child has continuing
symptoms or GP prescribes repeat course of antibiotics

Follow up CXR’s are only indicated in the following situations (7).
Lobar collapse or in a child with persistent symptoms.
Author: Dr Maria Atkinson
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1.
2.
3.
4.
5.
6.
7.
Guidelines For Treatment of Community Acquired Pneumonia In Children.
2002, British Thoracic Society.
Clements, H., et al., Rationalised prescribing for community acquired
pneumonia: a closed loop audit. Archives of Disease in Childhood, 2000. 83:
p. 320-324.
Virkki, R., et al., Differentiation of bacterial and viral pneumonia in children.
Thorax, 2002. 57(57): p. 428-441.
Swingler, G. and M. Zwarenstein, Chest radiograph in acute respiratory
infections in children. Cochrane Database Systematic Reviews, 2000. 2.
Harris, J., et al., Safety and efficacy of azithromycin in the treatment of
community-acquired pneumonia in children. The Pediatric Infectious Disease
Journal, 1998. 17(10): p. 865-871.
Eposito, S., et al., Mycoplasma pneumoniae and Chlamydia pneumoniae
infections in children with pneumonia. Europea Respiratory Journal, 2001. 17:
p. 241-254.
Gibson N, Hollman A, Paton J BMJ 307 1117 1993 Value of radiological FU
of childhood pneumonia)
Author: Dr Maria Atkinson
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