Learning Outcome

After reading the following article, the reader should be able to: 

• Describe the etiology and risks for pneumonia in children worldwide.
• Describe the presentation of pneumonia in children.
• Identify appropriate nursing care for a hospitalized child with pneumonia.
• Identify a strategy to reduce the risk of pneumonia in children.

Introduction

Pneumonia is a disease of the lower airway that occurs when viruses, bacteria, fungi, or a combination of these, cause inflammation and fluid accumulation in the pulmonary parenchyma.[1] Globally, pneumonia is a leading cause of morbidity and mortality in children younger than the age of 5 years.[2] Although the majority of deaths attributed to pneumonia in children are mostly in the developing world, the burden of disease is substantial, and there are significant healthcare-associated costs related to pneumonia in the developed world.[3]

Nursing Diagnosis

• Wheezing
• Cough
• Fever
• Poor nutrition
• Difficulty with breathing
• Copious secretions
• Malaise
• Impaired gas exchange
• Ineffective breathing
• Cyanosis
• Respiratory distress

Causes

Pneumonia can be classified as either community-acquired [4] or hospital-acquired.[5] The most common causes of pneumonia in children vary based on age: [6] 

Neonates: Neonates are at risk for bacterial pathogens present in the birth canal; this includes organisms such as group B streptococci, Klebsiella, Escherichia coli, and Listeria monocytogenes.[7][8][9] Streptococcus pneumonia, Streptococcus pyogenes, and Staphylococcus aureus can be identified in late-onset neonatal pneumonia.[7]

Older Infants and Toddlers: Viruses are the main cause of pneumonia in older infants and toddlers between 30 days and 2 years old.[10] 

Preschool:  In children 2 to 5 years old, respiratory viruses are also the most common.[11][12] The rise of cases related to S. pneumoniae and H. influenzae type B is observed in this age group.[13][14] 

School-age: Mycoplasma pneumonia frequently occurs in children in the range from 5 to 13 years old[15][16]; however, S. pneumoniae is still the most commonly identified organism.[11]

Adolescents: Adolescents usually have the same infectious risks as adults. It is important to consider tuberculosis (TB) in immigrants from high prevalence areas, and children with known exposures.

Special cases: Children with chronic diseases are also at risk for specific pathogens. In cystic fibrosis, pneumonia secondary to S. aureus and Pseudomonas aeruginosa is ubiquitous.[17] Patients with sickle cell disease are at risk of infection from encapsulated organisms.[18] Children who are immunocompromised should be evaluated for Pneumocystis jirovecii, cytomegalovirus, and fungal species if no other organism is identified.[19] Unvaccinated children are at risk for vaccine-preventable pathogens.

Risk Factors

There are an estimated 120 million cases of pneumonia annually worldwide, resulting in as many as 1.3 million deaths.[6] Younger children under the age of 2 in the developing world, account for nearly 80% of pediatric deaths secondary to pneumonia.[20] Prognosis of pneumonia is better in the developed world, with fewer lives claimed, but the burden of disease is extreme, with roughly 2.5 million cases yearly.[21] Approximately a third to half of these cases lead to hospitalizations.[21]

Assessment

In many cases, complaints associated with Pneumonia are nonspecific, including cough, fever, tachypnea, and difficulty breathing.[22] Young children may present with abdominal pain; infants may present with reported inability to tolerate feedings. Important history to obtain includes the duration of symptoms, exposures/travel, sick contacts, baseline health of the child, chronic diseases, recurrent symptoms, choking, immunization history, maternal health, or birth complications in neonates.[23]

Physical exam should include observation for signs of respiratory distress, including tachypnea, nasal flaring, lower chest in-drawing, or hypoxia on room air.[22] Auscultation for rales, rhonchi, and wheezing in all lung fields with the appropriately sized stethoscope can also aid in diagnosis. Infants may experience grunting or apnea. In the developed world, other adjuncts like laboratory testing and imaging can be a helpful part of the physical exam. No isolated physical exam finding can accurately diagnose pneumonia.[24] However, the combination of symptoms, including fever, tachypnea, focal crackles, and decreased breath sounds together, raises the sensitivity for finding pneumonia on x-ray.[24] Pneumonia is a clinical diagnosis that should take into consideration the history of present illness, physical exam findings, adjunct testing, and possible imaging modalities.

Evaluation

Diagnosis of pneumonia in a child with a respiratory illness can be challenging in a primary care setting.  It should involve a comprehensive assessment of the child, combined with the assessment of laboratory values. [25]

Primary laboratory evaluation: Ideally, laboratory testing should start with non-invasive, rapid bedside testing, including nasopharyngeal swab assays for influenza, respiratory syncytial virus, and human metapneumovirus when available and appropriate. This can help minimize unnecessary imaging and antibiotic treatment in children with influenza or bronchiolitis.

Secondary laboratory evaluation: Children who present with severe disease and appear toxic should have complete blood count (CBC), electrolytes, renal and hepatic function testing, and blood cultures performed.[26] These tests are generally not required in children who present with mild disease. Inflammatory markers do not help distinguish between viral and bacterial pneumonia in the pediatric population.[26][27] However, these tests may be obtained to trend disease progression and serve as prognostic indicators. Children who have been in areas endemic to TB, or have exposure history, and present with signs and symptoms suspicious for pneumonia should have sputum samples or gastric aspirates collected for culture.

There are no clear guidelines for the routine use of chest x-ray in the pediatric population.[26] Although the chest x-ray can be helpful in diagnosis/confirmation of pneumonia,[28] it carries with it risks, including radiation exposure, healthcare-associated costs, and false-negative results, increasing the use of unwarranted antibiotics. Imaging should be restricted to children who appear toxic, those with the recurrent or prolonged course of illness despite treatment, infants age 0 to 3 months with a fever, suspected foreign body aspiration, or congenital lung malformation. Imaging can also be considered in children younger than 5 years old, who present with fever, leukocytosis, and no identifiable source of infection.[28] Imaging may also be useful in those with acute worsening of upper respiratory infections or to rule out underlying mass in children who have "round pneumonia."[29][30]

Medical Management

Treatment should be targeted to a specific pathogen that is suspected based on information obtained from history and physical exam. Supportive and symptomatic management is key and includes supplemental oxygen for hypoxia, antipyretics for fever, and fluids for dehydration. This is especially important for non-infectious pneumonitis and viral pneumonia for which antibiotics are not indicated.[22][31] Cough suppressants are not recommended.

If bacterial pneumonia is suspected, treat empirically with antibiotics, keeping in mind significant history and bacterial pathogens that are common to specific age groups.

Neonates should receive ampicillin plus an aminoglycoside or third-generation cephalosporin[22][32], however, not ceftriaxone, as it can displace bound bilirubin and lead to kernicterus.

Atypical pneumonia is common in infants 1 to 3 months old, and this group should have additional antibiotic coverage with erythromycin or clarithromycin.[22][32]

For infants and children over 3 months old, S. pneumoniae is the most common, for which the drug of choice is high-dose oral amoxicillin[22][32] or another beta-lactam antibiotic.

In children older than 5 years old, atypical agents have a more important role, and macrolide antibiotics are usually first-line therapy.[22]

Special attention should be given to children with chronic illnesses, as these might alter choices for antibiotics[22]. Children with sickle cell anemia will need cefotaxime, macrolide, vancomycin if severely ill. Children with cystic fibrosis will require piperacillin or ceftazidime plus tobramycin. Treat fulminant viral pneumonia as indicated, depending on the virus identified. ForVaricella, use acyclovir and for respiratory syncytial virus (RSV), use ribavirin for high-risk patients. Patients with HIV should be treated with sulfamethoxazole/trimethoprim and prednisone, and for Cytomegalovirus, ganciclovir and gamma globulin are the preferred agents. If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, clindamycin or vancomycin may be given.

It is important to have a high index of suspicion for complications, especially in patients returning for repeat evaluation. For patients sent home with symptomatic or supportive management for suspected viral pneumonia, consider a secondary bacterial infection or other diagnosis upon re-evaluation.[33] Children with uncomplicated bacterial infections who fail to respond to treatment within 72 hours should be assessed for complications, including pneumothorax, empyema, or pleural effusion.[34] Other systemic complications of pneumonia include sepsis, dehydration, arthritis, meningitis, and hemolytic uremic syndrome.

Neonates and infants younger than 90 days old should be hospitalized for treatment, in addition to children who are immunocompromised or have other underlying chronic diseases like sickle cell anemia or cystic fibrosis.[22] Children with social factors that preclude access to care, have failed outpatient therapy, or present with presumed tuberculosis, should also be hospitalized.[35]

It is essential to ensure that clear discharge instructions and return precautions are given to parents or caregivers of children being discharged home in addition to close pediatrician follow-up.

Nursing Management

Nursing care of the child with pneumonia in the hospital is mostly supportive and will involve routine monitoring and assessment of the child for respiratory status and oxygenation, fluid status, and sepsis risk. The child may require supplemental oxygen and SpO2 monitoring, depending on the severity of the illness. [22][31] 

Respiratory status and oxygenation: The nurse should assess oxygenation and for the adequacy of air movement in lung fields, the presence of accessory muscle usage, nasal flaring, grunting, and diminished breath sounds at each routine assessment, and more frequently if indicated. In addition, assessment of the child's disposition and level of activity can help the nurse determine the child's status. The hospitalized child with pneumonia may require a chest tube in the case of a pleural effusion or pneumothorax.[36]  Depending on the age of the child, bronchodilator and chest physiotherapy may be indicated.[37]

Fluid status: The child may be at risk for a fluid deficit if eating and drinking poorly.  The risk for dehydration increases if the child is febrile.  Careful monitoring of intake and output can help the nurse determine the risk for a fluid deficit. Supplemental intravenous fluids may be required. Nasogastric tube placement may be indicated to provide nutrition.

Sepsis risk: Routine monitoring for fever and risk of sepsis is required.  Prompt initiation of antibiotic or antifungal therapy is required if the etiology is bacterial or fungal. The nurse should routinely assess vital signs with more frequent follow-up if out of range.  Fever may be treated with antipyretics. If the child is determined to be experiencing sepsis, prompt initiation of a sepsis protocol should be initiated.[38]

Monitoring

The child with mild illness may be monitored from home. Parents should be instructed to bring the child to the primary care office or emergency department if symptoms indicate the child has worsened. Symptoms requiring additional evaluation may include increased difficulty breathing or change in color, fever, change in levels of activity or alertness, and inadequate fluid intake.

The child with more serious illness will require hospitalization with an appropriate level of care and monitoring depending on the severity of the illness.  One criterion to determine the need for hospitalization is if the child sustains oxygen saturation less than 90%.[39] A child requiring positive pressure ventilation or intubation will need to be admitted to an intensive care unit.

The nurse caring for a child with pneumonia in an inpatient setting should monitor the child based on the severity of the illness. Respiratory status on an inpatient hospital unit (non-intensive care) should be assessed at least every 4 hours. If supplemental oxygen is required, pulse oximetry can be used to determine the appropriate amount of oxygen to be delivered.[40] If the child becomes unstable and requires more frequent monitoring than staffing allows, the child should be transferred to an intensive care setting.

Coordination of Care

Healthcare professionals, including physicians, nurses, PAs/NPs, and pharmacists ideally work together in close environments for optimum patient care. When caring for children with pneumonia, pharmacists can be of significant help with geographic resistance patterns for better treatment outcomes with selected antibiotic choices.

Health Teaching and Health Promotion

Encourage parents to vaccinate their children according to recommended guidelines.  Vaccinations have effectively reduced the incidence and severity of pneumonia in populations of children.[41]