Pneumonia in Children

Symptoms of Pneumonia in Children are Easily Missed

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Pneumonia in children can be difficult to spot as the most common symptoms often differ from those in adults. What signs and symptoms should you watch for, what are the common causes pneumonia in children, and how is it treated?

Pneumonia in Children

Pneumonia is an infection or inflammation of the lungs to which children are particularly vulnerable. Often following a cold or the flu, pneumonia can affect one or both lungs.

When you have pneumonia, air sacs (alveoli) in your lungs fill with pus or other liquid and oxygen has trouble reaching your blood.

In the United States, pneumonia in children is not feared as it was before the advent of antibiotics and immunizations. Yet worldwide it remains a significant problem. Globally, pneumonia is the leading cause of death for children under the age of five, often due to a lack of antibiotics and medical resources.

Causes of Pneumonia in Children

In adults, community acquired pneumonia is most commonly caused by bacteria, especially Streptococcus pneumoniae. Children are also susceptible to bacterial pneumonia, but pneumonia in children is often caused by viral infections, or "milder" bacterial infections such as Mycoplasma. 

  Common causes of viral pneumonia in children include:

  • Respiratory syncytial virus (RSV) - RSV is often a parent of a young child's nightmare with its unrelenting cough, and is a significant cause of pneumonia in young children. It is most common between November and April, and usually follows a few days of upper respiratory symptoms such as a runny nose. Children under the age of two are most at risk.
  • Parainfluenza virus
  • Adenovirus
  • Coronovirus
  • Influenza
  • Human metapneumovirus (hMPV)

Bacterial pneumonia occurs in children as well as adults, but is often related to different bacteria. The most common bacterial causes in children include:

  • Mycoplasma pneumoniae (walking pneumonia) - Mycoplasma related pneumonia is often referred to as walking pneumonia since it often less serious than other forms of bacterial pneumonia (in other words, people are walking around because they aren't very ill.) In some cases, however, symptoms may be much more severe. Walking pneumonia often lingers for several weeks.
  • Streptococcus pneumoniae (pneumococcal pneumonia) - Pneumococcal pneumonia is the leading cause of pneumonia in adults and can occur in children as well. Thankfully, immunization has reduced the incidence of this type of pneumonia in children in recent years.
  • Haemophilus influenzae type b (Hib) - Pneumonia due to H. flu has also become less prevalent in recent years due to vaccination.

There are many other causes of pneumonia, and these become especially important in children who are immunocompromised due to problems with their immune systems, chemotherapy, or HIV infection.

Of the types of pneumonia listed above, viral pneumonia is more common in very young children, whereas walking pneumonia is often seen in school age children.

What Else Could it Be?

The symptoms of pneumonia cross over with many other childhood conditions. The common cold may cause symptoms similar to pneumonia, and pneumonia often occurs after a respiratory infection making the distinction more difficult. Pneumonia can be difficult to distinguish from bronchitis in children as well, with a significant overlap in symptoms. In general, children tend to appear less ill with bronchitis than with pneumonia. The hacking cough of whooping cough (pertussis) can sometimes mimic the symptoms of pneumonia.

It's important to note that even with immunization, children may still develop the infection.

Asthma can lead to wheezing and coughing similar to pneumonia and may be difficult to distinguish based on symptoms alone. In addition, there appears to be a relationship between mycoplasma pneumonia and asthma. Other conditions such as acid reflux can lead to coughing, but do not usually have the associated fever.

How Common is Pneumonia in Children?

Pneumonia is diagnosed in about four percent of children in the United States each year, with the highest rates in children under the age of 12 months. Children who get pneumonia more than once in a single year may have a problem with their immune system and should be carefully evaluated.

Pneumonia Symptoms in Children

In adults, pneumonia is often suspected when a person develops a fever and cough. With children, however, the symptoms can be both more subtle and more varied. Symptoms to heed in children may include:

  • Fever - Sometimes the only sign that a child may have pneumonia is the presence of a fever.
  • Rapid respiratory rate (tachypnea) - An increased respiratory rate, known medically as "tachypnea" can be an important sign of pneumonia in children. Respiratory rate is unfortunately often called the "neglected vital sign" and though it can give important information is often overlooked. Tachypnea is defined by the World Health Organization as a respiratory rate greater than 50 breaths per minute for infants two to twelve months of age, more than 40 breaths per minute for children between the ages of one and five, and greater than 30 breaths per minute for children over the age of five.
  • Nasal flaring and retractions (tightening of neck muscles) - These symptoms may be a sign of labored breathing.
  • Wheezing - Wheezing is common, especially with viral pneumonia.
  • Cyanosis, or a bluish appearance to a child's lips, nose, and fingers.
  • Vomiting (often do to labored breathing.)
  • Cough - A cough may be either dry, or productive of phlegm which can be clear, white, yellow-green, or even blood-tinged.

If your child has any of these symptoms it doesn't necessarily mean she has pneumonia. Children can sometimes appear very ill with simple viral infections, especially if they have a high fever.

How is Pneumonia Diagnosed in Children?

The most important step in diagnosing pneumonia in children is to have a high index of suspicion. Even if your child is not coughing, symptoms such as a fever without an obvious source, change in eating habits, a worsening of symptoms following an upper respiratory tract infection, or your gut reaction that something just isn't right, should prompt you to see your pediatrician. A parent's intuition isn't often listed as a symptom of pneumonia, but may be one of the best indicators that something is wrong. Trust your instinct.

If your child has any of the above symptoms, or if she just doesn't seem like herself, your doctor will ask about her history. Has anyone in the household been ill? Has she had any recent infections? How has she been eating and sleeping?

Your doctor will then perform a careful physical exam taking note of her temperature, checking her ears, heart, and lungs. Again, checking respiratory rate is very important and should be a part of any examination in which a fever is present. Pulse oximetry is often done to check a child's oxygen saturation level, and your pediatrician will look to see if there are any signs of difficulty breathing, such as tightening of muscles in her neck (accessory muscles) or nasal flaring.

Blood tests may be done to look for evidence of a viral or bacterial infection, and imaging tests such as a chest x-ray may be recommended. It's important to note that sometimes pneumonia in children isn't readily apparent on a chest x-ray, and changes are not always seen early on with the infection.

Pneumonia Treatments for Children

The treatment recommended for your child if she has pneumonia will depend on many factors, including how ill she appears and the suspected cause of the pneumonia (viral or bacterial.)

Most children with pneumonia can be treated at home, though some children may need to be admitted to the hospital for intravenous fluids (if they are dehydrated,) for intravenous antibiotics, or for oxygen therapy. Rarely, ventilatory assistance (a respirator) will be needed for a child who is becoming very tired with trying to breathe.

Antibiotics are the usual treatment when a child is suspected of having bacterial pneumonia. If a child has walking pneumonia (Mycoplasma pneumonia) antibiotics typically used for ear infections (such as Amoxicillin) do not work. Instead, antibiotics such as erythromycin, Zithromax, Biaxin, or tetracyclines (in older children) are often needed.

Many people wonder about cough suppressants. While medications may be important in order for your child to get rest, coughing is the body's mechanism for removing debris from the lungs and many physicians hesitate to prescribe these.

Complications (Uncommon) of Pneumonia in Children

The risk of any complications related to your child's pneumonia is uncommon and will depend on many factors.

Sometimes children develop a pleural effusion or empyema with pneumonia. The pleura are the membranes which surround and cushion the lungs with each breath. If a pneumonia occurs near the outer regions of the lung this region can become inflamed and filled with fluid or pus. When this occurs, the fluid or pus may need to be drained. This sounds frightening, but is a fairly easy procedure in children in which a fine needle is inserted into the pleural cavity to withdraw fluid. If a large empyema is present, a chest tube may need to be placed while the infection clears.

If your child's pneumonia is very severe, the work of breathing can become exhausting. If this occurs—and this is very uncommon—a child may need to be placed on a respirator for a period of time. Sedative medications are usually used if this is needed so that your child is not frightened.

Pneumonia Prevention - The Importance of Vaccines and More

Pneumonia in children is much less frequent than it was just a few short decades ago, a reduction that we can attribute to widespread vaccination. Childhood vaccines that may help prevent pneumonia include the Prevnar 13 pneumococcal vaccine, Hib, Varivax, MMR, and the flu vaccine.

In addition to immunizations, the risk of pneumonia can be decreased by breastfeeding, by careful handwashing, and by limiting contact with others who are ill.

Bottom Line on Pneumonia in Children

Pneumonia in children is common, but often occurs with symptoms different than those you would expect with an adult. The possible causes of pneumonia in children often differ from those in adults as well. Pneumonia in children can be terribly frightening as children become ill very rapidly. Thankfully, unlike adults they often recover and heal very rapidly as well.

Sources

  • Haq, I., Battersby, A., Eastham, K., and M. McKean. Community Acquired Pneumonia in Children. BMJ. 2017. 356:j686.
  • Jain, S. Epidemiology of Viral Pneumonia. Clinical Chest Medicine. 2017. 38(1):1-9.
  • Kliegman, Robert M., Bonita Stanton, St Geme III Joseph W., Nina Felice. Schor, Richard E. Behrman, and Waldo E. Nelson. Nelson Textbook of Pediatrics. 20th Edition. Philadelphia, PA: Elsevier, 2015. Print.

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