HNY Policy and Pathway Repository - York

An acute infection of the pulmonary parenchyma in a child who has acquired the infection in the community.

Paediatric Normal Values (adapted from APLS)
Age	Resp Rate	Heart Rate	Systolic BP
Neonate <4w	40-6	120-160	>60
Infant <1 y	30-40	110-160	70-90
Toddler 1-2 yrs	25-35	100-150	75-95
2-5 yrs	25-30	95-140	85-100

Exclude Red Flag Symptoms

• Worsening work of breathing (e.g. grunting, nasal flaring, marked chest recession)
• Fluid intake is less than 50-75% of normal or no wet nappy for 12 hours
• Apnoea or cyanosis
• Exhaustion (e.g. not responding normally to social cues, wakes only with prolonged simulation)
   

Low Threshold for Admission

• Chronic lung disease
• Haemodynamically significant congenital heart disease
• Age < 12 weeks (corrected)
• Premature birth, particularly under 32 weeks
• Neuromuscular disorders
• Immunodeficiency
• Duration of illness <3 days with amber symptoms (see assessment box)
• Re-attendance

General Points

• Severity is influenced by both the pathogen and host susceptibility to infection
• Severe disease is more common in children under 5 and those with a history of prematurity
• Can be caused by bacteria and viruses
• Streptococcus pneumoniae is the single most common cause in children
• Group A streptococci and Staphylococcus aureus are less common, but more likely to progress to severe infections
• Viruses are more commonly found in those under 1 year. Respiratory syncytial virus (RSV) is the most common viral aetiology
• Streptococcus pneumoniae is a rare cause of haemolytic uraemic syndrome (HUS). Consider HUS in a child with anuria and profound anaemia.

Assessment

• Fever, cough, difficulty breathing and tachypnoea
• Wheeze, chest pain and abdominal pain may be present
• Cough may be absent in the initial stages
• Crackles often heard on auscultation, bronchial breathing is a later sign of consolidation
• Reduced air entry and dull percussion note suggest pleural effusion
• Symptoms begin in the community or within 48 hours of admission
• Prolonged fever associated with influenza may be a feature of secondary bacterial pneumonia
   

Management

• All children diagnosed with pneumonia should receive antibiotics as it is not possible to distinguish between bacterial and viral pneumonia
• Children <2y with mild symptoms do not usually have pneumonia and often don’t need antibiotics but should be reviewed if symptoms persist
• Oral antibiotics are safe and effective for most children
• Duration: 5-7 days is usually sufficient for non-severe pneumonia, up to 14 days may be required in severe cases

 

Drug	Age	Weight	Dose
First Line Options
Amoxicillin	1-11m		125 mg TDS
	1-4y		250 mg TDS
	5-17y		500 mg TDS
Can be added if there is no response to Amoxicillin. Use first line if penicillin allergic
Clarithromycin	1m-11y	<8kg	7.5mg/kg BD
		8-11kg	62.5 mg BD
		12-19kg	125 mg BD
		20-29kg	187.5mg BD
		30-40kg	250mg BD
	12-18y		250mg BD
Second Line Options (should be used in pneumonia associated with influenza)
Co-amoxiclav	1-11m		0.25ml/kg of 125/31 suspension TDS
	1-5y		5ml of 125/31 suspension TDS
	6-11y		5ml of 250/62 suspension TDS
	12-17y		250/125mg or 500/125mg tablets TDS
Seek microbiologist advice in penicillin allergy

Treatment Failure

If the child is still pyrexial or unwell at 48 hours seek advice from secondary care and consider

• Is an appropriate dose being used? Consider adding clarithromycin
• Has a complication developed?
• Is the child immunocompromised or have an underlying condition?
• Consider tuberculosis

Patient information leaflets/ PDAs

RSS Parent Leaflet
 

References

• Harris M et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax Oct 2011; 66 Suppl 2:ii1-ii23
• National Institute for Clinical Excellent [NICE] (2021) Cough – acute with chest signs in children. [Viewed 16 Nov 2021] https://cks.nice.org.uk/topics/cough-acute-with-chest-signs-inchildren/management/community-acquired-pneumonia/