Trust Guideline for the Management of Childhood Pneumonia

A Clinical Guideline:

Children’s Assessment Unit (CAU)

For Use in: Accident & Emergency (A&E)
Buxton Ward
By: Medical staff in the above areas
Children one month to fifteen years with
For: pneumonia (see also Page 3, Paragraph 1 on
Inclusions and exclusions)
Division responsible for document: Women’s and Children’s Services
Key words: Pneumonia, children
Name and job title of document
Dr Caroline Kavanagh, Consultant Paediatrician
author:
Name and job title of document Dr David Booth ,Chief of Women’s and
author’s Line Manager: Children’s Services
Supported by: Mr M Kulkarni, Clinical Director

Clinical Guidelines Assessment Panel

Assessed and approved by the:
(CGAP)

Date of approval: 13th June 2016

Ratified by or reported as approved Clinical Standards Group and Effectiveness
to (if applicable): Sub-Board
To be reviewed before:
This document remains current after this 13th June 2019
date but will be under review
To be reviewed by: Dr Caroline Kavanagh
Reference and / or Trust Docs ID No: CA1043 – Id 1150
Version No: 6
Description of changes: Minor changes
Compliance links: (is there any NICE
None
related to guidance)
If Yes - does the strategy/policy
deviate from the recommendations of N/A
NICE? If so why?
This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management
of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the
guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment
options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for
any departure from relevant guidance should be documented in the patient's case notes.

The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of
healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or
misapplication of this document.

Clinical Guideline for: Management of Childhood Pneumonia

Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 1 of 8
 Trust Guideline for the Management of Childhood Pneumonia

Quick reference guideline/s Broad recommendations

Oral macrolide antibiotics (clarithromycin) for most previously well children with
community acquired pneumonia. Intravenous penicillin should be added for toxic
children with dense whole lobar consolidation, or large effusion, or unable to tolerate
oral treatment.
Inclusions and exclusions

This guideline is to be used for children with proven consolidation on Chest X-Ray
(CXR). However a CXR should not be performed routinely in children with symptoms
and signs of mild uncomplicated lower respiratory tract infection (1).
Most commonly presenting are previously healthy children with community
acquired pneumonia but there are a number of special situations.

The following are excluded from this Guideline:

i) Children with crackles and/or wheeze and no consolidation on CXR - see
comments in section B5 on Page 7.
ii) Neonates.
iii) Children in whom pneumonia is part of a septicaemic illness.
iv) Children with collapse rather than consolidation on CXR.

Community acquired pneumonia in previously healthy children

1. Aetiology

Sophisticated techniques including PCR have shown the current commonest

causes of community acquired pneumonia in previously healthy children in the UK
are, in descending order of frequency: viruses, mycoplasma, pneumococci and
pertussis (2).

2. Clinical presentation

Radiological appearances do not correlate well with the causative organism –

however, there are two broad clinical presentations; lobar pneumonia and patchy or
“atypical” pneumonia.

a) Lobar Pneumonia
 Acute lobar pneumonia is a relatively common reason for admission to
hospital in childhood. Pneumococcal disease is the commonest cause,
particularly if there is an associated pleural effusion.
 Symptoms - These are usually non-specific initially - high fever, rigors and
general malaise. Pleuritic chest pain is common. Referred abdominal pain +/-
vomiting may mimic an acute abdomen. Cough is usually a late symptom.
Frank respiratory distress is not common, though grunting respiration with
flared nostrils can occur.

Clinical Guideline for: Management of Childhood Pneumonia

Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 2 of 8
 Trust Guideline for the Management of Childhood Pneumonia

 Signs - Toxic, ill child with fever. Classical signs of consolidation - dull
percussion note, reduced air entry, bronchial breath sounds, fine creps,
increased vocal resonance - may be present, especially in lower lobe
pneumonias.
 There may be no signs in the chest, especially in upper lobe pneumonias -
these may cause meningism. A CXR may reveal consolidation in up to 25% of
febrile children <5years with no chest signs (1).

b) Patchy or "Atypical" Pneumonia

 The so-called "atypical" pneumonia with patchy consolidation is in fact more

common than classic lobar pneumonia. Many are viral in origin. Viral
pneumonias +/- secondary bacterial infection are difficult to distinguish
clinically from the primary atypical pneumonias, of which mycoplasma is the
commonest - also chlamydia, psittacosis, Q fever, and legionella. CXR often
shows a nodular/reticular pattern if primary and patchy consolidation if
secondary. In practice it is not always easy to distinguish.
 Signs and symptoms are more variable - but cough, fever and crackles
common.
 Respiratory distress with recession and/or wheeze may occur due to airways
obstruction with oedema and mucus. There may be some reversibility with
bronchodilators. The wheeze may be managed as described in the Trust
Guideline for the Management of acute wheeze/asthma in infants and children
(CA2064).

3. Investigations

 CXR initially – only if likely to change management. i.e. not necessary in those
with mild symptoms and signs
 U&Es if dehydrated or otherwise severely ill (prone to inappropriate ADH).
 FBC, Blood cultures - from iv cannula if commencing iv treatment. Not needed
otherwise.
 Consider atypical pneumonia and viral serology if severely ill child with patchy
consolidation.
 Acute phase reactants (e.g. CRP, ESR) do not distinguish between bacterial
and viral causes and do not need to be measured (1) in simple pneumonias.
 Sputum culture if available - often not.
 Cough swab for culture if productive cough present.
 Pernasal swab to be considered if any suspicion of pertussis.
 Consider naso-pharyngeal aspirate for virology in younger children,
particularly to look for RSV.
 Check SaO2 +/- blood gases if severe.
Clinical Guideline for: Management of Childhood Pneumonia
Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 3 of 8
 Trust Guideline for the Management of Childhood Pneumonia

4. Management

a) Supportive
 Admit to hospital if SaO2< 92% in air, moderate breathing difficulties or if the
family unable to provide appropriate supervision and oral antibiotics.
 Give oxygen via cannulae or face mask to maintain SaO2 > 92%.
 Maintain adequate hydration – insensible losses will be greater with fever. Oral
fluids are preferred but the very sick child may require iv fluids. These should
be restricted to two thirds of requirements to avoid inappropriate ADH (see
Trust Guideline on Intravenous fluids in children CA2052(v2)).
 Frequency of observations of pulse, temperature, respiratory rate, SaO2 and
degree of recession should be guided by the child’s condition, but at least 4-
hourly initially if requiring oxygen or otherwise very sick.
 Analgesics and anti-pyretics should be used as necessary, to keep the child
comfortable.
 Chest physiotherapy is not beneficial (1,3).

b) Antibiotics
 There is little evidence for the superiority of intravenous over oral antibiotics for
pneumonia in childhood, either in the Emergency Department (4) or in more
severe pneumonia as an inpatient (5).
 Although intravenous penicillin is relatively cheap, the nursing costs and time
involved in administering i.v. therapy are very significant. Intravenous
cannulation may also be traumatic for the young child.
 There has perhaps been a tendency to give initial treatment intravenously for
those requiring hospital admission, as a matter of course. The evidence
suggests we should be more selective about those requiring intravenous
therapy and to be prepared to observe an ill child with pneumonia, either in
hospital or by review in CAU, on oral treatment.

Oral treatment
 All children with pneumonia to receive oral clarithromycin (<8kg 7.5 mg/kg
b.d.; 1-2 years 62.5 mg b.d.; 3-6 years 125mg b.d.; 7-9 years 187.5 mg b.d.; 10
years and above 250 mg b.d.) unless they are known to be macrolide
intolerant. Some children with vomiting on erythromycin will tolerate oral
clarithromycin.
 In macrolide intolerant children, the alternatives are:
Amoxicillin (in the under-fives) 1month - 2 years 125mg tds, 2 - 5 years
250mg tds;
Cefalexin <1 year 62.5 mg tds, 1-5 years 125mg tds, 5-15 years 250mg tds;
Co-amoxiclav 1 month-1year 0.25mL/kg of the 125/31 suspension tds, 1-
Clinical Guideline for: Management of Childhood Pneumonia
Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 4 of 8
 Trust Guideline for the Management of Childhood Pneumonia
6years 5mL of the 125/31 suspension tds, 7-15 years either 5mL of 250/62
suspension or a 250/125 tablet tds.

Intravenous treatment
 Pneumococci remain uniformly penicillin sensitive locally (at time of writing), so
benzyl penicillin remains our iv drug of choice - but beware the child visiting
from abroad where penicillin resistance may be more of a problem - ask
microbiologists for up to date advice.
 Sick toxic child with dense total lobar picture or large effusion present or
unable to tolerate oral antibiotics (usually because of vomiting)- iv benzyl
penicillin 25 mg/kg q.d.s. (100 mg/kg/day) if not penicillin allergic.
 Alternatives if penicillin allergic or there are concerns about resistance are iv
cefuroxime (20 mg/kg t.d.s.) or clarithromycin (7.5 mg/kg b.d.), although the
latter is quite toxic to veins.
 Oral clarithromycin should be given in addition to the intravenous treatment
when IV pencillin or cephalosporin is used, unless vomiting is the reason,
when it should start once vomiting has settled.
 If mycoplasma pneumonia is suspected and oral clarithromycin is not tolerated,
then this must be given intravenously.
 Give iv treatment for 24-72 hours until temperature down, then continue oral
clarithromycin or alternative.
 Discharge once temperature down and tolerating oral antibiotics.
 There is no strong evidence to determine the total duration of treatment, but 7
to 10 days is usually sufficient.

5. Complications
 Treatment failure is the major complication. If the child remains unwell and
pyrexial after 48 hours treatment, consideration should be given to the
possibility of antibiotic resistance (review investigations and discuss with
microbiology) or to the possibility of underlying disease (see Special Situations
below, consider referral to Dr Kavanagh, Dr Pillay or another member of the
Children’s Respiratory team).
 Parapneumonic effusion or empyema is however the commonest reason for
failure to respond. See the Trust Guideline for the management of
parapneumonic effusion in children (CA2055).

6. Follow-Up

It has been shown that children with uncomplicated pneumonia do not require a
follow-up X-Ray (6). In this situation follow-up should be via the GP, not hospital.
Exceptions that need follow up in respiratory clinic include empyemas, large
effusions, those slow to settle, those with other underlying disease and if there is
doubt about the diagnosis, e.g. not sure if consolidation or collapse. If hospital follow-
up is required, at the time of discharge arrange a CXR for immediately prior to the
OPD appointment, usually in about 8-12 weeks.
Clinical Guideline for: Management of Childhood Pneumonia
Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 5 of 8
 Trust Guideline for the Management of Childhood Pneumonia

Special situations

1. Hospital acquired and/or known underlying respiratory disease

Children in this group need very careful assessment, including common pathogens
on ward/ITU at the time and previous respiratory pathogens. The likely organisms
and therapy will change with time and up to date advice required from
microbiologists. Do not reflexly treat as for community acquired pneumonia.

2. Unusual pneumonias

Always take senior advice if the X-Ray is unusual or the child unexpectedly ill.
Pertussis can cause an acute severe pneumonia and even death in the first year of
life, as well as the well-recognised upper respiratory presentation.
Abscesses visible in the lung parenchyma suggest Staphylococcus aureus or
Klebsiella as a cause. Both these are now exceedingly rare in previously healthy
children.
Tuberculosis should never be forgotten but is again rare locally unless the child is
from abroad.

3. Pneumonia in children with special needs

Pneumonia in children with special needs such as spastic quadriplegia with scoliosis
or muscular dystrophy, have a different pathophysiology. There is often a
combination of aspiration, gastro-oesophageal reflux and diminishing lung function.
Management of these children is always difficult. It is appropriate to consider
sensitive issues such as quality of life and parental views, prior to embarking on
treatment.
Senior involvement in decision-making is highly desirable and those with
deteriorating respiratory function are often best discussed once this has started and
clear plans made. Chest physiotherapy, good general care and suctioning is probably
more important for this group of children than the type or route of administration of
antibiotics.

4. Immuno-compromised children

Immuno-compromised children, for instance those with neutropaenia on

chemotherapy, or with risk factors present for AIDS, e.g. baby from Africa – are at
risk of pneumocystis carinii pneumonia. Respiratory distress may be present with few
or no chest signs. The CXR is often non-specific. A firm diagnosis requires bronchial
lavage (or sputum induction with nebulised hypertonic saline in older co-operative
child). If suspicious treat before confirmation with iv co-trimoxazole 120 mg/kg/day
in 2 divided doses. Other opportunistic infections are possible and microbiological
advice highly desirable.

Clinical Guideline for: Management of Childhood Pneumonia

Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 6 of 8
 Trust Guideline for the Management of Childhood Pneumonia

5. Recurrent “Chest Infections"

 There is often an underlying diagnosis in children supposedly having frequent

"chest infections" and asthma is by far the commonest. Young children with
virally precipitated asthma or recurrent viral wheeze often have crackles from
airways oedema and mucus. Respiratory distress is common but wheeze
minimal or absent - hence the inclination to label them as chest infections.
Chest x-rays should be looked at critically - perihilar thickening, mucus
plugging and over-expansion suggest asthma, though secondary consolidation
is occasionally present as well. The primary treatment is as for asthma, though
oral antibiotics are sometimes indicated for definite consolidation on X-Ray.
Do not reflexly give antibiotics to this group.
 If true recurrent consolidation is present on X-Ray then the underlying
diagnosis should be sought. Consider aspiration, oesophageal reflux, H-type
tracheo-oesophageal fistula, cystic fibrosis and other forms of bronchiectasis,
ciliary dyskinesias and immune deficiencies. Most children in this group
warrant referral to the Children’s Respiratory clinic.

Objective/s

To simplify and improve the management of children with pneumonia.

Rationale

This is an update of a guideline that has been in existence since 1999. It has been
updated with more recent relevant references, particularly the BTS Guidelines for the
Management of Community Acquired Pneumonia in Childhood (1). There has been

no new evidence to substantially change the recommendations, except evidence of a

lack of superiority of intravenous over oral antibiotics. The BTS guideline suggests a
macrolide antibiotic for children with pneumonia over 5 years old and amoxicillin
under 5 with a macrolide as an alternative (1). As macrolides give good cover against
pneumococci, as well as covering Mycoplasma and pertussis, which amoxicillin does
not, we decided on the simpler approach of a macrolide antibiotic for all, unless there
is intolerance. This guideline should be read in conjunction with the Trust Guideline
for the Management of Parapnuemonic Effusion in Children (CA2055).

Clinical audit standards

All children admitted to hospital with pneumonia should have their SaO2 measured.
Children with pneumonia should be treated with a suitable oral antibiotic. Intravenous
antibiotics should only be used for the specific indications in the guideline: toxic
children with dense whole lobar involvement, or large effusion, or inability to tolerate
oral treatment. Radiological/hospital follow up not required in uncomplicated
community acquired pneumonia.

Clinical Guideline for: Management of Childhood Pneumonia

Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 7 of 8
 Trust Guideline for the Management of Childhood Pneumonia

Summary of development and consultation process undertaken before

registration and dissemination

The guideline was drafted by the author listed above and discussed at the Paediatric
Guideline Meeting, which has agreed the final content. During its development it has
been circulated for comment to: Consultants in Paediatric Medicine, Surgery and
Radiology, Accident & Emergency and Microbiology, and senior members of the
Paediatric Nursing and Pharmacy teams. 30 May 2006 Guideline was reviewed by
the author and discussed at the Paediatric Guideline Meeting. No changes were
considered necessary.

Dr C Upton reviewed the clinical content and the only change was to amend
Cefradine to Cefalexin as the oral cephalosporin.

This guideline is endorsed by the Clinical Guidelines Assessment Panel.

Distribution list/ dissemination method

Trust Intranet, CAU, A&E and Buxton Ward

References/ source documents

1. BTS Guidelines for the Management of Community Acquired Pneumonia in

Childhood. British Thoracic Society Standards of Care Committee. Thorax 2002;
57: 1-24.
2. Pneumonia: current challenges and treatment. Clements H, Stephenson T.
Current Paediatrics 1999; 9: 154-7.
3. Who needs chest physiotherapy? Moving from anecdote to evidence. Wallis C,
Prasad A. Arch Dis Child 1999; 80: 393-7.
4. Effectiveness of intramuscular penicillin versus oral amoxicillin in the early
treatment of outpatient pediatric pneumonia. Tsarouhas N, Shaw KN et al. Pediatr
Emerg Care 1998; 14: 338-41.
5. Oral amoxicillin versus injectable penicillin for severe pneumonia in children aged
3 to 59 months: a randomised multicentre equivalency study. Addo-Yobo E,
Chisaka N et al. Lancet 2004; 364: 1141-8.
6. Value of radiological follow up of childhood pneumonia. Gibson NA, Hollman AS,
Paton JY. BMJ 1993; 307: 1117.

Clinical Guideline for: Management of Childhood Pneumonia

Author/s: Dr Caroline Kavanagh Author/s title: Consultant Paediatrician
Approved by: CGAP Date approved: 13th June 2016 Review date: 13th June 2019
Available via Trust Docs Version: 6 Trust Docs ID: CA1043 Id 1150 Page 8 of 8