Pneumonia in children
Pneumonia in kids can be scary. We are seeing a lot of it right now, especially Mycoplasma pneumonia.
Here is an overview of community acquired pneumonia in children. For more on mycoplasma pneumonia (also called “walking” pneumonia), click here. It may also be helpful to check out my article on managing coughs in kids.
What is pneumonia, exactly?
Pneumonia is an infection of the lungs. It is not common, but when it occurs (especially in younger children) it can be serious. It can be caused by viruses, bacteria and in some cases, even fungi.
Pneumonia often follows an upper respiratory infection (in other words, a cold). This makes it tricky, and it means that it’s important to have your child checked out if they are sick and the illness is not following an expected trajectory. If your child has a standard cold but is not improving, or improved and then worsened again (eg: if fever went away and then came back), this could be a sign of pneumonia.
What causes pneumonia in kids?
The most common cause of Community Acquired Pneumonia in children varies by age.
Under 3 months:
The most common cause of bacterial pneumonia in this age group is actually chlamydia (although it is not the only cause).
Viruses can cause pneumonia too, and this may be more likely if an infant is exposed to more viruses because of older siblings.
Under 1 year:
Viruses cause 80% of pneumonia in this age group. Some examples include:
Bacterial causes are not as common but can certainly happen. Bacterial pneumonia in this age group has decreased since the introduction of the pneumococcal and Hib vaccines.
Under 5 years
Viruses cause about half of pneumonia cases in this age group (similar list as above).
Certain bacteria are also common culprits, particularly Streptococcus pneumoniae (S. pneumo) and Haemophilus influenza Type B (Hib).
Over 5 years
Pneumonia in general is not that common in healthy older children, but when it happens the cause is most likely bacteria. S.pneumo is still the most common cause, although as children get older, we see more and more Mycoplasma pneumonia.
Chronic illnesses and immunocompromise
A wider range of viruses, bacteria and even fungi can cause pneumonia in higher-risk individuals.
Transmission & Incubation:
These depend a lot on the specific cause of the pneumonia itself. Some forms of pneumonia are not contagious, although the respiratory viruses and bacteria that lead to it often are. These can spread via coughing, sneezing and sometimes on surfaces / shared utensils etc.
The Pediatrician Mom Tip: Certain types of pneumonia, such as mycoplasma, actually have a long incubation period (up to 3 weeks!)
Symptoms:
Again, symptoms can vary based on the specific cause of pneumonia. Those caused by viruses may have accompanying upper respiratory or GI symptoms.
Not every child will have every symptom. Watch for:
Fever
Difficulty breathing or rapid breathing (see this post)
Cough (can be productive or dry depending on the cause)
Decreased appetite and dehydration
Fatigue, confusion, fussiness
Abnormal lung exam findings (crackles, wheezing, decreased air exchange)
Low oxygen levels
How can you tell if pneumonia is viral or bacterial?
Often, you cannot. The symptoms can overlap, which is why clinical judgment is so important. It is also why you need to be thoughtful about going back to your doctor if your child is not improving as expected.
How is pneumonia diagnosed?
Pneumonia can be diagnosed clinically and based on history. In some situations, we do a chest x ray. Hospitalized / more serious cases often get more testing, including sputum cultures or PCR testing, but in the outpatient or pediatric office setting, these are not easy to do.
Treatment
Treatment is a two-pronged approach, based on symptom severity and clinical judgment about cause. It can include:
Supportive care
For example, fever reducing medication, intravenous or oral fluids, supplemental oxygen, and medications to help with cough.
Not every child needs to be hospitalized, but some do.
Medications
If the pneumonia is thought to be due to a bacteria, the choice of antibiotic is targeted based on the most likely cause. These decisions are often based on the clinical presentation, age, what else is going on in the community. Not every antibiotic will work for every bacterium.
If the pneumonia is thought to be caused by a virus, treatment options are more limited (although we do consider antiviral medications like Tamiflu if the cause is influenza).
What else should parents know?
Expect improvement after starting an antibiotic
If your child is diagnosed with bacterial pneumonia and is on an antibiotic but is not getting better within 24-48h of starting that antibiotic, or if they seem like they are getting worse, TALK TO YOUR DOCTOR.
Illnesses evolve
This is key! Especially early in an illness, it can be hard to tell if a cough is from a viral upper respiratory infection or a pneumonia. Especially for a child in daycare, making the assumption that a virus is the likely cause is often reasonable. Doing so does not mean that a pneumonia was “missed” — oftentimes the pneumonia component develops a few days into a viral illness.
But this also means you should stay alert. Whether or not your child was seen, if you feel like they are not improving appropriately — or you have concerns — it’s completely appropriate to have them evaluated again. Trust your spidey sense!
Manage Fever
Remember, your goal is comfort! Don't obsess over numbers, but recognize that when children have fever they often are less comfortable, breathe more rapidly, and refuse fluids.
Manage hydration
Dehydration is often the reason children end up in the emergency room, regardless of the cause of their illness. Make sure you know what to look for and how to manage it!
Prevention
The best way to prevent pneumonia is to use common sense infection control measures and to stay up to date on prevention.
Frequent handwashing for 20 seconds at a time using soap and water
Immunization:
The frequency and severity of pneumonia in children has substantially decreased since the introduction of the Pertussis, Prevnar and Hib vaccines. These are typically given multiple times in the first 2 years of life. Stay up to date!
The flu vaccine decreases the likelihood of pneumonia.
For eligible children, the RSV monoclonal antibody is extremely effective!
Distancing from others who are sick
Masks
Disinfect frequently touched household surfaces at least 1-2 times per day (doorknobs, counters, etc).
Make sure that chronic illnesses like asthma are well controlled
Decrease environmental pollution (for example, exposure to secondhand smoke).
When to call the pediatrician
This is not a comprehensive list. In general, always err on the side of calling your pediatrician if you have any concerns about your child. There is a lot to be said for a parent’s gut instinct, and I promise: your pediatrician would rather you called!
If your child is not improving within a few days, or if they seem to be getting worse, call your pediatrician. Other concerning symptoms include:
Ongoing symptoms: dry, hacking or persistent coughing for longer than a week that is not improving (or cough that improved then got worse again)
Significant cough in a child without any cold symptoms or congestion
Breathing difficulty (see my video on instagram with more details).
Rapid breathing (Infant <12mo: more than 60 breaths/minute)
Retractions: when the skin pulls in between the ribs or at the base of the throat with each breath
Pauses/irregular breathing
Nasal flaring
Grunting with each breath
Wheezing
There is also a free download in the guides section that covers how to assess vital signs as well as what is normal at different ages.
Dehydration
Change in color (blue OR pale)
Ongoing malaise / low energy / fatigue that is not improving within 3-5 days.
Poor feeding
Chest pain or pain with deep breathing
Fever is persistent beyond 3-5 days, or a fever that went away and then came back
Anything else tickling your spidey sense!!
FAQs
My child was prescribed Albuterol breathing treatments. Is this right?
In some cases, pneumonia can cause the airways to spasm and become more narrow. This makes air passage more difficult. It is more likely to happen in a child with underlying RSV or a history of wheezing / asthma. Albuterol works by relaxing those airways and making air passage easier. However, it is not needed for every child.
Can you get pneumonia more than once?
Yes. But if your child has a history of multiple episodes of pneumonia (especially if it is severe pneumonia requiring admission), it is important to talk to your pediatrician. In many offices where you say an array of pediatric providers, there isn’t anyone looking at the big picture - there’s a tendency to just treat the illness in front of you. So if your child has a history of recurrent pneumonia (or really, recurrent anything), bring that up with their pediatrician. They may need immunologic testing, repeat Pneumococcal immunization, or a pulmonology evaluation.
Is there anything I should avoid?
In general we do not recommend nasal decongestants, cough suppressants, or essential oils in children because of potential side effects. In particular, certain essential oils can release VOCs and cause bronchospasm (spasming of the airways) which can worsen pneumonia. Some of the biggest culprits here are lavender, eucalyptus and tea tree oil.
Does my child need to stay home from school?
Yes. Keep them home until they are feeling better (able to stay hydrated, acting more like themselves), fever free for >24h, no longer wheezing and respiratory symptoms are improving. Talk to your pediatrician for more guidance.
