eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Pneumonia: Follow-up

Author: Mark I Neuman, MD, MPH, Assistant Professor of Pediatrics, Harvard Medical School; Attending Physician, Division of Emergency Medicine, Children's Hospital Boston
Contributor Information and Disclosures

Updated: Jul 24, 2009

Follow-up

Further Inpatient Care

  • Hospitalization and treatment with parenteral antibiotics should be considered for certain groups of children:
    • Infants younger than 6 months of age
    • Children with immunocompromise
    • Children who appear toxic, have respiratory distress, or require supplemental oxygen
    • Children in whom outpatient treatment has failed
  • Additionally, many patients without distress are admitted for hydration.
  • In some admitted patients, further testing to identify the etiologic agent is warranted.

Further Outpatient Care

  • Most children with uncomplicated pneumonia recover without sequelae.
  • In children who remain well appearing but have recurrent or chronic symptoms, further testing is warranted. Further testing may include skin testing to identify fungal pathogens and tuberculosis, sweat testing to identify cystic fibrosis, titers against rare organisms, and bronchoscopy.

Inpatient & Outpatient Medications

  • The initial outpatient treatment of children with pneumonia depends upon the clinical findings and the patient's age.
  • Children in whom pneumococcal disease is suspected initially should be treated with amoxicillin or penicillin.
  • A macrolide antibiotic alone, or in combination with sulfisoxazole or an oral cephalosporin is an alternative.
  • For most other children, particularly school-aged children, azithromycin alone or in combination with sulfisoxazole may be given. Other macrolide agents are acceptable alternatives to erythromycin.
  • Children who are being admitted should be treated with cefuroxime or another broad-spectrum cephalosporin.
  • Vancomycin may be added to the treatment of toxic-appearing children in areas where there is a high rate of penicillin resistance among pneumococcal isolates.
  • Acyclovir is indicated for the treatment of pneumonia caused by herpesviruses.

Transfer

  • Infants and children being admitted for pneumonia may require transfer because they need admission to a critical care unit.
  • Transfer should be considered when pneumonia complicates chronic illness. In such patients, the purpose of the transfer is continuity of care with the child's subspecialist.
  • Since the great risk faced by children with pneumonia is respiratory compromise, the unit performing the transfer should feel comfortable with the full spectrum of respiratory support that may be required.

Deterrence/Prevention

  • Several vaccines exist that may prevent certain types of pneumonia.
    • Heptavalent pneumococcal vaccine is recommended for all children in the United States.
    • Influenza vaccines are recommended for young children and those with chronic pulmonary disease including asthma.
    • H influenzae type b vaccine is given to all children and has reduced the incidence of infections caused by this organism.
    • Varicella vaccine has a dramatic impact upon the incidence of varicella.
    • An injection of RSV-specific immunoglobulins holds some promise for the prevention of severe RSV infections in certain infants. Likely candidates for this treatment are former premature infants and those with chronic heart and lung diseases.

Complications

  • Fortunately, most children with pneumonia recover without complications.
  • Persistent effusions and empyemas are the most common serious complications of bacterial pneumonia.
  • Pulmonary abscess
  • Respiratory distress
  • Sepsis

Prognosis

  • Patients who were placed on a protocol-driven pneumonia clinical pathway are more likely to have favorable outcomes.
  • The prognosis for most forms of pneumonia is excellent. Most cases of viral pneumonia resolve without treatment; common bacterial pathogens and atypical organisms respond to antimicrobial therapy.
  • The prognosis for varicella pneumonia is somewhat more guarded.
  • Staphylococcal pneumonia, although rare, can be very serious despite treatment.
  • Immunocompromised children, those with underlying lung disease, and neonates are at high risk for severe sequelae.
  • Some forms of viral pneumonia, particularly adenoviral disease, may cause necrotizing bronchiolitis or bronchiolitis obliterans.

Patient Education

  • Parents should be cautioned to look for the signs of increasing respiratory distress and to seek medical attention immediately should any of these signs appear.
  • Most children treated with outpatient antibiotics will be much improved within 48 hours after the initiation of treatment. If such improvement does not occur, medical attention should be sought.
  • For excellent patient education resources, visit eMedicine's Pneumonia Center. Also, see eMedicine's patient education articles Bacterial Pneumonia and Viral Pneumonia.

Miscellaneous

Medicolegal Pitfalls

  • Attempting to treat neonates and very young infants on an outpatient basis
  • Failure to recognize and treat signs of respiratory compromise and sepsis
  • Failure to give parents clear discharge instructions
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Laura E Ferguson, MD, Brent R King, MD, and Lakshmi V Atkuri, MD, to the development and writing of this article.



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References
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Further Reading

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Keywords

pneumonia in children, symptoms of pneumonia in children, treatment of pneumonia in children, bacterial pneumonia, respiratory syncytial virus, RSV, lower respiratory tract infection, empiric antibiotics, interstitial pneumonia, miliary pneumonia, lobar pneumonia, bronchopneumonia, dyspnea, hypoxemia

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Contributor Information and Disclosures

Author

Mark I Neuman, MD, MPH, Assistant Professor of Pediatrics, Harvard Medical School; Attending Physician, Division of Emergency Medicine, Children's Hospital Boston
Mark I Neuman, MD, MPH is a member of the following medical societies: Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Director, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia, Australia.
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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