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Pediatric Pneumonia Clinical Presentation

  • Author: Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP; Chief Editor: Russell W Steele, MD  more...
 
Updated: Jun 30, 2016
 

History

Newborns with pneumonia rarely cough; they more commonly present with poor feeding and irritability, as well as tachypnea, retractions, grunting, and hypoxemia. Grunting in a newborn suggests a lower respiratory tract disease and is due to vocal cord approximation as they try to provide increased positive end-expiratory pressure (PEEP) and keep their lower airways open.

After the first month of life, cough is the most common presenting symptom of pneumonia. Infants may have a history of antecedent upper respiratory symptoms. Grunting may be less common in older infants; however, tachypnea, retractions, and hypoxemia are common and may be accompanied by a persistent cough, congestion, fever, irritability, and decreased feeding. Any maternal history of Chlamydia trachomatis infection should be determined.

Infants with bacterial pneumonia are often febrile, but those with viral pneumonia or pneumonia caused by atypical organisms may have a low-grade fever or may be afebrile. The child's caretakers may complain that the child is wheezing or has noisy breathing. Toddlers and preschoolers most often present with fever, cough (productive or nonproductive), tachypnea, and congestion. They may have some vomiting, particularly posttussive emesis. A history of antecedent upper respiratory tract illness is common.

Older children and adolescents may also present with fever, cough (productive or nonproductive), congestion, chest pain, dehydration, and lethargy. In addition to the symptoms reported in younger children, adolescents may have other constitutional symptoms, such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea, pharyngitis, and otalgia/otitis are other common symptoms.

Travel history is important because it may reveal an exposure risk to a pathogen more common to a specific geographic area (eg, dimorphic fungi). Any exposure to TB should always be determined. In addition, exposure to birds (psittacosis), bird droppings (histoplasmosis), bats (histoplasmosis), or other animals (zoonoses, including Q fever, tularemia, and plague) should be determined.

In children with evidence for recurrent sinopulmonary infections, a careful history to determine the underlying cause is needed. The recurrent nature of the infections may be unveiling an innate or acquired immune deficiency, an anatomic defect, or another genetic disease (cystic fibrosis, ciliary dyskinesia).

Tuberculosis

A history of TB exposure to possible sources should be obtained in every patient who presents with signs and symptoms of pneumonia (eg, immigrants from Africa, certain parts of Asia, and Eastern Europe; contacts with persons in the penal system; close contact with known individuals with TB). Children with TB usually do not present with symptoms until 1-6 months after primary infection. These may include fever, night sweats, chills, cough (which may include hemoptysis), and weight loss.

Next

Physical Examination

The signs and symptoms of pneumonia are often nonspecific and widely vary based on the patient’s age and the infectious organisms involved. Tachypnea is the most sensitive finding in patients with diagnosed pneumonia.

Initial evaluation

Early in the physical examination, identifying and treating respiratory distress, hypoxemia, and hypercarbia is important. Visual inspection of the degree of respiratory effort and accessory muscle use should be performed to assess for the presence and severity of respiratory distress. The examiner should simply observe the patient's respiratory effort and count the respirations for a full minute. In infants, observation should include an attempt at feeding, unless the baby has extreme tachypnea.

Pulmonary findings in all age groups may include accessory respiratory muscle recruitment, such as nasal flaring and retractions at subcostal, intercostal, or suprasternal sites. Signs such as grunting, flaring, severe tachypnea, and retractions should prompt the clinician to provide immediate respiratory support. Retractions result from the effort to increase intrathoracic pressure to compensate for decreased compliance.

An emergency department (ED)-based study conducted in the United States found that respiratory rate alone and subjective clinical impression of tachypnea did not discriminate children with and without radiographic pneumonia.[24] The WHO clinical criteria for pneumonia has also been reported to demonstrate poor sensitivity (34.3%) in diagnosing radiographic pneumonia in children presenting to a pediatric ED.[25] However, children with tachypnea as defined by WHO respiratory rate thresholds were more likely to have pneumonia than children without tachypnea. The WHO thresholds are as follows:

  • Children younger than 2 months - Greater than or equal to 60 breaths/min
  • Children aged 2-11 months - Greater than or equal to 50 breaths/min
  • Children aged 12-59 month - Greater than or equal to 40 breaths/min

Airway secretions may vary substantially in quality and quantity but are most often profuse and progress from serosanguineous to a more purulent appearance. White, yellow, green, or hemorrhagic colors and creamy or chunky textures are not infrequent. If aspiration of meconium, blood, or other proinflammatory fluid is suspected, other colors and textures reflective of the aspirated material may be seen.

Infants may have external staining or discoloration of skin, hair, and nails with meconium, blood, or other materials when they are present in the amniotic fluid. The oral, nasal, and, especially, tracheal presence of such substances is particularly suggestive of aspiration.

An assessment of oxygen saturation by pulse oximetry should be performed early in the evaluation of all children with respiratory symptoms. Cyanosis may be present in severe cases. When appropriate and available, capnography may be useful in the evaluation of children with potential respiratory compromise.

Cyanosis of central tissues, such as the trunk, implies a deoxyhemoglobin concentration of approximately 5 g/dL or more and is consistent with severe derangement of gas exchange from severe pulmonary dysfunction as in pneumonia, although congenital structural heart disease, hemoglobinopathy, polycythemia, and pulmonary hypertension (with or without other associated parenchymal lung disease) must be considered.

Chest pain may be observed with inflammation of or near the pleura. Abdominal pain or tenderness is often seen in children with lower lobe pneumonia. The presence and degree of fever depends on the organism involved, but high temperature (38.4°C) within 72 hours after admission and the presence of pleural effusion have been reported to be significantly associated with bacterial pneumonia.[6]

Pneumonia may occur as a part of another generalized process. Therefore, signs and symptoms suggestive of other disease processes, such as rashes and pharyngitis, should be sought during the examination.

Auscultation

Auscultation is perhaps the most important portion of the examination of the child with respiratory symptoms. The examination is often very difficult in infants and young children for several reasons. Babies and young children often cry during the physical examination making auscultation difficult. The best chance of success lies in prewarming hands and instruments and in using a pacifier to quiet the infant. The opportunity to listen to a sleeping infant should never be lost.

Older infants and toddlers may cry because they are ill or uncomfortable, but, most often, they have stranger anxiety. For these children, it is best to spend a few minutes with the parents in the child's presence. If the child sees that the parent trusts the examining physician then he or she may be more willing to let the examiner approach. A small toy may help to gain the child's trust. Any part of the examination using instruments should be deferred as long as possible, because the child may find the medical equipment frightening. Occasionally, if the child is allowed to hold the stethoscope for a few minutes, it becomes less frightening. Even under the best of circumstances, examining a toddler is difficult. If the child is asleep when the physician begins the evaluation, auscultation should be performed early.

Children with respiratory symptoms may have a concomitant upper respiratory infection with copious upper airway secretions. This creates another potential problem, the transmission of upper airway sounds. In many cases, the sounds created by upper airway secretions can almost obscure true breath sounds and lead to erroneous diagnoses. If the etiology of sounds heard through the stethoscope is unclear, the examiner should listen to the lung fields and then hold the stethoscope near the child's nose. If the sounds from both locations are approximately the same, the likely source of the abnormal breath sounds is the upper airway.

Even when the infant or young child is quiet and has a clear upper airway, the child's normal physiology may make the examination difficult. The minute ventilation is the product of the respiratory rate and tidal volume. In young children, respiratory rate makes a very large contribution to the overall minute ventilation. In other words, babies take many shallow breaths as opposed to a few deep ones. Therefore, a subtle finding, particularly one at the pulmonary bases, can be missed.

The sine qua non for pneumonia has always been the presence of crackles or rales. Although often present, focal crackles as a stand-alone physical examination finding is neither sensitive nor specific for the diagnosis of pneumonia.[26, 27, 28] Additionally, not all children with pneumonia have crackles.

Rales, rhonchi, and cough are all observed much less frequently in infants with pneumonia than in older individuals. If present, they may be caused by noninflammatory processes, such as congestive heart failure, condensation from humidified gas administered during mechanical ventilation, or endotracheal tube displacement. Although alternative explanations are possible, these findings should prompt careful consideration of pneumonia in the differential diagnosis.

Other examination findings suggestive of pneumonia include asymmetry of breath sounds in infants, such as focal wheezing or decreased breath sounds in one lung field, and asymmetry of chest excursions, which suggest air leak or emphysematous changes secondary to partial airway obstruction. Similarly, certain more diffuse lung infections (eg, viral infections) may result in generalized crackles or wheezing.

In lobar pneumonia, fibrinous inflammation may extend into the pleural space, causing a rub heard by auscultation. Pericardial effusion in patients with lower lobe pneumonia due to H influenzae may also cause a rub. Other signs and/or findings in lobar pneumonia include abdominal pain or an ileus accompanied by emesis in patients with lower lobe pneumonia and nuchal rigidity in patients with right upper lobe pneumonia.

Percussion may reveal important information. Occasionally, a child presents with a high fever and cough but without ausculatory findings suggestive of pneumonia. In such cases, percussion may help to identify an area of consolidation.

Systemic and localized findings

Systemic findings in newborns with pneumonia may provide clues to the etiology. Rash or jaundice at birth may indicate congenital infection. Nonspecific findings such as tachycardia, glucose intolerance, abdominal distention, hypoperfusion, and oliguria are very common is moderately to severely ill newborns, and are not specific for a lung focus of infection. Localized findings include conjunctivitis (consider C trachomatis), vesicles or other focal skin lesions (consider HSV), and unusual nasal secretions (consider congenital syphilis).

Adenopathy in older children suggests long-standing infection and should suggest a more chronic cause such as TB or a dimorphic fungal infection (eg, histoplasmosis, blastomycosis). Hepatomegaly from infection may result from the presence of some chronic causative agents, cardiac impairment, or increased intravascular volume. Apparent hepatomegaly may result if therapeutic airway pressures allow generous lung inflation and downward displacement of a healthy liver.

Other considerations

Infants infected with organisms in utero or via the maternal genital tract commonly present within the first few hours after birth, but if infection is acquired during the delivery, the presentation may be delayed. The usual presenting symptoms include tachypnea, hypoxemia, and signs of respiratory distress. Auscultation may reveal diffuse fine crackles.

Early onset group B streptococci infection usually presents via ascending perinatal infection as sepsis or pneumonia within the first 24 hours of life. C trachomatis pneumonia should be considered in infants aged 2-4 weeks and is often associated with conjunctivitis. Infants infected with C pneumoniae,U urealyticum,Mycoplasma hominis, CMV, and P carinii present between age 4 and 11 weeks with an afebrile pneumonia characterized by a staccato cough, tachypnea, and, occasionally, hypoxia.

Infants or toddlers with bacterial pneumonia may present with lethargy, irritability, acidosis, hypotonia, or hypoxia that is out of proportion to ausculatory findings; school-aged children and adolescents are often febrile and appear ill. Mycoplasma infections are indolent, with gradual onset of malaise, low-grade fever, headache, and cough. C pneumoniae is also fairly common in children aged 5 years and presents in a similar fashion.

Pneumonia caused by B pertussis occurs predominantly in infants who have not completed their vaccinations or in children who did not receive vaccinations. Their clinical presentation includes coryza, malaise, fever, paroxysms of cough occasionally accompanied by emesis, apnea, poor feeding, and cyanosis. Older adolescents infected with pertussis present with a paroxysmal cough, which persists for more than 3 weeks and may last up to 3 months, unlike the whooping cough of younger children. Chest radiographs in this group of patients are almost always normal, despite the intensity of the cough illness.

Although infection with H capsulatum is usually asymptomatic in older children and adolescents, infants and young children are at risk for symptomatic infection, which may cause respiratory distress and hypoxemia.

Pneumonia is the most common cause of acute chest syndrome, which occurs in 15-43% of patients with sickle cell disease. This syndrome is characterized by fever, chest pain, dyspnea, cough, tachypnea, crackles.

To see complete information on Afebrile Pneumonia Syndrome, please go to the main article by clicking here.

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Patients With Recurrent Pneumonias

Occasionally, a patient has pneumonia that continues to manifest clinically (persistent or unresponsive pneumonia) , radiographically (eg, 8 wk after antibiotic treatment), or both despite adequate medical management. Studies have documented that the usual pathogens (eg, pneumococcus, non-typeable H influenza, Moraxella catarrhalis) are causative agents.

Other patients may present with a history of recurrent pneumonias, defined as more than 1 episode per year or more than 3 episodes in a lifetime and again the organisms responsible are the common pathogens.

These patients merit special mention because they require a more extensive workup by a specialist. One useful way to categorize these patients is based on radiographic findings with and without symptoms. This method places these children in 1 of 3 categories (see the Table below) that help to narrow the differential diagnoses.

A careful history and examination are helpful to further narrow the differential diagnosis (see Differential Diagnosis). However, more testing is often needed to confirm most of these diagnoses and is generally outside the scope of a primary care provider.

Table. Categorizing Patients Based on Symptoms, Which Assists in Differential Diagnosis of Those With Recurrent Pneumonias (Open Table in a new window)

Category Laboratory and Imaging Findings Clinical Findings Differential Diagnosis
1 Persistent or recurrent radiologic findings Persistent or recurrent fever and symptoms Cystic fibrosis, immunodeficiencies, obstruction (intrinsic [eg, foreign body] or extrinsic [eg, compressing nodes or tumor]), pulmonary sequestration, bronchial stenosis, or bronchiectasis
2 Persistent radiologic findings No clinical findings Anatomic abnormality (eg, sequestration, fibrosis, pleural lesion)
3 Recurrent pulmonary infiltrates with interval radiologic clearing No clinical findings Asthma and atelectasis that has been misdiagnosed as a bacterial pneumonia; aspiration syndrome, hypersensitivity pneumonitis, idiopathic pulmonary hemosiderosis, or a mild immunodeficiency disorder

 

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Contributor Information and Disclosures
Author

Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP Assistant Professor of Pediatrics, Co-Director of Antimicrobial Stewardship, Medical Director, Division of Pediatric Infectious Diseases and Immunology, Connecticut Children's Medical Center

Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Received research grant from: Cubist Pharmaceuticals, Durata Therapeutics, and Biota Pharmaceutical<br/>Received income in an amount equal to or greater than $250 from: HealthyCT insurance<br/>Medico legal consulting for: Various.

Coauthor(s)

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Disclosure: Nothing to disclose.

Brent R King , MD, MMM Clive Nancy and Pierce Runnells Distinguished Professor of Emergency Medicine; Professor of Pediatrics, University of Texas Health Science Center at Houston; Chair, Department of Emergency Medicine, Chief of Emergency Services, Memorial Hermann Hospital and LBJ Hospital

Disclosure: Nothing to disclose.

Jeff L Myers, MD, PhD Chief, Pediatric and Congenital Cardiac Surgery, Department of Surgery, Massachusetts General Hospital; Associate Professor of Surgery, Harvard Medical School

Disclosure: Nothing to disclose.

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.

José Rafael Romero, MD Director of Pediatric Infectious Diseases Fellowship Program, Associate Professor, Department of Pediatrics, Combined Division of Pediatric Infectious Diseases, Creighton University/University of Nebraska Medical Center

José Rafael Romero, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, New York Academy of Sciences, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Manika Suryadevara, MD Fellow in Pediatric Infectious Diseases, Department of Pediatrics, State University of New York Upstate Medical University

Disclosure: Nothing to disclose.

Isabel Virella-Lowell, MD Department of Pediatrics, Division of Pulmonary Diseases, Pediatric Pulmonology, Allergy and Immunology

Disclosure: Nothing to disclose.

Garry Wilkes, MBBS, FACEM Director of Emergency Medicine, Calvary Hospital, Canberra, ACT; Adjunct Associate Professor, Edith Cowan University, Western Australia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Disclosure: Nothing to disclose.

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(Left) Gram stain demonstrating gram-positive cocci in pairs and chains and (right) culture positive for Streptococcus pneumoniae.
A breakdown of test results and recommended treatment for pneumonia with effusion. Gm = Gram; neg = negative; pos = positive; VATS = video-assisted thoracic surgery
(A) Anteroposterior radiograph from a child with presumptive viral pneumonia. (B) Lateral radiograph of the same child with presumptive viral pneumonia.
Radiograph from a patient with bacterial pneumonia (same patient as in the preceding image) a few days later. This radiograph reveals progression of pneumonia into the right middle lobe and the development of a large parapneumonic pleural effusion.
Right lower lobe consolidation in a patient with bacterial pneumonia.
(A) Anteroposterior radiograph from a child with a left lower lobe infiltrate. (B) Lateral radiograph of the same child with a left lower lobe infiltrate.
Anteroposterior radiograph from a child with a round pneumonia.
Table. Categorizing Patients Based on Symptoms, Which Assists in Differential Diagnosis of Those With Recurrent Pneumonias
Category Laboratory and Imaging Findings Clinical Findings Differential Diagnosis
1 Persistent or recurrent radiologic findings Persistent or recurrent fever and symptoms Cystic fibrosis, immunodeficiencies, obstruction (intrinsic [eg, foreign body] or extrinsic [eg, compressing nodes or tumor]), pulmonary sequestration, bronchial stenosis, or bronchiectasis
2 Persistent radiologic findings No clinical findings Anatomic abnormality (eg, sequestration, fibrosis, pleural lesion)
3 Recurrent pulmonary infiltrates with interval radiologic clearing No clinical findings Asthma and atelectasis that has been misdiagnosed as a bacterial pneumonia; aspiration syndrome, hypersensitivity pneumonitis, idiopathic pulmonary hemosiderosis, or a mild immunodeficiency disorder
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