Community-Acquired Pneumonia in Children - Clinical Features and Diagnosis

11/11/2015
Community-acquired pneumonia in children: Clinical features and diagnosis
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Communityacquiredpneumoniainchildren:Clinicalfeaturesanddiagnosis
Author
WilliamJBarson,MD
SectionEditors
SheldonLKaplan,MD
GeorgeBMallory,MD
DeputyEditor
MaryMTorchia,MD
Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Oct2015.|Thistopiclastupdated:Oct07,2015.
INTRODUCTIONCommunityacquiredpneumonia(CAP)isdefinedassignsandsymptomsofanacute
infectionofthepulmonaryparenchymainapreviouslyhealthypatientwhoacquiredtheinfectioninthe
community,asdistinguishedfromhospitalacquired(nosocomial)pneumonia[1,2].CAPisacommonand
potentiallyseriousillnesswithconsiderablemorbidity.
TheclinicalfeaturesanddiagnosisofCAPinchildrenwillbereviewedhere.Theepidemiology,
pathogenesis,andtreatmentofpneumoniainchildrenarediscussedseparately.(See"Pneumoniain
children:Epidemiology,pathogenesis,andetiology"and"Communityacquiredpneumoniainchildren:
Outpatienttreatment"and"Pneumoniainchildren:Inpatienttreatment".)
CLINICALPRESENTATIONTheclinicalpresentationofchildhoodpneumoniavariesdependingupon
theresponsiblepathogen,theparticularhost,andtheseverity.Thepresentingsignsandsymptomsare
nonspecificnosinglesymptomorsignispathognomonicforpneumoniainchildren.
Symptomsandsignsofpneumoniamaybesubtle,particularlyininfantsandyoungchildren.The
combinationoffeverandcoughissuggestiveofpneumoniaotherrespiratoryfindings(eg,tachypnea,
increasedworkofbreathing)mayprecedecough.Coughmaynotbeafeatureinitiallysincethealveolihave
fewcoughreceptors.Coughbeginswhentheproductsofinfectionirritatecoughreceptorsintheairways.
Thelongerfever,cough,andrespiratoryfindingsarepresent,thegreaterthelikelihoodofpneumonia[3].
Neonatesandyounginfantsmaypresentwithdifficultyfeeding,restlessness,orfussiness[4].Young
children(ie,<5to10yearsofage)maypresentwithfeverandleukocytosis[3,5].Olderchildrenmay
complainofpleuriticchestpain(painwithrespiration),butthisisaninconsistentfinding.Occasionally,the
predominantmanifestationmaybeabdominalpain(becauseofreferredpainfromthelowerlobes)ornuchal
rigidity(becauseofreferredpainfromtheupperlobes)."Walkingpneumonia"isatermthatissometimes
usedtodescribepneumoniainwhichtherespiratorysymptomsdonotinterferewithnormalactivity.
CLINICALEVALUATIONTheevaluationofthechildwithcoughandpotentiallowerrespiratorytract
diseasehastwogoals:theidentificationoftheclinicalsyndrome(eg,pneumonia,bronchiolitis,asthma)and
anassessmentoftheseverityoftheillness[4].Theseverityofillnessdeterminestheneedforadditional
evaluation.
HistoryImportantaspectsofthehistoryforchildrenwithpossiblecommunityacquirepneumoniaare
listedinthetable(table1)[4,6,7].Historicalfeaturescanbehelpfulindeterminingtheetiologicagent,the
likelihoodofinfectionwithanorganismthatisresistanttoantibiotics,andtheseverityofillness.(See
"Pneumoniainchildren:Epidemiology,pathogenesis,andetiology",sectionon'Etiologicagents'.)
ExaminationImportantaspectsoftheexaminationaresummarizedinthetable(table2)anddiscussed
ingreaterdetailbelow.
GeneralappearanceIntheyounginfant,assessmentofgeneralappearanceincludestheabilityto
attendtotheenvironment,tofeed,tovocalize,andtobeconsoled.Thestateofawarenessandpresenceof
cyanosisshouldbeassessedinallchildren,althoughchildrenmaybehypoxemicwithoutcyanosis[8].Most
childrenwithradiographicallyconfirmedpneumoniaappearill[9].
FeverFeverisacommonmanifestationofpneumoniainchildren[10].However,itisnonspecificand
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variablypresent.YounginfantsmayhaveafebrilepneumoniarelatedtoChlamydiatrachomatisorother
pathogens.(See"Chlamydiatrachomatisinfectionsinthenewborn",sectionon'Pneumonia'and
"Pneumoniainchildren:Epidemiology,pathogenesis,andetiology",sectionon'Ininfants'.)
Fevermaybetheonlysignofoccultpneumoniainhighlyfebrileyoungchildren.Inonereport,26percentof
146children(<5years)withfever39C(102.2F),noclinicalevidenceofpneumoniaorotherlocalizing
signs,andperipheralwhitebloodcellcount20,000/microLhadradiographicevidenceofpneumonia[5].
TachypneaTachypneaisthemostsensitiveandspecificsignofradiographicallyconfirmed
pneumoniainchildren[4,1113].Inasystematicreviewofstudiesevaluatingthecorrelationbetweenclinical
examinationfindingsandradiographicpneumonia,tachypneawastwiceasfrequentinchildrenwiththan
withoutradiographicpneumonia,andtheabsenceoftachypneawasthesinglemostvaluablesignfor
excludingpneumonia[4].Tachypneaininfantswithpneumonia(respiratoryrate>70breaths/min)alsohas
beenassociatedwithhypoxemia[14].Tachypneamaybelessusefulearlyinthecourseofillness(eg,less
thanthreedays)[11].
TheWorldHealthOrganizationagerelateddefinitionsoftachypneaareasfollows[15,16]:
Youngerthantwomonths:>60breaths/min
Twoto12months:>50breaths/min
Oneto5years:>40breaths/min
5years:>20breaths/min
Therespiratoryratevarieswithactivityininfantsandyoungchildren,andinthesepatientsisbestassessed
bycountingforafull60seconds[4,1719].Observationofchestwallmovementsispreferableto
auscultationbecauseauscultationmaystimulatethechild,falselyelevatingtherate[4].Therespiratoryrate
mayincreasebyasmanyas10breathsperminuteperdegree(Celsius)offeverinchildrenwithout
pneumonia[20]theeffectoffeveronrespiratoryrateinchildrenwithpneumoniahasnotbeeninvestigated
[4].
RespiratorydistressSignsofrespiratorydistressincludetachypnea,hypoxemia(peripheralarterial
oxygensaturation[SpO2]<90percentonroomairatsealevel),increasedworkofbreathing(intercostal,
subcostal,orsuprasternalretractionsnasalflaringgruntinguseofaccessorymuscles),apnea,andaltered
mentalstatus[1].
Oxygensaturationshouldbemeasuredinanychildwithincreasedworkofbreathing,particularlyifheorshe
hasadecreasedlevelofactivityoragitation[1,2,21].Infantsandchildrenwithhypoxemiamaynotappear
cyanotic[8].Hypoxemiaisasignofseverediseaseandanindicationforadmission[1,2].
Signsofrespiratorydistressaremorespecificthanfeverorcoughforlowerrespiratorytractinfection.Ina
reviewof192febrileinfantsyoungerthanthreemonthsofage,thespecificityofatleastonesignof
respiratorydistressforradiographicpneumonia(respiratoryrate>60breaths/min,retractions,flaring,
crackles,grunting,apnea,orcyanosis)was93percent,butthesensitivitywasonly59percent[22].
Signsofrespiratorydistressthatarepredictiveofpneumoniaincludehypoxemia(defineddifferentlyin
differentstudies,usuallyoxygensaturation<94to96percentinroomair),retractions,headbobbing,and
nasalflaring[7,9,12,23].Unliketachypnea,theabsenceofthesefindingsdoesnotexcludeadiagnosisof
pneumonia.
Inareviewofchildren2to59monthsofage,oxygensaturation96percentinroomairwas2.8times
morefrequentamongchildrenwithpneumoniathanwithout[12]
Inasystematicreview,retractionswere2.5timesmorefrequentininfantswithpneumoniathanwithout
[4]
Nasalflaringisapproximatelythreetimesmorefrequentinchildren<5yearswithpneumoniathan
without[4],andfivetimesmorefrequentininfants2to12monthswithpneumoniathanwithout[12]
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Grunting,whenpresent,isasignofseverediseaseandimpendingrespiratoryfailure[24]
LungexaminationExaminationofthelungsmayprovidecluestothediagnosisofpneumoniaand/or
potentialcomplications.
Auscultationisanimportantcomponentoftheexaminationofthechildwhopresentswithfindingsindicative
ofpneumonia.However,auscultatoryfindingshavelessinterobserveragreementthanobservablefindings,
suchasretractions[4].Auscultationofalllungfieldsshouldbeperformed.
Examinationfindingsconsistentwithradiographicallyconfirmedpneumoniainclude[13]:
Crackles,alsocalledralesorcrepitationsinasystematicreview,crackleswere3.5timesmore
frequentininfantswithradiographicpneumoniathanwithout[4]
Findingsconsistentwithconsolidatedlungparenchyma,including:
Decreasedbreathsounds
Bronchialbreathsounds(louderthannormal,withshortinspiratoryandlongexpiratoryphases,
andhigherpitchedduringexpiration),egophony(EtoAchange)
Bronchophony(thedistincttransmissionofsoundssuchasthesyllablesofninetynine)
Whisperedpectoriloquy(transmissionofwhisperedsyllables)
Tactilefremitus(eg,whenthepatientsaysninetynine)
Dullnesstopercussion
Wheezingismorecommoninpneumoniacausedbyatypicalbacteriaandviruses[25]thanbacteria
(see'Cluestoetiology'below)
Findingssuggestiveofpleuraleffusionincludechestpainwithsplinting,dullnesstopercussion,distant
breathsounds,andapleuralfrictionrub(see"Epidemiologyclinicalpresentationandevaluationof
parapneumoniceffusionandempyemainchildren",sectionon'Clinicalpresentation')
SeverityassessmentAnassessmentofpneumoniaseverityisnecessarytodeterminetheneedfor
laboratoryandimagingstudiesandtheappropriatetreatmentsetting.Theseverityofpneumoniais
assessedbythechild'soverallclinicalappearanceandbehavior,includinganassessmentofhisorher
degreeofawarenessandwillingnesstoeatordrink(table3)[7].
CluestoetiologyClinicalfeaturesclassicallytaughttobecharacteristicofbacterialpneumonia,atypical
bacterialpneumonia,orviralpneumoniaaresummarizedinthetable(table4).However,thefeatures
frequentlyoverlapandcannotbeusedreliablytodistinguishbetweenthevariousetiologies[26,27].In
addition,asmanyas50percentofinfectionsmaybemixedbacterial/viralinfections.(See"Pneumoniain
children:Epidemiology,pathogenesis,andetiology",sectionon'Communityacquiredpneumonia'.)
BacterialClassically,bacterial("typical")pneumonia,usuallyresultingfromStreptococcus
pneumoniaeandlesscommonlyfromStaphylococcusaureusandgroupAStreptococcus,whichmay
followdaysofupperrespiratorytractinfectionsymptoms,isconsideredabruptinonset,withthefebrile
patientappearingillandsometimestoxic.Respiratorydistressismoderatetosevereauscultatory
findingsmaybefewandfocal,limitedtotheinvolvedanatomicsegment.Signsandsymptomsof
sepsisandlocalizedchestpain(signifyingpleuralirritation)aremoresuggestiveofbacterialetiology
[10],astheyarerarelypresentinnonbacterialpneumonia.Complications,discussedbelow,alsoare
moresuggestiveofbacterialetiology(see'Complications'below)Ontheotherhand,primarybacterial
pneumoniaisunlikelyinchildrenolderthanfiveyearsifwheezingispresent[28].
Pneumococcalpneumoniaisthemostcommontypicalbacterialpneumoniainchildrenofallages.In
oneretrospectivereviewof254childrenandyoungadults(age<1monthto26years)with
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pneumococcalpneumonia,themostcommonsignsandsymptomsandtheirapproximatefrequencies
arelistedbelow[29]:
Fever:90percent
Cough:70percentproductivecough:10percent
Tachypnea:50percent
Malaise/lethargy:45percent
Emesis:43percent
Hypoxemia(oxygensaturation95percent):50percent
Decreasedbreathsounds:55percent
Crackles:40percent
Pneumococcalpneumoniainchildrenisdiscussedingreaterdetailseparately.(See"Pneumococcal
pneumoniainchildren".)
Atypicalbacterial"Atypical"bacterialpneumoniaresultingfromMycoplasmapneumoniaeor
Chlamydiapneumoniaeusuallypresentsabruptlywithconstitutionalfindingsoffever,malaiseand
myalgia,headache,photophobia,sorethroat,andgraduallyworseningnonproductivecoughdespite
improvementofothersymptoms[25,28].Althoughhoarsenessmaybeseenindiseasecausedbyboth
agents,itismorefrequentlyseenwithC.pneumoniaeinfection.Wheezingisafrequentfindingin
atypicalbacterialandviralpneumonias[10].(See"PneumoniacausedbyChlamydiaspeciesin
children"and"Mycoplasmapneumoniaeinfectioninchildren",sectionon'Clinicalfeatures'.)
M.pneumoniaemaybeassociatedwithavarietyofextrapulmonarymanifestations.Dermatologic
manifestationsmayrangefromamilderythematousmaculopapularrashorurticariatotheStevens
Johnsonsyndrome.Otherextrapulmonarymanifestationsincludehemolyticanemia,polyarthritis,
pancreatitis,hepatitis,pericarditis,myocarditis,andneurologiccomplications[30].(See"Mycoplasma
pneumoniaeinfectioninchildren",sectionon'Clinicalfeatures'.)
Infantsyoungerthanoneyearofagemaydevelop"afebrilepneumoniaofinfancy".Afebrilepneumonia
ofinfancyisasyndromegenerallyseenbetweentwoweeksandthreetofourmonthsoflife.Itis
classicallycausedbyC.trachomatis,butotheragents,suchascytomegalovirus,M.hominis,and
Ureaplasmaurealyticum,alsoareimplicated.Theclinicalpresentationisoneofinsidiousonsetof
rhinorrheaandtachypneafollowedbyastaccatocoughpattern(individualcoughsseparatedby
inspirations).Physicalexaminationtypicallyrevealsdiffuseinspiratorycrackles.Conjunctivitismaybe
present,ortheremayhavebeenapasthistoryofconjunctivitis[31].(See"Chlamydiatrachomatis
infectionsinthenewborn",sectionon'Pneumonia'.)
ViralTheonsetofviralpneumoniaisgradualandassociatedwithprecedingupperairwaysymptoms
(eg,rhinorrhea,congestion).Thechilddoesnotappeartoxic.Auscultatoryfindingsareusuallydiffuse
andbilateral.Inonestudyof98ambulatorychildrenwithpneumonia,wheezingwasmorefrequentin
patientswithviralthanbacterialpneumonia(43versus16percent),butotherclinicalfeaturesoften
associatedwithviralillness,suchasrhinorrhea,myalgia,andillcontacts,werenot[32].
Someviralcausesofpneumoniaareassociatedwithcharacteristicdermatologicfindings:
Measles(picture1AB)(see"Clinicalmanifestationsanddiagnosisofmeasles")
Varicella(picture2)(see"Clinicalfeaturesofvaricellazostervirusinfection:Chickenpox")
Herpessimplexvirus(picture3AB)(see"Clinicalmanifestationsanddiagnosisofherpessimplex
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virustype1infection",sectionon'Respiratorytractinfections'and"Neonatalherpessimplexvirus
infection:Clinicalfeaturesanddiagnosis",sectionon'Disseminateddisease')
RADIOLOGICEVALUATIONAninfiltrateonchestradiographisoftenusedtodefinepneumonia,
particularlyinclinicalresearch[23,33].Theradiographicdefinitionisnecessarybecauseofthedifficultyin
obtainingappropriatespecimensfromthelowerrespiratorytractforcultureormicrobiologicevaluation.This
peculiaritymakesitdifficulttoassessthedegreetowhichchestradiographsareactuallyneededto
diagnosepneumoniaintheclinicalsetting,asthelikelihoodratioofastandardcannotbemeasured[4,7].
IndicationsRoutinechestradiographsarenotnecessarytoconfirmthediagnosisofsuspected
communityacquiredpneumonia(CAP)inchildrenwithmild,uncomplicatedlowerrespiratorytractinfection
whoarewellenoughtobetreatedasoutpatients[1,2,7].Indicationsforradiographsinchildrenwithclinical
evidenceofpneumoniainclude[1,2,7]:
Severedisease(table3)(see'Severityassessment'above)
Confirmationofthediagnosiswhenclinicalfindingsareinconclusive
Hospitalization(todocumentthepresence,size,andcharacterofparenchymalinfiltratesandevaluate
potentialcomplications)
Exclusionofalternateexplanationsforrespiratorydistress(eg,foreignbodyaspiration,heartfailure),
particularlyinpatientswithunderlyingcardiopulmonaryormedicalconditions(see'Differential
diagnosis'below)
Assessmentofcomplications,particularlyinchildrenwhosepneumoniaisprolongedandunresponsive
toantimicrobialtherapy[7](see"Communityacquiredpneumoniainchildren:Outpatienttreatment",
sectionon'Treatmentfailure'and'Complications'below)
Exclusionofpneumoniainyoungchildren(3to36months)withfever>39C(102.2F)and
leukocytosis(20,000whitebloodcell[WBC]/microL)andolderchildren(<10years)withfever>38C
(100.4F),cough,andleukocytosis(15,000WBC/microL)[3,5](see"Feverwithoutasourcein
children3to36monthsofage")
Thereareanumberofcaveatstoconsiderwhendecidingwhethertoobtainradiographsandwhether
radiographswillaltermanagement.Theseinclude:
Radiographicfindingsarepoorindicatorsoftheetiologicdiagnosisandmustbeusedinconjunction
withotherclinicalfeaturestomaketherapeuticdecisions[2,3437](see"Communityacquired
pneumoniainchildren:Outpatienttreatment",sectionon'Treatmentfailure')
Radiographicfindingsmaylagbehindtheclinicalfindings[38]
Patientswhoarehypovolemicmayhavenormalappearingchestradiographybeforevolumerepletion
Thereisvariationinintraobserverandinterobserveragreement[2,39]
Radiographicinterpretationmaybeinfluencedbytheclinicalinformationthatisprovidedtothe
radiologist[40]
Obtainingoutpatientchestradiographsdoesnotaffectoutcome[41,42]
ViewsWhenradiographsareindicated,therecommendedviewsdependupontheageofthechild[43].
Inchildrenolderthanfouryears,thefrontalposteroanterior(PA)uprightchestviewisusuallyobtainedto
minimizethecardiacshadow[44].Inyoungerchildren,positiondoesnotaffectthesizeofthecardiothoracic
shadow,andtheanteroposterior(AP)supineviewispreferredbecauseimmobilizationiseasierandthe
likelihoodofabetterinspirationisimproved[44].
Thereisalackofconsensusregardingtheneedforlateralradiographstodemonstrateinfiltratesbehindthe
domeofthediaphragmorthecardiacshadowthatmaynotbevisualizedonAPorPAviews[45].Ina
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reviewofchestradiographsin201childrenwithpneumonia,thelateralfilmwasabnormalin91percentof
109childrenwithdefinitepneumonia[46].However,itwasthesolebasisforthediagnosisinonlythree
cases.
Wesuggestthatalateralviewbeobtainedinsettingswheretheradiographsareinterpretedby
nonradiologists.ThePediatricInfectiousDiseasesSocietyandInfectiousDiseasesSocietyofAmerica
suggestPAandlateralviewsforallchildrenwhoarehospitalizedformanagementofCAP[1].TheBritish
ThoracicSocietyguidelinesrecommendagainstlateralradiographs[2].
Alateraldecubitusradiograph(withtheaffectedsidedown)maybeneededtoidentifypleuraleffusion.(See
"Epidemiologyclinicalpresentationandevaluationofparapneumoniceffusionandempyemainchildren",
sectionon'Radiologicevaluation'.)
Highresolutioncomputedtomographyandultrasonographyareavailableforpatientswhorequiremore
extensiveimagingorclarificationofplainradiographicfindings[47].
EtiologiccluesCertainradiographicfeaturesthataremoreoftenassociatedwithbacterial,atypical
bacterial,orviraletiologiesarelistedbelow.However,nonecanreliablydifferentiatebetweenabacterial,
atypicalbacterial,andviralpneumonia(table4)[26,4850].
Segmentalconsolidationisreasonablyspecificforbacterialpneumoniabutlackssensitivity[36,51].
Radiologicfeaturesofsegmentalconsolidationarenotalwayseasytodistinguishfromsegmental
collapse(atelectasis),whichisapparentinabout25percentofchildrenwithbronchiolitis[52,53].
Inclinicalpracticeitiscommontoconsideralveolarinfiltratestobecausedbybacteriaandbilateral
diffuseinterstitialinfiltratestobecausedbyatypicalbacterialorviralinfections.However,thisisnot
supportedintheliterature.Inastudyof254childrenwithradiographicallydefinedpneumonia,the
etiologywasdeterminedin215[35].Thesensitivityandspecificityofalveolarinfiltrateforbacterial
pneumoniawere72and51percent,respectivelythesensitivityandspecificityofinterstitialinfiltrates
forviralpneumoniawere49and72percent,respectively.Alobarinfiltrateisreasonablyspecificfora
bacterialpneumoniabutlackssensitivity[29,54].
Pulmonaryconsolidationinyoungchildrensometimesappearstobespherical(ie,"roundpneumonia")
[55,56].Roundpneumoniastendtobe>3cm,solitary,andposteriorlylocated[56,57].Themost
commonbacterialetiologyforroundpneumoniaisS.pneumoniaeadditionalbacterialcausesinclude
otherstreptococci,Haemophilusinfluenzae,S.aureus,andM.pneumoniae[36,58].
Pneumatoceles,cavitations,largepleuraleffusions(image1AB),andnecrotizingprocesses(image2)
aresupportiveofabacterialetiology.
M.pneumoniaeandvirusesaremostlikelytospreaddiffuselyalongthebranchesofthebronchialtree,
resultinginabronchopneumonicpattern(image3).However,S.pneumoniaehavebeenassociated
withasimilarradiographicpatterninchildren.(See"Pneumococcalpneumoniainchildren",sectionon
'Radiographicfeatures'.)
Inyounginfants,hyperinflationwithaninterstitialprocessischaracteristicofafebrilepneumoniaof
infancy,typicallycausedbyC.trachomatis.(See"Chlamydiatrachomatisinfectionsinthenewborn",
sectionon'Pneumonia'.)
Significantmediastinal/hilaradenopathysuggestsamycobacterialorfungaletiology.
LABORATORYEVALUATIONThelaboratoryevaluationofthechildwithcommunityacquired
pneumonia(CAP)dependsontheclinicalscenario,includingtheageofthechild,severityofillness,
complications,andwhetherthechildrequireshospitalization[1].Moreaggressiveevaluationisrequired
whenitisnecessarytodetermineamicrobiologicetiology(eg,inchildrenwithseveredisease,potential
complications,andwhorequirehospitaladmission)[2].Anetiologicdiagnosisinsuchchildrenhelpstodirect
pathogenspecifictherapyandpermitscohortingofchildrenifnecessarytopreventthespreadofnosocomial
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infection.
Younginfantsinwhompneumoniaissuspected,particularlythosewhoarefebrileandtoxicappearing,
requireafullevaluationforsepsisandotherseriousbacterialinfections.(See"Evaluationandmanagement
ofthefebrileyounginfant(7to90daysofage)".)
BloodtestsCompletebloodcount(CBC)withdifferentialandacutephasereactantsmayprovide
supportiveevidenceforbacterialorviralpneumonia,butshouldnotbeusedastheonlycriteriain
determiningtheneedforantimicrobialtherapy.Serumelectrolytesmaybeusefulinassessingthedegreeof
dehydrationandthepresenceofhyponatremia,whichmayindicatethesyndromeofinappropriate
antidiuretichormonesecretion(SIADH).(See"Pathophysiologyandetiologyofthesyndromeof
inappropriateantidiuretichormonesecretion(SIADH)",sectionon'Pulmonarydisease'.)Bloodpolymerase
chainreaction(PCR)forpneumococcusisdiscussedbelow.(See'Rapiddiagnostictests'below.)
CompletebloodcountCBCusuallyisnotnecessaryforchildrenwithmildlowerrespiratorytract
infectionwhowillbetreatedasoutpatients,unlesstheCBCwilldeterminetheneedforantibiotic
therapy.CBCtypicallyisperformedininfantsandchildrenwhorequirehospitaladmission.Certain
CBCfindings,describedbelow,aremorecharacteristicofbacterial,atypicalbacterial,orviral
pneumonias.However,thefindingsoverlapandcannotreliablydifferentiatebetweentheetiologic
agents.
Whitebloodcell(WBC)count<15,000/microLsuggestsanonbacterialetiology,exceptinthe
severelyillpatient,whoalsomaybeneutropenicandhaveapredominanceofimmaturecells.
WBCcount>15,000/microLissuggestiveofpyogenicbacterialdisease[59].However,children
withM.pneumoniae,influenza,oradenoviruspneumoniaalsomayhaveWBCcount
>15,000/microL[6062].
Peripheraleosinophiliamaybepresentininfantswithafebrilepneumoniaofinfancy,typically
causedbyC.trachomatis.(See"Chlamydiatrachomatisinfectionsinthenewborn",sectionon
'Pneumonia'.)
AcutephasereactantsAcutephasereactants,suchastheerythrocytesedimentationrate,Creactive
protein(CRP),andserumprocalcitonin(PCT),neednotberoutinelymeasuredinfullyimmunized
children(table5)withCAPmanagedasoutpatients[1].However,forthosewithmoreseriousdisease
requiringhospitalization,measurementofacutephasereactantsmayprovideusefulinformationto
assistclinicalmanagement.
MeasurementofserumCRPmaybehelpfulindistinguishingbacterialfromviralpneumonia.Ameta
analysisofeightstudiesincluding1230patientssuggestedthatchildrenwithbacterialpneumoniawere
morelikelytohaveserumCRPconcentrationsgreaterthan35to60mg/L(3.5to6mg/dL)than
childrenwithnonbacterialpneumonia(oddsratio2.6,95%CI1.25.6)[63].Givena41percent
prevalenceofbacterialpneumonia,thepositivepredictivevalueforCRPvaluesof40to60mg/L(4to
6mg/dL)was64percent.AnelevatedserumPCTconcentrationmaybeassensitiveasbutmore
specificthananincreasedCRPlevelfordifferentiatingabacterialfromaviralprocess[26,64,65].
However,predictableutilityhasnotbeendocumented[1,66,67].
Acutephasereactantsshouldnotbeusedasthesoledeterminanttodistinguishbetweenviraland
bacterialetiologiesofCAPbutmaybehelpfulinfollowingthediseasecourse,responsetotherapy,and
indeterminingwhentherapycanbediscontinued[1,66,6870].(See"Pneumoniainchildren:Inpatient
treatment",sectionon'Durationoftreatment'.)
SerumelectrolytesMeasurementofserumelectrolytesmaybehelpfulinassessingthedegreeof
dehydrationinchildrenwithlimitedfluidintakeandwhetherhyponatremiaispresent(aspneumonia
maybecomplicatedbySIADH).(See'Complications'below.)
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Microbiology
IndicationsIfpossible,amicrobiologicdiagnosisshouldbeestablishedinchildrenwithsevere
disease(table3),potentialcomplications,andthosewhorequirehospitalization.Accurateandrapid
diagnosisoftheresponsiblepathogenhelpstodeterminetheappropriateantimicrobialtherapy[1].(See
"Pneumoniainchildren:Inpatienttreatment",sectionon'Overview'.)
Amicrobiologicdiagnosisalsoshouldbeestablishedifthereappearstobeacommunityoutbreak[71]orif
anunusualpathogenissuspected,particularlyifitrequirestreatmentthatdiffersfromstandardempiric
regimens(eg,S.aureusincludingmethicillinresistantstrains,Mycobacteriumtuberculosis).(See'Critical
microbes'below.)
Childrenwithmilddiseasewhoaretreatedasoutpatientsusuallycanbetreatedempirically,basedonage
andotherepidemiologicfeatures,withoutestablishingamicrobiologicetiology[2,72].(See"Community
acquiredpneumoniainchildren:Outpatienttreatment",sectionon'Empirictherapy'.)
Microbiologicdiagnosiscanbeestablishedwithculture,rapiddiagnostictesting(enzymeimmunoassay,
immunofluorescence,PCR,orserology).
Cultures
BloodculturesWesuggestthatbloodculturesbeperformedinchildrenwithCAPwhorequire
admissiontothehospitalandinchildrenwithparapneumoniceffusionorothercomplication[1,2,73].
Althoughbloodculturesarepositiveinatmost10to12percentofchildrenwithpneumonia,when
positivetheyhelptoconfirmtheetiologicdiagnosis[7478].Theyieldofbloodculturesincreasesto30
to40percentinpatientswithaparapneumoniceffusionorempyema[76,79,80].Theutilityofblood
cultureislimitedwhenantibioticsareadministeredbeforeobtainingthespecimen.(See"Bloodcultures
forthedetectionofbacteremia".)
BloodculturesarenotnecessaryinchildrenwithCAPwhowillbetreatedasoutpatients[1,7,74,81].In
theoutpatientsetting,thelikelihoodofapositivebloodcultureinchildrenwithCAPislessthan3
percent[74,75].
NasopharyngealculturesWedonotsuggestobtainingnasopharyngeal(NP)culturesforetiologic
diagnosisinchildrenwithpneumonia.Bacterialorganismsrecoveredfromthenasopharynxdonot
accuratelypredicttheetiologyofpneumoniabecausebacteriathatcausepneumoniaalsomaybe
normalupperrespiratoryflora.TheresultsofNPculturesforvirusesandatypicalbacterialalthough
helpfulmaynotbeavailablesoonenoughtoassistwithmanagementdecisions[7].Rapiddiagnostic
testsforvirusesandatypicalbacteriaarediscussedbelow.(See'Rapiddiagnostictests'below.)
SputumculturesWesuggestthatsputumsamplesforGramstainandculturebeobtainedinchildren
whorequirehospitaladmissioniftheyareabletoproducesputum[1].Childrenyoungerthanfiveyears
usuallyswallowsputum,soitisrarelyavailableforexamination.Goodqualitysputumsamplescanbe
obtainedbysputuminduction[82].However,sputuminductionisunpleasantandnotroutinely
necessarybecausemostchildrenrespondtoempiricantimicrobialtherapy.Itmaybebeneficialin
childrenwhorequireintensivecaretherapy,haveapleuraleffusion,orfailtorespondtoempiric
therapy[82,83].(See"Pneumoniainchildren:Inpatienttreatment",sectionon'Empirictherapy'.)
Asageneralguide,anappropriatesputumspecimenforexaminationisonewith10epithelialcells
and25polymorphonuclearleukocytes(PMN)underlowpower(x100)[84].Apredominant
microorganismand/orintracellularorganismssuggesttheetiologicagent.Whenthefollowingcriteria
areused,thespecificityoftheGramstainforidentifyingpneumococcihasbeenshowntobe85
percent,withasensitivityof62percent:predominantfloraormorethan10Grampositive,lancet
shapeddiplococciperoilimmersionfield(x1000)(picture4)[85].
PleuralfluidculturesDiagnostic(andpossiblytherapeutic)thoracentesisgenerallyiswarrantedfor
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childrenwithmorethanminimalpleuraleffusion.Specimensforcultureofpleuralfluidideallyshouldbe
obtainedbeforeadministrationofantibiotics.Theevaluationofpleuralfluidisdiscussedseparately.
(See"Epidemiologyclinicalpresentationandevaluationofparapneumoniceffusionandempyemain
children",sectionon'Pleuralfluidanalysis'.)
RapiddiagnostictestsWhenavailable,rapiddiagnostictests,suchasmoleculartestingusingPCR
techniquesandimmunofluorescence,onNPspecimensandbloodcanbehelpfulinthemanagementof
infantsandchildrenwhoareadmittedtothehospitalwithprobablepneumococcal,mixedbacterial/viral,
viral,atypicalbacterialCAP.Theresultsofrapiddiagnostictestscanbeusedtomakedecisionsabout
treatmentandcohortingofpatients[1].
Inprospectivestudies,PCRofbloodandrespiratorysampleshadahigheryieldthancultureforS.
pneumoniae[8688].QuantitativeS.pneumoniaePCRtestingofanasopharyngealspecimenmaybe
helpfulifmixedviral/bacterialpneumoniaisaconcern[89].
Therapiddiagnosticteststhatareavailableforthefollowingviralpathogensarediscussedseparately:
Respiratorysyncytialvirus(see"Respiratorysyncytialvirusinfection:Clinicalfeaturesanddiagnosis",
sectionon'Diagnosis')
Influenzaviruses(see"Seasonalinfluenzainchildren:Clinicalfeaturesanddiagnosis",sectionon
'Diagnosis')
Parainfluenzaviruses(see"Parainfluenzavirusesinchildren",sectionon'Diagnosis')
Adenovirus(see"Diagnosis,treatment,andpreventionofadenovirusinfection",sectionon
'Pneumonia')
M.pneumoniae(see"Mycoplasmapneumoniaeinfectioninchildren",sectionon'Diagnosis')
Chlamydiaspp(see"PneumoniacausedbyChlamydiaspeciesinchildren",sectionon'Diagnosis')
Humanmetapneumovirus(see"Humanmetapneumovirusinfections",sectionon'Diagnosis')
Theuseofrapiddiagnostictestsforidentificationofpathogensinchildrenwithparapneumoniceffusionis
discussedseparately.(See"Epidemiologyclinicalpresentationandevaluationofparapneumoniceffusion
andempyemainchildren",sectionon'Pleuralfluidanalysis'.)
SerologyWedonotsuggestroutineserologictestingforspecificpathogens(eg,S.pneumoniae,M.
pneumoniae,C.pneumoniae)becausetheresultsusuallydonotinfluencemanagement[7,90,91].Serologic
diagnosisofviralpathogensisnotpracticalbecauseacuteandconvalescentspecimensareneeded.S.
pneumoniaehastoomanypotentialinfectingserotypestomakeantibodydeterminationspractical.Serologic
testsforChlamydiaspparenotreadilyavailable.
AlthoughmostolderchildrenwithatypicalpneumoniacanbetreatedempiricallyforM.pneumoniae,
serologicandPCRtestingcanbehelpfulinevaluatingtheyoungerchild.Thesetestsalsomaybehelpfulin
establishingthediagnosisofM.pneumoniaeinpatientswithextrapulmonarymanifestations,particularly
centralnervoussystemmanifestations.(See"Mycoplasmapneumoniaeinfectioninchildren",sectionon
'Clinicalfeatures'.)
OthertestsOtherteststhatmaybehelpfulinestablishinglesscommonmicrobiologicetiologiesof
CAPinchildreninclude:
Tuberculinskinandinterferongammareleaseassayifpulmonarytuberculosisisaconsideration
additionaldiagnostictestingfortuberculosisinchildrenisdiscussedseparately(see"Tuberculosis
diseaseinchildren",sectionon'Diagnosis')
Urineantigentestingforlegionellosisduetoserogroup1(see"Clinicalmanifestationsanddiagnosisof
Legionellainfection",sectionon'Urinaryantigentesting')
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Serumandurineantigentestingforhistoplasmosis(see"Diagnosisandtreatmentofpulmonary
histoplasmosis",sectionon'Antigendetection')
UrineantigentestingforS.pneumoniaeinchildrenshouldnotbeperformedbecauseoffalsepositive
reactions,someofwhichmaymerelyindicatecolonizationwithS.pneumoniae[1,2]
InvasivestudiesInvasiveproceduresmaybenecessarytoobtainlowerrespiratorytractspecimens
forcultureandotherstudiesinchildreninwhomanetiologicdiagnosisisnecessaryandhasnotbeen
establishedbyothermeans[1,9295].Theseproceduresaretypicallyreservedforseriouslyillpatients
whoseconditionisworseningdespiteempirictherapy,orindividualswithsignificantcomorbidities(eg,
immunecompromise).Theyinclude[1,9294]:
Bronchoscopywithbronchoalveolarlavage(BAL).Becausetheaccurateidentificationofbacterial
pathogensviabronchoscopyishamperedbyspecimencontaminationwithupperairwaynormalflora,
quantitativeculturetechniquesareutilizedinmanycenterstodifferentiatetrueinfectionfromupper
airwaycontamination[9698].
Percutaneousneedleaspirationoftheaffectedlungtissueguidedbycomputedtomographyor
ultrasonography.AsmallstudyfromFinlandfoundthatneedleaspirationdeterminedaninfectious
etiology(21bacteriaand2viruses)in20of34patients(59percent)studiedandin18of26(69
percent)ofthoseinwhomanadequatespecimenwasobtained[92].Sixpatientsdevelopeda
pneumothorax,whichspontaneouslyresolvedovertwotothreedayswithoutintervention.
Lungbiopsyeitherbyathoracoscopicorthoracotomyapproach.Openbiopsyyieldsdiagnostic
informationthatmayaffectmedicalmanagementinupto90percentofpatients[94].Inone
retrospectivereview,aninfectiousetiologywasdeterminedbyopenlungbiopsyin10of33patients
withrespiratoryfailure,eightofwhomhadapriornondiagnosticBAL[93].Inanotherretrospective
review,lungbiopsyprovidedadefinitivediagnosisin25of50immunocompromisedpatients,nineof
whomhadapriornondiagnosticBAL[99].
CriticalmicrobesSomemicrobesarecriticaltodetectbecausetheyrequiretreatmentthatdiffers
fromstandardempiricregimensorhavepublichealthimplications.Diagnostictestingforthesepathogensis
discussedseparately.
InfluenzaAandB(see"Seasonalinfluenzainchildren:Clinicalfeaturesanddiagnosis",sectionon
'Diagnosis')
CommunityassociatedmethicillinresistantS.aureus(see"MethicillinresistantStaphylococcusaureus
inchildren:Treatmentofinvasiveinfections",sectionon'Pneumonia'and"Methicillinresistant
Staphylococcusaureusinfectionsinchildren:Epidemiologyandclinicalspectrum",sectionon
'Epidemiologyandriskfactors')
M.tuberculosis(see"Tuberculosisdiseaseinchildren")
Fungaletiologies(Coccidioidesimmitis,Blastomycesdermatitidis,Histoplasmacapsulatum)(see
"Primarycoccidioidalinfection"and"Mycology,pathogenesis,andepidemiologyofblastomycosis"and
"Treatmentofblastomycosis"and"Diagnosisandtreatmentofpulmonaryhistoplasmosis")
Legionellaspecies(see"ClinicalmanifestationsanddiagnosisofLegionellainfection",sectionon
'Specificlaboratorydiagnosis')
Avianinfluenza(see"Clinicalmanifestationsanddiagnosisofavianinfluenza",sectionon'Diagnosis')
Hantavirus(see"Hantaviruscardiopulmonarysyndrome")
Agentsofbioterrorism(see"Identifyingandmanagingcasualtiesofbiologicalterrorism")
DIAGNOSISThediagnosisofpneumoniarequireshistoricalorphysicalexaminationevidenceofan
acuteinfectiousprocesswithsignsorsymptomsofrespiratorydistressorradiologicevidenceofanacute
http://www.uptodate.com/contents/community-acquired-pneumonia-in-children-clinical-features-and-diagnosis?topicKey=PEDS%2F5986&elapsedTimeMs=
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pulmonaryinfiltrate[7,30].
Thediagnosticapproachdepends,tosomeextent,uponthesettingandtheseverityofillness.Inthe
appropriateclinicalsetting,thediagnosiscanbemadewithoutradiographs.Inchildrenwithsevereillness,
andinthosewhorequirehospitaladmission,thediagnosisshouldbeconfirmedwithradiographs.If
possible,etiologicdiagnosisshouldbeestablishedinchildrenwhorequireadmissiontothehospitalandin
thosewhofailtorespondtoinitialtherapy.(See"Pneumoniainchildren:Inpatienttreatment",sectionon
'Overview'.)
ClinicaldiagnosisThediagnosisofpneumoniashouldbeconsideredininfantsandchildrenwith
respiratorycomplaints,particularlycough,tachypnea,retractions,andabnormallungexamination[2,3,7].
Thediagnosisofpneumoniacanbemadeclinicallyinchildrenwithfeverandhistoricalorphysical
examinationevidenceofaninfectiousprocesswithsymptomsorsignsofrespiratorydistress[7].
Tachypnea,nasalflaring,grunting,retractions,crackles,anddecreasedbreathsoundsincreasethe
likelihoodofpneumonia[4,9,30,100].Theabsenceoftachypneaishelpfulinexcludingpneumoniathe
absenceoftheothersignsisnot.(See'Tachypnea'above.)
Indevelopingcountrieswherethereisahighprevalenceofpneumonia,asinglepositiverespiratorysign
increasesthecertaintyofpneumonia[4].TheWorldHealthOrganizationusestachypnea(>60breaths/min
ininfants<2months>50breaths/minininfants2to12monthsand>40breaths/mininchildren1to5
yearsand>20breaths/mininchildren5years)asthesolecriteriontodefinepneumoniainchildrenwith
coughordifficultybreathing[15].Indevelopedcountrieswithalowerprevalenceofpneumonia,multiple
respiratorysignsarenecessarytoincreasethecertaintyofpneumonia[4,101].
RadiographicconfirmationAninfiltrateonchestradiographconfirmsthediagnosisofpneumoniain
childrenwithcompatibleclinicalfindings.Radiographsshouldbeobtainedinchildreninwhomthediagnosis
isuncertainandinthosewithsevere,complicated,orrecurrentpneumonia[1,2,102].Radiographic
confirmationisnotnecessaryinchildrenwithmild,uncomplicatedlowerrespiratorytractinfectionwhowillbe
treatedasoutpatients.(See'Indications'above.)
Radiographicfindingscannotreliablydistinguishbetweenbacterial,atypicalbacterial,andviraletiologiesof
pneumonia.Radiographicfindingsshouldbeusedinconjunctionwithclinicalandmicrobiologicdatatomake
therapeuticdecisions[2,4].(See"Communityacquiredpneumoniainchildren:Outpatienttreatment",section
on'Empirictherapy'and"Pneumoniainchildren:Inpatienttreatment",sectionon'Empirictherapy'.)
EtiologicdiagnosisTheetiologicagentissuggestedbyhostcharacteristics,clinicalpresentation,
epidemiologicconsiderations,and,tosomedegree,theresultsofnonspecificlaboratorytestsandchest
radiographicpatterns(table4).(See'Cluestoetiology'aboveand'Etiologicclues'aboveand"Pneumoniain
children:Epidemiology,pathogenesis,andetiology",sectionon'Etiologicagents'.)
Specificmicrobiologictestscanbeusedtoconfirmtheetiologicdiagnosis.Confirmationofetiologic
diagnosisisnotnecessaryinmildlyillpatientswhocanbetreatedempiricallyintheoutpatientsetting.
Confirmationofetiologicdiagnosisshouldbeattemptedinchildrenwhoareadmittedtothehospitalorare
suspectedtobeinfectedwithanunusualpathogen,orapathogenthatrequirestreatmentthatdiffersfrom
standardempiricregimens,sothattherapycanbedirectedtowardtheappropriatepathogen.Etiologic
diagnosisalsoisnecessaryinchildrenwhofailtorespondtoinitialtherapy.(See'Microbiology'aboveand
'Criticalmicrobes'aboveand"Pneumoniainchildren:Inpatienttreatment",sectionon'Empirictherapy'.)
DIFFERENTIALDIAGNOSISAlthoughpneumoniaishighlyprobableinachildwithfever,tachypnea,
cough,andinfiltrate(s)onchestradiograph,alternatediagnosesandcoincidentconditionsmustbe
consideredinchildrenwhofailtorespondtotherapyorhaveanunusualpresentation/course[7].
TheTablelistsanumberofotherconditionsthatcanmimicaninfectiouspneumonia(table6).Historyand/or
associatedclinicalfeaturesusuallyhelptodistinguishtheconditionsinthetablefrominfectiouspneumonia.
Insomecases,laboratorystudiesoradditionalimagingmaybenecessary.
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Foreignbodyaspirationmustbeconsideredinyoungchildren.Theaspirationeventmaynothavebeen
witnessed.(See"Airwayforeignbodiesinchildren",sectionon'Presentation'.)
Othercausesoftachypnea,withorwithoutfeverandcough,ininfantsandyoungchildreninclude[103]:
Bronchiolitis(see"Bronchiolitisininfantsandchildren:Clinicalfeaturesanddiagnosis",sectionon
'Clinicalfeatures')
Heartfailure
Sepsis
Metabolicacidosis(see"Approachtothechildwithmetabolicacidosis",sectionon'Clinicalevaluation
anddiagnosis')
Theseconditionsusuallycanbedistinguishedfrompneumoniabyhistory,examination,andlaboratorytests.
Lemierresyndrome(jugularveinsuppurativethrombophlebitis)isanimportantconsiderationinadolescents
andyoungadultswhoseillnessbeganwithpharyngitis.InLemierresyndrome,thevesselsofthecarotid
sheathbecomeinfected(typicallywithFusobacteriumspp),leadingtobacteremiaandmetastaticspreadof
infectiontothelungsandmediastinum.(See"Suppurative(septic)thrombophlebitis",sectionon'Jugular
vein'.)
Communityacquiredpneumonia(CAP)canbemisdiagnosedinyoungchildrenwithasthmawhohaveviral
respiratoryinfections[104].Manysuchchildrenhaverespiratorydistressandmayhavehypoxemia.The
diagnosisofCAPandtreatmentwithantibioticsmustbecarefullyconsideredinyoungchildrenwhohavea
prodromecompatiblewithaviralrespiratoryinfectionandwheezing,eveniftherearepulmonaryinfiltrates
(versusatelectasis)onchestradiograph.(See"Asthmainchildrenyoungerthan12years:Initialevaluation
anddiagnosis",sectionon'Respiratorytractinfections'.)
Rare,noninfectiouslungdiseasesmaypresentwithanintercurrentinfectiousillness.Pulmonaryalveolar
proteinosis,eosinophilicpneumonia,acuteinterstitialpneumonitis,andcryptogenicorganizingpneumonia
areentitiesthatshouldbeconsidered,especiallyiftheacuteillnessisatypicalortheradiographicand
clinicalfindingsdonotresolveasexpectedwithuncomplicatedCAP.(See"Clinicalmanifestationsand
etiologyofpulmonaryalveolarproteinosisinadults"and"Idiopathicacuteeosinophilicpneumonia"and
"Acuteinterstitialpneumonia(HammanRichsyndrome)"and"Cryptogenicorganizingpneumonia".)
COMPLICATIONSBacterialpneumoniasaremorelikelythanatypicalbacterialorviralpneumoniastobe
associatedwithcomplicationsinvolvingtherespiratorytract.Complicationsofbacterialpneumoniainclude
pleuraleffusion(image1AB),empyema,pneumatoceles,necrotizingpneumonia(image2),andlung
abscesses.
PleuraleffusionandempyemaTheclinicalfeatures,evaluation,andmanagementofparapneumonic
effusionandempyemainchildrenarediscussedseparately.Hypoalbuminemiaiscommoninchildrenwith
parapneumoniceffusionsandhypogammaglobulinemiamaybeencountered.(See'Bloodtests'aboveand
"Epidemiologyclinicalpresentationandevaluationofparapneumoniceffusionandempyemainchildren"
and"Managementandprognosisofparapneumoniceffusionandempyemainchildren".)
NecrotizingpneumoniaNecrotizingpneumonia,necrosis,andliquefactionoflungparenchyma,isa
seriouscomplicationofcommunityacquiredpneumonia(CAP).Necrotizingpneumoniausuallyfollows
pneumoniacausedbyparticularlyvirulentbacteria[102].S.pneumoniae(especiallyserotype3and
serogroup19)isthemostcommoncauseofnecrotizingpneumonia(image2)[105110].Necrotizing
pneumoniaalsomayoccurwithS.aureusandgroupAStreptococcusandhasbeenreportedduetoM.
pneumoniae,Legionella,andAspergillus.[110115].
Clinicalmanifestationsofnecrotizingpneumoniaaresimilartothoseofuncomplicatedpneumonia,butthey
aremoresevere[115117].Necrotizingpneumoniashouldbeconsideredinachildwithprolongedfeveror
septicappearance[102].Thediagnosiscanbeconfirmedbychestradiograph(whichdemonstratesa
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radiolucentlesion)(image4)orcontrastenhancedcomputedtomography(image2)[118]thefindingson
chestradiographmaylagbehindthoseofcomputedtomography[113].
Pleuraleffusion/empyemagenerallyaccompaniesnecrotizingpneumoniawhereasbronchopleuralfistula,
pneumatocele,orabscessformation(whichtypicallyisinsidious)ismuchlesscommon.Drainageofthe
pleuralfluidcollectionisfrequentlyrequiredbutpneumonectomyisrarelyneeded.(See'Pneumatocele'
belowand'Lungabscess'below.)
Treatmentofnecrotizingpneumoniaisdiscussedseparately.(See"Pneumoniainchildren:Inpatient
treatment",sectionon'ComplicatedCAP'.)
LungabscessAlungabscessisanaccumulationofinflammatorycells,accompaniedbytissue
destructionornecrosisthatproducesoneormorecavitiesinthelung[45].Aspirationisthemostimportant
predisposingfactorforlungabscess,whichmaydeveloponetotwoweeksaftertheaspirationeventother
predisposingfactorsincludeairwayobstructionandcongenitallyabnormallung[45].S.aureusisthe
organismmostfrequentlyinvolved[103].
Clinicalmanifestationsoflungabscessarenonspecificandsimilartothoseofpneumonia[45].Theyinclude
fever,cough,dyspnea,chestpain,anorexia,hemoptysis,andputridbreath[45,102,119121].Thecourse
maybeindolent.
Thediagnosisissuggestedbyachestradiographdemonstratingathickwalledcavitywithanairfluidlevel
(image4)[45],andconfirmedbycontrastenhancedcomputedtomography[118].Lungabscessisoften
accompaniedbyparapneumoniceffusion[122,123].Lungabscessshouldbesuspectedwhenconsolidation
isunusuallypersistent,whenpneumoniaremainspersistentlyroundormasslike,andwhenthevolumeof
theinvolvedlobeisincreased(assuggestedbyabulgingfissure)[45,124].
Interventionalradiologymaybehelpfulinobtainingaspecimenfromtheabscesscavityfordiagnostic
studies.Treatmentoflungabscessisdiscussedseparately.(See"Pneumoniainchildren:Inpatient
treatment",sectionon'ComplicatedCAP'.)
Themostcommoncomplicationoflungabscessisintracavitaryhemorrhage.Thiscancausehemoptysisor
spillageoftheabscesscontentswithspreadofinfectiontootherareasofthelung[116].Othercomplications
oflungabscessincludeempyema,bronchopleuralfistula,septicemia,cerebralabscess,andinappropriate
secretionofantidiuretichormone[116].
PneumatocelePneumatocelesarethinwalled,aircontainingcystsofthelungs.Theyareclassically
associatedwithS.aureus,butmayoccurwithavarietyoforganisms[125,126].Pneumatocelesfrequently
occurinassociationwithempyema[125].Inmostcases,pneumatocelesinvolutespontaneously,andlong
termlungfunctionisnormal[125,127,128].However,onoccasion,pneumatocelesresultinpneumothorax
[126].
HyponatremiaHyponatremia(serumsodiumconcentration135meq/L)occursinapproximately45
percentofchildrenwithCAPandonethirdofchildrenhospitalizedwithCAP,butisusuallymild[129131].
Inappropriatesecretionofantidiuretichormone(ADH)isthemostfrequentcause[129,130].Hyponatremiais
associatedwithincreasedlengthofhospitalstay,complications,andmortality.(See"Pathophysiologyand
etiologyofthesyndromeofinappropriateantidiuretichormonesecretion(SIADH)",sectionon'Pulmonary
disease'.)
INDICATIONSFORHOSPITALIZATIONIndicationsforhospitalizationarediscussedseparately.(See
"Pneumoniainchildren:Inpatienttreatment",sectionon'Indications'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasics
andBeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6th
gradereadinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagiven
condition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easyto
readmaterials.BeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore
th
th
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detailed.Thesearticlesarewrittenatthe10thto12thgradereadinglevelandarebestforpatientswhowant
indepthinformationandarecomfortablewithsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremail
thesetopicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsby
searchingonpatientinfoandthekeyword(s)ofinterest.)
Basicstopic(see"Patientinformation:Pneumoniainchildren(TheBasics)")
SUMMARYANDRECOMMENDATIONS
Thepresentingsignsandsymptomsofcommunityacquiredpneumonia(CAP)arenonspecificno
singlesymptomorsignispathognomonicforpneumoniainchildren.Thecombinationoffeverand
coughissuggestiveofpneumonia,butthepresentationmaybesubtle,ormisleading(eg,abdominal
painornuchalrigidity).(See'Clinicalpresentation'above.)
Thehistoryshouldfocusonfeaturesthatcanhelptodefinetheclinicalsyndrome(eg,pneumonia,
bronchiolitis)andnarrowthelistofpotentialpathogens(table1).(See'History'aboveand"Pneumonia
inchildren:Epidemiology,pathogenesis,andetiology",sectionon'Etiologicagents'.)
Examinationfindingsthathavebeencorrelatedwithradiographicpneumoniaincludetachypnea,
increasedworkofbreathing(retractions,nasalflaring,grunting,useofaccessorymuscles),hypoxemia,
andadventitiouslungsounds.Combinationsoffindingsaremorepredictivethansinglefindings.The
absenceoftachypneaisusefulinexcludingpneumonia.(See'Examination'above.)
Thehistoryandexaminationareusedtodeterminetheseverityofillness(table3),whichdetermines,
inpart,theneedforradiologicandlaboratoryevaluation.(See'Severityassessment'above.)
Neitherclinicalnorradiologicfeaturesreliablydistinguishbetweenbacterial,atypicalbacterial,andviral
pneumonia.(See'Cluestoetiology'aboveand'Etiologicclues'above.)
Radiographsarenotnecessaryforchildrenwithpneumoniawhoarewellenoughtobetreatedas
outpatients.Wesuggestthatchestradiographsbeobtainedforthefollowingindications:
Severedisease(table3)(see'Severityassessment'above)
Confirmationofthediagnosiswhenclinicalfindingsareinconclusive
Exclusionofalternateexplanationsforrespiratorydistress(see'Differentialdiagnosis'above)
Evaluationforcomplications(see'Complications'above)
Exclusionofoccultpneumoniainyoungchildren(3to36months)withfever>39C(102.2F),
leukocytosis(whitebloodcellcount>20,000/microL),andnoobviousfocusofinfection(see
'Radiologicevaluation'above)
Routinelaboratoryevaluationisnotnecessaryforchildrenwithclinicalevidenceofmilduncomplicated
lowerrespiratorytractinfectionwhowillbetreatedasoutpatientsunlessthefindingswillhelpin
decidingwhetherantimicrobialtherapyisnecessary.(See'Laboratoryevaluation'above.)
WerecommendthatattemptsbemadetoestablishanetiologicdiagnosisinchildrenwithCAPwho
requirehospitaladmission.Acompletebloodcountwithdifferentialandbloodcultureshouldbe
obtainedinallsuchpatients.Ifproduced,agoodqualitysputumshouldbesubmittedforGramstain
andculture.Otherspecimensformicrobiologictestingshouldbeobtainedasindicatedbytheclinical
scenario.(See'Microbiology'above.)
Attemptsalsoshouldbemadetoestablish(orexclude)anetiologicdiagnosisinpatientssuspectedto
haveCAPcausedbypathogensthatrequiretreatmentregimensthatdifferfromstandardempiric
regimens(eg,influenza,communityassociatedmethicillinresistantStaphylococcusaureus,
Mycobacteriumtuberculosis,fungi,Legionella,hantavirus).(See'Criticalmicrobes'above.)
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Alternatediagnosesandcoincidentconditionsmustbeconsideredinchildrenwhofailtorespondto
therapyorwhohaveanunusualpresentationorcourse(table6).(See'Differentialdiagnosis'above
and"Communityacquiredpneumoniainchildren:Outpatienttreatment",sectionon'Treatmentfailure'
and"Pneumoniainchildren:Inpatienttreatment".)
ComplicationsofCAPinchildrenincludepleuraleffusionandempyema,necrotizingpneumonia,lung
abscess,pneumatocele,andhyponatremia.(See'Complications'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
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Topic5986Version31.0
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GRAPHICS
Importantaspectsofthehistoryinachildwithpneumonia
Historicalfeature
Ageofthechild
Possiblesignificance
Viraletiologiesaremostcommonininfantsandpreschool
children
Atypicalbacterialpathogensaremorecommoninschoolage
children
Recentviralupper
respiratorytractinfection
MaypredisposetobacterialsuperinfectionwithStreptococcus
pneumoniaeorStaphylococcusaureus
Associatedsymptoms
Mycoplasmapneumoniaeisoftenassociatedwith
extrapulmonarymanifestations(eg,headache,photophobia,
rash)
Cough,chestpain,
shortnessofbreath,
difficultybreathing
"Classic"featuresofpneumonia,butnonspecific
Increasedworkof
Suggestiveofseverepneumonia
breathingintheabsence
ofstridororwheezing
Chokingepisode
Mayindicateforeignbodyaspiration
Durationofsymptoms
Chroniccough(>4weeks)suggestsetiologyotherthanacute
pneumonia(refertoUpToDatetopiconcausesofchroniccough
inchildren)
Previousepisodes
Recurrentepisodesmayindicateaspiration,congenitalor
acquiredanatomicabnormality,cysticfibrosis,
immunodeficiency,asthma,missedforeignbody
Immunizationstatus
Completionoftheprimaryseriesofimmunizationsfor
Haemophilusinfluenzaetypeb,Streptococcuspneumoniae,
Bordetellapertussis,andseasonalinfluenzadecreases,butdoes
noteliminate,theriskofinfectionwiththeseorganisms
Previousantibiotictherapy
Increasesthelikelihoodofantibioticresistantbacteria
Maternalhistoryof
chlamydiaduring
pregnancy(forinfants<4
MayindicateChlamydiatrachomatisinfection
monthsofage)
Exposuretotuberculosis
MayindicateMycobacteriumtuberculosisinfection
Illcontacts
Morecommonwithviraletiologies
Traveltoorresidencein
certainareasthatsuggest
endemicpathogens
Measles:Developingworld
Coccidioidomycosis:SouthwesternUS,northernMexico,Central
andSouthAmerica
Blastomycosis:SoutheasternandcentralUSstatesbordering
theGreatLakes
Histoplasmosis:Ohio,Missouri,andMississippiRivervalleysin
theUnitedStatesCanadaCentralAmericaeasternand
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southernEuropepartsofAfricaeasternAsiaandAustralia
Hantavirus:WestoftheMississippiRiverfourcornersregionof
UnitedStates(wherebordersofColorado,NewMexico,Arizona,
andUtahmeet)
Animalexposure
Mayindicatehistoplasmosis,psittacosis,Qfever
Daycarecenter
attendance
Exposuretovirusesandantibioticresistantbacteria
Fluidandnutritionintake
Difficultyorinabilitytofeedsuggestssevereillness
Graphic52510Version6.0
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Importantaspectsofthephysicalexaminationinachildwith
suspectedpneumonia
Examination
feature
General
appearance(state
ofawareness,
cyanosis)*
Possiblesignificance
Mostchildrenwithradiographicallyconfirmedpneumoniaappearill
Vitalsigns
Temperature
Fevermaybetheonlysignofpneumoniainhighlyfebrileyoung
childrenhowever,itisvariablypresentandnonspecific
Respiratoryrate
Tachypnea correlateswithradiographicallyconfirmedpneumoniaand
hypoxemia
Absenceoftachypneahelpstoexcludepneumonia
Degreeof
respiratory
distress
Respiratorydistressismorespecificthanfeverorcoughforlower
respiratoryinfection
Tachypnea
Hypoxemia
Predictiveofpneumonia
Increasedworkofbreathing:
Retractions
Morecommoninchildrenwithpneumoniathanwithoutabsencedoesnot
excludepneumonia
Nasalflaring
Morecommoninchildrenwithpneumoniathanwithoutabsencedoesnot
excludepneumonia
Grunting
Signofseverediseaseandimpendingrespiratoryfailure
Accessory
muscleuse
Signofseveredisease
Headbobbing
Signofseveredisease
Lungexamination
Cough
Nonspecificfindingofpneumonia
Auscultation
Findingssuggestiveofpneumoniainclude:crackles(rales,
crepitations),decreasedbreathsounds,bronchialbreathsounds,
egophany,bronchophony,andwhisperedpectoriloquy
Wheezingmorecommoninviralandatypicalpneumonias
Tactilefremitus
Suggestiveofparenchymalconsolidation
Dullnessto
percussion
Suggestiveofparenchymalconsolidationorpleuraleffusion
Mentalstatus
Alteredmentalstatusmaybeasignofhypoxia
*Foryounginfants:Abilitytoattendtotheenvironment,feed,vocalize,andbeconsoled.
WorldHealthOrganizationdefinitionsoftachypneaaccordingtoageareasfollows:<2months:
>60breaths/min2to12months:>50breaths/min1to5years:>40breaths/min5years:
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>20breaths/min.
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Severityofcommunityacquiredpneumoniaininfantsandchildren
Clinicalfeaturesofmildpneumonia
Clinicalfeaturesofsevere
pneumonia
Temperature<38.5C(101.3F)
Temperature38.5C(101.3F)
Mildorabsentrespiratorydistress:
Moderatetosevererespiratorydistress:
IncreasedRR,butlessthantheagespecificRR
thatdefinesmoderatetosevererespiratory
RR>70breaths/minuteforinfants
RR>50breaths/minuteforolder
distress
children
Mildorabsentretractions
Moderate/severesuprasternal,
intercostal,orsubcostalretractions
(<12months)
Nogrunting
Nonasalflaring
Noapnea
Mildshortnessofbreath
Severedifficultybreathing(12
months)
Grunting
Nasalflaring
Apnea
Significantshortnessofbreath
Normalcolor
Cyanosis
Normalmentalstatus
Alteredmentalstatus
Normoxemia(oxygensaturation92percentin
roomair)
Hypoxemia(sustainedoxygensaturation
<90percentinroomairatsealevel)
Normalfeeding(infants)novomiting
Notfeeding(infants)orsignsof
dehydration(olderchildren)
Normalheartrate
Tachycardia
Capillaryrefill<2seconds
Capillaryrefill2seconds
RR:respiratoryrate.
Datafrom:
1. BradleyJS,ByingtonCL,ShahSS,etal.Themanagementofcommunityacquired
pneumoniaininfantsandchildrenolderthan3monthsofage:Clinicalpracticeguidelinesby
thePediatricInfectiousDiseasesSocietyandtheInfectiousDiseasesSocietyofAmerica.Clin
InfectDis201153:e25.
2. HarrisM,ClarkJ,CooteN,etal.BritishThoracicSocietyguidelinesforthemanagementof
communityacquiredpneumoniainchildren:update2011.Thorax201166:ii1.
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Clinicalandradiographiccluestotheetiologyofpneumoniain
children*
Etiology
Bacteria
(mostcommonly
Streptococcus
pneumoniae)
Clinicalfeatures
Radiographic
features
Childrenofallages
Alveolarinfiltrates
Abruptonset
Segmental
consolidation
Illappearance
Chills
Moderatetosevererespiratorydistress
Focalauscultatoryfindings
Localizedchestpain
WBCcount>15,000/microL(ifobtained)
Elevatedacutephasereactants(if
obtained)
Lobar
consolidation
"Round"
pneumonia
Complications:
Pleural
effusion/empyema
Lungabscess
Necrotizing
pneumonia
Pneumatocele
Atypicalbacterial
(Mycoplasma
pneumoniae,
Chlamydophila
pneumoniae)
Childrenofallages(mostcommonin
children>5years)
Interstitialinfiltrates
Abruptonsetwithconstitutionalfindings
(malaise,myalgia,headache,rash,
conjunctivitis,photophobia,sorethroat,
headache)
Graduallyworseningnonproductivecough
Wheezing
Extrapulmonarymanifestationsor
complications(eg,StevensJohnson
syndrome,hemolyticanemia,hepatitis,
etc)
Viral
Usuallychildren<5years
Interstitialinfiltrates
Gradualonset
Precedingupperairwaysymptoms
Nontoxicappearing
Diffuse,bilateralauscultatoryfindings
Wheezing
Mayhaveassociatedrash(eg,measles,
varicella)
Afebrilepneumonia
ofinfancy(most
commonlyChlamydia
trachomatis)
Usuallyininfants2weeksto4months
Insidiousonset
Hyperinflationwith
interstitialprocess
Rhinorrhea
Staccatocoughpattern
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Peripheraleosinophilia(ifCBCobtained)
Fungal
Appropriategeographicorenvironmental
exposure
Mediastinalorhilar
adenopathy
Mycobacterium
tuberculosis
Childrenofanyage
Mediastinalorhilar
adenopathy
Chroniccough
Constitutionalsymptoms
Exposurehistory
WBC:whitebloodcellCBC:completebloodcount.
*Theclinicalfeaturesfrequentlyoverlapandcannotreliablydistinguishbetweenbacterial,atypical
bacterial,andviraletiologiesuptoonehalfofcommunityacquiredpneumoniasinchildrenmaybe
mixedbacterial/viralinfections.Chestradiographygenerallyisnothelpfulindeterminingthe
potentialcausativeagentofpneumonia.Nonetheless,thesefeaturesmayfacilitatedecisions
regardingempirictherapy.
Datafrom:
1. BartlettJG,MundyLM.Communityacquiredpneumonia.NEnglJMed1995333:1618.
2. BoyerKM.Nonbacterialpneumonia.In:TextbookofPediatricInfectiousDiseases,6thed,
FeiginRD,CherryJD,DemmlerHarrisonGJ,KaplanSL(Eds),Saunders,Philadelphia2009.
p.289.
3. BroughtonRA.InfectionsduetoMycoplasmapneumoniaeinchildhood.PediatrInfectDis
19865:71.
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Boywithmeasles
Source:CentersforDiseaseControlandPrevention.
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Measlesexanthem
Blanchingerythematousmaculeswithsomeconfluentareasonthe
trunkinapatientwithmeasles.
CopyrightDr.MichaelBennishreproducedwithhispermission.
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Primaryvaricellalesions
Vesicularlesionsonanerythematousbasearecharacteristicof
chickenpox.Thelesionsoccurincropsandarepresentinavarietyof
stagesfrommaculopapulartovesicularorevenpustular.Central
necrosisandearlycrustingisalsovisible.
CourtesyofLeeTNesbitt,Jr.TheSkinandInfection:AColorAtlasandText,
SandersCV,NesbittLTJr(Eds),Williams&Wilkins,Baltimore1995.
http://www.lww.com
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Herpessimplexvirusinfectionofthehand
Closeupviewofvesiclesonanerythematousbase.
CourtesyofBethGGoldstein,MDandAdamOGoldstein,MD.
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Herpessimplexlabialis
Groupedvesiclesareevidentonthelowervermilionborder.
Reproducedwithpermissionfrom:BickleyLS,SzilagyiP.Bates'GuidetoPhysical
ExaminationandHistoryTaking,EighthEdition.Philadelphia:LippincottWilliams&
Wilkins,2003.Copyright2003LippincottWilliams&Wilkins.
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Rightsidedpneumoniawithpleuraleffusion
CourtesyofDwightAPowell,MD.
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Computedtomography:Leftsidedpneumoniawith
pleuraleffusion
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Computedtomography:LeftsidedStreptococcus
pneumoniaenecrotizingpneumonia
CourtesyWilliamJBarson,MD.
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Plainradiograph:Mycoplasmapneumoniaepneumonia
DiffusebilateralinterstitialinfiltrateswithM.pneumoniaeinfection.
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SuggestedcriteriaforfullHaemophilusinfluenzatypeband
Streptococcuspneumoniaeimmunizationstatuswhenconsidering
empiricantibioticsforcommunityacquiredpneumoniainchildren
Currentage*
Criteriaforfullimmunization
Haemophilusinfluenzaetypeb
12to15months
2dosesofHibconjugatevaccine,withat
leastonedoseat12monthsofage
15monthsto5years
2dosesofHibconjugatevaccine,withat
leastonedoseat12monthsofage,or
1doseofHibconjugatevaccineat15
monthsofage
5years,nothighrisk
Hibimmunizationnotnecessary
Streptococcuspneumoniae
12to24months
3dosesofPCVat<16months,with1
doseat12months,or
2dosesofPCV,bothat12months
24monthsthrough5years
3dosesofPCVat<16months,with1
doseat12months,or
2dosesofPCV,bothat12months,or
1doseofPCVat24months
>5years,nothighrisk
PCVimmunizationnotnecessary
Hib:HaemophilusinfluenzaetypebPCV:pneumococcalconjugatevaccine.
*Childrenyoungerthan12monthsareincompletelyimmunizedagainstHibandS.pneumoniae.
Immunizationsmustbecompletedatleasttwoweeksbeforepneumoniadiagnosis.
ChildrenathighriskforinvasiveHibdiseaseincludechemotherapyrecipientsandthosewith
anatomicorfunctionalasplenia(includingsicklecelldisease),humanimmunodeficiencyvirus(HIV)
infection,immunoglobulindeficiency,orearlycomponentcomplementdeficiency.Pleaserefertothe
UpToDatetopiconpreventionofHaemophilusinfluenzaeinfectionforadiscussionoffullHib
immunizationinchildrenathighriskforinvasiveHibdisease.
ChildrenathighriskforinvasiveS.pneumoniaediseaseincludethosewithchronicheartdisease
(particularlycyanoticcongenitalheartdiseaseandcardiacfailure)chroniclungdisease(including
asthmaiftreatedwithhighdoseoralcorticosteroidtherapy)diabetesmellituscerebrospinalfluid
leakcochlearimplantsicklecelldiseaseandotherhemoglobinopathiesanatomicorfunctional
aspleniaHIVinfectionchronicrenalfailurenephroticsyndromediseasesassociatedwith
treatmentwithimmunosuppressivedrugsorradiationtherapy,includingmalignantneoplasms,
leukemias,lymphomas,andHodgkindiseasesolidorgantransplantationorcongenital
immunodeficiency.PleaserefertotheUpToDatetopicsonpneumococcalconjugatevaccineand
pneumococcalpolysaccharidevaccinesforadiscussionoffullS.pneumoniaeimmunizationin
childrenathighriskforinvasiveS.pneumoniaedisease.
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Sputumfromapatientwithpneumococcal
pneumonia
Gramstainofsputum(x1000)showsabundantinflammatorycellsand
grampositivediplococciStreptococcuspneumoniaewasidentifiedfrom
thisspecimenbycultureandbytheoptochindisktest.
CourtesyofHarrietProvine.
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Noninfectiouscondititionsthatcanmimicpneumoniainchildren
Anatomicalconsiderations
Drugsandchemicalexposures
Prominentthymus
Nitrofurantoin
Breastshadows
Bleomycin
Bronchogeniccyst
Cytotoxicdrugs
Vascularring
Opiates
Pulmonarysequestration
Radiationtherapy
Congenitallobaremphysema
Smokeinhalation
Atelectasis(duetoaforeignbodyormucus
plug)
Lipoidpneumonia
Aspirationofgastriccontents
Gastroesophagealreflux
Vasculiticdisorders
Systemiclupuserythematosus
Tracheoesophagealfistula
Granulomatosiswithpolyangiitis
(Wegener's)
Cleftpalate
Juvenileidiopathicarthritis
Neuromusculardisorders
Others
Chronicpulmonarydisorders
Hypersensitivitypneumonitis
Asthma
Neoplasm
Bronchiectasis
Pulmonaryedemaduetoheartfailure
Bronchopulmonarydysplasia
Pulmonaryinfarction
Cysticfibrosis
Acuterespiratorydistresssyndrome
Pulmonaryfibrosis
Graftversushostdisease
Alpha1antitrypsindeficiency
Poorinspiratoryfilm
Pulmonaryhemosiderosis
Neardrowningevent
Alveolarproteinosis
Underpenetratedfilm
Desquamativeinterstitialpneumonitis
Sarcoidosis
HistiocytosisX
Datafrom:
1. KleinJO.Bacterialpneumonias.In:TextbookofPediatricInfectiousDiseases,5thed,Feigin
RD,CherryJD,DemmlerGJ,KaplanSL(Eds),WBSaunders,Philadelphia2004.p.299.
3. GastonB.Pneumonia.PediatrRev200223:132.
4. BoyerKM.Nonbacterialpneumonia.In:TextbookofPediatricInfectiousDisease,5thed,
FeiginRD,CherryJD,DemmlerGJ,KaplanSL(Eds),WBSaunders,Philadelphia2004.p.286.
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Complicationsofpneumococcalpneumonia
Radiographicimagesofthecomplicationsofpneumococcalpneumonia.
(Leftpanel)Lungabscesswithanairfluidlevelintherightlung.Abscess
cavitymaterialisnearlyalwaysculturepositive,andpatientscommonly
defervescewithin48hoursofinterventionaldrainage.
(Rightpanel)Radiographofnecrotizingpneumoniaintheleftlung.
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Disclosures
Disclosures:WilliamJBarson,MDGrant/Research/ClinicalTrialSupport:Pfizer[USPediatricMulticenterPneumococcal
SurveillanceGroup(Pneumococcalconjugatevaccine(13valent))].SheldonLKaplan,MDGrant/Research/ClinicalTrialSupport:
Pfizer[vaccine(PCV13)]ForestLab[antibiotic(Ceftaroline)]Optimer[antibiotic(fidaxomicin)].Consultant/AdvisoryBoards:Pfizer
[vaccine(PCV13)].GeorgeBMallory,MDNothingtodisclose.MaryMTorchia,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvetting
throughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriately
referencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy
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Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

Community-acquired pneumonia in children: Clinical features and diagnosis

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