Pneumonia in children

Pneumonia is a disease of the respiratory system characterized by inflammation of the pulmonary alveoli.


Cause of pneumonia in children

Pneumonia in children often has the same causes as those in adults, i.e. a:

The virus-related cause is much more common in children: 70-80% of cases.

Types of virus that cause pneumonia in children

  • influenza virus (orthomyxovirus), very common,
  • parainfluenza virus (paramyxovirus),
  • adenovirus,
  • Respiratory syncytial virus (RSV).

Bacteria that cause pneumonia in children

Responsible bacteria are mainly:

  • Streptococcus pneumoniae,
  • Haemophilus influenzae,
  • Mycoplasma pneumoniae,
  • Staphylococcus aureus (less common).

Others (even rarer):

  • Chlamydia trachomatis, pneumoniae and psittaci,
  • Pseudomonas aeruginosa (especially in children with other respiratory diseases),
  • Mycobacterium tuberculosis (although tuberculosis should not be counted among pneumonia).

To understand the cause, it is very important to know the age of the affected child:

  • Under one year, bacterial pneumonia is very rare.
  • Under 2 years of age, most pneumonia is of viral origin.

In neonatal age (or during the first 4 weeks of life), group B streptococci are the most frequently involved microorganisms with which the newborn can become infected in the birth canal at birth.

For this reason, vaginal tampons are used during pregnancy, and if there are positive results, antibiotic prophylaxis is carried out before birth.
In some cases, however, an infection can only occur later.
Children born by cesarean section do not have this risk.
Other bacteria responsible for pneumonia in the first 28 days include:

  • Escherichia coli, Listeria,
  • Staphylococcus aureus,
  • Chlamydia trachomatis (infection usually during passage through the birth canal).

The latter is also found in pneumonia up to the 6th month of life together with other bacteria and viruses such as:

  • Streptococcus pneumoniae,
  • Haemophilus influenzae,
  • Staphylococcus aureus,
  • respiratory syncytial virus,
  • Parainfluenza and influenza virus.

Pneumonia caused by Staphylococcus aureus is very serious because this bacterium destroys the pulmonary parenchyma (lung tissue) and offers little chance of recovery (it is often irreversible), but it is very rare.
In children under one year of age, the staphylococcal forms can be very severe.
In the X-ray horax you can see cystic-bullous structures.

In children over 6 months of age, pneumonia of viral origin predominates, but bacterial suprainfections are common: up to the age of 5, these are mainly caused by:

  • Haemophilus influenzae,
  • Streptococcus pneumoniae.

In children over 5 years of age, i.e. at school year’s age, pneumonia caused by Mycoplasma pneumoniae is most common (more common than in adults) and the doctor must take these microorganisms into account in the therapy (if he does not know the germ responsible).
Pneumonia caused by pneumococci is possible

Atypical pneumonia

Pneumonia caused by Mycoplasma

This pneumonia usually proceeds quite differently from pneumonia caused by pneumococci, because there are no local inflammations of the alveoli, but only small compacted areas.
Nevertheless, the radiological image of a patient with mycoplasma pneumonia is similar to that of a purely bacterial pneumonia.

Pneumonia caused by mycoplasma is often accompanied by inflammation of the upper respiratory tract, for example:

Usually, this does not occur in a purely bacterial pneumonia.
Another common symptom of this type of infection is headache.
As with viral pneumonia, there is no relevant increase in leukocytes, but mild lymphocytosis, and the inflammatory parameters (erythrocyte sedimentation and CRP) are not increased.

Pneumonia caused by chlamydia
Infection with Chlamydia trachomatis can manifest itself up to 4 months after birth, and initially it manifests itself as viral bronchiolitis.
Differential diagnosis, it must be remembered that chlamydia is transmitted during childbirth. So they are present in the child’s body since birth.
The infection may begin with conjunctivitis, followed by weeks of rhinitis, which can progress into pneumonia.

With bronchiolitis caused by the respiratory syncytial virus, the infection begins like a cold with a persistent cough, which worsens in a few days.
Even if the symptoms are similar, the clinical course differs and for the diagnosis the developmental history is important.

Pneumonia caused by chlamydia is very rare, but pneumonia
caused by Chlamydia trachomatis is very common in premature infants.
This bacterium can cause pneumonia in a child with HIV infection.

Difference Between Bacterial and Viral Pneumonia

Characteristic symptoms of bacterial pneumonia

Initial symptoms of viral pneumonia

  • Creeping onset with mild fever,
  • diffuse symptoms,
  • Severe cough or runny nose (cold).

Complications of pneumonia in children

Possible complications of pneumonia include:

  • pleural effusion,
  • Pleural empyema (accumulation of pus-containing fluid). Lobar pneumonia is usually characterized by germ-containing pleural effusion, which stimulates the formation of fibrin. This substance forms sacs in which the antibiotic concentrates only slightly.

How do you recognize them? Diagnosis of pneumonia in children

Bacterial pneumonia
Especially in the streptococcal type, the lung tissue becomes compact and white, red or gray.
During auscultation, the doctor hears a coarse and fine crackle.
Bacterial pneumonia manifests itself with:

  • high fever and chills,
  • productive cough,
  • Sepsis (symptoms of a general infection of the whole body).

Usually a lung lobe is affected, the clinical picture is quite pronounced.

Physical examination

With auscultation, the doctor can hear:

  • a soft and muffled sound,
  • superficial bronchial breathing,
  • fine rattling noises (these occur at the beginning and at the end of the course of pneumonia).

Studies of pneumonia in children

The X-ray image is positive, a classic triangle appears, trapezoidal or wedge-shaped opaque (white). If the X-ray image does not show this type, but a simple compression, this does not give a precise indication.


  • Increase in neutrophils (white blood cells). It should be noted that children from 5-6 years have a reverse leukocyte formula compared to adults.
  • There are more lymphocytes than neutrophils, so the result of 60-70% neutrophils indicates neutrophilia.
  • Erythrocyte sedimentation and CRP are elevated.

What should you do? Treatment of pneumonia in children

Therapy depends on the microorganisms that most often provoke pneumonia in children of this age.
In case of doubt, or if the children are very small or their general condition is impaired, the doctor can start antibiotic therapy.

One should wait and delay the start of treatment with antibiotics in older children (for example, of school age) in:

  • good general conditions,
  • mild dyspnea and mild fever,
  • auscultation findings not typical of pneumonia.

Pneumonia in babies

In babies, treatment will always be for septic-bacterial pneumonia, even if the toddler does not show corresponding symptoms, because it can develop into a systemic bacterial infection in a short time.
For these reasons, the doctor prescribes:

  • a penicillin,
  • an aminoglycoside.

In this way, gram-positive and gram-negative bacteria are combated.

The baby is considered immunosuppressed, so general treatment is required, avoiding the intramuscular route if possible.
In general, the doctor prescribes two drugs in combination:

  • Ampicillin 100 mg per kg body weight per day in 3-4 doses intravenously or intramuscularly,
  • Aminoglycoside, for example netilmicin, 7.5 mg per kg body weight per day in 2 doses intravenously or intramuscularly.

Alternatively, penicillin can be administered with a third-generation cephalosporin:

  • Cephalosporin of the third generation intravenously or intramuscularly (for example, ceftazidime 50-100 mg per kg body weight per day in 2 doses),
  • Aminoglycoside.

In some cases, for example, if there is a suspicion of staphylococcal infection, an antibiotic with a strong anti-staphylococcal effect (for example, teicoplanin) is added.

Infants under 6 months of age

In infants under 6 months of age, the preferred therapy is a cephalosporin of the third generation, for example:

  • Ceftriaxone 50-100 mg per kg body weight per day every 24 hours and over 10 days, or
  • Ceftazidime 50-100 mg per kg body weight per day in 2 doses (also for Pseudomonas).

Cephalosporin is effective for:

  • Haemophilus influenzae,
  • pneumococcus,
  • Staphylococcus, which reacts to methicillin.

In general, these two drugs cover Gram infections well, while ceftriaxone (and also cefotaxime, which is very similar) is the only cephalosporin that also shows significant efficacy against gram-positive bacteria.§
The only contraindication to be considered is that high doses favor the formation of gallstones.

However, if atypical pneumonia is suspected, for example due to Chlamydia trachomatis or mycoplasma, the more specific drug is a macrolide.
A macrolide is prescribed for:

  • Conjunctivitis
  • Increase in eosinophils.

Caution: Staphylococcal pneumonia can become very severe in children under one year of age.

For the diagnosis, cystic changes are fundamental, which can be seen in the chest X-ray.

Children from six months to 5 years

If the infant is older than six months, but before the age of 5, the doctor recommends:
amoxicillin in high doses (50-100 mg per kg body weight per day in 3 doses) or amoxicillin-clavulanic acid (in the same dosage as amoxicillin in 3 doses)

or cephalosporin of the second or

third generation orally, especially if an antibiotic cycle has previously taken place.

Treatment failure after 48 hours of antibiotic administration is likely to be:

  • A viral infection,
  • A mycoplasma infection (even if the child is younger than 5 years).

In this case, the doctor recommends adding a macrolide.
In the event of a general or respiratory deterioration, the doctor may arrange hospitalization.

Children over 5 years

Children over 5 years of age are initially treated with a macrolide because of the high tendency to mycoplasma infections:

  • Erythromycin
  • clarithromycin,
  • rokitamycin,
  • Josamycin,
  • Azithromycin.

Erythromycin can have significant side effects, especially in the gastrointestinal area.
In fact, many doctors apply the same therapy to children between the ages of 6 months and 5 years as to infants, adding a macrolide only in case of failure.

If the patient does not react within 48 hours, it is necessary to make a few considerations:

If the clinical presentation is mild and there are no special concerns, one can:

  • if a viral disease is suspected, continue macrolide therapy for prophylactic purposes,
  • add a third-generation cephalosporin intramuscularly if atypical pneumonia (e.g. caused by mycoplasma) or resistant germs is suspected.

If, on the other hand, the clinical picture becomes more and more serious, it is necessary to consider:

  • the possibility of complications, for example:
    • a pleural effusion,
    • an empyema,
    • colliquative pneumonia in Staphylococcus aureus,
  • pneumonia caused by an unusual pathogen,
  • an underlying pathology in the child (such as immunodeficiency).

In these cases, the doctor recommends hospitalization.

If the situation is serious, the doctor may prescribe two complementary antibiotics:

  • Penicillin
  • Macrolide.

Antibiotic therapy is prescribed for at least 10 days, and therefore about 2-3 days after healing.

High doses of quinolones such as ciprofloxacin were once used in children, but some animal studies have shown that malformations in cartilage growth occur in young animals.
For this reason, quinolones are no longer allowed in pediatric therapy, except in patients who still suffer from other diseases, such as:

  • cystic fibrosis
  • neuromuscular diseases,
  • Diseases in which the protective effect of cilia in the respiratory system and mucus is reduced.

In these cases, pneumonia can develop due to Pseudomonas aeruginosa.

Why does the doctor recommend antibiotic therapy even if the patient could be ill with a viral infection?
Because there is no absolute safety and the doctor also prescribes antibiotics as a precaution against:

  • bacterial infections,
  • Otitis

However, according to some studies, a bacterial infection still develops and the antibiotic coverage leads to resistance of the bacteria to the antibiotic, making the treatment of the infection increasingly difficult.


  • If the child is hospitalized, you can try to discontinue the antibiotic, because in case of deterioration you can intervene immediately.
  • If, on the other hand, the child remains at home, antibiotic therapy should not be interrupted as a precaution.

Therapy for empyema

With accumulation of purulent fluid in the pleural cavity, it is necessary to administer antibiotics, namely:

  • in higher doses,
  • over a longer period of time.

drainage of the accumulated fluid can take place:

  • by means of video-assisted thoracoscopy to loosen adhesions between two pleural sheets,
  • by applying a suction drainage,
  • by performing a pleural cavity irrigation with urokinase (substance that promotes the breakdown of fibrin).

Thickening of the pleura and scarring (constructive pleurisy) must be prevented, as these prevent the lungs from developing correctly.
In recent years, the number of pleural empyema in children has increased.
This is probably the result of the spread of the pneumococcal vaccine (especially the heptavalent). The number of pneumococcal pneumonia has decreased, but more aggressive pneumococcal strains have remained, which can cause empyema much more easily.

In this group of children, amoxicillin + clavulanic acid is usually not administered, because macrolides are generally sufficient, except for infections with beta-hemolytic streptococci of group A, which, however, occur rarely.

When does a child with pneumonia need hospitalization?

It is necessary to evaluate various aspects:

  • Age – if the child is small, the doctor often recommends inpatient treatment. Older children are often treated at home unless their general condition worsens or there is shortness of breath.
  • The general condition (Does the child eat? Is it breathing well?).
  • Necessary special treatments: intravenous therapy or oxygenation.
  • Reliability of the family.

The child is not hospitalized just because he:

  • has rattling noises.
  • Has visible shading in the X-ray.

Recovery periods of pneumonia in children

Recovery times depend on:

  • the microorganisms that caused the problem,
  • the general condition of the child,
  • Complications that can occur.

In general, the condition in children cures in three and six weeks after the onset of symptoms.

Pneumonia vaccine

  1. The lung complications caused by flu viruses are the reason why the doctor recommends a flu shot.
  2. Often, these complications are caused or exacerbated by bacterial superinfections.
  3. As far as Streptococcus pneumoniae is concerned, there is an anti-pneumococcal vaccine, but the bacterial serotypes are so diverse that vaccination protection is quite limited, even if a heptavalent vaccine is used.
  4. Although the latter protects quite well against pneumococcal infections (pneumococci are the bacteria that cause meningitis), it does not protect against those that cause pneumonia.
  5. Vaccination against Haemophilus influenzae protects against most strains and has reduced the number of children suffering from pneumonia.

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