Pediatrics 7: Pneumonia Portal
PEDS: Because this entire portal pertains only to pediatric patients, the convention of underlining has been omitted.
Infants under the age of 3 months may have non-specific findings of poor feeding, mild temperature, vomiting, and general malaise. In older children, examine for fever, purulent sputum, and respiratory distress. A chest x-ray may be helpful in making the diagnosis.
Management
- Respiratory
Give oxygen to all children with significant pneumonia. Hypoxia causing depressed LOC, anxiety, or tiring are indications for orotracheal intubation ( Vol II—AIR SKILLS 3, Orotracheal Intubation). Tracheal suction assists in mobilization of purulent secretions. - Laboratory
Obtain a blood culture and a tracheal secretion specimen for gram stain and culture. When you suspect a clinical diagnosis of respiratory syncytial virus (RSV) antigen, perform a nasal wash or aspirate. - Circulatory Management
IV fluids are necessary. If the patient is hypotensive or appears to be in shock, this may be septic shock with volume depletion and an expanded vascular space secondary to peripheral vasodilation.
Administer a bolus of NS 20 mL/kg. Watch for signs of fluid overload because overshooting the mark may cause acute pulmonary edema and worsening of respiratory status.
A purulent pericarditis, which has been caused by organisms from the pneumonia, may cause cardiac tamponade resulting in shock. If the heart shadow is large on the chest x-ray or if echocardiogram demonstrates significant fluid within the pericardium, perform pericardiocentesis (Vol II—CIRC SKILLS 6, Pericardiocentesis). - Antibiotic Management
Under 3 months: First choice: Give ampicillin 50 mg/kg IV every 6 hours, plus either cefotaxime (Claforan) 50 mg/kg IV every 8 hours. Add vancomycin 10-15 mg/kg/dose if the infant has lobar pneumonia or meningitis or is very sick. Gentamicin may be used but it provides no coverage for Staphylococcus pneumoniae. The gentamicin dose is 2 to 2.5 mg/kg every 8 hours; check levels.
Over 3 months: Give cefotaxime (Claforan) 50 mg/kg IV or IM every 6 hours or ceftriaxone (Rocephin) 50 mg/kg IV or IM every 12 hours. Add vancomycin if the child is very sick. Consider azithromycin (10 mg/kg/day) for non-lobar pneumonia. Ampicillin is not necessary unless there is an aspiration.