Max is a 4-year-old boy who presents with a 2-day history of cough, fever, and chills. He tells you that his tummy hurts. On examination, he appears moderately ill and his breathing is rapid (about 55 breaths per minute); his oxygen saturation on room air is 94 percent. You hear decreased breath sounds and crackles on the left side of his chest and possibly on the right. You obtain a chest x-ray which is concerning for bacterial pneumonia. (Figures 50-1 and 50-2). You admit him to the hospital with a diagnosis of probable bacterial pneumonia and prescribe intravenous antibiotics. He improves considerably over 48 hours and is discharged home on oral antibiotics.
Left lower and partial left upper lobe consolidation and pleural effusion on PA chest x-ray in a 4-year-old child, concerning for bacterial pneumonia. (Used with permission from Camille Sabella, MD).
Lateral chest x-ray in the same child. (Used with permission from Camille Sabella, MD.)
Pneumonia refers to an infection in the lower respiratory tract (distal airways, alveoli, and interstitium of the lung). Community-acquired pneumonia (CAP) has traditionally referred to pneumonia occurring outside of the hospital setting. A subgroup of CAP that is associated with health care risk factors (e.g., prior hospitalization, dialysis, immunocompromised state) has been classified as health care-associated pneumonia.
CAP can be caused by a wide variety of viral, bacterial, and “atypical” pathogens. The age and immune status of the host are important in considering the potential causes and management of pneumonia in the pediatric population.
The incidence rate of CAP among children in the first 5 years of life is 10 to 40 cases/1000,1 with an incidence rate of 6 to 12 cases/1000 in children older than 9 years in North America.2
In the National Hospital Discharge Survey (2006) of 1,232 first-listed pneumonia discharges from short-stay hospitals, 172 (14%) were children aged <15 years.3
The distribution of the pneumococcal vaccine in 2000 has resulted in an approximately 35 percent decrease in all-cause pneumonia hospitalizations in US children since 1997–1999, with incident rates in 2005 and 2006 for children aged <2 years of 9.1/1,000 and 8.1/1,000, respectively.4 For pneumococcal pneumonia, rates of hospitalizations between 1997–1999 and 2004 in an employer-based population study of children <age 2 years declined from 0.6 to 0.3 per 1000 children (57.6% decline) and rates of ambulatory visits declined from 1.7 to 0.9 per 1000 children (46.9% decline).
CAP is the most frequent cause of death due to infectious disease in the US and the eighth leading cause of death overall (2007).5,6
Deaths in 2009 from influenza and pneumonia occurred in 5.9/50,000 children <age 1 year, 0.9/50,000 for children aged 1 to 4 years, 0.6/50,000 for children aged 5 to 14 years and 1.0/50,000 for those aged 15 to 24 years.7
Etiology and Pathophysiology