350 Paediatric Emergencies
BREATHLESS CHILDPneumonia
DIAGNOSIS
1 Bronchopneumonia occurs in young children, or older children with chronic
illness, e.g. cerebral palsy, and may be bacterial or viral. Up to 60% of
pneumonias are caused by viruses.
2 Bacterial pneumonias are more frequently associated with high fever, local-
ized findings on chest examination and lobar consolidation and pleural
effusion on CXR.
(i) However, bacterial and viral aetiologies cannot be reliably
distinguished on either clinical or radiological criteria.
3 Lobar pneumonia commonly presents with sudden illness, fever, breathless-
ness and pleuritic chest pain. Wheeze and hyperinf lation are more typically
associated with asthma, bronchiolitis and croup.
4 The presentation of pneumonia in younger children is often atypical.
Consider this diagnosis in infants and children with:
(i) Cough, fever and dyspnoea.
(ii) Abdominal pain, vomiting and diarrhoea.
(iii) Poor feeding, lethargy.
(iv) Persistent fever.
5 Tachypnoea with nasal f laring and intercostal recession are associated with
respiratory compromise in infants. Chest auscultation may be normal,
especially in children under 12 months, or may reveal classic signs of
bronchial breathing, crepitations and decreased breath sounds.
6 Send blood for FBC, U&Es, blood sugar and blood cultures in severe cases.
Attach a pulse oximeter.
7 Perform a CXR in every case to confirm lung pathology such as lobar consol-
idation, empyema or a pleural effusion, as clinical signs are unreliable.MANAGEMENT
1 Give oxygen to maintain oxygen saturations above 94%.
2 Administer i.v. maintenance f luids to maintain hydration, particularly if the
child is hypotensive or has difficulty feeding secondary to dyspnoea.
3 Administer antibiotic therapy according to local guidelines, and expert
advice. Treatment regimens include:
(i) Birth to 1 week
(a) benzylpenicillin 60 mg/kg i.v., 12-hourly for 7 days plus
gentamicin (neonate less than 34 weeks postconceptional age:
3 mg/kg; 34 weeks or more postconceptional age: 3.5 mg/kg)
i.v. daily for 7 days
(b) consider the possibility of HSV pneumonitis.
(ii) 1 week to <4 months