Pneumonia in kids

Pneumonia is an infection of one or both of the lungs caused by bacteria, viruses, or fungi and is sometimes called a chest infection. Pneumonia can be mild or serious. Pneumonia is generally more common in children younger than 5 years old. Because of the infection, the small airways in the lungs become swollen and make more mucus (sticky fluid). The mucus blocks the airways and reduces the amount of oxygen that is able to get into the body.

Pneumonia often comes after another respiratory infection, such as a cold. Sometimes there may be complications associated with pneumonia, but these are not common, and your doctor will monitor your child for these.

Pneumonia can be:

• Lobar pneumonia affects one or more sections (lobes) of the lungs.
• Bronchial pneumonia affects patches throughout both lungs. It is also called bronchopneumonia.

A child is more likely to get pneumonia if he or she has:

• Weak immune system, such as from cancer
• Ongoing (chronic) health problem, such as asthma or cystic fibrosis
• Problems with the lungs or airways

In addition, children younger than 1 year old are at risk if they are around secondhand tobacco smoke. This is especially true if their mother smokes.

Pneumonia in kids key points to remember:

• You should take your child to see your doctor if you think your child has pneumonia.
• If your child has pneumonia he/she will need to rest and drink small amounts of fluid often to prevent dehydration.
• It is very important for your child to complete the full course of antibiotics if they have been prescribed.
• Cough medicines do not help children with pneumonia.

What causes pneumonia in a child?

There are more than 30 different causes of pneumonia, but pneumonia is most often caused by bacteria or viruses. Some of these bacteria and viruses can be spread by direct contact with a person who is already infected with them.

The main types of pneumonia are:

• Bacterial pneumonia. This type is caused by various bacteria. Bacterial pneumonia often occurs when the body is weakened in some way. This may be from illness, poor nutrition, older age, or impaired immunity. Then the bacteria can work their way into the lungs. Bacterial pneumonia can affect all ages. But you are at greater risk if you abuse alcohol, smoke, are weak, have just had surgery, have a respiratory disease or viral infection, or have a weakened immune system.
  • Common bacteria that may cause pneumonia are:
    • Streptococcus pneumoniae (pneumococcus). Streptococcus pneumoniae bacteria is the most common bacteria that causes bacterial pneumonia (pneumococcal pneumonia). Pneumococcal infections can range from ear and sinus infections to pneumonia and bloodstream infections. There are vaccines to help prevent pneumococcal disease.
    • Mycoplasma pneumoniae. This often causes a mild form of the illness called walking pneumonia.
    • Group B streptococcus
    • Staphylococcus aureus
• Viral pneumonia. This type is caused by different viruses, including the flu. Viral pneumonia is responsible for about one-third of all pneumonia cases. You may be more likely to get bacterial pneumonia if you have viral pneumonia.
  • Common viruses that may cause pneumonia are:
    • Respiratory syncytial virus (RSV). This is most often seen in children younger than 5 years old.
    • Parainfluenza virus
    • Influenza virus
    • Adenovirus

Pneumonia may sometimes be caused by fungi.

Walking pneumonia in kids

Walking pneumonia also called atypical pneumonia, is a less serious form of the lung infection pneumonia, since symptoms tend to be milder than pneumonia caused by other germs ¹⁾. Walking pneumonia is caused by Mycoplasma pneumoniae bacteria, and causes cold-like symptoms, a low-grade fever, and a hacking cough.

Most kids with ‘atypical pneumonia’ will not feel sick enough to stay at home — hence, the name “walking” pneumonia. But even a child who feels fine needs to stay at home for a few days until antibiotic treatment kicks in and symptoms improve.

In general, illness caused by Mycoplasma pneumoniae is mild with symptoms that appear and get worse over a period of 1 to 4 weeks. These bacteria can cause several types of infections.

The most common type of illness, especially in children, is tracheobronchitis, commonly known as a chest cold. Common symptoms of a chest cold include:

• Sore throat
• Fatigue (being tired)
• Fever
• Slowly worsening cough that can last for weeks or months
• Headache

Experts have estimated that up to 1 in 10 people who get ill from Mycoplasma pneumoniae get pneumonia. Common symptoms of pneumonia include:

• Cough that may produce mucus
• Fever and chills
• Shortness of breath
• Chest pain
• Fatigue

Children younger than 5 years old often do not run a fever when they have an illness caused by Mycoplasma pneumoniae. Instead they may have signs that appear more like a cold than pneumonia. They sometimes wheeze, vomit, or have diarrhea.

All mycoplasmas lack a cell wall and, therefore, all are inherently resistant to beta-lactam antibiotics (e.g., penicillin) ²⁾. There are several types of antibiotics available to treat pneumonia caused by Mycoplasma pneumoniae. If a doctor diagnoses you or your child with an Mycoplasma pneumoniae illness, your doctor will explain how to treat it.

Mycoplasma pneumoniae key facts:

• Mycoplasma pneumoniae is a small bacterium that infects the lungs and other parts of the respiratory tract. People can spread these bacteria to others by coughing or sneezing.
• Pneumonia caused by Mycoplasma pneumoniae is considered an atypical bacterial pneumonia (walking pneumonia) because:
  • It tends to cause milder illness but symptoms tend to last longer
  • It can appear differently on an x-ray
  • The antibiotics commonly used in the past to treat bacterial pneumonia did not work against it
• Symptoms of illness caused by Mycoplasma pneumoniae usually start gradually. It can take someone between 1 to 4 weeks to get sick after they are exposed to the bacteria.
• Most Mycoplasma pneumoniae infections are mild and get better on their own without treatment, but serious complications can occur.
• An estimated 2 million cases of Mycoplasma pneumoniae infections occur each year in the United States ³⁾. The true number is unknown and likely underestimated.
• Mycoplasma pneumoniae is the second most common cause of pneumonia-related hospitalization in adults with community-acquired pneumonia (lung infections developed outside of a hospital) ⁴⁾.
• Mycoplasma pneumoniae may cause between 1 and 10 in every 50 cases of community-acquired pneumonia in the United States ⁵⁾.

What causes walking pneumonia?

Walking pneumonia is caused by Mycoplasma pneumoniae bacteria that spread from person to person by coughing and sneezing. People without symptoms may carry the bacteria in their nose or throat at one time or another. People spread Mycoplasma pneumoniae by coughing or sneezing, which creates small respiratory droplets in the air that contain the bacteria. Other people then breathe in the bacteria.

Most people who spend a short amount of time with someone who is sick with Mycoplasma pneumoniae do not become ill. However, it is common for the bacteria to spread between people who live together. Mycoplasma pneumoniae infections usually have long incubation periods (the time between breathing in the bacteria and developing symptoms). The incubation period is usually between 1 to 4 weeks ⁶⁾.

Mycoplasma pneumoniae outbreaks occur mostly in crowded settings like schools, college residence halls, military barracks, nursing homes, and hospitals. During school-based outbreaks, if people in the community get sick it is usually family members of ill school children ⁷⁾.

People at risk

Mycoplasma pneumoniae infections are most common in young adults and school-aged children, but can affect anyone. People at increased risk include those who live or work in crowded settings, such as:

• Schools
• College residence halls
• Military barracks
• Nursing homes
• Hospitals

People at increased risk for serious infections include people:

• Recovering from a respiratory illness
• With a weakened immune system.

Mycoplasma pneumoniae prevention

Like many respiratory germs, Mycoplasma pneumoniae spread by coughing and sneezing. Some tips to prevent the spread of Mycoplasma pneumoniae include:

• Cover your mouth and nose with a tissue when you cough or sneeze.
• Put your used tissue in a waste basket.
• If you don’t have a tissue, cough or sneeze into your upper sleeve or elbow, not your hands.
• Wash your hands often with soap and water for at least 20 seconds.
• If soap and water are not available, use an alcohol-based hand rub.

There is no vaccine to prevent Mycoplasma pneumoniae infections.

Walking pneumonia signs and symptoms

Colds that last longer than 7 to 10 days or respiratory illnesses like respiratory syncytial virus (RSV) can develop into walking pneumonia. Symptoms can come on suddenly or take longer to appear. Those that start slowly tend to be more severe.

Here’s what to look for:

• a fever of 101°F (38.5°C) or below
• headache, chills, sore throat, and other cold or flu-like symptoms
• fast breathing or breathing with grunting or wheezing sounds
• labored breathing that makes the rib muscles retract (when muscles under the ribcage or between ribs draw inward with each breath)
• hacking cough
• ear pain
• chest pain or stomach pain
• malaise (feeling of discomfort)
• vomiting
• loss of appetite (in older kids) or poor feeding (in infants)
• rash
• joint pain

Symptoms usually depend on where the infection is concentrated. A child whose infection is in the top or middle part of the lungs will probably have labored breathing. Another whose infection is in the lower part of the lungs (near the belly) may have no breathing problems, but may have an upset stomach, nausea, or vomiting.

Walking pneumonia complications

While Mycoplasma pneumoniae usually causes mild disease, severe complications can occur, resulting in needing care in a hospital. Mycoplasma pneumoniae infections can cause or worsen the following complications ⁸⁾:

• Serious pneumonia
• Asthma attacks or new asthma symptoms
• Encephalitis (swelling of the brain)
• Hemolytic anemia (too few red blood cells, which means fewer cells to deliver oxygen in the body)
• Renal dysfunction (kidney problems)
• Skin disorders (Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis)

Walking pneumonia diagnosis

Walking pneumonia is usually diagnosed through a physical examination. Your doctor will check your child’s breathing and listen for a hallmark crackling sound that often indicates walking pneumonia.

If needed, a chest X-ray or tests of mucus samples from the throat or nose might be done to confirm the diagnosis.

Walking pneumonia treatment

Antibiotics are an effective treatment for walking pneumonia. A 5- to 10-day course of oral antibiotics is usually recommended. If your doctor prescribes antibiotics, make sure your child takes them on schedule for as long as directed to recover more quickly.

Clinicians treat walking pneumonia with macrolide, tetracycline, or fluoroquinolone classes of antibiotics, taking age of the patient and local antibiotic resistance patterns into consideration:

• Macrolides (e.g., azithromycin): Children and adults
• Tetracyclines (e.g., doxycycline): Older children and adults
• Fluoroquinolones: Adults

Clinicians should NOT prescribe fluoroquinolones and tetracyclines for young children under normal circumstances. Macrolides are generally considered the treatment of choice. However, clinicians should practice prudent use of macrolide drugs due to the emergence of macrolide-resistant strains of Mycoplasma pneumoniae ⁹⁾.

Once on antibiotics, your child has a minimal risk of passing the illness on to other family members. But encourage everyone in your household to wash their hands well and often.

Don’t let your child share drinking glasses, eating utensils, towels, or toothbrushes. Wash your hands after touching any used tissues. Also make sure that your kids are up to date on their immunizations to help protect them from other infections.

Antibiotic resistance

Resistance to macrolides has been emerging in Mycoplasma pneumoniae since 2000 ¹⁰⁾. This issue is especially troubling in Asia, where resistance rates have been as high as 90%. The United States and Europe have also reported macrolide resistance. Current data suggest that the prevalence of macrolide resistance in Mycoplasma pneumoniae is probably rising in the United States ¹¹⁾. The increased use of azithromycin in recent years to treat a number of illnesses could help explain this rise.

Studies have reported that patients with infections due to macrolide-resistant strains may have fever and cough for a longer duration than patients infected with macrolide-sensitive strains ¹²⁾.

Experts need to learn more about the extent of macrolide resistance and its clinical implications to inform prescribing decisions.

Pneumonia in kids prevention

Pneumococcal pneumonia caused by Streptococcus pneumoniae bacteria can be prevented with a vaccine that protects against 13 types of pneumococcal pneumonia. Doctors recommend that children get a series of shots beginning at age 2 months. Talk with your child’s healthcare provider about this vaccine. Another vaccine is available for children older than 2 years who are at increased risk for pneumonia. Talk with your child’s healthcare to see if it is recommended for your child. Also make sure your child is up-to-date on all vaccines, including the yearly flu shot. Pneumonia can occur after illnesses such as whooping cough and the flu.

Two pneumococcal vaccines used in the United States help protect against pneumococcal disease:

• Pneumococcal conjugate vaccine (PCV13)
• Pneumococcal polysaccharide vaccine (PPSV23)

These vaccines are good at preventing severe pneumococcal disease, which often require treatment in the hospital and can be deadly. However, these vaccines will not prevent all infections.

The Centers for Disease Control and Prevention (CDC) recommends PCV13 (pneumococcal conjugate vaccine) for:

• All children younger than 2 years old
• People 2 years or older with certain medical conditions

In addition, adults 65 years or older may discuss and decide, with their clinician, to receive PCV13.

CDC recommends PPSV23 (pneumococcal polysaccharide vaccine) for:

• All adults 65 years or older
• People 2 through 64 years old with certain medical conditions
• Adults 19 through 64 years old who smoke cigarettes

Some groups may need multiple or booster doses. Talk with your or your child’s doctor about what is best for your specific situation.

You can also help your child prevent pneumonia with good hygiene. Teach your child to cover their nose and mouth when coughing or sneezing. Your child should also wash their hands often. These measures can help prevent other infections, too.

Your child can be vaccinated against pneumococcal pneumonia. There are 2 types of vaccines that can help prevent pneumococcal disease. The vaccine that is right for your child depends on their age and risk factors. Talk with your child’s healthcare provider about which vaccine is best for your child and when they should get it.

Signs and symptoms of pneumonia in kids

Signs and symptoms of pneumonia may be a bit different for each child and depend on your child’s age and may also depend on what is causing the pneumonia.

Children with pneumonia often have one or more of the following:

• high fever (temperature higher than 100.4 °F [38°C]). A normal temperature range for children is 97.7 °F – 100.4 °F (36.5°C to 38°C).
• fast and/or difficult breathing – your child’s breathing will become hard work, and you may see the ribs or skin under the neck ‘sucking in’ or nostrils flaring when they are breathing;
• younger babies may bob their heads when breathing
• cough or moist cough
• irritability or more tired than usual
• might complain of sharp chest pains when she breathes deeply or coughs
• abdominal (tummy) aches or pain
• vomiting.

Most children also lose their appetite and might not want to drink. A younger baby might just look very ill and breathe rapidly, without showing any of the other symptoms above.

Young babies and children with severe pneumonia are at risk of dehydration.

Cases of bacterial pneumonia tend to happen suddenly with these symptoms:

• Cough that produces mucus
• Cough pain
• Vomiting or diarrhea
• Loss of appetite
• Tiredness (fatigue)
• Fever

Early symptoms of viral pneumonia are the same as those of bacterial pneumonia. But with viral pneumonia, the breathing problems happen slowly. Your child may wheeze and the cough may get worse. Viral pneumonia may make a child more at risk for bacterial pneumonia.

In addition to the symptoms listed above, your child may have:

• Chills
• Fast or hard breathing
• Headache
• Fussiness

Some symptoms give important clues about which germ is causing the pneumonia. For example:

• In older kids and teens, pneumonia due to Mycoplasma (also called walking pneumonia) is very common. It causes a sore throat, headache, and rash in addition to the usual symptoms of pneumonia.
• In babies, pneumonia due to chlamydia may cause conjunctivitis (pinkeye) with only mild illness and no fever.
• When pneumonia is due to whooping cough (pertussis), a child may have long coughing spells, turn blue from lack of air, or make the classic “whoop” sound when trying to take a breath. Fortunately, the pertussis vaccine can help protect kids against whooping cough.

The length of time between exposure to the germ and when someone starts feeling sick varies, depending on which germ caused the pneumonia (for instance, 4 to 6 days for RSV, but just 18 to 72 hours for the flu).

The symptoms of pneumonia may look like other health problems. Make sure your child sees his or her healthcare provider for a diagnosis.

Pneumonia in kids possible complications

Pneumonia can be a life-threating illness. Children with pneumonia may have these complications:

• Severe breathing problems
• Bacteria that enters the blood (bacteremia)

Pneumonia in kids diagnosis

Your child’s doctor can often diagnose pneumonia with a full health history and physical exam. He or she may include these tests to confirm the diagnosis:

• Chest X-ray. This test makes images of internal tissues, bones, and organs.
• Blood tests. A blood count looks for signs of an infection. An arterial blood gas test looks at the amount of carbon dioxide and oxygen in the blood.
• Sputum culture. This test is done on the mucus (sputum) that is coughed up from the lungs and into the mouth. It can find out if your child has an infection. It’s not routinely done because it is hard to get sputum samples from children.
• Pulse oximetry. An oximeter is a small machine that measures the amount of oxygen in the blood. To get this measurement, the provider tapes a small sensor onto a finger or toe. When the machine is on, a small red light can be seen in the sensor. The sensor is painless and the red light does not get hot.
• Chest CT scan. This test takes images of the structures in the chest. It is very rarely done.
• Bronchoscopy. This procedure is used to look inside the airways of the lungs. It is very rarely done.
• Pleural fluid culture. This test takes a sample of fluid from the space between the lungs and chest wall (pleural space). Fluid may collect in that area because of the pneumonia. This fluid may be infected with the same bacteria as the lung. Or the fluid may just be caused by the inflammation in the lung.

Pneumonia in children treatment

Pneumonia in children treatment may include antibiotics for bacterial pneumonia. No good treatment is available for most viral pneumonias. They often get better on their own. Flu-related pneumonia may be treated with an antiviral medicine.

Other treatments can ease symptoms. They may include:

• Plenty of rest
• Getting more fluids
• Cool mist humidifier in your child’s room
• Acetaminophen (paracetamol) for fever and discomfort
• Medicine for cough

Some children may be treated in the hospital if they are having severe breathing problems.

Children might need treatment in a hospital if the pneumonia causes a lasting high fever, breathing problems, or if they:

• need oxygen therapy
• have a lung infection that may have spread to the bloodstream
• have a chronic illness that affects the immune system
• are vomiting so much that they cannot take medicine by mouth
• keep getting pneumonia
• might have whooping cough

While in the hospital, treatment may include:

• Antibiotics by IV (intravenous) or by mouth (oral) for bacterial infection
• IV fluids if your child is unable to drink well
• Oxygen therapy
• Frequent suctioning of your child’s nose and mouth to help get rid of thick mucus
• Breathing treatments, as ordered by your child’s healthcare provider.

More severe cases might be treated in the intensive care unit (ICU).

Care at home

After a doctor has diagnosed your child with mild pneumonia, you can treat most children with pneumonia at home:

• Your child will need a lot of rest.
• It is important to give your child fluids frequently to prevent dehydration. Offer small sips of water, and offer babies breastmilk or formula more often.
• Most children refuse to eat when they have pneumonia. This is not a problem, as long as they are drinking fluids.
  • If your breastfed child is younger than six months, offer extra breastfeeds.
  • If your formula-fed child is younger than six months, offer her usual amount of formula. You might need to feed her smaller amounts more frequently if she’s unwell.
  • If your child is older than six months, keep breastfeeding or bottle-feeding. You can also offer your child clear fluids, like water. If your child isn’t hungry while he has a fever, that’s OK.
• If your child’s pneumonia is caused by bacteria, your doctor might prescribe antibiotics, which your child will need to take for a week or so. Follow your doctor’s instructions for giving antibiotics, if they have been prescribed. Antibiotics don’t work for pneumonia caused by a virus. Sometimes it can be hard to tell the difference between viral and bacterial pneumonia.
• It may be more comfortable for older children to sleep propped up on a couple of pillows, rather than laying completely flat.
• If your child has chest pains or a fever and is feeling miserable, they may need some pain relief, such as acetaminophen (paracetamol) or ibuprofen. Do not give ibuprofen to children under three months old or to children who are dehydrated. Never give aspirin to children.
• Do not give cough medicines. They do not help children with pneumonia.
• Do not allow anyone to smoke in the home or around your child.
• Your doctor will tell you if you need to go back for review of your child’s recovery.

Smoke can make pneumonia worse, so keep your home smoke free.

If your child is very ill, or is less than one year old, he’ll probably need to go to hospital for special treatment. In hospital, your child will have antibiotics through a drip (intravenously) if the pneumonia is bacterial. Some children also need oxygen to ease their breathing. Your child might also get extra fluids through a drip.

You should go back to see your doctor if your child has pneumonia and:

• their breathing becomes more difficult, or they develop a grunt when they breathe
• they become more drowsy or sleepy, or are hard to wake
• they begin vomiting and are unable to drink much
• you are worried about your child at any stage during the illness or you have other questions.

Bacterial pneumonia

If your child’s pneumonia is caused by bacteria, they will be prescribed antibiotics. In mild cases of bacterial pneumonia, this medicine can be taken orally at home. Children with bacterial pneumonia usually improve within 48 hours of starting antibiotics. It is very important to complete the whole course of antibiotics, even if your child seems much better. Treatment will continue for 3 to 7 days. Your child may continue to cough for up to three weeks after treatment, but this is nothing to worry about if they are otherwise getting better.

Children who are very unwell with bacterial pneumonia may be admitted to hospital for antibiotics given directly into a vein through a drip (intravenous or IV therapy). Some children may also need oxygen or extra fluids.

Viral pneumonia

Viral pneumonia is usually not as severe as bacterial pneumonia. However, recovery can be slower, taking up to four weeks. Antibiotics do not cure viruses and are not given for viral pneumonia.

Antiviral medicine is now available too, but is reserved for the flu when found early in the course of illness.

Child pneumonia recovery time

Childhood pneumonia recovery time depends on the child’s age, health condition and the type of pneumonia. Children with bacterial pneumonia usually improve within 48 hours of starting antibiotics. It is very important to complete the whole course of antibiotics, even if your child seems much better. Treatment will continue for 3 to 7 days. Your child may continue to cough for up to three weeks after treatment, but this is nothing to worry about if they are otherwise getting better. Viral pneumonia is usually not as severe as bacterial pneumonia. However, recovery can be slower, taking up to four weeks.