Pediatric Pneumonia: Nursing Study Guide

Pneumonia is one of the leading causes of illness and death in children worldwide. This guide reviews how it develops, how it presents differently by age, and how nurses assess, treat, and prevent complications.

Definition

• Pneumonia is an infection of the lower respiratory tract causing inflammation of the lung parenchyma.
• It leads to consolidation of the alveoli and impaired gas exchange.
• It is a leading cause of morbidity and mortality in children worldwide.

Pathophysiology

• Infection triggers an inflammatory response, filling alveolar spaces with inflammatory cells and fluid.
• Consolidation develops as alveoli fill with exudate, impairing gas exchange and causing hypoxemia.
• Ventilation-perfusion (V/Q) mismatch occurs because consolidated areas are perfused but not ventilated.
• In viral pneumonia, bronchiolar inflammation and mucus plugging cause air trapping and atelectasis.

Risk Factors

• Age: infants <12 months, especially preterm infants
• Immunization: unvaccinated or under-vaccinated children
• Environmental: daycare attendance, overcrowding, secondhand smoke, air pollution
• Nutritional: malnutrition, vitamin D deficiency, zinc deficiency
• Medical conditions: congenital heart disease, chronic lung disease (BPD), cystic fibrosis, immunodeficiency, sickle cell disease
• Perinatal: prematurity, low birth weight, lack of breastfeeding

Key points:

• Age <12 months and prematurity are major risks due to small airways and immature immunity.
• Secondhand smoke damages respiratory mucosa and increases susceptibility.
• Sickle cell disease raises the risk of pneumococcal pneumonia due to functional asplenia.
• Lack of breastfeeding removes an important source of passive immunity.

Causes by Age Group

• Neonates (<1 month): Group B Streptococcus, E. coli, Listeria, CMV
• Infants (1–3 months): RSV, Chlamydia trachomatis, S. pneumoniae, H. influenzae
• Children (3 months–5 years): RSV, S. pneumoniae, H. influenzae, Mycoplasma pneumoniae
• Children (>5 years): M. pneumoniae, S. pneumoniae, S. pyogenes, Influenza
• Adolescents: M. pneumoniae, S. pneumoniae, Influenza

High-yield facts:

• Streptococcus pneumoniae is the most common bacterial cause across all pediatric ages.
• Mycoplasma pneumoniae is the most common cause in school-age children and adolescents.
• RSV is the most common viral cause in infants and young children.

Clinical Manifestations

• Fever — often high in bacterial pneumonia
• Cough — hallmark symptom; may be dry or productive
• Tachypnea — an early sign of respiratory distress
• Retractions — substernal, intercostal, suprasternal
• Nasal flaring — sign of distress, especially in infants
• Grunting — expiratory sound indicating significant distress
• Crackles on auscultation — fluid in alveoli
• Decreased breath sounds over areas of consolidation
• Cyanosis — late sign of severe hypoxemia; requires immediate intervention
• Abdominal pain — possible with lower-lobe pneumonia (diaphragmatic irritation)
• Poor feeding — a key sign of respiratory distress in infants

Bacterial vs. Viral Pneumonia

• Onset: sudden (bacterial) vs. gradual (viral)
• Fever: high (bacterial) vs. low–moderate (viral)
• Cough: productive/purulent (bacterial) vs. dry/non-productive (viral)
• Chest X-ray: lobar consolidation (bacterial) vs. diffuse infiltrates, hyperinflation (viral)
• Antibiotic response: good (bacterial) vs. none (viral)

Diagnosis

• History: age, symptoms, immunization status, sick contacts
• Physical exam: respiratory rate, retractions, grunting, auscultation
• Pulse oximetry: SpO₂ <90% indicates significant hypoxemia
• Chest X-ray: gold standard — shows infiltrates, consolidation, or effusion
• CBC: leukocytosis with left shift suggests bacterial cause
• Nasopharyngeal swab: viral testing (RSV, influenza)

Management

By severity

• Mild (outpatient): oral antibiotics (amoxicillin or macrolide); supportive care
• Moderate (hospitalized): IV antibiotics (ceftriaxone), oxygen, supportive care
• Severe (ICU): IV antibiotics, oxygen, respiratory support, possible intubation

Antibiotic selection

• Amoxicillin — first-line for bacterial pneumonia
• Azithromycin — atypical pneumonia (e.g., Mycoplasma)
• Ceftriaxone — severe pneumonia needing IV therapy
• Vancomycin — reserved for suspected MRSA
• Typical course: 7–10 days
• Do not use antibiotics for viral pneumonia

Supportive care

• Hydration: encourage oral fluids; IV fluids if needed
• Oxygen therapy for SpO₂ <90%
• Upright positioning facilitates breathing

Nursing Interventions

• Assess respiratory status frequently: rate, SpO₂, retractions, work of breathing.
• Administer oxygen to maintain SpO₂ >90%.
• Administer medications as ordered.
• Provide hydration; encourage oral fluids.
• Position upright to ease breathing.
• Suction nasal passages in infants to clear secretions and improve feeding.
• Monitor for complications using the SLAP HER mnemonic.
• Educate parents on home care and signs of worsening.

Complications — SLAP HER Mnemonic

• S – Septicemia: infection spreads from the lung, causing bacteremia, sepsis, and septic shock.
• L – Lung abscess: localized pus collection; recurrent fever, foul-smelling sputum, weight loss.
• A – ARDS: severe inflammatory lung injury with refractory hypoxemia; often needs mechanical ventilation.
• P – Pericarditis/Myocarditis: spread of infection causing cardiac inflammation.
• H – Hypotension: from dehydration or sepsis-induced vasodilation; needs fluids ± vasopressors.
• E – Empyema: pus in the pleural space; persistent fever, needs drainage and prolonged antibiotics.
• R – Respiratory failure: most serious complication; requires intubation and mechanical ventilation.

Additional pediatric complications

• Parapneumonic effusion: fluid accumulation in the pleural space.
• Necrotizing pneumonia: severe complication with lung tissue necrosis.

Prevention

• Vaccination is the most effective prevention:
  • PCV13 — protects against S. pneumoniae
  • Hib vaccine — protects against H. influenzae
  • Influenza vaccine — given annually
• Hand hygiene limits spread of respiratory infections.
• Avoid smoke exposure.
• Breastfeeding provides passive immunity and reduces risk.

Exam Traps

• Do not ignore tachypnea — it is an early sign of respiratory distress.
• Do not confuse bacterial and viral pneumonia patterns.
• Remember Mycoplasma pneumoniae as the most common cause in school-age children.
• Do not discharge a child with significant respiratory distress or poor feeding.
• Do not use cough suppressants in children with pneumonia.
• Memorize SLAP HER: Septicemia, Lung abscess, ARDS, Pericarditis, Hypotension, Empyema, Respiratory failure.

Key takeaways

• Tachypnea, retractions, grunting, and poor feeding are early red flags of respiratory distress in children.
• S. pneumoniae is the most common bacterial cause overall; RSV dominates in infants; Mycoplasma in school-age kids.
• Chest X-ray is the gold standard; treat SpO₂ <90% with oxygen.
• First-line antibiotic is amoxicillin; ceftriaxone for severe/hospitalized cases; no antibiotics for viral pneumonia.
• Use SLAP HER to monitor for complications — respiratory failure is the most serious.
• PCV13, Hib, and influenza vaccines plus breastfeeding are the pillars of prevention.