Community Acquired Pneumonia in Children - LRTI

Comments from Expert Advisory Committee

• Pneumonia in children age ≤2 years is usually caused by viruses and should not be routinely treated with antibiotics
  • Wheeze is strongly correlated with viral pneumonia
• The absence of tachypnoea makes pneumonia very unlikely
• It is very difficult to distinguish between viral or bacterial pneumonia based on clinical signs and symptoms
• Bacterial pneumonia should be considered in children when there is:
  • Persistent or repetitive fever >38.5°C AND
  • Chest recession AND
  •  Raised respiratory rate
• Risk factors for bacterial pneumonia are similar to the risk factors for sepsis. They include:
  • Immunodeficiency
  • Prematurity
  • Neuro-disability
  • Chronic respiratory disease i.e. cystic fibrosis
• Reassess if symptoms do not improve as expected or worsen rapidly
• Influenza antiviral therapy should be administered as soon as possible to children with moderate to severe pneumonia consistent with influenza virus infection during widespread local circulation of influenza.

General management for child in community setting

The general management of a child who does not require hospital referral comprises advising parents and carers about:

• management of fever
  
  • use of antipyretics when child is off form with pyrexia
  • avoidance of tepid sponging
• preventing dehydration by encouraging fluids
• identifying signs of deterioration
• identifying signs of other serious illness
• how to access further healthcare (providing a ‘safety net’). The ‘safety net’ should be one or more of the following:
  • provide the parent or carer with verbal and/or written information on warning symptoms and how further healthcare can be accessed
  • arrange a follow-up appointment at a certain time and place
  • liaise with other healthcare professionals, including out-of-hours providers, to ensure the parent/carer has direct access to a further assessment for their child.

Over-the-counter remedies: No over-the-counter cough medicines have been found to be effective in pneumonia.

Indications for hospital referral:

Infants (up to 1 year old):

• O2 saturation <92%, or cyanosis.
• Respiratory rate >70 breaths/min.
• Difficulty breathing.
• Intermittent apnoea or grunting.
• Not feeding (taking <2/3 normal feeds).
• Family unable to provide appropriate observation or supervision.

Children (>1 year old):

• O2 saturation <92%, or cyanosis.
• Respiratory rate >50 breaths/min.
• Difficulty breathing.
• Grunting.
• Signs of dehydration.

Family unable to provide appropriate observation or supervision

Treatment

Drug	Dose	Duration	+/- Notes
1st choice options
Amoxicillin	Refer to dosing table	5 days
2nd choice options  / penicillin allergy
Doxycycline only if ≥8 years*	Refer to dosing table	5 days in total	*For children over 8yrs, doxycycline can be used if benefit outweighs risk
Clarithromycin**	Refer to dosing table	5 days	For pneumococcus, resistance to macrolides is becoming increasingly common, so reserve for bacterial pneumonia if documented penicillin allergy, or if treating suspected Mycoplasma or other “atypical” pathogen*.

**Mycoplasma pneumonia infections occur in outbreaks approx. every four years and are more common in school aged children

Sample Calculation (information for dispensing pharmacist)

Child requiring treatment using Doxycycline 100mg unlicensed dispersible tablets:
Child weight=30kg (specify child weight on prescription)
Dose: 4.4mg per kg
30kg x 4.4mg/kg = 132mg dose required i.e. 100mg + 32mg

How to disperse tablet to give a part dose of 32mg:
Dissolve 1x 100mg dispersible doxycycline tablet in 5mL of water
100mg=5mL so 32mg=1.6mL. (Draw up and give 1.6ml using 5ml syringe supplied by pharmacist to give 32mg).

Therefore for a total dose of 132mg, give the appropriately dispersed 100mg tablet plus 1.6mL (32mg) of the dispersed liquid prepared as above

Discard remaining dose by returning to local pharmacy in child resistant closure container.
If required, to improve palatability, can add squash/fruit juice to water. Make dose fresh each time.

Patient Information

• We recommend patients use the website developed by HSE/ICGP/IPU partnership www.undertheweather.ie for tips on how to get better from common infections without using antibiotics, what you can do for yourself or a loved one and when to seek help.
• HSE > Symptoms, Condition and Treatment: Pneumonia

Safe Prescribing (visit the safe prescribing page)

• Dosing in children quick reference dosage/weight guide
• Clarithromycin and other macrolides warning
• Penicillin allergy – tips on prescribing in penicillin allergy
• Renal impairment dosing table
• Drug interactions table. Extensive drug interactions for clarithromycin, fluoroquinolones, azole antifungals and rifampicin. Many antibiotics increase the risk of bleeding with anticoagulants.
• Visit the Health Products Regulatory Authority (HPRA) website for detailed drug information (summary of product characteristics and patient information leaflets). Dosing details, contraindications and drug interactions can also be found in the Irish Medicines Formulary (IMF) or other reference sources such as British National Formulary (BNF) / BNF for children (BNFC).

Reviewed March 2022