Pneumonia in Children

Your child has been coughing for a few days and has a fever. So how can you tell whether this is a simple upper respiratory tract infection, bronchitis or pneumonia?

If rapid breathing, difficulty breathing, pulling in of the chest or a clear decline in the child's general condition accompanies the cough and fever, an evaluation for pneumonia is needed.

Pneumonia is an infection of the lung tissue. Different microorganisms, mainly viruses and bacteria, can cause pneumonia.

In childhood, pneumonia can run a range of courses, from a mild illness to a serious infection requiring treatment in hospital.

For this reason, the diagnosis takes into account not only the level of the fever or the severity of the cough, but also the child's breathing and general condition.

What Is Pneumonia in Children?

Inside the lungs there are small air sacs that allow air to reach the tissue. In pneumonia, the infection and inflammation developing in the lung tissue can make it harder for breathing to take place normally.

Pneumonia can be caused by:

• Viruses
• Bacteria
• More rarely, fungi and other infectious agents

The microorganisms causing the illness in children can vary according to age, the child's health status and the season.

That is why an approach along the lines of "it is pneumonia, so it must have been caused by this particular germ" is not correct.

What Are the Symptoms of Pneumonia in Children?

The symptoms of pneumonia can vary according to the child's age and the severity of the infection.

The most commonly seen symptoms include:

• Fever
• Cough
• Rapid breathing
• Difficulty breathing
• Pulling in of the chest wall while breathing
• Chest pain
• Fatigue
• Poor appetite
• Reduced feeding in babies
• Abdominal pain in some children

In young children, pneumonia may not always show up as "a child who coughs a lot."

Rapid breathing, labored breathing and disrupted feeding in particular can be important signs.

How Is Pneumonia Recognized in Children?

The child's history of illness and the physical examination are of fundamental importance in diagnosing pneumonia.

The pediatrician evaluates in particular:

• The breathing rate
• Whether the child is having difficulty breathing
• Whether there is pulling in of the chest
• The lung sounds
• The oxygen level
• The course of the fever and the other symptoms
• The child's general condition

Rapid breathing is one of the important clinical findings for pneumonia, especially in young children.

However, a child's breathing rate should be evaluated according to their age. The normal breathing rate of babies is higher than that of older children.

For this reason, it is not right for families to try to diagnose pneumonia based only on a number they found on the internet.

How Are Pneumonia and the Common Cold Told Apart in Children?

In a simple upper respiratory tract infection, what may stand out more is:

• Runny nose
• Stuffy nose
• Sore throat
• Mild cough

In pneumonia, on the other hand, what draws more attention is:

• Rapid or labored breathing alongside the cough
• A clear change in the child's breathing
• Pulling in of the chest
• A decline in general condition
• A high or continuing fever

Even so, it is not always possible to make a definite distinction at home by looking at the symptoms alone.

Can There Be Pneumonia Without a Fever?

Yes.

Fever is one of the common symptoms of pneumonia, but a fever does not have to be present in every case of pneumonia.

The clinical picture can be different, especially in young babies, in some viral infections or in special situations involving the immune system.

For this reason, the absence of fever does not on its own rule out pneumonia.

Is Pneumonia in Children Viral or Bacterial?

In childhood, pneumonia can be caused by both viruses and bacteria.

Viral causes hold an important place, especially in young children.

RSV, influenza and other respiratory viruses can cause pneumonia.

In bacterial pneumonia, Streptococcus pneumoniae is one of the important agents.

However, the symptoms of viral and bacterial pneumonia can resemble each other.

This distinction cannot always be made with certainty by looking only at:

• How high the fever is
• The character of the cough
• The lung sounds

The child's age, the clinical course, the examination findings and, when necessary, further investigations are evaluated together.

How Is Pneumonia Diagnosed in Children?

A diagnosis of pneumonia is made primarily through clinical evaluation.

The child's cough, fever, breathing pattern and general condition are evaluated, and the lungs are listened to.

When necessary, the following may be requested:

• The oxygen level in the blood measured with a pulse oximeter
• A chest X-ray
• Blood tests
• Certain microbiological tests

However, the same tests do not need to be done for every child with suspected pneumonia.

Is a Chest X-Ray Essential to Diagnose Pneumonia?

No.

A chest X-ray is not always necessary to diagnose pneumonia, especially in children whose illness runs a mild course and who can be followed as outpatients.

A chest X-ray may become more important in situations where:

• The diagnosis is unclear
• The illness is running a severe course
• A low oxygen level is present
• A complication is being considered
• The expected response to treatment has not been obtained

For this reason, neither the view that "if there is pneumonia it must be visible on an X-ray" nor the view that "pneumonia cannot be diagnosed without an X-ray" is correct.

How Is Pneumonia Treated in Children?

Treatment is determined according to the cause of the pneumonia, the child's age, the severity of the illness and any accompanying health problems.

In Bacterial Pneumonia

Antibiotic treatment may be needed in children in whom bacterial pneumonia is being considered.

A large share of children with a mild illness and a good general condition can be treated at home with an appropriate oral antibiotic and close follow-up.

The antibiotic to be used, its dose and the duration of treatment should be determined by the pediatrician.

In Viral Pneumonia

In viral pneumonia, an antibiotic does not treat the virus.

Treatment is mostly built on:

• Taking in enough fluid
• Control of fever and pain
• Monitoring of breathing
• Oxygen and other supportive treatments when necessary

In certain specific viral infections, antiviral treatment may come into question depending on the child's age and risk status.

Are Antibiotics Used in Every Case of Pneumonia?

No.

Pneumonia is not an illness caused only by bacteria.

Antibiotics have no curative effect in pneumonia caused by viruses.

However, especially in young children, it may not always be possible to determine the responsible agent with certainty on clinical grounds.

For this reason, the decision about an antibiotic should be made by a physician after evaluating the child's age, the clinical picture and the likelihood of a bacterial infection.

Can Pneumonia Be Treated at Home in Children?

Yes, some children can be treated at home.

Children who are in good general condition, who can take in enough fluid, whose oxygen level is appropriate and who do not have severe respiratory distress can be followed as outpatients after a physician's evaluation.

However, it is important for the child to be watched closely.

If the child's breathing gets worse, fluid intake drops or the general condition declines, the child should be evaluated again.

When Might Hospital Admission Be Needed for Pneumonia in Children?

Not every case of pneumonia requires hospital admission.

However, follow-up in hospital may be needed in situations such as:

• Clear respiratory distress
• A low oxygen level in the blood
• Being unable to take in fluids or to feed
• A serious decline in general condition
• A change in alertness
• Very young age
• The presence of a significant chronic illness
• Outpatient treatment not being able to continue safely
• The development of a complication related to the pneumonia

How Is a Low Oxygen Level Recognized in Pneumonia in Children?

The oxygen level in the blood can be measured at health care facilities with a device called a pulse oximeter.

However, certain clinical signs can also suggest a low oxygen level or serious respiratory distress.

These are findings such as:

• Very rapid breathing
• Flaring of the nostrils with breathing
• Grunting
• Clear pulling in of the chest
• A bluish color of the lips or the skin
• The child being extremely weak or unusually sleepy

A bluish color or serious difficulty breathing in particular requires emergency evaluation.

Once Treatment for Pneumonia Has Started, When Is Improvement Expected?

After appropriate treatment has been started, improvement in the child's fever, general condition and respiratory symptoms is expected over time.

The cough going away completely may take longer than the other symptoms.

The child should be evaluated again if, despite treatment:

• The fever continues
• Breathing is getting worse
• The general condition is not improving
• New symptoms are appearing

Does Pneumonia Come Back in Children?

Yes, a child may have pneumonia more than once during different periods of life.

Having pneumonia a single time usually does not mean that there is an underlying specific illness.

However, recurrent pneumonia should be evaluated separately.

In pneumonia that recurs in the same part of the lung or that develops with unusual frequency, it may be necessary to look into the underlying causes.

What Causes Recurrent Pneumonia in Children?

There is no single cause of recurrent pneumonia.

In some children, it may be necessary to look into conditions such as:

• Asthma or airway diseases
• Foreign body aspiration
• Reflux and aspiration
• Diseases of the immune system
• Cystic fibrosis
• Congenital airway or lung anomalies
• Certain neuromuscular diseases

What matters here is not only the question "how many times has there been pneumonia?"

Whether the pneumonia recurs in the same area, whether the lung findings clear completely in between, and what other symptoms the child has are also evaluated.

What Should Be Done If Pneumonia Does Not Clear Completely?

If a child is not improving as expected despite appropriate treatment, the following should be evaluated again:

• The diagnosis
• The agent causing the infection
• Whether the treatment is appropriate
• Whether a complication has developed
• Whether another underlying illness is present

Pneumonia that keeps coming back or does not clear should not be brushed aside with the thought that "children get sick often anyway."

How Can Pneumonia Be Prevented in Children?

It is not possible to remove the risk of pneumonia in childhood completely, but certain measures can significantly reduce the risk.

The main ones are:

• Completing the vaccines appropriate for the child's age
• Paying attention to hand hygiene
• Protecting the child from cigarette smoke
• A balanced and adequate diet
• Supporting appropriate feeding during infancy
• Regular follow-up of any chronic illnesses

Vaccines given against illnesses such as pneumococcus, Haemophilus influenzae type b (Hib), whooping cough, measles and influenza contribute through different mechanisms to preventing some cases of pneumonia and serious respiratory tract infections.

Does Cigarette Smoke Increase the Risk of Pneumonia in Children?

Yes.

A child's exposure to cigarette smoke has a negative effect on respiratory health and can increase the risk of lower respiratory tract infections.

For this reason, no one should smoke in enclosed spaces where the child is present, such as the home and the car.

If My Child Has Had Pneumonia, What Should I Watch for Afterward?

The following should be monitored:

• The course of the child's fever
• Whether their breathing has become easier
• Fluid and food intake
• Activity level
• Regular use of medications

It can take time for the child's energy and appetite to return completely to how they were.

However, a high fever developing again or respiratory distress increasing after recovery has begun requires a new evaluation.