Pneumonia

What is it?

Pneumonia is an infection of the lungs. The word "pneumonia" is still very frightening for many people. With today’s medications it is usually easy to treat, however. There is no one cause of pneumonia. Germs of many kinds can cause the lungs to become infected. Most cases of pneumonia begin with a cold or another viral respiratory infection such as the flu. Some kinds of viruses can cause pneumonia, while in other cases the viral infection sets the stage for a bacterial infection to follow. The difference is important because doctors can treat bacterial and bacteria-like infections with antibiotics. These drugs don’t work to treat viral pneumonia.

Pneumonia can range from quite mild to very severe and even life-threatening if not treated. Mild pneumonia usually starts as a cold or flu-like illness. A child with early pneumonia develops a significant fever, usually above 102.4 °F or 39 °C. Next, most children develop a wet cough that some parents describe as "deep," because it seems to come from deep in the chest. Children older than 8 or 9 years old may bring up mucous or phlegm ("flem," or "flame"). Younger children also produce the phlegm but they have a tendency to swallow it, so parents may not see it. Some children complain of chest pain that is much worse when they cough. As the illness gets worse, children may develop shaking chills called "rigors." In severe cases of pneumonia, children may have trouble breathing, or it may hurt to breathe in. If a large area of lung is infected, the child may be unable to get enough oxygen. This can cause bluish or pale lips and fingernail beds. Very severe pneumonias can cause permanent damage to lungs or other organs.

Fortunately, most children with pneumonia improve quickly with medication and other support. If your child has pneumonia, your doctor will want to follow him or her very closely for the first few days. The doctor will want to follow up again a week or so after symptoms clear up.

The biggest danger with pneumonia is that infected lungs can’t absorb oxygen well. Children with severe pneumonia may also be unable to get rid of carbon dioxide. If a child has a severe bacterial pneumonia, the germs can get into the bloodstream. This can cause serious infections in other parts of the body. Children with pneumonia also feel miserable and may not eat or drink enough. This can cause dehydration and even malnutrition in extreme cases. The fever and cough can also cause headaches and chest pain, so we need to pay attention to pain and comfort issues as well.

Your doctor may have done a chest X-ray to diagnose pneumonia. Many experienced doctors can make an accurate diagnosis of pneumonia without an X-ray. Your doctor may have chosen to skip that step. In either case, the doctor will use all the evidence to decide if the pneumonia is from a bacterial or bacteria-like cause. If so, the doctor will start an antibiotic for your child. If not, your doctor will recommend comfort measures and careful follow up. Although viral pneumonia can be serious, especially in very young infants or people with weak immune systems, it is usually fairly mild.

If your doctor has prescribed antibiotic medication for your child, please be sure to follow the instructions carefully. Antibiotics do not relieve symptoms immediately. They only work when they reach a steady level in the child’s blood stream. This means that every dose is important, and so is timing. Please try not to miss doses. If you do miss a dose, please give the medicine as soon as you remember, and give the next dose right on the original schedule. Many newer antibiotics work on a once- or twice-a-day schedule. This makes it easier to manage the dosing.

Liquid antibiotic medicines settle in the bottle. If your child is taking liquid medication, please be sure to shake it up before each dose. If you skip that step, your child may get nothing but syrup in the first doses, and then very high doses of medication later on. Please be sure you supervise your older child or teen taking antibiotic chewables or tablets. This will help to make sure s/he doesn’t miss any doses. You may want to read our Aftercare Instructions on Administering Oral Medications.

Comfort at home is a very big concern for the child with pneumonia. Coughing will continue for several days after starting antibiotics, and the cough can become quite painful. Fever also lasts for up to 72 hours after starting medicine, and fever causes weakness, loss of appetite, and achy muscles and joints. Some antibiotics cause nausea or loose stools. All of this together can create a thoroughly miserable and unhappy child.

Fortunately, you can do a great deal to soothe and comfort your child with pneumonia. You can put a humidifier or vaporizer in his or her room and run it day and night. This helps to loosen secretions and get them out of the lungs. Please don’t put any medication in the humidifier, though. These can cause worse irritation and actually make the cough more severe. You can use acetaminophen (Tylenol®) or ibuprofen (Advil® or Motrin®) to relieve fever in children over 3 months. Check with your doctor about using it in younger babies. Fever less than 106.0 °F or 41.1 °C is not dangerous, but it can make the child uncomfortable. If your child seems comfortable there is no reason to give any medication just for fever. Please read our Aftercare Instructions about Fever.

Your child with pneumonia won’t have much appetite for a few days. Dehydration is a bigger risk than poor nutrition, so if your child doesn’t want solid food, don’t force the issue. Now is a good time to offer lots of fluids and soups. Many doctors recommend avoiding milk products with respiratory infections, but it can be worth trying them because they are high in nutrition. If your child’s cough or mucous production gets worse, then stop the milk products.

The cough itself can be very irritating for both the child and the family. Please remember that the cough serves an important function. It helps the child to bring up and get rid of infected material. Doctors generally prefer not to suppress coughing in children early in their pneumonia. For a persistent or troublesome cough, your doctor may recommend either an over-the-counter or a prescription cough medicine. Please follow the directions carefully – many of these medications can be harmful in overdose.

Please check with your doctor before you give any over-the-counter cough or cold medication. Most doctors feel that cold medicines and decongestants do not help children with pneumonia. These medicines always increase heart rate and can make younger children fussy. If you do decide to try one of the cough or cold medicines, whether over-the-counter or by prescription, please read the label carefully. Many of these medicines (such as Nyquil® or Theraflu®) contain multiple ingredients. It is easy to accidentally overdose a child with one of the ingredients if you are giving several different medicines that all contain one or more of the same ingredient. If you have any doubt about which medicines you can give in combination, please ask your doctor or pharmacist.

Most children with pneumonia begin to improve within the first 3 days of treatment. Improvement is not immediate, though, so it is important to be prepared to cope with your sick child for the first few days. Please try not to become discouraged, and do keep giving the medications even if they don’t seem to help at first. Children with more severe cases of pneumonia, or with complications, may not get better, or may get better and then get worse. Here are some things to look for as you help your doctor monitor your child with pneumonia:

• Fever that is not at least somewhat lower by the third day on medication
• Fever that returns after having been gone for at least 24 hours
• Worsening cough after the first 48 hours on treatment – it is normal for cough to get a bit worse as the treatment begins to work over the first 2 days
• Chest pain that gets worse instead of better over time
• Chest pain that the child can localize to one specific part of the chest
• Coughing up blood or increasing amounts of phlegm
• Signs of dehydration, like sunken eyes, dry tongue or mouth (dry lips are normal), reduced urination, or cool hands and feet
• Vomiting or diarrhea
• Difficult or painful breathing
• Blue or pale lips or nail beds
• Agitation, confusion, or lethargy (excessive sleepiness)
• "Grunting" sounds with breathing
• Flaring nostrils
• Pulling in the skin between the ribs or above the collarbone
• Stiff neck
• Rapidly spreading rash

Although most pneumonia gets better with treatment and support, sometimes complications develop. These complications may not be obvious at first. If your child goes home with mild pneumonia and then gets worse, it doesn’t mean that you "missed" anything or didn’t do a good job. Most doctors prefer to try children at home with mild or moderate pneumonia, and to keep them out of the hospital if possible. Sometimes it just isn’t possible, and the child has to stay in the hospital for a few days. If this happens to you, try to remember that it isn’t your fault.

Some children with bacterial pneumonia develop fluid or pus inside the chest cavity but outside of the lungs. This is called "pleural effusion" or "empyema" (emm-pie-ee-mah). It may require longer treatment with antibiotics, drainage with a tube, or even surgery. Signs of pleural effusion are difficult or painful breathing, persistent fever, or fever that returns after being gone. In rare cases, children with pneumonia suffer partial or complete collapse of a lung. Signs of a lung collapse are sudden sharp pain in one area of the chest, often with difficulty breathing afterwards. Your doctor will do a chest X-ray if s/he is concerned about these conditions.

Children with severe bacterial pneumonia can develop infections in other parts of their bodies as well. The most dangerous is meningitis, or infection of the brain and its coverings. Children with meningitis usually have changes in their level of consciousness. They may become agitated, confused, or lethargic (sleepy). Children older than 2 years will usually complain of headache and stiff neck. Younger children with meningitis may not have these signs. Some children and teens with very severe bacterial infections develop a rash that looks either like tiny flat red spots or flat reddish-purple patches on the skin. If your child develops any of these things, please call an ambulance right away.

Common viruses and bacteria cause most cases of pneumonia. There are some unusual causes, particularly in children who have been outside of the US other industrialized countries. Other unusual pneumonias can happen in children with weakened immune systems or other serious illnesses. If your child has traveled abroad, been in close contact with someone recently incarcerated, or been around someone with tuberculosis (Tb), please tell your doctor. S/he will want to do a skin test for Tb. If your child has a weakened immune system or is taking steroids or other medicines that suppress the immune system, your doctor may want to test for Tb as well as other unusual germs like Pneumocystis carinii (new-moe-siss-tiss car-inn-ee-ee).

Having a sick child at home can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Babies and children who are sick are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.