++
The clinical presentation of pneumonia in children is quite variable and is dependent on many factors including age, comorbidity, risk factors (Table 36-3), disease severity, and causative microorganism. The classic triad of fever, cough, and rales that is often present in adults or adolescents with pneumonia is rarely present in the infant or young child.14 In the neonate, nonspecific signs and symptoms such as lethargy, irritability, apnea, vomiting, poor feeding, isolated fever or hypothermia, and poor muscle tone are more common and frequently occurs in the context of a sepsis syndrome.
++
++
Similarly, infants often lack the typical findings of pneumonia. They may present with nonspecific signs and symptoms. They may present as “a fever without source,” sepsis, or vital sign abnormalities (fever, hypothermia, bradycardia, tachycardia, and tachypnea); gastrointestinal symptoms (poor feeding, vomiting, diarrhea, and abdominal pain); or grunting, lethargy, and shock. Infants with a bacterial pneumonia may be febrile with respiratory distress manifesting as tachypnea, retractions, and hypoxia, whereas infants with Chlamydia pneumonia may be afebrile and have a cough as their only symptom with a normal physical examination.
++
The toddler with pneumonia frequently has a fever and cough; although gastrointestinal complaints, such as vomiting or abdominal pain, are common and may be the presenting symptom or chief complaint.14 The clinical presentation in older children and adolescents is similar to that in adults with cough, sometimes chest pain (which is usually pleuritic), and often generalized symptoms from abdominal pain to headache.
++
Although there is much overlap, two clinical presentations have been delineated: “typical” and “atypical” pneumonia. Typical pneumonia, presumed to be due to a bacterial microorganism, is characterized by sudden symptom onset with fever, chills, pleuritic chest pain, productive cough, a toxic appearance, and rales on lung examination. Atypical pneumonia is usually attributed to a viral etiology, mycoplasma, or Chlamydia with a gradual onset of low-grade fever, nonproductive cough, malaise, headache, and physical examination findings that may include wheezing, a viral enanthem, an upper respiratory infection (URI) with rhinitis, pharyngitis, and conjunctivitis. However, determination of the etiologic agent based on clinical presentation alone is difficult.
++
The clinical presentation usually indicates the severity of the pneumonia and the need for hospitalization or outpatient therapy. The lethargic infant who is not feeding or has respiratory distress will need hospitalization more so than the playful nontoxic, well-appearing infant. Any infant or child with respiratory distress (e.g., hypoxia, cyanosis, grunting, flaring, retractions), or an altered mental status (whether lethargic or irritable, inconsolable, or unresponsive), with pneumonia will require hospitalization. Patients with any risk factors such as immunosuppression or chronic diseases (including chronic lung disease, congenital heart disease, and sickle cell disease) tend to have a more serious life-threatening pneumonia (Table 36-2).
++
Although rales, decreased breath sounds, and wheezing may be heard in children with pneumonia, such findings may be absent with “normal” auscultation of the lungs. Rales may not be heard in infants or young children because of poor inspiration, poor ventilation of affected areas, transmission of sounds throughout the chest, which precludes localization, and noisy upper-airway sounds. Respiratory distress and signs of increased work of breathing, retractions, grunting, flaring, head bobbing, or paradoxical (seesaw) breathing may occur in children with pneumonia. Abdominal pain and/or distention from swallowed air, an ileus, or diaphragmatic irritation from lower lobe pneumonia may occur. Meningismus, without meningeal infections, can occur with upper lobe pneumonia.
++
Other physical examination findings may be useful in detecting the source of the pneumonia as with contiguous or hematogenous spread from other sites, and in diagnosing comorbidity (e.g., immunosuppression, chronic diseases). Extrapulmonary findings suggesting specific etiologic agents may occur: such as conjunctivitis with Chlamydia, pharyngitis with streptococcal or mycoplasma, a preceding or coexistent URI, and skin exanthems with bacterial or viral pathogens. The physical examination may reveal complications of pneumonia, such as dehydration, pleural effusion, respiratory failure, or even sepsis.