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Pneumonia is an infection of the lung and respiratory tract below the level of the larynx. Globally it is a leading cause of morbidity and mortality, with up to 1.9 million childhood deaths per year in the developing world.1 Even in industrialized countries, according to World Health Organization estimates, there are 4 million cases annually in children <5 years of age.2

This chapter addresses the clinical and radiographic diagnosis of pneumonia, common viral and bacterial causes, evidence-based and historically based treatments, and appropriate consultation and follow-up for children seen in the ED.

An exhaustive discussion of pathogens and preexisting pediatric pathology is beyond the scope of this text. However, wherever possible, special mention is made of unusual microbes, changing patterns of immunization and resistance, and special considerations for children with underlying medical problems. For the clinician with less pediatric experience, a brief overview on the use and interpretation of chest radiographs in this population is included.

In the vast majority of cases, pediatric pneumonia is caused by viral or bacterial agents, with a smaller number due to unusual pathogens such as Mycobacterium tuberculosisor opportunistic organisms such as fungi.

In most cases the etiologic agent is never known. Definitive microbiologic diagnosis requires invasive procedures such as bronchial lavage, sampling of pleural effusion for culture, or lung puncture, which are unavailable or impractical in the ED. Although blood cultures are frequently performed for the very sick and the very young, they have limited relevance in the ED. They are used primarily to refine treatment at a later date, once culture results are known.

Most diagnostic algorithms estimate the likely cause of pneumonia based on the patient’s age and the presumed incidence and prevalence of particular microbes for each age group. Detailed summaries exist in the literature,3 but typical causes of community-acquired pneumonia in healthy children are listed in (Table 121-1).4 The clinician still must take into account local and regional epidemics, individual immunization status, and underlying health problems that may influence which pathogens are likely. Infections vary considerably across the spectrum of age, and a few general rules and specific exceptions are described below.

Table 121-1 Age-Specific Causes of Pneumonia in Otherwise Healthy Children

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