UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Community-acquired pneumonia in children: Clinical features and diagnosis

Author
William J Barson, MD
Section Editors
Sheldon L Kaplan, MD
George B Mallory, MD
Deputy Editor
Mary M Torchia, MD

INTRODUCTION

Community-acquired pneumonia (CAP) is defined as signs and symptoms of an acute infection of the pulmonary parenchyma in an individual who acquired the infection in the community, as distinguished from hospital-acquired (nosocomial) pneumonia [1,2]. CAP is a common and potentially serious illness with considerable morbidity.

The clinical features and diagnosis of CAP in children will be reviewed here. The epidemiology, pathogenesis, and treatment of pneumonia in children are discussed separately. (See "Pneumonia in children: Epidemiology, pathogenesis, and etiology" and "Community-acquired pneumonia in children: Outpatient treatment" and "Pneumonia in children: Inpatient treatment".)

CLINICAL PRESENTATION

The clinical presentation of childhood pneumonia varies depending upon the responsible pathogen, the particular host, and the severity. The presenting signs and symptoms are nonspecific; no single symptom or sign is pathognomonic for pneumonia in children.

Symptoms and signs of pneumonia may be subtle, particularly in infants and young children. The combination of fever and cough is suggestive of pneumonia; other respiratory findings (eg, tachypnea, increased work of breathing) may precede the cough. Cough may not be a feature initially since the alveoli have few cough receptors. Cough begins when the products of infection irritate cough receptors in the airways. The longer fever, cough, and respiratory findings are present, the greater the likelihood of pneumonia [3].

Neonates and young infants may present with difficulty feeding, restlessness, or fussiness rather than with cough and/or abnormal breath sounds [4]. Neonates, young infants, and young children (ie, <5 to 10 years of age) may present only with fever and leukocytosis [3,5]. Older children may complain of pleuritic chest pain (pain with respiration), but this is an inconsistent finding. Occasionally, the predominant manifestation may be abdominal pain (because of referred pain from the lower lobes) or nuchal rigidity (because of referred pain from the upper lobes). "Walking pneumonia" is a term that is sometimes used to describe pneumonia in which the respiratory symptoms do not interfere with normal activity.

                                        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Wed Jun 08 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.
  2. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011; 66 Suppl 2:ii1.
  3. Murphy CG, van de Pol AC, Harper MB, Bachur RG. Clinical predictors of occult pneumonia in the febrile child. Acad Emerg Med 2007; 14:243.
  4. Margolis P, Gadomski A. The rational clinical examination. Does this infant have pneumonia? JAMA 1998; 279:308.
  5. Bachur R, Perry H, Harper MB. Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med 1999; 33:166.
  6. Bradley JS. Management of community-acquired pediatric pneumonia in an era of increasing antibiotic resistance and conjugate vaccines. Pediatr Infect Dis J 2002; 21:592.
  7. Community acquired pneumonia guideline team, Cincinnati Children's Hospital Medical Center. Evidence-based care guidelines for medical management of community acquired pneumonia in children 60 days to 17 years of age. Guideline 14. www.cincinnatichildrens.org/svc/alpha/h/health-policy/ev-based/pneumonia.htm (Accessed on September 22, 2011).
  8. Jadavji T, Law B, Lebel MH, et al. A practical guide for the diagnosis and treatment of pediatric pneumonia. CMAJ 1997; 156:S703.
  9. Pereira JC, Escuder MM. The importance of clinical symptoms and signs in the diagnosis of community-acquired pneumonia. J Trop Pediatr 1998; 44:18.
  10. McIntosh K. Community-acquired pneumonia in children. N Engl J Med 2002; 346:429.
  11. Palafox M, Guiscafré H, Reyes H, et al. Diagnostic value of tachypnoea in pneumonia defined radiologically. Arch Dis Child 2000; 82:41.
  12. Mahabee-Gittens EM, Grupp-Phelan J, Brody AS, et al. Identifying children with pneumonia in the emergency department. Clin Pediatr (Phila) 2005; 44:427.
  13. Lynch T, Platt R, Gouin S, et al. Can we predict which children with clinically suspected pneumonia will have the presence of focal infiltrates on chest radiographs? Pediatrics 2004; 113:e186.
  14. Smyth A, Carty H, Hart CA. Clinical predictors of hypoxaemia in children with pneumonia. Ann Trop Paediatr 1998; 18:31.
  15. World Health Organization. The management of acute respiratory infections in children. In: Practical guidelines for outpatient care. World Health Organization, Geneva 1995.
  16. Russell G. Community acquired pneumonia. Arch Dis Child 2001; 85:445.
  17. Simoes EA, Roark R, Berman S, et al. Respiratory rate: measurement of variability over time and accuracy at different counting periods. Arch Dis Child 1991; 66:1199.
  18. Gadomski AM, Khallaf N, el Ansary S, Black RE. Assessment of respiratory rate and chest indrawing in children with ARI by primary care physicians in Egypt. Bull World Health Organ 1993; 71:523.
  19. Berman S, Simoes EA, Lanata C. Respiratory rate and pneumonia in infancy. Arch Dis Child 1991; 66:81.
  20. Gadomski AM, Permutt T, Stanton B. Correcting respiratory rate for the presence of fever. J Clin Epidemiol 1994; 47:1043.
  21. Margolis PA, Ferkol TW, Marsocci S, et al. Accuracy of the clinical examination in detecting hypoxemia in infants with respiratory illness. J Pediatr 1994; 124:552.
  22. Heulitt MJ, Ablow RC, Santos CC, et al. Febrile infants less than 3 months old: value of chest radiography. Radiology 1988; 167:135.
  23. Harari M, Shann F, Spooner V, et al. Clinical signs of pneumonia in children. Lancet 1991; 338:928.
  24. Campbell H, Byass P, Lamont AC, et al. Assessment of clinical criteria for identification of severe acute lower respiratory tract infections in children. Lancet 1989; 1:297.
  25. Broughton RA. Infections due to Mycoplasma pneumoniae in childhood. Pediatr Infect Dis 1986; 5:71.
  26. Korppi M, Don M, Valent F, Canciani M. The value of clinical features in differentiating between viral, pneumococcal and atypical bacterial pneumonia in children. Acta Paediatr 2008; 97:943.
  27. Wang K, Gill P, Perera R, et al. Clinical symptoms and signs for the diagnosis of Mycoplasma pneumoniae in children and adolescents with community-acquired pneumonia. Cochrane Database Syst Rev 2012; 10:CD009175.
  28. British Thoracic Society Standards of Care Committee. British Thoracic Society Guidelines for the Management of Community Acquired Pneumonia in Childhood. Thorax 2002; 57 Suppl 1:i1.
  29. Leventhal JM. Clinical predictors of pneumonia as a guide to ordering chest roentgenograms. Clin Pediatr (Phila) 1982; 21:730.
  30. Tipple MA, Beem MO, Saxon EM. Clinical characteristics of the afebrile pneumonia associated with Chlamydia trachomatis infection in infants less than 6 months of age. Pediatrics 1979; 63:192.
  31. Turner RB, Lande AE, Chase P, et al. Pneumonia in pediatric outpatients: cause and clinical manifestations. J Pediatr 1987; 111:194.
  32. Alario AJ, McCarthy PL, Markowitz R, et al. Usefulness of chest radiographs in children with acute lower respiratory tract disease. J Pediatr 1987; 111:187.
  33. Virkki R, Juven T, Rikalainen H, et al. Differentiation of bacterial and viral pneumonia in children. Thorax 2002; 57:438.
  34. Korppi M, Kiekara O, Heiskanen-Kosma T, Soimakallio S. Comparison of radiological findings and microbial aetiology of childhood pneumonia. Acta Paediatr 1993; 82:360.
  35. Bettenay FA, de Campo JF, McCrossin DB. Differentiating bacterial from viral pneumonias in children. Pediatr Radiol 1988; 18:453.
  36. Bruns AH, Oosterheert JJ, El Moussaoui R, et al. Pneumonia recovery: discrepancies in perspectives of the radiologist, physician and patient. J Gen Intern Med 2010; 25:203.
  37. Davies HD, Wang EE, Manson D, et al. Reliability of the chest radiograph in the diagnosis of lower respiratory infections in young children. Pediatr Infect Dis J 1996; 15:600.
  38. Kramer MS, Roberts-Bräuer R, Williams RL. Bias and 'overcall' in interpreting chest radiographs in young febrile children. Pediatrics 1992; 90:11.
  39. Swingler GH, Hussey GD, Zwarenstein M. Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children. Lancet 1998; 351:404.
  40. Cao AM, Choy JP, Mohanakrishnan LN, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database Syst Rev 2013; :CD009119.
  41. Ablin DS, Newell JD 2nd. Diagnostic imaging for evaluation of the pediatric chest. Clin Chest Med 1987; 8:641.
  42. Gaisie G, Dominguez R, Young LW. Comparison of AP supine vs PA upright methods of chest roentgenography in infants and young children. J Natl Med Assoc 1984; 76:171.
  43. Miller MA, Ben-Ami T, Daum RS. Bacterial pneumonia in neonates and older children. In: Pediatric Respiratory Medicine, Taussig LM, Landau LI (Eds), Mosby, St. Louis 1999. p.595.
  44. Kiekara O, Korppi M, Tanska S, Soimakallio S. Radiological diagnosis of pneumonia in children. Ann Med 1996; 28:69.
  45. Tapiainen T, Aittoniemi J, Immonen J, et al. Finnish guidelines for the treatment of community-acquired pneumonia and pertussis in children. Acta Paediatr 2016; 105:39.
  46. Kuhn JP, Brody AS. High-resolution CT of pediatric lung disease. Radiol Clin North Am 2002; 40:89.
  47. Guerra M, Crichiutti G, Pecile P, et al. Ultrasound detection of pneumonia in febrile children with respiratory distress: a prospective study. Eur J Pediatr 2016; 175:163.
  48. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults. JAMA Pediatr 2013; 167:119.
  49. Caiulo VA, Gargani L, Caiulo S, et al. Lung ultrasound characteristics of community-acquired pneumonia in hospitalized children. Pediatr Pulmonol 2013; 48:280.
  50. Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics 2015; 135:714.
  51. Courtoy I, Lande AE, Turner RB. Accuracy of radiographic differentiation of bacterial from nonbacterial pneumonia. Clin Pediatr (Phila) 1989; 28:261.
  52. McCarthy PL, Spiesel SZ, Stashwick CA, et al. Radiographic findings and etiologic diagnosis in ambulatory childhood pneumonias. Clin Pediatr (Phila) 1981; 20:686.
  53. Clements H, Stephenson T, Gabriel V, et al. Rationalised prescribing for community acquired pneumonia: a closed loop audit. Arch Dis Child 2000; 83:320.
  54. Lahti E, Peltola V, Virkki R, Ruuskanen O. Influenza pneumonia. Pediatr Infect Dis J 2006; 25:160.
  55. Simpson W, Hacking PM, Court SD, Gardner PS. The radiological findings in respiratory syncytial virus infection in children. II. The correlation of radiological categories with clinical and virological findings. Pediatr Radiol 1974; 2:155.
  56. Dawson KP, Long A, Kennedy J, Mogridge N. The chest radiograph in acute bronchiolitis. J Paediatr Child Health 1990; 26:209.
  57. Tan TQ, Mason EO Jr, Barson WJ, et al. Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998; 102:1369.
  58. Finnegan OC, Fowles SJ, White RJ. Radiographic appearances of mycoplasma pneumonia. Thorax 1981; 36:469.
  59. Griscom NT. Pneumonia in children and some of its variants. Radiology 1988; 167:297.
  60. McLennan MK. Radiology rounds. Round pneumonia. Can Fam Physician 1998; 44:751, 757.
  61. Kim YW, Donnelly LF. Round pneumonia: imaging findings in a large series of children. Pediatr Radiol 2007; 37:1235.
  62. Redd SC, Patrick E, Vreuls R, et al. Comparison of the clinical and radiographic diagnosis of paediatric pneumonia. Trans R Soc Trop Med Hyg 1994; 88:307.
  63. Shuttleworth DB, Charney E. Leukocyte count in childhood pneumonia. Am J Dis Child 1971; 122:393.
  64. Peltola V, Mertsola J, Ruuskanen O. Comparison of total white blood cell count and serum C-reactive protein levels in confirmed bacterial and viral infections. J Pediatr 2006; 149:721.
  65. Tabain I, Ljubin-Sternak S, Cepin-Bogović J, et al. Adenovirus respiratory infections in hospitalized children: clinical findings in relation to species and serotypes. Pediatr Infect Dis J 2012; 31:680.
  66. Chen SP, Huang YC, Chiu CH, et al. Clinical features of radiologically confirmed pneumonia due to adenovirus in children. J Clin Virol 2013; 56:7.
  67. Flood RG, Badik J, Aronoff SC. The utility of serum C-reactive protein in differentiating bacterial from nonbacterial pneumonia in children: a meta-analysis of 1230 children. Pediatr Infect Dis J 2008; 27:95.
  68. Moulin F, Raymond J, Lorrot M, et al. Procalcitonin in children admitted to hospital with community acquired pneumonia. Arch Dis Child 2001; 84:332.
  69. Schützle H, Forster J, Superti-Furga A, Berner R. Is serum procalcitonin a reliable diagnostic marker in children with acute respiratory tract infections? A retrospective analysis. Eur J Pediatr 2009; 168:1117.
  70. Toikka P, Irjala K, Juvén T, et al. Serum procalcitonin, C-reactive protein and interleukin-6 for distinguishing bacterial and viral pneumonia in children. Pediatr Infect Dis J 2000; 19:598.
  71. van Rossum AM, Wulkan RW, Oudesluys-Murphy AM. Procalcitonin as an early marker of infection in neonates and children. Lancet Infect Dis 2004; 4:620.
  72. Korppi M. Non-specific host response markers in the differentiation between pneumococcal and viral pneumonia: what is the most accurate combination? Pediatr Int 2004; 46:545.
  73. Korppi M, Remes S, Heiskanen-Kosma T. Serum procalcitonin concentrations in bacterial pneumonia in children: a negative result in primary healthcare settings. Pediatr Pulmonol 2003; 35:56.
  74. Williams DJ, Hall M, Auger KA, et al. Association of White Blood Cell Count and C-Reactive Protein with Outcomes in Children Hospitalized for Community-acquired Pneumonia. Pediatr Infect Dis J 2015; 34:792.
  75. Ostapchuk M, Roberts DM, Haddy R. Community-acquired pneumonia in infants and children. Am Fam Physician 2004; 70:899.
  76. McCracken GH Jr. Diagnosis and management of pneumonia in children. Pediatr Infect Dis J 2000; 19:924.
  77. Hickey RW, Bowman MJ, Smith GA. Utility of blood cultures in pediatric patients found to have pneumonia in the emergency department. Ann Emerg Med 1996; 27:721.
  78. Claesson BA, Trollfors B, Brolin I, et al. Etiology of community-acquired pneumonia in children based on antibody responses to bacterial and viral antigens. Pediatr Infect Dis J 1989; 8:856.
  79. Shah SS, Dugan MH, Bell LM, et al. Blood cultures in the emergency department evaluation of childhood pneumonia. Pediatr Infect Dis J 2011; 30:475.
  80. Myers AL, Hall M, Williams DJ, et al. Prevalence of bacteremia in hospitalized pediatric patients with community-acquired pneumonia. Pediatr Infect Dis J 2013; 32:736.
  81. Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis 2002; 34:434.
  82. Byington CL, Korgenski K, Daly J, et al. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006; 25:250.
  83. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009; 44:106.
  84. Andrews AL, Simpson AN, Heine D, Teufel RJ 2nd. A Cost-Effectiveness Analysis of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia. J Pediatr 2015; 167:1280.
  85. Lahti E, Peltola V, Waris M, et al. Induced sputum in the diagnosis of childhood community-acquired pneumonia. Thorax 2009; 64:252.
  86. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
  87. Murray PR, Washington JA. Microscopic and baceriologic analysis of expectorated sputum. Mayo Clin Proc 1975; 50:339.
  88. Rein MF, Gwaltney JM Jr, O'Brien WM, et al. Accuracy of Gram's stain in identifying pneumococci in sputum. JAMA 1978; 239:2671.
  89. Subramony A, Zachariah P, Krones A, et al. Impact of Multiplex Polymerase Chain Reaction Testing for Respiratory Pathogens on Healthcare Resource Utilization for Pediatric Inpatients. J Pediatr 2016; 173:196.
  90. Cvitkovic Spik V, Beovic B, Pokorn M, et al. Improvement of pneumococcal pneumonia diagnostics by the use of rt-PCR on plasma and respiratory samples. Scand J Infect Dis 2013; 45:731.
  91. De Schutter I, Vergison A, Tuerlinckx D, et al. Pneumococcal aetiology and serotype distribution in paediatric community-acquired pneumonia. PLoS One 2014; 9:e89013.
  92. Selva L, Benmessaoud R, Lanaspa M, et al. Detection of Streptococcus pneumoniae and Haemophilus influenzae type B by real-time PCR from dried blood spot samples among children with pneumonia: a useful approach for developing countries. PLoS One 2013; 8:e76970.
  93. Esposito S, Zampiero A, Terranova L, et al. Pneumococcal bacterial load colonization as a marker of mixed infection in children with alveolar community-acquired pneumonia and respiratory syncytial virus or rhinovirus infection. Pediatr Infect Dis J 2013; 32:1199.
  94. Honda J, Yano T, Kusaba M, et al. Clinical use of capillary PCR to diagnose Mycoplasma pneumonia. J Clin Microbiol 2000; 38:1382.
  95. Skerrett SJ. Diagnostic testing for community-acquired pneumonia. Clin Chest Med 1999; 20:531.
  96. Vuori-Holopainen E, Salo E, Saxén H, et al. Etiological diagnosis of childhood pneumonia by use of transthoracic needle aspiration and modern microbiological methods. Clin Infect Dis 2002; 34:583.
  97. Kornecki A, Shemie SD. Open lung biopsy in children with respiratory failure. Crit Care Med 2001; 29:1247.
  98. Hayes-Jordan A, Benaim E, Richardson S, et al. Open lung biopsy in pediatric bone marrow transplant patients. J Pediatr Surg 2002; 37:446.
  99. De Schutter I, De Wachter E, Crokaert F, et al. Microbiology of bronchoalveolar lavage fluid in children with acute nonresponding or recurrent community-acquired pneumonia: identification of nontypeable Haemophilus influenzae as a major pathogen. Clin Infect Dis 2011; 52:1437.
  100. Loens K, Van Heirstraeten L, Malhotra-Kumar S, et al. Optimal sampling sites and methods for detection of pathogens possibly causing community-acquired lower respiratory tract infections. J Clin Microbiol 2009; 47:21.
  101. de Blic J, Midulla F, Barbato A, et al. Bronchoalveolar lavage in children. ERS Task Force on bronchoalveolar lavage in children. European Respiratory Society. Eur Respir J 2000; 15:217.
  102. Kirkpatrick MB, Bass JB Jr. Quantitative bacterial cultures of bronchoalveolar lavage fluids and protected brush catheter specimens from normal subjects. Am Rev Respir Dis 1989; 139:546.
  103. Naiditch JA, Barsness KA, Rothstein DH. The utility of surgical lung biopsy in immunocompromised children. J Pediatr 2013; 162:133.
  104. Crain EF, Bulas D, Bijur PE, Goldman HS. Is a chest radiograph necessary in the evaluation of every febrile infant less than 8 weeks of age? Pediatrics 1991; 88:821.
  105. Wingerter SL, Bachur RG, Monuteaux MC, Neuman MI. Application of the world health organization criteria to predict radiographic pneumonia in a US-based pediatric emergency department. Pediatr Infect Dis J 2012; 31:561.
  106. Mani CS, Murray DL. Acute pneumonia and its complications. In: Principles and Practice of Pediatric Infectious Diseases, 4th, Long SS, Pickering LK, Prober CG. (Eds), Elsevier Saunders, Edinburgh 2012. p.235.
  107. Gaston B. Pneumonia. Pediatr Rev 2002; 23:132.
  108. Clark CE, Coote JM, Silver DA, Halpin DM. Asthma after childhood pneumonia: six year follow up study. BMJ 2000; 320:1514.
  109. Chen KC, Su YT, Lin WL, et al. Clinical analysis of necrotizing pneumonia in children: three-year experience in a single medical center. Acta Paediatr Taiwan 2003; 44:343.
  110. Kerem E, Bar Ziv Y, Rudenski B, et al. Bacteremic necrotizing pneumococcal pneumonia in children. Am J Respir Crit Care Med 1994; 149:242.
  111. McCarthy VP, Patamasucon P, Gaines T, Lucas MA. Necrotizing pneumococcal pneumonia in childhood. Pediatr Pulmonol 1999; 28:217.
  112. Ramphul N, Eastham KM, Freeman R, et al. Cavitatory lung disease complicating empyema in children. Pediatr Pulmonol 2006; 41:750.
  113. Bender JM, Ampofo K, Korgenski K, et al. Pneumococcal necrotizing pneumonia in Utah: does serotype matter? Clin Infect Dis 2008; 46:1346.
  114. Sawicki GS, Lu FL, Valim C, et al. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. Eur Respir J 2008; 31:1285.
  115. Cengiz AB, Kanra G, Caĝlar M, et al. Fatal necrotizing pneumonia caused by group A streptococcus. J Paediatr Child Health 2004; 40:69.
  116. Wang RS, Wang SY, Hsieh KS, et al. Necrotizing pneumonitis caused by Mycoplasma pneumoniae in pediatric patients: report of five cases and review of literature. Pediatr Infect Dis J 2004; 23:564.
  117. Hodina M, Hanquinet S, Cotting J, et al. Imaging of cavitary necrosis in complicated childhood pneumonia. Eur Radiol 2002; 12:391.
  118. Schwartz KL, Nourse C. Panton-Valentine leukocidin-associated Staphylococcus aureus necrotizing pneumonia in infants: a report of four cases and review of the literature. Eur J Pediatr 2012; 171:711.
  119. Lemaître C, Angoulvant F, Gabor F, et al. Necrotizing pneumonia in children: report of 41 cases between 2006 and 2011 in a French tertiary care center. Pediatr Infect Dis J 2013; 32:1146.
  120. Groskin SA, Panicek DM, Ewing DK, et al. Bacterial lung abscess: a review of the radiographic and clinical features of 50 cases. J Thorac Imaging 1991; 6:62.
  121. Emanuel B, Shulman ST. Lung abscess in infants and children. Clin Pediatr (Phila) 1995; 34:2.
  122. Donnelly LF, Klosterman LA. The yield of CT of children who have complicated pneumonia and noncontributory chest radiography. AJR Am J Roentgenol 1998; 170:1627.
  123. Tan TQ, Seilheimer DK, Kaplan SL. Pediatric lung abscess: clinical management and outcome. Pediatr Infect Dis J 1995; 14:51.
  124. Lorber B. "Bad breath": presenting manifestation of anaerobic pulmonary infection. Am Rev Respir Dis 1975; 112:875.
  125. Brook I. Lung abscesses and pleural empyema in children. Adv Pediatr Infect Dis 1993; 8:159.
  126. Brook I, Finegold SM. Bacteriology and therapy of lung abscess in children. J Pediatr 1979; 94:10.
  127. Hacimustafaoglu M, Celebi S, Sarimehmet H, et al. Necrotizing pneumonia in children. Acta Paediatr 2004; 93:1172.
  128. Johnson JF, Shiels WE, White CB, Williams BD. Concealed pulmonary abscess: diagnosis by computed tomography. Pediatrics 1986; 78:283.
  129. Kunyoshi V, Cataneo DC, Cataneo AJ. Complicated pneumonias with empyema and/or pneumatocele in children. Pediatr Surg Int 2006; 22:186.
  130. Amitai I, Mogle P, Godfrey S, Aviad I. Pneumatocele in infants and children. Report of 12 cases. Clin Pediatr (Phila) 1983; 22:420.
  131. Ceruti E, Contreras J, Neira M. Staphylococcal pneumonia in childhood. Long-term follow-up including pulmonary function studies. Am J Dis Child 1971; 122:386.
  132. Soto M, Demis T, Landau LI. Pulmonary function following staphylococcal pneumonia in children. Aust Paediatr J 1983; 19:172.
  133. Singhi S, Dhawan A. Frequency and significance of electrolyte abnormalities in pneumonia. Indian Pediatr 1992; 29:735.
  134. Dhawan A, Narang A, Singhi S. Hyponatraemia and the inappropriate ADH syndrome in pneumonia. Ann Trop Paediatr 1992; 12:455.
  135. Don M, Valerio G, Korppi M, Canciani M. Hyponatremia in pediatric community-acquired pneumonia. Pediatr Nephrol 2008; 23:2247.