Aspiration Pneumonia in Children

Aspiration pneumonia in children is lung inflammation or infection after inhalation of oropharyngeal secretions, gastric contents, feeds or foreign material, commonly affecting dependent lung segments.

• Aspiration pneumonitis is chemical injury from gastric acid and develops within hours. Aspiration pneumonia is bacterial infection from oral flora and develops over days.
• Risk factors include neurological impairment (cerebral palsy), swallowing disorders, gastro-oesophageal reflux, tracheo-oesophageal fistula, cleft palate, reduced consciousness, seizures, vomiting, nasogastric tube feeding, bottle feeding in a lying position and hydrocarbon ingestion.
• Foreign body aspiration is a distinct cause in toddlers.
• Recurrent aspiration leads to chronic lung damage and bronchiectasis.

Presentation depends on the material aspirated.

• Sudden choking, coughing or cyanosis during or after feeding or vomiting.
• Fast breathing, wheeze, crackles, fever and cough developing over hours to days.
• Signs most often in the right lower lobe or posterior upper lobe segments (supine) or in the right middle and lower lobes.
• Recurrent chest infections, chronic wet cough and poor weight gain in chronic aspiration.
• Hydrocarbon ingestion: cough, choking, tachypnoea and sometimes central nervous system depression.
• Differential diagnosis: bacterial or viral pneumonia, asthma, foreign body, tuberculosis, cystic fibrosis, bronchiectasis, heart failure and tracheo-oesophageal fistula.
• Complications: respiratory failure, acute respiratory distress syndrome, lung abscess, empyema, necrotising pneumonia, bronchiectasis, chronic lung disease and recurrent pneumonia.

Diagnosis is clinical with imaging and swallowing assessment.

• Chest X-ray: infiltrates in dependent segments, often right-sided; may show a foreign body or abscess.
• Full blood count, C-reactive protein and blood cultures if febrile and unwell.
• Oxygen saturation and blood gas.
• Swallowing assessment: clinical feeding assessment, videofluoroscopic swallow assessment and fibreoptic endoscopic evaluation.
• Reflux assessment (pH-impedance) and upper gastrointestinal contrast imaging for anatomical defects (fistula, vascular ring).
• Bronchoscopy when foreign body is suspected or in recurrent unexplained disease.

Treat the pneumonia and the cause.

• Supportive: nil by mouth if unsafe swallow, nasogastric or gastrostomy feeding, oxygen, positioning (head-up 30 degrees, side-lying), airway suction and chest physiotherapy.
• Pharmacological: pneumonitis alone does not need antibiotics. For aspiration pneumonia, give amoxicillin-clavulanate 25 to 30 mg/kg (amoxicillin component) every 8 hours (intravenous 30 mg/kg every 8 hours), or ampicillin 50 mg/kg every 6 hours with metronidazole 7.5 mg/kg every 8 hours, or clindamycin 10 mg/kg every 8 hours, for 5 to 10 days. Longer (2 to 4 weeks) for abscess or empyema.
• Corticosteroids are not used.
• Treat reflux where significant: omeprazole 1 mg/kg once daily and thickened feeds.
• Procedures: bronchoscopy to remove foreign body or suck out aspirated material. Chest drainage for empyema. Surgery for abscess or anatomical defect. Gastrostomy with or without fundoplication for chronic aspiration in neurologically impaired children.
• Special groups: neurologically impaired children need dietetic, speech and swallowing therapy input. Hydrocarbon ingestion needs observation for 6 hours.
• Red flags: respiratory failure, persistent fever after 72 hours, abscess or empyema, recurrent episodes, choking with feeds, and failure to thrive.
• Follow-up: review at 48 to 72 hours. Follow-up X-ray at 4 to 6 weeks. Refer for swallowing evaluation if recurrent.