Above, photo provided by Dr. Todd A. Florin. Right middle lobe pneumonia in an adolescent requiring hospitalization.
The question of disposition to home or hospital has been called the “most important management decision” in children with pneumonia in the British Thoracic Society pneumonia guidelines.1 For adults with pneumonia, rigorously derived severity scores assist with these decisions. The two most commonly used are the pneumonia severity index2 and the CURB-65 score.3 These scores, consisting of clinical findings and conventional laboratory tests, generally discriminate for mortality fairly well, though perform less well at predicting pneumonia complications.
For children, the evidence base for risk stratification is still in its infancy, particularly in high resource settings. In 2011, the Pediatric Infectious Diseases Society and Infectious Diseases Society of America published guidelines for the management of children with pneumonia.4 As no validated severity criteria existed for children, the guideline proposed a set of severity criteria for hospitalization adapted from the adult pneumonia guideline. When we examined how well these criteria performed in children, we found that more than half of those discharged safely from the ED met criteria for intensive care/continuous monitoring with only fair ability to predict the need for hospitalization, suggesting that more accurate pediatric risk stratification tools are needed.5
There are several exciting innovations on the horizon to overcome this gap – I’ll name a just a few. In 2016, Williams and colleagues published a prediction model for severe outcomes in hospitalized children with pneumonia, finding that age, vital signs, chest indrawing, and radiographic infiltrate pattern were the strongest predictors of severity.6 As this rule was developed in children who were already hospitalized and thus cannot be generalized to those evaluated in the clinic or ED, this score is currently being evaluated in the ED setting.
Our team has enrolled more than 1100 children with suspected pneumonia evaluated in the ED and are currently developing a pneumonia severity score for children intended for use in the ED, the site of most site-of-care decisions. An area of focus for our work is the role of biomarkers in improving risk stratification, where we have found that a vasodilatory peptide called proadrenomedullin appears to be a stronger predictor of disease severity than other conventional biomarkers such as white blood cell count or c-reactive protein. We hypothesize that a score that combines clinical factors with biomarkers will be most accurate at discriminating those children at highest risk of severe outcomes.
Finally, we are leading a global initiative to develop an ED-based risk stratification score in more than 100 EDs that are part of the Pediatric Emergency Research Networks (PERN), a consortium of the 6 major pediatric emergency medicine research networks in the developed world. We have just started enrollment for this study that will enroll 5000 children to develop a generalizable severity score for children evaluated in the ED with pneumonia.
With the results of these studies on the horizon, I expect that we will soon have evidence-based tools at our disposal to improve our ability to risk stratify children with pneumonia in high resource settings. These tools will allow for focused therapies, hospitalization and critical care to be used in children at risk for severe outcomes, while avoiding costly, unnecessary, and potentially harmful resource use in low risk children.
Bio: Todd A. Florin, MD, MSCE is Associate Professor of Pediatrics at Ann and Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine. He is the Director of Research and Head of the Grainger Initiative for Pediatric Emergency Medicine Research in the Division of Emergency Medicine at Lurie Children’s Hospital. His NIH-funded research program focuses on risk stratification, the use of biomarkers, and diagnostic and antimicrobial stewardship in the management of children with pneumonia.
- 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: ii1-23.
- Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336(4): 243-50.
- Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 2003; 58(5): 377-82.
- 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(7): e25-76.
- Florin TA, Brokamp C, Mantyla R, et al. Validation of the Pediatric Infectious Diseases Society-Infectious Diseases Society of America Severity Criteria in Children With Community-Acquired Pneumonia. Clin Infect Dis 2018; 67(1): 112-9.
- Williams DJ, Zhu Y, Grijalva CG, et al. Predicting Severe Pneumonia Outcomes in Children. Pediatrics 2016; 138(4).