Pneumonia’s Ominous Rattle
I saw two cases of bacterial pneumonia this week and thought it would be worthwhile to share a story and follow up with information and advice. Last winter, my worst pneumonia case involved a school-aged girl whose mother is a very close friend of mine. First off, I would like to mention, she rarely calls me with medical questions; sometimes, I wish she would call me a little more often, especially that particular Sunday night.
She said her daughter had been sick for about 10 days, starting with a day or two of fever 100-101 and typical virus symptoms, cough and runny nose. She was better day 3 to 9 with slight cough still and then woke up Sunday morning (day 10) with decreased appetite (bad sign #1), fatigue (bad sign #2), and now had a fever of 104 (really bad sign.) She had pneumonia, I knew it right then and there on the phone. No exam, no labs, just the story. My heart sank. Hoping I was wrong, I told her to come in first thing.
Monday morning at 9am, she looks pale, has a deep cough, and crackles in her lung, also known as “rales” derived from the French word for ‘rattle.’ Rales sound just like crinkling cellophane wrap when a child takes a deep breath. I heard it, my ears know that ominous sound. A chest x-ray confirmed her diagnosis of a ‘consolidation’, which is a ball of pus in the lower lobe of her lung.
Understanding the difference between bronchitis and pneumonia is very important for parents. Bronchitis is that wet, juicy cough your kids get; it sounds impressive, yet there is no fever after day 1 or 2 and they are usually coughing while running outside and playing tag. It is most often caused by a virus. These kids are full of energy, hungry, talkative, and look like normal kids do.
Bacterial pneumonia is a deep, hacking, persistent cough; the child is pale, tired, and has a high fever, often 7-10 days in the illness timeline. The ball of pus is often located in a lower lobe of the left or right lung, just above the diaphragm, which is the muscle separating your chest from your belly. Children often vomit or refuse to eat because the diaphragm gets irritated by the pus ball which in turn causes stomach upset. Children sometimes need to be hospitalized.
Pneumonia can be debilitating once you are officially to the pus ball stage. My little girl needed heavy antibiotics, rest, and chest physical therapy with instructions to see her in the morning. I worried about her all night. She looked slightly better the following day, but still had a long recovery ahead. In total, she missed two weeks of school, could not participate in her normal physical activities for a month, and will always have a small scar in her lung from that dreadful infection.
To look at her today, you would never know she had pneumonia at all; however both her lungs and I will remember. They have repaired themselves to the best of their ability; however microscopic weakness remains in the lung tissue itself. She will be more prone to get another infection there in the future.
A younger girl presented with bacterial pneumonia this past week and I had this same discussion with yet another mother. I started thinking parents need to know when to wait and watch or bring your child to their healthcare provider. Children can decompensate so quickly. They look good, literally until the very moment they do not. So here are some guidelines.
Viral respiratory infections have associated fevers on Day 1 and 2 of symptoms, then their temperature normalizes. Symptoms peak around day 4-6 including runny nose, cough, fatigue, decreased appetite, and watery eyes, then settle down by day 7-10. If a child worsens after day 7, develops fever above 101 degrees, complains of pain when they take a deep breath, they need to be seen and evaluated. If they are short of breath, cannot stop coughing, look lethargic, or your “parent” warning bells are going off, they MUST be seen that night.
I try to teach my families the importance of listening to their own “gut instincts.” You know your child and when you sense something is wrong, trust that sixth sense. Do not ignore those feelings, your child’s health, now and in the future, depends up on it. I hope many of you find this helpful.