What are the appropriate admitting orders for a 2-year-old female patient, weighing 9.2kg, suspected of having pneumonia?

Admitting Orders for 2-Year-Old Female with Suspected Pneumonia (9.2kg)

This 2-year-old patient weighing 9.2kg requires hospital admission with continuous monitoring, oxygen therapy to maintain saturation >92%, IV fluids at 80% maintenance, and empiric antibiotic therapy with ampicillin/amoxicillin plus a macrolide. 1

Admission Status and Monitoring

• Admit to pediatric ward with continuous pulse oximetry monitoring 1
• Consider ICU or step-down unit if oxygen saturation ≤92% on FiO2 ≥0.50, signs of impending respiratory failure (grunting, severe retractions, altered mental status), or hemodynamic instability 1
• Infants under 6 months with suspected bacterial pneumonia warrant admission given increased morbidity risk; at 2 years, admission is appropriate for moderate-severe disease 1

Vital Signs and Clinical Assessment

• Continuous pulse oximetry monitoring - maintain SpO2 >92% 1
• Vital signs every 4 hours including respiratory rate, heart rate, temperature, blood pressure 1
• Assess for signs of severe respiratory distress: grunting (indicates impending respiratory failure), nasal flaring, retractions (suprasternal, subcostal, intercostal), use of accessory muscles 1
• Monitor for altered mental status, which may indicate hypoxemia or hypercarbia requiring ICU transfer 1

Oxygen Therapy

• Administer supplemental oxygen if SpO2 <92% on room air 1
• Delivery methods: nasal cannula (up to 2 L/min), face mask, or head box - all equally effective 1
• Titrate to maintain SpO2 >92% 1
• If requiring FiO2 ≥0.50 to maintain SpO2 >92%, transfer to ICU or unit with continuous cardiorespiratory monitoring 1
• Gentle nasal suctioning if secretions block nasal passages 1

Fluid Management

Calculate maintenance fluids:

• For 9.2kg child: 100 mL/kg/day for first 10kg = 920 mL/day (38 mL/hr)
• Administer IV fluids at 80% of maintenance = 736 mL/day (approximately 30 mL/hr) once any hypovolemia is corrected 1
• Use isotonic fluids (0.9% normal saline or lactated Ringer's) 1
• Monitor serum electrolytes daily - inappropriate ADH secretion is a recognized complication of pneumonia 1
• Avoid nasogastric tubes in severely ill children as they compromise breathing, especially in young children with small nasal passages 1
• NPO or clear liquids only if respiratory distress is severe; advance diet as tolerated 1

Antibiotic Therapy

For suspected bacterial community-acquired pneumonia:

• Ampicillin 200 mg/kg/day IV divided every 6 hours (for 9.2kg = 460 mg IV every 6 hours) OR Amoxicillin 90 mg/kg/day PO divided every 12 hours (for 9.2kg = 414 mg PO every 12 hours, approximately 8.3 mL of 250mg/5mL suspension) 1, 2, 3
• PLUS Azithromycin 10 mg/kg PO/IV on day 1, then 5 mg/kg daily for days 2-5 (for 9.2kg = 92 mg day 1, then 46 mg days 2-5) 1, 3
• Alternative: Ceftriaxone 50 mg/kg/day IV once daily (for 9.2kg = 460 mg IV daily) plus azithromycin 1, 3
• Minimum treatment duration: 3 days for hospitalized patients, continue until afebrile for 48-72 hours and clinically improved 1, 2

Diagnostic Studies

Initial laboratory work:

• Blood cultures x2 before antibiotics - obtain in all hospitalized children with moderate-severe pneumonia 1
• Complete blood count with differential 1
• Basic metabolic panel (monitor electrolytes given fluid restriction) 1
• Nasopharyngeal aspirate for viral testing (RSV, influenza, COVID-19, parainfluenza, adenovirus) - particularly important in children under 18 months 1, 3
• Save acute serum sample for convalescent titers if diagnosis unclear 1

Imaging:

• Chest radiograph (PA and lateral if possible) 1
• Repeat chest X-ray if not improving after 48 hours 1

Respiratory Support and Positioning

• Position patient in supported sitting position to help expand lungs and improve respiratory symptoms 1
• Do NOT perform chest physiotherapy - no benefit shown and may prolong fever 1
• No postural drainage, percussion, or deep breathing exercises 1

Fever and Pain Management

• Acetaminophen 15 mg/kg/dose PO/PR every 4-6 hours PRN fever >38.5°C or pain (for 9.2kg = 138 mg per dose) 1
• Ibuprofen 10 mg/kg/dose PO every 6-8 hours PRN fever or pain (for 9.2kg = 92 mg per dose) 1

Reassessment Criteria

• If no clinical improvement after 48 hours on antibiotics, reassess for:
  • Parapneumonic effusion/empyema (repeat chest X-ray) 1
  • Resistant organisms 1
  • Alternative diagnosis 1
  • Complications (sepsis, ARDS) 1

ICU Transfer Criteria

Transfer to ICU if any of the following develop:

• SpO2 ≤92% on FiO2 ≥0.50 1
• Impending respiratory failure (rising respiratory rate with exhaustion, rising PaCO2) 1
• Grunting, recurrent apnea, or slow irregular breathing 1
• Hemodynamic instability (sustained tachycardia, inadequate blood pressure, need for vasopressor support) 1
• Altered mental status from hypoxemia or hypercarbia 1
• Need for invasive or noninvasive positive pressure ventilation 1

Common Pitfalls to Avoid

• Do not under-restrict fluids - giving full maintenance increases risk of hyponatremia from SIADH 1
• Do not place nasogastric tubes in severely ill infants/young children - compromises breathing 1
• Do not delay antibiotics for culture results in moderate-severe pneumonia 1
• Do not rely solely on severity scores for ICU admission decisions - use clinical judgment 1
• Agitation may indicate hypoxia, not just anxiety - check oxygen saturation 1