Three year old(almost four) son has pnuemonia, wtf??
 

I'm a little upset with his doctor and maybe I shouldn't be. We had him in on Monday with a fever 103-104 and they said it was viral. At noon today he was above even that at 105+(I'm not sure of the accuracy) so we rushed him in. Low and behold he has a bad case of pneumonia and 2/3 of one lung is filled(which was characterized as "really bad"), other is clear. Doc gave him a antibiotic shot that she equated with a nuclear bomb that should produce very fast recovery. His oxygen level was at 93.

She says she missed it because she couldn't hear it in his lungs and even now she says she can't which is odd. I'm having my wife swing by another doc just to have them listen so I can see if his current doc is full of it.

Doc says he'll be just fine and not to worry but I'm still upset that it didn't get caught two days ago. This doc is highly regarded but.....

I know docs get tired of people bringing their kids in for every sniffle but we are not that way and I feel like she didn't take this seriously enough. Am I being to hard on the doc? FWIW I did not express any anger to the doc, I don't want her to associate my kids with a hassle if you get what I mean.

Hopefully all is OK wit the lil guy. The anti-biotics should help if it is bacterial but it could be viral to which the shot won't much but stave off other infections. I have had it at least 7 times in my life. The first and worst the docs didn't hear any rattle in my lungs either but 2 days later I was in the hospital with Plurasy and a severe case that kept me there for 8 days.

Keep in mind, kids are built to last (like Snap-On tools!) - they can really pull through so much more then us and come out of it unharmed.

I know how you feel though. Stay strong brotha. It'll be alright.

My son went through the same think Len - and I felt exactly the same - unfortunately you have to get agressive with some doctors these days...

Yea, he's a strong little guy and I "know" he'll be OK but when it comes to your kids it's hard to be objective. Part of me wants to give the doc a "would your kid have gotten an X-ray on Monday" talk and the rational part of me understands how these things go down.

yeah, I have been there with three kids. Sometimes you wonder, but then I remember that medicine sometimes is more art than engineering. You are his first defense. Keep up the good work.


BTW being protective about your children does not stop even when they move out. trust me.

Definitely let the doctor know how you feel... sometimes I think these doctors lose a little bit of reality as they themselves are being squeezed between seeing as many patients as they can in 10 minutes and getting paid for what they are worth. I would be pissed off if I were you.

Same deal with our 4 y/o doc missed it on the first 2 visits then picked it up on the 3rd.

It would be awesome if he didn't charge for 2 of the 3 visits.

Once on the right meds he recovered quickly.

Learn as much about his symptoms right now while he still has them. Once you get pnuemonia, you are inclined to get it again. If he gets the same symptoms - you know what to do.

My wife gets pnuemonia every 4-5 years like clockwork. As soon as she feels the familiar pain in her chest, it's time to go to the emergency room.

Does he have asthma?

No, no other heath issues. My two year old does have asthma though.

Just curious. My wife has asthma, and seems to be more susceptible to pneumonia after an attack. Well, best wishes to a speedy recovery for your son.

It's simple probability, really. Kid comes in with a cough and fever. 99% of the time it is viral. So, you treat it as viral. Once it declares itself as something more, then you move forward.

If you reversed the equation in order to treat every possible bacterial pneumonia then you would have everyone on antibiotics all the time.

By the way, just because he has infiltrates in his lung does not mean it isn't viral, viral pneumonitis can be pretty bad as well. I'm sure he is getting antibiotics but that is really to cover the increased possibility of bacterial infection now that you have a chest film with infiltrates on it.

It sounds like your doctor acted appropriately.

As said above, kids are super tough, like those super bounce balls. Your son will be fine!

My son had it right at his 4th birthday. He was fine, had a cough that lingered and lingered and was low on energy. I was surprised how well he handled it in terms of his disoposition and how well he continued to just be a happy little kid through it all!!

Cheers

Especially since they call it "practicing medicine."

"So if you're practicing, you don't charge for it, right?" :D

Thanks Rick, like I said it's hard to be objective when it comes to your own children.

From personal experience: I got double pnuemonia years ago and the only way they could actually confirm it was with an x-ray. Apparently listening doesn't always give a good indication. So don't be too mad at the doctor in this case. Oh and I went into the hospital for IV antibiotics and was back home in 2 days feeling great!

We had a nurse listen to him and she said she also could not hear anything, so I'm relieved that his doc is being straight up. I had no reason to doubt her other than the paranoia:)

Rick, he has had a chest X-raay and it's definitely filled with fluid. Are you saying that even then it's still likely viral? I really got the impression that she knew it was bacterial now. She did do a couple other tests (urine and something else) would those have told her? Thanks again.

Well first of all you would have to define what you mean by filled with fluid. If you mean fluid in the pleural space (outside the lung itself but inside the chest cavity) then that is called a pleural effusion and might have to be drained. The more likely thing is that the little guy has an infiltrate on his chest film which basically indicates inflammation of the lung tissue. It gets inflamed, the tissue swells (fills with fluid) and then it becomes more radio-opaque on chest film. So basically all an infiltrate tells you is that the lung tissue is inflamed. It does not tell you anything about what is doing the inflaming. It could be viral, could be bacterial...the only way to really tell for sure is to either culture a bacterium out of the sputum (lugie) or get a bacteria out of the blood. Then you could infer reasonably that the bacteria got into the blood via the lungs.

It is standard of care to start antibiotics on patients who meet clinical criteria for pneumonia, even though the problem COULD still be viral. The reasoning is that when you have an infection serious enough to produce an infiltrate on chest film (see above) the likelihood of a bacteria being the problem increases. Not only that, even if it isn't a bacteria in the first place, the inflamed lung doesn't fight off infection as well so getting a secondary bacterial infection is possible too. Plus, if you withhold antibiotics in a situation like that the patient could get much sicker if it is in fact bacterial and then you are up ***** creek, so to speak.

Make sense?

The urine test I would assume is a urinary strep antigen, streptococcus pneumonia (also called pneumococcus) is a common player in bacterial pneumonias. Whatever antibiotics your son is on would cover the common organisms including strep so it really is just trying to sort out what the source was.

Thanks Rick,

That does make sense. He is feeling much better already and his temp is normal. This is after the antibiotic shot, is this a sign that it was bacterial or is it too soon to tell. I get the idea that we may never know? FWIW, they also did a throat swab and I am told that was "normal" if that tells you anything. Regarding the fluid, the doc said he would eventually "bring it up through coughing" does that make sense?

Yeah, some of the "fluid" you see on chest film is basically phlegm, a combination of lung mucus (which is produced at an increased rate during infections), dead bacteria or viruses and dead white blood cells. This stuff tends to collect in the airways (think dead bodies piling up during the war) and eventually he will cough it out. Again, most of what you see on XRay is edema (swelling) of the tissues and inflammation.

The throat swab was probably a rapid strep test, looking for streptococcal infection in the throat.

As to whether the antibiotic is working or not, antibiotics really take 24-48 hours to start having a true effect on an infection so if his fever is already gone it shouldn't be the antibiotics, assuming he got the shot today.

What people (and LAWYERS) sometimes fail to realize is that Doctors are Human beings and are subject to incorrect decisions at one point or another. This may or may not be the case in your situation. Not far from now, I would venture to guess, you may never get a diagnosis for fear of it possible not being the absolutely correct one.

Yeah, thats REALLY going to help the situation, because after all, your a fellowship trained doctor too, right? After all, medicine is just like operating a microwave oven! The doctor obviously wasn't pushing the right buttons. You better 'get aggressive' with them, and tell them who's boss! Wave some American flags around while your at it! Kick Ass! Take names!

Sorry to hear about your experience. Rick has got it covered completely, leaving nothing for me to add. I was curious however, you say your son got a shot of antibiotics. Was that just an initial doses, followed by oral antibiotics ? In that case, what is the generic name of that oral antibiotic ?

In a previous thread we were discussing the alarming trend of resistance among common bacteria so I would be interested to know what kind your son got. As I said before, here in Sweden we still have a pretty native bacterial flora and common simple oral penicillin is usually the drug of choice for a community acquired pneumonia in children here in Sweden.

Hope your son gets well quickly. They usually do.

Yeah, one thing. The stethoscope is many time completely useless as a diagnostic tool with preschool children and airway symptoms. I would say that, perhaps paradoxically, the less you here with a child that has fever and rapid breathing - the more likely it is a bacterial pneumonia.

Sometimes it is helpful to have a CRP taken. A capillary blood test. Generally bacterial infections will provoce a higher value than viral infections.

No fevers last night or this morning:D

Thanks Livi, my wife is checking on the name of the antibiotic and he goes in today for another shot and he'll be getting a script.

Rick, thanks again! You did get me thinking about the antibiotic and I know the doc left me with the impression that this one was somehow different than most and we would see him "perk up"(her words) within a couple of hours. I specifically said "really, just a matter of a few hours" and she confirmed by telling me a story of how it relieved her own daughters ear infection within two-three. I told my wife to get a clarification this morning when he goes in as I have also always heard 24-48 hours which is why I pressed her on it. I'll let you know what she said.

Finally, all of you docs on here are amazing and I speak for all of us when I say thank you, deeply and sincerely. Being docs yourself you are void of the frustration and pain that ignorance in these matters causes and likely don't realize how valuable your gifts to us have been. If any of you ever need anything please ask (maybe some stainless tube for exhaust or something welded or fabbed, whatever...just ask.)

not a doctor here but have been through the same anguish a time or two (son is 3). there are two things i don't want my ped. doing every single time we visit: x-ray and antibiotics. in the long term odds are both will do him more harm than good.

if you can accept this premise then you learn to semi-trust the peds judgement. it's hard, but i think we all kinda learn to do it.

btw, when our son gets a fever he gets a FEVER! per ear thermometer (confirmed at docs) it is not uncommon for him to run 103. he has been to 105+ on several occasions.

No kids, but I know where I'm going when I get sick...PPOT :)! You guys are great, and I really mean that...

Well Harddrive - you took that wrong - What I meant by aggressive is to ask questions - determine what next steps are -

What I mean by aggressive - is be very participatory in the process. Ask why a medical direction and a next course of action.

SmileWavy

I agree, the comment by HardDrive is silly. You can't just go into the doctor and play stupid and not say anything. There has to be a relationship. If everyone keeps their mouth shut during a visit, you'll see health care costs go even higher because as soon as something goes worse, it turns into an ER visit.

I agree with being aggressive - assertive. During any consultation with a professional in any field, I ask lots of questions and take notes. I then do my own research and return with follow up questions and ideas. While these ideas are usually shot down, I have on occasion came up with an additional theory that is worthy of consideration.

This method works with lawyers, doctors, mechanics, contractors, etc.

jeremy has it right. participate and don't be afraid to ask questions. i'm sure todays docs suffer quite a bit at the hands of todays parents who read up online then try to self medicate their kids or tell the doc what is wrong and 'we just need a prescription'.

Livi,

Here are the antibiotics:

The shot was Rocephin and he is now on Omnicef.

Rick, the doc stands by her comment that Rocephin works within a few hours depending on the infection. She said with Strep it is usually 24 hours for results as an example. I'm not sure this makes sense to me, but that's what she said.

I'm sorry, I came on way to strong with my comments above. Not called for. You guys are correct. It is important to ask questions, and people should not feel afraid to ask questions. And doctors have a duty to explain whats going on.

But berettafan, you are on to something. I should explain the my wife is a pediatric anesthesiologist at a childrens hospital, but her specialty is pain management. The majority of familys are good natured folks, and they simply want their child to be better.

But sometimes....dear lord....she gets monsters. And the worst of these folks are people who have done their own 'research', and want my wife to write a prescription for some powerful drug. Because my wife is in pain managment, they are often asking for narcotics. Basically the parents have turned their kid into a little junkie, and they go beserk if you try and point this out to them. Even suggesting a family psych consult will cause a huge blowout.

Ya know what is WAY worse? Other doctors who have not had the guts to stand up to these familys, then try and foist their little junkies off on my wife! It happens at least a couple times a year. Some family practioner who has way over prescribed narcotics for way to long will try and make the problem go away by sending them to my wife, the 'expert'. She has had some very blunt conversations with docs at 2am after their patients parents have had my wife paged 15 TIMES looking for dope for their kid. Its ugly.

Sorry for the over reaction, but I have had my life disrupted by 'agressive' parents more than once.

Thanks!

As I suspected. They are both very broad spectrum antibiotics. Won´t miss a thing, as it were. No harm in that for your son. As far as the advertised few hours until noticeable effect, that is debatable. Yes, given intravenously the drug will reach the bugs very quickly and likely even been able to kill or arrest quite a few in a few hours. That does not automatically mean you look or feel any better.

Pretty much all the symptoms during an infectious desease is due to the bodies immune defense system. Fever, couphing, rash, vomiting, diareea, pain...you name it. It is all different defense mechanisms. Now even after the antibiotics have helped killing off most bacteria, it takes time for the immune response reaction to cool down - during which time the symptoms will prevail.

Some infections provoke a more 'hard headed' reaction with prolonged fever and other symptom even after adequate antibiotics has been give. An example of that is urinary infections. The opposite can often be said about a simple strep throat, where just a couple of penicillin doses will have almost back to normal.

So depends what you mean. Yes the killing of bacteria will start within a couple of hours, but feeling that effect will usually take a day or two.

HardDrive i figured it was a misinterpretation of 'aggressive'. Also, (and i've said this about Livi), please tell your wife that although i have never met her i appreciate her willingness to work with sick children and i firmly believe there is a special place in heaven for her and those that do such work. God bless your family.

I would agree with what Livi said. If you look at the pharmacokinetics of Rocephin, it takes 3 hours from time of injection to peak blood concentration. So if her statement is that Rocephin is active in the blood within 3 hours, then she is correct. Will the Rocephin be killing some of those bacteria during that time? Sure. The problem is that "illness" is not just bacteria being alive, it is the inflammatory response by the body, reactions to substances produced by the bacteria AND the fact that bacteria are alive.

I am talking about time to clinical improvement though, which has been well established as 24-48 hours after initial administration of antibiotics. I tried to find the original article I have at home in my files, but I couldn't get it on the internet. This link is to a .pdf file from The Chest Journal that looks at time to clinical improvement. Their average time was 3.5 days in patients with moderate to severe community acquired pneumonia.

http://www.chestjournal.org/cgi/reprint/124/5/1798.pdf

I guess the bottom line is the little guy is feeling better! :D

Thanks Rick, though I'm doubt the doc again. A lack of such a basic understanding of the science behind what she's doing is upsetting to be sure.

I'm not trying to bash your doc, len, I'm just saying that if your son felt 100% better within hours of the shot it probably wasn't the antibiotic that did it. More likely that the tylenol kicked in and broke the fever, etc. You probably have him on scheduled doses of tylenol and/or motrin to avoid fever, muscle pains, etc which is most likely why he feels better.

I wouldn't be too hard on your doc, most likely she knows the science behind the drug but just didn't take the time to explain it to you.