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peds.cap.v1

Pediatric community-acquired pneumonia (CAP)

pediatricsacutepediatricacuteinpatientoutpatient
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NEW pediatric dossier authored 2026-05-15 (shard-5-obped-id Phase C wave 12 NEW-dossier): peds.cap.v1 — pediatric CAP acute presentation. Manifest field intentionally blank per §5.5 pragmatic policy (prisma/seed/manifests/peds.cap.v1.{ts,atoms.ts} authoring deferred to future shard once seed manifest pipeline catches up). Phenotypes encoded via regimen-axis steps (outpatient_3mo_to_5yr_immunized, outpatient_5yr_and_above, inpatient_immunized_no_picu, inpatient_incomplete_immunization_or_severe, picu_severe_complicated, neonatal_under_28d_cap) + severity_triggers (10 total): viral / typical bacterial / atypical / neonatal × outpatient / inpatient / PICU × complicated vs uncomplicated. Three regimen axes: peds_cap_empiric_antibiotics (6 steps across setting × age × immunization × severity), peds_cap_oxygen_support (NC → HFNC → CPAP/BiPAP → mechanical ventilation per PARIS Franklin NEJM 2018 + PALICC-2), peds_cap_fluid_management (judicious bolus + isotonic maintenance + vasopressor escalation per SSC Pediatrics 2020 + FEAST 2011 PMID 21615299). RxCUIs reused from validated peds.brue.v1 + pulm.cap.peds.v1: amoxicillin 723, ampicillin 733, ceftriaxone 2193, azithromycin 18631, vancomycin 11124, clindamycin 2582, doxycycline 3640, oseltamivir 260101, gentamicin 1596450, acyclovir 281, norepinephrine 7531, epinephrine 3992, NS/LR crystalloid 9863. Sibling differentiation: pulm.cap.peds.v1 (pulmonology-domain sibling — same disease, different workspace entry-point), peds.bronchiolitis.v1 (<2 yr URI + supportive doctrine), peds.febrile-infant.core.v1 (<60 d sepsis pathway routes out). Bayesian linkage (pre-test bacterial CAP prior ~ 15-30% in febrile child with respiratory symptoms, age-banded; LRs: focal crackles LR+ ~ 5-7 (Wingerter 2012), age-band tachypnea LR+ ~ 3-4 (Shah JAMA 2017), SpO2 <92% LR+ ~ 3-5 for severe disease, CRP >40 LR+ ~ 2-3 bacterial, procalcitonin <0.25 LR− ~ 0.3 bacterial; T_treat ~ 30% post-test for empiric outpatient amoxicillin OR overt features; T_admit ~ 40% post-test for inpatient; T_picu ~ 70% post-test for septic shock / mechanical ventilation; conditional dependencies: CRP and procalcitonin not independent — use combined; CXR consolidation depends on disease duration > 24 h) documented in _research-bundles/peds.cap.v1.md. ROS/DDx LR seed data audited by npm run audit:ros-ddx-coverage (cross-cutting; not touched by this shard). Status: INTEGRATED — full regimen + workup + 12-phase flow + 3 setting playbooks + 10 severity triggers + 3 regimen axes + sibling differentiation + 10 PMIDs (above acute floor of 8) + evidence + terminology + tests. Phenotype matrix (age band × immunization × pathogen class × severity tier × complication state — 720-cell collapsed cross-product) encoded indirectly via regimen-axis steps + severity_triggers + setting_playbook logic. First-class TS field for phenotype matrix is schema-blocked. Cross-cutting registry not touched per task contract (DO NOT touch _registry.ts — main session batches). Alternate-index PMIDs requiring verification at next research:pubmed loop: 21880587 (Bradley IDSA/PIDS 2011 pediatric CAP), 34499792 (CAP-IT trial), 26019034 (Pereda lung US peds CAP meta-analysis).

Entry points (6)

  • symptom
    Fever + cough + age-band tachypnea in a child (PIDS/IDSA 2011 Bradley; WHO IMCI 2025)
    fever_cough_tachypnea_child
  • symptom
    Retractions / nasal flaring / grunting / accessory muscle use (WHO IMCI 2025; BTS 2024)
    increased_work_of_breathing_child
  • vital_abnormality
    SpO2 <92% in a child with respiratory illness (PIDS/IDSA 2011; BTS 2024)
    hypoxemia_child
  • imaging
    New infiltrate on CXR OR consolidation on lung ultrasound (PIDS/IDSA 2011; BTS 2024)
    new_infiltrate_or_consolidation_peds
  • symptom
    WHO IMCI severe: chest indrawing / cyanosis / inability to feed / AMS (WHO IMCI 2025)
    severe_pediatric_pneumonia_who
  • symptom
    Focal crackles / decreased breath sounds / bronchial breathing on auscultation (PIDS/IDSA 2011)
    focal_crackles_or_decreased_breath_sounds

Required inputs (26)

  • age_monthsrequired
    demographic • used at CONTEXT
    Age tier drives pathogen probability + antibiotic selection (<3 mo neonatal pathway; 3 mo to <5 yr S. pneumoniae predominant; ≥5 yr Mycoplasma rises) (PIDS/IDSA 2011)
  • weight_kgrequired
    demographic • used at TREATMENT
    All antibiotic + fluid dosing is weight-based (mg/kg/day; mL/kg) (PIDS/IDSA 2011)
  • temperaturerequired
    vital • used at CONTEXT
    Fever pattern + magnitude; <3 mo + fever ≥38°C → route to peds.febrile-infant.core.v1 (AAP 2021 Pantell)
  • rrrequired
    vital • used at CONTEXT
    Age-band tachypnea per WHO IMCI 2025: ≥60 (<2 mo), ≥50 (2-12 mo), ≥40 (1-5 yr), ≥30 (≥5 yr); LR+ ~3-4 for radiographic pneumonia (Shah JAMA 2017)
  • spo2required
    vital • used at CONTEXT
    SpO2 <92% → admission threshold per PIDS/IDSA 2011; LR+ ~3-5 for severe disease
  • hrrequired
    vital • used at CONTEXT
    Tachycardia + perfusion assessment for sepsis (SSC Pediatrics 2020)
  • work_of_breathingrequired
    symptom • used at CONTEXT
    Retractions / grunting / nasal flaring / head bobbing — severity (WHO IMCI 2025; BTS 2024)
  • feeding_statusrequired
    symptom • used at CONTEXT
    Inability to feed / drink in young child = WHO IMCI severe pneumonia
  • mental_status_childrequired
    symptom • used at RED_FLAGS
    Lethargy / irritability / AMS = severe disease marker (WHO IMCI 2025; SSC Pediatrics 2020)
  • focal_lung_findingsrequired
    symptom • used at INITIAL_WORKUP
    Focal crackles + bronchial breathing + decreased breath sounds — LR+ ~ 5-7 for radiographic pneumonia vs viral bronchiolitis (Wingerter 2012)
  • immunization_status_pedsrequired
    history • used at CONTEXT
    PCV13/PCV15/PCV20, Hib, influenza, COVID coverage drives pathogen risk + empiric choice (PIDS/IDSA 2011; ACIP 2025)
  • recent_antibiotics_or_hospitalization
    history • used at CONTEXT
    Resistant pathogen risk; HAP overlay if hospitalized in last 90 d (PIDS/IDSA 2011)
  • underlying_lung_disease
    history • used at CONTEXT
    CF / neuromuscular / BPD / asthma raise risk + change empiric coverage (PIDS/IDSA 2011)
  • sickle_cell_or_immunocompromise
    history • used at CONTEXT
    Sickle cell / HIV / transplant / malignancy / chronic steroid — broaden coverage + consider atypical pathogens (PIDS/IDSA 2011)
  • household_contact_tb_pertussis_covid
    history • used at CONTEXT
    TB / pertussis / COVID household contact alters differential + workup (WHO 2024 TB peds; Red Book 2021)
  • cbc_with_diff
    lab • used at INITIAL_WORKUP
    WBC + bandemia pattern — severity adjunct, not specific (PIDS/IDSA 2011)
  • crp
    lab • used at INITIAL_WORKUP
    CRP >40-100 mg/L + procalcitonin >0.5-1 ng/mL raises bacterial probability — LR+ ~2-3 for bacterial CAP (NICE 2019)
  • procalcitonin
    lab • used at INITIAL_WORKUP
    PCT <0.25 ng/mL → bacterial CAP unlikely (LR− ~0.3); selective use to shorten duration (NICE 2019; CAP-IT 2021)
  • blood_culture
    lab • used at INITIAL_WORKUP
    Required if hospitalized / severe / complicated CAP per PIDS/IDSA 2011; low yield ~ 1-7% in uncomplicated CAP (Myers 2013)
  • nasopharyngeal_viral_pcr
    lab • used at INITIAL_WORKUP
    RSV / influenza / SARS-CoV-2 / parainfluenza / adenovirus — viral predominance under 5 yr (PIDS/IDSA 2011)
  • mycoplasma_pcr_or_serology
    lab • used at BRANCHING_WORKUP
    Atypical screen ≥5 yr or extrapulmonary features (PIDS/IDSA 2011)
  • pleural_fluid_analysis
    lab • used at BRANCHING_WORKUP
    Moderate-large effusion → diagnostic + therapeutic drainage (PIDS/IDSA 2011; BTS 2024)
  • cxr_pa_lateral
    imaging • used at INITIAL_WORKUP
    Required for moderate-severe / hospitalized / complicated CAP; NOT routine for outpatient mild (PIDS/IDSA 2011; BTS 2024)
  • lung_ultrasound
    imaging • used at INITIAL_WORKUP
    Sensitive for consolidation + effusion; replaces or supplements CXR in many centers (BTS 2024; Pereda Pediatrics 2015)
  • chest_ct_complicated
    imaging • used at BRANCHING_WORKUP
    CT chest for non-resolving / complicated pneumonia (necrosis / abscess / fistula) (PIDS/IDSA 2011)
  • current_meds_and_allergiesrequired
    medication • used at CONTEXT
    β-lactam allergy severity drives macrolide vs alternative; baseline meds for interactions (PIDS/IDSA 2011)

12-phase flow (12)

  1. 1FRAME
    Confirm pediatric CAP scope (age 3 mo to 18 yr; community-onset within 48 h of presentation); exclude HAP / aspiration / foreign body / TB / bronchiolitis (PIDS/IDSA 2011 Bradley; WHO IMCI 2025)
    inputs: age_months
    advance: CAP framing confirmed; neonatal / bronchiolitis / aspiration / FB pathways excluded
  2. 2ENTRY
    Trigger captured: fever + age-band tachypnea OR hypoxemia OR new infiltrate OR severe respiratory distress (PIDS/IDSA 2011; WHO IMCI 2025)
    inputs: age_months, weight_kg
    advance: Entry trigger captured + initial vitals collected
  3. 3CONTEXT
    Vitals + WOB + feeding ability + AMS; age tier + weight; immunization status (PCV/Hib/flu/COVID); recent abx / hospitalization; chronic lung disease / sickle cell / immunocompromise; household TB / pertussis / COVID exposure; medications + allergies (PIDS/IDSA 2011; WHO IMCI 2025)
    inputs: temperature, rr, spo2, hr, work_of_breathing, feeding_status, immunization_status_peds, current_meds_and_allergies
    advance: Severity inputs + risk factors documented
  4. 4RED_FLAGS
    Septic shock / severe hypoxemia (SpO2 <90%) / AMS / apnea in infant / complicated pneumonia (large effusion / necrotizing / abscess) / inability to maintain airway → emergent escalation (PIDS/IDSA 2011; SSC Pediatrics 2020; WHO IMCI 2025)
    inputs: spo2, mental_status_child, work_of_breathing
    actions: protocol.septic_shock
    advance: Emergent escalation initiated OR red-flags excluded
  5. 5INITIAL_WORKUP
    Outpatient mild: clinical diagnosis, NO routine CXR / labs. Inpatient / severe: CXR PA + lateral (or lung ultrasound), CBC + CRP / procalcitonin, blood culture, nasopharyngeal viral PCR (RSV / influenza / SARS-CoV-2), BMP (hydration / SIADH), ABG if respiratory failure (PIDS/IDSA 2011; BTS 2024)
    inputs: focal_lung_findings, cxr_pa_lateral, cbc_with_diff, crp, blood_culture, nasopharyngeal_viral_pcr
    actions: panel.cbc, panel.renal, panel.inflammation, workup.pediatric_fever
    advance: Bedside diagnosis + targeted labs/imaging complete per severity tier
  6. 6BRANCHING_WORKUP
    Mycoplasma PCR/serology ≥5 yr or extrapulmonary; pleural fluid analysis if moderate-large effusion; chest CT if necrotizing / abscess / non-resolving; bronchoscopy if FB / non-resolving + immunocompromised; TB workup (IGRA + sputum AFB) if endemic / household / chronic cough / weight loss (PIDS/IDSA 2011; BTS 2024; WHO 2024 TB peds)
    inputs: mycoplasma_pcr_or_serology, pleural_fluid_analysis, chest_ct_complicated
    actions: workup.tb
    advance: Branch tests obtained when triggered
  7. 7DIFFERENTIAL
    Bacterial typical (S. pneumoniae > H. influenzae > GAS > S. aureus including MRSA) vs atypical (Mycoplasma ≥5 yr, Chlamydophila) vs viral (RSV / influenza / SARS-CoV-2 / parainfluenza / adenovirus / hMPV) vs aspiration vs TB vs FB vs bronchiolitis (<2 yr) vs asthma exacerbation with mucus plugging (PIDS/IDSA 2011)
    advance: Working pathogen category assigned + atypical / viral / typical bacterial probability noted
  8. 8RISK_STRATIFICATION
    Severity tier: outpatient mild (afebrile or low-grade, SpO2 ≥92%, tolerating PO, mild WOB, age >3 mo, immunized, no comorbidity) vs inpatient moderate (SpO2 <92%, dehydration, age <3-6 mo, moderate WOB, immunocompromise, comorbidity, failure of outpatient therapy) vs PICU (apnea, septic shock, mechanical ventilation, complicated pneumonia with respiratory compromise) — uses age-band RR + SpO2 + WOB + feeding + AMS rather than CURB-65 (not validated in peds) (PIDS/IDSA 2011; WHO IMCI 2025)
    inputs: rr, spo2, work_of_breathing, feeding_status, mental_status_child
    advance: Severity tier (outpatient / inpatient / PICU) assigned
  9. 9TREATMENT
    Outpatient: high-dose amoxicillin 90 mg/kg/d divided BID/TID × 5 d (CAP-IT validated short course); add macrolide if atypical suspected ≥5 yr. Inpatient immunized: ampicillin 200 mg/kg/d IV q6h; non-immunized or severe: ceftriaxone 50-100 mg/kg/d IV; add azithromycin if atypical; oseltamivir if influenza confirmed. PICU / complicated: high-dose ceftriaxone + vancomycin 60-80 mg/kg/d q6-8h (or clindamycin if low local resistance) for MRSA / necrotizing / empyema; pleural drainage / VATS / fibrinolysis for empyema; lung-protective ventilation if intubated; norepinephrine + epinephrine per SSC Pediatrics 2020 cold vs warm shock phenotype; isotonic crystalloid 10-20 mL/kg bolus then reassess (avoid over-resuscitation per FEAST 2011); judicious maintenance fluids to avoid SIADH (PIDS/IDSA 2011 Bradley; PIDS 2024 update; WHO IMCI 2025; SSC Pediatrics 2020; CAP-IT 2021)
    inputs: weight_kg, spo2
    advance: Empiric regimen + oxygen support + fluid plan + duration + complication plan documented
  10. 10DISPOSITION
    Outpatient if mild + tolerating PO + reliable caregiver + immunized + age >3 mo; ward if SpO2 <92% / dehydration / moderate-severe WOB / age <3-6 mo with significant illness / outpatient failure; PICU if shock / mechanical ventilation / complicated pneumonia with compromise / apnea (PIDS/IDSA 2011; WHO IMCI 2025)
    advance: Disposition documented per severity tier + caregiver context
  11. 11MONITORING
    Clinical response at 48-72 h (afebrile, improving WOB, weaning oxygen, tolerating PO); switch IV→PO when afebrile 24 h + tolerating PO; reassess for resistance / complication / alternate diagnosis if failure; vancomycin trough or AUC if used (PIDS/IDSA 2011; BTS 2024)
    advance: Improvement documented OR therapy escalation initiated
  12. 12FOLLOWUP
    PCP follow-up 1-2 wk; CXR at 4-6 wk for round / lobar / non-resolving pneumonia (BTS 2024); immunization catch-up (PCV / Hib / influenza / COVID) per ACIP 2025; smoke-exposure cessation; immunology workup if recurrent / non-resolving; pulmonology referral if structural concern (PIDS/IDSA 2011; AAP Bright Futures)
    advance: Follow-up scheduled + prevention plan + immunization catch-up documented