What is the treatment approach for pneumonia in children?

Treatment of Pneumonia in Children

Oral amoxicillin is the first-line antibiotic for children under 5 years with community-acquired pneumonia, while macrolide antibiotics (azithromycin, clarithromycin, or erythromycin) are first-line for children 5 years and older. 1

Age-Based Treatment Algorithm

Children Under 5 Years

• Amoxicillin is the first-choice antibiotic because it effectively targets the majority of pathogens causing pneumonia in this age group, is well-tolerated, and inexpensive 1
• Dosing: 90 mg/kg/day divided in 2 doses for outpatient management 2
• Standard treatment duration is 5 days for most cases 1

Children 5 Years and Older

• Macrolide antibiotics are first-line empirical treatment due to higher prevalence of Mycoplasma pneumoniae and Chlamydophila pneumoniae in this age group 1, 3
• Azithromycin is the preferred macrolide: 10 mg/kg on day 1, then 5 mg/kg/day once daily on days 2-5 3
• Alternative macrolides include clarithromycin (15 mg/kg/day divided in 2 doses) or erythromycin (40 mg/kg/day divided in 4 doses) 3
• For children over 7 years, doxycycline may be used at 2-4 mg/kg/day in 2 doses 3

Pathogen-Specific Modifications

• If Streptococcus pneumoniae is suspected at any age: Use amoxicillin regardless of age 1
• For suspected Mycoplasma or Chlamydia pneumonia: Use macrolide antibiotics with treatment duration of at least 14 days (longer than typical 5-day course) 1, 3
• If Staphylococcus aureus is likely: Use macrolide or combination of flucloxacillin with amoxicillin 1

Severity-Based Treatment Decisions

Mild Pneumonia (Outpatient Management)

• Young children with mild lower respiratory tract symptoms may not require antibiotics 1
• Oral antibiotics are appropriate when the child can absorb oral medications 1

Severe Pneumonia (Hospitalization Required)

Admit to hospital if any of the following are present 2:

• Oxygen saturation <92% or cyanosis
• Respiratory rate >50 breaths/min
• Difficulty breathing or grunting
• Signs of dehydration
• Family unable to provide appropriate observation

Intravenous antibiotics for severe pneumonia include 1, 2:

• Co-amoxiclav (ampicillin-clavulanate)
• Cefuroxime
• Cefotaxime or ceftriaxone
• Add vancomycin or clindamycin if MRSA is suspected 2

Key Severity Predictors

• Hypoxemia (oxygen saturation ≤92%) and chest indrawing/retractions are the strongest predictors of need for major medical interventions 4
• These findings have high specificity (94% or greater) but limited sensitivity (<40%) for ruling out severe disease 4
• Age, vital signs, chest indrawing, and radiologic infiltrate pattern are the strongest predictors of severity 5

Critical Clinical Pitfalls to Avoid

Reassessment Timing

• Re-evaluate at 48 hours if the child remains febrile or unwell after starting treatment 1, 2
• For atypical pathogens (mycoplasma), apyrexia may take 2-4 days, unlike pneumococcal pneumonia where fever resolves in <24 hours 3
• Do not assume treatment failure too early with mycoplasma pneumonia—allow 2-4 days for clinical improvement 3
• Persistent cough does not indicate treatment failure 3

Respiratory Rate Assessment

• Count respiratory rate for a full 60 seconds for accurate measurement 6
• Absence of tachypnea is the best individual finding for ruling out pneumonia 6

Supportive Care Measures

Oxygen Management

• Maintain oxygen saturation above 92% in children who are hypoxic 1, 3, 2
• Provide supplemental oxygen via nasal cannulae, head box, or face mask 2

Symptomatic Treatment

• Antipyretics and analgesics help keep the child comfortable and assist with coughing 1, 3
• Ensure adequate hydration and monitor serum electrolytes in severely ill children 2
• Avoid nasogastric tubes if possible 2

What NOT to Do

• Chest physiotherapy is not beneficial and should not be performed in children with pneumonia 1, 3

Special Populations

HIV-Endemic Areas

• For children in areas of high HIV prevalence or with suspected/diagnosed HIV infection presenting with non-severe pneumonia, amoxicillin is still recommended regardless of co-trimoxazole prophylaxis status 1
• If first-line therapy fails, refer to hospital for HIV testing and broad-spectrum parenteral antibiotics 1
• Children with rapid breathing should be assessed for severe anemia 1
• Any child with pneumonia and severe anemia requires hospital referral 1

Resource-Limited Settings

• In areas where referral is not possible, injectable antimicrobials such as ceftriaxone, penicillin/gentamicin, or chloramphenicol should be used 1