What is the treatment approach for pneumonia in children?

Treatment Approach for Pneumonia in Children

For children under 5 years, oral amoxicillin is the first-line treatment, while macrolide antibiotics should be used as first-line therapy for children aged 5 years and older due to the higher prevalence of atypical pathogens in this age group. 1

Age-Based Antibiotic Selection

Children Under 5 Years

• Amoxicillin is the preferred first-line agent because it effectively targets the majority of pathogens causing community-acquired pneumonia (CAP) in this age group, is well-tolerated, and cost-effective 2, 1
• Dosing for mild to moderate infections: 25 mg/kg/day divided every 12 hours or 20 mg/kg/day divided every 8 hours 3
• Dosing for severe infections: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours 3
• Alternative agents include co-amoxiclav, cefaclor, erythromycin, clarithromycin, and azithromycin 2

Children 5 Years and Older

• Macrolide antibiotics (erythromycin, clarithromycin, or azithromycin) are recommended as first-line empirical treatment because Mycoplasma pneumoniae and Chlamydophila pneumoniae predominate as causative pathogens in this age group 1, 4
• Azithromycin dosing: 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5 4
• Clarithromycin alternative: 15 mg/kg/day divided in 2 doses 4
• Erythromycin alternative: 40 mg/kg/day divided in 4 doses 4

Pathogen-Specific Modifications

• If Streptococcus pneumoniae is suspected, use amoxicillin as first-line treatment at any age 2, 1
• For suspected Mycoplasma or Chlamydia pneumonia, macrolide antibiotics should be used regardless of age 2, 1
• If Staphylococcus aureus is the likely pathogen, use a macrolide or combination of flucloxacillin with amoxicillin 2, 1

Treatment Duration

• Standard treatment course is 5 days for most cases of pediatric CAP 1
• Atypical pneumonia (mycoplasma) requires at least 14 days of macrolide therapy 4
• Continue treatment for a minimum of 48-72 hours beyond when the patient becomes asymptomatic 3
• For Streptococcus pyogenes infections, at least 10 days of treatment is required to prevent acute rheumatic fever 3

Severity Assessment and Admission Criteria

Infants Requiring Hospitalization

• Oxygen saturation <92% or cyanosis 2
• Respiratory rate >70 breaths/min 2
• Difficulty breathing, intermittent apnea, or grunting 2
• Not feeding 2
• Family unable to provide appropriate observation 2

Older Children Requiring Hospitalization

• Oxygen saturation <92% or cyanosis 2
• Respiratory rate >50 breaths/min 2
• Difficulty breathing or grunting 2
• Signs of dehydration 2
• Family unable to provide appropriate observation 2

Grunting respiration and cyanosis are independent predictors of hypoxemia and should prompt immediate oxygen therapy even without pulse oximetry confirmation 5

Route of Administration

• Oral antibiotics are safe and effective for children presenting with CAP and should be the preferred route 2
• Intravenous antibiotics are indicated when:
  • The child cannot absorb oral antibiotics (e.g., due to vomiting) 2, 1
  • The child presents with severe signs and symptoms 2, 1
• Appropriate IV antibiotics for severe pneumonia include co-amoxiclav, cefuroxime, and cefotaxime 2, 1

Supportive Care Management

Oxygen Therapy

• Maintain oxygen saturation above 92% using nasal cannulae, head box, or face mask 2, 1
• Patients on oxygen therapy require at least 4-hourly observations including oxygen saturation monitoring 2
• Agitation may indicate hypoxia 2

Fluid Management

• Intravenous fluids, if needed, should be given at 80% basal levels with serum electrolyte monitoring 2, 1
• Nasogastric tubes may compromise breathing and should be avoided in severely ill children, especially infants with small nasal passages 2

Additional Supportive Measures

• Chest physiotherapy is not beneficial and should not be performed 2, 1, 4
• Antipyretics and analgesics can be used to keep the child comfortable and help with coughing 2, 1, 4
• Minimal handling may reduce metabolic and oxygen requirements in ill children 2

Follow-Up and Reassessment

• Children managed at home should be reviewed if deteriorating or not improving after 48 hours on treatment 2, 1
• Patients remaining febrile or unwell 48 hours after starting treatment require re-evaluation with consideration of complications 6, 4
• For atypical pneumonia, fever may take 2-4 days to resolve, so do not assume treatment failure too early 4
• Persistent cough does not indicate treatment failure 4

Special Populations

Mild Symptoms

• Young children presenting with mild symptoms of lower respiratory tract infection may not require antibiotics 2, 1

HIV-Endemic Areas

• In areas with high HIV prevalence, amoxicillin is still recommended for non-severe pneumonia regardless of co-trimoxazole prophylaxis status 1
• If first-line therapy fails, refer to hospital for HIV testing and broad-spectrum parenteral antibiotics 1

Infants Under 3 Months

• Maximum recommended dose is 30 mg/kg/day divided every 12 hours due to incompletely developed renal function 3
• Treatment should continue for a minimum of 48-72 hours beyond symptom resolution 3

Common Pitfalls to Avoid

• Do not delay antibiotic therapy in children with clear clinical signs of bacterial pneumonia while awaiting diagnostic confirmation 2
• Do not assume hypothermia indicates improvement; it may signal worsening sepsis or metabolic decompensation 6
• Do not discontinue macrolide therapy prematurely in suspected atypical pneumonia; clinical improvement may take 2-4 days 4
• Do not use chest physiotherapy, as it provides no benefit 2, 1, 4