What is the first line of treatment for a 13-month-old child with pneumonia?

First-Line Treatment for Pneumonia in a 13-Month-Old Child

Oral amoxicillin at 90 mg/kg/day divided into 2 doses is the first-line treatment for a 13-month-old child with community-acquired pneumonia. 1

Age-Specific Treatment Rationale

A 13-month-old child falls into the under-5-years age category where Streptococcus pneumoniae is the most prominent invasive bacterial pathogen causing pneumonia. 2, 1

• Amoxicillin provides optimal coverage for the typical bacterial pathogens in this age group, is well-tolerated, inexpensive, and has proven efficacy. 1
• Viral pathogens are responsible for the majority of clinical disease in preschool-aged children, but when bacterial pneumonia is suspected, amoxicillin remains the appropriate choice. 2

Specific Dosing Recommendations

For mild to moderate pneumonia:

• Amoxicillin 45 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours) 3
• High-dose amoxicillin (90 mg/kg/day) is preferable given pneumococcal resistance patterns 1

For severe pneumonia:

• Amoxicillin 45 mg/kg/day divided every 12 hours remains appropriate 3
• Treatment duration should be 5 days for most cases 1

Route of Administration

• Oral antibiotics are safe and effective for children presenting with mild to moderate pneumonia 1
• Intravenous antibiotics are indicated only when:
  • The child cannot absorb oral medications 2, 1
  • Severe signs/symptoms are present 1
  • Oxygen saturation is <92% on room air 1
  • The child has respiratory distress, is unable to tolerate oral intake, or shows signs of dehydration 1

Important Clinical Considerations

Reassessment timeline:

• Patients should be re-evaluated if they remain febrile or unwell 48-72 hours after starting treatment 1
• Treatment should continue for a minimum of 48-72 hours beyond when the patient becomes asymptomatic 3

Common pitfall to avoid:

• Do not empirically use macrolide antibiotics in this age group. 4 Macrolides are reserved for children aged 5 years and older where Mycoplasma pneumoniae becomes more prevalent. 1, 5
• Macrolides as monotherapy provide inadequate coverage for S. pneumoniae, the primary pathogen in toddlers. 4

Second-Line Treatment Options

If the child fails to improve on amoxicillin after 48-72 hours:

• High-dose amoxicillin-clavulanate (80-90 mg/kg daily of amoxicillin component) enhances activity against beta-lactamase-producing H. influenzae and resistant S. pneumoniae 2
• Consider broader-spectrum coverage with cefuroxime or ceftriaxone 1
• Evaluate for complications and consider hospitalization for intravenous therapy 4

Special Populations

HIV-endemic areas:

• Amoxicillin remains the recommended treatment for non-severe pneumonia regardless of co-trimoxazole prophylaxis status 2, 1
• If first-line therapy fails, refer to hospital for HIV testing and broad-spectrum parenteral antibiotics 2, 1

Severe anemia:

• Children presenting with rapid breathing should be assessed for severe anemia in malaria-endemic regions 2
• Any child with pneumonia and severe anemia requires hospital referral 2, 1

Supportive Care Measures

• Maintain oxygen saturation >92% with supplemental oxygen if needed 1
• Antipyretics and analgesics help keep the child comfortable and assist with coughing 1
• Ensure adequate hydration 4
• Do not perform chest physiotherapy - it is not beneficial in children with pneumonia 1, 4