Management of Pediatric Pneumonia
Severity Assessment and Hospitalization Criteria
Hospitalize infants with oxygen saturation <92%, respiratory rate >70 breaths/min, difficulty breathing, intermittent apnea, grunting, inability to feed, or if the family cannot provide adequate supervision. 1, 2, 3
For older children (>1 year), admission indicators include oxygen saturation <92%, respiratory rate >50 breaths/min, difficulty breathing, grunting, dehydration, or inadequate family supervision. 1, 3
Key pitfall: Elevated inflammatory markers (WBC 19, CRP 124) with normal oxygen saturation still warrant hospitalization if difficulty breathing is present, as this indicates severe bacterial infection requiring inpatient management. 2
Initial Diagnostic Workup
Mandatory Testing
- Blood cultures in all children with suspected bacterial pneumonia 1, 2
- Nasopharyngeal aspirate for viral antigen detection in all children <18 months 1, 2
- Pulse oximetry continuously or minimum every 4 hours 1, 2, 3
Chest Radiography
- Not routinely required for well-appearing outpatient children 3
- Obtain chest X-ray if hypoxemia present, significant respiratory distress, failed initial antibiotic therapy, or hospitalization required 1, 3
- Repeat imaging only if clinical deterioration or no improvement at 48-72 hours 1, 3
Antibiotic Management
Outpatient Treatment (Mild-Moderate Disease)
For children <5 years: Amoxicillin 90 mg/kg/day divided twice daily is first-line therapy. 1, 2, 3, 4
This provides optimal coverage for Streptococcus pneumoniae, the most common bacterial pathogen in this age group. 1, 3
For children ≥5 years: Consider macrolide antibiotics (azithromycin, clarithromycin) as first-line empirical treatment due to higher prevalence of Mycoplasma pneumoniae in school-aged children. 1, 3
- Azithromycin dosing: 10 mg/kg Day 1, then 5 mg/kg Days 2-5 5
- Alternative: 10 mg/kg once daily for 3 days 5
Important caveat: Young children with mild lower respiratory tract symptoms may not require antibiotics at all, as viral pathogens cause the majority of cases. 1, 3
Inpatient Treatment (Severe Disease)
Use intravenous antibiotics when the child cannot tolerate oral medications (vomiting) or presents with severe signs/symptoms. 1
First-line IV options:
- Ampicillin or penicillin G for suspected S. pneumoniae 1, 6
- Co-amoxiclav, cefuroxime, ceftriaxone, or cefotaxime for broader coverage 1, 6, 4
Add vancomycin or clindamycin if Staphylococcus aureus (including MRSA) is suspected. 6
Switch to oral therapy when clear clinical improvement is evident, typically after 48-72 hours. 1
Duration of Therapy
Treat for 5-7 days for uncomplicated bacterial pneumonia, or minimum 48-72 hours beyond symptom resolution. 2
Supportive Care
Oxygen Therapy
Initiate supplemental oxygen if saturation ≤92% using nasal cannulae, head box, or face mask to maintain saturation >92%. 1, 2, 6, 3
Monitor oxygen saturation at least every 4 hours in all patients receiving oxygen therapy. 1, 2
Hydration and Nutrition
- Administer IV fluids at 80% basal requirements if oral intake inadequate 1, 2
- Monitor serum electrolytes in severely ill children 1, 2, 6
- Avoid nasogastric tubes in severely ill infants with small nasal passages as they may compromise breathing 1
Fever and Comfort Management
- Use acetaminophen or ibuprofen for fever and discomfort 1, 2
- Minimize handling in severely ill children to reduce metabolic and oxygen requirements 1, 2
- Do NOT perform chest physiotherapy as it provides no benefit in pediatric pneumonia 1, 3
Monitoring and Follow-Up
Inpatient Monitoring
- Vital signs and oxygen saturation every 4 hours minimum 1, 2, 3
- Clinical reassessment at 48-72 hours to evaluate treatment response 2, 3
ICU Transfer Criteria
Escalate to ICU if:
- Oxygen saturation cannot be maintained >92% despite FiO2 >0.6 2
- Signs of shock or severe respiratory distress develop 2
- Apnea episodes occur 2
Outpatient Follow-Up
Review within 48 hours if deteriorating or not improving on treatment. 1, 2, 3
Provide families with education on managing fever, maintaining hydration, and recognizing signs of deterioration. 1, 2, 3
Discharge Criteria
Ensure 48-72 hours of clinical improvement before discharge, with stable vital signs and ability to maintain oral intake. 2
Special Considerations
Atypical Pathogens
Use macrolide antibiotics when Mycoplasma or Chlamydia pneumonia is suspected, particularly in school-aged children and adolescents. 1, 3
Recent evidence suggests macrolide-resistant M. pneumoniae is increasing, but most cases still respond clinically to macrolides, and severe cases may benefit from corticosteroids. 7
Penicillin-Resistant S. pneumoniae
High-dose amoxicillin (90 mg/kg/day) or extended-spectrum cephalosporins remain effective despite resistance patterns. 1, 4, 8
Vancomycin should be reserved for documented penicillin-resistant pneumococcal pneumonia unresponsive to standard therapy. 9