When should pediatric patients with pneumonia be admitted to the hospital?

When to Admit Pediatric Patients with Pneumonia

Children with community-acquired pneumonia should be admitted to the hospital if they have oxygen saturation ≤92% on room air, respiratory distress (including grunting, retractions, or tachypnea), inability to tolerate oral intake or medications, age less than 6 months with suspected bacterial pneumonia, or concern about home observation and follow-up compliance. 1

General Admission Criteria

Infants (Younger Children)

The following indicators warrant hospitalization in infants 1:

• Oxygen saturation <92% or presence of cyanosis 1
• Respiratory rate >70 breaths/min 1
• Difficulty breathing with significant work of breathing 1
• Intermittent apnea or grunting respirations 1
• Inability to feed or maintain hydration 1
• Family unable to provide appropriate observation or supervision 1

Older Children

Admission criteria for older children include 1:

• Oxygen saturation <92% or cyanosis 1
• Respiratory rate >50 breaths/min 1
• Difficulty breathing or significant respiratory distress 1
• Grunting respirations 1
• Signs of dehydration 1
• Family unable to provide appropriate observation or supervision 1

Age-Specific Considerations

Infants up to 6 months of age with suspected bacterial CAP should generally be admitted given the increased risk of morbidity in this age group, even though prospective data on specific age cutoffs are limited. 1 Very young infants up to 3 months are routinely hospitalized for initial management in the United States. 1

Younger age is an independent risk factor for severe pneumonia, with attack rates highest in infants under 12 months (35-40 per 1000) and decreasing with age. 1, 2, 3

High-Risk Conditions Requiring Admission

Children with the following conditions should be hospitalized 1:

• Underlying chronic medical conditions (reactive airway disease, genetic syndromes, neurocognitive disorders, immunologic disorders, cardiac conditions, chronic pulmonary disease) that would benefit from hospitalization 1
• Suspected or documented infection with high-virulence pathogens such as community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) 1
• Congenital heart disease, which is an independent risk factor for severe CAP and ICU admission 2, 3

ICU-Level Care Criteria

A child requires ICU admission or continuous cardiorespiratory monitoring if any of the following are present 1:

Respiratory Criteria

• Requires invasive mechanical ventilation via endotracheal tube (strong recommendation; high-quality evidence) 1
• Acutely requires noninvasive positive pressure ventilation (CPAP or BiPAP) 1
• Impending respiratory failure 1
• Pulse oximetry ≤92% on inspired oxygen ≥0.50 (FiO2 ≥50%) 1

Hemodynamic Criteria

• Sustained tachycardia 1
• Inadequate blood pressure 1
• Need for pharmacologic support of blood pressure or perfusion 1

Neurologic Criteria

• Altered mental status due to hypercarbia or hypoxemia from pneumonia 1

Clinical Predictors of Severity

Research has identified several independent risk factors for severe CAP requiring ICU admission 2, 3:

• Respiratory distress symptoms at admission (greatly increases risk with OR = 12.10) 3
• Abnormal white blood cell counts 2, 3
• Elevated C-reactive protein 2, 3
• Low albumin levels 2
• RSV infection in younger children (<1 year) 2

Important caveat: Wheezing in preschool children suggests viral etiology and makes primary bacterial pneumonia unlikely, which may influence admission decisions. 1 However, wheezing can still be associated with severe disease requiring hospitalization. 2

Outpatient Management Appropriateness

Children can be managed as outpatients if they meet ALL of the following 4:

• No respiratory distress
• Oxygen saturation >92% on room air 1
• Able to tolerate oral antibiotics and maintain hydration 4
• Reliable family able to provide appropriate observation 1
• Access to follow-up within 48-72 hours 1, 5

Children managed at home should be reviewed if deteriorating or not improving after 48 hours on treatment. 1

Common Pitfalls to Avoid

• Do not rely solely on severity of illness scores for admission decisions; use them in context with clinical, laboratory, and radiologic findings 1
• Do not discharge patients with positive blood cultures until organism identification and susceptibility are known, even if clinically improving 1
• Remember that absence of cough or fever does not rule out severe pneumonia; focus on respiratory distress signs 2
• Young age alone (particularly <6 months) should lower your threshold for admission even without other severe features 1