What are the classification and treatment options for pediatric pneumonia based on clinical severity?

Pediatric Pneumonia Classification and Treatment by Clinical Severity

Classification Framework

Pediatric community-acquired pneumonia (CAP) should be classified into three severity categories—mild, moderate, and severe—based on specific clinical criteria that guide site of care and treatment intensity. 1

Severity Criteria

Major Criteria (≥1 indicates severe disease):

• Invasive mechanical ventilation required 1
• Fluid-refractory shock 1
• Acute need for noninvasive positive pressure ventilation (NIPPV) 1
• Hypoxemia requiring FiO₂ greater than what is feasible in general care areas 1

Minor Criteria (≥2 indicates consideration for ICU/continuous monitoring):

• Respiratory rate exceeding WHO age-based thresholds 1
• Apnea episodes 1
• Increased work of breathing (retractions, dyspnea, nasal flaring, grunting) 1
• PaO₂/FiO₂ ratio <250 1
• Multilobar infiltrates on imaging 1
• Pediatric Early Warning Score (PEWS) >6 1
• Altered mental status 1
• Hypotension 1
• Presence of pleural effusion 1
• Comorbid conditions (sickle cell disease, immunosuppression, immunodeficiency) 1
• Unexplained metabolic acidosis 1

Practical Severity Definitions

Mild CAP:

• Discharge home or hospitalization <24 hours without oxygen or IV fluids 2, 3
• Absence of congestion/rhinorrhoea is actually a negative predictor (its presence suggests milder disease) 3

Moderate CAP:

• Hospitalization <24 hours requiring oxygen or IV fluids, OR hospitalization ≥24 hours without severe criteria 2, 3

Severe CAP:

• ICU stay >24 hours, septic shock, vasoactive agents, positive-pressure ventilation, chest drainage, ECMO, or death 2, 3

Diagnostic Approach by Severity

Outpatient (Mild) Cases

Pulse oximetry is mandatory for all children with suspected pneumonia to guide site-of-care decisions. 1

• Do NOT obtain routine chest radiographs in children well enough for outpatient treatment 1
• Do NOT obtain blood cultures in nontoxic, fully immunized children managed outpatient 1
• Do NOT routinely measure acute-phase reactants (CRP, ESR, procalcitonin) in fully immunized outpatient children 1

Obtain chest radiographs (PA and lateral) if: 1

• Suspected or documented hypoxemia present
• Significant respiratory distress evident
• Failed initial antibiotic therapy

Inpatient (Moderate to Severe) Cases

Obtain chest radiographs (PA and lateral) in ALL hospitalized patients to document infiltrates and identify complications requiring intervention beyond antibiotics 1

Obtain blood cultures in children requiring hospitalization for moderate to severe bacterial CAP, particularly with complications 1

Acute-phase reactants may be used in conjunction with clinical findings to assess response to therapy in hospitalized patients 1

Treatment Algorithm by Severity

Mild CAP (Outpatient Management)

Antimicrobial therapy is NOT routinely required for preschool-aged children (<5 years) with CAP, as viral pathogens cause most cases. 4

When bacterial pneumonia is suspected clinically: 5, 4

• First-line: Amoxicillin 90 mg/kg/day divided in 2 doses for 5 days 5
• Alternative (penicillin allergy): Azithromycin 10 mg/kg day 1, then 5 mg/kg days 2-5 6

For children ≥5 years, consider macrolides first-line due to higher prevalence of Mycoplasma pneumoniae 4

Supportive care: 5, 4

• Maintain adequate hydration with oral fluids
• Antipyretics (acetaminophen or ibuprofen) for fever control and comfort
• Adequate rest
• Do NOT use chest physiotherapy (not beneficial) 5, 4
• Do NOT use OTC cough/cold medications in children <4-5 years 5

Follow-up: 5, 4

• Re-evaluate if deteriorating or not improving after 48 hours
• Educate parents on fever management, hydration, and signs of deterioration

Moderate CAP (Hospitalization Required)

Hospitalization criteria: 1

• Hypoxemia (oxygen saturation ≤92%) 1
• Moderate to severe respiratory distress 1
• Suspected CA-MRSA infection 1
• Inability to maintain oral hydration 1
• Concerns about home observation or compliance 1

Treatment: 4

• IV antibiotics: Ampicillin, ceftriaxone, or cefotaxime
• Oxygen therapy to maintain saturation >92% 4
• IV fluids at 80% basal levels with electrolyte monitoring 4
• Consider atypical coverage (macrolides) for children 3-5 years with perihilar/bilateral infiltrates and wheezing 7

Monitoring: 1

• Reassess clinically within 48-72 hours
• Obtain repeat chest radiographs if no clinical improvement or clinical deterioration 1

Severe CAP (ICU Admission)

ICU admission criteria (any of the following): 1

• Requires invasive mechanical ventilation 1
• Acute need for NIPPV (CPAP or BiPAP) 1
• Impending respiratory failure 1
• Sustained tachycardia, inadequate blood pressure, or need for vasoactive support 1
• Oxygen saturation <92% on FiO₂ ≥0.50 1
• Altered mental status due to hypercarbia or hypoxemia 1

Treatment approach: 7

• Broad-spectrum IV antibiotics with consideration for resistant organisms
• Mechanical ventilation support as needed
• Obtain tracheal aspirates for Gram stain and culture in mechanically ventilated children 1
• Hemodynamic support with fluids and vasoactive agents as needed

For non-responders after 48-72 hours: 1

• Reassess severity and need for higher level of support
• Imaging to assess progression
• BAL specimen for mechanically ventilated children 1
• Consider percutaneous lung aspirate or open lung biopsy in persistently critically ill children without microbiologic diagnosis 1

Management of Complicated Pneumonia

Parapneumonic Effusion

Classification by size: 1

• Small: <10mm rim or <¼ thorax opacified
• Moderate: ≥¼ but <½ thorax opacified
• Large: ≥½ thorax opacified

Small effusions: 1

• Treat with antibiotics alone
• Do NOT obtain pleural fluid or attempt drainage
• Reassess effusion size; if enlarges, follow moderate/large effusion algorithm

Moderate effusions with low respiratory compromise: 1

• Treat with IV antibiotics alone
• Obtain chest ultrasound
• Obtain pleural fluid for culture by thoracentesis or chest tube

Large effusions or high respiratory compromise: 1

• Drainage options: Chest tube alone, chest tube with fibrinolytics, or VATS
• Preferred approach: Chest tube with fibrinolytics; if not responding (~15% of patients), proceed to VATS 1
• Antibiotic duration: 2-4 weeks depending on drainage adequacy and clinical response 1

Necrotizing Pneumonia/Abscess

Initial treatment with IV antibiotics for pulmonary abscess or necrotizing pneumonia 1

Well-defined peripheral abscesses without bronchial tree connection may be drained via imaging-guided aspiration or catheter placement, but most drain through bronchial tree and heal without surgical intervention 1

Follow-up and Discharge Criteria

Discharge eligibility: 1

• Documented overall clinical improvement
• Improved activity level and appetite
• Decreased fever for at least 12-24 hours

Follow-up imaging: 1

• Do NOT obtain routine follow-up chest radiographs in children recovering uneventfully 1
• Obtain follow-up radiographs at 4-6 weeks for recurrent pneumonia in same lobe or lobar collapse with suspicion of anatomic anomaly, mass, or foreign body 1

Critical Pitfalls to Avoid

• Do NOT reflexively prescribe antibiotics for preschool-aged children, as most cases are viral 5, 4
• Do NOT use severity scores as sole criteria for ICU admission; use in context of clinical, laboratory, and radiologic findings 1
• Do NOT perform routine daily chest radiography in stable children with parapneumonic effusion after chest tube or VATS 1
• Do NOT give honey to infants <12 months due to botulism risk 5
• Do NOT delay antiviral therapy (oseltamivir) when influenza is suspected in moderate-severe cases 7