What is the recommended treatment for a child with pneumonia, considering age and severity of symptoms?

Treatment of Pneumonia in Children

Oral amoxicillin at 90 mg/kg/day divided into 2 doses is the first-line treatment for children under 5 years with community-acquired pneumonia, while macrolide antibiotics (azithromycin or clarithromycin) are recommended as first-line for children 5 years and older. 1, 2

Age-Based Treatment Algorithm

Children Under 5 Years (Preschool Age)

For outpatient management:

• Amoxicillin 90 mg/kg/day divided into 2 doses for 5 days is the definitive first-line choice 1, 2
• This provides optimal coverage against Streptococcus pneumoniae, the most common bacterial pathogen in this age group 1, 2
• Alternative agents if amoxicillin cannot be used: amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component in 2 doses) 1

For hospitalized children:

• Fully immunized with minimal local penicillin resistance: IV ampicillin or penicillin G 1
• Not fully immunized or significant local resistance: IV ceftriaxone or cefotaxime 1
• Add vancomycin or clindamycin if community-associated MRSA is suspected 1

Children 5 Years and Older

For outpatient management:

• Macrolide antibiotics are first-line: azithromycin 10 mg/kg on day 1, then 5 mg/kg daily on days 2-5 (maximum 500 mg day 1, then 250 mg days 2-5) 1, 2, 3
• Alternative macrolides: clarithromycin 15 mg/kg/day in 2 doses for 7-14 days, or erythromycin 1
• If bacterial pneumonia is strongly suspected (rather than atypical): amoxicillin 90 mg/kg/day in 2 doses (maximum 4 g/day) 1, 2
• When bacterial versus atypical pneumonia cannot be distinguished clinically, add a macrolide to amoxicillin for empiric coverage 1

For hospitalized children:

• Same IV beta-lactam approach as younger children (ampicillin/penicillin G or ceftriaxone/cefotaxime based on immunization status and local resistance) 1
• Add azithromycin if atypical pneumonia (Mycoplasma or Chlamydophila) cannot be excluded 1

Severity-Based Hospitalization Criteria

Hospitalize immediately if ANY of the following are present:

• Age less than 2 months (all pneumonia in this age group is severe by definition) 1, 4
• Oxygen saturation <92% on room air 1, 2, 5
• Moderate to severe respiratory distress (lower chest indrawing, grunting, nasal flaring) 1, 2, 5
• Inability to tolerate oral medications, persistent vomiting, or dehydration 1, 2
• Failure to respond to oral antibiotics within 48-72 hours 1, 2
• IMCI danger signs: inability to drink/breastfeed, convulsions, lethargy, or unconsciousness 1

Treatment Duration and Monitoring

Standard treatment course:

• 5 days for most cases of community-acquired pneumonia 2
• 3-day courses may be acceptable in areas with low HIV prevalence for non-severe pneumonia 1
• In high HIV prevalence areas, use 5-day courses regardless of co-trimoxazole prophylaxis status 1, 2

Reassessment timeline:

• All children must be re-evaluated at 48-72 hours if they remain febrile or show no clinical improvement 1, 2, 5
• Expect clinical improvement (decreased fever, improved respiratory rate, decreased work of breathing) within this timeframe 1, 5

Management of Treatment Failure

If no improvement at 48-72 hours, escalate as follows:

• Broaden antibiotic coverage to amoxicillin-clavulanate, ceftriaxone, or cefuroxime 2, 6
• Add macrolide coverage if not already included and atypical pathogens are suspected 2, 6
• Perform further investigation including chest radiography if not already done 1
• Consider complications: parapneumonic effusion, empyema, or necrotizing pneumonia 1, 5
• In high HIV prevalence areas, refer for HIV testing and broad-spectrum parenteral antibiotics 1, 2

Supportive Care Measures

Oxygen therapy:

• Maintain oxygen saturation >92% using nasal cannula, head box, or face mask 2, 5
• Monitor oxygen saturation at least every 4 hours in hospitalized children on oxygen 5

Hydration and comfort:

• Ensure adequate oral hydration in outpatients 5
• IV fluids at 80% of basal requirements if needed, with electrolyte monitoring 5, 6
• Antipyretics and analgesics to maintain comfort and help with coughing 2, 5

Critical Pitfalls to Avoid

Do NOT perform chest physiotherapy - it provides no benefit and should not be done in children with pneumonia 2, 5

Avoid nasogastric tubes in severely ill infants - they may compromise breathing, especially in young infants 5

Do not routinely obtain follow-up chest radiographs in children who are clinically improving 5

Do not use antibiotics routinely for presumed viral pneumonia in well-appearing preschool children with mild symptoms 5

Never rely on azithromycin alone to treat syphilis in adolescents with sexually transmitted infections - always perform serologic testing 3

Special Populations

Infants ≤8 weeks:

• All pneumonia in this age group requires hospitalization with parenteral antibiotics for at least 8 days 4
• Careful monitoring of body temperature and serum glucose is essential 4
• This age group has the highest mortality and requires most urgent attention 4

Children with HIV or high HIV prevalence areas:

• Amoxicillin remains first-line regardless of co-trimoxazole prophylaxis 1, 2
• Use 5-day treatment courses 1
• Lower threshold for hospitalization and broader-spectrum antibiotics if treatment fails 1, 2