How should I assess and manage a child with suspected pneumonia, including criteria for outpatient versus inpatient care, antibiotic selection, supportive measures, and follow‑up?

Management of Pediatric Pneumonia

Assessment and Initial Evaluation

Pulse oximetry is mandatory in all children with suspected pneumonia and should guide all subsequent management decisions, including site of care and need for hospitalization. 1, 2

Key Clinical Indicators to Assess

• Respiratory rate: Tachypnea >70 breaths/min in infants is a critical indicator for hospitalization 3
• Work of breathing: Assess for retractions, dyspnea, nasal flaring, and grunting 1, 3
• Oxygen saturation: SpO2 <92% mandates hospital admission 1, 3
• Feeding difficulties and altered mental status: Both indicate severe disease requiring hospitalization 3
• Hemodynamic stability: Assess for sustained tachycardia, inadequate blood pressure, or need for pharmacologic support 1

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Criteria for Outpatient vs. Inpatient Care

Outpatient Management is Appropriate When:

• Child is well-appearing, fully immunized, and nontoxic 1
• SpO2 ≥92% on room air 1, 2
• No significant respiratory distress or increased work of breathing 1
• Able to tolerate oral intake and medications 1
• Reliable caregivers with ability to follow up 1

Hospitalization is Required When:

• SpO2 <92% on room air 1, 3
• Moderate to severe respiratory distress with increased work of breathing 1, 3
• Inability to tolerate oral intake or medications 1
• Suspected community-acquired MRSA 1
• Concerns about home observation or inability to follow up 1

ICU Admission Criteria:

Major criteria (any one requires ICU):

• Invasive mechanical ventilation needed 1
• Fluid-refractory shock 2
• Acute need for noninvasive positive pressure ventilation 1
• SpO2 <92% on FiO2 ≥0.50 1

Minor criteria (≥2 require ICU or continuous monitoring):

• PaO2/FiO2 ratio <250 2
• Multilobar infiltrates 2
• Altered mental status due to hypercarbia or hypoxemia 1
• Hypotension or need for vasopressor support 1
• Presence of pleural effusion 2

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Diagnostic Testing Strategy

Outpatient Setting:

• Pulse oximetry: Mandatory in all cases 1, 2
• Chest radiograph: NOT routinely necessary for well-appearing children 1, 4
• Complete blood count: NOT routinely necessary 1, 4
• Blood cultures: Should NOT be routinely performed in nontoxic, fully immunized children 1

Inpatient Setting:

• Chest radiograph (PA and lateral): Should be obtained in all hospitalized patients to document infiltrates and identify complications 1, 2
• Blood cultures: Should be obtained in moderate to severe cases, particularly with complicated pneumonia 1
• Complete blood count: Should be obtained for severe pneumonia 1, 2
• Acute-phase reactants (CRP, ESR, procalcitonin): Cannot distinguish viral from bacterial causes as sole determinant, but may help assess response to therapy in severe cases 1, 4

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Antibiotic Selection

Outpatient Management:

High-dose oral amoxicillin (90 mg/kg/day divided twice daily, maximum 4 g/day) is the first-line therapy for all fully immunized children with presumed bacterial pneumonia. 2, 3

• For fully immunized children: Amoxicillin 90 mg/kg/day in 2 divided doses provides adequate coverage against penicillin-resistant Streptococcus pneumoniae 3
• For incompletely immunized children: Consider amoxicillin-clavulanate or second/third-generation cephalosporins (cefpodoxime, cefuroxime, cefprozil) 3
• For children ≥5 years with suspected atypical pneumonia: Add azithromycin or consider macrolide monotherapy 3, 4
• Macrolides should NOT be used as monotherapy in children <5 years due to inadequate S. pneumoniae coverage 3

Inpatient Management:

For fully immunized children in areas with minimal penicillin resistance:

• Ampicillin 150-200 mg/kg/day IV every 6 hours OR 2, 3
• Penicillin G 200,000-250,000 U/kg/day IV every 4-6 hours 3

For incompletely immunized children or areas with high penicillin resistance:

• Ceftriaxone 50-100 mg/kg/day IV every 12-24 hours OR 3
• Cefotaxime 150 mg/kg/day IV every 8 hours 3

If community-acquired MRSA is suspected:

• Add vancomycin 40-60 mg/kg/day IV every 6-8 hours OR 3
• Add clindamycin 40 mg/kg/day IV every 6-8 hours 3

For suspected atypical pneumonia in hospitalized patients:

• Add azithromycin IV 10 mg/kg on days 1 and 2 to β-lactam therapy 3

Treatment Duration:

• Standard duration for uncomplicated pneumonia is 7 days 2, 3

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Supportive Care Measures

Oxygen Therapy:

• Provide supplemental oxygen to maintain SpO2 >92% at all times 2, 4
• Use nasal cannula, head box, or face mask as needed 2

Fluid Management:

• Administer IV fluids at 80% basal levels with monitoring of serum electrolytes 2, 4
• Ensure adequate hydration and monitor for dehydration 3

Symptomatic Management:

• Antipyretics and analgesics can be used for comfort 3, 4
• Chest physiotherapy is NOT beneficial and should NOT be performed 4

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Monitoring and Reassessment

Clinical Reassessment Timeline:

• Children should demonstrate clinical improvement within 48-72 hours of initiating therapy, including decreased fever, improved respiratory rate, and reduced work of breathing 2, 3
• If no improvement or deterioration occurs within 48-72 hours, further investigation is mandatory 3, 4

Switching from IV to Oral Therapy:

• Switch when child is afebrile for ≥24 hours, has improved respiratory rate and work of breathing, and is tolerating oral intake without vomiting 3

Follow-up Chest Radiographs:

• NOT routinely required in children recovering uneventfully 1, 2
• Should be obtained in children who fail to demonstrate clinical improvement or have progressive symptoms within 4-6 weeks 1, 2, 4
• Consider follow-up imaging for recurrent pneumonia in the same lobe or lobar collapse with suspicion of anatomic anomaly 4

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Discharge Criteria

Children can be discharged when ALL of the following are met: 2

• Afebrile for ≥24 hours 2
• SpO2 >92% on room air 2
• Normalized respiratory rate 2
• Improved work of breathing 2
• Tolerating oral intake 2

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Common Pitfalls and Caveats

• Do NOT obtain routine chest radiographs in well-appearing outpatients – this leads to overdiagnosis and unnecessary antibiotic use 1, 4
• Do NOT use macrolides as monotherapy in children <5 years – inadequate coverage of S. pneumoniae 3
• Do NOT rely on acute-phase reactants alone to distinguish viral from bacterial pneumonia 1, 4
• Blood cultures in outpatients are low-yield and should be reserved for treatment failures 1
• Ensure families understand warning signs for deterioration and when to return for reassessment 4
• Verify immunization status as this fundamentally changes antibiotic selection 3