In a hemodynamically stable 7-year-old boy with fever, cough, oxygen saturation 94% on room air, able to tolerate oral fluids, and a localized left lower lobe consolidation consistent with bacterial pneumonia, what is the most appropriate next step in management?

Management of 7-Year-Old with Community-Acquired Pneumonia

Discharge this child on oral amoxicillin with clear instructions for follow-up (Option B).

Rationale for Outpatient Management

This 7-year-old does not meet criteria for hospital admission based on established guidelines:

• Oxygen saturation of 94% is above the <92% threshold that mandates hospitalization in older children 1, 2
• Ability to drink fluids indicates adequate hydration and oral tolerance, which supports safe outpatient care 2
• Absence of severe respiratory distress markers such as respiratory rate >50 breaths/min, grunting, signs of dehydration, or inability of family to provide supervision 1

The British Thoracic Society explicitly states that oxygen saturation <92% is an absolute admission criterion for older children, and this patient's SpO₂ of 94% does not warrant hospitalization on this basis alone 1, 2.

First-Line Antibiotic Selection

Oral amoxicillin is the definitive first-line treatment for community-acquired pneumonia in this age group:

• Amoxicillin remains the preferred choice because Streptococcus pneumoniae is the primary bacterial pathogen across all pediatric age groups, and amoxicillin is effective, well-tolerated, and cost-effective 1, 2
• Recommended dosing is 45 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours) for lower respiratory tract infections 1, 3, 4
• Treatment duration should be 5-7 days for uncomplicated bacterial pneumonia 2, 5

Why Not Macrolides?

• Macrolides are reserved for children ≥5 years when atypical organisms (Mycoplasma or Chlamydia) are specifically suspected 1
• In this case with lobar consolidation, typical bacterial pneumonia (S. pneumoniae) is most likely, making amoxicillin the appropriate choice 1, 2
• Option C (macrolide) would be incorrect as first-line therapy for this presentation 1

Critical Discharge Instructions

Families must receive specific guidance on monitoring for deterioration 2:

• Return immediately if: increased work of breathing, inability to drink, worsening fever, lethargy, cyanosis, or altered consciousness 2, 6
• Mandatory follow-up within 48 hours if not improving on treatment 1, 2, 6
• Education on fever management (antipyretics), maintaining hydration, and completing the full antibiotic course 1, 6

Why Not Admit for IV Antibiotics?

• IV antibiotics are indicated only when the child cannot absorb oral antibiotics due to vomiting or presents with severe signs such as SpO₂ <92%, respiratory distress, or inability to feed 1, 7
• This child tolerates oral fluids, making oral therapy both safe and appropriate 2, 4
• Admission (Option A) would represent overtreatment in a hemodynamically stable child without hypoxia or severe respiratory distress 1, 2

Common Pitfalls to Avoid

• Do not order routine chest X-ray for follow-up unless there is lobar collapse, round pneumonia appearance, or continuing symptoms beyond expected resolution 1
• Do not prescribe antibiotics reflexively without clinical suspicion of bacterial pneumonia, though this case with fever, cough, and lobar consolidation clearly warrants treatment 6
• Do not use chest physiotherapy, as it provides no benefit in pneumonia 1, 6