A clinically stable 7‑year‑old boy with fever, cough, left lower‑lobe consolidation on chest radiograph, mild hypoxemia (SpO2 94% on room air) and able to maintain oral intake—what is the most appropriate next step?

Management of Community-Acquired Pneumonia in a 7-Year-Old with Mild Hypoxemia

Discharge the child on oral amoxicillin with clear instructions for home management and mandatory 48-hour follow-up (Option B).

Rationale for Outpatient Management

This child does not meet admission criteria. The British Thoracic Society specifies that oxygen saturation <92% is the threshold for hospital admission in older children; an SpO₂ of 94% therefore does not mandate admission 1, 2. The ability to drink fluids indicates adequate hydration and supports safe outpatient care 1, 2. At age 7 years, this child is well beyond the high-risk infant age group (<3–6 months) that necessitates hospitalization 2. The absence of severe respiratory distress signs—such as grunting, marked retractions, altered mental status, or inability to feed—further supports outpatient management 1, 2.

First-Line Antibiotic Selection

Oral amoxicillin is the definitive first-line treatment for community-acquired pneumonia in school-age children 1, 2. Streptococcus pneumoniae remains the predominant bacterial pathogen across all pediatric age groups, and amoxicillin offers high efficacy, good tolerability, and low cost 1, 2.

Dosing Recommendation

• Amoxicillin 45 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours) for 5–7 days 1, 3, 4
• The higher dose (45 mg/kg/day) is preferred for lower respiratory tract infections to ensure adequate coverage against S. pneumoniae 1, 3

Why Not Macrolides?

Macrolides should be reserved for children ≥5 years only when atypical organisms (Mycoplasma, Chlamydia) are specifically suspected; they are not first-line for typical lobar pneumonia 1, 2. In a 7-year-old with localized consolidation and fever, S. pneumoniae is the most likely pathogen, making amoxicillin the appropriate choice 1, 2.

Why Admission for IV Antibiotics Is Inappropriate

Intravenous antibiotics are indicated only when oral intake is unreliable (e.g., persistent vomiting) or when severe clinical features are present (SpO₂ <92%, marked respiratory distress, inability to feed) 1, 2. In a hemodynamically stable child without hypoxia or severe distress, admission for IV therapy constitutes overtreatment according to British Thoracic Society recommendations 1, 2. Oral antibiotics are safe and effective for children presenting with community-acquired pneumonia 1.

Discharge Instructions and Safety-Netting

Families must receive specific guidance on monitoring for deterioration 1, 2:

• Return immediately if:

  • Increased work of breathing or respiratory distress develops 1, 2
  • Inability to drink or maintain oral intake 1, 2
  • Worsening fever despite antibiotics 1, 2
  • Lethargy, altered consciousness, or cyanosis 1, 2

• Mandatory follow-up within 48 hours if clinical improvement is not evident after starting oral therapy 1, 2

• Education on supportive care:

  • Fever management with antipyretics (acetaminophen or ibuprofen) 1
  • Maintaining adequate hydration 1
  • Completing the full antibiotic course 1, 2

Common Pitfalls to Avoid

• Do not routinely obtain chest radiography for mild, uncomplicated cases when the clinical diagnosis is clear 1, 2
• Do not admit based solely on radiographic findings (e.g., consolidation) if clinical parameters are reassuring and the family can provide appropriate observation 2
• Do not prescribe broad-spectrum antibiotics such as co-amoxiclav or cephalosporins as first-line agents in uncomplicated pediatric pneumonia 1, 2
• Do not use macrolides as first-line therapy unless there is specific suspicion for atypical pathogens 1, 2