In a stable 7-year-old boy with community-acquired left lower-lobe pneumonia, oxygen saturation 94% on room air, and ability to maintain oral intake, what is the most appropriate next step in management?

Discharge on Oral Amoxicillin with Clear Instructions

This 7-year-old boy should be discharged home on oral amoxicillin with clear safety-netting instructions and mandatory 48-hour follow-up (Option B). His oxygen saturation of 94% exceeds the <92% threshold that mandates hospital admission, and his ability to maintain oral fluid intake confirms adequate hydration and supports safe outpatient management. 1, 2

Why Discharge is Appropriate

The British Thoracic Society establishes specific admission criteria for older children with pneumonia, and this patient meets none of them:

• Oxygen saturation 94% is above the <92% admission threshold – SpO₂ <92% is an absolute criterion for hospitalization in children >5 years; therefore 94% does not mandate admission 1, 2
• Ability to drink fluids indicates adequate hydration – this is explicitly documented and represents a key criterion supporting outpatient care 1, 2
• No severe respiratory distress signs are documented – the absence of grunting, respiratory rate >50/min, marked retractions, altered consciousness, or inability to feed all favor discharge 1, 2
• Age 7 years is not high-risk – infants <6 months require hospitalization for uncomplicated pneumonia, but school-age children do not 2

Why Amoxicillin is First-Line (Not Macrolides)

Oral amoxicillin is the definitive first-line agent for pediatric community-acquired pneumonia because Streptococcus pneumoniae remains the predominant bacterial pathogen across all pediatric age groups, and amoxicillin provides high efficacy, excellent tolerability, and low cost. 1, 2

Specific Dosing Recommendation

• Prescribe amoxicillin 45 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours) for 5–7 days 2
• The higher dose is preferred for lower respiratory tract infections to ensure adequate coverage of S. pneumoniae 3

Why NOT Macrolides

Macrolides should be reserved for children ≥5 years ONLY when atypical organisms (Mycoplasma or Chlamydia) are specifically suspected – they are not first-line for typical lobar pneumonia with consolidation. 1, 2 This patient has classic bacterial pneumonia with localized consolidation, making S. pneumoniae the most likely pathogen. 4, 5

Why NOT Admit for IV Antibiotics

Hospital admission for IV antibiotics is indicated only when:

• Oxygen saturation falls below 92% (this child's 94% does not meet this criterion) 1, 2
• Oral intake is unreliable (persistent vomiting) 1, 2
• Severe clinical features are present: marked respiratory distress, inability to feed, grunting, or altered mental status 1, 2

In a hemodynamically stable child without hypoxia or severe distress, admission for IV therapy constitutes overtreatment according to British Thoracic Society recommendations. 2

Critical Safety-Netting Instructions

Families must receive explicit guidance to return immediately for any of the following red flags:

• Increased work of breathing or respiratory distress 1, 2
• Inability to maintain oral intake (unable to drink) 1, 2
• Worsening fever despite 48 hours of antibiotics 1, 2
• Lethargy, altered consciousness, or cyanosis 1, 2

Mandatory Follow-Up

• A follow-up visit within 48 hours is required if clinical improvement is not evident after initiating oral therapy 1, 2
• Caregivers should receive education on fever management using antipyretics (acetaminophen or ibuprofen) and maintaining adequate hydration 1, 2

Common Pitfalls to Avoid

Do NOT Order Routine Chest X-Ray for Follow-Up

• Chest radiography should not be performed routinely in children with mild uncomplicated acute lower respiratory tract infection 1
• Follow-up imaging is only indicated for lobar collapse, "round pneumonia" appearance, or persistent symptoms beyond expected resolution 1, 2
• Hospital admission should not be based solely on radiographic findings (e.g., consolidation) if clinical parameters are reassuring 2

Do NOT Prescribe Broad-Spectrum Antibiotics

• Co-amoxiclav or cephalosporins should not be used as first-line agents in uncomplicated pediatric pneumonia 2
• Reserve these for treatment failures or specific risk factors for resistant organisms 4

Do NOT Underestimate the Importance of Clear Instructions

The British Thoracic Society emphasizes that families of children cared for at home need specific information on:

• Managing fever 1
• Preventing dehydration 1
• Identifying any deterioration – this is the most critical element to prevent delayed recognition of clinical worsening 1, 2