In a hemodynamically stable 7-year-old boy with fever, cough, localized left lower lobe consolidation on chest radiograph, oxygen saturation 94% on room air, and ability to maintain oral hydration, what is the most appropriate next step in management?

Management of Community-Acquired Pneumonia in a 7-Year-Old

Discharge on oral amoxicillin with clear instructions is the most appropriate management for this hemodynamically stable 7-year-old with uncomplicated community-acquired pneumonia. 1

Why Admission is NOT Indicated

• Oxygen saturation of 94% exceeds the <92% threshold that mandates hospital admission according to the British Thoracic Society guidelines—this child does not meet admission criteria based on oxygenation. 2, 1

• The ability to maintain oral fluid intake ("can drink fluids") is a key criterion supporting safe outpatient management, indicating adequate hydration and absence of severe illness. 2, 1

• Age 7 years places this child well beyond the high-risk infant age group (<3-6 months) that would necessitate hospitalization. 1

• Absence of severe respiratory distress signs (no documented grunting, marked retractions, altered mental status, or inability to feed) further justifies outpatient care. 2, 1

• Admission for IV antibiotics would constitute overtreatment in a hemodynamically stable child without hypoxia or severe distress, according to British Thoracic Society recommendations. 1

Why Oral Amoxicillin is First-Line

• Oral amoxicillin is the definitive first-line treatment for community-acquired pneumonia in school-age children because Streptococcus pneumoniae remains the predominant bacterial pathogen across all pediatric age groups, and amoxicillin offers high efficacy, good tolerability, and low cost. 2, 1, 3

• The recommended dose is 45 mg/kg/day divided every 12 hours (or 40 mg/kg/day divided every 8 hours) for lower respiratory tract infections, with treatment duration of 5-7 days. 1, 3

• Macrolides should NOT be used as first-line therapy unless atypical organisms (Mycoplasma, Chlamydia) are specifically suspected—they are reserved for children ≥5 years with documented atypical pathogen infection or true penicillin allergy. 1

Critical Discharge Instructions (Safety-Netting)

Families must receive explicit instructions to return immediately for any of the following red flags: 1

• Increased work of breathing or respiratory distress

• Inability to maintain oral fluid intake

• Worsening fever despite 48 hours of antibiotics

• Lethargy, altered consciousness, or cyanosis

• Oxygen saturation dropping below 92% (if monitoring at home)

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

• Supportive care education should include: fever management with antipyretics (acetaminophen or ibuprofen), ensuring adequate hydration, and completing the full 5-7 day antibiotic course. 1

Common Pitfalls to Avoid

• Do not order routine chest radiography for follow-up unless there is lobar collapse, a "round pneumonia" appearance, or persistent symptoms beyond expected resolution. 2, 1

• Do not prescribe broad-spectrum antibiotics (co-amoxiclav, cephalosporins) as first-line agents in uncomplicated pediatric pneumonia—this promotes unnecessary antimicrobial resistance. 1

• Do not admit based solely on radiographic findings (such as consolidation) when clinical parameters are reassuring and the family can provide appropriate observation. 1

• IV antibiotics are indicated ONLY when: oral intake is unreliable (persistent vomiting), SpO₂ <92%, marked respiratory distress is present, or the child is unable to feed. 1