What is the likely diagnosis and appropriate management—including paracetamol dose, need for antibiotics, salbutamol syrup, and carbocisteine—for a 5‑year‑old girl weighing 27 kg with a 2‑day history of fever and a productive cough with green sputum?

Diagnosis and Management of a 5-Year-Old with Fever and Productive Cough

Most Likely Diagnosis

This clinical presentation—2 days of fever with productive greenish sputum in a 5-year-old—strongly suggests bacterial community-acquired pneumonia, most likely caused by Streptococcus pneumoniae. 1 The presence of purulent (greenish) sputum is particularly concerning in children and is not typical of viral infections or asthma. 2

---

Immediate Assessment: Does This Child Need Antibiotics?

Yes, antibiotics are indicated. The combination of fever plus productive cough with green phlegm in a preschool-aged child points toward bacterial rather than viral etiology. 1 However, you must first assess severity to determine whether outpatient oral therapy is safe or whether hospital admission is required.

Red Flags Requiring Immediate Hospital Admission 3, 1:

• Respiratory rate > 50 breaths/min
• Oxygen saturation ≤ 92% on room air
• Grunting, intercostal retractions, or cyanosis
• Inability to maintain oral intake or signs of dehydration
• Altered mental status or extreme lethargy
• Severe respiratory distress

If any of these are present, admit the child and start intravenous antibiotics immediately. 1 If none are present, outpatient oral antibiotic therapy is appropriate.

---

Antibiotic Selection and Dosing

First-Line: High-Dose Amoxicillin

Amoxicillin 80–100 mg/kg/day divided into three doses is the recommended first-line treatment. 3, 1

For this 27-kg child:

• Total daily dose: 2,160–2,700 mg/day
• Per-dose amount: 720–900 mg three times daily
• Duration: 10 days 1

Critical point: Amoxicillin must be given three times daily—twice-daily dosing fails to maintain adequate drug levels against S. pneumoniae. 1

When to Use Amoxicillin-Clavulanate Instead 1:

• Incomplete immunization against Haemophilus influenzae type b or Streptococcus pneumoniae
• Concurrent purulent acute otitis media
• Recent antibiotic use within the past 3 months
• No improvement after 48–72 hours of amoxicillin

If switching to co-amoxiclav: Use the same amoxicillin component dosing (80–100 mg/kg/day divided three times daily). 1

Consideration of Atypical Pathogens

At age 5 years, atypical organisms (Mycoplasma pneumoniae, Chlamydophila pneumoniae) become more common. 3, 4 However, the presence of purulent green sputum strongly favors typical bacterial pneumonia over atypical pathogens. 1, 2

If the child does not improve after 48–72 hours of amoxicillin, consider adding or switching to azithromycin (10 mg/kg on day 1, then 5 mg/kg daily on days 2–5) to cover atypical bacteria. 3, 1, 4

---

Paracetamol (Acetaminophen) Dosing

For fever control and comfort: 15 mg/kg per dose every 4–6 hours as needed. 1

For this 27-kg child:

• Per dose: 405 mg (round to 400 mg for practical dosing)
• Maximum daily dose: 75 mg/kg/day = approximately 2,000 mg/day 1
• Do not exceed 5 doses in 24 hours

Important: Aspirin should never be used in children under 16 years due to the risk of Reye syndrome. 3

---

Salbutamol Syrup: Is It Indicated?

No, salbutamol is not indicated for bacterial pneumonia. 1 Salbutamol is a bronchodilator used for asthma or bronchospasm. This child has a productive cough with purulent sputum, which is not characteristic of asthma. 2 Bacterial pneumonia does not cause bronchospasm requiring bronchodilator therapy.

Do not prescribe salbutamol unless there is a documented history of asthma or wheezing on examination. 1

---

Carbocisteine Suspension: Is It Indicated?

No, carbocisteine is not recommended for acute bacterial pneumonia in children. 1 While carbocisteine is a mucolytic agent that may reduce exacerbations in chronic obstructive pulmonary disease (COPD) in adults 5, there is no evidence supporting its use in acute pediatric pneumonia.

Chest physiotherapy and mucolytics provide no benefit in pediatric pneumonia and should be omitted. 1, 4

---

Clinical Monitoring and Reassessment

Expected Clinical Course 1:

• Fever should resolve within 24–48 hours of starting appropriate antibiotics
• Overall clinical improvement (reduced respiratory distress, better feeding) should be evident within 48–72 hours
• Cough may persist beyond fever resolution but should gradually diminish

Mandatory Reassessment at 48–72 Hours 3, 1:

Re-evaluate immediately if any of the following occur:

• Persistent or worsening fever beyond 48–72 hours
• Deterioration of respiratory symptoms
• Increased work of breathing or oxygen saturation ≤ 92%
• Inability to maintain oral intake or new signs of dehydration
• Altered mental status

If no improvement after 48–72 hours: Consider atypical pathogens, add azithromycin, and obtain chest radiography to rule out complications such as empyema. 3, 1

---

Common Pitfalls to Avoid

1. Do not use twice-daily amoxicillin dosing—three times daily is required for adequate coverage. 1
2. Do not prescribe antibiotics for mild cough without clear bacterial signs—most cases in young children are viral. 1
3. Do not use first-generation cephalosporins (e.g., cephalexin)—they have inadequate activity against respiratory pathogens. 1
4. Do not prescribe chest physiotherapy or mucolytics—they provide no benefit. 1, 4
5. Do not assume treatment failure too early—bacterial pneumonia typically improves within 48–72 hours, but atypical pneumonia may take longer. 4

---

Summary Treatment Plan for This 27-kg Child

Medication	Dose	Frequency	Duration	Indication
Amoxicillin	720–900 mg	Three times daily	10 days	First-line for bacterial pneumonia [1]
Paracetamol	400 mg	Every 4–6 hours as needed	Until fever resolves	Fever control [1]
Salbutamol	Not indicated	—	—	No bronchospasm present [1]
Carbocisteine	Not indicated	—	—	No benefit in acute pneumonia [1]

Reassess at 48–72 hours. If no improvement, consider adding azithromycin and obtain chest imaging. 3, 1