What is the recommended assessment and management of pneumonia in children, including severity classification, antibiotic choice and dosing, and supportive care?

Management of Community-Acquired Pneumonia in Children

For children with community-acquired pneumonia, use high-dose oral amoxicillin 90 mg/kg/day divided twice daily for 7 days as first-line therapy, reserve chest radiographs for hospitalized patients or those with hypoxemia/respiratory distress, and admit any child with oxygen saturation <92% or significant respiratory distress. 1, 2

Initial Assessment and Severity Classification

Mandatory Clinical Measurements

• Perform pulse oximetry on every child with suspected pneumonia—oxygen saturation directly determines site of care and guides all subsequent management decisions. 1, 2

• Assess respiratory rate using WHO age-specific thresholds: >70 breaths/min in infants, >50 breaths/min in children 1-5 years, and >40 breaths/min in older children. 1, 2

• Evaluate work of breathing by documenting presence of retractions, nasal flaring, grunting, or dyspnea—these findings indicate moderate to severe disease. 1, 2

Criteria for Outpatient Management (All Must Be Present)

• Oxygen saturation ≥92% on room air 1, 2
• No significant respiratory distress or increased work of breathing 1, 2
• Able to tolerate oral fluids and medications 1, 2
• Reliable caregivers who can ensure follow-up within 48 hours 1, 2
• Fully immunized child with no toxic appearance 2

Criteria for Hospital Admission (Any One Present)

• Oxygen saturation <92% on room air 1, 2
• Moderate to severe respiratory distress with increased work of breathing 1, 2
• Inability to tolerate oral intake or medications 1, 2
• Age <3 months with fever and respiratory symptoms 1
• Suspected community-acquired MRSA infection 2
• Concerns about safe home observation or inability to secure follow-up 1, 2

ICU Admission Criteria

Transfer to intensive care if ≥1 major criterion OR ≥2 minor criteria are present: 1, 2

Major criteria:

• Need for invasive mechanical ventilation 1
• Fluid-refractory shock requiring vasopressors 1
• Acute need for non-invasive positive pressure ventilation 1
• Hypoxemia requiring FiO₂ >0.50 or flow not feasible on general ward 1

Minor criteria:

• Altered mental status from hypercarbia or hypoxemia 1
• Hypotension or requirement for vasopressor support 1
• Multilobar infiltrates on chest radiograph 1
• Presence of parapneumonic effusion 1
• PaO₂/FiO₂ ratio <250 1

Diagnostic Testing Strategy

Outpatient Setting

• Do NOT obtain routine chest radiographs in well-appearing children who can be managed as outpatients—this leads to overdiagnosis and unnecessary antibiotic use. 1, 2

• Do NOT obtain routine blood cultures in non-toxic, fully immunized children managed as outpatients—yield is extremely low. 1, 2

• Do NOT measure acute-phase reactants (CRP, ESR, procalcitonin) routinely in outpatients—they cannot distinguish viral from bacterial pneumonia and do not change management. 1, 2

• Obtain chest radiograph (PA and lateral) only if: 1, 2

  • Documented or suspected hypoxemia (oxygen saturation <92%)
  • Significant respiratory distress present
  • Failed initial antibiotic therapy after 48-72 hours
  • Suspicion of complications (effusion, pneumothorax, necrotizing pneumonia)

Inpatient Setting

• Obtain PA and lateral chest radiograph on all hospitalized children to document infiltrate characteristics and identify complications requiring intervention beyond antibiotics. 1, 2

• Obtain blood cultures in all children with moderate to severe pneumonia requiring hospitalization. 1, 2

• Consider complete blood count for severe pneumonia, though it does not reliably distinguish bacterial from viral etiology. 2

• Acute-phase reactants may be used in conjunction with clinical findings to monitor response to therapy in hospitalized patients with more serious disease. 1

Follow-Up Imaging

• Do NOT obtain routine follow-up chest radiographs in children who recover uneventfully—radiographic abnormalities lag behind clinical improvement. 1

• Obtain repeat chest radiograph if: 1

  • No clinical improvement or deterioration within 48-72 hours of antibiotic initiation
  • Persistent fever not responding to therapy over 48-72 hours
  • Worsening respiratory distress in complicated pneumonia

• Obtain follow-up chest radiograph 4-6 weeks after diagnosis if: 1

  • Recurrent pneumonia involving the same lobe
  • Lobar collapse at initial radiography with suspicion of anatomic anomaly, chest mass, or foreign body aspiration

Antibiotic Selection and Dosing

First-Line Outpatient Therapy

Prescribe high-dose oral amoxicillin 90 mg/kg/day divided into 2 doses (maximum 4 g/day) for 7 days as first-line therapy for all children >3 months with presumed bacterial community-acquired pneumonia. 1, 2, 3, 4

• This high-dose regimen achieves adequate drug levels against penicillin-resistant Streptococcus pneumoniae with MICs up to 2-4 mg/L. 2, 3

• S. pneumoniae remains the most common bacterial pathogen causing community-acquired pneumonia across all pediatric age groups. 2, 3

• Calculate total daily dose by multiplying weight (kg) × 90 mg/kg/day, then divide into two equal doses given every 12 hours. 2, 3

• Do NOT exceed 2 g per single dose or 4 g per day regardless of weight. 2

When to Add Macrolide Coverage

Add azithromycin to β-lactam therapy in the following situations: 2, 5, 3

• Children ≥5 years when clinical, laboratory, or radiographic findings cannot reliably differentiate typical from atypical pneumonia 2
• No clinical improvement within 48-72 hours of amoxicillin monotherapy 2, 3
• Mycoplasma pneumoniae or Chlamydia pneumoniae suspected based on epidemiology (school-age children, prolonged cough, lack of toxic appearance) 2, 5

Azithromycin dosing: 10 mg/kg (maximum 500 mg) on day 1, then 5 mg/kg (maximum 250 mg) once daily on days 2-5 for a total 5-day course. 2, 5

Critical caveat: Do NOT use macrolide monotherapy in children <5 years due to inadequate coverage of S. pneumoniae—always combine with β-lactam or use β-lactam alone. 2

Alternative Regimens for Specific Situations

For penicillin-allergic patients (non-anaphylactic reactions):

• Use second- or third-generation cephalosporin (cefdinir, cefuroxime, cefpodoxime) under medical supervision. 2

For penicillin-allergic patients with type I hypersensitivity (anaphylaxis):

• Use respiratory fluoroquinolone (levofloxacin for growth-mature adolescents) or linezolid. 2

For suspected β-lactamase-producing organisms (H. influenzae, M. catarrhalis) or incomplete immunization:

• Prescribe amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component (maximum 4 g/day) divided twice daily. 2, 3

Inpatient Parenteral Therapy

For fully immunized children in areas with minimal penicillin resistance:

• Ampicillin 150-200 mg/kg/day IV divided every 6 hours OR penicillin G 200,000-250,000 units/kg/day IV divided every 4-6 hours. 2

For incompletely immunized children or areas with high penicillin resistance:

• Ceftriaxone 50-100 mg/kg/day IV divided every 12-24 hours OR cefotaxime 150 mg/kg/day IV divided every 8 hours. 2

If community-acquired MRSA suspected (necrotizing pneumonia, empyema, severe sepsis):

• Add vancomycin 40-60 mg/kg/day IV divided every 6-8 hours OR clindamycin 40 mg/kg/day IV divided every 6-8 hours. 2

For suspected atypical pneumonia in hospitalized patients:

• Add azithromycin 10 mg/kg IV (maximum 500 mg) once daily on days 1-2, then transition to oral therapy. 2, 5

Transition to Oral Therapy

Switch from IV to oral antibiotics when: 2

• Child is afebrile for 24 hours
• Improved respiratory rate and work of breathing
• Tolerating oral intake without vomiting
• Typically occurs within 48-72 hours of admission

Complete a total antibiotic course of 7 days for uncomplicated community-acquired pneumonia—do not extend beyond 7 days if clinically resolved. 2, 4

Supportive Care Measures

Oxygen Therapy

• Administer supplemental oxygen via nasal cannula, head box, or face mask to maintain oxygen saturation >92% in all children with documented hypoxemia. 1, 2

• Monitor oxygen saturation at least every 4 hours in all patients receiving oxygen therapy. 1

Fluid Management

• Administer intravenous fluids at 80% of basal maintenance requirements if IV hydration is needed, and monitor serum electrolytes closely to avoid hyponatremia. 1

• Avoid nasogastric tubes in severely ill children, especially infants with small nasal passages, as they may compromise breathing—if necessary, use the smallest tube in the smallest nostril. 1

Symptomatic Management

• Use antipyretics (acetaminophen or ibuprofen) and analgesics to keep the child comfortable and help with coughing. 1

• Minimize handling in ill children to reduce metabolic and oxygen requirements. 1

• Do NOT perform chest physiotherapy—it provides no benefit and should not be used in children with pneumonia. 1

Expected Clinical Response and Re-evaluation

Timeline for Improvement

Children on appropriate antibiotic therapy should demonstrate clinical improvement within 48-72 hours, including: 2, 5, 3

• Decreased or resolved fever
• Improved respiratory rate
• Reduced work of breathing
• Better oral intake and activity level

Re-evaluation Protocol if No Improvement

If the child remains febrile or unwell 48-72 hours after starting therapy, reassess for: 2, 3

• Inadequate antibiotic dosing or inappropriate drug selection—verify correct weight-based calculation and consider resistance patterns 2

• Atypical pathogens requiring macrolide addition—particularly in school-age children with prolonged symptoms 2, 3

• Complications:

  • Parapneumonic effusion or empyema requiring drainage 1, 2
  • Necrotizing pneumonia 1, 2
  • Pneumothorax 1
  • Lung abscess 2

• Resistant organisms—consider MRSA, highly resistant S. pneumoniae, or β-lactamase-producing organisms 2

• Alternative diagnoses—foreign body aspiration, tuberculosis, fungal infection, malignancy, or non-infectious causes 2

Obtain repeat chest radiograph to evaluate for these complications if clinical deterioration or lack of improvement occurs. 1

Common Pitfalls to Avoid

• Do NOT underdose amoxicillin—the 90 mg/kg/day regimen (not 45 mg/kg/day) is required for adequate pneumococcal coverage in the era of resistant S. pneumoniae. 2, 3

• Do NOT obtain chest radiographs routinely in well-appearing outpatients—this leads to overdiagnosis, as 55-65% of children with clinical findings suggestive of pneumonia do not have radiographic infiltrates. 6

• Do NOT use macrolide monotherapy in children <5 years—inadequate S. pneumoniae coverage leads to treatment failure. 2

• Do NOT confuse azithromycin dosing with other macrolides—azithromycin is dosed once daily, whereas clarithromycin requires twice-daily dosing. 5

• Do NOT withhold antibiotics in young children with mild symptoms and wheeze—primary bacterial pneumonia is unlikely when wheeze is the predominant finding. 1

• Do NOT rely solely on acute-phase reactants to distinguish viral from bacterial pneumonia—they lack sufficient specificity and sensitivity for this purpose. 1, 2