History

• Common symptoms
  • Fever ^c1
  • Cough ^c2
  • Respiratory distress (eg, tachypnea, nasal flaring, grunting, retractions) ^c3c4c5
  • Poor feeding ^c6
  • Irritability ^c7
• Less common
  • Abdominal pain ^c8
  • Nausea or vomiting ^c9c10
  • Chest pain ^c11
• Receipt of conjugate pneumococcal vaccine decreases probability of bacterial pneumonia ^r3

Physical examination

• Tachypnea alone is a sensitive sign of pneumonia ^r4c12
  • Aged 2 to 12 months: more than 50 breaths per minute ^r1
  • Aged 1 to 5 years: more than 40 breaths per minute ^r1
  • Older than 5 years: more than 20 breaths per minute ^r1
  • Less sensitive in early illness (within first 3 days) ^r4
• Nasal flaring, retractions, and reduced oxygen saturation increase likelihood of pneumonia diagnosis ^c13c14c15
• Fever
• Abnormal lung examination
  • Localized rales on auscultation in younger children ^c16
  • Rales, bronchial breathing, and pleural rub on auscultation in older children ^{c17c18c19c20c21c22}
  • Wheezing more commonly associated with atypical or viral pneumonia ^c23
  • Absent breath sounds and dull percussion raise concern for an effusion ^r3c24c25

Causes

• Most common, by age group
  • Neonatal
    • Bacterial ^r5
      • Group B streptococci ^c26c27c28
      • Listeria monocytogenes
      • Gram-negative bacilli
      • Chlamydia trachomatis ^c29
  • Children older than 1 month
    • Viral (up to 70% of cases) ^r5
      • Human respiratory syncytial virus (more common among children younger than 5 years) ^r6c30c31
      • Parainfluenzavirus 1, 2, and 3 ^c32
      • Influenza A and B virus ^c33c34
      • Human adenovirus (more common among children younger than 5 years) ^r6c35c36
      • Human rhinovirus ^c37
      • Human herpesvirus 1 and 2 ^c38
      • Human metapneumovirus (more common among children younger than 5 years) ^r6c39c40
      • Human enterovirus ^c41
    • Bacterial ^r5
      • Streptococcus pneumoniae (routine childhood vaccination has led to reduced incidence) ^c42
      • Haemophilus influenzae type b (routine childhood vaccination has led to reduced incidence) ^c43
      • Moraxella catarrhalis^c44
      • Staphylococcus aureus^c45
      • Mycoplasma pneumoniae (more common among older children and adolescents) ^c46
      • Chlamydia pneumoniae (more common among older children and adolescents) ^c47

Risk factors and/or associations

Primary diagnostic tools

• History and physical examination are the primary diagnostic tools ^c72
  • WHO criteria for pneumonia require only the findings of cough and tachypnea on physical examination ^r9
    • WHO definition of tachypnea
      • Aged 2 to 12 months: more than 50 breaths per minute
      • Aged 1 to 5 years: more than 40 breaths per minute
  • Perform pulse oximetry in all children with suspected hypoxemia ^c73
• Additional testing for patients admitted to the hospital (those meeting requirements for moderate to severe pneumonia)
  • Chest radiograph ^c74
  • Blood and sputum cultures ^c75c76
  • Viral pathogen testing ^c77
  • Testing for Mycoplasma infection (if suspected) ^c78
  • CBC ^c79
  • Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein, serum procalcitonin concentration) may be helpful in some patients ^c80c81c82

Laboratory

• Blood cultures ^c83
  • Obtain if child has probable bacterial pneumonia that is moderate to severe, associated with complications, or requires admission ^r1
  • Not routinely needed in children with community-acquired pneumonia who have nontoxic appearance, are fully immunized, and are being treated in the outpatient setting ^r1
    • Obtain if child deteriorates or symptoms get worse after antibiotics are started ^r1
• Sputum culture ^c84
  • Obtain culture and Gram stain in children who are hospitalized and can produce sputum ^r1c85
• Tracheal aspirates ^r1
  • Obtain if child requires endotracheal intubation ^c86
    • Gram stain and culture
    • Viral pathogens, including influenza virus
• Viral pathogen testing ^c87
  • Obtain in hospitalized patients
  • Use sensitive and specific tests for the rapid diagnosis of influenza virus and other respiratory viruses
    • Positive influenza test result reduces additional diagnostic studies and antibiotic use, and guides use of antiviral agents ^r1
    • Initial negative results, especially from rapid antigen tests, do not exclude influenza ^r1
• Atypical bacterial testing
  • Polymerase chain reaction ^c88
    • If suspicion exists for Mycoplasma pneumoniae, a variety of diagnostic tests are available, but polymerase chain reaction is the most rapid and accurate method ^r1r10
    • Testing for Chlamydia pneumoniae is not recommended ^r1
• CBC ^c89
  • Obtain in hospitalized patients ^r1
• Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein concentration, serum procalcitonin concentration) ^c90c91c92
  • No need to measure routinely in fully immunized children with community-acquired pneumonia who will be treated as outpatients, but may be helpful to measure in children with more serious disease or complications ^r1
    • May help in monitoring response to therapy and course of disease
    • May help distinguish between bacterial and viral disease but should not be the sole criteria used ^r1
      • Elevated levels of procalcitonin are associated with greater likelihood of bacterial cause for pneumonia; however, predictive thresholds are not well established ^r11

Imaging

• Chest radiography ^c93
  • Not necessary for patients with suspected community-acquired pneumonia with mild symptoms who do not require admission ^r1r12
  • Use posteroanterior and lateral radiographic views for patients with hypoxemia, respiratory distress, or other indications for hospitalization and for patients who do not respond to initial outpatient antibiotic therapy ^r1r12
    • British Thoracic Society guidelines do not advocate for routine lateral films ^r3
  • Lobar consolidation is typically seen in pneumococcal pneumonia
  • Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing is seen in viral pneumonia
  • Repeat chest radiography in children who do not improve, have worsening of symptoms, or have clinical deterioration within 48 to 72 hours of starting antibiotic therapy
• Lung ultrasonography ^c94
  • Indicated as first line imaging in patients with complicated pneumonia ^r12r13
    • Valuable for diagnosis and assessment of pleural effusions
  • Evidence supports lung ultrasonography (which does not require radiation exposure) as an alternative to chest radiography for initial diagnosis of pneumonia in children ^r14r15r16
• Chest CT ^c95
  • Reserve chest CT for complicated pneumonia cases in which chest ultrasonography is technically limited or discrepant with the clinical findings ^r13
  • Indicated for investigation of suspected bronchopleural fistula, lung abscess, or recurrent pneumonia ^r12

Functional testing

• Pulse oximetry ^c96
  • Perform in all children with pneumonia and suspected hypoxemia
    • Hypoxemia guides admission and discharge decisions and need for further diagnostic evaluation ^r1

Most common

• Bronchitis ^c97d1
  • Occurs in older adolescents; acute bronchitis is not usually diagnosed in young children
  • Afebrile or low-grade fever (lower than 38 °C), malaise, chest pain, and protracted dry, hacking cough (which may be productive) lasting for 1 to 3 weeks
  • Chest radiographs are usually normal or may have increased bronchial markings
  • Absence of tachycardia, tachypnea, and high fever helps to differentiate from pneumonia
• Bronchiolitis ^c98d2
  • Acute infection of the lower respiratory tract resulting in small airway obstruction
  • Respiratory syncytial virus is the most common cause of bronchiolitis in children younger than 2 years and can be confirmed with rapid viral antigen or polymerase chain reaction, but the diagnosis is clinical
  • Commonly occurs in infants aged 1 to 3 months, with peak incidence during winter and early spring
  • Usually starts with sneezing and clear rhinorrhea; fine crackles or overt wheezes with prolongation of the expiratory phase of breathing can be heard on auscultation
  • Chest radiographs may show hyperinflated lungs with patchy atelectasis
• COVID-19 (coronavirus disease 2019) ^c99d3
  • Spectrum of illness ranging from fever, cough, and shortness of breath to mild upper respiratory tract symptoms, gastrointestinal symptoms, fatigue, or loss of appetite
    • Hospitalization for severe respiratory symptoms is rare in children
  • May have known exposure to confirmed case (typically within own household)
  • Diagnosed based on rapid polymerase chain reaction for SARS-CoV-2 (2019 novel coronavirus) on specimens from upper respiratory tract
  • Chest imaging may reveal bilateral pulmonary infiltrates
• Pertussis ^c100d4
  • Symptoms occur in 3 phases:
    • Catarrhal
      • Low-grade fever, upper respiratory tract infection symptoms, and cough
      • Apnea may occur
    • Paroxysmal
      • Coughing episodes; whoop occurs in older children
      • Vomiting
      • Infants typically do not produce a whoop but have paroxysmal cough and/or apnea with color change
    • Convalescent
      • Persistent cough
  • Differentiate by cough history and polymerase chain reaction
• Asthma ^c101d5
  • Symptoms include episodic dry cough, expiratory wheezing, chest tightness, feeling of discomfort in the chest, and shortness of breath in response to physical exertion or airway irritants
  • Severe exacerbations are associated with inspiratory and expiratory wheezing, retractions, nasal flaring, and use of accessory respiratory muscles
  • Dyspnea is present, but signs of infection are usually absent
  • Airway obstruction reversible with bronchodilators in the setting of a clear chest radiograph is diagnostic
• Tuberculosis ^c102d6
  • Suspect when child is from an endemic area or has had contact with persons who are at high risk of having the disease, including those who are urban homeless, are incarcerated, and have HIV infection
  • Presents subacutely with anorexia, weight loss, and night sweats
  • Differentiate based on history of either being from an endemic area or having exposure to high-risk individuals
• Acute respiratory distress syndrome ^c103d7
  • Mild respiratory distress with tachypnea, dyspnea, and increased oxygen requirement progresses rapidly to severe hypoxia accompanied by carbon dioxide retention and respiratory failure
  • Chest radiograph may reveal interstitial and alveolar pulmonary edema
  • Patients with a measured PaO₂ to percentage of the FiO₂ ratio of less than 200 are considered to have severe hypoxia and are classified as having acute respiratory distress syndrome

Admission criteria

Respiratory distress ^r1

• Tachypnea
  • Aged 0 to 2 months: more than 60 breaths per minute
  • Aged 2 to 12 months: more than 50 breaths per minute
  • Aged 1 to 5 years: more than 40 breaths per minute
  • Older than 5 years: more than 20 breaths per minute
• Retractions (ie, suprasternal, intercostals, subcostal)
• Grunting
• Nasal flaring
• Apnea
• Altered mental status

Hypoxemia (defined by pediatric pneumonia guidelines as sustained saturation less than 90% on room air) ^r1

Age younger than 3 to 6 months and suspected bacterial community-acquired pneumonia ^r1

Suspected or documented community-acquired pneumonia caused by a potentially virulent pathogen, such as community-associated MRSA ^r1

Concern about observation at home, inability to comply with therapy, or unavailability for follow-up ^r1

Recommendations for specialist referral

• Refer to pediatric infectious disease specialist for:
  • Age younger than 6 months
  • No improvement on antibiotics
  • Recurrent or complicated pneumonia
• Refer to pediatric surgeon for:
  • Pleural effusion

Drug therapy

• Penicillins ^c104
  • Amoxicillin ^c105
    • Amoxicillin Trihydrate Oral suspension; Infants and Children 4 months to 12 years: 90 mg/kg/day PO divided every 8 to 12 hours (Max: 4 g/day). May adjust dose to 45 to 100 mg/kg/day PO in divided doses based on identified pathogen.
    • Amoxicillin Trihydrate Oral capsule; Adolescents: 90 mg/kg/day PO divided every 8 to 12 hours (Max: 4 g/day) for 5 to 7 days. May adjust dose to 45 to 100 mg/kg/day PO in divided doses based on identified pathogen.
  • Ampicillin ^c106
    • Ampicillin Sodium Solution for injection; Infants 4 to 11 months, Children, and Adolescents: 150 to 400 mg/kg/day IV/IM in divided doses every 6 hours for 10 days.
    • Dosages of 300 to 400 mg/kg/day IV/IM in divided doses every 6 hours are used as an alternative to ceftriaxone for resistant strains of S. pneumoniae.
  • Penicillin G ^c107
    • Penicillin G Sodium Solution for injection; Infants 4 to 11 months, Children, and Adolescents: 100,000 to 250,000 units/kg/day IV/IM divided every 4 to 6 hours for 10 days.
• Macrolides ^c108
  • Azithromycin ^c109
    • Oral
      • Azithromycin Oral suspension; Infants 3 to 5 months†: 10 mg/kg/dose PO for 1 day, followed by 5 mg/kg/dose PO once daily for 4 days.
      • Azithromycin Oral suspension; Infants and Children 6 months to 12 years: 10 mg/kg/dose (Max: 500 mg/dose) PO for 1 day, followed by 5 mg/kg/dose (Max: 250 mg/dose) PO once daily for 4 days.
      • Azithromycin Oral suspension; Adolescents: 10 mg/kg/dose (Max: 500 mg/dose) PO for 1 day, followed by 5 mg/kg/dose (Max: 250 mg/dose) PO once daily for 4 days.
    • Intravenous
      • Azithromycin Solution for injection; Infants, Children, and Adolescents 3 months to 15 years†: 10 mg/kg/dose (Max: 500 mg/dose) IV once daily for 2 days, followed by oral therapy to complete a 5-day treatment course.
      • Azithromycin Solution for injection; Adolescents 16 to 17 years: 500 mg IV once daily for at least 2 days, followed by oral therapy to complete a 7- to 10-day treatment course
  • Clarithromycin ^c110
    • Clarithromycin Oral suspension; Infants 3 to 5 months†: 7.5 mg/kg/dose PO every 12 hours for 10 days.
    • Clarithromycin Oral suspension; Infants and Children 6 months to 12 years: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 10 days.
    • Clarithromycin Oral tablet; Adolescents: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 5 to 10 days.
  • Erythromycin ^c111
    • Oral
      • Erythromycin Ethylsuccinate Oral suspension; Infants 4 to 11 months, Children, and Adolescents: 40 mg/kg/day PO in 4 divided doses (Usual Max: 2 g/day) for 10 days.
    • Intravenous
      • Erythromycin Lactobionate Solution for injection; Infants 4 to 11 months, Children, and Adolescents: 20 mg/kg/day IV divided every 6 hours (Max: 4 g/day) for 10 days.
• Cephalosporins ^c112
  • Ceftriaxone ^c113
    • Ceftriaxone Sodium Solution for injection; Infants and Children: 50 to 100 mg/kg/day IV divided every 12 to 24 hours (Max: 4 g/day) for up to 10 days.
    • Ceftriaxone Sodium Solution for injection; Adolescents: 50 to 100 mg/kg/day IV divided every 12 to 24 hours (Max: 4 g/day) for 5 to 10 days.
  • Cefotaxime ^c114
    • Cefotaxime Sodium Solution for injection; Infants and Children: 150 mg/kg/day IV divided every 8 hours (Max: 6 g/day) for 10 days.
    • Cefotaxime Sodium Solution for injection; Adolescents: 150 mg/kg/day IV divided every 8 hours (Max: 6 g/day) for 5 to 10 days.
• Vancomycin ^c115c116
  • Vancomycin Hydrochloride Solution for injection; Infants and Children 3 months to 11 years: 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients. Treat for 7 to 21 days for MRSA pneumonia.
  • Vancomycin Hydrochloride Solution for injection; Obese Infants and Children 3 months to 11 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 80 mg/kg/day IV divided every 6 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 7 to 21 days for MRSA pneumonia.
  • Vancomycin Hydrochloride Solution for injection; Children and Adolescents 12 to 17 years: 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg (Max: 3,000 mg/dose) IV in critically ill patients. Treat for 7 to 21 days for MRSA pneumonia.
  • Vancomycin Hydrochloride Solution for injection; Obese Children and Adolescents 12 to 17 years: 20 mg/kg/dose (Max: 3,000 mg/dose) IV loading dose, followed by 60 to 70 mg/kg/day IV divided every 6 to 8 hours (Usual Max: 3,000 mg/day; may require up to 3,600 mg/day); adjust dose based on target PK/PD parameter. Treat for 7 to 21 days for MRSA pneumonia.
• Clindamycin ^c117c118
  • Clindamycin Solution for injection; Infants 4 to 11 months and Children: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for 10 days.
  • Clindamycin Solution for injection; Adolescents: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for 10 days.
• Antivirals ^c119
  • Oseltamivir ^c120
    • Oseltamivir Phosphate Oral suspension; Infants 1 to 8 months: 3 mg/kg/dose PO twice daily for 5 days.
    • Oseltamivir Phosphate Oral suspension; Infants 9 to 11 months: 3.5 mg/kg/dose PO twice daily for 5 days.
    • Oseltamivir Phosphate Oral suspension; Children weighing 15 kg or less: 30 mg PO twice daily for 5 days.
    • Oseltamivir Phosphate Oral suspension; Children weighing 16 to 23 kg: 45 mg PO twice daily for 5 days.
    • Oseltamivir Phosphate Oral suspension; Children weighing 24 to 40 kg: 60 mg PO twice daily for 5 days.
    • Oseltamivir Phosphate Oral suspension; Children and Adolescents weighing more than 40 kg: 75 mg PO twice daily for 5 days.
  • Zanamivir ^c121
    • Zanamivir Inhalation powder; Children and Adolescents 7 to 17 years: 10 mg by oral inhalation every 12 hours for 5 days.
    • Administer 2 doses on the first day provided there are at least 2 hours between doses
  • Peramivir ^c122
    • For the treatment of uncomplicated acute influenza (eg, influenza A virus infection or influenza B virus infection)
      • Peramivir Solution for injection; Infants and Children 6 months to 12 years: 12 mg/kg/dose (Max: 600 mg/dose) IV as a single dose.
      • Peramivir Solution for injection; Adolescents: 600 mg IV as a single dose.
    • For the treatment of novel influenza A viruses associated with severe human disease†, including avian influenza A virus infection†
      • Peramivir Solution for injection; Infants 91 to 180 days: 10 mg/kg/dose IV once daily for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
      • Peramivir Solution for injection; Infants older than 180 days and Children 1 to 5 years: 10 to 12 mg/kg/dose IV once daily for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
      • Peramivir Solution for injection; Children and Adolescents 6 to 17 years: 10 mg/kg/dose IV once daily (Max: 600 mg/dose) for 5 days as alternative in patients who are unable to tolerate or absorb oseltamivir. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
  • Baloxavir
    • Baloxavir Marboxil Oral tablet; Children and Adolescents 12 to 17 years weighing less than 80 kg: 40 mg PO as a single dose.
    • Baloxavir Marboxil Oral tablet; Children and Adolescents 12 to 17 years weighing 80 kg or more: 80 mg PO as a single dose.

Nondrug and supportive care

IV fluids ^c123

• Indicated for patients who are unable to tolerate oral fluids, have an oxygen requirement, or have moderate to severe disease

Supplemental oxygen ^c124

• Indicated for patients with pulse oximetry readings lower than 90% ^r1

Comorbidities

• Children with the following comorbidities require more careful evaluation for pneumonia (in addition to consultation with an appropriate subspecialist):
  • Congenital heart disease ^c126
  • Chronic lung disease of prematurity ^c127
  • Chronic respiratory conditions leading to infection, such as:
    • Cystic fibrosis ^c128
    • Bronchiectasis ^c129
  • Immune deficiency ^c130
• There is a lower threshold for admission of patients with these comorbidities, and they should be monitored for possible worsening of disease