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: greater than 50 breaths per minute ^r1
  • Aged 1 to 5 years: greater than 40 breaths per minute ^r1
  • Older than 5 years: greater 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 ^c23c24c25
  • Absent breath sounds and dull percussion raise concern for an effusion ^r3c26c27

Causes

• Most common, by age group
  • Neonatal
    • Bacterial
      • Group B streptococci, gram-negative bacilli, and Listeria monocytogenes^c28c29c30
  • Children older than 1 month
    • Viral (up to 90% of cases)
      • Human respiratory syncytial virus (more common among children younger than 5 years) ^r5c31c32
      • Parainfluenzavirus 1, 2, and 3^c33
      • Influenza A and B virus^c34c35
      • Human adenovirus (more common among children younger than 5 years) ^r5c36c37
      • Human rhinovirus^c38
      • Human herpesvirus 1 and 2^c39
      • Human metapneumovirus (more common among children younger than 5 years) ^r5c40c41
      • Human enterovirus^c42
    • Bacterial
      • Streptococcus pneumoniae^c43
      • Haemophilus influenzae type b ^c44
      • Moraxella catarrhalis^c45
      • Staphylococcus aureus^c46
  • Older children and adolescents
    • Bacterial
      • Mycoplasma pneumoniae ^c47
      • Chlamydophila pneumoniae^c48

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 ^r8
    • 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
  • Pulse oximetry should be performed in all children with suspected hypoxemia
• Additional testing for patients admitted to the hospital (those meeting requirements for moderate to severe pneumonia)
  • Chest radiograph
  • Blood and sputum cultures
  • Viral pathogen testing
  • Testing for Mycoplasma infection (if suspected)
  • CBC
  • Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein, serum procalcitonin concentration) may be helpful in some patients

Laboratory

• Blood cultures ^c73c74
  • 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 ^c75
  • Obtain culture and Gram stain in children who are hospitalized and can produce sputum ^r1c76
• Tracheal aspirates ^r1
  • Obtain if child requires endotracheal intubation ^c77
    • Gram stain and culture
    • Viral pathogens, including influenza virus
• Viral pathogen testing ^c78
  • 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 ^c79
    • If suspicion exists for Mycoplasma pneumoniae, a variety of diagnostic tests are available, but polymerase chain reaction is the most rapid and accurate method ^r1r9
    • Testing for Chlamydophila pneumoniae is not recommended ^r1
• CBC ^c80
  • Obtain in hospitalized patients ^r1
• Acute phase reactants (eg, erythrocyte sedimentation rate, C-reactive protein concentration, serum procalcitonin concentration) ^c81c82c83
  • Cannot be used to distinguish between bacterial and viral disease ^r1
  • Should not be routinely measured in fully immunized children with community-acquired pneumonia, but may be helpful to assess response to therapy or in patients with more serious disease or complications ^r1

Imaging

• Chest radiography ^c84c85c86c87
  • Not necessary in patients with suspected community-acquired pneumonia who do not require admission ^r1
  • Posteroanterior and lateral views should be done when patient has hypoxemia, respiratory distress, antibiotic therapy failure, or upon admission ^r1
    • British Thoracic Society guidelines do not advocate for routine lateral films ^r3
    • Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing is seen in viral pneumonia
    • Lobar consolidation is typically seen in pneumococcal 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 ^c88c89c90c91
  • Indicated as first line imaging in patients with complicated pneumonia ^r10
  • Current evidence supports lung ultrasonography as an imaging alternative for the diagnosis of childhood pneumonia ^r11
  • Valuable for diagnosis/assessment of pleural effusions
• Chest CT ^c92c93c94c95
  • Reserve chest CT for complicated pneumonia cases in which chest ultrasonography is technically limited or discrepant with the clinical findings ^r10
  • Lung ultrasonography and chest CT are similar in their ability to detect loculated effusion and lung necrosis or abscess

Functional testing

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

Most common

• Bronchitis ^c97
  • 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 ^c98d1
  • Acute infection of the lower respiratory tract resulting in small airway obstruction
  • Respiratory syncytial virus is the most common cause of bronchiolitis in infants younger than 2 years and can be confirmed with rapid viral antigen or polymerase chain reaction testing, 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
• Pertussis ^c99d2
  • Symptoms occur in 3 phases
    • Catarrhal
      • Low-grade fever, upper respiratory 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 testing
• Asthma ^c100d3
  • 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 ^c101d4
  • Suspect when child is from endemic area or has had contact with persons who are at high risk of having the disease, urban homeless, incarcerated individuals, and persons with HIV infection
  • Presents subacutely with anorexia, weight loss, and night sweats
  • Differentiate based on history of either being from an endemic area or exposure to high-risk individuals
• Acute respiratory distress syndrome ^c102
  • 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 classified as having acute respiratory distress syndrome
• Severe acute respiratory syndrome–associated coronavirus ^c103
  • Characterized by:
    • Temperature higher than 38°C and 1 or more clinical findings of respiratory illness:
      • Cough
      • Shortness of breath
      • Difficulty breathing or hypoxia
    • Travel to an endemic area within 10 days of symptom onset
    • Close contact with a person known or suspected to have severe acute respiratory syndrome
  • Differentiate based on history of travel to endemic area

Admission criteria

Respiratory distress ^r1

• Tachypnea
  • Aged 0 to 2 months: greater than 60 breaths per minute
  • Aged 2 to 12 months: greater than 50 breaths per minute
  • Aged 1 to 5 years: greater than 40 breaths per minute
  • Older than 5 years: greater 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 older than 3 months, Children, and Adolescents: 45 mg/kg/day PO divided every 12 hours (Max: 875 mg/dose) or 40 mg/kg/day PO divided every 8 hours (Max: 500 mg/dose) is FDA-approved dosing; 90 mg/kg/day PO divided every 8 to 12 hours (Max: 4 g/day) recommended by IDSA for CAP.
  • Ampicillin ^c106
    • Ampicillin Sodium Solution for injection; Infants, Children, and Adolescents: 100 to 150 mg/kg/day IV/IM divided every 6 hours (Max: 4 g/day) for mild/moderate infections and 200 to 400 mg/kg/day divided every 6 hours (Max: 12 g/day) for severe infections is recommended by AAP. Per IDSA: 150 to 200 mg/kg/day IV/IM divided every 6 hours (Max: 12 g/day) for empiric treatment of CAP; 300 to 400 mg/kg/day IV/IM divided every 6 hours as alternative for resistant strains of S. pneumoniae. FDA-approved dosage is 25 to 50 mg/kg/day IV/IM divided every 6 hours (Max: 2 g/day).
  • Penicillin G ^c107
    • Penicillin G Sodium Solution for injection; Infants, Children, and Adolescents: 150,000 to 300,000 units/kg/day IV/IM divided every 4 to 6 hours (Max: 24 million units/day).
• Macrolides ^c108
  • Azithromycin ^c109
    • Oral
      • Azithromycin Oral suspension; Infants (3 - 6 months): 10 mg/kg/dose PO on day 1, followed by 5 mg/kg/day PO once daily on days 2 through 5.
      • 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.
    • Intravenous
      • Azithromycin Solution for injection; Infants older than 3 months†, Children†, and Adolescents less than 16 years†: 10 mg/kg/dose (Max: 500 mg/dose) IV once daily for at least 2 days, then conversion to 5 mg/kg/day (Max: 250 mg/day) PO once daily if possible to complete a 5 day course. 
      • Azithromycin Solution for injection; Adults and Adolescents 16 years and older: 500 mg IV infusion daily for at least 2 days, then 500 mg PO daily to complete 7 to 10 day course; switch to PO at physician discretion and clinical response.
  • Clarithromycin ^c110
    • Clarithromycin Oral suspension; Infants 3?5 months†: 7.5 mg/kg PO q12h x10 days is recommended by IDSA.
    • Clarithromycin Oral tablet; Infants and Children 6 months to 12 years: 7.5 mg/kg/dose (Max: 250 mg/dose) PO every 12 hours for 10 days.
  • Erythromycin ^c111
    • Oral
      • Erythromycin Ethylsuccinate Oral suspension; Infants, Children, and Adolescents: 30 to 50 mg/kg/day (Max: 1 to 2 g/day) PO in 3 to 4 divided doses; 40 mg/kg/day PO in 4 divided doses is recommended by the IDSA for CAP due to presumed/confirmed atypical pathogens as an alternative therapy to azithromycin.
    • Intravenous
      • Erythromycin Lactobionate Solution for injection; Infants, Children, and Adolescents: 15 to 20 mg/kg/day (Max: 2 to 4 g/day) IV divided every 6 hours; IDSA recommends 20 mg/kg/day IV divided every 6 hours in children with CAP due to presumed/confirmed atypical pathogens as an alternative therapy to azithromycin.
• Cephalosporins ^c112
  • Ceftriaxone ^c113
    • Ceftriaxone Sodium Solution for injection; Infants, Children, and Adolescents: 50 to 100 mg/kg/day IV/IM divided every 12 to 24 hours (Max: 4 g/day) for up to 10 days.
  • Cefotaxime ^c114
    • Cefotaxime Sodium Solution for injection; Infants, Children, and Adolescents weighing less than 50 kg: 150 to 180 mg/kg/day IV/IM divided every 6 to 8 hours (Max: 2 g/dose); treat for 10 days for CAP in infants and children aged 3 months and older.
    • Cefotaxime Sodium Solution for injection; Children and Adolescents weighing 50 kg or more: For uncomplicated infections: 1 g IV/IM every 12 hours; for moderate/severe infections: 1 to 2 g IV/IM every 8 hours; for severe infections: 2 g IV every 6 to 8 hours. IDSA recommends 2 g IV every 8 hours for 10 days is for CAP.
• Vancomycin ^c115c116
  • Vancomycin Hydrochloride Solution for injection; Infants, Children, and Adolescents: 60 mg/kg/day IV divided every 6 hours for MRSA per IDSA. FDA-approved dosage = 40 mg/kg/day IV divided every 6 hours. For MRSA, IDSA recommends to treat for 7 to 21 days for pneumonia and 10 days for CAP.
• Clindamycin ^c117c118
  • Clindamycin Phosphate Solution for injection; Infants, Children, and Adolescents 13 to 16 years: 40 mg/kg/day IV divided every 6 to 8 hours (Max: 1,800 mg/day) for MRSA pneumonia; transition to PO when appropriate; total course = 7 to 21 days depending on type and extent of infection. FDA approved dosage is 20 to 40 mg/kg/day IV/IM divided every 6 to 8 hours (Max: 2,700 mg/day) depending on severity.
  • Clindamycin Phosphate Solution for injection; Adolescents 17 years: 600 mg IV every 8 hours for MRSA pneumonia; transition to PO when appropriate; total course = 7 to 21 days depending on type and extent of infection. FDA-approved dosage is 300 mg IV/IM every 6 to 12 hours (less severe infections) and 600 mg IV or IM every 6 to 12 hours to 900 mg IV every 8 to 12 hours (more severe infections); every 6 to 8 hour intervals most commonly used in pediatric practice.
• Antivirals ^c119
  • Oseltamivir ^c120
    • Oseltamivir Phosphate Oral suspension; Infants: 3 mg/kg/dose PO twice daily for 5 days; consider extended course for severely ill patients. AAP recommends 3.5 mg/kg/dose PO twice daily for infants 9 to 11 months old.
    • 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 weighing more than 40 kg and Adolescents: 75 mg PO twice daily for 5 days; consider extended course for severely ill patients.
  • Zanamivir ^c121
    • Zanamivir Inhalation powder; Children and Adolescents 7 to 17 years: 10 mg by oral inhalation every 12 hours for 5 days.
  • Peramivir ^c122
    • Peramivir Solution for injection; Infants 91—180 days†: 10 mg/kg/dose IV daily for 5 or 10 days was dosage approved in EUA and was well-tolerated in a pediatric study that included 3 infants < 1 year.
    • Peramivir Solution for injection; Infants > 180 days† and Children <= 5 years†: 12 mg/kg/dose IV daily for 5 or 10 days was dosage approved in EUA; 10 mg/kg/dose IV daily for up to 5 days was well-tolerated in a pediatric study.
    • Peramivir Solution for injection; Children >= 6 years† and Adolescents†: 10 mg/kg/dose IV daily (Max: 600 mg/dose) for 5 or 10 days was dosage approved in EUA and was well-tolerated in a pediatric study.

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 less 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