Community-Acquired Pneumonia in Children (Older Than 3 Months)

History

• Common symptoms
  • Fever ^c1
  • Cough ^c2
  • Respiratory distress (eg, tachypnea, nasal flaring, grunting, retractions) ^c3c4c5
  • Poor feeding ^c6
  • Irritability ^c7
• Less common symptoms
  • Abdominal pain ^c8
  • Nausea or vomiting ^c9c10
  • Chest pain ^c11
• Headache and/or sore throat are common in children presenting with SARS-CoV-2 infection ^r3r4
• Receipt of conjugate pneumococcal vaccine decreases probability of bacterial pneumonia ^r5

Physical examination

• Fever
• Tachypnea alone is a sensitive sign of pneumonia ^r6c12
  • Age 2 to 12 months: more than 50 breaths per minute ^r1
  • Age 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) ^r6
• Nasal flaring, retractions, and reduced oxygen saturation increase likelihood of pneumonia diagnosis ^c13c14c15
• 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 ^r5c24c25

Causes

• Most common, by age group
  • Neonatal
    • Bacterial ^r7
      • Group B streptococci ^c26c27c28
      • Listeria monocytogenes
      • Gram-negative bacilli
      • Chlamydia trachomatis ^c29
  • Children older than 1 month
    • Viral (up to 70% of cases) ^r7
      • Human respiratory syncytial virus (more common among children younger than 5 years) ^r8c30c31
      • Parainfluenza virus 1, 2, and 3 ^c32
      • Influenza A and B virus ^c33c34
      • SARS-CoV-2 ^d1
        • Limited data suggest that SARS-CoV-2 is responsible for up to 20% of community-acquired pneumonia cases among children requiring hospital admission during pandemic conditions ^r4
      • Human adenovirus (more common among children younger than 5 years) ^r8c35c36
      • Human rhinovirus ^c37
      • Human herpesvirus 1 and 2 ^c38
      • Human metapneumovirus (more common among children younger than 5 years) ^r8c39c40
      • Human enterovirus ^c41
    • Bacterial ^r7
      • 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 primary diagnostic tools ^c72
  • WHO criteria for pneumonia require only findings of cough and tachypnea on physical examination ^r11
    • WHO definition of tachypnea
      • Age 2 to 12 months: more than 50 breaths per minute
      • Age 1 to 5 years: more than 40 breaths per minute
  • Perform pulse oximetry in all children with suspected hypoxemia ^c73
• Suspected or probable infection with SARS-CoV-2
  • Implement early and strict transmission-based precautions using contact, respiratory droplet, and airborne precautions during aerosol-generating procedures
  • Chest imaging is not usually necessary in most children with lower respiratory tract infection with SARS-CoV-2 because imaging does not often change clinical management and poses risk to infection control measures ^r12
  • Confirm Sars-CoV-2 infection with nucleic acid amplification test or antigen test performed on respiratory specimen ^r13
• Additional testing for patients admitted to 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 outpatient setting ^r1
    • Obtain if child deteriorates or symptoms worsen 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 select studies for specific pathogens in hospitalized patients as clinically indicated for isolation measures and when treatment may be affected for certain pathogens (eg, influenza^r14 viruses, SARS-CoV-2^r13)
  • Use sensitive and specific tests for rapid diagnosis of influenza virus, SARS-CoV-2, and other respiratory viruses
    • Influenza viruses
      • Positive influenza virus test result reduces additional diagnostic studies and antibiotic use, and it guides use of antiviral agents ^r1
      • Initial negative test results, especially from rapid antigen tests, do not exclude influenza viruses ^r1
    • SARS-CoV-2
      • Confirm infection with detection of either viral nucleic acid (nucleic acid amplification test) or protein (antigen test) on respiratory specimen ^r13
• 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 most rapid and accurate method ^r1r15
    • 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 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 ^r16

Imaging

• Chest radiography ^c93
  • Not necessary for patients with suspected community-acquired pneumonia with mild symptoms who do not require admission ^r1r17
  • 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 ^r1r17
    • British Thoracic Society guidelines do not advocate for routine lateral films ^r5
  • Lobar consolidation is typically seen in pneumococcal pneumonia
  • Hyperinflation with bilateral interstitial infiltrates and peribronchial cuffing is seen in most instances of viral pneumonia
  • Findings in patients with COVID-19 pneumonia
    • Common findings include unilateral focal consolidation or bilateral patchy pulmonary infiltrates ^r13
    • Pleural effusions are rare and findings frequently noted in other lower viral respiratory tract infections are uncommon (eg, increased peribranchial markings, hyperinflation) ^r18
  • 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 ^r17r19
    • Valuable for diagnosis and assessment of pleural effusions
  • Evidence supports lung ultrasonography (which does not require radiation exposure) as alternative to chest radiography for initial diagnosis of pneumonia in children ^r20r21r22
• Chest CT ^c95
  • Reserve chest CT for complicated pneumonia cases in which chest ultrasonography is technically limited or discrepant with clinical findings ^r19
  • Indicated for investigation of suspected bronchopleural fistula, lung abscess, or recurrent pneumonia ^r17

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 ^c97d2
  • 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 ^c98d3
  • Acute infection of lower respiratory tract resulting in small airway obstruction
  • Respiratory syncytial virus is most common cause of bronchiolitis in children younger than 2 years and can be confirmed with rapid viral antigen or polymerase chain reaction, but 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 expiratory phase of breathing can be heard on auscultation
  • Chest radiographs may show hyperinflated lungs with patchy atelectasis
• COVID-19 ^c99d1
  • Spectrum of illness caused by SARS-CoV-2 is quite variable
    • Most children exhibit either asymptomatic or mild disease; when symptomatic, most common manifestations are fever, cough, and sore throat
    • Common presenting syndromes include acute respiratory tract infection; asthma exacerbation; influenzalike illness; isolated fever, gastroenteritis, and vomiting; and community-acquired pneumonia
    • Up to about 40% of children develop moderate disease (eg, evidence of lower airway disease by clinical assessment or imaging without hypoxia), about 2% develop severe illness (eg, lower airway disease with hypoxia), and about 0.7% develop critical illness (eg, shock, respiratory failure, multiple organ failure) ^r23r24
  • May have known exposure to confirmed case (typically within own household)
  • Infection with respiratory pathogens other than SARS-CoV-2 (eg, influenza, respiratory syncytial virus, Mycoplasma pneumoniae) does not exclude diagnosis because coinfection with additional respiratory pathogens occurs in up to 6% ^r25
  • Findings may be present on chest imaging before symptoms manifest; approximately 44% of children with COVID-19 in 1 systematic review data set show evidence of radiographic abnormalities on chest radiograph or chest CT ^r26
    • Chest imaging ^r18
      • May reveal unilateral or bilateral pulmonary infiltrates
      • Pleural effusions are rare
      • Findings frequently noted in other lower viral respiratory tract infections are uncommon (eg, increased peribranchial markings, hyperinflation)
  • Diagnosis is confirmed by rapid antigen or polymerase chain reaction for SARS-CoV-2 on specimens from upper respiratory tract ^r27d4
• Pertussis ^c100d5
  • 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 whoop but have paroxysmal cough and/or apnea with color change
    • Convalescent
      • Persistent cough
  • Differentiate by cough history and polymerase chain reaction
• Asthma ^c101d6
  • Symptoms include episodic dry cough, expiratory wheezing, chest tightness, feeling of discomfort in 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 setting of clear chest radiograph is diagnostic
• Tuberculosis ^c102d7
  • Suspect when child is from 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 endemic area or having exposure to high-risk people
• Acute respiratory distress syndrome ^c103d8
  • 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 measured PaO₂ to percentage of 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
  • Age 0 to 2 months: more than 60 breaths per minute
  • Age 2 to 12 months: more than 50 breaths per minute
  • Age 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 potentially virulent pathogen (eg, community-associated MRSA) ^r1

Moderate (clinical or radiographic evidence of lower airway disease without hypoxia) or severe COVID-19 disease (hypoxia, greater than 50% lung infiltrates, significant tachypnea, or severe respiratory distress) ^r28d1

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 (Max: 4 g/day) PO in divided doses every 12 hours for 5 to 7 days.
    • Amoxicillin Trihydrate Oral capsule; Adolescents: 90 mg/kg/day (Max: 4 g/day) PO divided every 8 to 12 hours for 5 to 7 days.
  • Ampicillin ^c106
    • Ampicillin Sodium Solution for injection; Infants, Children, and Adolescents 4 months to 17 years: 150 to 400 mg/kg/day (Max: 8 g/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 Streptococcus pneumoniae.
  • Penicillin G ^c107
    • Penicillin G Sodium Solution for injection; Infants, Children, and Adolescents 4 months to 17 years: 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 5-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, Children, and Adolescents: 50 mg/kg/dose (Max: 2 g/day) IV every 12 hours for 5 to 7 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, Children, and Adolescents: 150 to 200 mg/kg/day (Max: 6 g/day) IV divided every 8 hours for 5 to 7 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) for at least 7 days; adjust dose based on target PK/PD parameter. Consider loading dose of 20 to 35 mg/kg IV in critically ill patients.
  • 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) for at least 7 days; adjust dose based on target PK/PD parameter.
  • 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) for at least 7 days; 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.
  • 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) for at least 7 days; adjust dose based on target PK/PD parameter.
• 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; Children 2 to 12 years who are outpatients with uncomplicated, mild-to-moderate illness: 12 mg/kg (Max: 600 mg) IV as a single dose within 48 hours of symptom onset.
      • Peramivir Solution for injection; Hospitalized children 2 to 12 years who are unable to tolerate or absorb oseltamivir: 12 mg/kg/dose (Max: 600 mg/dose) IV once daily for 5 days as an alternative. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
      • Peramivir Solution for injection; Adolescent outpatients with uncomplicated, mild-to-moderate illness: 600 mg IV as a single dose within 48 hours of symptom onset.
      • Peramivir Solution for injection; Hospitalized adolescents who are unable to tolerate or absorb oseltamivir: 600 mg IV once daily for 5 days as an alternative. Consider longer courses (e.g., 10 days) for severely ill hospitalized patients or immunosuppressed patients.
  • Baloxavir
    • Baloxavir Marboxil Oral suspension; Children 5 to 12 years weighing less than 20 kg: 2 mg/kg PO as a single dose.
    • Baloxavir Marboxil Oral suspension; Children and Adolescents 5 to 17 years weighing 20 to 79 kg: 40 mg PO as a single dose.
    • Baloxavir Marboxil Oral suspension; Children and Adolescents 5 to 17 years weighing 80 kg or more: 80 mg PO as a single dose.
  • Remdesivir
    • for the treatment of hospitalized patients
      • Remdesivir Solution for injection; Infants, Children, and Adolescents weighing 3 to 39 kg NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO): 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
      • Remdesivir Solution for injection; Infants, Children, and Adolescents weighing 3 to 39 kg requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO): 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 9 days. The NIH recommends against starting remdesivir, but treatment may be continued (in combination with dexamethasone) in patients who progress to mechanical ventilation or ECMO.
      • Remdesivir Solution for injection; Children and Adolescents weighing 40 kg or more NOT requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO): 200 mg IV once on day 1, followed by 100 mg IV once daily for 4 days; may extend treatment for up to 5 additional days if no clinical improvement.
      • Remdesivir Solution for injection; Children and Adolescents weighing 40 kg or more requiring invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO): 200 mg IV once on day 1, followed by 100 mg IV once daily for 9 days. The NIH recommends against starting remdesivir, but treatment may be continued (in combination with dexamethasone) in patients who progress to mechanical ventilation or ECMO.
    • for the treatment of nonhospitalized patients with mild to moderate COVID-19 who are at high risk for progression
      • Remdesivir Solution for injection; Infants, Children, and Adolescents weighing 3 to 39 kg: 5 mg/kg/dose IV once on day 1, followed by 2.5 mg/kg/dose IV once daily for 2 days.
      • Remdesivir Solution for injection; Children and Adolescents weighing 40 kg or more: 200 mg IV once on day 1, followed by 100 mg IV once daily for 2 days.

Nondrug and supportive care

IV fluids ^c123

• Indicated for patients who are unable to tolerate oral fluids, have 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 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
• Threshold for admission of patients with these comorbidities is lower, and they should be monitored for possible worsening of disease