See also

Pleural effusion and empyema 
Sepsis
Sepsis in neonates (Neonatal eHandbook)
Influenza
Assessment of severity of respiratory conditions

Key Points

1. Community acquired pneumonia (CAP) can be diagnosed clinically when there are signs of a lower respiratory tract infection and wheezing syndromes have been ruled out
2. CXR is not required for routine diagnosis or management, unless severe or complicated pneumonia is suspected
3. Blood tests and microbiological investigations are not recommended for routine use in the diagnosis and management of CAP
4. For non-severe pneumonia, high dose oral amoxicillin is recommended, even for inpatient use 
5. For infants <1 month of age see Sepsis in neonates

Background

• Pneumonia can be defined clinically as the presence of fever, cough and tachypnoea at rest (and retractions in younger children) when clinical wheezing syndromes have been ruled out
• “Complicated pneumonia” occurs when there is a complication such as parapneumonic effusion, empyema, lung abscess, or necrotising pneumonia 

Assessment

History

• Fever
• Fast breathing at rest
• Cough
• Increased work of breathing/respiratory distress
• Apnoea

Examination

• Appears lethargic/unwell  
• Hypoxaemia
• Tachypnoea
• Chest wall in-drawing, retractions, grunting, nasal flaring
• Crackles and bronchial breathing on auscultation
• Absent breath sounds and a dull percussion note suggest a pleural effusion  

Assessment of severity

Severe pneumonia should be considered if there are clinical features of pneumonia and 1 or more of:

• severe respiratory distress
• severe hypoxaemia or cyanosis
• marked tachycardia
• altered mental state
• empyema

Management

Investigations

Investigations, including CXR, are not recommended routinely for CAP, particularly in those with mild disease who are expected to be managed as an outpatient 

Chest X-Ray (posteroanterior view)

• Recommended for children who require admission or if severe or complicated pneumonia is suspected
• Consider repeating if the child fails to clinically improve after 48–72 hours of appropriate antibiotic therapy
• Follow-up CXR is not required for those who recover uneventfully
• Follow-up CXR is recommended after 4–6 weeks for:
• complicated pneumonia
• persistent signs
• recurrent pneumonia involving the same lobe or if initial suspicion of a chest mass, anatomical abnormality or foreign body

Severe or complicated pneumonia

• UEC for children receiving intravenous fluids 
• FBE and blood film 
• Microbiological investigations 

• Blood culture has a low yield and is more likely to be positive if empyema is present or in a child with severe/complicated pneumonia
• Testing for influenza (nasal swab or aspirate for PCR)
• Avoid testing for other viral pathogens (will not change management)

• Acute phase reactants (particularly CRP and procalcitonin) cannot distinguish between a viral or bacterial cause nor indicate severity. Consider testing to monitor progress

Treatment

Admission to hospital is required for oxygenation, fluid therapy or moderate to severe work of breathing

• Check oxygen saturations and provide supplemental oxygen if saturations are <90%  
• If giving NG or IV fluids as maintenance therapy, limit fluids to 2/3rds of the child’s calculated fluid requirement to avoid fluid overload, with regular clinical review of fluid status
• Advice regarding antibiotic management is summarised in the algorithm below. High dose oral amoxicillin is considered as effective as IV benzylpenicillin   
• Most children can be managed with oral antibiotics 
• Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines

Child with suspected pneumonia

Penicillin hypersensitivity

Non-beta-lactam antibiotic alternatives include  

• Azithromycin 10 mg/kg (max 500 mg) oral daily — instead of oral amoxicillin or
• Doxycycline for 8–18 years, 2 mg/kg (maximum 100 mg) oral twice daily on day 1, then 2 mg/kg (maximum 100 mg) once daily — instead of oral amoxicillin. Use rounded doses:
• <26 kg: 50 mg
• 26 kg to 35 kg: 75 mg
• >35 kg: 100 mg
• Doxycycline has not been associated with tooth discolouration, enamel hypoplasia or bone deposition, even in children younger than 8 years, however, use is limited by the lack of a suitable formulation
  
• Vancomycin IV (see local hospital protocol for doses) instead of benzylpenicillin or cefotaxime/ceftriaxone

For further information refer to Therapeutic Guidelines 

Atypical pneumonia

• Testing for causes of atypical pneumonia (including Mycoplasma) rarely influences management, as it does not differentiate infection from asymptomatic carriage 
• There is no proven benefit from treatment with macrolides alone or in combination with β-lactams in children with suspected or confirmed atypical pneumonia. The only exception in practice is in cases of severe pneumonia — azithromycin may be considered (as the perceived benefit is greater) 

Consider consultation with local paediatric team when

• Fulfills criteria for hospital admission
• Outpatient therapy fails

Consider transfer when

• Severe or complicated pneumonia
• Comorbidities such as cardiac disease, chronic respiratory disease, immune deficiency or suppression are present
• Child requiring care above the level of comfort of the local hospital
• Child has an O₂ requirement is FiO2 of >50%

For emergency advice and paediatric or neonatal ICU transfers, call Retrieval Services

Consider discharge when

Child is maintaining adequate oxygenation and oral intake. 
Note: children managed as outpatients should have medical review in 24–48 hrs

Parent information sheet

Pneumonia

Last revised February, 2020