See also
Pleural effusion and empyema
Sepsis
Sepsis in neonates (Neonatal eHandbook)
Influenza
Assessment of severity of respiratory conditions
Key Points
- 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
- CXR is not required for routine diagnosis or management, unless severe or complicated pneumonia is suspected
- Blood tests and microbiological investigations are not recommended for routine use in the diagnosis and management of CAP
- For non-severe pneumonia, high dose oral amoxicillin is recommended, even for inpatient use
- 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:
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