See also

Parapneumonic effusion                                                      
Sepsis
Influenza
Assessment of severity of respiratory conditions

Key Points

1. Community acquired pneumonia (CAP) can be diagnosed clinically and is most often due to viruses
2. Chest X-Ray (CXR), blood tests and microbiological investigations are not recommended for routine use in the diagnosis and management of CAP
3. For non-severe pneumonia, high dose oral amoxicillin is recommended, even for inpatient use 
4. For infants <1 month of age see Recognition of the seriously unwell neonate and young infant and Sepsis guidelines

Background

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

Assessment

History

• Fever
• Tachypnoea at rest
• Cough
• Increased work of breathing/respiratory distress
• Apnoea (neonates)
• Abdominal pain

Examination

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

Assessment of severity

See Assessment of severity of respiratory conditions

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

• Severe respiratory distress
• Marked tachycardia
• Altered mental state
• SpO2 <80% or requiring respiratory support (eg CPAP, HFNP)
• Complicated pneumonia (see parapneumonic effusion)

Consider sepsis in children with severe pneumonia

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 (CXR)

• Recommended when severe or complicated pneumonia is suspected
• Consider repeating if the child deteriorates at any time or fails to clinically improve after 48-72 hours of appropriate antibiotic therapy
• Follow-up CXR is not required for those who have uncomplicated pneumonia or small parapneumonic effusion and recover uneventfully
• Follow-up CXR is recommended after 6 weeks for:
• complicated pneumonia
• 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
• Influenza PCR (nasal swab or aspirate)
• COVID-19 testing (as per local testing criteria)
• Testing for other viral pathogens will not change management
• Testing for atypical pathogens is unhelpful as it does not differentiate infection from asymptomatic carriage
• Acute phase reactants (including CRP and procalcitonin) cannot distinguish between a viral or bacterial cause nor indicate severity
• Consider sepsis

Treatment

Admission to hospital is required for children who require supplemental O2, hydration support with NG or IV fluids, or moderate to severe work of breathing

• Provide supplemental oxygen if saturations are <90%  
• If giving NG or IV maintenance fluids, limit fluids to 2/3 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 as effective as IV benzylpenicillin   
• Most children, including hospitalised children, can be managed with oral antibiotics 
• Antimicrobial recommendations may vary according to local antimicrobial susceptibility patterns; please refer to local guidelines
  
  
  

Penicillin hypersensitivity

Refer to Therapeutic Guidelines and Antibiotic prescribing in children with reported penicillin or cephalosporin allergy for guidance on assessing severity of allergy and appropriate antimicrobial options

For immediate and/or severe penicillin hypersensitivity, non-beta-lactam antibiotic alternatives for CAP include  

• Oral
• Azithromycin 10 mg/kg (max 500 mg) oral daily 
• Intravenous
• Ciprofloxacin 10 mg/kg (max 400 mg) IV 12 hourly

               PLUS

• Vancomycin  IV (see local hospital protocol for doses)

Atypical pneumonia

There is no proven benefit from treatment with macrolides but they may be considered in severe pneumonia not responding to treatment

Consider consultation with local paediatric team when

• Child 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

For emergency advice and paediatric or neonatal ICU transfers, see 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

Pneumonia

Last updated October 2023