Dynamed

DynaMed Plus: Community-acquired Pneumonia in Children 15/07/19 21)06
Community-acquired Pneumonia in Children

Overview and Recommendations
Background
Community-acquired pneumonia is a lower respiratory infection due to one or more pathogens acquired outside of a healthcare setting, in
contrast to pneumonias acquired within healthcare settings in a previously healthy child.
Children < 5 years old or with a history of significant prematurity (< 28 weeks gestation) are at higher risk of severe disease.
Viruses are the most common cause, but other common causes include bacteria and atypical bacteria. The likelihood of a specific organism
will vary according to age, season, vaccination history, exposures, and geographic location.
Evaluation
Presenting symptoms vary with age and may include cough, tachypnea, dyspnea, fever, wheezing, and chest pain. Systemic symptoms may
include lethargy, irritability, poor feeding, signs of dehydration, or headache. Physical signs may include tachypnea, grunting, nasal flaring,
rales/crackles/wheezes, diminished breath sounds, dullness to percussion, and chest retractions.
Individual findings are of limited utility, but the diagnosis of pneumonia can be made clinically by a combination of findings which all
support the diagnosis.
Finding of an infiltrate on a chest x-ray is often used as a diagnostic standard, but it is not needed in children with clinical evidence of
pneumonia and in mild, uncomplicated disease (Strong recommendation). Pneumonia can also be diagnosed by chest ultrasound.
There are no consistent clinical, laboratory, or chest x-ray findings that can reliably distinguish among viral, bacterial, or atypical bacterial
pneumonias.
Consider rapid testing for detection of influenza virus, other respiratory viruses, and some bacteria.
Management
Consider severity of illness and home setting in determining appropriateness of inpatient vs. outpatient treatment.
Outpatient therapy:
Antimicrobial therapy is not routinely recommended by the Pediatric Infectious Diseases Society for preschool-aged children,
because viral pathogens are responsible in most cases (Strong recommendation). The British Thoracic Society (BTS) recommends
that all children with a clear clinical diagnosis of pneumonia should receive antibiotics, since bacterial and viral pneumonia cannot
reliably be distinguished from each other clinically (Weak recommendation).
The recommended first-line treatment for children < 5 years old with nonsevere presumed bacterial pneumonia is oral amoxicillin
(Strong recommendation).
Oral amoxicillin is typically given at 90 mg/kg/day in 2 divided doses for up to 10 days.
If child is unable to take oral antibiotics or has signs of septicemia or complicated pneumonia, begin IV antibiotics.
Consider macrolides for treatment of presumed atypical pneumonia in children ≥ 5 years (Weak recommendation).
The recommended treatment for children ≥ 5 years old is amoxicillin or macrolides, depending on the clinical situation.
Consider amoxicillin 90 mg/kg/day in 2 divided doses (maximum 4 g/day) as first-line therapy for presumed bacterial
pneumonia in an otherwise healthy, fully vaccinated child.
Medication options for presumed atypical pneumonia include:
azithromycin 10 mg/kg/day for 1 day (maximum 500 mg/day), then 5 mg/kg/day orally (maximum 250 mg/day) for 4
days
clarithromycin 15 mg/kg/day in 2 divided doses (maximum 1,000 mg/day) for 7-10 days
erythromycin 40 mg/kg/day in 4 divided doses (maximum 2,000 mg/day) for 7-10 days
doxycycline 4 mg/kg/day in 2 divided doses (maximum 200 mg/day) for 7-10 days as an alternative in children > 8
years old
Antiviral medications should be based on circulating influenza viruses and antiviral resistance patterns and started as soon as possible
for patients with confirmed or suspected influenza who have severe, complicated, or progressive illness; require hospitalization; or
who are high risk of influenza complications.
Inpatient therapy:
Children should be admitted to the hospital if they are ≤ 28 days old, aged 29 days to 3 months with fever, or if there is toxic
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appearance, respiratory distress, dehydration, inability to feed, questionable ability to be cared for safely at home, and oxygen
saturation < 92% on room air.
IV antibiotics may be required for children hospitalized for community-acquired pneumonia especially if the patient is unable to take
oral medications.
Use ampicillin or penicillin G for fully immunized children in areas with minimal penicillin resistance to invasive
pneumococcal strains (Strong recommendation).
Use ceftriaxone or cefotaxime for children who are severely ill, not fully immunized, or in areas with penicillin-resistant
pneumococcus (Weak recommendation). Cefotaxime is no longer manufactured in the United States.
Add a macrolide (oral or parenteral) when either Mycoplasma pneumoniae or Chlamydophila pneumoniae is a significant
consideration (Weak recommendation).
If clinical, laboratory, or imaging findings suggest Staphylococcus aureus infection, add vancomycin or clindamycin (Strong
recommendation).
The British Thoracic Society recommends oral antibiotics as first-line therapy even for severe pneumonia.
Children should have a follow-up exam within 48 hours and additional testing or a change in management if there is no improvement
(Strong recommendation).
Related Summaries
Antibiotics for pediatric outpatients with community-acquired pneumonia
Antibiotics for pediatric inpatients with community-acquired pneumonia
Influenza in children
Parapneumonic effusion and empyema in children
Hospital-acquired pneumonia in infants and children
Community-acquired pneumonia in adults
General Information
Description
pneumonia is a lower respiratory tract infection typically associated with fever, respiratory symptoms, and evidence of parenchymal
involvement by either physical examination or presence of infiltrates on chest x-ray(3)
Definitions
definitions of different types of pneumonia(2, 3)

community-acquired pneumonia refers to an acute pulmonary infection in a previously healthy individual acquired in the community
walking pneumonia typically describes school-aged children and young adults with clinical and radiographic evidence of pneumonia
but with mild symptoms
hospital-acquired pneumonia or nosocomial pneumonia develops within 48 hours of admission
Epidemiology
Incidence/Prevalence
incidence in developed world about 30-40 cases per 1,000 children < 5 years old(2)
worldwide
estimated incidence of pneumonia worldwide in children < 5 years old in 2010
based on subgroup analysis of data from Child Health Epidemiology Reference Group (CHERG) working group on
pneumonia
pneumonia is the leading infectious cause of death worldwide
by region (in episodes/child-year)
0.27 in Africa
0.26 in Southeast Asia
0.23 in Eastern Mediterranean
0.11 in Western Pacific
0.08 in Americas
0.03 in Europe
15 countries account for 65% of total episodes of pneumonia and 64% of severe episodes (in episodes/child-year)
Africa - Niger, Burkina Faso, Mali, Democratic Republic of Congo, Nigeria, Ethiopia, Tanzania, Uganda, Angola,
Kenya
Southeast Asia - Afghanistan, India, Indonesia
Eastern Mediterranean - Pakistan
Western Pacific - China
Reference - Lancet 2013 Apr 20;381(9875):1405
United States
overall incidence of community-acquired pneumonia requiring hospitalization from 2010 to 2012 in United States 15.7 per
10,000 children with highest incidence in children < 2 years old
based on population-based surveillance of 3 hospitals in United States from 2010 to 2012
annual incidence per 10,000 patients of hospitalization for community-acquired pneumonia
15.7 overall (children ≤ 17 years old)
62.2 for children < 2 years old
23.8 for children aged 2-4 years
Reference - EPIC study ( N Engl J Med 2015 Feb 26;372(9):835 full-text)
annual incidence of community-acquired pneumonia outpatient visits 22.4 per 1,000 children in the United States in 2006-
2007
based on data from the National Ambulatory and National Hospital Ambulatory Medical Care Surveys (1994-2007)
estimated annual incidence of community-acquired pneumonia (CAP) outpatient visits in 2006-2007
22.4 per 1,000 children
48.8 per 1,000 children aged 1-5 years
rates of CAP visits over time from 1994 to 2007 had not significantly changed
Reference - Pediatrics 2011 Mar;127(3):411 full-text
reduced incidence of pneumococcal pneumonia reported after childhood vaccination
annual hospitalization rates for pneumococcal pneumonia appear to have decreased in children since introduction of 13-
valent pneumococcal conjugate vaccine in United States
based on retrospective cohort study
377 children ≤ 18 years old with pneumococcal pneumonia who were hospitalized in United States before (2006-2009) vs.
after (2011-2014) introduction of 13-valent pneumococcal conjugate vaccine (PCV13) were assessed
PCV13 was transitioned into regular rotation during 2010 and children hospitalized during that year were excluded
serotypes 19A, 1, 7F, and 3 accounted for 80% of hospitalizations for pneumococcal pneumonia from 2006-2014
comparing annual pneumococcal pneumonia hospitalization rates before vs. after introduction of PCV13
all-cause in 53.6 vs. 23.3 per 100,000 admissions (p < 0.0001)
complicated pneumonia in 38.6 vs. 15.6 per 100,000 admissions (p < 0.0001)
any PCV13 serotype in 47.2 vs. 15.7 per 100,000 admissions (p < 0.0001)
serotype 19A in 26.1 vs. 7.4 per 100,000 admissions (p < 0.001)
serotype 1 in 5 vs. 0.4 per 100,000 admissions (p < 0.0001)
no significant changes were seen in serotype 7F or 3
no significant differences in need for mechanical ventilation, invasive procedures, or intensive care
Reference - Clin Infect Dis 2017 Jun 15;64(12):1699
pneumococcal conjugate vaccine associated with 16% overall decrease in community-acquired pneumonia (CAP) and
decreased pneumococcal CAP in children presenting to emergency departments (level 2 [mid-level] evidence)
based on cohort study
5,645 children aged 1 month to 15 years (median 3 years) presenting to emergency department who had chest radiography-
confirmed pneumonia were evaluated and compared in 1-year periods
pre-PCV13 (June 2009 to May 2010) and post-PCV13 (June 2011 to May 2012) vaccine
routine vaccination with PCV13 started in June 2010
CAP with pleural effusion diagnosed in 365 children and pneumococcal CAP diagnosed in 136 children
16% overall decrease in CAP from 2,060 cases pre-PCV13 to 1,725 cases post-PCV13 vaccine period
comparing pre-PCV13 vs. post-PCV13 vaccine period, cases of
CAP declined in children < 2 years old by 31.8% (p < 0.001) and in children 2-5 years old by 16.6% (p < 0.001)
CAP with pleural effusion declined by 52.7% (p < 0.001)
pneumococcal CAP declined by 62.5% (p = 0.002)
Reference - Clin Infect Dis 2014 Apr;58(7):918 full-text, editorial can be found in Clin Infect Dis 2014 Apr;58(7):925
10- and 13-valent pneumococcal vaccine associated with reduced hospitalization and mortality in children aged < 5 years in
Latin America (level 2 [mid-level] evidence)
based on qualitative systematic review of observational studies
22 observational studies from Brazil, Chile, Uruguay, Argentina, Peru and Nicaragua evaluating effect of pneumococcal
vaccines PCV-10 and PCV-13 on hospitalization rates and/or mortality due to pneumonia, invasive pneumococcal disease,
meningitis, and sepsis

hospitalizations for pneumonia were significantly reduced in 10 studies with the reduction ranging from 7.4% to 49.3%
among 3 studies evaluating effect of PCV on pneumonia mortality
deaths due to pneumonia were reduced by 35% (95% CI 8.6%-53.8%) in 1 study and by 71.5% (95% CI 9%-91.8%) in 1
study
1 study reported non-significant reduction in deaths due to pneumonia
Reference - PLoS One 2016 Dec 12;11(12):e0166736 full-text
Risk factors
age < 5 years or prematurity (gestational age < 28 weeks) associated with higher risk of severe disease(1)
immunosuppressed state(1, 3)
incomplete or inadequate vaccination with pneumococcal conjugate and Haemophilus influenzae type B vaccines (Pediatr Radiol 2017
Oct;47(11):1392 full-text, correction can be found in Pediatr Radiol 2017 Dec;47(13):1855)
risk of pneumonia associated with clinical, socioeconomic and environmental factors(3)
Risk Factors by Age:
Neonates (Early Onset) Neonates (Late Onset) Childhood
Socioeconomic/environmental factors
Cigarette smoke
Lack of breastfeeding
Malnutrition
Zinc deficiency
Lower socioeconomic status
(family size, crowding)
Low maternal education level
Poor access to care
Indoor air pollution
Alcohol, drugs, and cigarette use in
teens
Underlying cardiopulmonary disorders
Prolonged rupture of fetal Airway anomalies (such as choanal
and medical conditions
membranes (> 18 hours) atresia, tracheoesophageal fistula, cystic
Congenital heart disease
Maternal amnionitis adenomatoid malformations)
Bronchopulmonary dysplasia and
Prematurity Neurologic impairment resulting in
chronic lung disease
Maternal intrapartum fever aspiration of gastric contents
Diabetes mellitus
Cystic fibrosis
Asthma
Sickle cell disease
Neuromuscular disorders
Gastrointestinal disorders (such as
gastroesophageal reflux,
tracheoesophageal fistula)
Congenital and acquired
immunodeficiency
Concomitant infections
Chronic diarrhea
Measles
Reference - Pediatr Rev 2013 Oct;34(10):438, correction can be found in Pediatr Rev 2014 Jan;35(1):29, Lancet 2013 Apr
20;381(9875):1405.
Etiology and Pathogenesis

Causes
identification of causative organism can be challenging(4)

viral and bacterial causes are not easily distinguished by clinical or radiological features
obtaining appropriate samples from lower respiratory tract in children can be difficult
blood cultures are rarely obtained in community setting and when taken in the hospital have low yield
if nasal specimens are used, distinguishing colonizing vs. pathogenic bacteria may not be possible
Reference - Pediatr Radiol 2017 Oct;47(11):1392 full-text, correction can be found in Pediatr Radiol 2017 Dec;47(13):1855
changing profile of causative pathogens
in studies predating availability of conjugate vaccines
most common bacterial causes were the targets of these vaccines, S. pnemoniae and H influenzae type B
in some severe cases, Staphylococcus aureus and Klebsiella pneumoniae were identified
most common viral cause was respiratory syncytial virus (reported in 15%-40%) followed by influenza A and B, parainfluenza,
human metapneumovirus, and adenovirus
post conjugate vaccine era
pneumonia may be caused by a mixed infection of > 1 viral and/or bacterial pathogen particularly in cases of severe disease
viral pathogens are more increasingly more common; identified in reported 73% to 87% of recent studies
incidence of pneumonia caused by pertussis has been increasing in countries such as the United States that use acellular
pertussis vaccine; infants may be born without sufficient protection due to waning pertussis antibody levels of their mothers
Mycobacterium tuberculosis is increasingly identified as causative agent in children who live in settings with high prevalence
of tuberculosis
Reference - Pediatr Radiol 2017 Oct;47(11):1392 full-text, correction can be found in Pediatr Radiol 2017 Dec;47(13):1855
pathogen can be identified in 65%-86% of cases(1)
30%-67% of cases caused by viruses
mixed viral-bacterial infection identified in 23%-33% of cases
Causes of Pneumonia in Children:
Frequency Bacterial Viral
S. pneumoniae
H. influenzae (where vaccine is
available, type B is uncommon, and
non-typeable is common)
Bordatella pertussis (young infants) Influenza virus types A and B
Mycoplasma pneumoniae Parainfluenza virus
Common Chlamydia trachomatis (especially in Human metapneumovirus
newborns) Adenovirus
Group B streptococci (young infants) Rhinovirus
Listeria monocytogenes (newborns)
Mycobacterium tuberculosis (not
common in United States, may be
more common in other countries)
Streptococcus pyogenes
Anaerobes (Streptococcus milleri,
Peptostreptococcus) Varicella zoster virus
Haemophilus influenza nontype B Coronaviruses
Klebsiella pneumoniae Enteroviruses (coxsackievirus and
Escherichia coli echovirus)
Listeria monocytogenes (beyond the Cytomegalovirus
newborn period) Epstein-Barr virus
Less Common
Neisseria meningitides (often group Y) Mumps virus
Legionella Herpes simplex virus (in newborns)
Burkholderia pseudomallei Bocaviruses
Francisella tularensis Polyomaviruses
Brucella abortus Measles virus
Leptospira Hantavirus
Chlamydia psittaci
Coxiella burnetii
Reference - Pediatr Clin North Am 2013 Apr;60(2):437, Pediatr Radiol 2017 Oct;47(11):1392 full-text.
Group B Streptococcal pneumonia. : Pneumonia is a frequent component of early onset Group B streptococcal disease.
respiratory syncytial virus, adenovirus, and human metapneumovirus more common in children < 5 years old, and Mycoplasma
pneumoniae more common in older children in United States with community acquired pneumonia
based on cohort of 2,638 hospitalized children from 3 United States hospitals from 2010 to 2012
89% had radiographic evidence of pneumonia
comparing children < 5 years old vs. > 5 years old
respiratory syncytial virus 37% vs. 8%
adenovirus in 15% vs. 3%
human metapneumovirus in 15% vs. 8%
M. pneumoniae in 3% vs. 19%
Reference - EPIC study ( N Engl J Med 2015 Feb 26;372(9):835)
pathogens associated with pneumonia in children ≤ 5 years old in developing and emerging countries
bacteria
Mycoplasma pneumonia
Streptococcus pneumoniae
viruses
influenza viruses A and B
respiratory syncytial virus
human metapneumovirus
parainfluenza viruses 1, 3 and 4
rhinovirus
Reference - Clin Infect Dis 2017 Aug 15;65(4):604
pneumoniae, influenza and Haemophilus influenzae are leading causes of severe pneumonia and death worldwide
based on subgroup analysis of data from Child Health Epidemiology Reference Group (CHERG) working group on pneumonia
analysis included 35 community-based prospective studies on pneumonia
major causes of severe vaccine-preventable pneumonia worldwide (defined as pneumonia requiring hospitalization)
S. pneumoniae in 18% of severe episodes and 33% of deaths
influenza virus in 7% of severe episodes and 11% of deaths
H. influenzae type b in 4% of severe episodes and 16% of deaths
other causes of severe pneumonia
respiratory syncytial virus (RSV)
Staphylococcus aureus
non-typhoidal Salmonella species in African regions where malaria is endemic
Klebsiella pneumoniae, especially in malnourished children and neonates
atypical bacteria, including Mycoplasma pneumoniae and Chlamydia pneumoniae in children > 3 years old
Bordetella pertussis, especially in first 6 months of life
less frequently parainfluenza viruses 1-3, human metapneumovirus, adenovirus, coronavirus, bocavirus, often in conjunction
with bacterial co-infection
additional causes of severe pneumonia in children with HIV infection include pneumocystis jirovecii, Mycobacterium tuberculosis,
cytomegalovirus, and Gram-negative infections
Klebsiella species is a common cause of bacterial pneumonia in severely malnourished children in addition to species that
frequently cause pneumonia in all children including S. aureus and S. pneumoniae
based on systematic review of cohort studies without evaluation of study quality
systematic review of 16 cohort studies evaluating pneumonia in malnourished children in Asia, Africa, and South America
causes of bacterial pneumonia from 11 studies in 509 severely malnourished children aged 0-84 months with 215 bacterial isolates
Klebsiella species in 26% isolates
S. aureus in 25% isolates
S. pneumoniae in 18% isolates
E. coli in 8% isolates
H. influenzae in 8% isolates
Salmonella species in 5% isolates
other in 10% isolates (for example, Acinetobacter species, Pseudomonas species, Moraxella species, Enterobacter species)
viral etiology in 35% in 1 study with 158 children aged 3-60 months, including
adenovirus in 17% children
RSV in 6% children
parainfluenza virus in 6% children
herpes simplex virus in 6% children
influenza virus in 6% children
measles virus in 3% children
Reference - Trop Med Int Health 2009 Oct;14(10):1173 full-text
DynaMed commentary -- The absence of data on pathogens in children with pneumonia but without malnutrition in same populations
limits ability to make a comparison.
History and Physical

Clinical presentation
clinical profile that should prompt suspicion of pneumonia in a child is the combination of persistent or repetitive fever > 38.5 degrees C
(101.3 degrees F) together with chest recession and a raised respiratory rate (BTS Grade D)(1)
presentation varies by severity and age(1, 2)
features of severe disease
fever > 38.5 degrees C (101.3 degrees F)
oxygen saturation < 92%
cyanosis
elevated respiratory rate (> 70 breaths/minute for infants, > 50 breaths/minute for older children)
significant tachycardia for level of fever
central capillary refill time >2 seconds
signs of difficulty with breathing including grunting and nasal flaring
presentation of infants with severe disease may also include intermittent apnea and not feeding
older children with severe disease may also present with signs of dehydration
presentation by underlying cause (clinical features do not reliably distinguish viral, bacterial and atypical pneumonias)(1, 4)
Streptococcus pneumoniae pneumonia(3)
sudden onset of fever (typically lower grade), nonproductive cough, and tachypnea
decreased breath sounds over affected lobe (typically lobar pneumonia)
atypical pneumonia caused by Mycoplasma pneumoniae or Chlamydia pneumoniae(3)
gradual onset of fever, malaise, myalgia, headache, photophobia, sore throat
progressive worsening, prolonged nonproductive cough
viral pneumonia(3)
gradual onset of cough, congestion and fever
diffuse findings on auscultation, including diffuse wheeze
tuberculosis
fever, cough and gradual weight loss
intrathoracic adenopathy commonly seen on chest x-ray, most often affecting the subcarinal, hilar, anterior mediastinal,
precarinal and right paratracheal lymph nodes

neonatal pneumonia(3)
early onset (< 1 week old)
presents as respiratory distress and is acquired from the mother through the placenta or aspiration of infected amniotic fluid
may also have nonspecific signs including lethargy, apnea, tachycardia, and poor perfusion
late onset (1 week to 3 months old) presents with nonspecific signs of fever, apnea, tachypnea, poor feeding, abdominal distension,
jaundice, emesis, respiratory distress, and circulatory collapse
History
Chief concern (CC)
presenting symptoms vary with age and may include(1, 34)

cough
tachypnea
dyspnea
fever
wheezing
chest pain
nonrespiratory symptoms may include(1, 2, 3)
lethargy, irritability
poor feeding
abdominal pain and vomiting, especially in children < 5 years old
headache
in infants < 3 months (3)
common symptoms include apnea, tachypnea and respiratory distress
may also have poor feeding, abdominal distension, jaundice, and vomiting
History of present illness (HPI)
ask about vaccination status (Pediatr Radiol 2017 Oct;47(11):1392 full-text

patient and environmental factors to consider(3)
age of child
season
microorganisms currently circulating in community
possible foreign body aspiration or toxin ingestion
ask about exposure history including
bats - Histoplasma capsulatum
roses or bales of hay - Sporothrix schenckii
mouse droppings in endemic areas (in United States: four corners region of Arizona, Colorado, New Mexico, Utah and Yosemite
National Park) - Hantavirus
ranching and rearing of sheep, goats and cattle - Coxiella burnetii
Reference - Pediatr Clin North Am 2013 Apr;60(2):437
ask about travel history(3, 4)
tuberculosis-endemic areas
regions with endemic pathogens causing pneumonia
Causes of Pneumonia Specific to Geographic Region:
Location Possible Agent
Southeast Asia Burkholderia pseudomallei
Coronavirus causing severe acute respiratory
China; Taiwan; Toronto, Canada; Middle East
syndrome (SARS)
Desert regions of southwestern United States, Central and South America Coccidioides immitis
Ohio and St. Lawrence River valleys, United States Histoplasma capsulatum
Peru Sporothrix schenckii
Vancouver Island, Canada; Pacific northwest, United States Cryptococcus gattii
Mississippi River and Ohio River valley basins, around Great Lakes, United States Blastomyces dermatitidis
Reference - Pediatr Clin North Am 2013 Apr;60(2):437.
clinical features do not reliably distinguish viral, bacterial and atypical pneumonias(1, 4)
signs and symptoms appear insufficient for diagnosis of Mycoplasma pneumoniae infection in children and adolescents with
community-acquired pneumonia (level 2 [mid-level] evidence)
based on Cochrane review of studies with methodologic limitations
systematic review of 7 diagnostic cohort studies evaluating signs and symptoms for detecting M. pneumoniae in 1,491 children
≤ 18 years old with community-acquired pneumonia
all studies had at least 1 of the following limitations
unclear blinding of index test results
patient sample not representative of patients for whom test would be appropriate
uninterpretable results were not reported
time delay between reference and index tests sufficient for change in disease status
reference standard for M. pneumoniae infection was serology with or without additional laboratory tests including culture or
polymerase chain reaction
Diagnostic Performance of Sign or Symptom for Detecting Mycoplasma Pneumoniae Infection:
Sign or Symptom Sensitivity Range Specificity Range Studies Analyzed
Wheeze 12%-43% 55%-64% 6 studies with 1,291 patients
Cough 58%-99% 1%-47% 5 studies with 1,076 patients
Crepitations 71%-92% 10%-38% 5 studies with 1,121 patients
Coryza 8%-85% 16%-93% 4 studies with 833 patients
Fever 53%-94% 2%-43% 5 studies with 1,246 patients
Rhonchi 11%-74% 33%-81% 4 studies with 928 patients
Chest pain 8%-19% 93%-97% 2 studies with 488 patients
Diarrhea 4%-21% 79%-85% 2 studies with 488 patients
Shortness of breath 67% 22% 1 study with 245 patients
Headache 4% 99% 1 study with 243 patients
Myalgia 14% 87% 1 study with 245 patients
Reference - Cochrane Database Syst Rev 2012 Oct 17;10:CD009175
Past medical history (PMH)
underlying conditions(3)
congenital heart disease
lung disease including bronchopulmonary dysplasia, chronic lung disease, cystic fibrosis and asthma
diabetes mellitus
sickle cell disease
neuromuscular disorders
gastrointestinal disorders including gastroesophageal reflux and tracheoesophageal fistula
congenital and acquired immunodeficiency
Social history (SH)
factors associated with increased risk of pneumonia(3)

lower socioeconomic status (family size, crowding such as living in a shelter)
low maternal education level
poor access to care
indoor air pollution
cigarette smoke
alcohol, drugs, and cigarette use in teens
Physical
General physical
evaluate for fever and signs of respiratory illness(1, 3, 4)

cough
tachypnea
measure oxygen saturation by pulse oximetry(2)
assess for altered mental status, including lethargy or irritability(3)
agitation may be indication that child is hypoxic(1)
Skin
look for cyanosis(1)
HEENT
look for signs of respiratory distress including(1, 3)

nasal flaring
perioral cyanosis
head bobbing
Chest
signs of respiratory distress(1, 2, 3)

tachypnea (may be absent in child with pronounced retractions or other signs of increased work of breathing)
World Health Organization (WHO) Criteria for Respiratory Rates by Age:
Age Approximate Normal Respiratory Rate Tachypnea
0-2 months 40-60 breaths/minute ≥ 60 breaths/minute
2-12 months 25-40 breaths/minute ≥ 50 breaths/minute
1-5 years 20-30 breaths/minute ≥ 40 breaths/minute
≥ 5 years 15-20 breaths/minute ≥ 20 breaths/minute
dyspnea
retractions (suprasternal, intercostal, or subcostal)
grunting
accessory muscle use
apnea(3)
Lungs
exam may be normal or show(1, 2, 3)

crackles (rales)
bronchial sounds
wheezing
findings consistent with consolidated lung parenchyma
decreased or absent breath sounds
egophony (spoken letter "e" becomes "a" over affected area) or bronchophony (spoken number "99" is distinctly heard over
affected area)
dullness to percussion
tactile fremitus
Abdomen
abdominal breathing (J Clin Microbiol 2018 Mar;56(3).doi: 10.1128/JCM.01318-17 full-text)

abdominal distension in neonates(3)
lower lobe pneumonias may present as vague abdominal pain or more localized, mimicking appendicitis(1, 3)
Diagnosis
Making the diagnosis
diagnosing pneumonia in children is challenging as clinical signs and symptoms vary by age, may be subtle (especially in infants and
young children), and are often nonspecific(1, 3)
suspect in children with fever, tachypnea, breathlessness, cough, chest pain, or wheeze; presentation may also include headache, abdominal
pain, and vomiting(1, 3)
constellation of specific signs and symptoms may help determine severity(1, 3)

clinical features do not reliably distinguish viral, bacterial and atypical pneumonias(1, 4)
testing usually not indicated in children with suspected pneumonia who do not require hospitalization(1)
chest x-ray often used as diagnostic standard, but not needed in children with clinical evidence of pneumonia and mild, uncomplicated
disease(1, 3, 4)
bedside ultrasound by emergency physician helps diagnose pneumonia in children and adolescents (level 1 [likely reliable] evidence)
clinical signs and physical examination findings may be insufficient to diagnose pneumonia in children (level 2 [mid-level]
evidence)
based on systematic review limited by clinical heterogeneity
systematic review of 23 diagnostic studies evaluating symptoms and physical examination findings for diagnosis of pneumonia in
13,833 children
2 studies included preverbal children only, 10 studies included preverbal children ≤ 5 years old, 2 studies included children ≤ 6
years old, 9 studies included children from preverbal age to adolescence
8 studies were in North America, and 15 outside North America
reference standard was chest radiography
prevalence of pneumonia by reference standard was 19% in North America and 37% outside of North America
studies varied in age of included patients, location (availability and access to medical care), and definition of radiographic pneumonia
pooled diagnostic performance of symptoms and physical findings for diagnosing pneumonia
Number of Number of Positive Negative
Symptom/Findings Sensitivity Specificity
Studies Children Likelihood Ratio Likelihood Ratio
Chest pain 3 3,164 22 91 1.9 0.82
Fever > 37.5 degrees 2 366 80-92 47-54 1.7-1.8 0.17-0.37
Respiratory rate > 40
3 859 79 51 1.5 0.41
breaths/minute
Hypoxemia (oxygen
1 510 64 77 2.8 0.47
saturation ≤ 96%)
Grunting 6 1,836 13 95 2.7 0.92
Nasal flaring 10 3,541 36 84 2.2 0.77
Reference - JAMA 2017 Aug 1;318(5):462
Differential diagnosis
other conditions present with similar signs or symptoms as community-acquired pneumonia(3)

Anatomical Chronic Pulmonary Drugs and
Aspiration Pneumonia Vasculitides Other
Malformations Disorders Inhalation
Foreign body
Hypersensitivity
pneumonitis
Asthma Neoplasm
Nitrofurantoin
Bronchiectasis Pulmonary
Bleomycin
Bronchogenic Bronchopulmonary edema due to
Cytotoxic
cyst dysplasia Systemic lupus heart failure
Gastroesophageal drugs
Vascular Cystic fibrosis erythematosus Pulmonary
reflux Opioids
rings or Pulmonary fibrosis Granulomatosis embolism or
Tracheoesophageal Radiation
slings Alpha1-antitrypsin with infarction
fistula therapy
Pulmonary deficiency polyangiitis Acute
Cleft palate Smoke
sequestration Pulmonary Juvenile respiratory
Neuromuscular inhalation
Congenital hemosiderosis idiopathic distress
disorders Lipoid
lobar Alveolar arthritis syndrome
pneumonia
emphysema proteinosis Graft-vs-host
Near
Sarcoidosis disease
drowning
Histiocytosis X Acute chest
syndrome in
sickle cell
disease
other diagnoses that present with tachypnea in infants and children3
foreign body aspiration
heart failure
sepsis
metabolic acidosis
bronchiolitis
Testing overview
testing usually not indicated in children with suspected pneumonia who do not require hospitalization(1)
perform testing in children with severe pneumonia requiring pediatric intensive care unit admission or in children with complications of
community-acquired pneumonia; should not be considered routine in children with milder disease or those treated in community (BTS
Grade C)(1)
tests to identify causative organism
blood culture recommended for severe or complicated pneumonia (BTS Grade C) and for pneumonia in inpatient setting
(PIDS/IDSA Strong recommendation, Low-quality evidence)
nasopharyngeal specimen for rapid viral antigen testing for influenza (PIDS/IDSA Strong recommendation, High-quality evidence)
and other respiratory viruses (PIDS/IDSA Strong recommendation, Low-quality evidence); rapid testing also available for
identification of some bacteria
sputum studies (Gram stain and culture) in hospitalized children who can produce sputum (PIDS/IDSA Strong recommendation,
Low-quality evidence)
tracheal aspirates at time of intubation for children requiring mechanical ventilation (PIDS/IDSA Strong recommendation, Low-
quality evidence)
urine antigen testing not recommended due to high false-positive rate (PIDS/IDSA Strong recommendation, High-quality evidence)
chest x-ray
not needed in patients well enough to be treated as outpatients (PIDS/IDSA Strong recommendation, High-quality evidence)
recommended if hypoxemia, significant respiratory distress, failed initial antibiotic therapy, or hospitalization (PIDS/IDSA Strong
recommendation, Moderate-quality evidence)
evidence inconsistent on which views to take
posteroanterior and lateral chest x-rays recommended by Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases
Society of America (IDSA)
British Thoracic Society (BTS) states lateral x-ray should not be performed routinely (BTS Grade B-)
point-of-care ultrasound is an emerging diagnostic imaging modality; bedside ultrasound by emergency physician helps diagnose
pneumonia in children and adolescents (level 1 [likely reliable] evidence)
additional testing to consider in children with severe disease but otherwise not routinely recommended,
complete blood count (PIDS/IDSA Weak recommendation, Low-quality evidence)
acute phase reactants (C-reactive protein, procalcitonin, erythrocyte sedimentation rate) may be useful for clinical management
(PIDS/IDSA Weak recommendation, Low-quality evidence)
blood urea nitrogen, creatinine, and electrolyte testing if patient requires IV fluids (BTS Grade C-)(1)
perform diagnostic thoracentesis if pleural effusion
pulse oximetry recommended if suspected hypoxemia, such as respiratory distress (PIDS/IDSA Strong recommendation, Moderate-quality
evidence)
Blood tests
Complete blood count (CBC)
obtain complete blood count (CBC) in patients with severe pneumonia (PIDS/IDSA Weak recommendation, Low-quality evidence)(2)
routine CBC measurement is not necessary in all children with suspected community-acquired pneumonia managed as outpatients, but may
provide useful information for clinical management in patients with more serious disease (PIDS/IDSA Weak recommendation, Low-quality
evidence)(2)
Blood cultures
recommendations
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendations on blood cultures
depend on treatment setting(2)
outpatient setting
do not routinely perform blood cultures in nontoxic, fully immunized children with community-acquired pneumonia
(PIDS/IDSA Strong recommendation, Moderate-quality evidence)
obtain blood cultures in children who fail to show clinical improvement or have progressive symptoms or clinical
deterioration after initiation of antibiotic therapy (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
inpatient setting - obtain blood cultures in children requiring hospitalization for presumed bacterial community-acquired
pneumonia if moderate to severe, especially if complicated pneumonia (PIDS/IDSA Strong recommendation, Low-quality
evidence)
for children with bacteremia
repeated blood cultures in children with clear clinical improvement not necessary to document resolution of
pneumococcal bacteremia (PIDS/IDSA Weak recommendation, Low-quality evidence)
obtain repeated blood cultures to document resolution of bacteremia in children with bacteremia caused by
Staphylococcus aureus, regardless of clinical status (PIDS/IDSA Strong recommendation, Low-quality evidence)
British Thoracic Society (BTS) recommendations(1)
perform microbiological investigations (including blood cultures) in children with severe pneumonia requiring admission to
pediatric intensive care unit or with complications of community-acquired pneumonia (BTS Grade C)
microbiological investigation should not be considered routine in children with milder disease or those treated in community
(BTS Grade C)
blood culture positive in only a small percentage of hospitalized children with community-acquired pneumonia
based on systematic review of observational studies
systematic review of 15 prospective and 6 retrospective cohort studies evaluating blood cultures in 6,975 children aged ≤ 18 years
hospitalized with community-acquired pneumonia
425 children (6.1%) had positive blood culture
rates of positive blood culture varied depending on when study was performed in relation to availability of pneumococcal vaccine
in 9 studies performed during pre-pneumococcal vaccine (PCV) era, rate of positive blood culture was 8.06% (95% CI
5.74%-11.2%)
in 12 studies performed after PCV became available, rate of positive blood culture found was 3.04% (95% CI 1.46%-6.21%))
most commonly isolated organisms
Streptococcus pneumoniae in 76.7%
Haemophilus influenzae in 3.1%
Staphylococcus aureus in 2.1%
false-positive blood cultures ranged from 0.7%-8.1%
Reference - Hosp Pediatr 2015 Jun;5(6):324 full-text
Acute phase reactants
acute phase reactants such as C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), or procalcitonin (PCT) level cannot be
used as sole determinant to distinguish between bacterial and viral causes of community-acquired pneumonia (PIDS/IDSA Strong
recommendation, High-quality evidence)(2)
recommendations for use of acute phase reactants
not routinely recommended because they are unable to distinguish between bacterial and viral infections in children (BTS Grade A-)
(1)
CRP not useful in management of uncomplicated pneumonia and should not be measured routinely (BTS Grade A+)(1)
not needed in fully immunized children with community-acquired pneumonia managed as outpatients, but it may provide useful
information for clinical management in patients with more serious disease (PIDS/IDSA Strong recommendation, Low-quality
evidence)(2)
may be used along with clinical findings to assess response to therapy in patients with more serious disease, such as those requiring
hospitalization or with complications (PIDS/IDSA Weak recommendation, Low-quality evidence)(2)
CRP, PCT, ESR, and white blood cell count (WBC) may not be useful in distinguishing bacterial vs. viral etiology in children with
pneumonia (level 2 [mid-level] evidence)
based on small diagnostic cohort study
68 children (median age 3.6 years) with community-acquired pneumonia confirmed by chest x-ray and etiology identified by
laboratory studies were tested for CRP, WBC, PCT levels, and ESR
etiology of pneumonia
pneumococcal (including mixed infections with atypical bacteria or viruses) in 18 children (26%)
atypical bacteria (including mixed infections with viruses) in 28 children (41%)
viral infection only in 21 children (31%)
mixed nonencapsulated Haemophilus influenzae and respiratory syncytial virus (RSV) infection found in 1 child
no combination of markers had clinically significant ability to distinguish between bacterial and viral etiologies
no significant differences in etiology between chest x-rays with alveolar compared to interstitial findings
Reference - Pediatr Int 2009 Feb;51(1):91
C-reactive protein levels do not appear sensitive or specific enough for diagnostic use for pneumonia (level 2 [mid-level] evidence)
based on 2 systematic reviews of studies with methodologic limitations
systematic review of 8 cross-sectional or cohort studies evaluating diagnostic usefulness of CRP against chest x-ray reference
standard in 2,194 patients > 14 years old
median prevalence of community-acquired pneumonia 14.6%
CRP cut-point of ≤ 20 mg/L had
pooled positive likelihood ratio 2.1 (95% CI 1.8-2.4)
pooled negative likelihood ratio 0.33 (95% CI 0.25-0.43)

Reference - Fam Pract 2009 Feb;26(1):10
systematic review of 17 studies in patients > 1 month old comparing CRP with chest x-ray or microbiologic work-up as reference test
for lower respiratory tract infection
all studies had methodologic shortcomings
6 studies using infiltrate on chest x-ray as reference standard had sensitivities ranging from 10% to 98% and specificities from
44% to 99%
12 studies using bacterial etiology as reference standard had sensitivities ranging from 8% to 99% and specificities from 27%
to 95%
meta-analysis not done due to epidemiologic and statistical heterogeneity
Reference - BMJ 2005 Jul 2;331(7507):26 full-text
procalcitonin appears to be more sensitive marker for bacterial pneumonia than CRP (level 2 [mid-level] evidence)
based on diagnostic case-control study
46 children aged 1-12 years with bacterial pneumonia (based on chest x-ray and identified pathogen) and 46 healthy controls had
measurement of PCT and CRP levels
at optimum diagnostic cutoff points for each test (PCT ≥ 1 ng/mL, CRP ≥ 6 mg/mL) pneumonia correctly diagnosed
by PCT in 38 children (83% sensitivity, 72% specificity)
by CRP in 26 children (57% sensitivity, 82% specificity)
Reference - J Clin Lab Anal 2010;24(1):1
Viral serology
serologic diagnosis for specific virus is not practical because acute and convalescent specimens are needed(3)
BTS recommends that serology for respiratory viruses be included in microbiological investigation if microbiological investigation is
needed (BTS Grade B+)(1)
Urine studies
urinary antigen detection tests for pneumococcal pneumonia

urinary antigen detection tests are not recommended for diagnosis of pneumococcal pneumonia in children because false-positive
tests are common (PIDS/IDSA Strong recommendation, High-quality evidence)(2)
urinary pneumococcal antigen detection should not be done in young children (BTS Grade C)(1)
may be helpful to rule out pneumococcal infection in older children (BTS Evidence Level Ib)
positive tests nonspecific and may represent carriage (BTS Evidence Level Ib)
Imaging studies
Chest x-ray
professional organizations do not recommend routine chest x-rays to confirm suspected community-acquired pneumonia
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendations(2)
in outpatient settings (office, clinic, or emergency department setting)
chest x-ray not necessary for confirmation of suspected community-acquired pneumonia in patients well enough to be
treated as outpatients (PIDS/IDSA Strong recommendation, High-quality evidence)
obtain chest x-rays (posteroanterior and lateral) in patients with suspected or documented hypoxemia, significant
respiratory distress, or failed initial antibiotic therapy (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
chest x-rays (posteroanterior and lateral) in all patients hospitalized for management of community-acquired pneumonia
used to document presence, size, and character of parenchymal infiltrates and identify complications of pneumonia
findings may lead to interventions beyond antimicrobial agents and supportive medical therapy
chest x-ray recommended to confirm presence of pleural fluid if parapneumonic effusion is suspected; if chest x-ray not
conclusive, chest ultrasound or computed tomography (CT) recommended (PIDS/IDSA Strong recommendation, High-quality
evidence)
follow-up chest x-ray
repeat chest x-rays not routinely required in children who recover uneventfully (PIDS/IDSA Strong recommendation,
Moderate-quality evidence)
obtain repeated chest x-rays in children who do not show clinical improvement or have progressive symptoms or clinical
deterioration within 48-72 hours after starting antibiotic therapy (PIDS/IDSA Strong recommendation, Moderate-quality
evidence)
obtain follow-up chest x-rays in patients with complicated pneumonia with worsening respiratory distress or clinical
instability, or persistent fever not responding to therapy over 48-72 hours (PIDS/IDSA Strong recommendation, Low-
quality evidence)
routine daily chest x-rays not recommended in children with pneumonia complicated by parapneumonic effusion after
chest tube placement or after video-assisted thoracoscopic surgery (VATS) if they remain clinically stable (PIDS/IDSA
Strong recommendation, Low-quality evidence)
obtain repeated chest x-rays 4-6 weeks after diagnosis of community-acquired pneumonia in patients with recurrent
pneumonia involving same lobe and in patients with lobar collapse at initial chest x-ray to consider anatomic anomaly,
chest mass, or foreign body aspiration (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
British Thoracic Society (BTS) recommendations focus on when not to perform chest x-ray and when follow-up x-ray is indicated(1)
chest x-ray should not be considered a routine investigation in children suspected of community-acquired pneumonia (BTS
Grade A-)
children with signs and symptoms of pneumonia treated as outpatients should not have a chest x-ray (BTS Grade A-)
lateral x-ray should not be performed routinely (BTS Grade B-)
radiographic findings too insensitive to differentiate viral or bacterial etiology (BTS Evidence Level II)
follow-up chest x-ray
not required in children who were previously healthy who are recovering well (BTS Grade B+)
consider in children with lobar collapse, apparent round pneumonia, or persistent symptoms (BTS Grade B+)
in children with severe pneumonia, empyema, and lung abscesses, follow-up after discharge until chest x-ray has
returned to normal and they have recovered completely (BTS Grade D)
may be negative early in patients with bacterial pneumonia(3)
radiographic findings may lag behind clinical signs
infiltrate may not be visible at first in dehydrated children
difficult to differentiate between atelectasis and pneumonia
Chlamydia pneumonia. : CXR in 3 month old with respiratory distress and chlamydial infection shows multiple lobe
consolidation. Usually the lower lobes are affected, often with pleural effusion.
chest x-ray may not affect management of children aged 2-59 months with uncomplicated clinical pneumonia (level 2 [mid-
level] evidence)
based on randomized trial with unclear allocation concealment and high loss to follow-up
522 children aged 2-59 months diagnosed with clinical pneumonia in general outpatient department randomized to chest x-ray
vs. no chest x-ray with clinical management at discretion of clinician
diagnosis of clinical pneumonia determined by World Health Organization (WHO) case definition including cough and
tachypnea (respiratory rate ≥ 40 breaths/minute or ≥ 50 breaths/minute if ≤ 11 months old) but without signs of severe disease
and with adequate oral hydration

exclusion criteria were cyanosis, chest indrawing, stridor, abnormal level of consciousness, cough > 14 days, tuberculosis
exposure, localized wheeze, or clinical signs of heart failure
final diagnoses included bronchiolitis, pneumonia, upper respiratory infection, asthma recurrence, and nonspecific lower
respiratory infection
follow-up in 295 patients (57%) contactable by phone
comparing chest x-ray vs. no chest x-ray, no significant differences in
median time to recovery (7 days in both groups)
antibiotic use
immediate hospital admission
hospitalization within 28 days
Reference - Lancet 1998 Feb 7;351(9100):404
no additional trials in children found in Cochrane review evaluating chest x-ray in management of lower respiratory tract
infections ( Cochrane Database Syst Rev 2013 Dec 26;(12):CD009119)
Ultrasound
diagnostic ultrasound
point-of-care lung ultrasound is an emerging diagnostic modality (Pediatr Radiol 2017 Oct;47(11):1412 full-text)
bedside ultrasound by emergency physician helps diagnose pneumonia in children and adolescents (level 1 [likely reliable]
evidence)
based on diagnostic cohort study
200 patients ≤ 21 years old (median age 3 years) with suspected community-acquired pneumonia had bedside ultrasound in
emergency department and chest x-ray (reference standard)
ultrasound performed by 15 pediatric emergency physicians (from 2 hospitals) with varying levels of emergency ultrasound
experience after 1-hour training session on use of ultrasound to identify pneumonia and other lung conditions
18% diagnosed with pneumonia by chest x-ray
diagnostic performance of bedside ultrasound for detection of pneumonia
sensitivity 86%
specificity 89%
positive likelihood ratio 7.8
negative likelihood ratio 0.2
interobserver agreement on interpretation of ultrasound was high comparing emergency physicians vs. experienced
sonographers (kappa 0.93, 95% CI 0.87-0.99)
Reference - JAMA Pediatr 2013 Feb 1;167(2):119, commentary can be found in JAMA Pediatr 2013 Feb;167(2):187
ultrasound may help diagnose pneumonia (level 2 [mid-level] evidence)
based on 1 systematic review with clinical heterogeneity and 1 systematic review of studies with methodologic limitations
systematic review of 9 diagnostic cohort studies evaluating lung ultrasound for diagnosis of pneumonia in 1,080 children and
adults
patient populations of studies included neonates, children, and adults
pneumonia diagnosed in 644 patients by various reference standards
chest radiography or computerized tomography in 6 studies with 761 patients
based on result of computerized tomography, clinical course, conventional tests, and follow-up outcomes in 3
studies with 275 patients
diagnostic performance of ultrasound for detection of pneumonia
sensitivity 97% (95% CI 93%-99%)
specificity 94% (95% CI 85%-98%)
positive likelihood ratio 15.62 (95% CI 6.31-38.68)
negative likelihood ratio 0.03 (95% CI 0.01-0.08)
Reference - Int J Clin Exp Med 2014;7(1):115 full-text
systematic review of 8 diagnostic cohort studies (5 studies included in systematic review above) evaluating lung ultrasound for
diagnosis of pneumonia in 765 children < 18 years old
lung ultrasound technicians were not blinded to clinical data
5 studies used chest x-ray alone as reference standard and 5 studies used chest x-ray plus addition of clinical criteria
diagnostic performance of ultrasound for detection of pneumonia
sensitivity 96% (95% CI 94%-97%)
specificity 93% (95% CI 90%-95.7%)
positive likelihood ratio 15.3 (95% CI 6.6-35.3)
negative likelihood ratio 0.06 (95% CI 0.03-0.11)
Reference - Pediatrics 2015 Apr;135(4):714
lung ultrasound with option for chest x-ray reduces use of chest x-ray without increasing missed cases of pneumonia in
children and adolescents with suspected pneumonia (level 1 [likely reliable] evidence)
based on randomized trial

191 patients < 21 years old with suspected pneumonia were randomized to lung ultrasound with option for chest x-ray if
clinical uncertainty after ultrasonography or x-ray requested vs. sequential chest x-ray then lung ultrasound
comparing lung ultrasound vs. chest x-ray
chest x-ray in 61% vs. 100% (p < 0.05, NNT 3)
no missed cases of pneumonia in either group
unscheduled healthcare visit within 1-2 weeks of index visit in 8.7% vs. 11.4% (not significant)
antibiotic use at emergency department exit in 37.9% vs. 27.3% (not significant)
admission rate 19.4% vs. 17% (not significant)
Reference - Chest 2016 Jul;150(1):131 full-text
ultrasound for identifying parapneumonic effusion in more severe cases(1, 2)
if parapneumonic effusion suspected but evidence of pleural fluid not obtained from chest x-ray, chest ultrasound or computed
tomography (CT) recommended (PIDS/IDSA Strong recommendation, High-quality evidence)
chest ultrasound considered to be safer imaging procedure than CT due to lack of ionizing radiation
can also be used to estimate amount of fluid in pleural space if pleural effusion detected on x-ray
Computed tomography (CT)
CT may be performed(1, 2)
in complicated cases of severe, unresolving pneumonia where intervention is considered
to confirm diagnosis of abscess or necrosis
if a chest mass is suspected
Other diagnostic testing
Pulse oximetry
pulse oximetry is frequently used in initial evaluation to identify hypoxemia(1, 2)

Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA) specifically recommends pulse oximetry
in all children with pneumonia and suspected hypoxemia (PIDS/IDSA Strong recommendation, Moderate-quality evidence)(2)
hypoxemia may be suspected if
tachypnea
age 0-2 months - respiratory rate > 60 breaths/minute
age 2-12 months - respiratory rate > 50 breaths/minute
age 1-5 years - respiratory rate > 40 breaths/minute
age > 5 years - respiratory rate > 20 breaths/minute
dyspnea
retractions (suprasternal, intercostals, or subcostal)
grunting
nasal flaring
apnea
altered mental status
hypoxemia is associated with poor prognosis and should therefore guide decisions regarding site of care and further diagnostic
testing
for reliable reading(1)
encourage child to be still and quiet
obtain good pulse signal
once signal obtained, watch saturation reading for ≥ 30 seconds and record value once adequate stable trace obtained
Rapid testing of nasopharyngeal specimens
rapid testing using immunofluorescence or polymerase chain reaction may help identify etiology; rapid tests are available for(3)
respiratory syncytial virus (RSV)
parainfluenza 1, 2, and 3
influenza A and B
adenovirus
coronaviruses
rhinovirus and enterovirus
human metapneumovirus
atypical bacteria, Mycoplasma pneumoniae and Chlamydia pneumoniae
Bordetella pertussis
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendations on viral testing(2)
use sensitive and specific tests for rapid diagnosis of influenza virus and other respiratory viruses in evaluation of children with
community-acquired pneumonia (PIDS/IDSA Strong recommendation, High-quality evidence)
positive influenza test may
decrease need for additional diagnostic studies and antibiotic use
guide appropriate use of antiviral agents
antibacterial therapy not necessary for children with positive test for influenza virus in absence of other findings suggestive of
bacterial co-infection (PIDS/IDSA Strong recommendation, High-quality evidence)
testing for respiratory viruses other than influenza virus can modify clinical decision making in children with suspected pneumonia
(PIDS/IDSA Weak recommendation, Low-quality evidence)
British Thoracic Society (BTS) recommends sending nasopharyngeal secretions and/or nasal swabs for viral detection by polymerase chain
reaction (PCR) and/or immunofluorescence if microbiological diagnosis is needed (BTS Grade C)(1)
rapid viral testing for children with acute febrile respiratory illness in emergency department may reduce chest x-rays but not
antibiotic use (level 2 [mid-level] evidence)
based on Cochrane review of trials with methodological limitations
systematic review of 3 randomized trials and 1 quasi-randomized trial comparing rapid viral testing in emergency department vs. no
testing in 1,588 children with acute febrile respiratory illness
rapid viral testing included direct or indirect immunofluorescent antibody test, enzyme immunoassay, optical immunoassay, or
molecular testing of nasal pharyngeal aspirates or swabs
3 trials evaluated influenza testing, 1 trial evaluated multiviral testing
methodological limitations included unclear allocation concealment in 3 trials specific to influenza testing
rapid testing associated with reduced use of chest x-rays (risk ratio 0.77, 95% CI 0.65-0.91) in analysis of all trials
no significant differences in
antibiotic use in emergency department
urine testing
mean time in emergency department
visits to medical department after emergency discharge
Reference - Cochrane Database Syst Rev 2014 Sep 15;(9):CD006452
Sputum Gram stain and culture
obtain sputum samples for Gram stain and culture in hospitalized children who can produce sputum (PIDS/IDSA Weak recommendation,
Low-quality evidence); infrequently performed in children due to difficulty of obtaining adequate sample(2)
adequate sputum sample is one with both(3)
< 10 epithelial cells per low power field
> 25 polymorphonuclear leukocytes per low power (x100) field
Viral cultures
viral cultures have limited clinical utility for pneumonia because

viral cultures have low sensitivity compared to serology or polymerase chain reaction (PCR)
cultures may take 3-14 days for results
virus may be thermolabile and may not survive transport to laboratory
cultures require expertise, are labor intensive and expensive
many viruses grow poorly in culture
patients may have low titer of virus
shedding from patient may be for shorter period of time than for upper respiratory illness
Reference - Curr Opin Infect Dis 2009 Apr;22(2):143
Pleural fluid aspiration
if pleural fluid present, send for microscopy, culture, pneumococcal antigen detection, and/or polymerase chain reaction (PCR) (BTS Grade
C)(1)
recommended laboratory testing on pleural fluid includes(2)
Gram stain and bacterial culture (PIDS/IDSA Strong recommendation, High-quality evidence)
antigen testing or PCR (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
pleural fluid white blood cell count with cell differential analysis may help differentiate bacterial cause from mycobacteria and
malignancy (PIDS/IDSA Weak recommendation, Moderate-quality evidence)
analysis of pleural fluid parameters (pH, glucose, protein, lactate dehydrogenase) not recommended because they rarely change
management (PIDS/IDSA Weak recommendation, Very low-quality evidence)(2)
Tracheal or lung specimens
reserve for critically ill children or children with significant comorbidity and inconclusive initial diagnostic workup in which the risk of
establishing the diagnosis outweighs the risk of the procedure(3)
in children requiring mechanical ventilation, obtain tracheal aspirates at time of initial intubation for Gram stain and culture and clinically
and epidemiologically guided testing for viral pathogens such as influenza virus (PIDS/IDSA Strong recommendation, Low-quality
evidence)(2)
in immunocompetent children, reserve bronchoscopic or blind protected specimen brush sampling, bronchoalveolar lavage (BAL),
percutaneous lung aspiration, or open lung biopsy for severe community-acquired pneumonia where initial testing is not diagnostic
(PIDS/IDSA Weak recommendation, Low-quality evidence)(2)
in children not responding to treatment for community-acquired pneumonia(2)
obtain BAL specimen for Gram stain and culture for mechanically ventilated child (PIDS/IDSA Strong recommendation, Moderate-
quality evidence)
obtain percutaneous lung aspirate for Gram stain and culture in persistently and seriously ill child for whom previous investigations
have not yielded microbiologic diagnosis (PIDS/IDSA Weak recommendation, Low-quality evidence)
obtain open lung biopsy for Gram stain and culture in persistently and critically ill mechanically ventilated child in whom previous
investigations have not yielded microbiologic diagnosis (PIDS/IDSA Weak recommendation, Low-quality evidence)
Management
Management overview
consider severity of illness and home setting in determining appropriateness of inpatient vs. outpatient treatment
admit to hospital if
oxygen saturation < 90% on room air, or respiratory distress (PIDS/IDSA Strong recommendation, High-quality evidence)
dehydration, inability to feed
questionable ability to be cared for safely at home (PIDS/IDSA Strong recommendation, Low-quality evidence)
British Thoracic Society (BTS) recommends all children with clear clinical diagnosis of pneumonia should receive antibiotics (BTS Grade
C)
recommendations for identifying those who do not need antibiotics
in young children < 4 years with mild symptoms of lower respiratory infection, underlying etiology is likely viral; in these cases,
guidelines do not recommend routinely giving antibiotics
antibacterial therapy not necessary for children with positive test for influenza virus in absence of clinical, laboratory, or radiographic
findings that suggests bacterial co-infection in the outpatient or inpatient setting (PIDS/IDSA Strong recommendation, High-quality
evidence)(2)
outpatient management
for children < 5 years old with nonsevere pneumonia
oral amoxicillin usually recommended as first-line empiric treatment for presumed bacterial pneumonia
oral amoxicillin is typically given at 90 mg/kg/day in 2 divided doses for up to 10 days
for children ≥ 5 years old - recommendations for first-line therapy vary between amoxicillin and macrolides
consider amoxicillin for presumed bacterial pneumonia (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
and/or macrolide for presumed atypical pneumonia (PIDS/IDSA Weak recommendation, Moderate-quality evidence)
dosing
amoxicillin 90 mg/kg/day in 2 divided doses (maximum 4 g/day)
azithromycin 10 mg/kg/day for 1 day (maximum 500 mg/day), then 5 mg/kg/day orally (maximum 250 mg/day) for 4
days
clarithromycin 15 mg/kg/day in 2 divided doses (maximum 1,000 mg/day) for 7-10 days
erythromycin 40 mg/kg/day in 4 divided doses (maximum 2,000 mg/day) for 7-10 days
alternative in children > 8 years old - doxycycline 4 mg/kg/day in 2 divided doses (maximum 200 mg/day) for 7-10 days
provide caretakers with information on fever management and dehydration prevention; also educate caretakers about the need for
reevaluation if symptoms persist or do not respond to treatment (BTS Grade D)(1)
inpatient management
BTS states oral antibiotics are safe and effective, even for severe pneumonia (BTS Grade A+)
if child is unable to tolerate oral fluids or absorb oral antibiotics or presents with signs of septicemia or complicated pneumonia, BTS
recommends IV antibiotics (BTS Grade D)
recommended IV antibiotics for children hospitalized for community-acquired pneumonia include
ampicillin or penicillin G for fully immunized children in areas with minimal penicillin resistance in invasive pneumococcus
strains (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
ceftriaxone or cefotaxime for children who are severely ill, not fully immunized, or in areas with penicillin-resistant
pneumococcus (PIDS/IDSA Weak recommendation, Moderate-quality evidence)
add macrolide (oral or parenteral) when either Mycoplasma pneumoniae or Chlamydia pneumoniae is significant consideration
(PIDS/IDSA Weak recommendation, Moderate-quality evidence)
BTS recommends oxygen treatment for patients with oxygen saturation ≤ 92% on room air; deliver by nasal cannulae, high-flow
delivery device, head box, or face mask to maintain oxygen saturation > 92% (BTS Grade B)(1)
antiviral medications for children with confirmed influenza or more complicated cases with suspected influenza
drugs of choice should be based on circulating viruses and antiviral resistance patterns
antiviral treatment recommended as soon as possible for patients with confirmed or suspected influenza who have severe,
complicated, or progressive illness, require hospitalization, or are at higher risk for influenza complications
antiviral treatment may be considered for any outpatient with confirmed or suspected influenza if treatment can be started within 48
hours of illness onset
other adjunctive treatments may include
zinc supplementation
adjuvant chest physiotherapy
2011 BTS guideline does not recommend adjuvant chest physiotherapy in children with pneumonia citing lack of evidence of
efficacy (BTS Grade A-)(1)
2019 Cochrane concludes that chest physical therapy might reduce mortality in hospitalized children with pneumonia (level 2
[mid-level] evidence)
follow-up and consider additional testing or change in management if no improvement 48 hours after starting treatment
Treatment setting
Indications for hospitalization
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommend hospitalization for community-
acquired pneumonia (CAP) in children with any of(2)
moderate-to-severe CAP, defined as any of (PIDS/IDSA Strong recommendation, High-quality evidence)
tachypnea (based on age)
dyspnea
retractions (suprasternal, intercostals, or subcostal)
grunting
nasal flaring
apnea
pulse oximetry measurement < 90% on room air
suspected or documented CAP caused by pathogen with increased virulence, such as community-associated methicillin-resistant
Staphylococcus aureus (CA-MRSA) (PIDS/IDSA Strong recommendation, Low-quality evidence)
concern about careful observation at home, inability to comply with therapy, or inability to be followed up (PIDS/IDSA Strong
recommendation, Low-quality evidence)
infants < 3-6 months old with suspected bacterial CAP (PIDS/IDSA Strong recommendation, Low-quality evidence)
evaluation and management at hospital should occur if
oxygen saturation < 92% (BTS Grade B+)
auscultation reveals absent breath sounds with dullness to percussion; raises suspicion of pneumonia complicated by effusion
(BTS Grade B-)
decision on whether to admit a child should be based on clinical severity, underlying risk factors for severe disease, and ability of
parents to manage illness in the community
features of severe disease that likely require hospital admission include
oxygen saturation < 92%, cyanosis
respiratory rate > 70 breaths/minute in infants or > 50 breaths/minute in older child
significant tachycardia for level of fever
prolonged central capillary refill time > 2 seconds
difficulty breathing
grunting
intermittent apnea in infant
not feeding in infant, signs of dehydration in older child
chronic conditions, such as
congenital heart disease
chronic lung disease of prematurity

chronic respiratory conditions leading to infection such as cystic fibrosis, bronchiectasis, immune deficiency
family unable to provide appropriate observation or supervision
Indications for intensive care
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendations for intensive care unit (ICU)
admission(2)
admit to ICU if
child requires invasive ventilation via nonpermanent artificial airway (such as endotracheal tube) (PIDS/IDSA Strong
recommendation, High-quality evidence)
pulse oximetry measurement < 92% on inspired oxygen ≥ 50% (PIDS/IDSA Strong recommendation, Low-quality evidence)
admit to ICU or unit with continuous cardiorespiratory monitoring capabilities if
impending respiratory failure (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
child acutely requires use of noninvasive positive pressure ventilation (such as continuous positive airway pressure or bilevel
positive airway pressure) (PIDS/IDSA Strong recommendation, Very low-quality evidence)
sustained tachycardia, inadequate blood pressure, or need for pharmacologic support of blood pressure or perfusion
altered mental status, whether due to hypercarbia or hypoxemia as result of pneumonia (PIDS/IDSA Strong recommendation,
consider admission to ICU or unit with continuous cardiorespiratory monitoring capabilities in children with ≥ 2 of
tachypnea
apnea
increased work of breathing (such as retractions, dyspnea, nasal flaring, grunting)
partial pressure of arterial oxygen (PaO2)/inspired fraction of oxygen (FiO2) ratio < 250
multilobar infiltrates
Pediatric Early Warning Scale score > 6 ( Paediatr Nurs 2005 Feb;17(1):32)
hypotension
presence of effusion
comorbid conditions (such as sickle cell disease, immunosuppression, immunodeficiency)
unexplained metabolic acidosis
use severity of illness scores in context of other clinical, laboratory, and radiologic findings and not as sole criteria for decisions on
ICU admission (PIDS/IDSA Strong recommendation, Low-quality evidence)
British Thoracic Society (BTS) recommends considering intensive care unit admission (or transfer) for (BTS Evidence Level IVb)(1)
failure to maintain oxygen saturation > 92% on oxygen therapy with FiO2 > 60%
shock
increasing respiratory and heart rates with clinical evidence of severe respiratory distress and exhaustion, with or without increased
arterial carbon dioxide tension (PaCO2)
recurrent apnea or slow irregular breathing
Comparing treatment settings in developing countries
home-based treatment with high-dose oral amoxicillin appears at least as effective as hospitalization with parenteral ampicillin for
children < 5 years old with severe pneumonia (level 2 [mid-level] evidence)
based on randomized trial in Pakistan with baseline differences
2,100 patients aged 3-59 months with severe pneumonia were randomized to home-based treatment vs. initial hospitalization
home-based treatment group given oral amoxicillin 80-90 mg/kg/day in 2 divided doses for 5 days
initial hospitalization group given parenteral ampicillin 100 mg/kg/day in 4 divided doses for 48 hours, then oral amoxicillin
80-90 mg/kg/day for 3 days
children excluded if known asthma or very severe pneumonia (unable to drink, convulsions, central cyanosis, abnormally sleepy or
difficult to wake, stridor in calm child, or clinically severe malnutrition)
hospitalized children were more likely than home-based group at baseline to have diarrhea, vomiting, previous antibiotic use, and
audible wheeze (absolute differences of about 5%)
follow-up assessments at 1, 3, 6, and 14 days after enrollment
treatment failure defined as any of
inability to take oral medication due to persistent vomiting
development of comorbid condition requiring antibiotic
persistence of fever > 38 degrees C (100.4 degrees F) with lower chest indrawing/retractions from days 3 to 6
fever or lower chest indrawing/retractions alone
hospitalization due to pneumonia
any serious adverse event

left against medical advice or lost to follow-up
voluntary withdrawal of consent or death
comparing home-based vs. hospital-based treatment in intention-to-treat analysis
treatment failure by 3 days in 4.5% vs. 7% (NNT 40, 95% CI for difference -4.5% to -0.5%)
treatment failure by 6 days in 8.5% vs. 10% (95% CI for difference -4% to +0.9%)
death within 14 days in 1 vs. 4 children
Reference - Lancet 2008 Jan 5;371(9606):49, editorial can be found in Lancet 2008 Jan 5;371(9606):7, commentary can be found in
Lancet 2008 Apr 19;371(9621):1333
day treatment for children < 5 years old with severe pneumonia in Bangladesh may have higher referral and readmission rates
compared to hospital care, especially for infants with hypoxemia (level 2 [mid-level] evidence)
based on randomized trial with baseline differences
360 children in Bangladesh aged 2-59 months with severe pneumonia randomized to day care (antibiotic treatment, feeding, and
supportive care from 8 AM to 5 PM) vs. hospital care with 24-hour treatment
children with severe-acute malnutrition were excluded from trial
hypoxemia at baseline in 63% with day care vs. 42% with hospital care (p < 0.001)
successful management defined as clinical improvement without referral to another hospital, full compliance with management
program, and not dropping out of study for any reason
comparing day care vs. hospital care
successful management in 87.7% vs. 96.1% (p = 0.001, NNH 12)
referral to hospital after initial care required in 12.8% vs. 2.2% (p < 0.001, NNH 9)
referral or readmission to hospital within 3 months required in 14.1% vs. 6.4% (p = 0.01, NNH 13)
hypoxemia associated with lower treatment success and increased readmission to hospital
Reference - Pediatrics 2010 Oct;126(4).doi:10.1542/peds.2009-3631
integration of modified guidelines for severe pneumonia in childhood associated with reduced hospital burden but similar case
fatality in Bangladesh (level 2 [mid-level] evidence)
based on comparison of 2 cohorts of children aged 2-59 months with severe pneumonia in Bangladesh
261 children presenting before implementation of modified WHO's Integrated Management of Childhood Illness guidelines
compared to 1,271 children admitted after full implementation of guidelines
modified guidelines allowed most children with severe pneumonia to be treated locally with referral to hospital for those with severe
classifications
comparing admission before vs. after modified guideline implementation
proportion of children referred to hospital 94% vs. 8% (p < 0.0001)
correct management received in 36% vs. 90% (p < 0.0001)
case-fatality rate of children presenting at first-level facilities 1.1% vs. 0.6% (not significant)
Reference - Lancet 2008 Sep 6;372(9641):822, editorial can be found in Lancet 2008 Sep 6;372(9641):781
community health worker management of severe pneumonia associated with similar treatment failure and similar detection of
treatment failure compared to referral to health facility for children living in Pakistan (level 2 [mid-level] evidence)
based on cluster-randomized trial with wide confidence intervals
4,691 Pakistani children aged 2-59 months with suspected severe pneumonia randomized by cluster to community health worker
identification and management vs. community health worker identification and health facility-based management
community health worker management included oral amoxicillin syrup 90 mg/kg/day in 2 doses for 5 days at home
health facility-based management included 1 age-based dose of oral co-trimoxazole with referral to nearest health facility for
admission and IV antibiotics per program policy and standard of care
all children in both groups had follow-up visits at home on days 2, 3, 6, and 14 by community health worker
treatment failure defined as meeting 1 of following criteria
appearance of any signs of very severe pneumonia
change of antibiotic treatment without objective criteria of treatment failure
80% persistence of fever > 38 degrees C (100.4 degrees F) with lower chest indrawing on day 3 (after 48 hours of initiation of
treatment)
either fever > 100 degrees F (37.78 degrees C) or lower chest indrawing alone at day 6
death
80% had complete assessment on day 3
94% had complete assessment on day 6 and were included in per-protocol analysis
comparing community health worker management group vs. health facility-based management group
specificity for detecting presence of severe pneumonia 93.5% vs. 96.5%
treatment failure by day 6 in 8% vs. 13% (adjusted risk difference -5.2% [95% CI -13.7% to 3.3%, not significant])
Reference - Lancet 2012 Feb 25;379(9817):729, editorial can be found in Lancet 2012 Feb 25;379(9817):692
community health worker providing antibiotics in home may reduce treatment failure in children with severe pneumonia living in
Pakistan (level 2 [mid-level] evidence)
based on cluster-randomized trial without blinding
3,472 Pakistani children (median age 10 months) with severe pneumonia randomized by cluster to community health worker-based
vs. health facility-based treatment

intervention included health workers providing complete course of weight-based dose oral amoxicillin daily to mother with
specific guidance about use and evaluated child on days 2, 3, 6, and 14
standard of care included health workers providing 1 weight-based dose of oral co-trimoxazole and referring children to health
facility with antibiotic choice by provider
treatment failure defined as inability to eat or drink, seizure, fever, chest retractions, and change of antibiotic (through self-referral or
by carers)
lower treatment failure rate at day 6 in community health worker group vs. health facility treatment group, 9% vs. 18% (p < 0.05,
NNT 12)
Reference - Lancet 2011 Nov 19;378(9805):1796 full-text, editorial can be found in Lancet 2011 Nov 19;378(9805):1762
Fluid and electrolytes

British Thoracic Society (BTS) recommends measuring plasma sodium, potassium, urea, and/or creatinine at baseline and at least daily if
IV fluids needed as part of management of hospitalized children (BTS Grade C)(1)
no randomized trials identified to evaluate effect of increasing fluid intake in acute respiratory infections
based on Cochrane review
Reference - Cochrane Database Syst Rev 2011 Feb 16;(2):CD004419
Diet
British Thoracic Society (BTS) recommendations regarding nasogastric tube feeding in children with pneumonia (BTS Grade D)(1)
nasogastric tube may compromise breathing - avoid in severely ill children, especially in infants with small nasal passages
if used, smallest tube should be passed down smallest nostril
Medications
Antibiotics
recommendations for identifying who needs antibiotics(1, 2)

British Thoracic Society (BTS) recommends all children with clear clinical diagnosis of pneumonia should receive antibiotics (BTS
Grade C)
in young children < 4 years, if symptoms of lower respiratory infection are mild, underlying etiology is likely viral; in these cases,
guidelines do not recommend routinely giving antibiotics
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendation applies to
preschool-aged children (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
BTS recommendation applies to children aged < 2 years; history of pneumococcal vaccination supports this decision (BTS
Grade C)
antibacterial therapy not necessary for children with positive test for influenza virus in absence of clinical, laboratory, or radiographic
findings that suggests bacterial co-infection in the outpatient or inpatient setting (PIDS/IDSA Strong recommendation, High-quality
evidence)
antibiotics for pediatric outpatients

general approach to outpatient treatment with antibiotics
for presumed bacterial pneumonia in otherwise healthy, fully immunized children, oral amoxicillin is usual first-line empiric
antibiotic in children < 5 years old, and amoxicillin with or without macrolides are usual first-line treatment in older children
bacterial infection and resistance patterns vary by region
recommendations for outpatient antibiotics in children < 5 years old
PIDS/IDSA recommendations for children aged 3 months to < 5 years
amoxicillin recommended as first-line therapy presumed bacterial pneumonia (PIDS/IDSA Strong recommendation,
Moderate-quality evidence); usually given 90 mg/kg/day orally in 2 divided doses
consider macrolides for presumed atypical pneumonia in school-aged children (PIDS/IDSA Weak recommendation,
Moderate-quality evidence)
antimicrobial therapy not routinely required in preschool-aged children (PIDS/IDSA Strong recommendation, Moderate-
quality evidence)
BTS recommendations
oral amoxicillin recommended; alternatives are amoxicillin-clavulanate, cefaclor, erythromycin, azithromycin, and
clarithromycin (BTS Grade B); high-dose amoxicillin given in 2 divided doses considered pharmacokinetically
satisfactory
macrolides recommended if Mycoplasma or Chlamydia pneumonia is suspected, if disease is very severe, or if there is
no response to first-line treatment (BTS Grade D)
amoxicillin-clavulanate recommended for pneumonia associated with influenza (BTS Grade D)

antimicrobial therapy not routinely required in children < 2 years old with mild symptoms of lower respiratory tract
infection (BTS Grade C)
recommendations for outpatient antibiotics in children ≥ 5 years old
PIDS/IDSA recommendations(2)
consider local susceptibility data when determining appropriate dose of empiric amoxicillin
for fully susceptible strains, 90 mg/kg/day in 2 divided doses is likely to be successful
for relatively resistant strains (minimum inhibitory concentrations [MICs] 2 mcg/mL), 90 mg/kg/day in 3 divided
doses associated with higher cure rate
recommended alternative to amoxicillin is oral amoxicillin-clavulanate with amoxicillin component given at 90
mg/kg/day in 2 or 3 divided doses depending on susceptibility data
consider addition of macrolides for presumed atypical pneumonia (PIDS/IDSA Weak recommendation, Moderate-
quality evidence); azithromycin 10 mg/kg orally on day 1, then 5 mg/kg orally once daily on days 2-5 preferred
if child with presumed bacterial CAP does not have clinical, laboratory, or radiographic evidence that distinguishes
bacterial CAP from atypical CAP, macrolide can be added to beta-lactam antibiotic
BTS recommends
oral amoxicillin; alternatives are amoxicillin-clavulanate, cefaclor, erythromycin, azithromycin, and clarithromycin
(BTS Grade B); high-dose amoxicillin given in 2 divided doses considered pharmacokinetically satisfactory
macrolides for very severe disease, if Mycoplasma or Chlamydia pneumonia suspected, or if no response to first-line
treatment (BTS Grade D)
amoxicillin-clavulanate for pneumonia associated with influenza (BTS Grade D)
see Antibiotics for pediatric outpatients with community-acquired pneumonia for details
antibiotics for pediatric inpatients

treatment for pneumonia varies according to bacterial infection and resistance patterns by region
PIDS/IDSA recommendations for children > 3 months old
give ampicillin or penicillin G for fully immunized children with non-life-threatening pneumonia in regions with minimal
penicillin resistance in local pneumococcus strains (PIDS/IDSA Strong recommendation, Moderate-quality evidence);
alternatives are ceftriaxone and cefotaxime
consider ceftriaxone or cefotaxime for children with life-threatening infection, who are not fully immunized, or reside in areas
with penicillin-resistant pneumococcus (PIDS/IDSA Weak recommendation, Moderate-quality evidence)
DynaMed commentary -- Cefotaxime is no longer manufactured in the United States.
add macrolide if Mycoplasma pneumoniae or Chlamydophila pneumoniae infection is a significant consideration (PIDS/IDSA
Weak recommendation, Moderate-quality evidence), azithromycin preferred
add vancomycin or clindamycin if clinical, laboratory, or imaging findings suggest Staphylococcus aureus infection
treatment courses of 10 days have been best studied, shorter courses may be just as effective (PIDS/IDSA Strong
recommendation, Moderate-quality evidence)
British Thoracic Society (BTS) recommends
antibiotics for all children with clear clinical diagnosis of pneumonia (BTS Grade C)
oral antibiotics are safe and effective, even for severe pneumonia (BTS Grade A+)
IV antibiotics (amoxicillin, amoxicillin-clavulanate, cefuroxime, cefotaxime, or ceftriaxone) for children unable to absorb oral
antibiotics or with signs of septicemia or complicated pneumonia (BTS Grade D)
macrolides for very severe disease, if Mycoplasma or Chlamydia pneumonia suspected, or if no response to first-line treatment
(BTS Grade D)
see Antibiotics for pediatric inpatients with community-acquired pneumonia for details
Antiviral medications for influenza
Centers for Disease Control and Prevention (CDC) 2018-2019 recommendations for treatment of influenza
indications for treatment
antiviral treatment recommended as soon as possible for patients with confirmed or suspected influenza who
have severe, complicated, or progressive illness
require hospitalization
are at higher risk for influenza complications, such as
children aged < 2 years
adults aged ≥ 65 years
persons with chronic pulmonary, cardiovascular, renal, hepatic, hematologic, and metabolic disorders
persons with neurologic and neurodevelopment conditions
persons with immunosuppression
women who are pregnant or postpartum (within 2 weeks of delivery)
persons aged < 19 years taking long-term aspirin or salicylate-containing therapy
American Indians/Alaska Natives

persons with body mass index ≥ 40 kg/m2
residents of nursing homes and other chronic care facilities
antiviral treatment may be considered for any previously healthy outpatient with confirmed or suspected influenza, regardless
of rapid diagnostic testing results, if treatment can be started within 48 hours of illness onset
timing
give antivirals as soon as possible
do not delay treatment while awaiting confirmatory diagnostic tests
antivirals given within 48 hours of symptom onset associated with greatest benefit
treatment up to 5 days after onset of illness also associated with reduced morbidity and mortality in hospitalized patients
agents and dosing
recommended agents and duration for outpatients with uncomplicated influenza
oral oseltamivir for 5 days
inhaled zanamivir for 5 days
IV peramivir for 1 day (1 dose)
baloxavir for 1 day (1 dose)
dosing
oseltamivir dosing
for children aged < 12 months, 3 mg/kg twice daily
for children aged ≥ 1 year
30 mg twice daily for patients weighing ≤ 15 kg (33.1 lbs)
45 mg twice daily for patients weighing > 15 kg to 23 kg (33.1 lbs to 50.7 lbs)
60 mg twice daily for patients weighing > 23 kg to 40 kg (50.7 lbs to 88.2 lbs)
75 mg twice daily for patients weighing > 40 kg (88.2 lbs)
for adults, 75 mg twice daily
zanamivir dosing 10 mg (two 5 mg inhalations) twice daily for patients aged ≥ 7 years (not approved for children aged
1-6 years)
peramivir dosing
for children aged 2-12 years, 12 mg/kg single dose (maximum 600 mg) IV over 15 minutes (not approved for
children aged < 2 years)
for patients aged ≥ 13 years, 600 mg single dose IV over 15 minutes
baloxavir (not approved for children aged < 12 years or patients < 40 kg [176.4 kg])
40 mg single dose orally for patients aged ≥ 12 years weighing 40 kg to < 80 kg (88.2 to < 176.4 kg),
80 mg single dose orally for patients aged ≥ 12 years weighing ≥ 80 kg (≥ 176.4 lbs)
considerations for special populations
for patients with underlying respiratory illness, inhaled zanamivir not recommended
for hospitalized patients or patients with severe or complicated illness
oral or enteric oseltamivir preferred
optimal dose and duration unknown and regimen may be altered based on clinical circumstances
consider IV peramivir in patients who cannot tolerate or absorb enterically administered oseltamivir
inhaled zanamivir and oral baloxavir not recommended due to lack of data in hospitalized patients
for pregnant women, oseltamivir preferred agent with same dosing as for nonpregnant persons
dose adjustment recommended for patients with renal impairment or end-stage renal disease (ESRD)
adjusted dosing for oral oseltamivir
75 mg twice daily for creatinine clearance 61-90 mL/minute
30 mg twice daily for creatinine clearance 31-60 mL/minute
30 mg once daily for creatinine clearance 11-30 mL/minute
30 mg after every hemodialysis cycle (treatment duration not to exceed 5 days) for patients with ESRD on
hemodialysis and creatinine clearance ≤ 10 mL/minute
single 30 mg dose immediately after a dialysis exchange for patients with ESRD on continuous ambulatory
peritoneal dialysis and creatinine clearance ≤ 10 mL/minute
adjusted dosing for IV peramivir (single dose)
600 mg for creatinine clearance ≥ 50 mL/minute
200 mg for creatinine clearance 30-49 mL/minute
100 mg for creatinine clearance 10-29 mL/minute
administer after dialysis at dose adjusted based on creatinine clearance for patients with ESRD on
hemodialysis
amantadine and rimantadine not recommended
Reference - CDC 2018 Nov 13
see Influenza in children for details
Adjunctive treatments
antipyretics may be used to keep child comfortable(1, 3)
systemic steroids may be helpful in subpopulations of children with community-acquired pneumonia but are not recommended by current
guidelines
addition of prednisolone to azithromycin may reduce duration of dyspnea in hospitalized children with Mycoplasma
pneumoniae pneumonia (level 2 [mid-level] evidence)
based on small randomized trial
58 children (mean age 8 years) admitted to hospital in China with Mycoplasma pneumoniae were randomized to azithromycin
IV 10 mg/kg once daily plus oral prednisolone 1 mg/kg twice daily vs. azithromycin IV 10 mg/kg once daily for 5 days
comparing azithromycin plus prednisolone vs. azithromycin alone
mean time to dyspnea resolution 1.5 days vs. 2.9 days (p < 0.05)
mean duration of hypoxemia 1.9 days vs. 2.7 days (p < 0.05)
resolution of pleural effusion in 88.9% vs. 20% (p = 0.005, NNT 2)
atelectasis resolution in 71.4% vs. 12.5% (p = 0.041, NNT 2)
resolution of fever within 48 hours in 100% vs. 0% (no p value reported)
Reference - Pediatr Pulmonol 2014 Apr;49(4):377
corticosteroids may reduce radiographic progression or clinical instability at day 5-8 in children with pneumonia (level 2
[mid-level] evidence)
based on Cochrane review of trials without blinding
systematic review of 17 randomized trials evaluating corticosteroids in 2,264 children and adults with radiographically
confirmed pneumonia
4 trials evaluated corticosteroids vs. no treatment or placebo in 310 children being treated with antibiotics
3 trials evaluated children with bacterial pneumonia, 1 evaluated children with viral pneumonia
no deaths reported in 4 trials, and no secondary infections reported in 3 trials
early clinical failure defined as any of death, radiographic progression, or clinical instability at day 5-8
clinical instability defined differently in studies; in 2 studies used in meta-analysis, definitions included no infiltrate resolution
at day 7 and lack of clinical improvement on day 7
corticosteroids associated with reduced early clinical failure in analysis of 2 trials of 88 children with bacterial pneumonia
risk ratio 0.41 (95% CI 0.24-0.70)
NNT 2-5 with early clinical failure in 66% of control group
Reference - Cochrane Database Syst Rev 2017 Dec 13;12;CD007720
systemic corticosteroids associated with shorter hospital stay overall for children with pneumonia, but among children with
pneumonia who did not require beta-agonist for wheezing at admission, systemic corticosteroids associated with longer
hospital stay and higher readmission rate (level 2 [mid-level] evidence)
based on retrospective cohort study
20,703 children aged 1-18 years hospitalized with community-acquired pneumonia with 35% receiving adjunct corticosteroid
therapy
53% of patients received beta-agonist therapy on admission to treat acute wheezing
systemic corticosteroid therapy was associated with shorter hospital stay in
overall study population (adjusted hazard ratio [HR] 1.24, 95% CI 1.18-1.3)
patients with concomitant beta-agonist therapy (adjusted HR 1.36, 95% CI 1.28-1.45)
in subgroup of children without concomitant beta-agonist therapy, corticosteroids associated with longer length of stay
(adjusted HR 0.85, 95% CI 0.75-0.96) and higher readmission rate (adjusted odds ratio 1.97, 95% CI 1.09-3.57) compared to
no corticosteroids
Reference - Pediatrics 2011 Feb;127(2).doi:10.1542/peds.2010-0983 full-text

insufficient evidence to evaluate benefit of nonprescription cough medications for cough in adults and children with pneumonia
systematic review of 4 randomized trials evaluating nonprescription cough medication to treat cough due to acute pneumonia in 224
patients taking antibiotics
1 trial was in children only, 3 trials included adolescents or adults
no significant differences in primary outcome of "not cured or not improved"
mucolytics associated with improvement in secondary outcome ("not cured") in children (p < 0.05, NNT 5) and adults (p < 0.05,
NNT 5) at day 10
Reference - Cochrane Database Syst Rev 2014 Mar 10;(3):CD006088
no randomized trials found evaluating surfactants for management of bacterial pneumonia in term and near-term infants
zinc supplementation
potential role of zinc in the management of pediatric pneumonia

zinc supports normal function of the immune system
in developing countries, children are at risk of zinc deficiency due to inadequate diet
zinc supplementation may help enhance immune response to infection
Reference - Can Fam Physician 2017 Oct;63(10):763 full-text
zinc supplementation may not improve clinical recovery in children with pneumonia in limited resource settings, but evidence
inconsistent
zinc supplementation as adjunct to antibiotics may not increase clinical recovery in children aged 2-35 months with
based on Cochrane review with inconsistent evidence
systematic review of randomized trials comparing zinc supplementation vs. placebo for pneumonia in children aged 2-59
months
4 trials with 3,267 children aged 2-35 months met inclusion criteria; trials conducted in Bangladesh, Nepal, and
India
all children received antibiotics
prevalence of zinc deficiency not reported in any trial
1 trial with 270 children summarized below found benefit with zinc supplementation
3 trials summarized below reported no significant differences between groups
Reference - Cochrane Database Syst Rev 2011 Oct 5;(10):CD007368
zinc supplementation does not appear to reduce risk of treatment failure or improve recovery time in children with
based on randomized trial with wide confidence intervals
2,628 children aged 2-35 months in Nepal with pneumonia (by WHO criteria) were randomized to zinc (10 mg for
children aged 2-11 months, 20 mg for children ≥ 12 months old) vs. placebo daily for 14 days as adjuvant to antibiotics
no significant differences between groups in rates of treatment failure (defined as need for change in antibiotics or
hospitalization) or time to recovery
regurgitation or vomiting within 15 minutes of supplement occurred in 37% of zinc group vs. 13% in placebo group (p <
0.05, NNH 4)
Reference - Am J Clin Nutr 2010 Jun;91(6):1667 full-text
zinc supplementation might reduce mortality but not risk of treatment failure in children aged 2-60 months with severe
based on systematic review limited by clinical heterogeneity
systematic review of 6 randomized trials comparing zinc supplementation as adjunct therapy vs. placebo in 2,216
children aged 2-60 months with severe pneumonia
cumulative dose of zinc sulfate ranged from 70 to 280 mg in 5 trials
treatment duration ranged from 7-14 days or until hospital discharge
zinc supplementation associated with reduced mortality in analysis of 3 trials with 1,318 children
risk ratio 0.43 (95% CI 0.22-0.83)
NNT 31-140 with 4.2% mortality in placebo group
2 of 3 trials with treatment duration > 7 days showed no difference in mortality
no significant difference in risk of treatment failure (defined as need for change in antibiotic therapy, clinical
deterioration, or mortality) in analysis of 5 trials with 1,822 children
Reference - Clin Respir J 2018 Mar;12(3):857
vitamin A supplementation not associated with significant reduction in morbidity or clinical course of nonmeasles pneumonia in
children in developing countries (level 2 [mid-level] evidence)
based on Cochrane review with inadequate power
systematic review of 6 randomized and quasi-randomized trials evaluating vitamin A supplementation in 1,740 children < 15 years
old with nonmeasles pneumonia in developing countries
limited number of studies in meta-analyses for specific outcomes limits statistical power to detect differences
no significant differences in mortality, hospital stay duration, vomiting, diarrhea, bulging of fontanelles, irritability, or chest x-ray
results
vitamin A associated with reduction in antibiotic first-line failure, change in antibiotic required in 18% with vitamin A vs. 25.3%
with placebo in 1 trial with 472 children (p = 0.054)
Reference - Cochrane Database Syst Rev 2010 Oct 6;(10):CD003700
single dose of 100,000 units of vitamin D3 did not reduce overall recovery time or risk of recurrence in 6 months in children with
severe pneumonia (level 1 [likely reliable] evidence)
324 children aged 6 months to 5 years (median age 1 year) in New Delhi, India with severe pneumonia (by WHO criteria of presence
of lower chest indrawing/retractions in children presenting with cough or difficult breathing) randomized to 100,000 units of vitamin
D3 (cholecalciferol) orally in single dose vs. placebo
126 children (39%) were vitamin D deficient, defined as 25-hydroxyvitamin D < 12 ng/mL (30 nmol/L)
comparing vitamin D3 supplementation vs. placebo
time to complete recovery of pneumonia 48.8 hours vs. 50.8 hours (not significant)
risk of recurrence in 6 months 25% vs. 23% (not significant)
no significant difference in duration of hospitalization and time to fever resolution
no adverse events reported related to intervention
Reference - Indian Pediatr 2016 Nov 15;53(11):967
Surgery and procedures

need for surgical procedures depends on associated complications (see Parapneumonic effusion and empyema in children for additional
information)
Other management
chest physiotherapy including noninvasive positive pressure ventilation (NPPV)
adjuvant therapy used in respiratory illnesses to help clear tracheobronchial secretions
conventional techniques include postural drainage, vibration, percussion, and thoracic squeezing defined as manually assisted
coughing in which manual compression of the thorax during expiration facilitates movement of pulmonary excretions)
modern techniques use variation of air flow though breath control to mobilize secretions
Reference - Cochrane Database Syst Rev 2019 Jan 2;1:CD010277
British Thoracic Society (BTS) states chest physiotherapy not beneficial and should not be performed in children with pneumonia
(BTS Grade A-)(1)
chest physical therapy might reduce mortality in hospitalized children with pneumonia (level 2 [mid-level] evidence)
based on Cochrane review with limited evidence
systematic review of 6 randomized trials comparing chest physical therapy vs. no chest physical therapy in 559 children with
pneumonia
children had community-acquired pneumonia only in 1 trial (72 patients), both community- and hospital-acquired
pneumonia in 1 trial (29 patients), and 4 trials did not specify pneumonia type
interventions included conventional chest physical therapy (3 trials), continuous positive airway pressure (CPAP, 1 trial),
bubble CPAP (1 trial), positive expiratory pressure (1 trial) and assisted autogenic drainage (1 trial)
all trials conducted in hospital settings
all children received antibiotic treatment and oxygen support as indicated
chest physical therapy associated with
reduced mortality in analysis of all trials with 559 patients
risk ratio (RR) 0.28 (95% CI 0.08-0.9)
NNT 19-167 with 6% mortality in control group
deaths reported in only 1 trial comparing bubble CPAP vs. high- and low-flow oxygen therapy in 225 children
greater improvement in peripheral oxygen saturation levels reported in 2 trials (1 evaluating CPAP in 94 children, 1
evaluating conventional chest physiotherapy in 50 children)
no significant differences in
length of hospital stay in analysis of 4 trials with 415 children
respiratory rate in analysis of 2 trials with 122 children
fever resolution in 2 trials (evaluating conventional chest physiotherapy and assisted autogenic drainage)
Reference - Cochrane Database Syst Rev 2019 Jan 2;1:CD010277
see also Noninvasive positive pressure ventilation (NPPV) in infants and children
Follow-up
Clinical follow-up
children on adequate therapy should demonstrate clinical and laboratory signs of improvement within 48-72 hours, further investigation
warranted if no improvement within 48-72 hours (PIDS/IDSA Strong recommendation, Moderate-quality evidence)(2)
if 48 hours after start of treatment child remains feverish or unwell, reevaluate and consider possible complications (BTS Grade D)(1)
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendations for community-acquired
pneumonia in children not responding to treatment(2)
manage children not responding to initial therapy after 48-72 hours by ≥ 1 of
determine whether higher levels of care or support required with clinical and laboratory assessment of current severity of
illness and anticipated progression (PIDS/IDSA Strong recommendation, Low-quality evidence)
assess extent and progression of pneumonic or parapneumonic process with imaging studies (PIDS/IDSA Weak
recommendation, Low-quality evidence)
investigate further to identify whether original pathogen persists, original pathogen has developed resistance to agent used, or
if there is new secondary infecting agent (PIDS/IDSA Weak recommendation, Low-quality evidence)
for seriously ill children not responding to treatment for community-acquired pneumonia
obtain bronchoalveolar lavage (BAL) specimen for Gram stain and culture for mechanically ventilated child (PIDS/IDSA
Strong recommendation, Moderate-quality evidence)
DynaMed commentary -- specimen ideally obtained at time of intubation
obtain percutaneous lung aspirate for Gram stain and culture in persistently and seriously ill child for whom previous
investigations have not yielded microbiologic diagnosis (PIDS/IDSA Weak recommendation, Low-quality evidence)
obtain open lung biopsy for Gram stain and culture in persistently and critically ill mechanically ventilated child in whom
previous investigations have not yielded microbiologic diagnosis (PIDS/IDSA Weak recommendation, Low-quality evidence)
if pulmonary abscess or necrotizing pneumonia is found in nonresponding patient (PIDS/IDSA Weak recommendation, Very low-
quality evidence)
treat initially with IV antibiotics
most abscesses will drain through bronchial tree and heal without surgical or invasive intervention but consider draining well-
defined peripheral abscesses without connection to bronchial tree under imaging-guided procedures either by aspiration or with
drainage catheter that remains in place
World Health Organization (WHO) definition of treatment failure is defined as the development of signs of severe pneumonia or severe
disease
not able to drink
persistent vomiting
convulsions
lethargy
unconscious
stridor while calm
severe malnutrition
Reference - WHO 2014 PDF
Discharge criteria
PIDS/IDSA consider patients eligible for safe discharge when the following are met(2)
documented overall clinical improvement, including level of activity, appetite, and decreased fever ≥ 12-24 hours (PIDS/IDSA
Strong recommendation, Very low-quality evidence)
consistent pulse oximetry measurements > 90% on room air ≥ 12-24 hours (PIDS/IDSA Strong recommendation, Moderate-quality
evidence)
stable and/or baseline mental status (PIDS/IDSA Strong recommendation, Very low-quality evidence)
documentation that patient can tolerate home anti-infective regimen, whether oral or IV, and home oxygen regimen, if applicable
for infants or young children requiring outpatient oral antibiotics, clinicians should demonstrate that parents are able to administer
and children are able to comply adequately with taking antibiotics (PIDS/IDSA Weak recommendation, Very low-quality evidence)
for children who have had chest tube and meet all other requirements, hospital discharge is appropriate after chest tube has been
removed for 12-24 hours if the following are met (PIDS/IDSA Strong recommendation, Low-quality evidence)
no clinical evidence of deterioration since removal
chest x-ray (if obtained for clinical concerns) shows no significant reaccumulation of parapneumonic effusion or
pneumothorax
patients are not eligible for discharge if they have substantially increased work of breathing or sustained tachypnea or tachycardia
(PIDS/IDSA Strong recommendation, High-quality evidence)(2)
in improving patients who otherwise meet criteria for discharge, positive blood culture with identification or susceptibility results pending
should not routinely prevent discharge with appropriate oral or IV antimicrobial therapy; patient can be discharged if close follow-up is
assured (PIDS/IDSA Weak recommendation, Low-quality evidence)(2)
issues that could lead to barriers to care should be identified and addressed before discharge (PIDS/IDSA Weak recommendation, Very
low-quality evidence), including(2)
concern about careful observation at home
inability to comply with therapy
lack of availability for follow-up
Follow-up chest x-rays
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendations for community-acquired
pneumonia in children(2)
repeat chest x-rays not routinely required in children who recover uneventfully (PIDS/IDSA Strong recommendation, Moderate-
quality evidence)
obtain repeated chest x-rays in children who do not show clinical improvement or have progressive symptoms or clinical
deterioration within 48–72 hours after starting antibiotic therapy (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
obtain follow-up chest x-rays in patients with complicated pneumonia with worsening respiratory distress or clinical instability, or
persistent fever not responding to therapy over 48-72 hours (PIDS/IDSA Strong recommendation, Low-quality evidence)
routine daily chest x-rays not recommended in children with pneumonia complicated by parapneumonic effusion after chest tube
placement or after video-assisted thoracoscopic surgery (VATS) if they remain clinically stable (PIDS/IDSA Strong recommendation,
obtain repeated chest x-rays 4-6 weeks after diagnosis of community-acquired pneumonia in patients with recurrent pneumonia
involving same lobe and in patients with lobar collapse at initial chest x-ray to consider anatomic anomaly, chest mass, or foreign
body aspiration (PIDS/IDSA Strong recommendation, Moderate-quality evidence)
follow-up chest x-ray not required in children who were previously healthy who are recovering well; consider follow-up chest x-ray
in children with lobar collapse, apparent round pneumonia, or persistent symptoms (BTS Grade B+)
follow-up children with severe pneumonia, empyema, and lung abscesses after discharge until they have recovered completely and
chest x-ray returns to near normal (BTS Grade D)
Follow-up blood cultures
for children with bacteremia(2)

repeated blood cultures in children with clear clinical improvement not necessary to document resolution of pneumococcal
bacteremia (PIDS/IDSA Weak recommendation, Low-quality evidence)
obtain repeated blood cultures to document resolution of bacteremia in children with bacteremia caused by Staphylococcus aureus,
regardless of clinical status (PIDS/IDSA Strong recommendation, Low-quality evidence)
Special Populations
Immunocompromised
differential diagnosis for immunocompromised children is similar to immunocompetent children, but immunocompromised children may
be particularly susceptible to(3)
Gram negative bacilli (including Pseudomonas aeruginosa) and Staphylococcus aureus (common with neutropenia or white blood
cell defects)
fungi such as Aspergillus and Candida
Legionella
treatment of pneumonia in HIV-infected children depends on their CD4 cell count(3)
treatment for children with normal CD4 counts is the same as non-immunocompromised children in the United States
in children with CD4 count < 200 cells/mcL, consider antibiotic coverage for opportunistic infections such as Pneumocystis jirovecii
or cryptococcus
World Health Organization (WHO) recommends
ampicillin plus gentamicin or ceftriaxone alone as first-line antibiotic regimen for HIV-infected and -exposed infants and
children < 5 years of age with chest indrawing/retractions or severe pneumonia
adding co-trimoxazole to treat suspected Pneumocystis jirovecii in all children 2 months to 1 year of age with HIV infection
with chest indrawing/retractions or very severe pneumonia
Reference - WHO 2014 PDF
Acute Chest Syndrome in Sickle Cell Disease

acute chest syndrome (ACS) presents as sudden onset of signs and symptoms associated with lower respiratory tract disease and is the
leading cause of death in sickle cell disease
ACS is defined as a new pulmonary infiltrate on chest x-ray and ≥ 1 of
fever ≥ 38.5° C (101.3 degrees F)
cough
> 2% decrease in oxygen saturation from steady-state
PaO2 < 60 mm Hg
tachypnea (based on age)
intercostal retractions, nasal flaring or use of accessory muscles
chest pain
cough
wheezing or rales
Reference - Am J Hematol 2010 Jan;85(1):6 full-text
ACS is mostly commonly caused by infection of viruses and bacteria, especially Chlamydia, Mycoplasma and Streptococcal pneumoniae
recommended management includes broad-spectrum antibiotics (an IV cephalosporin with or without an oral macrolide antibiotic),
supplemental oxygen, and close monitoring for bronchospasms, acute anemia, and hypoxemia
limited evidence for several commonly used treatments for acute chest syndrome in patients with sickle cell disease; no randomized trials
identified in systematic reviews of this patient population evaluating antibiotics, inhaled bronchodilators, or inhaled nitric oxide
see Management of acute events of sickle cell disease for details
Cystic Fibrosis
etiology of pneumonia depends on age(3)

younger children are most commonly infected by S. aureus, P. aeruginosa and H. influenza
older children are infected by opportunistic organisms including
multiple-drug resistant strains of gram negative organisms, such as Burkholderia cepacia, Stenotrophomonas maltophilia and
Achromobacter xylosoxidans
Aspergillus species
nontuberculous mycobacteria
review of previous cultures is critical as these children rarely clear bacteria from their respiratory tract(3)
see also Cystic fibrosis
Complications and Prognosis

Complications
suspect in children with prolonged or persistent fever or worsening symptoms despite adequate antibiotic coverage(3)
acute complications(1, 2)
parapneumonic effusion and empyema
reported incidence ranging 1%-12%, but may increase among patients hospitalized for pneumonia
empyema reported in up to 25% of children ≤ 16 years old hospitalized for pneumonia
based on prospective cohort study from 2009 to 2011 in England
160 children aged ≤ 16 years hospitalized with community acquired pneumonia
empyema developed in 40 children (25%)
bacterial infection associated with increased risk of empyema (odds ratio 3.34, 97.5% CI 1.7-5.14)
ibuprofen given prior to admission in 82% of children who developed empyema vs. 46% of children who didn't (not
significant)
Reference - Pediatr Pulmonol 2015 Jul;50(7):721
other rare complications include
lung abscess
necrotizing pneumonia
spread of infection
sepsis
bacterial meningitis, brain abscess
acute pericarditis
endocarditis
osteomyelitis (more common in Staphylococcus aureus pneumonia)
septic arthritis (more common in S. aureus pneumonia)
bronchopleural fistula
acute respiratory failure
pneumatoceles
occasionally leads to pneumothorax
more common in S. aureus pneumonia
hemolytic-uremic syndrome (HUS)
pneumococcal-associated HUS in 43 children aged 5-39 months in case series ( J Pediatr 2007 Aug;151(2):140),
editorial can be found in J Pediatr 2007 Aug;151(2):113
S. pneumoniae serotype 19A found in 67% of cases before vs. 100% of cases after introduction of pneumococcal
vaccine in case series of 12 children < 5 years old with confirmed S. pneumoniae-associated HUS ( Pediatrics 2010
Jan;125(1).doi:10.1542/peds/2007-2017)
atypical pneumonia may have extrapulmonary manifestations(1, 3)
hemolytic anemia
rashes, including erythematous maculopapular rash, urticaria, erythema nodosum and Stevens-Johnson syndrome
polyarthritis
pancreatitis and hepatitis
central nervous system involvement, such as encephalitis, aseptic meningitis and transverse myelitis
pericarditis and myocarditis
mild hyponatremia reported in 45% of 97 children with pneumonia
based on prospective cohort study
108 children aged 4 months to 16 years (mean age 4.6 years) with community-acquired pneumonia (based on chest x-ray) were
assessed for serum sodium concentration
97 children with serologic evidence of causative agent of pneumonia were analyzed
hyponatremia (defined as serum sodium < 135 mmol/L [135 mEq/L]) in 49 children (45%)
severe (< 125 mmol/L [125 mEq/L]) in 2 children
moderate (125-129 mmol/L [125-129 mEq/L]) in 2 children
mild (130-134 mmol/L [130-134 mEq/L]) in 45 children
hyponatremia not associated with x-ray findings or causative agent
Reference - Pediatr Nephrol 2008 Dec;23(12):2247, commentary can be found in Pediatr Nephrol 2009 Aug;24(8):1595
chronic complications uncommon and may include(1)

pulmonary fibrosis
bronchiectasis
Prognosis
mortality
mortality from pneumonia highest in Africa in children < 5 years old
based on subgroup analysis of Child Health Epidemiology Reference Group (CHERG) working group on pneumonia database
analysis included 35 community-based prospective studies on pneumonia from across the globe
pneumonia was leading cause of death in children < 5 years in 2011, responsible for estimated 1.3 million deaths
81% of deaths occurred in children < 2 years old
15 developing countries accounted for 74% of deaths from pneumonia worldwide
total deaths by region
Africa - 540,600
Southeast Asia - 443,800
Eastern Mediterranean - 168,400
Western Pacific - 61,900
America - 23,900
Europe - 18,100
risk of death may vary by serotype in bacteremic patients with invasive pneumococcal disease
based on systematic review
meta-analysis of 9 studies of serotype-specific disease outcomes in 8,253 patients with pneumococcal pneumonia and
meningitis
relative risk of death for each serotype was calculated compared to serotype 14, a common cause of invasive pneumococcal
disease that had non-zero number of fatalities in all studies
relative risk of death in patients with bacteremic pneumonia (referent was serotype 14)
increased risk of death in patients infected with
serotype 3 (risk ratio [RR] 1.9, 95% CI 1.54-2.35)
serotype 6A (RR 1.39, 95% CI 1.02-1.91)
serotype 6B (RR 1.59, 95% CI 1.2-2.11)
serotype 9N (RR 1.53, 95% CI 1.16-2.02)
serotype 19F (RR 2.22, 95% CI 1.71-2.88)
reduced risk of death in patients infected with
serotype 1 (RR 0.48, 95% CI 0.37-0.63)
serotype 7F (RR 0.58, 95% CI 0.43-0.79)
serotype 8 (RR 0.68, 95% CI 0.5-0.94)
no significant difference in risk of death by serotype among patients with meningitis
Reference - Clin Infect Dis 2010 Sep 15;51(6):692 full-text
malnutrition associated with increased mortality risk in children with pneumonia (level 2 [mid-level] evidence)
based on systematic review of cohort studies without evaluation of study quality
systematic review of 16 cohort studies evaluating pneumonia in children with and without malnutrition
mortality risk increased
significantly with severe malnutrition in 16 studies with 21,850 children aged 0-132 months
relative risk (RR) range was 2.8-27 in 6 studies reporting relative risks
odds ratio range was 2.5-121.2 in 11 studies reporting odds ratios
with moderate malnutrition in 7 studies with 14,429 children aged 0-60 months (RR range was 1.2-36.5)
Reference - Trop Med Int Health 2009 Oct;14(10):1173 full-text

anemia associated with increased risk of treatment failure in children hospitalized with severe pneumonia living at high altitude
based on cohort study of 958 children aged 2-59 months living in resource-poor settings hospitalized with severe pneumonia
20% living at high altitude (≥ 2,000 m [6,562 ft])
comparing high altitude vs. low altitude residence at baseline (p < 0.0001 for all)
median oxygen saturation 74% vs. 89%
severe hypoxemia (oxygen saturation < 80%) in 86% vs. 11%
median hemoglobin level 10.3 g/dL vs. 10 g/dL
anemia (hemoglobin level ≤ 11 g/dL) in 61% vs. 79%
no association found between altitude and treatment failure
at high altitudes, anemia associated with increased risk of treatment failure (adjusted relative risk 4.07, 95% CI 2.6-6.38)
Reference - Pediatrics 2013 Nov;132(5).doi:10.1542/peds.2013-0761
Prevention and Screening

Prevention
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) recommendations to prevent community-
acquired pneumonia in children(2)
immunize children with vaccines for bacterial pathogens (PIDS/IDSA Strong recommendation, High-quality evidence) including
Haemophilus influenzae type b
pertussis
immunize all children and adolescents ≥ 6 months old annually with influenza virus vaccine (PIDS/IDSA Strong recommendation,
High-quality evidence)
immunize parents and caretakers of infants < 6 months old, including pregnant adolescents, with vaccines for influenza virus and
pertussis to protect infants from exposure (PIDS/IDSA Strong recommendation, High-quality evidence)
give high-risk infants immune prophylaxis with palivizumab to decrease risk of severe pneumonia and hospitalization caused by
respiratory syncytial virus (RSV) (PIDS/IDSA Strong recommendation, High-quality evidence)
see Immunizations in children and adolescents for details
breastfeeding associated with decreased pneumonia prevalence and all-cause mortality in children < 24 months old (level 2 [mid-
level] evidence)
based on systematic review of observational studies
systematic review of 10 studies (7 prospective cohort and 3 case-control) evaluating the risk of pneumonia by levels of breastfeeding
exposure in infants and children aged < 24 months
in infants aged 0-5 months
compared to exclusive breastfeeding, no breastfeeding associated with increased
pneumonia prevalence (relative risk [RR] 5.61, 95% CI 1.23-25.53)
all-cause mortality (RR 14.4, 95% CI 6.13-33.86)
pneumonia hospitalization (RR 4.06, 95% CI 1.48-11.14)
all-cause hospitalization (RR 6.03, 95% CI 3.18-11.44)
higher risks also found in infants partially or predominantly breastfed compared to exclusively breastfed
in children aged 6-24 months
compared to any breastfeeding, no breastfeeding associated with increased
pneumonia prevalence (RR 1.93, 95% CI 1.39-2.69)
all-cause mortality (RR 3.69, 95% CI 1.49-9.17)
pneumonia incidence and pneumonia mortality both nonsignificantly increased in infants and children who were not breastfed
Reference - BMC Public Health 2013;13 Suppl 3:S18 full-text
zinc supplementation > 3 months (but not short-term use) may prevent respiratory infection in children in developing countries
zinc supplementation for ≥ 3 months may reduce risk of pneumonia in developing countries (level 2 [mid-level] evidence)
based on Cochrane review without significant differences in high-quality trials
systematic review of 6 randomized trials evaluating zinc supplementation for ≥ 3 months for prevention of pneumonia in 5,193
children aged 2-59 months in developing countries
compared to no zinc supplementation or placebo, zinc supplementation associated with reduced risk of pneumonia in
analysis of all trials
risk ratio 0.87 (95% CI 0.81-0.94)
2 largest trials described below
Reference - Cochrane Database Syst Rev 2016 Dec 4;(12):CD005978
daily zinc supplementation reduced pneumonia in young children in urban, low-income setting in India (level 1 [likely
reliable] evidence)

2,482 children aged 6-30 months old were given vitamin A 100,000-200,000 units then randomized to zinc gluconate
(10-20 mg elemental zinc/day) vs. placebo syrup daily for 4 months
pneumonia diagnosed by exam as chest x-rays not feasible
comparing zinc vs. placebo
follow-up at 4 months in 88.6% vs. 90.2%
pneumonia in 6.5% vs. 9% (p < 0.05, NNT 40)
any acute lower respiratory tract infection in 34.2% vs. 34.1% (not significant)
Reference - BMJ 2002 Jun 8;324(7350):1358 full-text
zinc supplementation may reduce pneumonia and mortality in infants living in urban, low-income setting (level 2 [mid-
level] evidence)
based on randomized trial with allocation concealment not stated
1,621 infants aged 2-12 months in poor, urban area of Bangladesh were randomized to zinc 70 mg vs. placebo orally per
week for 1 year
comparing zinc vs. placebo
death in 2 vs. 14 infants (p = 0.013, NNT 68)
pneumonia-related mortality in 0 vs. 10 infants (p = 0.013, NNT 82)
pneumonia episodes in 199 vs. 286 infants (relative risk 0.83, 95% CI 0.73-0.95)
Reference - Lancet 2005 Sep 17;366(9490):999
vitamin C may reduce risk of pneumonia in adolescents and adults (level 2 [mid-level] evidence)
based on Cochrane review of trials with methodologic limitations
systematic review of 6 randomized or controlled clinical trials evaluating vitamin C for pneumonia treatment or prophylaxis in 2,569
persons
all trials had ≥ 1 limitation including
unclear or lack of allocation concealment
unclear or lack of blinding
3 trials evaluated vitamin C prophylaxis for community-acquired pneumonia in 2,335 adolescents and adults
1 randomized double-blind placebo-controlled trial included 862 marine recruits (78% analyzed)
2 controlled trials included 226 soldiers with influenza A and 1,435 males in boarding school (mean age 16 years)
all 3 trials reported statistically significant reductions in pneumonia incidence
1 trial evaluated 1-day vitamin C prophylaxis for hospital-acquired pneumonia in 37 patients with severe burns; no significant
difference between groups in pneumonia incidence
Reference - Cochrane Database Syst Rev 2013 Aug 8;(8):CD005532
vitamin A supplementation
vitamin A may not reduce risk for acute lower respiratory tract infections in children < 7 years old (level 2 [mid-level]
evidence)
based on Cochrane review with inconsistent evidence
systematic review of 10 randomized trials evaluating vitamin A for prevention of acute lower respiratory tract infections in
33,179 children ≤ 7 years old
most trials found no significant effect of vitamin A on incidence of acute lower respiratory tract infection or prevalence of
symptoms
vitamin A associated with increased incidence of acute lower respiratory tract infection and increase in cough and fever in 1
trial and increased symptoms of cough and rapid breathing in 2 trials
2 trials reported that vitamin A significantly reduced incidence of acute lower respiratory tract infection in children with poor
nutritional status or weight, but increased it in normal children
Reference - Cochrane Database Syst Rev 2011 Jan 19;(1):CD006090
vitamin D supplementation
vitamin D supplementation as adjunct to antibiotics may not shorten time to resolve acute illness or duration of
hospitalization in children < 5 years old with acute community-acquired pneumonia (level 2 [mid-level] evidence)
based on Cochrane review limited by clinical heterogeneity
systematic review of 7 randomized trials evaluating vitamin D supplementation as adjunct to antibiotics in 1,529 children aged
1 month to 5 years who were hospitalized with acute community-acquired pneumonia
all trials were conducted in low-income countries
trials varied in pneumonia severity and vitamin D regimen (dose, route, and duration)
comparing vitamin D supplementation to placebo, no significant differences in
time to resolution of acute illness in analysis of 3 trials with 935 patients
duration of hospitalization in analysis of 4 trials with 835 patients
time to fever resolution in analysis of 4 trials with 584 patients
mortality in 1 trial with 193 patients
no major adverse events reported
Reference - Cochrane Database Syst Rev 2018 Jul 19;(7):CD011597
vitamin D3 supplementation may not reduce incidence of pneumonia and may increase risk of repeat pneumonia episodes in
infants in Kabul, Afghanistan (level 2 [mid-level] evidence)
based on randomized trial with low adherence
3,046 infants aged 1-11 months in socioeconomically deprived inner-city districts of Kabul, Afghanistan randomized to
vitamin D3 (cholecalciferol) 2.5 mg orally vs. placebo every 3 months for 18 months
71% received all 6 doses of treatment
children presenting at hospital with signs of pneumonia had radiological confirmation
in intention-to-treat analyses
no significant difference in incidence of first or only pneumonia episode
vitamin D3 associated with increased risk of repeat pneumonia episodes (p < 0.0001)
Reference - Lancet 2012 Apr 14;379(9824):1419 full-text, editorial can be found in Lancet 2012 Apr 14;379(9824):1373
antibiotics
ampicillin may not reduce risk of pneumonia in children with undifferentiated acute respiratory infections (level 2 [mid-level]
evidence)
based on Cochrane review of trials with methodologic limitations
systematic review of 4 randomized trials evaluating antibiotics for prevention of bacterial complications in 1,314 children aged
2-59 months with undifferentiated acute respiratory infections
undifferentiated acute respiratory infections were defined as a heterogeneous group of infections that are not restricted to a
specific part of the upper respiratory tract and last for up to 7 days
all trials had ≥ 1 limitation including
unclear allocation concealment
unclear blinding of outcome assessors
1 trial evaluated antibiotics for prevention of pneumonia
pneumonia in 12.5% with ampicillin (25-30 mg/kg every 6 hours for 5 days) plus supportive care vs. 12% with supportive care
alone (not significant) in 1 trial with 889 patients
azithromycin early during new respiratory tract illness might reduce risk of progression to severe lower respiratory tract
illness in children < 6 years old with history of recurrent severe lower respiratory tract illness (level 2 [mid-level] evidence)
based on randomized trial with methodologic and statistical limitations
607 children aged 12-71 months (mean age 42 months, 60% male) with history of recurrent severe lower respiratory tract
illness (LRTI) were randomized to azithromycin 12 mg/kg orally once daily vs. placebo for 5 days initiated early during new
respiratory tract illness
individualized care plan for starting treatment based on child's usual signs and symptoms prior to serious LRTI
children were excluded for > 4 courses of systemic corticosteroids or > 1 hospitalization in previous 12 months, use of
long-term asthma controller for > 8 of previous 12 months, or significant symptomatic asthma
children using single asthma controller were eligible for trial, but controller was discontinued at trial entry
all children received albuterol inhalation 4 times daily during first 48 hours of respiratory tract illness and as needed
during illness
severe LRTI defined as any of
symptoms rated as worse than mild after 3 albuterol doses over 1 hour
need for > 1 albuterol dose more than once every 4 hours
need for > 6 albuterol doses in 24 hours
moderate-to-severe cough or wheeze for ≥ 5 days since start of trial drug
respiratory tract illness defined as not progressing to severe LRTI if no severe LRTI within 14 days of initiating trial drug
protocol was amended during trial due to low rate of respiratory tract illnesses triggering treatment
follow-up extended from 52 to 78 weeks
maximum number of treated respiratory tract illnesses per child increased from 3 to 4
164 children (27%) who had no respiratory tract illness qualifying for treatment during study period were excluded from
analysis
35% discontinued after meeting early termination criteria or were lost to follow-up
primary analysis performed on per-illness basis, 937 illnesses in 443 were included
comparing early azithromycin vs. placebo
progression to severe LRTI occurred in 35 of 473 illnesses vs. 57 of 464 illnesses (adjusted hazard ratio 0.64, 95% CI
0.41-0.98)
urgent care or emergency department visits in 3.6% vs. 5.4% (no p value reported)
mild gastrointestinal adverse events in 3 children vs. 1 child (no p value reported)
azithromycin associated with reduced symptom severity during severe LRTI
no significant differences in albuterol use or time to second respiratory tract illness
Reference - JAMA 2015 Nov 17;314(19):2034, correction can be found in JAMA 2016 Jan 12;315(2):204, editorial can be
found in JAMA 2015 Nov 17;314(19):2027 (correction can be found in JAMA 2016 Jan 26;315(4):419)
DynaMed commentary -- this is not routinely recommended or practiced until further studies demonstrate strong evidence for
efficacy; additionally, widespread use of this strategy leads to increased antibiotic resistance thus strong consideration of
benefits and risks should be discussed
Screening
not applicable
Quality Improvement
Medicare/Joint Commission National Hospital Inpatient Quality Measures
ED-1 Median Time from emergency department (ED) Arrival to ED Departure for Admitted ED Patients
measured as time (in minutes) from ED arrival to ED departure for patients admitted to facility from emergency department
ED-2 Admit Decision Time to ED Departure Time for Admitted Patients
measured as time (in minutes) from admit decision time to time of departure from ED for ED patients admitted to inpatient status
see Medicare/Joint Commission National Hospital Inpatient Quality Measures for additional information
Guidelines and Resources

Guidelines
International guidelines
revised World Health Organization (WHO) classification and treatment of childhood pneumonia at health facilities can be found in WHO
2014 PDF
WHO recommendation on antibiotic use for community acquired pneumonia (CAP) in neonates and children: 2016 Evidence Update can
be found in WHO 2016 PDF
WHO recommendations on the inclusion of PCV10 and PCV13 in childhood immunization programs worldwide can be found in WHO
Pneumococcal Vaccine Position Paper 2012
WHO evidenced-based recommendations on treatment of childhood non-severe pneumonia can be found in Lancet Infect Dis 2009
Mar;9(3):185
United States guidelines
American Academy of Pediatrics (AAP) policy statement on immunization for Streptococcus pneumoniae infections in high-risk children
can be found in Pediatrics 2014 Dec;134(6):1230
Society for Healthcare Epidemiology of America (SHEA) 2013 guideline on infection prevention and control in residential facilities for
pediatric patients and their families can be found in Infect Control Hosp Epidemiol 2013 Oct;34(10):1003
Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) clinical guideline on management of
community-acquired pneumonia in infants and children older than 3 months of age can be found in Clin Infect Dis 2011 Oct;53(7):e25,
commentary can be found in Clin Infect Dis 2012 Jun;54(12):1816, executive summary can be found in Clin Infect Dis 2011
Oct;53(7):617 full-text
United Kingdom guidelines
British Thoracic Society (BTS) guideline on management of community-acquired pneumonia in children can be found in Thorax 2011
Oct;66 Suppl 2:ii1, summary can be found in Thorax 2011 Oct;66(10):927
Canadian guidelines
Canadian Paediatric Society (CPS) A practical guide for the diagnosis and treatment of pediatric pneumonia can be found in Paediatr Child
Health 2015 Nov-Dec;20(8):441 full-text
European guidelines
Italian Society of Preventive and Social Paediatrics consensus conference guidelines for the treatment of respiratory tract infections in
children can be found at Paediatr Respir Rev 2014 Sep;15(3):231
Finnish Medical Society Duodecim/Finnish Society of Pediatrics/Finnish Society of General Medicine current care guideline on lower
respiratory tract infections in children can be found at Duodecim 2015 Jun PDF [Finnish]
Spanish Society of Pediatric Pulmonology/Spanish Society of Pediatric Infectious Diseases (SENP/SEIP)

guideline on etiology and diagnosis of community-acquired pneumonia and its complicated forms can be found in An Pediatr (Barc)
2012 Mar;76(3):162.e1 [Spanish]
consensus statement on treatment of complicated cases and risk patients of community acquired pneumonia in children can be found
in An Pediatr (Barc) 2015 Sep;83(3);217.e1
Société de Pathologie Infectieuse de Langue Française/Agence Française de Sécurité Sanitaire des Produits de Santé (SPILF/AFSSPS)
guideline on systemic antibiotherapy for treatment of lower respiratory tract infections, community-acquired pneumonia, and acute
exacerbation of obstructive chronic bronchitis can be found at SPILF 2010 PDF or in Med Mal Infect 2011 May;41(5):221 [French]
Asian guidelines
Japanese expert guidelines on nursing and healthcare-associated pneumonia can be found in Nihon Naika Gakkai Zasshi 2012 Mar
10;101(3):787 [Japanese]
The Society of Pediatrics, Chinese Medical Association, and the Editorial Board of Chinese Journal of Pediatrics guideline on management
of community acquired pneumonia in children can be found in Zhonghua Er Ke Za Zhi 2013 Oct;51(10):745 and Zhonghua Er Ke Za Zhi
2013 Nov;51(11):856 [Chinese]
Taiwan Pediatric Working Group guideline on management of community-acquired pneumonia in children can be found in Acta Paediatr
Taiwan 2007 Jul-Aug;48(4):167
Japanese guideline for the treatment of respiratory infectious disease can be found in J Infect Chemother 2016 Jul;22(7 Suppl):S1 full-text
Central and South American guidelines
Sociedade Brasileira de Pneumologia e Tisiologia diretrizes em pneumonia adquirida na comunidade em pediatria pode ser encontrada em
Jornal Brasileiro de Pneumologia 2007 PDF [Portuguese]
Australian and New Zealand guidelines
Queensland Health Primary Clinical Care Manual: Paediatrics can be found at Queensland 2018 May 14
New South Wales (NSW) Ministry of Health clinical practice guideline on acute management of community-acquired pneumonia in
infants and children can be found at NSW 2018 Mar 16 PDF
Review articles
review can be found in BMJ 2017 Mar 2;356;j686
review can be found in Pediatr Radiol 2017 Oct;47(11);1392 full-text
review can be found in Pediatr Ann 2017 Jul 1;46(7);e257
review of management of community-acquired bacterial pneumonia in children can be found in Pediatr Rev 2017 Sep;38(9):394
review of microbiological testing in pediatric community-acquired pneumonia can be found in J Clin Microbiol 2018 Mar;56(3): full-text
review of epidemiology and diagnostic and therapeutic challenges can be found in Infect Dis Clin North Am 2018 Mar;32(1);47
review can be found in Am Fam Physician 2012 Oct 1;86(7):661 full-text
review of lung ultrasound for diagnosis of community-acquired pneumonia in children can be found in Pediatr Radiol 2017
Oct;47(11);1412 full-text
review of treatment of mycoplasma pneumonia can be found in Pediatrics 2014 Jun;133(6):1081 full-text
review of viral pneumonia can be found in Lancet 2011 Apr 9;377(9773):1264
MEDLINE search
to search MEDLINE for (community-acquired pneumonia AND children) with targeted search (Clinical Queries), click therapy, diagnosis,
or prognosis
Patient Information
handout on childhood pneumonia from JAMA 2017 Aug 1;318(5):490
handout from KidsHealth or in Spanish
handout on pneumonia considerations in children from Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG) in
English PDF or in German PDF
handout on pneumonia from Patient UK PDF
handout on shortness of breath from American Academy of Family Physicians or in Spanish
ICD Codes
ICD-10 codes
J10.0 influenza with pneumonia, other influenza virus identified
J11.0 influenza with pneumonia, virus not identified
J12 viral pneumonia, not elsewhere classified
J12.0 adenoviral pneumonia
J12.1 respiratory syncytial virus pneumonia
J12.2 parainfluenza virus pneumonia
J12.8 other viral pneumonia
J12.9 viral pneumonia, unspecified
J13 pneumonia due to Streptococcus pneumoniae
J14 pneumonia due to Haemophilus influenzae
J15 bacterial pneumonia, not elsewhere classified
J15.0 pneumonia due to Klebsiella pneumoniae
J15.1 pneumonia due to Pseudomonas
J15.2 pneumonia due to staphylococcus
J15.3 pneumonia due to streptococcus, group B
J15.4 pneumonia due to other streptococci
J15.5 pneumonia due to Escherichia coli
J15.6 pneumonia due to other aerobic Gram-negative bacteria
J15.7 pneumonia due to Mycoplasma pneumoniae
J15.8 other bacterial pneumonia
J15.9 bacterial pneumonia, unspecified
J16 pneumonia due to other infectious organisms, not elsewhere classified
J16.0 chlamydial pneumonia
J16.8 pneumonia due to other specified infectious organisms
J17 pneumonia in diseases classified elsewhere
J17.0 pneumonia in bacterial diseases classified elsewhere, such as
A01.0 typhoid fever
A02.2 localized salmonella infections
A21.2 pulmonary tularaemia
A22.1 pulmonary anthrax
A37 whooping cough
A42.0 pulmonary actinomycosis
A43.0 pulmonary nocardiosis
A48.1 Legionnaire's disease
A54.8 other gonococcal infections
J17.1 pneumonia in viral diseases classified elsewhere, such as
B01.2 varicella pneumonia
B05.2 measles complicated by pneumonia
B06.8 rubella with other complications
B25.0 cytomegaloviral pneumonitis
J17.2 pneumonia in mycoses, such as
B37.1 pulmonary candidiasis
B38 coccidioidomycosis
B38.0 acute pulmonary coccidioidomycosis
B38.1 chronic pulmonary coccidioidomycosis
B38.2 pulmonary coccidioidomycosis, unspecified
B39 histoplasmosis
B39.0 acute pulmonary histoplasmosis capsulati
B39.1 chronic pulmonary histoplasmosis capsulati
B39.2 pulmonary histoplasmosis capsulati, unspecified
B44 aspergillosis
J17.3 pneumonia in parasitic diseases, such as
B58.3 pulmonary toxoplasmosis

B59 pneumocystosis
B65 schistosomiasis [bilharziasis]
B77.8 ascariasis with other complications
J17.8 pneumonia in other diseases classified elsewhere, such as
A69.8 other specified spirochaetal infections
A70 chlamydia psittaci infection
A78 Q fever
I00 rheumatic fever without mention of heart involvement
J18 pneumonia, organism unspecified
J18.0 bronchopneumonia, unspecified
J18.1 lobar pneumonia, unspecified
J18.2 hypostatic pneumonia, unspecified
J18.8 other pneumonia, organism unspecified
J18.9 pneumonia, unspecified
P23 congenital pneumonia
P23.0 congenital pneumonia due to viral agent
P23.1 congenital pneumonia due to Chlamydia
P23.2 congenital pneumonia due to staphylococcus
P23.3 congenital pneumonia due to streptococcus, group B
P23.4 congenital pneumonia due to Escherichia coli
P23.5 congenital pneumonia due to Pseudomonas
P23.6 congenital pneumonia due to other bacterial agents
P23.8 congenital pneumonia due to other organisms
P23.9 congenital pneumonia, unspecified
References
General references used
1. Harris M, Clark J, Coote N, et al; British Thoracic Society Standards of Care Committee. British Thoracic Society guidelines for the
management of community-acquired pneumonia in children: update 2011. Thorax. 2011 Oct;66 Suppl 2:ii1-23
2. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3
months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.
Clin Infect Dis. 2011 Oct;53(7):e25-76
3. Gereige RS, Laufer PM. Pneumonia. Pediatr Rev. 2013 Oct;34(10):438-56, correction can be found in Pediatr Rev 2014 Jan;35(1):29
4. Haq IJ, Battersby AC, Eastham K, McKean M. Community acquired pneumonia in children. BMJ. 2017 Mar 2;356:j686
Recommendation grading systems used

Pediatric Infectious Diseases Society/Infectious Diseases Society of America (PIDS/IDSA) grades of recommendation
strength of recommendation
Strong recommendation - desirable effects clearly outweigh undesirable effects, or vice versa
Weak recommendation
if high-quality or moderate-quality evidence - desirable effects closely balanced with undesirable effects
if low-quality evidence - uncertainty in estimates of desirable effects, harms, and burden; desirable effects, harms, and
burden may be closely balanced
very low-quality evidence - major uncertainty in estimates of desirable effects, harms, and burden; desirable effects,
harms, and burden may be closely balanced
quality of evidence
High-quality evidence - consistent evidence from well-performed randomized controlled trials (RCTs) or exceptionally strong
evidence from unbiased observational studies
Moderate-quality evidence - evidence from RCTs with important limitations (inconsistent results, methodologic flaws, indirect,
or imprecise) or exceptionally strong evidence from unbiased observational studies
Low-quality evidence - evidence for ≥ 1 critical outcome from observational studies, RCTs with serious flaws or indirect
evidence
Very low-quality evidence - evidence for ≥ 1 critical outcome from unsystematic clinical observations or very indirect
evidence
Reference - PIDS/IDSA clinical practice guideline on management of community-acquired pneumonia in infants and children > 3
months old (Clin Infect Dis 2011 Oct;53(7):e25), commentary can be found in Clin Infect Dis 2012 Jun;54(12):1816
British Thoracic Society (BTS) grading of levels of evidence and guideline statement grades
Grade A+, Evidence Level Ia - good recent systematic review of studies designed to answer question of interest
Grade A-, Evidence Level Ib - ≥ 1 rigorous studies designed to answer question, not combined
Grade B+, Evidence Level II - ≥ 1 prospective clinical studies which illuminate, but do not rigorously answer the question
Grade B-, Evidence Level III - ≥ 1 retrospective clinical studies which illuminate, but do not rigorously answer the question
Grade C, Evidence Level IVa - formal combination of expert views
Grade D, Evidence Level IVb - other information
Reference - BTS guideline on management of community-acquired pneumonia in children (Thorax 2011 Oct;66 Suppl 2:ii1)
Synthesized Recommendation Grading System for DynaMed Plus

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clinical decision-making (see 7-Step Evidence-Based Methodology).
Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in
the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and
from the current evidence.
In DynaMed Plus (DMP), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide
recommendations to support clinical decision-making in the Overview & Recommendations section.
We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) to classify synthesized recommendations as
Strong or Weak.
Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have
a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable
consequences (harms, costs, burdens).
Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable
consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and
harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited
confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that
informed patients are likely to make different choices.
DynaMed Plus (DMP) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic
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Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain
expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or
phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or
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Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has
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Systematic searches will be conducted for any clinical questions where systematic searches were not already completed
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Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the
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Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise
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All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial),
and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the
likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and
preferences. Panel members will make Weak recommendationsif there is limited confidence (or inconsistent assessment or
dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient
values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
All steps in this process (including evidence summaries which were shared with the panel, and identification of panel
members) will be transparent and accessible in support of the recommendation.
Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or
development, with explicit confirmation that Strong recommendations are adequately supported.
Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by
all editors.
If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the
dissenting commentary is included in the topic details.

If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted
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DynaMed topics are created and maintained by the DynaMed Editorial Team and Process.
All editorial team members and reviewers have declared that they have no financial or other competing interests related to this topic, unless
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DynaMed provides Practice-Changing DynaMed Updates, with support from our partners, McMaster University and F1000.
Special acknowledgements
Adriana Cadilla, MD (Assistant Professor, Department of Pediatrics, University of Central Florida College of Medicine; Clinical Assistant
Professor, Department of Pediatrics, Florida State University College of Medicine; Pediatric Infectious Disease Physician, Nemours
Children's Hospital; Florida, United States)
Dr. Cadilla declares no relevant financial conflicts of interest.
Zbys Fedorowicz, MSc, DPH, BDS, LDSRCS (Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane
Collaboration; Awali, Bahrain)
Dr. Fedorowicz declares no relevant financial conflicts of interest.
Scott A. Barron, MD, FAAP (Deputy Editor of Pediatrics; Associate Professor of Pediatrics, University of Central Florida College of
Medicine; Florida, United States)
DynaMed Plus topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and
Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or
evaluation of guidelines.
Editorial Team role definitions

Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines,
clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Plus
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Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight
of Topic Editors, and systematic surveillance of the medical literature.
Recommendations Editors provide explicit review of DynaMed Plus Overview and Recommendations sections to ensure that all
recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
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How to cite
National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):
DynaMed Plus [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T113670, Community-acquired Pneumonia in
Children; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T113670.
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DynaMed Plus: Community-acquired Pneumonia in Children 15/07/19 21)06

Community-acquired Pneumonia in Children

definitions of different types of pneumonia(2, 3)

meningitis, and sepsis

Etiology and Pathogenesis

identification of causative organism can be challenging(4)

History and Physical

precarinal and right paratracheal lymph nodes

Chief concern (CC)

presenting symptoms vary with age and may include(1, 34)

History of present illness (HPI)

ask about vaccination status (Pediatr Radiol 2017 Oct;47(11):1392 full-text

Past medical history (PMH)

Social history (SH)

factors associated with increased risk of pneumonia(3)

evaluate for fever and signs of respiratory illness(1, 3, 4)

agitation may be indication that child is hypoxic(1)

look for cyanosis(1)

look for signs of respiratory distress including(1, 3)

signs of respiratory distress(1, 2, 3)

exam may be normal or show(1, 2, 3)

abdominal breathing (J Clin Microbiol 2018 Mar;56(3).doi: 10.1128/JCM.01318-17 full-text)

constellation of specific signs and symptoms may help determine severity(1, 3)

other conditions present with similar signs or symptoms as community-acquired pneumonia(3)

Complete blood count (CBC)

Acute phase reactants

pooled negative likelihood ratio 0.33 (95% CI 0.25-0.43)

urinary antigen detection tests for pneumococcal pneumonia

and with adequate oral hydration

based on randomized trial

Computed tomography (CT)

Other diagnostic testing

pulse oximetry is frequently used in initial evaluation to identify hypoxemia(1, 2)

Rapid testing of nasopharyngeal specimens

Sputum Gram stain and culture

viral cultures have limited clinical utility for pneumonia because

Pleural fluid aspiration

Tracheal or lung specimens

Indications for hospitalization

chronic lung disease of prematurity

Indications for intensive care

Comparing treatment settings in developing countries

any serious adverse event

vs. health facility-based treatment

Fluid and electrolytes

recommendations for identifying who needs antibiotics(1, 2)

antibiotics for pediatric outpatients

amoxicillin-clavulanate recommended for pneumonia associated with influenza (BTS Grade D)

antibiotics for pediatric inpatients

Antiviral medications for influenza

American Indians/Alaska Natives

see Influenza in children for details

antipyretics may be used to keep child comfortable(1, 3)

Reference - Pediatrics 2011 Feb;127(2).doi:10.1542/peds.2010-0983 full-text

potential role of zinc in the management of pediatric pneumonia

Surgery and procedures

Follow-up chest x-rays

Follow-up blood cultures

for children with bacteremia(2)

Acute Chest Syndrome in Sickle Cell Disease

etiology of pneumonia depends on age(3)

Complications and Prognosis