Summary
Pneumonia, a common infection in children, is a respiratory illness characterized by inflammation of the alveolar space and/or the interstitial tissue of the lungs. The etiology is typically bacterial or viral, with respiratory syncytial virus (RSV) being the most common pathogen overall, particularly in those < 2 years old. As with adults, pneumonia in children can be categorized as typical or atypical, according to clinical features. For typical pneumonia, the presentation may be similar to those in adults (including productive cough, tachypnea, fever, and lethargy), with possible additional features such as abdominal pain, difficulty feeding, and grunting. In atypical pneumonia, children may present with a mild, slowly-progressing course that includes malaise, low-grade fever, and widespread wheeze. Management depends on severity and etiology. The first step is to determine whether patients meet the admission criteria for pediatric CAP. All patients require a respiratory viral panel to help guide treatment; for children who meet admission criteria, additional diagnostic tests include imaging and blood studies. Empirical treatment consists of supportive measures (e.g., respiratory support, antipyretics), antibiotics for suspected bacterial infection, and antivirals when available (e.g., for influenza, COVID-19).
The information in this article does not apply to infants < 2 months old. In young infants that present with signs of pneumonia (e.g., apnea, hypotonia, poor feeding), a full workup for sepsis is indicated (see “Fever in infants ≤ 60 days).
Etiology
See also “Pneumonia pathogens according to affected population.”
Viral [1][2]
- Respiratory syncytial virus (RSV): most common overall pathogen, particularly in those < 2 years old
- Coronaviruses (including COVID-19)
- Human metapneumovirus
- Rhinovirus
- Influenza
- Parainfluenza
Bacterial [1][2]
- Streptococcus pneumoniae
- Streptococcus pyogenes
- Staphylococcus aureus
- Haemophilus influenzae
- Chlamydia trachomatis (in infants) [3][4]
- Chlamydia pneumoniae (in young children and adolescents) [5]
- Mycoplasma pneumoniae
Clinical features
Classic presentation
-
Similar to clinical features of pneumonia in adults, e.g.: [1][2][6]
- Productive cough with yellow-green sputum
- Tachypnea, dyspnea
- Increased work of breathing
- Fever
- Lethargy
- Chest pain
- Crackles on auscultation
- Reduced air entry
- May be preceded by symptoms of an upper respiratory tract infection
- Additional features in children may include: [1][2][6]
- Abdominal pain
- Difficulties feeding
- Grunting
Features of atypical pediatric pneumonia [7]
- Slow progression
- Mild disease
- Malaise
- Sore throat
- Headache
- Low-grade fever
- Widespread wheeze
- Development of cough over 3–5 days (suggestive of Mycoplasma pneumonia)
Differential diagnoses
- Bronchiolitis
- Asthma/virus-induced wheeze
- Croup
- Influenza
- Tuberculosis
- See also “Causes of cough” and “Differential diagnoses of acute wheezing in children.”
The differential diagnoses listed here are not exhaustive.
Management
Approach
- Perform an ABCDE assessment; initiate immediate stabilization measures when required.
- Screen for admission criteria for pediatric CAP.
- Order diagnostic studies as indicated.
- All children: respiratory viral panel
- Children requiring admission: blood studies and imaging
- Initiate recommended management (inpatient or outpatient).
- Provide supportive therapy for pneumonia (e.g., respiratory support, antipyretics) as needed.
Immediate stabilization
- Consult PICU.
- Start respiratory support.
- Hemodynamically unstable patients: Initiate management of septic shock.
Admission criteria for pediatric CAP [7]
- Hypoxemia (< 90%)
- Signs of respiratory distress
- Suspected bacterial CAP in infants < 6 months of age
- Suspected pathogen with increased virulence (e.g., MRSA)
- In caregivers, risk factors for poor adherence or barriers to follow up
- Underlying conditions/comorbidities that may affect illness severity
Validated criteria for determining severity and/or need for admission in pediatric pneumonia (equivalent to CURB-65 in adults) have not been successfully developed. [7][8][9]
Diagnostics for pediatric CAP
All patients require a respiratory viral panel. Further studies are usually reserved for patients with refractory disease or those who require hospitalization.
Laboratory studies
-
Respiratory viral panel
- Helps determine if antibiotics or targeted antiviral therapy is appropriate.
- For findings see “Etiology of pediatric CAP.”
- Blood tests
- CBC [10]
- CRP/ESR [1]
- Procalcitonin [1]
- Blood cultures
-
Sputum samples are not routinely performed because of:
- Difficulties obtaining a sample in younger children
- Poor yield
Imaging
-
Chest x-ray (AP and lateral)
- Indications include hypoxemia, signs of respiratory distress, or refractory disease
- Findings: See “X-ray findings in pneumonia.”
- Chest ultrasound
- Indications
- Can be used as an alternative to CXR
- Suspected parapneumonic effusions, empyema
- Findings: See “Lung ultrasound in pneumonia.”
- Indications
Additional studies
- Bronchoscopy; and thoracentesis are among the additional studies that may be performed in severe or complicated disease.
- For further information, see “Advanced diagnostics for pneumonia.”
Inpatient management [1][7]
- Start supportive therapy for pneumonia including respiratory support.
- Consider infectious disease/pulmonology/PICU consults as appropriate.
- Start pathogen-directed management.
- Tailor treatment to culture results when available.
- Regularly reassess patients for complications of pediatric CAP; treat if present.
- Consider discharge when the following criteria are met: [7]
- Clinical improvement for at least 12 hours
- Stable pediatric vital signs
- Able to tolerate oral medication
- Caregivers are able to give medication and there are no barriers to follow-up.
Outpatient management [1][7]
- Initiate supportive therapy for pneumonia.
- Start pathogen-directed management.
- Educate caregivers on return precautions and arrange for a follow-up in 48–72 hours.
- At follow-up: [7]
- Clinical improvement: Continue treatment.
- No improvement
- Assess for complications (see “Diagnostics for pediatric CAP”).
- Reevaluate for admission criteria for pediatric CAP.
- Outpatient oral antibiotic therapy is typically given for a maximum of 7 days. [1]
For pre-school-aged children (2–5 years old), antibiotics are not routinely recommended, as viruses are the most common cause.
Management of bacterial pneumonia in children
Overview [1][7]
- Start empiric antibiotics for all patients with suspected bacterial pneumonia.
- Patients requiring hospitalization: usually intravenous antibiotic therapy
- Outpatients: oral antibiotic therapy
- If features of atypical pediatric pneumonia are present, cover for atypical pathogens.
- Features of sepsis: Initiate treatment of sepsis.
- Provide supportive treatment for pneumonia.
- Tailor treatment to culture results if possible.
- Switch patients on IV antibiotics to oral therapy when: [1]
- Symptoms improve.
- Patients can tolerate oral intake.
- Regularly reassess patients, and escalate care as needed.
If typical and atypical CAP cannot be distinguished from each other, combine a beta-lactam and a macrolide for empiric therapy. [7]
Empiric antibiotic therapy for pediatric CAP
Intravenous antibiotic therapy
| Empiric intravenous antibiotics for CAP in children [7] | ||
|---|---|---|
| Suspected etiology | Fully immunized | Not fully immunized |
| Typical bacteria |
|
|
| Atypical bacteria |
| |
Transition to oral antibiotics when patients are clinically improving and can tolerate oral fluids including medications. [1]
Oral antibiotics for pediatric pneumonia
| Empiric oral antibiotics for CAP in children [7] | |
|---|---|
| Typical bacteria |
|
| Atypical bacteria |
|
Outpatient oral antibiotic therapy is typically given for a maximum of 7 days. [1]
Management of viral pneumonia in children
Viral pneumonia is the most common cause of CAP in children < 5 years of age.
Overview
- Provide supportive therapy for pneumonia.
- Offer antiviral therapy when indicated.
- Regularly reassess (until recovered) for the development of bacterial superinfection. [7]
Management of influenza pneumonia in children
- Specific antiviral therapy for influenza is available and licensed for pediatric use.
- Start antivirals in children with:
- Suspected or confirmed influenza infection in children < 5 years [12]
- Moderate-to-severe CAP likely due to influenza
- For further information, see “Treatment of influenza.”
Start antivirals immediately in patients with moderate-to-severe CAP and suspected influenza, even before confirming influenza infection. [7]
Management of COVID-19 pneumonia in children
- Depending on the severity, antiviral therapy (e.g., with remdesivir) may be recommended.
- See “COVID-19 in children” for more information.
Complications
- Pulmonary complications [7]
- Parapneumonic effusion
- Empyema
- Lung abscess
- Multilobar disease
- Pneumothorax
- Bronchopleural fistula
- Dissemination of infection, causing: [7]
- Sepsis
- Septic arthritis
- Osteomyelitis
- Meningitis
- Cardiac involvement (endocarditis or pericarditis)
- CNS abscess
We list the most important complications. The selection is not exhaustive.
Prevention
General preventative measures
- Educate caregivers and patients about hand hygiene and respiratory hygiene.
- Encourage breastfeeding. [13]
- Children attending daycare have an increased risk of pneumonia; alternatives may be preferable for high-risk infants. [14]
- Advise caregivers to keep immunizations up-to-date (see also “Immunization schedule”).
Immunizations [1]
- During each pregnancy, advise mothers to get a booster for: [1]
- Ensure children receive recommended immunizations.
Pharmacotherapy for high-risk children
- For the RSV season: RSV prophylaxis
-
COVID-19
- Consider preexposure prophylaxis for COVID-19.
- Confirmed infection: COVID-19 pharmacotherapy for children
- Cystic fibrosis patients: Consider long-term azithromycin (see “Prevention of infection in CF”).