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).
- Respiratory syncytial virus (RSV): most common overall pathogen, particularly in those < 2 years old
- Coronaviruses (including COVID-19)
- Human metapneumovirus
- Similar to in adults, e.g.: 
- May be preceded by symptoms of an upper respiratory tract infection
- Additional features in children may include: 
- Abdominal pain
- Difficulties feeding
Features of atypical pediatric pneumonia 
- 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 respiratory support, antipyretics) as needed. (e.g.,
- Consult PICU.
- Start .
- Hemodynamically unstable patients: Initiate .
Admission criteria for pediatric CAP 
- Hypoxemia (< 90%)
- Suspected bacterial CAP in infants < 6 months of age
- Suspected pathogen with increased virulence (e.g., MRSA)
- In caregivers, or
- Underlying conditions/comorbidities that may affect illness severity
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.
- Respiratory viral panel
- Blood tests
Sputum samples are not routinely performed because of:
- Difficulties obtaining a sample in younger children
- Poor yield
- Chest x-ray (AP and lateral)
- Chest ultrasound
- 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 
- Start including .
- 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: 
- Clinical improvement for at least 12 hours
- Able to tolerate oral medication
- Caregivers are able to give medication and there are no .
Outpatient management 
- Initiate .
- Start pathogen-directed management.
- Educate caregivers on return precautions and arrange for a follow-up in 48–72 hours.
- At follow-up: 
- Outpatient oral antibiotic therapy is typically given for a maximum of 7 days. 
- Start empiric antibiotics for all patients with suspected bacterial pneumonia.
- If are present, cover for atypical pathogens.
- : Initiate .
- Provide .
- Tailor treatment to culture results if possible.
- Switch patients on IV antibiotics to oral therapy when: 
- Symptoms improve.
- Patients can tolerate oral intake.
- Regularly reassess patients, and escalate care as needed.
Empiric antibiotic therapy for pediatric CAP
Intravenous antibiotic therapy
Empiric intravenous antibiotics for CAP in children 
|Suspected etiology||Fully immunized||Not fully immunized|
Transition to oral antibiotics when patients are clinically improving and can tolerate oral fluids including medications. 
Oral antibiotics for pediatric pneumonia
|Empiric oral antibiotics for CAP in children |
Outpatient oral antibiotic therapy is typically given for a maximum of 7 days. 
- Provide supportive therapy for pneumonia.
- Offer antiviral therapy when indicated.
- Regularly reassess (until recovered) for the development of bacterial superinfection. 
Management of influenza pneumonia in children
- Specific antiviral therapy for influenza is available and licensed for pediatric use.
- Start antivirals in children with:
- For further information, see “Treatment of influenza.”
Management of COVID-19 pneumonia in children
- Pulmonary complications 
- Dissemination of infection, causing: 
We list the most important complications. The selection is not exhaustive.
General preventative measures
- Educate caregivers and patients about and .
- Encourage breastfeeding. 
- Children attending daycare have an increased risk of pneumonia; alternatives may be preferable for high-risk infants. 
- Advise caregivers to keep immunizations up-to-date (see also “Immunization schedule”).
- During each pregnancy, advise mothers to get a booster for: 
- Ensure children receive .