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These guidelines may not be appropriate for immunocompromised children or those with chronic lung disease (e.g. cystic fibrosis, bronchiectasis, neonatal chronic lung disease). Seek senior medical advice.
NOTE: not all the features below may be present.
- persistent fever
- tachypnoea at rest
- increased work of breathing/respiratory distress
- lethargy/ unwell appearance
- hypoxaemia (especially <93%) on pulse oximetry
- crackles and bronchial breathing on auscultation
- elevated respiratory rate for age
- chest wall indrawing, retractions, grunting, nasal flaring
- absent breath sounds and a dull percussion note suggest a pleural effusion
|Tachypnoea by age (World Health Organisation)|
|< 2 months age||> 60 breaths per minute|
|2- 12 months age||> 50 breaths per minute|
|12 months to 5 years age||> 40 breaths per minute|
Occasionally children present with atypical symtpoms, such as abdominal pain (from referred pain) and vomiting.
Indications of severe pneumonia
Consider severe pneumonia if there are clinical features of pneumonia and 2 or more of the following:
- Severe respiratory distress
- Severe hypoxaemia or cyanosis
- Marked tachycardia
- Altered mental state
There are clinical features of complicated pneumonia (including empyema, parapneumonic effusion, lung abscess, or necrotising pneumonia). See Empyema guideline
Staphylococcus aureus is a cause of severe pneumonia. If suspected, discuss with senior staff. Features:
- Lung abscess or pneumatocoeles
- Multisystem infection
- Very unwell
- Pneumonia as a consequence of chickenpox, influenza or measles
Consider MRSA coverage (clindamycin or vancomycin) if the child is very unwell (eg requiring PICU admission) or has positive blood cultures indicating Staphylococcus (pending sensitivity).
Investigations are guided by clinical features. Many children with pneumonia may be diagnosed and managed on clinical grounds alone and do not require a chest x-ray (especially if mild, and expected to be managed as an outpatient).
Chest x-ray if:
- Presentation not typical
- Diagnostic uncertainty
- Infants <3 months of age
- Severely unwell
- History suggesting underlying respiratory disease
- Suspected complications (such as effusion) based on clinical signs
- Not making expected clinical progress.
Other investigations are usually only needed in patients requiring admission:
- Blood cultures if febrile and unwell, or septic, or complicated pneumonia
- Serum electrolytes for any child receiving intravenous fluids (risk of hyponatraemia due to SIADH)
- Full blood count does not differentiate between viral and bacterial causes, but may help identify other issues such as anaemia.
- Nasopharyngeal swab not always needed, however:
- Consider viral PCR panel if diagnostic uncertainty, or during influenza season to assist with treatment choice such as antiviral medication in selected cases.
- Consider atypical pneumonia PCR panel for severe or persistent illness.
Indications for admission:
- Ill or toxic appearance
- Age < 3 months
- Oxygen saturation less than 93% on air
- Respiratory distress interfering significantly with feeding
- Significant dehydration
- Complicated pneumonia
- Deterioration despite appropriate oral antibiotics
- Significant co-morbidity
- Social concerns (eg transport or communication barriers)
- Signs of severe pneumonia can include:
- Shock or toxic appearance
- Oxygen saturations < 85%, or diifficulty maintaining oxygenation > 92% with supplemental oxygen.
- Severe tachycardia
- Severe respiratory distress
Treat suspected bacterial pneumonia with antibiotics. Likely viral pneumonia does not require antibiotic treatment.
Oral antibiotics can be used for most mild to moderate episodes of pneumonia. This may include some of those requiring admission.
|< 1 month||
Oral antibiotics not appropriate in this age group
< 7 days old:
7 days - 1 month old:
|> 1 month
Mild to moderate pneumonia
Oral antibiotics not appropriate in < 3 month olds
Mild/moderate pneumonia > 3 months old
Moderate/Uncomplicated pneumonia needing admission
and IV therapy:
Cefotaxime 50 mg/kg/dose (max 2g) IV 6 hourly PLUS
|> 3 months
Cefuroxime 30 mg/kg/dose (max 1.5g) IV 6-8 hourly
Amoxicillin + clavulanic acid 30 mg/kg/dose (combined dosing, max 1.2g) IV 6-8 hourly
|Severe pneumonia possibly due to MRSA||
Add Clindamycin (requires ID approval) or
|Possible Bordetella pertussis
or Chlamydia trachomatis
Consider pertussis in younger age group or unimmunised children. Presents with apnoea in the very young, or paroxysmal coughing
Chlamydia usually presents at 3-8 weeks of age with prominent coughing
Send nasopharyngeal swab for PCR testing
Treat with Azithromycin - see NZFC dosing https://nzfchildren.org.nz/nzf_3150
|Possible Mycoplasma pneumonia||
Consider ADDING a macrolide if
Mycoplasma suspected clinically, and failed beta-lactam in
NOTE - no evidence that empiric treatment affects outcome compared to beta-lactam alone
Erythromycin 12.5mg/kg/dose (max 400mg/dose) PO 4 times a day 7-10 days OR
Roxithromycin (tablets only) 4mg/kg (max 150mg/dose) PO twice a day 7 days
|Severe pneumonia possibly due to influenza||
Consider ADDING oseltamivir and send urgent viral nasopharyngeal specimen - see NZFC for dosing https://nzfchildren.org.nz/nzf_3472
Also see: Influenza guideline
|History of penicillin/amoxicillin
allergy (urticarial rash or delayed type hypersensitivity)
|Mild/moderate pneumonia not
requiring intravenous therapy
Roxithromycin (tablets only) 4mg/kg (max 150mg/dose) PO twice a day for 7 days
If >10 years and weight >35kg Doxycyline 100mg PO twice a day for 7 days
If intravenous therapy required and/or severe pneumonia
Cefuroxime 30mg/kg IV 8 hourly (if anaphylactic or delayed type hypersensitivity to beta-lactams - discuss with Infectious diseases)
Duration of intravenous therapy
- Determined by clinical response
- Usually intravenous treatment until afebrile
- Total duration of treatment for radiologically confirmed pneumonia is usually 5-7 days.
- Intravenous treatment can be switched to oral treatment to complete course when appropriate (cephalexin can be used to follow cefuroxime).
- Rationalise if bacterial identification and/or sensitivity is available (eg from a positive blood culture). For example, penicillin or amoxicillin for proven susceptible Streptococcus pneumoniae or Flucloxacillin for proven MSSA.
Progression of pneumonia while on treatment
- Undertake nasopharyngeal swab for viral and atypical pneumonia panel (if not done already).
- Consider broader antibiotic cover to cover severe pneumonia +/- empiric addition of macrolide
- Consider repeat chest x-ray
Most children with pneumonia respond to quickly to treatment and make full recovery.
- Cough usually resolves within 6 weeks
- Review by the child's General Practitioner (GP) if cough persists, or other concerns.
- Follow up chest x-ray is not needed for uncomplicated pneumonia, but may be required in those with complicated pneumonia or chronic/recurrent symptoms.
Children with recurrent pneumonia or persistent symptoms
A history of recurrent pneumonia or chronic cough / respiratory symptoms at admission. This may be a sign of underlying vulnerabilities, chronic lung disease or environmental factors (see table below). History and clinical examination is the best starting point to investigate further.
See Guideline on Cough
Consider referral to General Paediatric outpatient clinic if the child has recurrent pneumonia or persistent symptoms.
Predisposing factors associated with pneumonia
|Environmental factors||Underlying conditions|
Tobacco smoke exposure
|Chronic lung diseases (chronic
Congenital lung malformation
Factsheet on pneumonia at Kidshealth.org.nz
Did you find this information helpful?
- Date last published: 16 April 2019
- Document type: Clinical Guideline
- Services responsible: General Paediatrics, Paediatric Infectious Diseases, Children’s Emergency Department
- Author(s): Mike Shepherd, Emma Best
- Editor: Greg Williams
- Review frequency: 2 years
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