Key Facts

Pneumonia is common in children and a significant cause of hospitalisation. Most cases are viral and self-limiting, but bacterial pneumonia requires prompt antibiotic treatment. The BTS guidelines provide a structured evidence-based approach.

Epidemiology

Community-acquired pneumonia (CAP) affects approximately 14-33 per 10,000 children per year in the UK. It is the most common serious bacterial infection in children. Hospitalisation rate is approximately 1-4 per 1,000 per year. PCV13 vaccination has significantly reduced invasive pneumococcal disease.

Aetiology

<5 years: Predominantly viral (RSV, influenza, parainfluenza, adenovirus, rhinovirus) >5 years: Increasing bacterial (S. pneumoniae, Mycoplasma pneumoniae) All ages: S. pneumoniae is the most common bacterial cause; Staphylococcus aureus causes severe necrotising pneumonia (rare)

Pathophysiology

Clinical Features

• Cough (dry → productive), fever, tachypnoea, breathlessness
• Reduced air entry, dullness to percussion, bronchial breathing, crackles (focal)
• Abdominal pain (referred from lower lobe pneumonia - common in children)
• Grunting (in infants - sign of significant respiratory distress)

Tachypnoea (WHO Definition)

• <2 months: RR >60
• 2-12 months: RR >50
• 1-5 years: RR >40

• 5 years: RR >20

Red Flags

• SpO2 <92% - admit, supplemental O2
• Grunting - significant respiratory distress
• Not responding to 48h oral antibiotics - consider empyema, resistant organism, alternative diagnosis
• Staphylococcal pneumonia - rapidly progressive, cavitation, pneumatoceles
• Recurrent pneumonia (≥2 in same lobe) - investigate for underlying cause (FB, bronchiectasis, immunodeficiency)

Bedside

• SpO2: Essential in all children with suspected pneumonia
• Temperature: Fever assessment
• Respiratory assessment: RR, work of breathing, auscultation

Bloods

• FBC, CRP: If admitted; CRP >80 more suggestive of bacterial (not diagnostic)
• Blood culture: If admitted or severe
• Mycoplasma serology/PCR: If atypical pneumonia suspected

Imaging

• CXR: NOT routinely required for non-severe community-managed cases; indicated if: severe, not responding to treatment, recurrent, suspected complication
• USS chest: If effusion suspected - more sensitive than CXR for small effusions
• CT chest: Rarely needed; for complex empyema or abscess

Special Tests

• NPA/throat swab: Viral PCR if viral aetiology needs confirmation
• Sputum culture: In older children who can expectorate
• Pleural fluid MC&S: If effusion drained

Community Management (Non-Severe)

• Amoxicillin 25mg/kg TDS (or 50mg/kg BD) for 5 days - first-line for all ages
• Clarithromycin/erythromycin: If penicillin allergy or atypical pneumonia suspected (Mycoplasma)
• Safety-net: Review if not improving at 48h; return if worsening

Hospital Management (Severe)

• Oxygen: If SpO2 <92%
• IV antibiotics: Amoxicillin 25mg/kg TDS IV ± clarithromycin 7.5mg/kg BD; co-amoxiclav 30mg/kg TDS if severe or <2 years
• IV fluids: If not feeding adequately
• Switch to oral: When afebrile for 24h and improving; total course 5-7 days (longer for complications)

Complications Management

• Lung abscess: Prolonged IV antibiotics (4-6 weeks); rarely needs drainage

Referral Criteria

• SpO2 <92% - admit
• Not responding to 48h oral antibiotics - investigate (CXR, bloods, USS)
• Empyema - paediatric surgery/respiratory for drainage
• Recurrent pneumonia - investigate for underlying cause (immunodeficiency, CF, structural, FB)

• Uncomplicated CAP: Full recovery in 1-2 weeks
• Empyema: Prolongs illness to 2-6 weeks; excellent long-term lung recovery in children
• Mortality: <1% in previously healthy children in UK; higher in immunocompromised, neonates
• Post-PCV13: Significant reduction in pneumococcal pneumonia and invasive disease
• Mycoplasma: Self-limiting but slow recovery; macrolide treatment shortens duration of symptoms

BTS Paediatric Pneumonia Antibiotic Choice

When to CXR in Childhood Pneumonia