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

Bacterial pneumonia involves alveolar invasion by bacteria (usually following mucosal damage from viral URTI), triggering neutrophilic inflammation, exudate formation, and consolidation. Viral pneumonia causes interstitial inflammation, alveolar oedema, and impaired gas exchange. Complications include parapneumonic effusion (reactive) → empyema (infected) → lung abscess (rare).

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

• Parapneumonic effusion/empyema: If fever persists >48h despite appropriate antibiotics → USS chest → drain + fibrinolytics or VATS
• 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