Pneumonia Management in Children

Aka: Pneumonia Management in Children, Community Acquired Pneumonia Management in Children

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II. Management: General

  1. See Pneumonia Management
  2. See age directed management below

III. Indications: Hospitalization

  1. Respiratory distress (Apnea, grunting, nasal flaring)
    1. See Respiratory Distress in Children with Pneumonia
    2. See Pediatric Early Warning Score (PEWS Score)
    3. Tachypnea (>60 bpm age <2 months, >50 bpm age 2-12 months, >40 bpm age 1 to 5 years)
  2. Hypoxemia (<90 to 92% Oxygen Saturation) or Cyanosis
  3. Virulent pathogen suspected (e.g. MRSA, Pneumococcal Pneumonia, Group A Streptococcal Pneumonia)
  4. Altered Mental Status
  5. Infants under age 3 to 6 months with suspected Bacterial Pneumonia
  6. Toxic appearance
  7. Dehydration with Vomiting or poor oral intake
  8. Immunocompromised patient
  9. Serious comorbidity (cardiopulmonary disease, Genetic Syndromes, Neurocognitive Disorder, metabolic disorder)
  10. Pneumonia refractory to oral Antibiotics
  11. Unreliable home environment
  12. (2002) Thorax 57:i1-24 [PubMed]

IV. Indications: PICU admission

  1. Mechanical Ventilation or CPAP
  2. Impending Respiratory Failure
  3. Shock state
  4. Pulse Oximetry <92% despite Supplemental Oxygen with FIO2 50% or higher
  5. Altered Mental Status

V. Management: General

  1. Manage Hypoxia and Respiratory Distress
    1. See ABC Management
    2. Supplemental Oxygen
    3. See High Flow Nasal Cannula
    4. See Advanced Airway in Children
    5. Frequent nasal suctioning
  2. Manage Infection
    1. See Pediatric Sepsis
    2. Antibiotics
      1. See below for empiric Antibiotic selection
      2. Tailor Antibiotic selection if causative organism is identified
      3. Antibiotic course in all patients is 5 to 7 days
    3. Reevaluation at 48 to 72 hours if not responding to initial therapy
    4. Expect cough to persist for weeks
  3. Manage Hydration
    1. Oral hydration
    2. Intravenous Fluids
  4. Other supportive care
    1. Antipyretics (e.g. Acetaminophen)
    2. Zinc supplementation in critically ill children with Pneumonia
      1. Associated with decreased mortality, shorter hospitalizations and fewer treatment failures
      2. Greatest benefit appears to be in developing countries
        1. Zinc Deficiency occurs frequently in developing countries (30% of world population)
      3. References
        1. Basnet (2012) Pediatrics 129(4): 701-8 [PubMed]
        2. Srinivasan (2012) BMC Med 10: 14 [PubMed]
  5. Other measures that appear ineffective in Pneumonia clearance
    1. Mucolytics

VI. Management: Newborn (under 3 weeks old)

  1. Admit all newborns with Pneumonia
  2. Antibiotic regimen (Use 2-3 Antibiotics combined)
    1. Antibiotic 1: Ampicillin
      1. Age <7 days
        1. Weight <2 kg: 50-100 mg/kg divided q12 hours
        2. Weight >2 kg: 75-150 mg/kg divided q8 hours
      2. Age >7 days
        1. Weight <1.2 kg: 50-100 mg/kg divided q12 hours
        2. Weight 1.2-2 kg: 75-150 mg/kg divided q8 hours
        3. Weight >2 kg: 100-200 mg/kg divided q6 hours
    2. Antibiotic 2: Gentamicin (dosing below if >37 weeks)
      1. Age <7 days
        1. Weight <2 kg: 2.5 mg/kg IV every 18 to 24 hours
        2. Weight >2 kg: 2.5 mg/kg IV every 12 hours
      2. Age >7 days
        1. Dose: 2.5 mg/kg IV every 12 hours
    3. Antibiotic 3: Cefotaxime (optional)
      1. Age <7 days: 50 mg/kg IV every 12 hours
      2. Age >7 days: 50 mg/kg IV every 8 hours
  3. Organisms requiring additional Antibiotic coverage
    1. Methicillin Resistant Staphylococcus Aureus (MRSA): Choose 1
      1. Vancomycin
        1. Age <7 days
          1. Weight <2 kg: 12.5 mg/kg IV every 12 hours
          2. Weight >2 kg: 15 mg/kg IV every 12 hours
        2. Age >7 days
          1. Weight <2 kg: 18 mg/kg IV every 12 hours
          2. Weight >2 kg: 22 mg/kg IV every 12 hours
      2. Linezolid
        1. Dose: 10 mg/kg every 8 hours
    2. Chlamydia trachomatis
      1. Erythromycin 12.5 mg/kg orally or IV every 6 hours for 14 days

VII. Management: Age 3 weeks to 3 months

  1. Precautions
    1. Erythromycin is associated with increased risk of Hypertrophic Pyloric Stenosis in infants under 6 weeks of age
    2. No empiric therapy is needed for Staphylococcus aureus coverage as this rarely occurs in this age group
  2. Outpatient (if affebrile without respiratory distress)
    1. Consider hospital admission in all children with suspected Bacterial Pneumonia <3 to 6 months
    2. Azithromycin 10 mg/kg (max 500 mg) orally on day 1 then 5 mg/kg (max 250 mg) orally on days 2 to 5 or
    3. Erythromycin 12.5 mg/kg orally every 6 hours for 14 days
  3. Inpatient (if febrile or hypoxic)
    1. Macrolide
      1. Azithromycin 10 mg/kg (max 500 mg) IV on day 1 then 5 mg/kg (max 250 mg) IV on days 2 to 5 or
      2. Erythromycin 10 mg/kg IV every 6 hours for 7 days
    2. Febrile
      1. Add Cefotaxime 50 mg/kg IV every 8 hours
    3. Lobar Pneumonia (presumed Streptococcus Pneumoniae)
      1. Add Ampicillin 50-75 mg/kg IV every 6 hours

VIII. Management: Age 3 months to 5 years (outpatient)

  1. See inpatient Antibiotic selection below
  2. Precautions
    1. Viral Pneumonia (esp. Influenza, RSV) predominates in preschool children
      1. Most common in under age 2 years old
      2. Viral PneumoniaIncidence decreases with age
    2. Empiric Antibiotic therapy is not recommended unless Bacterial Pneumonia is suspected
      1. Coverage below first addresses Streptococcus Pneumoniae coverage
      2. Streptococcus Pneumoniae has high resistance to macrolide Antibiotics (e.g. Azithromycin)
    3. May treat as outpatient if patient affebrile without respiratory distress
  3. First-line oral agent for presumed Bacterial cause (choose one)
    1. Amoxicillin (preferred)
      1. Dose: 90 mg/kg/day orally divided every 12 hours for 5 days
        1. Five day course is non-inferior to 10 days
        2. Hazir (2008) Lancet 371(9606): 49-56 [PubMed]
        3. Pernica (2021) JAMA Pediatr 175(5): 475-82 [PubMed]
    2. Augmentin (alternative)
      1. Not recommended
        1. Pneumococcus rarely produces Beta-Lactamase
        2. Clavulanic Acid causes more Diarrhea
      2. Dose: 90 mg/kg (of extra strength formulation) every 12 hours
    3. Cephalosporin Alternatives in Non-Anaphylactic Penicillin Allergy
      1. Cefuroxime (Ceftin)
      2. Cefdinir (Omnicef)
      3. Cefpodoxime (Vantin)
    4. Alternatives in Anaphylactic Penicillin Allergy
      1. Clindamycin
      2. Levofloxacin (caution in under age 12 years due to cartilage effects)
  4. Presumed Atypical Pneumonia (choose one)
    1. Do NOT use as monotherapy in Pneumonia (50% pneumococcus resistance)
      1. Add Macrolide to first-line Antibiotic
    2. Azithromycin
      1. Dose: 10 mg/kg (max 500 mg) orally on day 1 then 5 mg/kg (max 250 mg) orally on days 2 to 5
    3. Clarithromycin
      1. Dose: 7.5 mg/kg twice daily for 7 days
    4. Erythromycin
      1. Dose: 10 mg/kg orally four times daily
  5. Consider initial ParenteralAntibiotic at diagnosis
    1. See inpatient Antibiotic regimen below
    2. Start oral Antibiotics concurrently as below
  6. Influenza suspected
    1. Oseltamavir (Tamiflu)

IX. Management: Age 5 to 18 years (outpatient)

  1. See inpatient Antibiotic selection below
  2. Approach
    1. Choose an agent based on typical versus atypical Bacterial cause suspected
    2. In more severe cases, or in which typical can not be distinguished from each other
      1. Choose an Antibiotic from each category (one from typical, one from atypical)
  3. Typical Bacterial Pneumonia (i.e. Streptococcus Pneumoniae): Choose one
    1. Amoxicillin (preferred)
      1. Dose: 90 mg/kg/day orally divided every 12 hours for 5 days
      2. Hazir (2008) Lancet 371(9606): 49-56 [PubMed]
    2. Augmentin (alternative)
      1. Not recommended
        1. Pneumococcus rarely produces Beta-Lactamase
        2. Clavulanic Acid causes more Diarrhea
      2. Dose: 90 mg/kg (of extra strength formulation) every 12 hours
    3. Cephalosporin Alternatives in Non-Anaphylactic Penicillin Allergy
      1. Cefuroxime (Ceftin)
      2. Cefdinir (Omnicef)
      3. Cefpodoxime (Vantin)
    4. Alternatives in Anaphylactic Penicillin Allergy
      1. Clindamycin
      2. Levofloxacin (caution in under age 12 years due to cartilage effects)
  4. Presumed Atypical Bacterial Pneumonia: Choose one
    1. Avoid as monotherapy in Pneumonia (50% pneumococcus resistance)
      1. Add Macrolide to first-line Antibiotic
    2. Azithromycin
      1. Dose: 10 mg/kg (max 500 mg) orally on day 1 then 5 mg/kg (max 250 mg) orally on days 2 to 5
    3. Clarithromycin
      1. Dose: 7.5 mg/kg twice daily for 7 days
    4. Erythromycin
      1. Dose: 10 mg/kg orally four times daily
    5. Doxycycline (use only if over age 8 years)
      1. Dose: 100 mg orally every 12 hours
  5. Consider initial ParenteralAntibiotic at diagnosis
    1. See inpatient Antibiotic regimen below
    2. Start oral Antibiotics concurrently as below
  6. Influenza suspected
    1. Oseltamivir (Tamiflu) or
    2. Zanamavir
      1. Indicated only for children 7 years or older

X. Management: Age 3 months to 18 years (inpatient, Parenteral)

  1. See outpatient Antibiotics above
  2. Primary Antibiotic (choose one)
    1. Fully immunized and not life-threatening infection
      1. Ampicillin 40-50 mg/kg IV every 6 hours (preferred)
    2. Not fully immunized against S. Pneumoniae and H. Influenzae or life-threatening infection
      1. Cefotaxime 50 mg/kg IV every 8 hours or
      2. Ceftriaxone 75 to 100 mg/kg/day up to 1-2 g/day divided every 12 to 24 hours
  3. Atypical Pneumonia suspected (choose one)
    1. Add Azithromycin 10 mg/kg (max 500 mg) IV on day 1 then 5 mg/kg (max 250 mg) IV on days 2 to 5 or
    2. Add Erythromycin 40 mg/kg/day IV divided q6 hours or
    3. Add Clarithromycin 7.5 mg/kg twice daily for 7 to 14 days
  4. MRSA suspected (choose one)
    1. Add Vancomycin 14 to 20 mg/kg IV every 8 hours or
    2. Add Linezolid (Zyvox) 10 mg/kg IV/PO every 8h or if >12 yo, 600 mg PO/IV twice daily
    3. Add Clindamycin 14 mg/kg IV every 8 hours or
      1. If patient stable without bacteremia and Clindamycin resistance <10%

XI. References

  1. (2022) Presc Lett 29(3): 15-6
  2. (2019) Sanford Guide to Antimicrobial Therapy, accessed IOS, 12/23/2019
  3. Bradley (2011) Clin Infect Dis 53(7): e1-52 [PubMed]
  4. McIntosh (2002) N Engl J Med 346:429-37 [PubMed]
  5. Nelson (2000) Pediatr Infect Dis 19:251-3 [PubMed]
  6. Ostapchuk (2004) Am Fam Physician 70(5):899-908 [PubMed]
  7. Smith (2021) Am Fam Physician 104(6): 618-25 [PubMed]
  8. Stuckey-Schrock (2012) Am Fam Physician 86(7): 661-7 [PubMed]

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