Pneumonia Management in Children

See Also

Management
General

See Pneumonia Management
See age directed management below

Indications
Hospitalization

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)
Hypoxemia (<90 to 92% Oxygen Saturation) or Cyanosis
Virulent pathogen suspected (e.g. MRSA, Pneumococcal Pneumonia, Group A Streptococcal Pneumonia)
Altered Mental Status
Infants under age 3 to 6 months with suspected Bacterial Pneumonia
Toxic appearance
Dehydration with Vomiting or poor oral intake
Immunocompromised patient
Serious comorbidity (cardiopulmonary disease, Genetic Syndromes, Neurocognitive Disorder, metabolic disorder)
Pneumonia refractory to oral Antibiotics
Unreliable home environment
(2002) Thorax 57:i1-24 [PubMed]

Indications
PICU admission

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

Management
General

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
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
Manage Hydration
1. Oral hydration
2. Intravenous Fluids
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]
Other measures that appear ineffective in Pneumonia clearance
1. Mucolytics

Management
Newborn (under 3 weeks old)

Admit all newborns with Pneumonia
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
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

Management
Age 3 weeks to 3 months

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
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
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

Management
Age 3 months to 5 years (outpatient)

See inpatient Antibiotic selection below
Precautions
1. Viral Pneumonia (esp. Influenza, RSV) predominates in preschool children
  1. Most common in under age 2 years old
  2. Viral Pneumonia Incidence 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
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)
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
Consider initial ParenteralAntibiotic at diagnosis
1. See inpatient Antibiotic regimen below
2. Start oral Antibiotics concurrently as below
Influenza suspected
1. Oseltamavir (Tamiflu)

Management
Age 5 to 18 years (outpatient)

See inpatient Antibiotic selection below
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)
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)
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
Consider initial ParenteralAntibiotic at diagnosis
1. See inpatient Antibiotic regimen below
2. Start oral Antibiotics concurrently as below
Influenza suspected
1. Oseltamivir (Tamiflu) or
2. Zanamavir
  1. Indicated only for children 7 years or older

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

See outpatient Antibiotics above
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
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
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%

References

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