Practice Essentials

The United Nations Children's Fund (UNICEF) estimates that pediatric pneumonia kills 3
million children worldwide each year. These deaths occur almost exclusively in children with
underlying conditions, such as chronic lung disease of prematurity, congenital heart disease,
and immunosuppression. Although most fatalities occur in developing countries, pneumonia
(see the image below) remains a significant cause of morbidity in industrialized nations.

Right lower lobe consolidation in a patient with bacterial

pneumonia.

Essential update: Pediatric pneumonia may be effectively treated with twicedaily amoxicillin
In a randomized, placebo-controlled study of 820 pediatric patients with mild pediatric
pneumonia, researchers found that treatment with oral amoxicillin (50 mg/kg/day) twice daily
was as effective as amoxicillin given three times a day. Treatment failure occurred in 23% of
the twice-daily group and 22.8% of the thrice-daily group in the intention-to-treat analysis,
and in 21.3% and 20.1% of these groups, respectively, in the per-protocol analysis. Among
the 277 patients with radiologically confirmed pneumonia, treatment failure occurred in
18.8% of patients in both groups.[1, 2]

Signs and symptoms

Pneumonia can occur at any age, although it is more common in younger children.
Pneumonia accounts for 13% of all infectious illnesses in infants younger than 2 years.
Newborns with pneumonia commonly present with poor feeding and irritability, as well as
tachypnea, retractions, grunting, and hypoxemia. Infections with group B Streptococcus,
Listeria monocytogenes, or gram-negative rods (eg, Escherichia coli, Klebsiella pneumoniae)
are common causes of bacterial pneumonia. Group B streptococci infections are most often
transmitted to the fetus in utero. The most commonly isolated virus is respiratory syncytial
virus (RSV).
Cough is the most common symptom of pneumonia in infants, along with tachypnea,
retractions, and hypoxemia. These may be accompanied by congestion, fever, irritability, and
decreased feeding. Streptococcus pneumoniae is by far the most common bacterial pathogen
in infants aged 1-3 months.

Adolescents experience similar symptoms to younger children. They may have other
constitutional symptoms, such as headache, pleuritic chest pain, and vague abdominal pain.
Vomiting, diarrhea, pharyngitis, and otalgia/otitis are also common in this age group.
Mycoplasma pneumoniae is the most frequent cause of pneumonia among older children and
adolescents.
See Clinical Presentation for more detail.

Diagnosis
The signs and symptoms of pneumonia are often nonspecific and widely vary based on the
patients age and the infectious organisms involved.
Observing the childs respiratory effort during a physical exam is an important first step in
diagnosing pneumonia. The World Health Organization (WHO) respiratory rate thresholds for
identifying children with pneumonia are as follows:

Children younger than 2 months: Greater than or equal to 60 breaths/min

Children aged 2-11 months: Greater than or equal to 50 breaths/min

Children aged 12-59 months: Greater than or equal to 40 breaths/min

Assessment of oxygen saturation by pulse oximetry should be performed early in the

evaluation when respiratory symptoms are present. Cyanosis may be present in severe cases.
Capnography may be useful in the evaluation of children with potential respiratory
compromise.
Other diagnostic tests may include the following:

Auscultation by stethoscope
Cultures

Serology

Complete blood cell count (CBC)

Chest radiography

Ultrasonography

New data show that point-of-care ultrasonography accurately diagnoses most cases of
pneumonia in children and young adults. Ultrasonography may eventually replace x-rays for
diagnosis.[3, 4]
See Workup for more detail.

Management
Initial priorities in children with pneumonia include the identification and treatment of
respiratory distress, hypoxemia, and hypercarbia. Grunting, flaring, severe tachypnea, and
retractions should prompt immediate respiratory support. Children who are in severe

respiratory distress should undergo tracheal intubation if they are unable to maintain
oxygenation or have decreasing levels of consciousness. Increased respiratory support
requirements such as increased inhaled oxygen concentration, positive pressure ventilation, or
CPAP are commonly required before recovery begins.
Antibiotics
The majority of children diagnosed with pneumonia in the outpatient setting are treated with
oral antibiotics. High-dose amoxicillin is used as a first-line agent for children with
uncomplicated community-acquired pneumonia. Second- or third-generation cephalosporins
and macrolide antibiotics such as azithromycin are acceptable alternatives. Combination
therapy (ampicillin and either gentamicin or cefotaxime) is typically used in the initial
treatment of newborns and young infants.
Hospitalized patients can also usually be treated with a narrow-spectrum penicillin such as
ampicillin. The choice of agent and dosing may vary based on local resistance rates (high
rates of intermediate or resistant pneumococcus may require higher dosing of ampicillin to
surmount the altered penicillin-binding protein that is the cause of resistant pneumococcus).
In areas where resistance is very high (>25% of strains being nonsusceptible), a thirdgeneration cephalosporin might be indicated instead. Older children, in addition, may receive
a macrolide to cover for atypical infections.
Although the fluoroquinolones would cover all the common respiratory pathogens of
childhood, they are not approved for this indication and have significant potential adverse
effects, including short-term tendon damage and long-term impact on antibiotic resistance.
They should be reserved for cases in which other therapies have failed and ideally should be
used after consultation with an infectious disease specialist with whom other options, or
alternative diagnoses, can be considered.
Children who are toxic appearing should receive antibiotic therapy that includes vancomycin
(particularly in areas where penicillin-resistant pneumococci and methicillin-resistant S
aureus [MRSA] are prevalent) along with a second- or third-generation cephalosporin.
Vaccines
Aside from avoiding infectious contacts (difficult for many families who use daycare
facilities), vaccination is the primary mode of prevention. Influenza vaccine is recommended
for children aged 6 months and older. The pneumococcal conjugate vaccine (PCV13) is
recommended for all children younger than 59 months old. The 23-valent polysaccharide
vaccine (PPVSV) is recommended for children 24 months or older who are at high risk of
pneumococcal disease.
See Treatment and Medication for more detail.

History
Newborns with pneumonia rarely cough; they more commonly present with poor feeding and
irritability, as well as tachypnea, retractions, grunting, and hypoxemia. Grunting in a newborn
suggests a lower respiratory tract disease and is due to vocal cord approximation as they try

to provide increased positive end-expiratory pressure (PEEP) and keep their lower airways
open.
After the first month of life, cough is the most common presenting symptom of pneumonia.
Infants may have a history of antecedent upper respiratory symptoms. Grunting may be less
common in older infants; however, tachypnea, retractions, and hypoxemia are common and
may be accompanied by a persistent cough, congestion, fever, irritability, and decreased
feeding. Any maternal history of Chlamydia trachomatis infection should be determined.
Infants with bacterial pneumonia are often febrile, but those with viral pneumonia or
pneumonia caused by atypical organisms may have a low-grade fever or may be afebrile. The
child's caretakers may complain that the child is wheezing or has noisy breathing. Toddlers
and preschoolers most often present with fever, cough (productive or nonproductive),
tachypnea, and congestion. They may have some vomiting, particularly posttussive emesis. A
history of antecedent upper respiratory tract illness is common.
Older children and adolescents may also present with fever, cough (productive or
nonproductive), congestion, chest pain, dehydration, and lethargy. In addition to the
symptoms reported in younger children, adolescents may have other constitutional symptoms,
such as headache, pleuritic chest pain, and vague abdominal pain. Vomiting, diarrhea,
pharyngitis, and otalgia/otitis are other common symptoms.
Travel history is important because it may reveal an exposure risk to a pathogen more
common to a specific geographic area (eg, dimorphic fungi). Any exposure to TB should
always be determined. In addition, exposure to birds (psittacosis), bird droppings
(histoplasmosis), bats (histoplasmosis), or other animals (zoonoses, including Q fever,
tularemia, and plague) should be determined.
In children with evidence for recurrent sinopulmonary infections, a careful history to
determine the underlying cause is needed. The recurrent nature of the infections may be
unveiling an innate or acquired immune deficiency, an anatomic defect, or another genetic
disease (cystic fibrosis, ciliary dyskinesia).

Tuberculosis
A history of TB exposure to possible sources should be obtained in every patient who
presents with signs and symptoms of pneumonia (eg, immigrants from Africa, certain parts of
Asia, and Eastern Europe; contacts with persons in the penal system; close contact with
known individuals with TB). Children with TB usually do not present with symptoms until 16 months after primary infection. These may include fever, night sweats, chills, cough (which
may include hemoptysis), and weight loss.

Diagnostic Considerations
Pneumonia can occur at any age, although it is more common in younger children. Different
age groups tend to be infected by different pathogens, which affects diagnostic and
therapeutic decisions.

Many patients referred for evaluation for recurrent pneumonia are diagnosed with asthma. In
emergency department studies, 35% of children with an asthma exacerbation have
abnormalities visible on chest radiographs. In a child not yet diagnosed with asthma, these
abnormalities are frequently interpreted as pneumonia. Inflammation, often triggered by viral
infection, is part of the asthmatic response. Wheezing responsive to bronchodilators, a history
of atopy, a family history of asthma, and a history of cough or wheeze with exercise may be
helpful in identifying these patients.
Consider any other diseases that may present with respiratory dysfunction in the first 24
hours of life. Keep in mind that any of the conditions listed below may also have
superimposed pneumonia:

Alveolar-capillary dysplasia
Arrhythmia

Asphyxia

Bronchial duplication

Chest wall injury or anomaly

Choanal atresia

Chylothorax

Diaphragmatic eventration

Heart block

Intracranial hemorrhage

Laryngeal cleft

Laryngeal nerve injury

Mutation of ABCA3 gene (for surfactant phospholipid transport)

Neuromuscular disorders

Phrenic nerve injury

Pulmonary hemorrhage

Pulmonary hypoplasia

Pulmonary lymphangiectasia

Spinal injury

Surfactant-related protein B deficiency

Tachycardia syndromes

Tracheoesophageal fistula

Transplacental medications

Vascular catheter accident

Other causes of airway obstruction

Other congenital heart diseases

Other inborn errors of metabolism

Other neuromuscular diseases

A careful history and examination in patients with recurrent pneumonia are helpful to further
narrow the differential diagnosis. However, more testing is often needed to confirm most of
these diagnoses and is generally outside the scope of a primary care provider.

Differential Diagnoses

Acidosis, Metabolic
Acute Anemia

Acute Respiratory Distress Syndrome

Afebrile Pneumonia Syndrome

Agammaglobulinemia

Airway Foreign Body

Alveolar Proteinosis

Aortic Stenosis

Aortic Stenosis, Subaortic

Aortic Stenosis, Valvar

Aseptic Meningitis

Asphyxiating Thoracic Dystrophy (Jeune Syndrome)

Aspiration Syndromes

Asthma

Atelectasis, Pulmonary

Atrial Flutter

Atrioventricular Septal Defect, Complete

Atrioventricular Septal Defect, Unbalanced

Bacteremia

Birth Trauma

Bowel Obstruction in the Newborn

Bronchiectasis

Bronchiolitis

Bronchitis

Bronchitis, Acute and Chronic

Bronchogenic Cyst

Cardiomyopathy, Hypertrophic

Chronic Anemia

Chronic Granulomatous Disease

Coarctation of the Aorta

Coccidioidomycosis

Combined B-Cell and T-Cell Disorders

Common Variable Immunodeficiency

Complement Deficiency

Complement Receptor Deficiency

Congenital Diaphragmatic Hernia

Congenital Pneumonia

Congenital Stridor

Cystic Adenomatoid Malformation

Cystic Fibrosis

Double Outlet Right Ventricle, Normally Related Great Arteries

Double Outlet Right Ventricle, With Transposition

Ebstein Anomaly

Empyema

Esophageal Atresia With or Without Tracheoesophageal Fistula

Foreign Body Aspiration

Gastroesophageal Reflux

Goodpasture Syndrome

Head Trauma

Hemosiderosis

Hemothorax

Histoplasmosis

Human Immunodeficiency Virus Infection

Hypersensitivity Pneumonitis

Hypocalcemia

Hypoglycemia

Hypoplastic Left Heart Syndrome

IgA and IgG Subclass Deficiencies

Inhalation Injury

Interrupted Aortic Arch

Legionella Infection

Meningitis, Bacterial

Neural Tube Defects

Patent Ductus Arteriosus

Pediatric Respiratory Distress Syndrome

Pertussis

Pleural Effusion

Pneumococcal Infections

Pneumococcal Infections

Pneumonia, Aspiration

Pneumonia, Bacterial

Pneumonia, Empyema and Abscess

Pneumonia, Immunocompromised

Pneumonia, Mycoplasma

Pneumothorax

Pulmonary Atresia With Intact Ventricular Septum

Pulmonary Atresia With Ventricular Septal Defect

Pulmonary Hypertension, Persistent-Newborn

Pulmonary Hypoplasia

Pulmonary Sequestration

Q Fever

Respiratory Distress Syndrome

Respiratory Distress Syndrome

Smoke Inhalation

Total Anomalous Pulmonary Venous Connection

Transient Tachypnea of the Newborn

Transposition of the Great Arteries

Tricuspid Atresia

Truncus Arteriosus

Vascular Ring, Double Aortic Arch

Vascular Ring, Right Aortic Arch

Medication Summary
Drug therapy for pneumonia is tailored to the situation. Because the etiologic agents vary,
drug choice is affected by the patient's age, exposure history, likelihood of resistance (eg,
pneumococcus), and clinical presentation. Beta-lactam antibiotics (eg, amoxicillin,
cefuroxime, cefdinir) are preferred for outpatient management. Macrolide antibiotics (eg,
azithromycin, clarithromycin) are useful in most school-aged children to cover the atypical
organisms and pneumococcus. Local variations in resistance require different approaches to
therapy, including cases caused by pneumococcus. Any child with a positive purified protein
derivative (PPD) test result and infiltrate on chest radiographs requires additional testing for
tuberculosis and polymicrobial treatment.
Agents typically used initially in the treatment of newborns and young infants with
pneumonia include a combination of ampicillin and either gentamicin or cefotaxime. The
selection of cefotaxime or gentamicin must be based on experience and considerations at
each center and in each patient. Combination therapy provides reasonable antimicrobial
efficacy against the pathogens that typically cause serious infection in the first days of life.
Other agents or combinations may be appropriate for initial empiric therapy if justified by the
range of pathogens and susceptibilities encountered in a particular clinical setting.
Isolation of a specific pathogen from a normally sterile site in the infant allows revision of
therapy to the drug that is least toxic, has the narrowest antimicrobial spectrum, and is most
effective. Dosing intervals for ampicillin, cefotaxime, gentamicin, and other antimicrobial
agents typically require readjustment in the face of renal dysfunction or once the infant is
older than 7 days (if the infant still requires antimicrobial therapy).

Cephalosporins
Class Summary
Cephalosporins are structurally and pharmacologically related to penicillins. They inhibit
bacterial cell wall synthesis, resulting in bactericidal activity. Cephalosporins are divided into
first, second, and third generation. First-generation cephalosporins have greater activity
against gram-positive bacteria, and succeeding generations have increased activity against
gram-negative bacteria and decreased activity against gram-positive bacteria.
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Cefpodoxime (Vantin)

Cefpodoxime inhibits bacterial cell wall synthesis by binding to one or more of the penicillinbinding proteins. The tablet should be administered with food.
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Cefprozil (Cefzil)

Cefprozil binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell
wall synthesis and results in bactericidal activity.
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Cefdinir (Omnicef)

Cefdinir binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell
wall synthesis and results in bactericidal activity.
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Ceftriaxone (Rocephin)

Ceftriaxone is a third-generation cephalosporin with broad-spectrum gram-negative activity

that arrests bacterial growth by binding to one or more penicillin-binding proteins.
Ceftriaxone has lower efficacy against gram-positive organisms but higher efficacy against
resistant organisms.

Cefotaxime (Claforan)

Cefotaxime is a third-generation cephalosporin with gram-negative spectrum that arrests

bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. This drug has a lower
efficacy against gram-positive organisms.
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Cefuroxime (Zinacef, Ceftin, Kefurox)

Cefuroxime is a second-generation cephalosporin that maintains the gram-positive activity

first-generation cephalosporins have. This drug adds activity against P mirabilis, H
influenzae, E coli, K pneumoniae, and M catarrhalis. The condition of the patient, severity of
infection, and susceptibility of the causative microorganism determines the proper dose and
route of administration.

Aminoglycosides
Class Summary
Aminoglycosides are bactericidal antibiotics used to primarily treat gram-negative infections.
They interfere with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits.
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Gentamicin

Gentamicin is an aminoglycoside antibiotic for gram-negative coverage that is typically used

in combination with agents against gram-positive organisms. When administered parenterally,
this agent offers antimicrobial efficacy against many gram-negative pathogens commonly
encountered in the first few days of life, including E coli, Klebsiella species, and other enteric
organisms, as well as many strains of nontypeable H influenzae.
Gentamicin is also variably effective against some strains of certain gram-positive organisms,
including S aureus, enterococci, and L monocytogenes. Gentamicin crosses the blood-brain
barrier into the CNS less well and theoretically poses a greater risk of renal toxicity or
ototoxicity than cefotaxime and other third-generation cephalosporins, which are the common
alternatives.
Gentamicin is associated with much less rapid emergence of resistant organisms in a closed
environment (eg, neonatal ICU), and has a broader range of susceptible gram-negative
organisms. Gentamicin has been reported to offer additive or synergistic activity against
enterococci when used with ampicillin.