In many cases, complaints associated with pneumonia are nonspecific, including cough, fever, tachypnea, and difficulty breathing.[21] Young children may present with abdominal pain. Important history to obtain includes the duration of symptoms, exposures, travel, sick contacts, baseline health of the child, chronic diseases, recurrent symptoms, choking, immunization history, maternal health, or birth complications in neonates.[22]

Physical exam should include observation for signs of respiratory distress, including tachypnea, nasal flaring, lower chest in-drawing, or hypoxia on room air.[21] Note that infants may present with reported inability to tolerate feeds, with grunting or apnea. Auscultation for rales or rhonchi in all lung fields with the appropriately sized stethoscope can also aid in diagnosis. In the developed world, other adjuncts like laboratory testing and imaging can be a helpful part of the physical exam. No isolated physical exam finding can accurately diagnose pneumonia.[23] However, the combination of symptoms, including fever, tachypnea, focal crackles, and decreased breath sounds together, raises the sensitivity for finding pneumonia on x-ray.[23] Pneumonia is a clinical diagnosis that should take into consideration the history of present illness, physical exam findings, adjunct testing, and imaging modalities.

Laboratory evaluation in children suspected of having pneumonia should ideally start with non-invasive, rapid bedside testing including nasopharyngeal swab assays for influenza, respiratory syncytial virus, and human metapneumovirus when available and appropriate. This can help minimize unnecessary imaging and antibiotic treatment in children with influenza or bronchiolitis. Children who present with severe disease and appear toxic should have complete blood count (CBC), electrolytes, renal/hepatic function testing, and blood cultures performed.[24] These tests are generally not required in children who present with mild disease. Inflammatory markers do not help distinguish between viral and bacterial pneumonia in the pediatric population.[24][25] However, these tests may be obtained to trend disease progression and serve as prognostic indicators. Children who have been in areas endemic to TB, or have exposure history, and present with signs and symptoms suspicious for pneumonia should have sputum samples or gastric aspirates collected for culture.

Sputum gram stain and culture are not productive as the samples are often contaminated by oral flora. Blood cultures can be done but are often negative. Today, serology is being used to determine the presence of mycoplasma, legionella, and chlamydia species. PCR is becoming available in most hospitals, but still, the results take 24-48 hours.

There are no clear guidelines for the routine use of chest x-ray in the pediatric population.[24] Although the chest x-ray can be helpful in diagnosis and confirmation of pneumonia,[26] it carries with it risks, including radiation exposure, healthcare-associated costs, and false-negative results, increasing the use of unwarranted antibiotics. Imaging should be restricted to children who appear toxic, those with the recurrent or prolonged course of illness despite treatment, infants age 0 to 3 months with a fever, suspected foreign body aspiration, or congenital lung malformation. Imaging can also be considered in children younger than 5 years old, who present with fever, leukocytosis, and no identifiable source of infection.[26] Imaging may also be useful in those with acute worsening of upper respiratory infections or to rule out underlying mass in children who have "round pneumonia."[27][28]

Treatment should be targeted to a specific pathogen that is suspected based on information obtained from history and physical exam. Supportive and symptomatic management is key and includes supplemental oxygen for hypoxia, antipyretics for fever, and fluids for dehydration. This is especially important for non-infectious pneumonitis and viral pneumonia for which antibiotics are not indicated.[21][29] Cough suppressants are not recommended.

If bacterial pneumonia is suspected, treat empirically with antibiotics, keeping in mind significant history and bacterial pathogens that are common to specific age groups.

Neonates should receive ampicillin plus an aminoglycoside or third-generation cephalosporin[21][30], however, not ceftriaxone, as it can displace bound bilirubin and lead to kernicterus.

Atypical pneumonia is common in infants 1 to 3 months old, and this group should have additional antibiotic coverage with erythromycin or clarithromycin.[21][30]

For infants and children over 3 months old, S. pneumoniae is the most common, for which the drug of choice is high-dose oral amoxicillin[21][30] or another beta-lactam antibiotic.

In children older than 5 years old, atypical agents have a more important role, and macrolide antibiotics are usually first-line therapy.[21]

Special attention should be given to children with chronic illnesses, as these might alter choices for antibiotics[21]. Children with sickle cell anemia will need cefotaxime, macrolide, vancomycin if severely ill. Children with cystic fibrosis will require piperacillin or ceftazidime plus tobramycin. Treat fulminant viral pneumonia as indicated, depending on the virus identified. For Varicella, use acyclovir and for the respiratory syncytial virus (RSV), use ribavirin for high-risk patients. Patients with HIV should be treated with sulfamethoxazole/trimethoprim and prednisone, and for Cytomegalovirus, ganciclovir and gamma globulin are the preferred agents. If methicillin-resistant Staphylococcus aureus (MRSA) is suspected, clindamycin or vancomycin may be given.

It is important to have a high index of suspicion for complications, especially in patients returning for repeat evaluation. For patients sent home with symptomatic or supportive management for suspected viral pneumonia, consider a secondary bacterial infection or other diagnoses upon re-evaluation.[31] Children with uncomplicated bacterial infections who fail to respond to treatment within 72 hours should be assessed for complications, including pneumothorax, empyema, or pleural effusion.[32] Other systemic complications of pneumonia include sepsis, dehydration, arthritis, meningitis, and hemolytic uremic syndrome.

Neonates and infants younger than 90 days old should be hospitalized for treatment, in addition to children who are immunocompromised or have other underlying chronic diseases like sickle cell anemia or cystic fibrosis.[21] Children with social factors that preclude access to care, have failed outpatient therapy, or present with presumed tuberculosis, should also be hospitalized.[33]

Admission is often required for patients with respiratory distress and low oxygenation. In most cases, the presence of a parapneumonic effusion requires admission. Children with severe respiratory distress may require chest therapy, CPAP, or even mechanical ventilation. A large pleural effusion requires drainage for diagnostic and therapeutic purposes.

It is essential to ensure that clear discharge instructions and return precautions are given to parents or caregivers of children being discharged home in addition to close pediatrician follow-up.

• Alveolar proteinosis

• Aortic stenosis

• Aseptic meningitis 

• Asphyxiating thoracic dystrophy 

• Aspiration syndromes 

• Asthma 

• Atelectasis

• AV septal defect, complete 

• AV septal defect, unbalanced 

• Bacteremia

• Birth trauma

For most children, the prognosis is good. Viral pneumonia tends to resolve without treatment. Long term sequelae are rare. However, both staphylococcal and varicella pneumonia have guarded outcomes in children. 

Children with tuberculosis are at high risk for disease progression if the condition is not treated Immunocompromized children have the worst prognosis. Each year, roughly 3 million children die from pneumonia and the majority of these children also have other comorbidities like congenital heart disease, immunosuppression or chronic lung disease of prematurity.

• Empyema
• Pleural effusion
• Lung abscess
• Necrotizing pneumonia
• Sepsis

Pediatric pneumonia is often undertreated or missed, leading to high morbidity and mortality. The condition is best managed by an interprofessional team to improve outcomes. The majority of patients are managed by the pediatrician, nurse practitioner, or primary care provider.  Patient and caregiver education is vital. Parents need to be told to avoid smoking, and the importance of handwashing cannot be overstated. In addition, all clinicians looking after children should emphasize vaccination against pneumococcus and influenza.

Healthcare professionals, including physicians, nurses, physician assistants, nurse practitioners, pharmacists, ideally work together in close environments for optimum patient care. When caring for children with pneumonia, pharmacists can be of significant help with geographic resistance patterns for better treatment outcomes with selected antibiotic choices.

Caregivers should be educated about signs of respiratory difficulty and when to seek medical assistance. Only through a team approach can pneumonia in children be treated promptly with minimal morbidity.