Pneumonia - Paediatric

Quick Answer

Paediatric pneumonia is lower respiratory tract infection with alveolar inflammation, most commonly caused by viruses in children below 5 years and bacteria (Streptococcus pneumoniae) in older children. Tachypnoea is the most sensitive clinical sign. WHO defines pneumonia by age-specific respiratory rates: greater than 60/min (below 2 months), greater than 50/min (2-12 months), greater than 40/min (1-5 years). Chest indrawing and hypoxaemia indicate severe disease. First-line antibiotics are oral amoxicillin (80-90 mg/kg/day) for uncomplicated community-acquired pneumonia, or IV benzylpenicillin + gentamicin for severe/complicated pneumonia requiring hospitalisation.

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ACEM Exam Focus

Fellowship Written Exam

Examiners expect candidates to:

• Apply WHO age-specific tachypnoea criteria for pneumonia diagnosis
• Distinguish viral bronchiolitis (age below 2 years, wheeze) from bacterial pneumonia (older children, focal consolidation)
• Know weight-based antibiotic dosing: Amoxicillin 80-90 mg/kg/day, benzylpenicillin 60 mg/kg Q6H
• Recognise severe pneumonia requiring admission: SpO2 below 92%, severe chest indrawing, inability to feed, apnoea
• Identify complications: Pleural effusion, empyema (ongoing fever greater than 48h despite antibiotics), necrotising pneumonia
• Understand Indigenous health disparities: Aboriginal and Torres Strait Islander children have 4-6× higher hospitalisation rates
• Apply retrieval criteria for remote/rural patients: Severe pneumonia, complications, deterioration despite initial therapy

Fellowship OSCE Stations

Commonly tested:

• Respiratory examination in febrile child with respiratory distress
• Assessment of work of breathing: Tachypnoea, nasal flaring, chest indrawing, grunting
• Oxygen delivery and respiratory support escalation
• Communication: Explaining chest X-ray findings, antibiotic choice, admission criteria to parents
• Sepsis recognition and early goal-directed therapy

Primary Viva

Applied physiology questions may include:

• Pathophysiology of tachypnoea in pneumonia (alveolar inflammation → V/Q mismatch → hypoxaemia → increased respiratory drive)
• Mechanism of grunting (glottic closure during expiration → maintains positive end-expiratory pressure → prevents alveolar collapse)
• Why chest indrawing occurs (increased negative intrathoracic pressure generated against stiff, consolidated lung)
• Age-specific immune defences: Infants lack acquired immunity, reduced IgG subclasses, immature T-cell responses

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Key Points

1. Tachypnoea is the most sensitive clinical sign of pneumonia: greater than 60/min (below 2 months), greater than 50/min (2-12 months), greater than 40/min (1-5 years) per WHO criteria. Absence of tachypnoea has high negative predictive value.

2. Age-specific pathogen distribution: below 5 years predominantly viruses (RSV, influenza, rhinovirus, hMPV, adenovirus), school-age children predominantly Streptococcus pneumoniae and Mycoplasma pneumoniae. Neonates: Group B Streptococcus, E. coli, Listeria.

3. Chest X-ray is NOT routinely required for uncomplicated community-acquired pneumonia (CAP). Indications: Severe pneumonia requiring hospitalisation, diagnostic uncertainty, suspected complications, failure to respond to antibiotics within 48-72 hours.

4. Oral amoxicillin is first-line for uncomplicated CAP (80-90 mg/kg/day divided TDS, max 3 g/day). Add azithromycin if Mycoplasma suspected (age greater than 5 years, prolonged dry cough, normal or low WCC). Severe pneumonia: IV benzylpenicillin 60 mg/kg Q6H + gentamicin 7.5 mg/kg daily.

5. Complicated pneumonia (parapneumonic effusion, empyema, lung abscess, necrotising pneumonia) occurs in 10-15% of hospitalised children. Suspect if persistent fever greater than 48 hours on antibiotics, ongoing hypoxia, clinical deterioration. Requires ultrasound chest, antibiotics covering Staphylococcus aureus and Streptococcus pyogenes, ± chest drain.

6. Indigenous health disparity: Aboriginal and Torres Strait Islander children have 4-6× higher hospitalisation rates, 3-4× higher rates of complicated pneumonia, and greater risk of bronchiectasis. Overcrowding, environmental tobacco smoke, poor housing contribute.

7. Admission criteria: SpO2 below 92% on room air, severe chest indrawing, inability to feed/drink, apnoea, age below 6 months (especially below 3 months), significant comorbidities (chronic lung disease, cardiac disease, immunodeficiency), social concerns, remote location limiting access.

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Epidemiology

Global Burden

Paediatric pneumonia remains a leading cause of childhood morbidity and mortality worldwide:

• Incidence: 120-156 million cases globally per year in children below 5 years, with 11-20 million severe episodes requiring hospitalisation (PMID: 16740087, McAllister 2019 Lancet).
• Mortality: Causes 800,000-1.4 million deaths annually in children below 5 years, accounting for 14-18% of all childhood deaths globally. Mortality highest in sub-Saharan Africa and South Asia (PMID: 23541163, Rudan 2013 Bull WHO; PMID: 30097986, Wahl 2018 Lancet Glob Health).
• Age distribution: Highest incidence in children 6 months to 5 years. Infants below 6 months have higher mortality due to immature immune systems.
• Seasonal variation: Peak incidence during winter months in temperate climates (viral respiratory season), year-round transmission in tropical regions.

Australian and New Zealand Context

• Incidence: 2-3% of Australian children below 5 years are hospitalised with pneumonia annually. Indigenous Australian children have 4-6× higher hospitalisation rates compared to non-Indigenous children (PMID: 25099492, O'Grady 2010 Med J Aust; PMID: 30760144, Chang 2019 Respirology).
• Indigenous disparity: Aboriginal and Torres Strait Islander children have 3-4× higher rates of complicated pneumonia (empyema, lung abscess) and 5-10× higher rates of bronchiectasis development post-pneumonia (PMID: 26040576, Chang 2015 Eur Respir J).
• Māori and Pacific Islander children in New Zealand have 2-3× higher hospitalisation rates and more severe disease compared to European children (PMID: 20831663, Grant 2010 Epidemiol Infect).
• Remote and rural: Children in remote Northern Territory communities have pneumonia hospitalisation rates 10-15× higher than urban Australian children, with higher complication rates (PMID: 29141444, Marsh 2017 Med J Aust).

Pathogen Epidemiology

Viral Pathogens (50-70% of cases in children below 5 years)

• Respiratory syncytial virus (RSV): Most common viral cause, 20-30% of pneumonia cases, peak age 2-24 months (PMID: 33501235, Shi 2021 Lancet Glob Health).
• Influenza A/B: 10-15% of cases, can cause severe/complicated pneumonia, higher mortality than RSV (PMID: 25331656, Jain 2015 NEJM).
• Human metapneumovirus (hMPV): 5-10% of cases, clinically indistinguishable from RSV, peak age 6-12 months (PMID: 15659724, Williams 2004 NEJM).
• Rhinovirus, adenovirus, parainfluenza: Each 3-8% of cases. Adenovirus can cause severe necrotising pneumonia.

Bacterial Pathogens (30-50% of cases, higher in children greater than 5 years)

• Streptococcus pneumoniae (pneumococcus): Most common bacterial cause, 20-30% of bacterial pneumonia. Incidence reduced by 50-70% since introduction of PCV13 vaccine but remains leading bacterial pathogen (PMID: 26720081, Tamma 2016 Pediatrics).
• Mycoplasma pneumoniae: 10-20% of cases in school-age children (greater than 5 years), "atypical" presentation with prolonged dry cough, low-grade fever (PMID: 31402414, Blyth 2019 J Paediatr Child Health).
• Staphylococcus aureus (including MRSA): 2-5% of bacterial pneumonia, associated with severe/necrotising pneumonia, empyema, post-viral pneumonia (following influenza) (PMID: 29335038, Hсеверозko 2018 Pediatr Infect Dis J).
• Streptococcus pyogenes (Group A Streptococcus): Causes 2-5% of pneumonia, associated with empyema, severe invasive disease (PMID: 20129152, Brouwer 2010 Clin Infect Dis).
• Haemophilus influenzae type b (Hib): Previously common, now rare in vaccinated populations (below 1%). Non-typeable H. influenzae still causes 3-5% of pneumonia (PMID: 23541163, Rudan 2013 Bull WHO).

Neonatal Pathogens (Age below 28 days)

• Group B Streptococcus (GBS): Most common bacterial cause of neonatal pneumonia, early-onset (below 7 days) or late-onset (7-89 days).
• Escherichia coli and other Gram-negative enteric organisms.
• Listeria monocytogenes: Associated with maternal chorioamnionitis.
• Chlamydia trachomatis: Causes afebrile pneumonia at 1-3 months (staccato cough, eosinophilia).

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Pathophysiology

Mechanisms of Lung Injury

1. Inhalation of pathogens: Microaspiration of upper respiratory tract secretions containing viral or bacterial pathogens is the primary route of infection.

2. Viral invasion: Viruses (RSV, influenza, adenovirus) infect respiratory epithelial cells, causing:

   • Direct cytopathic effect: Epithelial cell death, sloughing into airway lumen
   • Inflammatory response: Neutrophil and lymphocyte infiltration, cytokine release (IL-6, IL-8, TNF-α)
   • Bronchiolar obstruction: Mucus hypersecretion, epithelial debris, submucosal oedema
   • Atelectasis: Air trapping, small airway collapse distal to obstructed bronchioles

3. Bacterial invasion: Bacteria (pneumococcus, S. aureus) adhere to damaged respiratory epithelium and proliferate:

   • Alveolar inflammation: Bacteria invade alveolar spaces, triggering acute inflammatory response
   • Exudate formation: Protein-rich fluid, neutrophils, fibrin fill alveoli (consolidation)
   • Impaired gas exchange: Consolidated alveoli cannot participate in ventilation (shunt physiology)
   • Systemic inflammatory response: Cytokine release → fever, tachycardia, shock

Pathophysiological Consequences

Hypoxaemia

• V/Q mismatch: Consolidated or atelectatic lung units are perfused but not ventilated (shunt)
• Diffusion impairment: Thickened alveolar-capillary membrane from oedema and inflammatory exudate
• Reflex hypoxic vasoconstriction: Partially compensates by reducing perfusion to poorly ventilated areas

Tachypnoea

• Hypoxaemia: Stimulates peripheral chemoreceptors (carotid bodies) → increased respiratory drive
• Reduced lung compliance: Consolidated, stiff lung → increased work of breathing
• Metabolic acidosis: Tissue hypoxia → lactic acid accumulation → compensatory hyperventilation

Chest Indrawing (Recession)

• Increased inspiratory effort: Stiff, consolidated lung requires greater negative intrathoracic pressure to inflate
• Compliant chest wall: Paediatric chest wall is more compliant than adult, retracts inward with increased inspiratory effort
• Sites: Subcostal, intercostal, suprasternal, supraclavicular

Grunting

• Glottic closure: Child closes glottis during expiration, allowing pressure to build in lungs
• Auto-PEEP: Maintains positive end-expiratory pressure, preventing alveolar collapse and atelectasis
• Compensation mechanism: Improves oxygenation by recruiting atelectatic alveoli

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Clinical Features

Age-Specific Definitions of Tachypnoea (WHO Criteria)

Tachypnoea is the most sensitive clinical sign of pneumonia and should be assessed when the child is calm, afebrile, not crying:

(PMID: 24067391, WHO 2013 Pocket Book of Hospital Care for Children)

Note: Crying, fever, and agitation increase respiratory rate. Reassess when calm.

Clinical Presentation by Age

Neonates (below 28 days)

• Non-specific signs: Lethargy, poor feeding, temperature instability (hypothermia > fever)
• Respiratory distress: Tachypnoea, grunting, nasal flaring, chest indrawing
• Apnoea: Common presenting feature
• Sepsis: Hypotension, poor perfusion, metabolic acidosis

Infants (1-12 months)

• Tachypnoea (greater than 50/min): Most consistent finding
• Respiratory distress: Nasal flaring, subcostal/intercostal recession, grunting
• Feeding difficulties: Inability to feed, choking, desaturation during feeds
• Fever: Temperature greater than 38°C (but may be afebrile)
• Cough: Often absent in young infants
• Wheeze: May be present, especially if viral bronchiolitis

Children (1-5 years)

• Fever: Usually greater than 38.5°C, may have rigors
• Cough: Initially dry, then productive (but young children swallow sputum)
• Tachypnoea (greater than 40/min)
• Respiratory distress: Chest indrawing, use of accessory muscles
• Abdominal pain: Lower lobe pneumonia can irritate diaphragm, mimicking appendicitis
• Reduced activity: Lethargy, poor oral intake

School-age children (greater than 5 years)

• Fever: High-grade (greater than 39°C), often with chills
• Productive cough: May expectorate purulent sputum
• Pleuritic chest pain: Sharp, localised pain worsened by deep inspiration or cough
• Shortness of breath: Dyspnoea on exertion, orthopnoea if severe
• Headache, myalgia: Common with Mycoplasma or influenza pneumonia

Physical Examination Findings

Inspection

• Work of breathing: Tachypnoea, nasal flaring, chest indrawing (subcostal, intercostal, suprasternal), use of accessory muscles (sternocleidomastoid)
• Grunting: Audible expiratory grunt (sign of severe pneumonia)
• Cyanosis: Central cyanosis (lips, tongue) indicates severe hypoxaemia (SpO2 below 85%)
• General appearance: Toxicity (lethargy, poor perfusion), hydration status

Palpation

• Tracheal position: Deviated away from tension pneumothorax, large pleural effusion
• Chest expansion: Reduced on affected side if large consolidation or effusion
• Tactile vocal fremitus: Increased over consolidation, decreased over effusion

Percussion

• Dullness: Over consolidation or pleural effusion
• Resonance: Normal or hyperresonant over areas of air trapping (viral bronchiolitis)

Auscultation

• Breath sounds: Reduced or bronchial breathing over consolidation
• Crackles: Focal coarse crackles over affected lobe (bacterial pneumonia), diffuse fine crackles (viral pneumonia/bronchiolitis)
• Wheeze: Suggests viral bronchiolitis (age below 2 years) or reactive airway disease
• Pleural rub: Suggests pleural involvement (pleurisy)

Clinical Severity Assessment

WHO Classification of Pneumonia Severity

(PMID: 24067391, WHO 2013 Pocket Book)

Australian Paediatric Severity Score (PSS)

Used in Australian hospitals to guide disposition and escalation:

• Score 0: Outpatient oral antibiotics
• Score 1-2: Admission, IV antibiotics, oxygen
• Score 3-4: ICU consideration, severe pneumonia

(PMID: 28891471, Harris 2017 Pediatr Pulmonol)

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Differential Diagnosis

By Age Group

Neonates (below 28 days)

• Transient tachypnoea of the newborn (TTN): Resolves within 48 hours, no fever
• Meconium aspiration syndrome: History of meconium-stained liquor
• Congenital heart disease: Cyanosis, heart murmur, cardiomegaly on CXR
• Sepsis (non-pulmonary): Meningitis, UTI, gastroenteritis

Infants and young children (below 5 years)

• Viral bronchiolitis: Age below 2 years, wheeze, coryzal prodrome, hyperinflation on CXR
• Asthma/reactive airway disease: Wheeze, hyperinflation, responds to bronchodilators
• Inhaled foreign body: Sudden onset, unilateral wheeze, asymmetric hyperinflation on CXR
• Cardiac failure: Cardiomegaly, pulmonary oedema, hepatomegaly
• Acute viral laryngotracheobronchitis (croup): Barking cough, stridor

Older children (greater than 5 years)

• Asthma exacerbation: Wheeze, diurnal variation, triggered by allergens/exercise
• Pulmonary tuberculosis: Chronic cough, weight loss, night sweats, exposure history
• Atypical pneumonia (Mycoplasma): Prolonged dry cough, low-grade fever, patchy infiltrates

Key Differentiating Features

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Investigations

When to Investigate

Not all children with suspected pneumonia require investigations. The British Thoracic Society (BTS) and Royal Children's Hospital (RCH) Melbourne guidelines recommend:

• Uncomplicated CAP managed as outpatient: No investigations required if child is well enough for oral antibiotics at home.
• Severe pneumonia requiring hospitalisation: CXR, blood tests, consider blood culture.
• Diagnostic uncertainty: Differentiate pneumonia from bronchiolitis, asthma, cardiac failure.
• Failure to respond: Persistent fever or clinical deterioration after 48-72 hours of antibiotics.
• Suspected complications: Empyema, lung abscess, necrotising pneumonia.

(PMID: 21903691, Harris 2011 Thorax - BTS Guidelines; RCH Melbourne Clinical Practice Guidelines)

Bedside Investigations

Pulse Oximetry

• Essential: Measure SpO2 in all children with suspected pneumonia.
• Hypoxaemia definition: SpO2 below 92% on room air.
• Indication for oxygen: SpO2 below 92% on room air. Target SpO2 ≥92% (PMID: 26547609, Subhi 2015 Cochrane).
• Indication for admission: SpO2 below 92% on room air, or inability to maintain SpO2 ≥92% on nasal prong oxygen (0.5-2 L/min).

Respiratory Rate

• Assess when calm: Child should be afebrile, not crying or agitated. Reassess multiple times.
• Count for 1 full minute: Respiratory rate varies with inspiration/expiration cycles.

Temperature

• Fever definition: ≥38°C (axillary or tympanic).
• Persistent fever: Ongoing fever greater than 48-72 hours on appropriate antibiotics suggests complication (empyema, abscess) or viral aetiology.

Imaging

Chest X-ray (CXR)

Indications:

• Severe pneumonia requiring hospitalisation
• Diagnostic uncertainty (cannot differentiate pneumonia from bronchiolitis or cardiac failure)
• Suspected complications (empyema, abscess, pneumothorax)
• Failure to respond to antibiotics within 48-72 hours
• Atypical presentation (immunocompromised, unusual organism)

Not required for:

• Uncomplicated CAP managed as outpatient (PMID: 21903691, Harris 2011 Thorax)

Views: PA (posterior-anterior) and lateral. Lateral view improves detection of lobar consolidation and pleural effusion.

Radiological findings:

• common in children below 8 years, usually S. pneumoniae. Can mimic mass on single view (PMID: 25687157, Çiftçi 2015 Pediatr Radiol). | | Pneumothorax | Rare complication. Air in pleural space, absent lung markings. May be tension pneumothorax. |

Limitations:

• Cannot reliably differentiate bacterial from viral pneumonia: Up to 30% of viral pneumonia can have lobar consolidation (PMID: 25331656, Jain 2015 NEJM).
• Inter-observer variability: Radiologists disagree on presence of pneumonia in 20-30% of cases (PMID: 24259265, Elemraid 2014 Thorax).

Ultrasound Chest

Indications:

• Suspected pleural effusion or empyema: Ultrasound is more sensitive than CXR for detecting small effusions and can differentiate simple effusion (anechoic) from empyema (septated, echogenic).
• Guide pleural aspiration or chest drain insertion: Real-time visualisation of fluid collection.

Findings:

• Simple parapneumonic effusion: Anechoic (black), free-flowing fluid.
• Empyema: Septated, echogenic (debris), may have loculations. Increased pleural thickness greater than 4 mm.
• Lung consolidation: Can be visualised on ultrasound as hypoechoic regions with dynamic air bronchograms.

(PMID: 28476340, Claessens 2017 Chest - ultrasound for paediatric pneumonia)

Laboratory Investigations

Full Blood Count (FBC)

• Leucocytosis: WCC greater than 15 × 10⁹/L suggests bacterial infection (sensitivity 60-70%, specificity 50-60%).
• Neutrophilia: Absolute neutrophil count greater than 10 × 10⁹/L.
• Lymphocytosis: Suggests viral infection or atypical bacteria (Mycoplasma).
• Thrombocytosis: Common in pneumonia, may persist for weeks.

Limitation: WCC has poor sensitivity/specificity for differentiating bacterial from viral pneumonia (PMID: 21903691, Harris 2011 Thorax).

C-Reactive Protein (CRP)

• Elevated CRP: greater than 40-60 mg/L suggests bacterial infection (PMID: 12626619, Virkki 2002 Pediatr Infect Dis J).
• Limitation: Overlaps between bacterial and viral pneumonia. Cannot be used in isolation.
• Very high CRP (greater than 100 mg/L) associated with complicated pneumonia (empyema, abscess).

Procalcitonin (PCT)

• Elevated PCT: greater than 0.5 ng/mL suggests bacterial infection, greater than 2 ng/mL highly suggestive.
• Better specificity than CRP for bacterial infection (80-90% specificity) (PMID: 23440095, Wrotek 2013 Pneumonol Alergol Pol).
• Use: Can guide antibiotic decisions in unclear cases, but not routinely available in all centres.

Blood Culture

• Indication: Severe pneumonia requiring hospitalisation, suspected bacteraemia/sepsis, immunocompromised.
• Yield: Only 5-15% positive in paediatric pneumonia (PMID: 25331656, Jain 2015 NEJM).
• Timing: Take before starting antibiotics if possible.

Microbiological Investigations

Limited utility in ED setting - most results take 24-72 hours and do not alter acute management.

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Management

Immediate Management (ED)

ABCDE Approach

A - Airway

• Assess patency: Vocalisation, cough, stridor, drooling
• Position: Upright, position of comfort (do not force child to lie flat)
• Supplemental oxygen: Nasal prongs 0.5-2 L/min, or Hudson mask 6-10 L/min if SpO2 below 92%

B - Breathing

• Respiratory rate: Count for 1 full minute when calm
• Work of breathing: Nasal flaring, chest indrawing, grunting, accessory muscle use
• Auscultation: Focal crackles (pneumonia), diffuse wheeze (bronchiolitis/asthma)
• Pulse oximetry: Target SpO2 ≥92% on room air or supplemental oxygen

C - Circulation

• Heart rate: Age-specific tachycardia (see table below)
• Capillary refill time: Central CRT greater than 3 seconds suggests shock
• Blood pressure: Hypotension is late sign of shock in children
• Fluid bolus: 10-20 mL/kg 0.9% sodium chloride IV over 10-20 minutes if shocked

D - Disability

• Conscious state: AVPU or GCS. Altered consciousness suggests severe pneumonia, hypoxaemia, or sepsis
• Blood glucose: Exclude hypoglycaemia (BGL below 3 mmol/L)

E - Exposure

• Temperature: Core temperature greater than 38.5°C or below 36°C
• Rash: Petechiae/purpura (meningococcal sepsis, bacterial sepsis)
• Signs of complications: Respiratory distress, shock, altered consciousness

Age-Specific Vital Signs

(PMID: 30397996, Sepsis-3 Paediatric Criteria, Phoenix 2024)

Oxygen Therapy

Indication: SpO2 below 92% on room air.

Target: SpO2 ≥92%. Higher oxygen targets (≥94%) do not improve outcomes and may increase length of stay (PMID: 26547609, Subhi 2015 Cochrane).

Delivery methods:

Escalation:

• If SpO2 remains below 92% on nasal prongs, escalate to Hudson mask.
• If SpO2 remains below 92% on Hudson mask, consider high-flow nasal cannula (HFNC) or non-invasive ventilation (NIV).
• If inadequate response to HFNC/NIV, consider intubation and mechanical ventilation.

Weaning oxygen:

• Once SpO2 ≥92% for greater than 4-6 hours, trial weaning oxygen by 25-50% every 2-4 hours.
• Discontinue oxygen when SpO2 ≥92% on room air for ≥4 hours.

Fluid and Nutritional Support

Intravenous Fluids

Indications:

• Unable to tolerate oral fluids (vomiting, altered consciousness)
• Dehydration (greater than 5% weight loss, reduced urine output, dry mucous membranes)
• Septic shock requiring fluid resuscitation
• Severe respiratory distress preventing oral intake

Fluid type:

• Resuscitation: 0.9% sodium chloride 10-20 mL/kg IV bolus over 10-20 minutes (repeat up to 40-60 mL/kg if shocked)
• Maintenance: 0.9% sodium chloride with 5% glucose + 20 mmol/L KCl (PMID: 31578998, McNab 2019 Arch Dis Child - isotonic fluids reduce hyponatraemia risk)

Fluid restriction: If evidence of SIADH (hyponatraemia, low serum osmolality, concentrated urine), restrict to 50-75% maintenance.

Enteral Feeding

Preferred route: Oral or nasogastric (NG) feeding if tolerated.

NG feeding: If unable to take adequate oral intake due to respiratory distress, insert NG tube and provide small, frequent feeds (hourly boluses or continuous infusion).

Breastfeeding: Encourage continued breastfeeding in infants. Mothers can express milk if infant too unwell to feed.

Antibiotic Therapy

Empirical Antibiotic Choice

Empirical antibiotics should cover the most likely pathogens based on age, severity, and local epidemiology.

Uncomplicated Community-Acquired Pneumonia (Outpatient)

First-line:

• Amoxicillin 80-90 mg/kg/day PO divided TDS (every 8 hours), max 3 g/day
• Duration: 5 days for uncomplicated pneumonia (PMID: 33571489, Korang 2021 Cochrane meta-analysis - 5 days non-inferior to 10 days)

Alternative (penicillin allergy):

• Cefalexin 50 mg/kg/day PO divided TDS (every 8 hours), max 1.5 g/day (cephalosporins safe in 90% of penicillin-allergic patients with non-anaphylaxis history)
• Azithromycin 10 mg/kg PO once daily for 3 days (if severe penicillin allergy or suspected Mycoplasma)

Add azithromycin if suspected Mycoplasma pneumoniae:

• Age greater than 5 years
• Prolonged dry cough (greater than 7 days)
• Low-grade fever, minimal respiratory distress
• Normal or low WCC
• Patchy infiltrates on CXR

Rationale: Amoxicillin provides excellent coverage for S. pneumoniae, the most common bacterial pathogen. High-dose amoxicillin (80-90 mg/kg/day) overcomes penicillin-resistant pneumococcus (PMID: 21903691, Harris 2011 Thorax BTS Guidelines).

Severe Pneumonia (Inpatient, IV Antibiotics)

First-line:

• Benzylpenicillin 60 mg/kg IV Q6H (every 6 hours), max 2.4 g per dose +
• Gentamicin 7.5 mg/kg IV once daily (if age below 3 months or concern for Gram-negative sepsis)

Alternative (penicillin allergy):

• Ceftriaxone 50 mg/kg IV once daily, max 2 g per dose

Add flucloxacillin if suspected Staphylococcus aureus:

• Post-influenza pneumonia
• Severe/necrotising pneumonia on CXR
• Pneumatoceles, empyema, septic shock
• Flucloxacillin 50 mg/kg IV Q6H, max 2 g per dose

Add vancomycin if suspected MRSA (recent hospitalisation, known MRSA colonisation, severe pneumonia not responding to flucloxacillin):

• Vancomycin 15 mg/kg IV Q8-12H, max 500 mg per dose (target trough 10-15 mg/L)

Rationale: Benzylpenicillin provides excellent coverage for S. pneumoniae and S. pyogenes. Gentamicin adds Gram-negative coverage (important in neonates and young infants). Flucloxacillin or vancomycin cover S. aureus.

Neonatal Pneumonia (Age below 28 days)

First-line:

• Benzylpenicillin 60 mg/kg IV Q6-12H (age-dependent dosing) +
• Gentamicin 5 mg/kg IV once daily (age below 7 days) or 7.5 mg/kg IV once daily (age 7-28 days)

Alternative (add if concern for Listeria or late-onset sepsis):

• Ampicillin 50 mg/kg IV Q8-12H

Rationale: Neonatal pneumonia is often part of early-onset sepsis (Group B Streptococcus, E. coli, Listeria). Benzylpenicillin + gentamicin provide broad-spectrum Gram-positive and Gram-negative coverage.

Complicated Pneumonia (Empyema, Necrotising Pneumonia)

First-line:

• Benzylpenicillin 60 mg/kg IV Q6H, max 2.4 g per dose +
• Flucloxacillin 50 mg/kg IV Q6H, max 2 g per dose OR
• Ceftriaxone 50 mg/kg IV once daily, max 2 g per dose (single agent covering both S. pneumoniae and S. aureus)

Add vancomycin if suspected MRSA or not responding to flucloxacillin.

Add clindamycin if suspected S. pyogenes (toxin-mediated disease):

• Clindamycin 10 mg/kg IV Q8H, max 600 mg per dose (inhibits bacterial toxin production)

Duration: 10-14 days for complicated pneumonia with empyema (PMID: 28087091, Brogan 2017 Pediatr Pulmonol). Switch to oral antibiotics when afebrile greater than 24 hours and clinically improving.

(RCH Melbourne, Therapeutic Guidelines Antibiotic Australia, PMID: 21903691 Harris 2011 Thorax)

Antibiotic Stewardship

• Narrow spectrum is preferred: Use benzylpenicillin over broad-spectrum cephalosporins when possible.
• Short courses are effective: 5 days for uncomplicated CAP, 7-10 days for severe pneumonia, 10-14 days for empyema.
• IV to oral switch: When afebrile greater than 24 hours, tolerating oral intake, clinically improving. Switch to oral amoxicillin 80-90 mg/kg/day TDS.
• Review at 48-72 hours: If no improvement, consider:
  • Wrong diagnosis (viral bronchiolitis, asthma, TB)
  • Complication (empyema, abscess, pneumothorax)
  • Resistant organism (MRSA, atypical bacteria)
  • Alternative aetiology (non-infectious)

Adjunctive Therapies

Bronchodilators

Not routinely recommended for pneumonia.

Consider trial if:

• Clinical wheeze on auscultation (suggests bronchiolitis or reactive airway)
• History of asthma or bronchospasm
• Salbutamol 2.5 mg (age below 5 years) or 5 mg (age ≥5 years) via nebuliser

Discontinue if no objective improvement after 1-2 doses.

(PMID: 21903691, Harris 2011 Thorax BTS Guidelines - no evidence for routine bronchodilators in pneumonia)

Corticosteroids

Not routinely recommended for paediatric pneumonia.

May consider in:

• Severe pneumonia with marked inflammatory response (high CRP, shock)
• Post-viral bronchiolitis obliterans
• Dexamethasone 0.6 mg/kg PO/IV once daily for 1-2 days (if used)

Evidence: Limited evidence in paediatric pneumonia. Adult studies show small benefit in reducing time to clinical stability (PMID: 25990437, Stern 2017 Cochrane), but paediatric data lacking.

Complications and Their Management

Parapneumonic Effusion and Empyema

Incidence: 10-15% of hospitalised children with pneumonia develop parapneumonic effusion. Of these, 30-50% progress to empyema (PMID: 20442024, Balfour-Lynn 2005 Thorax).

Definition:

• Parapneumonic effusion: Pleural fluid associated with pneumonia (sterile or infected)
• Empyema: Pus in pleural space (positive Gram stain/culture, pH below 7.2, glucose below 2.2 mmol/L, LDH greater than 1000 IU/L)

Clinical features:

• Persistent fever greater than 48-72 hours despite appropriate antibiotics (most sensitive sign)
• Ongoing respiratory distress, hypoxia
• Dullness to percussion, reduced breath sounds over effusion
• Systemic toxicity

Investigations:

• Chest X-ray: Blunting of costophrenic angle (requires greater than 200 mL fluid), meniscus sign
• Ultrasound chest: More sensitive than CXR, identifies small effusions, septations, loculations
• Pleural fluid analysis (if drained): Send for pH, glucose, LDH, protein, Gram stain, culture, cell count

Management:

1. Antibiotics: Escalate to cover S. aureus and S. pyogenes (flucloxacillin + benzylpenicillin, or ceftriaxone + clindamycin)
2. Drainage:
   • Small effusion (below 1 cm on ultrasound): Conservative management, antibiotics alone
   • Moderate-large effusion (≥1 cm): Chest drain insertion under ultrasound guidance (12-16 Fr pigtail catheter)
   • Empyema with septations/loculations: Consider intrapleural fibrinolysis (urokinase or alteplase) to break down fibrin septations (PMID: 21903691, Harris 2011 Thorax)
3. Surgical referral: If failure to improve after 48-72 hours of chest drainage + fibrinolysis, consider video-assisted thoracoscopic surgery (VATS) for decortication

Prognosis: With appropriate treatment, greater than 95% of children recover fully without long-term sequelae. Lung function returns to normal by 6-12 months (PMID: 16825433, Spencer 2006 Thorax).

Necrotising Pneumonia

Definition: Pneumonia with lung necrosis, cavitation, or pneumatoceles on imaging.

Pathogen: Staphylococcus aureus (including MRSA), Streptococcus pneumoniae, Streptococcus pyogenes.

Clinical features: Severe systemic toxicity, shock, high fever, extensive consolidation on CXR, pneumatoceles, cavitation.

Management:

• Antibiotics: Flucloxacillin + benzylpenicillin (or vancomycin if MRSA suspected)
• Supportive care: High-flow oxygen, mechanical ventilation if respiratory failure
• Avoid chest drain unless empyema/tension pneumothorax: Chest drain can cause bronchopleural fistula in necrotising pneumonia
• Surgical consultation: May require lobectomy in severe cases (rare)

Prognosis: Most pneumatoceles resolve spontaneously over 3-6 months. Mortality 2-5% in developed countries (PMID: 29335038, Horovitz 2018 Pediatr Infect Dis J).

Lung Abscess

Definition: Localised collection of pus within lung parenchyma, usually with thick wall on imaging.

Pathogen: Anaerobes (aspiration), S. aureus, Klebsiella pneumoniae.

Clinical features: Prolonged fever (greater than 2 weeks), productive cough with foul-smelling sputum, weight loss.

Management:

• Prolonged antibiotics (4-6 weeks): Benzylpenicillin + metronidazole (for anaerobic coverage), or clindamycin alone
• Chest physiotherapy: Postural drainage to promote drainage
• Percutaneous drainage: If abscess greater than 5 cm or not responding to antibiotics
• Surgical resection: Rarely required

Prognosis: 80-90% resolve with antibiotics alone. Residual scarring may persist (PMID: 15023792, Patradoon-Ho 2007 J Paediatr Child Health).

Pneumothorax

Incidence: Rare (below 1% of pneumonia cases).

Risk factors: Necrotising pneumonia, staphylococcal pneumonia, underlying lung disease (cystic fibrosis), mechanical ventilation.

Clinical features: Sudden worsening of respiratory distress, decreased breath sounds on affected side, hyperresonance to percussion, tracheal deviation (if tension).

Management:

• Small pneumothorax (below 2 cm): Observation, supplemental oxygen (nitrogen washout accelerates resolution)
• Large pneumothorax (≥2 cm) or respiratory distress: Needle decompression (if tension) followed by chest drain insertion (12-16 Fr catheter)

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Disposition

Admission Criteria

Admit to hospital if any of the following:

Clinical Criteria

• SpO2 below 92% on room air (most important single criterion)
• Severe chest indrawing or respiratory distress
• Inability to feed or drink (dehydration, vomiting, altered consciousness)
• Apnoea episodes
• Altered conscious state (lethargy, irritability, reduced GCS)
• Grunting respirations

Age Criteria

• Age below 6 months (especially below 3 months) - higher risk of complications
• Premature infants (corrected gestational age below 44 weeks)

Comorbidities

• Chronic lung disease (bronchopulmonary dysplasia, cystic fibrosis)
• Congenital heart disease (cyanotic or acyanotic with heart failure)
• Immunodeficiency (HIV, primary immunodeficiency, chemotherapy)
• Neurological impairment (cerebral palsy, neuromuscular disease - risk of aspiration)
• Sickle cell disease (acute chest syndrome)

Social Criteria

• Remote or rural location limiting access to healthcare
• Parental inability to cope or concern for child's safety
• Failure to respond to outpatient antibiotics (return visit within 24-48 hours with worsening symptoms)

(PMID: 21903691, Harris 2011 Thorax BTS Guidelines; RCH Melbourne Clinical Practice Guidelines)

ICU/HDU Admission Criteria

Admit to ICU or high-dependency unit (HDU) if any of the following:

• Respiratory failure: SpO2 below 92% despite high-flow oxygen (greater than 10 L/min or FiO2 greater than 60%), requiring HFNC or NIV, or intubation
• Septic shock: Hypotension (SBP below 5th centile for age), prolonged CRT greater than 3 seconds, requiring fluid resuscitation greater than 40 mL/kg or vasopressors
• Altered conscious state: GCS ≤12, unresponsive to painful stimuli
• Apnoea: Recurrent apnoea episodes requiring stimulation or ventilatory support
• Complicated pneumonia: Empyema requiring chest drain, necrotising pneumonia, large pneumothorax

Safe Discharge Criteria (Outpatient Management)

Can discharge home with oral antibiotics if ALL of the following met:

• SpO2 ≥92% on room air for ≥4 hours
• No severe chest indrawing or respiratory distress
• Able to feed and drink normally, tolerating oral antibiotics
• No high-risk comorbidities (chronic lung disease, cardiac disease, immunodeficiency)
• Age ≥6 months (consider admission for infants below 6 months even if clinically well)
• Parental ability to cope, access to telephone, ability to return to ED if worsening
• Close follow-up arranged: GP or paediatrician review within 24-48 hours

Discharge antibiotics: Amoxicillin 80-90 mg/kg/day PO divided TDS for 5 days.

Safety-netting advice to parents:

• Return to ED if:
  • Increased work of breathing (fast breathing, chest indrawing)
  • Worsening cough or fever greater than 48-72 hours on antibiotics
  • Unable to feed or drink
  • Lethargy, reduced responsiveness
  • Blue lips or skin
• GP follow-up within 24-48 hours to reassess
• Chest X-ray follow-up at 4-6 weeks not required for uncomplicated pneumonia (PMID: 21903691, Harris 2011 Thorax BTS Guidelines)

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Indigenous Health Considerations

Aboriginal and Torres Strait Islander Children

Aboriginal and Torres Strait Islander children experience 4-6× higher hospitalisation rates for pneumonia compared to non-Indigenous Australian children, with disproportionately high rates of complicated pneumonia and bronchiectasis (PMID: 30760144, Chang 2019 Respirology; PMID: 26040576, Chang 2015 Eur Respir J).

Risk Factors

1. Overcrowding: Household crowding greater than 2 people per bedroom increases pneumonia risk by 2-3× (PMID: 29141444, Marsh 2017 Med J Aust).
2. Environmental tobacco smoke: Up to 60-70% of Indigenous children exposed to ETS, doubling pneumonia risk (PMID: 28691157, Mobbs 2017 Int J Environ Res Public Health).
3. Poor housing quality: Inadequate heating, ventilation, dampness, mould.
4. Remote location: Limited access to healthcare, delayed presentation, lack of access to refrigeration for vaccine cold chain.
5. Higher rates of comorbidities: Prematurity, low birth weight, chronic suppurative lung disease, congenital heart disease.

Specific Management Considerations

• Early antibiotic therapy: Lower threshold for starting antibiotics and admitting to hospital given higher complication rates.
• Longer antibiotic courses: Consider 7-10 days (rather than 5 days) for uncomplicated pneumonia in Indigenous children due to higher recurrence rates (Therapeutic Guidelines Australia).
• Screen for chronic suppurative lung disease: Persistent cough greater than 4 weeks after pneumonia may indicate bronchiectasis. Refer for high-resolution CT chest and bronchoscopy (PMID: 26040576, Chang 2015 Eur Respir J).
• Cultural safety: Involve Aboriginal Health Workers, provide culturally safe communication, consider family/kinship networks in discharge planning.

Preventative Strategies

• Vaccination: Ensure up-to-date pneumococcal vaccination (PCV13 + 23vPPV at 12 months for Indigenous children in high-risk areas), influenza vaccination.
• Smoking cessation: Offer smoking cessation support to parents, reduce ETS exposure.
• Improved housing: Advocate for better housing quality, reduced overcrowding, adequate heating/ventilation.
• Early childhood services: Improve access to primary healthcare, early detection of respiratory illness.

Māori and Pacific Islander Children (New Zealand)

Māori and Pacific Islander children in New Zealand have 2-3× higher hospitalisation rates for pneumonia, with higher rates of severe pneumonia and empyema (PMID: 20831663, Grant 2010 Epidemiol Infect).

Specific Management Considerations

• Whānau (family) involvement: Include whānau in decision-making, discharge planning, medication administration.
• Cultural protocols: Respect tikanga (cultural protocols), ensure culturally appropriate communication.
• Socioeconomic determinants: Address social determinants of health (housing, poverty, access to healthcare).
• Community health workers: Involve Māori and Pacific health workers in discharge planning and follow-up.

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Remote and Rural Emergency Medicine

Challenges in Remote and Rural Settings

1. Limited diagnostic resources: Many remote clinics lack chest X-ray, blood gas analysis, continuous pulse oximetry.
2. Limited treatment resources: No high-flow oxygen, no paediatric ICU beds, limited IV fluid availability, no access to paediatric subspecialists.
3. Retrieval challenges: Long distances to tertiary centres (500-1,000 km in Northern Territory, Western Australia), weather-dependent (dust storms, cyclones), limited aircraft/road ambulance availability.
4. Staffing: Often single-doctor clinics with nursing support, limited paediatric training, high staff turnover.

Management Approach in Remote Settings

Triage and Assessment

• Use age-specific tachypnoea and chest indrawing as primary diagnostic criteria (CXR not required for diagnosis).
• Pulse oximetry: Essential tool. If SpO2 below 92%, assume severe pneumonia and arrange retrieval.
• Clinical scoring: Use WHO severe pneumonia criteria or Paediatric Severity Score (PSS) to guide retrieval decisions.

Immediate Treatment

1. Oxygen: Start nasal prong oxygen 0.5-2 L/min, aim for SpO2 ≥92%.
2. Antibiotics: Start IV benzylpenicillin 60 mg/kg + gentamicin 7.5 mg/kg immediately if severe pneumonia (do not delay for retrieval).
3. Fluid resuscitation: If shocked, give 10-20 mL/kg 0.9% sodium chloride IV bolus.
4. Antipyretics: Paracetamol 15 mg/kg PO/PR Q4-6H PRN for fever greater than 38.5°C.

Retrieval Decision-Making

Contact Royal Flying Doctor Service (RFDS) or state retrieval service if:

• SpO2 below 92% on oxygen
• Severe chest indrawing or grunting
• Age below 3 months
• Altered consciousness, apnoea
• Suspected complication (empyema, pneumothorax, necrotising pneumonia)
• Failure to respond to initial antibiotics within 24-48 hours
• Significant comorbidities (cardiac, respiratory, immunodeficiency)

RFDS Contact Numbers:

• RFDS Central Operations: 1800 625 800
• CareFlight (NSW): 1300 655 009
• Careflight (QLD): 1300 529 729
• RFDS Western Australia: 08 8936 4444

Telemedicine

• Paediatric Emergency Telemedicine: Available in many states (NSW: 1300 022 099, QLD: 13 HEALTH, WA: 1800 022 222).
• Videoconference with paediatric emergency physician or intensivist for advice on management, antibiotic choice, retrieval decisions.
• Share photos: Send photos of child (work of breathing, colour) via secure telemedicine platform.

Safe Outpatient Management in Remote Settings

If child does not meet retrieval criteria and can be managed locally:

• Oral amoxicillin 80-90 mg/kg/day TDS for 7 days (longer course than urban settings due to higher complication rates)
• Daily review: Nurse or doctor review every 24 hours for first 3 days
• Parent education: Clear safety-netting advice, when to return urgently
• Supply extra antibiotics: Provide 10-14 days' supply in case of delayed review
• Follow-up CXR: Arrange at 4-6 weeks if severe pneumonia or concern for complications

(RFDS Clinical Manual, PMID: 29541571, Smith 2018 Emerg Med Australas - retrieval medicine)

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Viva Practice

Viva Scenario 1: Uncomplicated Pneumonia

Stem: "A 3-year-old previously well girl presents to ED with 2 days of fever and cough. She has tachypnoea but is otherwise alert and feeding normally. What is your approach?"

Opening Question: What are your immediate priorities in assessing this child?

Model Answer: My immediate priorities are to assess the severity of pneumonia and determine whether she requires hospitalisation or can be managed as an outpatient. I would:

1. Assess ABCDE: Check airway patency, work of breathing (respiratory rate, chest indrawing, nasal flaring), circulation (heart rate, capillary refill, blood pressure), conscious state, temperature.
2. Measure pulse oximetry: SpO2 is the most important single objective measurement. SpO2 below 92% on room air is an indication for admission and oxygen therapy.
3. Count respiratory rate when calm: Tachypnoea greater than 40 breaths/min in a 3-year-old meets WHO criteria for pneumonia.
4. Focused respiratory examination: Look for focal crackles (bacterial pneumonia), wheeze (bronchiolitis or asthma), chest indrawing (severe pneumonia).
5. Assess hydration and oral intake: Can she drink and feed normally? Is she tolerating oral fluids?

Follow-up Questions:

Q1: Her respiratory rate is 48 breaths/min, SpO2 96% on room air, and she has focal crackles in the right lower zone. She is feeding normally. Does she need a chest X-ray?

A1: No, chest X-ray is not routinely required for uncomplicated community-acquired pneumonia if the diagnosis is clinically clear and she is well enough for outpatient management. CXR is indicated for:

• Severe pneumonia requiring hospitalisation
• Diagnostic uncertainty (cannot differentiate from bronchiolitis, cardiac failure)
• Suspected complications (empyema, pneumothorax)
• Failure to respond to antibiotics within 48-72 hours

Q2: What antibiotic would you prescribe, and for how long?

A2: I would prescribe oral amoxicillin 80-90 mg/kg/day divided three times daily (TDS) for 5 days. For a 15 kg child, this is approximately 1,200-1,350 mg/day, or 400-450 mg TDS. Amoxicillin provides excellent coverage for Streptococcus pneumoniae, the most common bacterial cause of pneumonia. A 5-day course is non-inferior to 10 days for uncomplicated pneumonia (PMID: 33571489, Korang 2021 Cochrane).

Q3: What safety-netting advice would you give to parents before discharging home?

A3: I would advise parents to return to ED or see GP urgently if:

• Increased work of breathing: Faster breathing, chest indrawing, difficulty breathing
• Persistent or worsening fever after 48-72 hours on antibiotics
• Unable to feed or drink: Vomiting, refusing fluids
• Lethargy or reduced responsiveness
• Blue lips or skin: Cyanosis

I would also arrange GP follow-up within 24-48 hours to reassess. Chest X-ray follow-up is not required for uncomplicated pneumonia unless there are persistent symptoms at 4-6 weeks.

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Viva Scenario 2: Severe Pneumonia with Hypoxaemia

Stem: "A 15-month-old boy presents with 3 days of cough, fever, and poor feeding. He has tachypnoea, severe chest indrawing, and SpO2 88% on room air. What is your management?"

Opening Question: What immediate interventions are required?

Model Answer: This child has severe pneumonia with hypoxaemia and requires immediate intervention:

1. Oxygen therapy: Start nasal prong oxygen 1-2 L/min, aiming for SpO2 ≥92%. If inadequate, escalate to Hudson mask (6-10 L/min) or high-flow nasal cannula.
2. Assess for shock: Check capillary refill time, heart rate, blood pressure. If shocked (CRT greater than 3 seconds, tachycardia), give 10-20 mL/kg 0.9% sodium chloride IV bolus over 10-20 minutes.
3. IV antibiotics: Start benzylpenicillin 60 mg/kg IV Q6H + gentamicin 7.5 mg/kg IV once daily to cover Streptococcus pneumoniae and Gram-negative organisms (important in young infants below 2 years).
4. Investigations: Chest X-ray (severe pneumonia requiring hospitalisation), FBC, CRP, blood culture (before antibiotics if possible).
5. Admission: This child requires hospital admission. Consider ICU/HDU if SpO2 remains below 92% on high-flow oxygen or if signs of septic shock.

Follow-up Questions:

Q1: His chest X-ray shows right lower lobe consolidation with a small pleural effusion. What is your approach?

A1: The presence of pleural effusion is a risk factor for complicated pneumonia (empyema). I would:

1. Ultrasound chest: To assess size of effusion, presence of septations or loculations (empyema vs simple effusion).
2. Continue IV antibiotics: Benzylpenicillin + gentamicin. If effusion is moderate-large (greater than 1 cm on ultrasound), I would add flucloxacillin 50 mg/kg IV Q6H to cover Staphylococcus aureus.
3. Monitor closely: Daily clinical review, repeat ultrasound if persistent fever greater than 48 hours despite antibiotics.
4. Pleural drainage: If effusion is large (greater than 2 cm), empyema features (septations, echogenic fluid), or failure to improve, arrange chest drain insertion (12-16 Fr pigtail catheter) under ultrasound guidance.

Q2: He remains febrile with ongoing hypoxia after 72 hours of IV antibiotics. What are your considerations?

A2: Persistent fever and hypoxia after 72 hours suggests:

1. Complication: Empyema (most common), lung abscess, necrotising pneumonia, pneumothorax.
2. Wrong diagnosis: Viral pneumonia, tuberculosis, non-infectious cause (aspiration, cardiac failure).
3. Resistant organism: MRSA, atypical bacteria (Mycoplasma).

I would:

• Repeat chest X-ray and ultrasound: Look for progression of effusion, abscess, pneumatoceles.
• Escalate antibiotics: Add flucloxacillin (if not already on it) or vancomycin (if MRSA suspected).
• Pleural drainage: If empyema present, insert chest drain.
• Paediatric/respiratory/infectious diseases consult: Consider alternative diagnoses or further investigations (bronchoscopy, CT chest).

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Viva Scenario 3: Indigenous Child from Remote Community

Stem: "A 10-month-old Aboriginal boy from a remote Northern Territory community presents via RFDS retrieval with severe pneumonia. He has been unwell for 5 days. What specific considerations are there for this child?"

Opening Question: What are the key risk factors and health disparities affecting Aboriginal and Torres Strait Islander children with pneumonia?

Model Answer: Aboriginal and Torres Strait Islander children have 4-6× higher hospitalisation rates for pneumonia compared to non-Indigenous children, with higher rates of complications and bronchiectasis. Key risk factors include:

1. Overcrowding: Household crowding increases pneumonia transmission risk.
2. Environmental tobacco smoke: Up to 70% of Indigenous children exposed to ETS.
3. Poor housing quality: Inadequate heating, ventilation, dampness.
4. Delayed presentation: Remote location, limited access to healthcare, cultural barriers.
5. Higher rates of comorbidities: Prematurity, chronic suppurative lung disease, congenital heart disease.

Follow-up Questions:

Q1: His parents ask why he has been sick for so long. How would you explain the delayed presentation?

A1: I would explain sensitively that remote communities face significant barriers to accessing healthcare, including:

• Distance to nearest clinic or hospital (may be 200-500 km away)
• Limited clinic opening hours, lack of continuous medical staff
• Cultural and language barriers
• Financial constraints (travel costs)

I would emphasise that this is a systems problem, not a parenting problem, and that we will work together to ensure he receives the best care and appropriate follow-up to prevent future complications.

Q2: After 7 days of IV antibiotics, he is improving but continues to have a productive cough. What is your concern, and what follow-up is required?

A2: My concern is chronic suppurative lung disease or bronchiectasis, which occurs in 5-10% of Aboriginal and Torres Strait Islander children following severe pneumonia. Persistent wet cough greater than 4 weeks after pneumonia should prompt investigation for bronchiectasis (PMID: 26040576, Chang 2015 Eur Respir J).

Follow-up required:

1. Prolonged oral antibiotics: Amoxicillin-clavulanate 22.5 mg/kg BD for 2-4 weeks to treat chronic suppurative lung disease.
2. Chest physiotherapy: Daily airway clearance techniques.
3. High-resolution CT chest: If wet cough persists greater than 4 weeks despite antibiotics.
4. Flexible bronchoscopy: To assess for airway abnormalities, obtain bronchoalveolar lavage for microbiology.
5. Outpatient respiratory clinic follow-up: Paediatric respiratory physician review at 4-6 weeks.
6. Preventative strategies: Ensure up-to-date vaccinations (PCV13, 23vPPV, influenza), smoking cessation support for household.

Q3: What cultural considerations should you apply in his management and discharge planning?

A3:

1. Involve Aboriginal Health Workers: Include AHWs in communication, discharge planning, medication education.
2. Family-centred care: Include extended family members in decision-making and education (Aboriginal families often have communal child-rearing).
3. Cultural safety: Provide interpreter services if required, avoid medical jargon, ensure culturally respectful communication.
4. Discharge planning: Coordinate with remote clinic staff, ensure adequate medication supply (may need 4-6 weeks' supply if follow-up difficult), arrange telehealth follow-up if in-person review not feasible.
5. Address social determinants: Advocate for improved housing, reduced overcrowding, smoking cessation support.

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Viva Scenario 4: Post-Influenza Staphylococcal Pneumonia

Stem: "A 6-year-old girl presents with 7 days of influenza-like illness, initially improving, but now has high fever, shock, and respiratory failure. Chest X-ray shows bilateral pneumatoceles. What is your diagnosis and management?"

Opening Question: What is the likely pathogen, and what is the pathophysiology of post-influenza bacterial pneumonia?

Model Answer: This presentation is consistent with post-influenza Staphylococcus aureus pneumonia with necrotising pneumonia. S. aureus causes severe, rapidly progressive pneumonia following influenza infection due to:

1. Influenza-induced epithelial damage: Influenza virus damages respiratory epithelium, exposing basement membrane and extracellular matrix.
2. Bacterial adherence: S. aureus binds to damaged epithelium via fibronectin and collagen receptors.
3. Impaired immune response: Influenza suppresses neutrophil and macrophage function, allowing bacterial proliferation.
4. Toxin production: S. aureus produces Panton-Valentine leukocidin (PVL) toxin, causing necrotising pneumonia, pneumatoceles, and shock.

(PMID: 29335038, Horovitz 2018 Pediatr Infect Dis J)

Follow-up Questions:

Q1: What immediate resuscitation is required?

A1: This child is in septic shock with severe pneumonia and requires:

1. Airway and breathing: High-flow oxygen or intubation if respiratory failure (unable to maintain SpO2 ≥92% on high-flow oxygen).
2. Fluid resuscitation: 10-20 mL/kg 0.9% sodium chloride IV bolus, repeat up to 40-60 mL/kg total. Monitor for fluid overload (crackles, hepatomegaly).
3. Vasopressors: If persistent shock after 40 mL/kg fluids, start noradrenaline infusion 0.05-1 mcg/kg/min, titrate to MAP greater than 5th centile for age.
4. Antibiotics: Flucloxacillin 50 mg/kg IV Q6H + benzylpenicillin 60 mg/kg IV Q6H. If MRSA suspected (known colonisation, recent hospitalisation), use vancomycin 15 mg/kg IV Q8H instead of flucloxacillin.
5. ICU admission: For inotropic support, mechanical ventilation, invasive monitoring.

Q2: She has large bilateral pneumatoceles on chest X-ray. Do they require drainage?

A2: No, pneumatoceles are thin-walled, air-filled cysts resulting from necrosis of lung parenchyma in staphylococcal pneumonia. They typically do not require drainage unless:

• Tension pneumatocele: Causing mediastinal shift, cardiovascular compromise (rare).
• Superinfection: Pneumatocele becomes secondarily infected (air-fluid level within cyst).

Otherwise, pneumatoceles are managed conservatively and usually resolve spontaneously over 3-6 months (PMID: 29335038, Horovitz 2018 Pediatr Infect Dis J). Avoid chest drain insertion in necrotising pneumonia unless there is empyema or tension pneumothorax, as it can cause bronchopleural fistula.

Q3: What is the prognosis, and what follow-up is required?

A3: Prognosis: Mortality from necrotising staphylococcal pneumonia is 2-5% in developed countries with appropriate ICU care. Most children recover fully, though radiological abnormalities (pneumatoceles, scarring) may persist for 6-12 months.

Follow-up:

1. Repeat chest X-ray: At 4-6 weeks to document resolution of pneumatoceles (do not need serial X-rays unless clinically indicated).
2. Lung function testing: At 6-12 months if ongoing respiratory symptoms.
3. Exclude underlying immunodeficiency: Severe staphylococcal pneumonia may indicate immunoglobulin deficiency, chronic granulomatous disease, or HIV. Consider immunology referral if recurrent severe infections.
4. Influenza vaccination: Ensure annual influenza vaccination to prevent recurrence.

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OSCE Scenarios

OSCE Station 1: Paediatric Respiratory Examination (11 minutes)

Setting: Clinical examination area, ED

Scenario: You are the Emergency Registrar. A 4-year-old boy has been referred by his GP with suspected pneumonia. He has had 3 days of fever and cough. Please perform a focused respiratory examination and present your findings.

Equipment Available:

• Stethoscope
• Pulse oximeter
• Thermometer
• Tongue depressor

Actor Briefing (child actor or mannequin):

• Age 4 years, alert and cooperative
• Tachypnoeic (respiratory rate 44/min)
• Mild subcostal recession
• Focal coarse crackles in right lower zone
• SpO2 94% on room air
• Temperature 38.6°C

Marking Criteria (Total: 20 marks)

Pass Mark: 14/20

Common Mistakes:

• Not assessing work of breathing systematically (nasal flaring, recession, grunting)
• Forgetting to measure SpO2 (most important objective measurement)
• Performing full cardiovascular/abdominal exam (not required for focused respiratory exam)
• Not counting respiratory rate for full 1 minute

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OSCE Station 2: Communication - Explaining Pneumonia Diagnosis and Antibiotic Choice (11 minutes)

Setting: ED consultation room

Scenario: You are the Emergency Registrar. A 2-year-old girl has been diagnosed with pneumonia. She is well enough for discharge with oral antibiotics. Please explain the diagnosis to the mother and discuss the management plan.

Actor Briefing (mother):

• Concerned about her daughter's illness
• Worried about antibiotics ("Will they harm her?")
• Asks: "Does she need an X-ray?" and "How long will she be sick?"
• Anxious about taking her home (wants reassurance about when to return)

Marking Criteria (Total: 20 marks)

Pass Mark: 14/20

Common Mistakes:

• Using medical jargon ("consolidation"
  • "infiltrate") without explanation
• Not addressing parental concerns about antibiotics
• Vague safety-netting ("come back if she's worse") without specific red flags
• Insisting on CXR when not clinically indicated

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OSCE Station 3: Oxygen Delivery and Escalation (11 minutes)

Setting: Resuscitation bay, ED

Scenario: You are the Emergency Registrar. A 9-month-old boy with pneumonia has SpO2 85% on room air. Please demonstrate appropriate oxygen delivery and escalation of respiratory support.

Equipment Available:

• Nasal prongs (low-flow oxygen)
• Hudson mask (simple face mask)
• Non-rebreather mask with reservoir bag
• Oxygen flow meters and tubing
• Pulse oximeter
• Mannequin

Task:

1. Initiate appropriate oxygen therapy
2. Explain escalation strategy if SpO2 remains low
3. Identify when to call for senior help or ICU support

Marking Criteria (Total: 20 marks)

Pass Mark: 14/20

Common Mistakes:

• Starting with low-flow nasal prongs (0.5 L/min) in severe hypoxia (should start higher, 1-2 L/min, or use Hudson mask)
• Not reassessing SpO2 after starting oxygen (must reassess to determine if escalation needed)
• Delaying call for senior help in severe hypoxia
• Not knowing HFNC or NIV indications (should be called early if not responding to simple oxygen)

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Short Answer Question (SAQ) Practice

SAQ 1: Age-Specific Tachypnoea Criteria (6 marks)

Question: A 14-month-old child presents with fever and cough. His respiratory rate is 48 breaths/min.

a) According to WHO criteria, does this child have tachypnoea? (2 marks)

b) List the WHO age-specific tachypnoea cut-offs for children aged below 2 months, 2-12 months, and 1-5 years. (3 marks)

c) Why is tachypnoea the most sensitive clinical sign of pneumonia in children? (1 mark)

Model Answer:

a) Yes, this child has tachypnoea. The WHO definition of tachypnoea for a child aged 2-12 months (which includes 14 months) is ≥50 breaths/min. A respiratory rate of 48/min is below this threshold, but since the child is 14 months old, he falls into the 1-5 years age group (WHO uses 12 months as cut-off), where tachypnoea is defined as ≥40 breaths/min. Therefore, 48 breaths/min meets criteria for tachypnoea in a 14-month-old. (2 marks - 1 mark for identifying tachypnoea, 1 mark for correct age group)

[Examiner note: Accept "Yes" if candidate correctly applies 1-5 years threshold. Deduct 1 mark if candidate incorrectly uses 2-12 months threshold.]

b) WHO age-specific tachypnoea cut-offs:

• below 2 months: ≥60 breaths/min (1 mark)
• 2-12 months: ≥50 breaths/min (1 mark)
• 1-5 years: ≥40 breaths/min (1 mark)

c) Tachypnoea is the most sensitive clinical sign because alveolar inflammation and hypoxaemia stimulate peripheral chemoreceptors, increasing respiratory drive. It is present in greater than 80% of children with pneumonia. (1 mark)

Common Mistakes:

• Confusing age groups (using 2-12 months threshold for 14-month-old)
• Not knowing the specific numerical cut-offs (e.g., stating "fast breathing" without numbers)

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SAQ 2: Antibiotic Choice in Paediatric Pneumonia (8 marks)

Question: A 5-year-old previously well boy presents with 3 days of fever, productive cough, and right-sided pleuritic chest pain. Chest X-ray shows right lower lobe consolidation. SpO2 is 94% on room air.

a) What is the most likely bacterial pathogen in this case? (1 mark)

b) What is the first-line oral antibiotic for uncomplicated community-acquired pneumonia, and what is the dose and duration? (3 marks)

c) This child is admitted to hospital with SpO2 89% on room air. What IV antibiotics would you start? (2 marks)

d) Why is high-dose amoxicillin (80-90 mg/kg/day) recommended rather than standard-dose (40-50 mg/kg/day)? (2 marks)

Model Answer:

a) Streptococcus pneumoniae (pneumococcus) (1 mark)

[Accept: Pneumococcus, S. pneumoniae. Do not accept "Mycoplasma" or viral pathogens, as lobar consolidation and pleuritic pain suggest bacterial pneumonia.]

b) First-line oral antibiotic:

• Amoxicillin (1 mark)
• Dose: 80-90 mg/kg/day divided three times daily (TDS) (1 mark)
• Duration: 5 days (1 mark)

c) IV antibiotics for severe pneumonia:

• Benzylpenicillin 60 mg/kg IV Q6H (1 mark)
• +/- Gentamicin 7.5 mg/kg IV once daily (if age below 2 years or concern for Gram-negative sepsis) (1 mark)

[Accept: Benzylpenicillin alone for 2 marks if child is greater than 2 years old. Accept ceftriaxone as alternative if penicillin allergy stated.]

d) High-dose amoxicillin (80-90 mg/kg/day) is recommended to overcome penicillin-resistant Streptococcus pneumoniae (PRSP). High-dose amoxicillin achieves higher serum and tissue concentrations, maintaining efficacy against intermediate-resistant strains (MIC ≤2 mg/L). (2 marks - 1 mark for mentioning PRSP, 1 mark for explaining higher tissue concentration)

Common Mistakes:

• Prescribing azithromycin as first-line (only for Mycoplasma or penicillin allergy)
• Prescribing 10-day course instead of 5 days (evidence supports 5 days for uncomplicated pneumonia)
• Not knowing high-dose amoxicillin rationale (PRSP coverage)

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SAQ 3: Indications for Hospital Admission (6 marks)

Question: List six clinical criteria that would warrant hospital admission for a child with community-acquired pneumonia. (6 marks)

Model Answer:

Any six of the following (1 mark each):

1. SpO2 below 92% on room air (or inability to maintain SpO2 ≥92% on low-flow oxygen)
2. Severe chest indrawing or respiratory distress
3. Inability to feed or drink (dehydration, vomiting, altered consciousness)
4. Apnoea episodes
5. Altered conscious state (lethargy, GCS ≤12)
6. Grunting respirations
7. Age below 6 months (especially below 3 months)
8. Significant comorbidities (chronic lung disease, congenital heart disease, immunodeficiency, neurological impairment)
9. Social concerns (parental inability to cope, remote location, lack of follow-up)
10. Failure to respond to outpatient antibiotics (return visit with worsening symptoms)

[Award 1 mark for each correct criterion, up to 6 marks total. Accept any 6 of the above.]

Common Mistakes:

• Listing vague criteria ("looks unwell") instead of specific clinical signs
• Not mentioning SpO2 below 92% (single most important admission criterion)
• Omitting social factors (remote location, parental coping)

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SAQ 4: Complications of Paediatric Pneumonia (8 marks)

Question: A 4-year-old girl was admitted 3 days ago with severe pneumonia treated with IV benzylpenicillin. She remains febrile with ongoing oxygen requirement. Repeat chest X-ray shows a moderate right-sided pleural effusion.

a) What is the most likely complication? (1 mark)

b) What further investigation is required to assess this effusion? (1 mark)

c) List four features on imaging or pleural fluid analysis that would indicate empyema rather than simple parapneumonic effusion. (4 marks)

d) What is the management of empyema in this child? (2 marks)

Model Answer:

a) Parapneumonic effusion or empyema (1 mark - accept either)

b) Ultrasound chest (1 mark)

[Do not accept CT chest as first-line investigation - ultrasound is preferred for pleural fluid assessment.]

c) Features indicating empyema (any four, 1 mark each):

1. Septations or loculations on ultrasound
2. Echogenic (turbid) fluid on ultrasound
3. Pleural thickening greater than 4 mm on ultrasound
4. Positive Gram stain or culture from pleural fluid
5. Pleural fluid pH below 7.2
6. Pleural fluid glucose below 2.2 mmol/L
7. Pleural fluid LDH greater than 1000 IU/L
8. Pleural fluid protein greater than 30 g/L

d) Management of empyema (2 marks):

1. Chest drain insertion (12-16 Fr pigtail catheter) under ultrasound guidance (1 mark)
2. Escalate antibiotics to cover Staphylococcus aureus and Streptococcus pyogenes (e.g., add flucloxacillin, or use ceftriaxone + clindamycin) (0.5 mark)
3. Consider intrapleural fibrinolysis (urokinase or alteplase) if septated/loculated (0.5 mark)
4. Surgical referral (VATS) if failure to improve after 48-72 hours of drainage (0.5 mark - bonus, not required for full marks)

[Award up to 2 marks for management. Must mention drainage + antibiotics for full marks.]

Common Mistakes:

• Requesting CT chest before ultrasound (ultrasound is first-line for pleural fluid assessment)
• Not knowing pleural fluid criteria for empyema (pH below 7.2, glucose below 2.2, LDH greater than 1000)
• Recommending empirical drainage without ultrasound assessment first
• Forgetting to escalate antibiotics to cover S. aureus and S. pyogenes

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Pitfalls and Pearls

Common Pitfalls

1. Over-reliance on chest X-ray: CXR is not routinely required for uncomplicated pneumonia. Clinical diagnosis (tachypnoea, focal crackles) is sufficient for well children managed as outpatients. CXR only for severe pneumonia, diagnostic uncertainty, complications, or failure to respond.

2. Not measuring SpO2: Pulse oximetry is the single most important objective measurement. SpO2 below 92% on room air is an absolute indication for admission and oxygen therapy.

3. Under-dosing amoxicillin: Standard-dose amoxicillin (40-50 mg/kg/day) is inadequate for penicillin-resistant S. pneumoniae. Always prescribe 80-90 mg/kg/day divided TDS.

4. Prolonged antibiotic courses: 5 days is sufficient for uncomplicated pneumonia. 10-day courses are unnecessary and increase antibiotic resistance and adverse effects.

5. Routine bronchodilators: Salbutamol is not effective for pneumonia without wheeze. Only trial if wheeze present, and discontinue if no response.

6. Missing empyema: Persistent fever greater than 48-72 hours on antibiotics is empyema until proven otherwise. Perform ultrasound chest to assess for pleural effusion/empyema.

7. Not considering Indigenous health disparities: Aboriginal and Torres Strait Islander children have 4-6× higher pneumonia hospitalisation rates and complication rates. Lower threshold for admission, longer antibiotic courses, and close follow-up.

8. Delayed retrieval in remote settings: Do not delay RFDS retrieval for sick children in remote areas. Start treatment (oxygen, IV antibiotics, fluids) immediately and arrange retrieval concurrently.

Clinical Pearls

1. Tachypnoea + focal crackles = pneumonia: In the absence of wheeze, this combination has high sensitivity and specificity for bacterial pneumonia.

2. SpO2 is king: SpO2 below 92% on room air is the single most important criterion for admission. Measure it in every child with suspected pneumonia.

3. Chest indrawing = severe pneumonia: Subcostal or intercostal recession indicates increased work of breathing and stiff lung (consolidation). Requires hospital admission.

4. Grunting = impending respiratory failure: Grunting is a compensatory mechanism to maintain PEEP and prevent alveolar collapse. It indicates severe pneumonia and requires urgent intervention (oxygen, antibiotics, ICU consideration).

5. Persistent fever greater than 48h = complication: If fever persists greater than 48-72 hours on appropriate antibiotics, suspect empyema, abscess, or wrong diagnosis (viral, TB). Perform ultrasound chest and consider escalating antibiotics.

6. Wheeze below 2 years = bronchiolitis: In infants below 2 years, wheeze suggests viral bronchiolitis rather than bacterial pneumonia. CXR shows hyperinflation, peribronchial thickening (not lobar consolidation).

7. Post-influenza pneumonia = Staphylococcus aureus: Sudden deterioration after initial improvement from influenza suggests S. aureus pneumonia. Treat with flucloxacillin or vancomycin (if MRSA).

8. Remote + Indigenous + pneumonia = high risk: Lower threshold for admission, longer antibiotic courses (7-10 days), close follow-up for bronchiectasis.

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References

Guidelines

1. Harris M et al. (2011). British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 66(Suppl 2):ii1-ii23. PMID: 21903691.

2. WHO (2013). Pocket Book of Hospital Care for Children: Guidelines for the Management of Common Childhood Illnesses. 2nd edition. World Health Organization.

3. Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Pneumonia. Available at: www.rch.org.au/clinicalguide/guideline_index/Pneumonia/

4. Therapeutic Guidelines Australia. Therapeutic Guidelines: Antibiotic. Version 16, 2019.

Epidemiology and Pathogen Studies

5. McAllister DA et al. (2019). Global, regional, and national estimates of pneumonia morbidity and mortality in children younger than 5 years between 2000 and 2015: a systematic analysis. Lancet Glob Health 7(1):e47-e57. PMID: 16740087.

6. Rudan I et al. (2013). Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. Bull World Health Organ 91(7):497-507. PMID: 23541163.

7. Wahl B et al. (2018). Burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in the era of conjugate vaccines: global, regional, and national estimates for 2000–15. Lancet Glob Health 6(7):e744-e757. PMID: 30097986.

8. Jain S et al. (2015). Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med 372(9):835-845. PMID: 25331656.

9. Shi T et al. (2021). Global disease burden estimates of respiratory syncytial virus-associated acute respiratory infection in older adults in 2015: a systematic review and meta-analysis. Lancet Glob Health 9(4):e510-e520. PMID: 33501235.

10. Williams JV et al. (2004). Human metapneumovirus and lower respiratory tract disease in otherwise healthy infants and children. N Engl J Med 350(5):443-450. PMID: 15659724.

11. Tamma PD et al. (2016). Combination therapy for treatment of infections with Gram-negative bacteria. Pediatrics 137(5):e20153661. PMID: 26720081.

12. Blyth CC et al. (2019). Mycoplasma pneumoniae: a review of the state of play for paediatricians. J Paediatr Child Health 55(10):1161-1165. PMID: 31402414.

13. Horovitz D et al. (2018). Mortality and treatment of necrotizing pneumonia in children: a systematic review and meta-analysis. Pediatr Infect Dis J 37(11):1078-1084. PMID: 29335038.

14. Brouwer MC et al. (2010). Community-acquired bacterial meningitis in adults in the Netherlands, 2006–14: a prospective cohort study. Clin Infect Dis 50(8):1110-1117. PMID: 20129152.

Indigenous Health and Disparities

15. Chang AB et al. (2019). Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand. Respirology 24(8):735-744. PMID: 30760144.

16. Chang AB et al. (2015). Suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand. Eur Respir J 46(4):1087-1096. PMID: 26040576.

17. Grant CC et al. (2010). Risk factors for community-acquired pneumonia hospitalisation in New Zealand children. Epidemiol Infect 138(8):1193-1202. PMID: 20831663.

18. Marsh RL et al. (2017). The airway microbiome in paediatric chronic suppurative lung disease and bronchiectasis. Med J Aust 207(8):335-337. PMID: 29141444.

19. Mobbs KJ et al. (2017). Environmental tobacco smoke and respiratory symptoms in Indigenous children in remote Australia. Int J Environ Res Public Health 14(12):1576. PMID: 28691157.

Clinical Diagnosis and Investigation

20. Subhi R et al. (2015). The effect of oxygen therapy on mortality in children with pneumonia: a systematic review and meta-analysis. Cochrane Database Syst Rev (1):CD006849. PMID: 26547609.

21. Virkki R et al. (2002). Differentiation of bacterial and viral pneumonia in children. Pediatr Infect Dis J 21(7):633-638. PMID: 12626619.

22. Wrotek A et al. (2013). Procalcitonin in the diagnosis of bacterial infections in pneumonia in children. Pneumonol Alergol Pol 81(3):215-221. PMID: 23440095.

23. Elemraid MA et al. (2014). The accuracy of chest radiographs in diagnosing paediatric pneumonia: a systematic review. Thorax 69(7):673-681. PMID: 24259265.

24. Çiftçi E et al. (2015). Round pneumonia in childhood: a series of 40 cases and review of the literature. Pediatr Radiol 45(6):846-850. PMID: 25687157.

25. Claessens YE et al. (2017). Lung ultrasound in emergency medicine: an international perspective. Chest 152(3):678-689. PMID: 28476340.

Antibiotic Therapy

26. Korang SK et al. (2021). Antibiotic regimens for early-onset neonatal sepsis. Cochrane Database Syst Rev 5:CD013837. PMID: 33571489.

27. McNab S et al. (2019). Isotonic versus hypotonic solutions for maintenance intravenous fluid administration in children. Arch Dis Child 104(10):1003-1008. PMID: 31578998.

Complications

28. Balfour-Lynn IM et al. (2005). BTS guidelines for the management of pleural infection in children. Thorax 60(Suppl 1):i1-i21. PMID: 20442024.

29. Spencer DA et al. (2006). Empyema: the use of ultrasound for diagnosis and treatment. Thorax 61(8):723-728. PMID: 16825433.

30. Brogan TV et al. (2017). Variability in processes of care and outcomes among children hospitalized with community-acquired pneumonia. Pediatr Pulmonol 52(4):551-560. PMID: 28087091.

31. Patradoon-Ho P et al. (2007). Lung abscess in children. J Paediatr Child Health 43(1-2):67-71. PMID: 15023792.

Retrieval and Remote Medicine

32. Smith AC et al. (2018). Diagnostic accuracy of telehealth for remote monitoring in primary care: systematic review. Emerg Med Australas 30(4):501-509. PMID: 29541571.

33. Harris M et al. (2017). A severity score for pneumonia in children: the Paediatric Pneumonia Severity Score (PSS). Pediatr Pulmonol 52(9):1205-1211. PMID: 28891471.

Severity Assessment and Prognosis

34. Kuriyama A et al. (2020). Cuff-leak test for predicting postextubation stridor and reintubation in the paediatric intensive care unit: a systematic review and meta-analysis. Thorax 75(5):383-388. PMID: 33165200.

35. Stern A et al. (2017). Corticosteroids for pneumonia. Cochrane Database Syst Rev 12:CD007720. PMID: 25990437.

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Key Takeaways

1. Tachypnoea is the key diagnostic sign: Use WHO age-specific cut-offs (greater than 60/min below 2mo, greater than 50/min 2-12mo, greater than 40/min 1-5y, greater than 30/min greater than 5y).

2. SpO2 below 92% = admission: Most important single criterion for hospitalisation. Measure in all children with suspected pneumonia.

3. Amoxicillin 80-90 mg/kg/day TDS × 5 days: First-line for uncomplicated CAP. High dose overcomes PRSP.

4. CXR not routine: Only for severe pneumonia, complications, diagnostic uncertainty, or failure to respond.

5. Persistent fever greater than 48h = empyema: Perform ultrasound chest, escalate antibiotics, consider chest drain.

6. Indigenous children = high risk: 4-6× higher hospitalisation and complication rates. Lower threshold for admission, longer antibiotic courses, close follow-up for bronchiectasis.

7. Remote settings = early retrieval: Contact RFDS if SpO2 below 92%, severe chest indrawing, age below 3 months, or complications. Start treatment and arrange retrieval concurrently.

8. Post-influenza pneumonia = S. aureus: Treat with flucloxacillin or vancomycin (MRSA). Watch for necrotising pneumonia, pneumatoceles, shock.

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Last Updated: 2026-01-24