Last updated:
April 1, 2026
Pneumonia is an acute lower respiratory tract infection of the lungs. It is characterised by fast breathing and chest indrawing in children.
It is still the leading killer of children worldwide, 29% of pediatric deaths worldwide, 158 million cases per year, and 3 million deaths per year. The death rates in underdeveloped countries are 2000x that of children in developed countries.
The Pneumonia Aetiology Research for Child Health (PERCH) showed that viruses (particularly RSV) are the most common cause of pneumonia in pre-school children. Up to 30% of children with viral pneumonia develop co-existing bacterial pneumonia. Pneumocystis jirovecii as a cause of pneumonia may be more prevalent than Mycobacterium tuberculosis in Kenya.
WHO classification of respiratory tract infections
| Respiratory tract infection | Description |
|---|---|
| Cough and cold | Cough and other respiratory symptoms that do not include definitions of fast breathing, chest indrawing, or danger signs |
| Pneumonia | Fast breathing and/or chest indrawing |
| Severe pneumonia | Pneumonia as defined above, but with general danger signs (lethargy, convulsions, persistent vomiting, stridor, grunting, cyanosis, and inability to drink or breastfeed), which can lead to sepsis and death |
Common causative organisms for pneumonia according to age
| Age | Pathogen |
|---|---|
| Newborn (0-1 mo) | GBS, Gram negatives, Listeria |
| 3 wks. – 3mos. | RSV, Parainfluenza, Streptococcus pneumoniae, Staphylococcus aureus, Chlamydia trachomatis, Bordetella pertussis |
| 4 mos. – 4yrs | RSV, other viruses, Streptococcus pneumoniae, Mycoplasma pneumoniae |
| 5 yrs. – 15 yrs. | Mycoplasma pneumoniae, Streptococcus pneumoniae, Chlamycia pneumoniae |
| Other pathogens to consider | Tuberculosis (can have an acute presentation or predispose to pneumonia, consider in cough > 14 days), Pneumocystis jirovecii (immunocompromised patients, common in advanced HIV disease) |
- Risk factor for pneumonia
- Malnutrition is associated with an increased risk of death from pneumonia
- Low birth weight
- Lack of exclusive breastfeeding for the first six months of a child’s life
- HIV infection or exposure: higher risk of pneumonia and higher mortality than non-exposed infants. Additional risk of pneumocystis jirovecii pneumonia and pulmonary tuberculosis
- Indoor air pollution: caused by smoking or cooking with solid fuels
- Asthma/airway inflammation: associated with allergies and poor air quality. Patients with asthma who develop pneumonia have a more severe and prolonged course
- Common symptoms of pneumonia
- Productive cough
- From the onset
- Different from acute bronchitis, where the cough is initially unproductive and becomes more productive with time
- Fever
- Fast breathing: can be influenced by fever (up to 4 breaths per minute for every degree centigrade above normal). The respiratory rate should not be adjusted if the child has a fever. This might be a cause of overlap between the presentation of pneumonia and other febrile illnesses, e.g., malaria
- Chest indrawing: aka retractions. This is a sign of respiratory distress. Like respiratory rate, it is not specific and is fairly sensitive to pneumonia
- Productive cough
- Signs and symptoms of viral pneumonia
- Low-grade fever
- URTI symptoms
- Mild tachypnea
- Crackles/wheezing
- Signs and symptoms of bacterial pneumonia
- High-grade fever
- Chills
- Severe, hacking cough
- Chest pain
- More sick-looking
- Tachypnea
- Adventitious lung sounds
- Local dullness to percussion (important to ask the child to inhale and percuss to find areas of dullness)
- Respiratory distress
- Cyanosis
- Diminished breath sounds (indicate respiratory fatigue)
- Signs and symptoms of Mycoplasma/chlamydia pneumoniae
- Gradual onset of constitutional symptoms
- Worsening cough and Hoarseness
- URTI symptoms
- Dyspnea
- Crackles
- Chest X-ray out of proportion to presentation
- Differentials
- Acute bronchitis
- Bronchiolitis
- Cystic fibrosis
- Investigations
- Respiratory evaluation: RR, SpO2, supp. O2, apnea monitor if necessary
- CBC with differential
- <20K WBCs and Lymphocytes high**: Viral process**
- 20K WBC and left-shift: Bacterial process
- Sputum or blood Culture for the definitive diagnosis of a ****bacterial process – sepsis related
- Nasopharyngeal swab for the definitive diagnosis of a viral process
- IgM titres for the diagnosis of Mycoplasma pneumoniae
- Chest X-ray (AP and Lateral views)
- CXR viral findings: Hyperinflation, Generalized infiltrates, Peribronchial cuffing
- CXR pneumococcal findings: Lobar consolidation
- CXR S. aureus findings: Abscess/Cavitating lesions (suspect when child has been hospitalized)
- *CXR Mycoplasma and Chlamydia:*No CXR is pathognomic for Mycoplasma or Chlamydia pneumonia, Unilateral lower lobe interstitial pneumonia, CXR out of proportion to presentation
- Treatment of viral pneumonia
- Supportive care
- Monitor
- Return for any deterioration
- Treatment of bacterial pneumonia
- Outpatient:
- PO amoxicillin or amoxicillin/clavulanate or cefuroxime
- Inpatient:
- First line: IV penicillin and gentamicin
- Second line: IV ceftriaxone or cefotaxime
- Staphylococcal or Gram-negative pneumonia: IV flucloxacillin and gentamicin
- If developed pneumonia in hospital or CXR suggests S. aureus, add vancomycin or clindamycin (treatment for MRSA)
- Outpatient:
- Treatment of Mycoplasma/Chlamydia pneumoniae
- Azithromycin or erythromycin or Respiratory Fluoroquinolones (levofloxacin, gatifloxacin, moxifloxacin)
- Prevention
- Immunization for PCV, HiB, pertussis, and measles
- Improved air quality and reduced exposure to household air pollution
- Handwashing with soap
- Exclusive breastfeeding
- PCP prophylaxis for HIV-exposed and HIV-positive infants
Viral vs bacterial pneumonia
| Clinical Findings | Viral | Bacterial |
|---|---|---|
| Temperature | Low-grade | High-grade |
| URTI signs | + | – |
| Toxicity | + | +++ |
| Crackles | Scattered | Localized |
| Dullness to percussion | – | Localized |
| WBC | Normal | Elevated, left shift |
| CXR | Streaking | Lobar consolidation |
| Definitive diagnosis | Nasopharyngeal swab | Sputum/Blood culture |
Abnormal respiratory rates
| Age | Tachypnoea |
|---|---|
| 7 – 59 days | > 60 breaths per minute |
| 3 – 12 months of age | > 50 breaths per minute |
| 12 months – 5 years of age | > 40 breaths per minute |