Childhood pneumonia and respiratory infection

Red Flags

Severe respiratory distress (severe chest indrawing, head bobbing, grunting, central cyanosis, SpO2 <90%) — admit, oxygen, antibiotic^[1]
Inability to feed or drink, persistent vomiting, lethargy, convulsions in young infant — possible serious bacterial infection (PSBI); pre-referral antibiotics + urgent transfer^[1]
Children <2 months with fast breathing (>60/min), fever or hypothermia, or any danger sign — admit; do not manage as ambulatory ARI^[1]
Failure to respond to first-line antibiotic at 48 hours — switch antibiotic, investigate for empyema/abscess, escalate care^[1]

First-line treatment

Interventions

Distinguish viral ARI from bacterial pneumonia^[1]
Most ARIs in children are viral and self-limiting — runny nose, cough without fast breathing or chest indrawing. Bacterial pneumonia requires antibiotic. Avoid antibiotic for non-pneumonia viral ARI to combat AMR
Supportive care for non-severe ARI (home)^[1]
Increase fluids, continue feeding/breastfeeding, paracetamol for fever, saline drops + suction for nasal blockage, avoid cough/cold combinations in <6 years
Pre-referral antibiotic and urgent transfer for PSBI^[1]
Young infant <2 months with PSBI signs: IM gentamicin 5 mg/kg + oral amoxicillin 25 mg/kg BD as first dose; arrange immediate referral; if referral truly impossible, community management with daily ANM follow-up × 7 days
Inpatient management of severe pneumonia^[1]
Oxygen for SpO2 <90%, IV antibiotic, fluid management (avoid over-hydration; SIADH), nutrition (NG if unable to feed), monitor for empyema and treatment failure
Oxygen therapy^[1]
Targeted oxygen for SpO2 <90% via nasal cannula 1–2 L/min; high-flow nasal oxygen (1–2 L/kg/min) for moderate-severe distress; CPAP/HFNC pre-PICU

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Amoxicillin (oral)^[1]	Aminopenicillin	Not applicable — paediatric guideline	Pneumonia non-severe: 50 mg/kg/day in 2 divided doses × 5 days. PSBI pre-referral: 25 mg/kg single dose	First-line oral antibiotic for pneumonia in children ≥2 months; high-dose vs amoxicillin-resistance regions; PSBI uses lower stat dose with gentamicin
Co-amoxiclav (amoxicillin-clavulanate)^[1]	Aminopenicillin + beta-lactamase inhibitor	Not applicable — paediatric guideline	45–80 mg/kg/day amoxicillin component in 2 divided doses × 5–10 days	Severe pneumonia, treatment failure, suspected H influenzae or atypical; oral or IV; switch from IV when stable
Ampicillin (IV) + gentamicin^[1]	Aminopenicillin + aminoglycoside	Not applicable — paediatric guideline	Ampicillin 50 mg/kg every 6 h IV; gentamicin 7.5 mg/kg/day IV (neonates per local protocol)	First-line inpatient severe pneumonia or sepsis; switch oral after improvement; gentamicin levels and renal function in prolonged courses
Ceftriaxone (IV)^[1]	Third-generation cephalosporin	Not applicable — paediatric guideline	50–80 mg/kg/day IV once daily (max 2 g)	Severe pneumonia, suspected meningitis, treatment failure; covers H influenzae and pneumococcus
Salbutamol (nebulised) for wheeze^[1]	Short-acting beta-2 agonist	Not applicable — paediatric guideline	0.15 mg/kg/dose (min 2.5 mg, max 5 mg) every 20 min × 3 then every 4–6 h	For wheeze with respiratory distress; reassess after each dose; consider pneumonia plus reactive airways

Amoxicillin (oral)^[1]

Aminopenicillin

Adult: Not applicable — paediatric guideline
Paediatric: Pneumonia non-severe: 50 mg/kg/day in 2 divided doses × 5 days. PSBI pre-referral: 25 mg/kg single dose

First-line oral antibiotic for pneumonia in children ≥2 months; high-dose vs amoxicillin-resistance regions; PSBI uses lower stat dose with gentamicin

Co-amoxiclav (amoxicillin-clavulanate)^[1]

Aminopenicillin + beta-lactamase inhibitor

Adult: Not applicable — paediatric guideline
Paediatric: 45–80 mg/kg/day amoxicillin component in 2 divided doses × 5–10 days

Severe pneumonia, treatment failure, suspected H influenzae or atypical; oral or IV; switch from IV when stable

Ampicillin (IV) + gentamicin^[1]

Aminopenicillin + aminoglycoside

Adult: Not applicable — paediatric guideline
Paediatric: Ampicillin 50 mg/kg every 6 h IV; gentamicin 7.5 mg/kg/day IV (neonates per local protocol)

First-line inpatient severe pneumonia or sepsis; switch oral after improvement; gentamicin levels and renal function in prolonged courses

Ceftriaxone (IV)^[1]

Third-generation cephalosporin

Adult: Not applicable — paediatric guideline
Paediatric: 50–80 mg/kg/day IV once daily (max 2 g)

Severe pneumonia, suspected meningitis, treatment failure; covers H influenzae and pneumococcus

Salbutamol (nebulised) for wheeze^[1]

Short-acting beta-2 agonist

Adult: Not applicable — paediatric guideline
Paediatric: 0.15 mg/kg/dose (min 2.5 mg, max 5 mg) every 20 min × 3 then every 4–6 h

For wheeze with respiratory distress; reassess after each dose; consider pneumonia plus reactive airways

Safety-net

Return same-day if breathing becomes faster or harder, child becomes drowsy or floppy, cannot drink, develops fever above 39°C lasting >3 days, or fewer than half normal wet nappies^[1]
Pneumococcal and Hib vaccinations dramatically reduce pneumonia risk — bring vaccinations up to date per national schedule (UIP)^[1]
Avoid cough and cold combination medicines in children <6 years — they do not help and can cause harm; saline drops and bulb suction are safer^[1]

Referral criteria

Possible serious bacterial infection in young infant (<2 months)Pre-referral antibiotic and immediate referral to higher facility; JSSK transport scheme^[1]
Severe pneumonia, hypoxia, or failure of first-line outpatient antibiotic at 48 hPaediatric admission^[1]
Suspected complications (empyema, abscess, meningitis, sepsis)Tertiary paediatric centre^[1]
Recurrent pneumonia (>1 episode/year), failure to thrive, or chronic coughPaediatric respiratory medicine — consider immunodeficiency, foreign body, anatomical lesion, TB, asthma^[1]

Clinical summary

Triage and management of acute respiratory infection in children <5 years using IMNCI thresholds; antibiotic stewardship for viral vs bacterial.

References

1.MoHFW Standard Treatment Guidelines — Respiratory Infections in Children (2021); IMCI/IMNCI; WHO Pocket Book of Hospital Care for Children (2021)