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.