Clinical Signs of Pneumonia in Pediatric Patients

Diagnosis and Assessment

The American Academy of Pediatrics recommends that the diagnosis of pediatric pneumonia be based primarily on the presence of cough or difficulty breathing associated with age-specific tachypnea, with signs of respiratory distress indicating greater severity and need for hospitalization 1, 2
Tachypnea represents the sign with the best sensitivity (74%) and specificity (67%) for radiologically confirmed pneumonia in children under 5 years 3
Age-specific threshold values are:
Tachypnea >50 breaths/minute has a positive likelihood ratio of 1.90 (95% CI 1.45-2.48) for the diagnosis of pneumonia 2, 3
In children up to 3 years, bacterial pneumonia should be considered when there is fever >38.5°C along with chest wall indrawing and respiratory frequency >50/min 3

Lower chest wall indrawing has a positive likelihood ratio of 1.76 for radiologic pneumonia 2
Grunting has a positive likelihood ratio of 2.7 (95% CI 1.5-5.1) 2
Nasal flaring has a positive likelihood ratio of 2.2 (95% CI 1.3-3.1) 2
Any child with respiratory distress (chest wall indrawing, nasal flaring, grunting) should be hospitalized 1, 4

Cough and fever are present in the majority of cases, but are non-specific 2, 3
The World Health Organization recommends including vomiting among the signs of danger 2

Hypoxemia (SpO2 <90% at sea level) is a critical indicator for hospitalization 5, 4
Moderate to severe respiratory distress with chest wall indrawing, nasal flaring, or grunting 1, 2
Toxic appearance of the child (lethargy, inability to feed, persistent vomiting) 1
Age <3-6 months with suspected bacterial infection 4
Suspected high-virulence pathogen such as community-acquired MRSA 1, 6

SpO2 <92% with FiO2 ≥0.50 requires admission to intensive care 6
Need for invasive ventilation via endotracheal tube 6, 4
Need for acute non-invasive ventilation (CPAP or BiPAP) 6, 4
Imminent respiratory failure 6, 4
Sustained tachycardia, hypotension, or need for pharmacological cardiovascular support 6, 4
Alteration of mental status due to hypercarbia or hypoxia 6

Cough or difficulty breathing plus one of the following: vomiting 2, convulsions 6, lethargy/unconsciousness 6
The World Health Organization recommends including among the danger signs: grunting, nasal flaring, head nodding, tracheal traction, intercostal retractions, severe tachypnea 2
Hypoxemia and moderate to severe malnutrition (weight/age or weight/height <2 standard deviations) 2

The history, presentation, and examination of the child are the main determinants of the severity of the disease and the appropriate level of care 1
The overall assessment of the physician on the child's condition at the time of examination and the anticipated clinical course should determine the setting of care 1
There are no validated scoring systems to predict which children with pneumonia should be hospitalized 1

Pulse oximetry should be performed in all children with suspected pneumonia to guide decisions on the setting of care and determine the need for hospitalization 5
Radiographic data, pulse oximetry, and laboratory tests are used variably by physicians to support the decision-making process 1