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Severe Pneumonia in children


Cough and difficulty in breathing are common problems in children. Most episodes of cough are due to common cold. The commonest severe illness presenting with cough or difficulty in breathing is pneumonia.

Severe pneumonia is a condition characterized by extensive inflammation of lung parenchyma presenting with signs of respiratory distress.

Diagnostic Criteria

Cough or difficulty in breathing plus at least one of the following:

  • Central cyanosis or oxygen saturation <90% on pulse oximetry

  • Inability to breastfeed or drink, or vomiting everything

  • Convulsions, lethargy or unconsciousness.

  • Grunting, head nodding, lower chest wall in drawing.



  • Chest X-ray, PA and Lateral views

  • Blood for culture and sensitivity.

  • FBP

  • ESR

  • CRP




  • Give oxygen 2-4 litres/min

  • Maintain the airway by gentle suction of any thick secretions

  • Encourage breastfeeding and ensure that the child receives daily maintenance fluids


  • Give Ampicillin IV 50mg/kg 6 hourly and Gentamicin IV 7.5mg/kg once a day for at least 5 days; then complete treatment at home or at health facility with Amoxicillin PO 40mg/kg 12 hourly plus Gentamicin 7.5mg/kg 

  • IV/IM once daily for a further 5 days.

  • If the child does not improve within 48 hours, add Cloxacillin IV 50  mg/kg 6 hourly to cover for staphylococcal pneumonia. When the child  improves within 48 hours, continue Flucloxacillin PO 25mg/kg 6 hourly for a total course of 3 weeks. Complete a course of Ampicillin and Gentamicin for 10 days.

  • If the child does not improve within 48 hours and staphylococcal  pneumonia is not suspected use Ceftriaxone IV 75mg/kg once daily for 10 days or consider evaluation of other diseases or complications.

  • If HIV exposed/infected add Co-trimoxazole IV or PO 8mg/kg of Trimethoprim and 40mg/kg of Sulfamethoxazole 8 hourly for 3weeks for•


Pneumocystis pneumonia (PCP)


  • If the child has fever (≥38.5°C), give Paracetamol PO 15 mg/kg

  • If the child has a wheeze, give nebulized salbutamol 2.5mg i.e. 0.5ml of the 5mg/ml nebulizer solution.

Management of Complications of Severe Pneumonia


If the child has not improved after two days, consider the following complications:

  • Empyema/Pleural effusion.

  • Pleural effusion is the collection of fluid within the pleural cavity.

Diagnostic Criteria


  • The chest is stony dull to percussion over the affected area and a pleural rub may be heard.

  • Positive pleural tap.

  • Homogenous opacification with meniscus sign on a Chest X ray



  • Chest X-ray

  • Pleural fluid analysis : Microbiology, Biochemistry and Cytology


Non pharmacological

  • Drain any significant pleural effusion with under water seal drainage.

  • If fever and other signs of illness continue, despite adequate chest drainage and antimicrobial therapy, investigate for Tuberculosis.

Other complications:

Pneumothorax, Pericardial effusion, Lung abscess, Bronchial ectasis and Cor-pulmonale.

Refer patients to the next level health facility if there is inadequate expertise or facilities.

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Last updated on 23.08.2020


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