Pneumonia in children under 5 years of age

The most common causes are viruses, pneumococcus and Haemophilus influenzae.

Clinical features

– Cough or difficulty breathing
– Fever often high (> 39 °C), but the child may present with low-grade fever or may have no fever (often a sign of serious illness)

Clinical examination must be done on a calm child in order to correctly count the respiratory rate and look for signs of serious illness.

– A child has tachypnoea (increased respiratory rate) if:
RR ≥ 60 breaths/minute in children under 1 months
RR ≥ 50 breaths/minute in children from 1 to 11 months
RR ≥ 40 breaths/minute in children from 12 months to 5 years

– On pulmonary auscultation: dullness with diminished vesicular breath sounds, crepitations and sometimes bronchial breathing or normal pulmonary auscultation.

– Signs of serious illness (severe pneumonia):
• Chest indrawing: the inferior thoracic wall depresses on inspiration as the superior abdomen expands
• Cyanosis (lips, oral mucosa, fingernails) or SpO2 < 90%
• Nasal flaring
• Altered consciousness (child is abnormally sleepy or difficult to wake)
• Stridor (hoarse noise on inspiration)
• Grunting (a short repetitive noise produced by a partial closure of the vocal cords) on expiration
• Refusal to drink or feed
• Children under 2 months
• Severe malnutrition

– In malnourished children, the RR thresholds should be decreased by 5 breaths/minute from those listed above.
– Chest indrawing is significant if it is clearly visible and present at all times. If it is observed when a child is upset or feeding and is not visible when the child is resting, there is no chest indrawing.
– In children under 2 months of age, moderate chest indrawing is normal as the thoracic wall is flexible.
– If only the soft tissues between the ribs or above the clavicles depress, there is no chest indrawing.

Consider also:
– Malaria in endemic areas, as it may also cause cough and tachypnoea.
– Staphylococcal pneumonia in patients with empyema or painful abdominal swelling and diarrhoea.
– Pneumocystosis in children with confirmed or suspected HIV infection (see HIV infection and AIDS, Chapter 8).
– Tuberculosis:
• in a child with cough, fever and poor weight gain and a history of close contact with a tuberculous patient1 . For the diagnosis, refer to the MSF handbook, Tuberculosis.
• in the event of pneumonia complicated with empyema (pus in the pleural space).


Severe pneumonia (inpatient treatment)

Children under 2 months 

The first line treatment is the combination ampicillin slow IV (3 minutes) for 10 days + gentamicin slow IV (3 minutes) or IM for 5 days:

0 - 7 days

< 2 kg

ampicillin 50 mg/kg every 12 hours
+ gentamicin 3 mg/kg once daily

≥ 2 kg

ampicillin 50 mg/kg every 8 hours
+ gentamicin 5 mg/kg once daily

8 days - < 1 month

ampicillin 50 mg/kg every 8 hours
+ gentamicin 5 mg/kg once daily

1 month - < 2 months

ampicillin 50 mg/kg every 6 hours
+ gentamicin 6 mg/kg once daily

For ampicillin, IV route is preferred but IM route may be an alternative.

If ampicillin is not available, alternatives may be cefotaxime slow IV (3 minutes) or infusion (20 minutes) or IM for 10 days (for doses, see Meningitis, Chapter 7), or, as a last resort: ceftriaxone slow IV2 (3 minutes) or infusion (30 minutes; 60 minutes in neonates) or IM: 50 mg/kg once daily for 10 days.

If the child's condition does not improve3 after 48 hours of well administered treatment, add cloxacillin IV for 10 to 14 days:

Children 0 - 7 days

< 2 kg

cloxacillin 50 mg/kg every 12 hours

≥ 2 kg

cloxacillin 50 mg/kg every 8 hours

Children > 7 days

< 2 kg

cloxacillin 50 mg/kg every 8 hours

≥ 2 kg

cloxacillin 50 mg/kg every 6 hours

Children from 2 months to 5 years 

The first line treatment is:
ceftriaxone IM or slow IV2 (3 minutes): 50 mg/kg once daily
ampicillin slow IV (3 minutes) or IM: 50 mg/kg every 6 hours
gentamicin slow IV (3 minutes) or IM: 6 mg/kg once daily
Ampicillin is preferably administered in 4 divided doses. If the context does not permit it, the daily dose must be divided in at least 3 doses.

The treatment is administered by parenteral route for at least 3 days then, if the clinical condition has improved3 and oral treatment can be tolerated, switch to amoxicillin PO: 30 mg/kg 3 times daily to complete 10 days of treatment.

If the child's condition deteriorates or does not improve after 48 hours of correct administration, add cloxacillin IV: 25 to 50 mg/kg every 6 hours. After clinical improvement and 3 days with no fever, switch to amoxicillin/clavulanic acid (co-amoxiclav) PO to complete 10 to 14 days of treatment. Use formulations in a ratio of 8:1 or 7:1 exclusively. The dose is expressed in amoxicillin: 50 mg/kg 2 times daily.

If the child's condition does not improve after 48 hours with ceftriaxone + cloxacillin, consider tuberculosis. For the diagnosis, refer to the guide Tuberculosis, MSF.

If tuberculosis is unlikely, continue with ceftriaxone + cloxacillin and add azithromycin (see Atypical pneumonia).

– For malnourished children, refer to specific protocol.
– In the event of moderate-large empyema, assess if drainage is required. Administer antibiotics active against pneumococci and staphylococci (see Staphylococcal pneumonia).

Adjuvant therapy

– Fever: paracetamol PO (Chapter 1).
– Infants: keep warm.
– Install on an incline (head elevated) or in semi-sitting position.
– Clear the airway (nasal irrigation with 0.9% sodium chloride if needed).
– Oxygen at the flow rate required to maintain SpO2 ≥ 90% or, if pulse oxymeter is not available, minimum 1 litre/minute.

–  Maintain adequate hydration and nutrition:
• In children with severe respiratory difficulty: place an IV line and give 70% of normal maintenance fluids. Resume oral feeding as soon as possible (no severe respiratory difficulty, ability to eat normally).
Use a nasogastric tube only if an IV line cannot be established: children under 12 months: 5 ml/kg/hour; children over 12 months: 3 to 4 ml/kg/hour; alternate milk and water. Resume normal oral feeding as soon as possible.
• In the absence of severe respiratory difficulty: breastfeed on demand; milk/food and water by spoon on demand.
• ORS when required (Dehydration, Chapter 1).

Pneumonia with no signs of serious illness

Children under 2 months 

Admit the child for inpatient care and treat for severe pneumonia.

Children from 2 months to 5 years 

Treat as outpatient, except infants.
amoxicillin PO: 30 mg/kg 3 times daily for 5 days
Follow-up in 48 to 72 hours or sooner if the child’s condition deteriorates:
– If the condition is improving3 : continue with the same antibiotic to complete treatment.
– If there is no improvement after 3 days of correct administration: add azithromycin (see Atypical pneumonia).
– If the condition is deteriorating: hospitalise and treat as severe pneumonia.

Ref Notes
1 Contact is defined as living in the same household, or in close and regular contact with any known or suspected tuberculous case within the last 12 months.
2 The solvent of ceftriaxone for IM injection contains lidocaine. Ceftriaxone reconstituted using this solvent must never be administered by IV route. For IV administration, water for injection must always be used. [ a b ]
3 Improvement criteria include: fever reduction, diminished respiratory distress, improved SpO2, improved appetite and/or activity. [ a b c ]