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Guidelines for the management of
community acquired pneumonia in
children: update 2011
British Thoracic Society
Community Acquired Pneumonia in
Children Guideline Group
October 2011 Volume 66 Supplement 2
Thorax
AN INTERNATIONAL JOURNAL OF RESPIRATORY MEDICINE
Michael Harris, Julia Clark, Nicky Coote, Penny Fletcher,
Anthony Harnden, Michael McKean,
Anne Thomson
Community Acquired Pneumonia in Children Guideline Group
On behalf of the British Thoracic Society
Standards of Care Committee
Journal of the British Thoracic Society
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BTS guidelines
ii1 Abstract
ii1 Synopsis of recommendations
ii2 1. Introduction and methods
ii3 2. Incidence and economic consequences
ii5 3. Aetiology
ii8 4. Clinical features
ii9 5. Radiological, general and microbiological
investigations
ii13 6. Severity assessment
ii14 7. General management in the community and
in hospital
ii15 8. Antibiotic management
ii18 9. Complications and failure to improve
ii19 10. Prevention and vaccination
ii20 11. Audit criteria
ii20 References
Online Appendix 1 Search strategy
Online Appendix 2 Template data collection form
Contents Volume 66 Supplement 2 | THORAX October 2011
British Thoracic Society guidelines for the
management of community acquired pneumonia in
children: update 2011
Michael Harris,1 Julia Clark,2 Nicky Coote,3 Penny Fletcher,4 Anthony Harnden,5
Michael McKean,6 Anne Thomson,1 On behalf of the British Thoracic Society
Standards of Care Committee
ABSTRACT
The British Thoracic Society first published management
guidelines for community acquired pneumonia in children
in 2002 and covered available evidence to early 2000.
These updated guidelines represent a review of new
evidence since then and consensus clinical opinion where
evidence was not found. This document incorporates
material from the 2002 guidelines and supersedes the
previous guideline document.
SYNOPSIS OF RECOMMENDATIONS
Clinical features
< Bacterial pneumonia should be considered in
children when there is persistent or repetitive
fever >38.58C together with chest recession and
a raised respiratory rate. [D]
Investigations
< Chest radiography should not be considered
a routine investigation in children thought to
have community acquired pneumonia (CAP).
[A�]
< Children with signs and symptoms of pneu-
monia who are not admitted to hospital should
not have a chest x-ray. [A�]
< A lateral x-ray should not be performed
routinely. [B�]
< Acute phase reactants are not of clinical utility
in distinguishing viral from bacterial infections
and should not be tested routinely. [A�]
< C reactive protein is not useful in the manage-
ment of uncomplicated pneumonia and should
not be measured routinely. [A+]
< Microbiological diagnosis should be attempted
in children with severe pneumonia sufficient to
require paediatric intensive care admission, or
those with complications of CAP. [C]
< Microbiological investigations should not be
considered routinely in those with milder
disease or those treated in the community. [C]
< Microbiological methods used should include:
– Blood culture. [C]
– Nasopharyngeal secretions and/or nasal swabs
for viral detection by PCR and/or immunoflu-
orescence. [C]
– Acute and convalescent serology for respira-
tory viruses, Mycoplasma and Chlamydia. [B+]
– If present, pleural fluid should be sent for
microscopy, culture, pneumococcal antigen
detection and/or PCR. [C]
– Urinary pneumococcal antigen detection
should not be done in young children. [C]
Severity assessment
< For a child in the community, re-consultation to
the general practitioner with persistent fever or
parental concern about persistent fever should
prompt consideration of CAP. [D]
< Children with CAP in the community or in
hospital should be reassessed if symptoms
persist and/or they are not responding to
treatment. [D]
< Children who have oxygen saturations <92%
should be referred to hospital for assessment and
management. [B+]
< Auscultation revealing absent breath sounds
with a dull percussion note should raise the
possibility of a pneumonia complicated by
effusion and should trigger a referral to hospital.
[B�]
< A child in hospital should be reassessed medi-
cally if there is persistence of fever 48 h after
initiation of treatment, increased work of
breathing or if the child is becoming distressed
or agitated. [D]
General management
< Families of children who are well enough to be
cared for at home should be given information
on managing fever, preventing dehydration and
identifying any deterioration. [D]
< Patients whose oxygen saturation is#92% while
breathing air should be treated with oxygen
given by nasal cannulae, high flow delivery
device, head box or face mask to maintain
oxygen saturation >92%. [B]
< Nasogastric tubes may compromise breathing
and should therefore be avoided in severely ill
children and especially in infants with small
nasal passages. If use cannot be avoided, the
smallest tube should be passed down the
smallest nostril. [D]
< Plasma sodium, potassium, urea and/or creati-
nine should be measured at baseline and at least
daily when on intravenous fluids. [C]
< Chest physiotherapy is not beneficial and should
not be performed in children with pneumonia.
[A�]
Antibiotic management
< All children with a clear clinical diagnosis of
pneumonia should receive antibiotics as bacterial
< Additional appendices are
published online only. To view
these files please visit the
journal online (http://thorax.bmj.
com).
1Oxford Children’s Hospital, The
John Radcliffe, Headington,
Oxford, UK
2Department of Paediatric
Immunology and Infectious
Diseases, Old COPD, Great
North Children’s Hospital, Royal
Victoria Infirmary, Newcastle
upon Tyne, UK
3Children’s Ambulatory Unit,
Hammersmith Hospital, Imperial
College Healthcare NHS Trust,
London, UK
4Pharmacy Department, Imperial
College Healthcare NHS Trust,
St Mary’s Hospital, London, UK
5Department of Primary Health
Care, University of Oxford,
Headington, Oxford, UK
6Department of Paediatric
Respiratory Medicine, Royal
Victoria Infirmary, Newcastle
upon Tyne, UK
Correspondence to
Anne Thomson, Oxford
Children’s Hospital, The John
Radcliffe, Headley Way,
Headington, Oxford OX3 9DU,
UK; anne.thomson@orh.nhs.uk
Received 10 June 2011
Accepted 16 June 2011
Thorax 2011;66:ii1eii23. doi:10.1136/thoraxjnl-2011-200598 ii1
BTS guidelines
and viral pneumonia cannot reliably be distinguished from
each other. [C]
< Children aged <2 years presenting with mild symptoms of
lower respiratory tract infection do not usually have
pneumonia and need not be treated with antibiotics but
should be reviewed if symptoms persist. A history of
conjugate pneumococcal vaccination gives greater confidence
to this decision. [C]
< Amoxicillin is recommended as first choice for oral antibiotic
therapy in all children because it is effective against the
majority of pathogens which cause CAP in this group, is well
tolerated and cheap. Alternatives are co-amoxiclav, cefaclor,
erythromycin, azithromycin and clarithromycin. [B]
< Macrolide antibiotics may be added at any age if there is no
response to first-line empirical therapy. [D]
< Macrolide antibiotics should be used if either mycoplasma or
chlamydia pneumonia is suspected or in very severe disease.
[D]
< In pneumonia associated with influenza, co-amoxiclav is
recommended. [D]
< Antibiotics administered orally are safe and effective for
children presenting with even severe CAP and are recom-
mended. [A+]
< Intravenous antibiotics should be used in the treatment of
pneumonia in children when the child is unable to tolerate
oral fluids or absorb oral antibiotics (eg, because of vomiting)
or presents with signs of septicaemia or complicated
pneumonia. [D]
< Recommended intravenous antibiotics for severe pneumonia
include amoxicillin, co-amoxiclav, cefuroxime and cefotaxime
or ceftriaxone. These can be rationalised if a microbiological
diagnosis is made. [D]
< In a patient who is receiving intravenous antibiotic therapy
for the treatment of CAP, oral treatment should be considered
if there is clear evidence of improvement. [D]
Complications
< If a child remains feverish or unwell 48 h after treatment has
commenced, re-evaluation should be performed with consid-
eration given to possible complications. [D]
< Children with severe pneumonia, empyema and lung
abscesses should be followed up after discharge until they
have recovered completely and their chest x-ray has returned
to near normal. [D]
Follow-up
< Follow-up radiography is not required in those who were
previously healthy and who are recovering well, but should
be considered in those with a round pneumonia, collapse or
persisting symptoms. [B+]
1. INTRODUCTION AND METHODS
The British Thoracic Society (BTS) first published management
guidelines for community acquired pneumonia (CAP) in children
in 2002 and covered available evidence to early 2000. These
updated guidelines represent a review of new evidence since then
and consensus clinical opinion where evidence was not found.
As before, these guidelines have been produced in parallel with
those produced for adults, which have also been updated. This
document incorporates material from the 2002 guidelines and
supersedes the previous guideline document.
CAP can be defined clinically as the presence of signs and
symptoms of pneumonia in a previously healthy child due to an
infection which has been acquired outside hospital. In developed
countries this can be verified by the radiological finding of
consolidation. In the developing world a more practical
termdacute lower respiratory tract infectiondis preferred,
reflecting the difficulties in obtaining an x-ray.
Ideally, the definition would include the isolation of
a responsible organism. However, it is apparent from many
studies that a pathogen is not identified in a significant
proportion of cases that otherwise meet the clinical definition
(see Section 3). As it is assumed that CAP is caused by infection,
the presumption is that current techniques have insufficient
sensitivity to detect all relevant pathogens. Treatment guidelines
therefore have to assume that, where pathogens are isolated,
they represent all likely pathogens. There is a clear need for
better diagnostic methods.
In creating guidelines it is necessary to assess all available
evidence with consideration of the quality of that evidence. This
we have endeavoured to do. We have then produced a combina-
tion of evidence statements and recommendations about
management based on the available evidence, supplemented by
consensus clinical opinion where no relevant evidence was
found.
The guideline is framed in each chapter as a list of key ques-
tions that are then explored and discussed. These questions were
set based upon previous guidelines and those raised in the adult
CAP guideline.
Methods of guideline development
Scope of guidelines
These guidelines address the management of CAP in infants and
children in the UK. They do not include neonates, infants with
respiratory syncytial virus bronchiolitis or children with upper
respiratory tract infection, mild fever and wheeze. The specific
management of children with pre-existing respiratory disease or
that of opportunistic pneumonias in immunosuppressed chil-
dren is not addressed.
Guideline development group
The guideline development group was set up by the BTS Stan-
dards of Care Committee and comprised two paediatricians
with a special interest in respiratory disease, a paediatrician with
a special interest in paediatric infectious diseases, a general
paediatrician with a special interest in ambulatory paediatrics,
a specialist trainee in paediatrics, a general practitioner with an
interest in childhood infection and a paediatric pharmacist. An
information specialist developed the search strategy and ran the
searches. No external funding was obtained to support the
development of the guidelines.
Identification of evidence
A search strategy was developed by an information specialist
from the Centre for Reviews and Dissemination in York (part of
the National Institute for Health Research). The Search strategy
and the results are shown in appendix 1 in the online
supplement.
The Cochrane Library (DARE and Cochrane Database of
Systematic Reviews), MEDLINE and EMBASE were searched
from 2000 onwards. There were some technical changes made
to the original search strategies to reduce the chances of missing
studies: a single search strategy was used rather than separate
strategies for each subject. Studies were limited to English
language in view of the limitations on time and resources.
ii2 Thorax 2011;66:ii1eii23. doi:10.1136/thoraxjnl-2011-200598
BTS guidelines
Two thousand and seventy-six studies were identified by the
searches, which were rerun in July 2010. The updated search
identified a further 511 titles.
Assessing the literature
Initial review of the 2076 titles and abstracts was undertaken by
one reviewer, screening for relevance. This was repeated after the
second search by another reviewer. The relevant titles and
abstracts were grouped by subject matter with many papers
being relevant for more than one subject area.
Two reviewers then assessed the studies for inclusion. Studies
from countries where the populations or clinical practices were
very different from the UK were excluded unless they addressed
questions that could be generalised to the UK (such as clinical
assessment). Any differences of opinion were settled by a third
party. The studies were appraised using the Cochrane data
extraction template (see appendix 2 in online supplement).
Any guideline statements made were graded using the same
table as that used by the group developing the adult guidelines
(table 1).1 First, each paper was given an evidence level (Ia to
IVb) by the authors of each chapter. Then, at the end of each
chapter when evidence statements were collated, a summative
evidence level was attached to each statement depending on the
level of evidence underpinning that statement. Finally, each
recommendation was graded (A to D) based upon a considered
judgement of the body of evidence.
Review of the guideline
The guideline is due for review in 3 years from the date of
publication.
Provenance and peer review
The draft guideline was made available online for public
consultation (January/February 2011). The draft guideline was
reviewed by the BTS Standards of Care Committee (July 2010/
March 2011).
2. INCIDENCE AND ECONOMIC CONSEQUENCES
2.1 How common is CAP in children in the community and in
hospital?
Two recent European papers give incidence rates for CAP in
children seen in hospital (table 2) which are lower than those
reported previously from the 1980s in Finland.2[Ib]
A prospective population-based study of 278 Norwegian
children aged <16 years seen in hospital with pneumonia
(temperature, clinical signs and chest x-ray infiltrate in previ-
ously well child) from 2003 to 2005 in Oslo gave population
incidence rates per 10 000 of 14.7 in children aged 0e16 years,
32.8 in those aged 0e5 years and 42.1 in those aged 0e2
years.3[III]
UK data for children seen at hospital with pneumonia (clinical
findings and chest x-ray) in 2001e2 (n¼750) from a prospective
population-based study in 13 hospitals in the north of England
are remarkably similar with overall incidence rates of 14.4 per
10 000 in children aged 0e16 years per annum and 33.8 for those
aged <5 years. Rates of those admitted to hospital were less at
12.2 (11.3e13.2) in children aged 0e16 years and 28.7
(26.2e31.4) in those aged 0e5 years.4[II]
A population-based study performed in Kiel, Germany from
1996 to 2000 of children (n¼514) with severe (ie, hospitalised)
pneumonia (clinical assessment plus chest x-ray in 96.1%)
included children with comorbidities (22.8%) and almost
certainly what in the UK would be called bronchiolitis.5[II] The
overall incidence per 10 000 was 30 in children aged 0e16 years,
65.8 in those aged 0e5 years and 111.3 in those aged 0e1 year.
A series of retrospective population-based cohort studies from
the same Schleswig-Holstein area of Germany conducted in
1999e2001 from parental interviews at school entry permitted
the calculation of population-based incidence of all CAP diag-
nosed by physician as 181.1/10 000 in children aged 0e1 year
and 150.5/10 000 in those aged 0e5 years.6[III]
Further estimates of pneumonia incidence can be obtained
from the PRI.DE (Paediatric Respiratory Infection in Germany)
study.7[II] This prospective cohort study was designed to repre-
sent the German population of children aged <3 years and
included children with lower respiratory tract infection
(including pneumonia, wheeze, bronchitis, bronchiolitis and
croup) presenting to primary or secondary care from 1999 to
2001. A total of 2386 children were seen as outpatients (2870/
10 000 population, 95% CI 2770 to 2970) and 114 were given
a clinical diagnosis of pneumonia (137/10 000). In addition, 2924
inpatients (294/10 000 population, 95% CI 284 to 304) were
included in the study with 1004 given a clinical diagnosis of
pneumonia (101/10 000).
The incidence of all-cause and pneumococcal pneumonia in
children aged <2 years and pneumococcal pneumonia in chil-
dren aged 2e4 years decreased in the USA after pneumococcal
vaccination (PCV) became universal.8[