About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Most common in under-5s; viral causes predominate in younger children, bacterial in older
- Streptococcus pneumoniae is the most common bacterial cause at all ages
- Amoxicillin is first-line for community-acquired pneumonia in children
- Admit if SpO₂ <92%, severe respiratory distress, unable to feed, or age <3 months
- CXR is NOT routinely required for uncomplicated CAP managed in the community
Overview
Pneumonia is an infection of the lung parenchyma causing consolidation and impaired gas exchange. It is a leading cause of morbidity and mortality in children worldwide. Community-acquired pneumonia (CAP) in children is most commonly viral in those under 2 years and bacterial in school-age children. BTS and NICE guidelines provide the framework for assessment and management in the UK.
Epidemiology
CAP affects approximately 14–33 per 10,000 children per year in the UK. It is most common in winter months and in children under 5 years. The introduction of conjugate pneumococcal and Hib vaccines has significantly reduced incidence of bacterial pneumonia. Boys are slightly more commonly affected than girls.
Clinical Features
Symptoms
Cough — often productive in older children
Fever — often high (>38.5°C) in bacterial pneumonia
Tachypnoea — single most useful clinical sign
Breathlessness and increased work of breathing
Chest or abdominal pain (referred from lower lobe)
Poor feeding or lethargy in infants
Grunting respiration
SpO₂ <92% on air
Cyanosis
Signs
Tachypnoea (>60 in <2 months; >50 in 2–12 months; >40 in 1–5 years; >20 in >5 years)
Subcostal, intercostal, or sternal recession
Bronchial breathing over affected area
Crackles on auscultation
Dullness to percussion over consolidation
Reduced air entry on affected side
Nasal flaring
Head bobbing in infants
Investigations
First-line
Pulse oximetryEssential in all children — SpO₂ <92% indicates need for oxygen and admission
Clinical diagnosisCommunity-managed CAP is diagnosed clinically; no investigations routinely needed
Second-line
CXRIf admission required, diagnostic uncertainty, or suspected complication (effusion, empyema)
Blood culturesIf admitted with moderate-severe pneumonia — before antibiotics
FBC and CRPIf admitted — WCC and CRP elevated in bacterial infection but not specific
Specialist
Nasopharyngeal aspirateFor viral PCR if viral aetiology suspected or for infection control
Pleural fluid analysisIf significant effusion — send for MC&S, pH, protein, LDH, cytology
CT chestIf complicated pneumonia or suspicion of underlying structural abnormality
1
Community management
- Amoxicillin 5-day course (first-line at all ages)
- Alternative if penicillin-allergic: clarithromycin or erythromycin
- If atypical pneumonia suspected (school-age child, gradual onset, dry cough): macrolide (clarithromycin)
- Adequate fluid intake and regular paracetamol/ibuprofen for fever
- Safety-net: return if worsening, not drinking, or persistent fever >48 hours on antibiotics
2
Hospital admission criteria
- SpO₂ <92% on air
- Severe respiratory distress (grunting, marked recession, RR >70)
- Age <3 months with temperature ≥38°C
- Unable to maintain adequate oral fluid intake
- Failure to respond to oral antibiotics within 48 hours
- Suspected or confirmed complications (effusion, empyema, lung abscess)
3
Inpatient management
- Oxygen to maintain SpO₂ ≥92%
- IV amoxicillin (or co-amoxiclav) if unable to tolerate oral
- Add macrolide if no response within 48 hours or atypical infection suspected
- IV fluids if not tolerating oral intake
- Chest drain if significant empyema — discuss with paediatric surgery
4
Follow-up
- Routine follow-up CXR NOT recommended for uncomplicated pneumonia
- CXR at 4–6 weeks if round pneumonia, lobar collapse, or persistent symptoms
- Investigate for underlying cause if recurrent pneumonia (CF, immunodeficiency, inhaled foreign body)
Complications
- Parapneumonic effusion and empyema: Most common complication — consider if persistent fever despite 48 hours of antibiotics
- Lung abscess: Rare — may require prolonged IV antibiotics ± drainage
- Necrotising pneumonia: Rare but serious; often associated with Staphylococcus aureus or PVL-producing strains
- Sepsis: Monitor for systemic features of sepsis, especially in younger children
UKMLA Exam Tips
- 1Tachypnoea is the single most useful clinical sign for pneumonia in children
- 2Amoxicillin is first-line for ALL ages — not co-amoxiclav
- 3Macrolide (clarithromycin) for suspected ATYPICAL pneumonia (Mycoplasma) — think school-age child with gradual onset, dry cough, and bilateral CXR changes
- 4CXR is NOT routinely needed for community-managed pneumonia
- 5Persistent fever >48 hours after starting antibiotics → think complication (effusion/empyema)
- 6Recurrent pneumonia in the same lobe → consider inhaled foreign body or structural abnormality
practicetest your knowledge on pneumonia in childrenApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — paediatrics and beyond.
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