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Pediatric Pneumonia Nursing Guide

Content created by: Stephanie Smith, MS, BSN, RN, CPN

Overview: Pneumonia

This content is intended as a Quick Reference for pediatric pneumonia and will cover an overview as well as nursing considerations utilizing the nursing process.

Etiology and Epidemiology

Pneumonia in children is defined as inflammation of the lung tissues (Hockenberry et al., 2021). The alveoli become infected with pathogens, which cause inflammation and formation of pus in the parenchyma (DynaMed, 2020). Pneumonia is primarily classified by its cause, including viral or bacterial etiologies. Other terms associated with pneumonia include aspiration, atypical, community-acquired, and hospital-acquired.

Pneumonia can develop through directly breathing in the pathogen, aspirating the pathogen in oral secretions, or the pathogen traveling through the bloodstream to the lungs. Pneumonia can be either a primary or secondary illness. In infants 3 months of age or younger, the cause of pneumonia may be amniotic fluid aspiration.

Viral pneumonia is more common than bacterial pneumonia in children. Viral pneumonias are associated with viral upper respiratory infections. The primary pathogenic viruses in infants and older children include:

  • Adenovirus
  • Influenza virus
  • Parainfluenza virus
  • Respiratory syncytial virus (RSV)

Bacterial pneumonia is less common in children and may result from a viral upper respiratory infection. Common pathogenic bacteria include S. pneumoniae and S. aureus.

Atypical pneumonia is defined as a pneumonia with different characteristics than typical pneumonia. These characteristics include associated symptoms, chest-xray findings, and response to antibiotics usually prescribed for pneumonia. Pathogenic organisms associated with atypical pneumonia include (CDC, 2019):

  • Chlamydia pneumoniae, which causes mild pneumonia or bronchitis.
  • Chlamydia psittaci, which is due to exposure to infected pet birds or farm poultry.
  • Legionella pneumophila, which causes Legionnaire’s Disease.
  • Mycoplasma pneumoniae, which causes “walking pneumonia.”

The primary pathogenic organisms in infants less than 1 month of age is Group B streptococci and gram-negative bacteria. Children less than 5 years of age who experienced prematurity of less than 28 weeks are at elevated risk of experiencing severe symptoms from community-acquired pneumonia (DynaMed, 2020). Other risk factors include immunosuppression, incomplete series of Hib or pneumococcal vaccines, and low social and economic status.

Some children with underlying medical conditions can develop serious complications. Lung complications can include empyema, effusion, and abscess. In rare cases, the infection may spread to the cardiac, hematological, musculoskeletal, neurological, or renal systems. Around the world, the primary cause of death for children under the age of 5 years is pneumonia with most of these deaths occurring in underdeveloped countries (Kornusky & Lawrence, 2017). In the U.S., most children recover from pneumonia.

Pneumonia Diagnosis

Diagnosing children with pneumonia is challenging. In infants, there is no specific sign which defines diagnosis. In addition, symptoms of pneumonia in children may be very subtle (DynaMed, 2020; Hockenberry et al., 2021).

Although there are no definitive signs which can distinguish the pneumonia’s etiology, there are certain clinical presentations which may be suggestive of a specific etiology.

  • Viral pneumonia may present with fever, congestion, and a cough which gradually worsens.
  • S. pneumoniae may present with sudden low-grade fever, fast breathing, and diminished breath sounds.
  • M. pneumoniae and C. pneumoniae may present with gradual fever, headache, muscle aches, light sensitivity, and nonproductive cough which worsens over time.

Since pneumonia in children can mimic other common conditions, they are important to rule out. These conditions include foreign body aspiration, sepsis, bronchiolitis, and metabolic acidosis.

Children who do not require hospitalization typically do not require further diagnostic testing. If further diagnostic testing is indicated, a chest x-ray and ultrasound are the typical diagnostic imaging modalities.

For children requiring hospitalization, additional testing may include (DynaMed, 2020):

  • Rapid nasal viral antigen testing
  • Blood culture
  • Sputum gram stain and culture
  • Tracheal aspirate
  • Complete blood count
  • C-reactive protein or erythrocyte sedimentation rate
  • Comprehensive metabolic panel


The management of pneumonia is based on the child’s history, physical exam, and diagnostic testing. The severity of the illness will dictate inpatient or outpatient treatment. Most children with nonsevere viral pneumonia do not require hospitalization.

Children with the following indications require hospitalization:

  • Unable to remain adequately hydrated
  • Pulse oximetry reading less than 90% on room air
  • Respiratory distress
  • Poor social situation with questionable home safety

Intensive care is needed for the following:

  • Intubation and invasive ventilation
  • Oxygen saturations less than 92% on 50% or greater oxygen therapy
  • Likely respiratory failure
  • Requiring CPAP or BiPAP
  • Unstable vital signs
  • Altered mental status

The treatment for viral pneumonia is supportive care and includes the following:

  • Oxygen therapy as needed
  • Pulmonary hygiene (e.g. chest PT, postural drainage vibration, cough assist)
  • Adequate hydration
  • Fever management

Bacterial and atypical pneumonia require treatment with oral antibiotics.

  • The first-line treatment is amoxicillin (Amoxil®) 90 mg/kg/day divided into 2 doses for up to a total of 10 days in children younger than 5 years of age plus children 5 years of age and older with presumed bacterial pneumonia.
  • Children 5 years of age and older with presumed atypical pneumonia should be treated with a macrolide antibiotic such as azithromycin (Zithromax®) 10 mg/kg/day on day one then 5 mg/kg/day for the next 4 days
  • Intravenous antibiotics are recommended in hospitalized children but should be transitioned early to oral antibiotics

Children with confirmed influenza are treated with antiviral medications as appropriate. Surgical treatment of pneumonia is indicated in conditions such as pleural effusion and empyema. If the child does not improve within 48 to 72 hours with treatment further evaluation is necessary.

Nursing Considerations

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for pneumonia are listed below.


The typical clinical signs and symptoms associated with all pneumonia types in children include the following respiratory symptoms:

  • Tachypnea
  • Cough
  • Crackles or wheezing
  • Decreased or absent breath sounds
  • Retractions
  • Pallor

Severe cases may present with the following respiratory symptoms:

  • Respiratory rate greater than 70 breaths/min infants
  • Respiratory rate greater than 50 in older children
  • Grunting
  • Cyanosis
  • Nasal flaring
  • Apnea
  • Oxygen saturation less than 92%

Other symptoms which may be present in typical pneumonia cases include:

  • Fever
  • Headache
  • Tachycardia
  • Irritability or agitation
  • Lethargy
  • Vomiting
  • Poor feeding

Severe cases may present with the following additional symptoms:

  • Temperature greater than 101.3°F (38.5°C)
  • Significant elevation in heart rate for age
  • Dehydration
  • Delayed capillary refill
  • Circulatory collapse

Pneumonia Nursing Diagnosis/Risk For

  • Ineffective airway clearance related to obstruction of lower airways, as evidenced by:
    • Inability to remove airway secretions
    • Crackles or wheezing
    • Abnormal respiratory rate, rhythm, depth
    • Retractions
  • Deficient fluid volume related to fever and difficulty feeding, as evidenced by:
    • Vomiting
    • Poor feeding
    • Decreased urine output
    • Weight loss
    • Dry skin and/or mucous membranes
    • Loss of skin turgor
  • Ineffective breathing patterns related to lung inflammation, as evidenced by:
    • Tachypnea
    • Retractions
    • Crackles or wheezing
    • Decreased or absent breath sounds
    • Cough
  • Impaired gas exchange related to inflammation of alveoli, as evidenced by:
    • Pallor
    • Hypoxemia
    • Irritability
    • Cyanosis


  • Utilize pulmonary hygiene, as ordered.
  • Provide supplemental oxygen, as needed, to keep saturations greater than 90%.
  • Administer intravenous fluids and medications, as ordered.
  • Prepare child and caregiver for diagnostic testing.
  • Provide psychosocial support to child and caregiver.
  • Provide post-operative/post-procedure care, if applicable.
  • Monitor the following:
    • Temperature
    • Pulse
    • Respiratory rate
    • Work of breathing
    • Intake and output
    • Pulse oximetry

Expected Outcomes

  • Adequate oxygenation and ventilation
  • Maintain patent airway
  • Improved gas exchange
  • Maintain fluid balance
  • Effective breathing pattern

Individual/Caregiver Education

  • Disease process, treatments, expected course, and outcomes
  • Medication instructions and potential adverse effects
  • Importance of completing full antibiotic course
  • Adequate fluid intake and prevention of dehydration
  • Importance of Hib, PCV13, DTap/Tdap, and influenza vaccines
  • Palivuzmab (Synagis®) prophylaxis for high-risk infants
  • Notify medical provider(s) for vomiting, unable to maintain hydration or nutrition, mental status changes, or respiratory distress


Learn more and earn CEU credit with's Pediatric Nursing CEU Courses:

Pediatric Respiratory Infections: Pneumonia CE Course

This course provides evidence-based practices for care and treatment of bacterial, viral, and atypical pneumonias in children.
1.0 Contact Hours

Community-Acquired Pneumonia CE Course

The goal of this course is to educate nurses, respiratory therapists, and radiology services in all types of healthcare settings on CAP.
1.0 Contact Hours

Pediatric Nursing (CPN/PED-BC) Certification Review CE Course

Prepare for the Pediatric Nursing exam with's CPN/PED-BC certification test prep course.
18.0 Contact Hours

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Content Contributor

The content was created by Relias staff writer Stephanie Smith, MS, BSN, RN, CPN

She has been a clinical nurse for 25 years. Stephanie was educated and trained in New York State as a Licensed Practical Nurse where she practiced pediatric hematology/oncology nursing at the Children’s Hospital of Buffalo. She earned her Associate in Science in Nursing, Bachelor of Science in Nursing, and Master of Science in Nursing with a concentration in Nursing Leadership and Administration from Excelsior College. She is a Certified Pediatric Nurse (CPN), Pediatric Advanced Life Support (PALS) certified, and is a former PALS instructor. Her clinical expertise is in acute pediatric medical surgical nursing and case management for children with medical complexity. She most recently worked at Duke Children’s Hospital as a Nurse Clinician before coming to Relias.

Stephanie M. Smith MS, BSN, RN, CPN has no relevant financial or non-financial relationship(s) with ineligible companies to disclose.

Reference herein to any specific commercial product, process, or service by trade name, trademark, service mark, manufacturer or otherwise does not constitute or imply any endorsement, recommendation, or favoring of, or affiliation with, Relias, LLC.

All characteristics and organizations referenced in the following training are fictional. Any resemblance to any actual organizations or persons living or dead, is purely coincidental.




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