• Community-acquired pneumonia is an acute infection of the lung parenchyma, acquired in the community, that may be caused by bacteria, atypical bacteria, or viral infections.

• A child is considered to be at high risk if any of the following features are present:
• Respiratory rate (RR) > 60/minute, apnoea or grunting, moderate or severe chest indrawing
• Oxygen saturations < 90% on air
• No response to social cues, they are unable to be roused, or if rousable they do not stay awake
• Appears ill to healthcare professional
• Reduced skin turgor
• Age < 3 months and temperature > 38°C, or age 3–6 months and temperature > 39°C
• A child is considered to be at intermediate risk if they have no high risk features and have any of the following features:
• Age < 12 months and RR > 50/minute, or age > 12 months and RR > 40/minute, nasal flaring, crackles (pneumonia or bronchiolitis)
• Oxygen saturation < 95% on air
• Pallor reported by parent/carer
• No response to normal social cues, awakes only with prolonged stimulation, decreased activity
• Poor feeding in infants (less than 50% of normal fluid intake in preceding 24 hours), dry mucous membrane, reduced urine output
• Capillary refill time > 3 seconds
• Fever > 5 days duration
• A child is considered to be at low risk if no features of intermediate or high risk are present.
• Note: risk is higher in young infants, infants with syndromes or who were premature, and in children with any significant medical history, such as chronic lung disease or congenital heart disease. These additional factors should be considered before deciding on the level of risk.
• Assess the ability of the child's carers to cope with the ill child.

In depth

• Children with community-acquired pneumonia and any high risk features — admit immediately.
• Children with community-acquired pneumonia at intermediate risk — consider hospital assessment. The threshold for arranging this should be low. Arrange if the child has any significant health problems such as chronic respiratory disease or congenital heart disease, or the carers are not able to cope.
• Prescribe an antibiotic for children managed at home:
• For children less than 5 years of age — amoxicillin is the first-choice. For a child allergic to penicillin, a macrolide (erythromycin or clarithromycin) is an alternative.
• For a child over 5 years of age — prescribe either amoxicillin or a macrolide. Prescribe a macrolide for children allergic to penicillin and at times when there is a known Mycoplasma outbreak.
• For children who are managed at home advise carers to check on the child regularly, including through the night, and seek medical advice if they are unable to cope or if the child deteriorates, particularly if:
• The breathing rate increases, or if there are any episodes of apnoea or signs of increased effort of breathing.
• A baby takes less than 50% of its normal feeds, or there are signs of dehydration such as dry mouth or infrequent passage of urine.
• The child becomes less responsive or difficult to rouse.
• A persistent increase in fever develops.
• If a child deteriorates on treatment or does not improve after 48 hours of treatment, review and refer for hospital assessment.

In depth

• Treat a child who is feeling miserable due to fever with either paracetamol or ibuprofen. Do not try to reduce fever by under-dressing the child or by tepid sponging.
• If there is a lack of effect with one treatment alone then consider alternate use of ibuprofen and paracetamol every 4 hours.
• Encourage the child to take fluids regularly. Continue breastfeeding as normal.

In depth

• A child is considered to be at low risk if no features of intermediate or high risk are present.
• Note: risk is higher in young infants, infants with syndromes or who were premature, and in children with any significant medical history, such as chronic lung disease or congenital heart disease. These additional factors should be considered before deciding on the level of risk.
• Assess the ability of the child's carers to cope with the ill child.