MBBS SAQ · Paediatrics
Pneumonia in children — WHO classification and empirical antibiotics
NEET-PG SAQ on paediatric pneumonia: WHO fast-breathing thresholds, severity tiers, oxygen, ampicillin+gentamicin, step-down amoxicillin, and prevention vaccines.
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Question
A 3-year-old girl has 2 days of fever (39 °C), cough and fast breathing. RR 52/min, SpO2 88% on air, lower chest wall indrawing present. She is alert, irritable, and drinks when offered. No grunting, convulsions, or severe malnutrition. Outline WHO classification, danger signs for very severe disease, immediate management with drug doses, and prevention messages.
Model answer
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WHO classification: severe pneumonia.
Operational definition: cough/difficulty breathing + fast breathing for age and/or lower chest wall indrawing. Fast breathing thresholds: >50/min (2–12 months), >40/min (12 months–5 years), >20/min (>5 years). Here RR 52 at age 3 years exceeds 40, and indrawing upgrades to severe pneumonia requiring hospital care. SpO2 88% is hypoxaemia (oxygen indicated; WHO often uses SpO2 <90% as a key threshold).[1]
Very severe pneumonia — danger signs (any one):
- Inability to drink / breastfeed
- Convulsions
- Vomiting everything
- Lethargy / unconsciousness
- Severe acute malnutrition
- Grunting (especially young infants); central cyanosis / head nodding also flag critical illness
This child currently lacks danger signs but is still severe (indrawing + hypoxia).
Immediate management:
- Hospitalise; ABC; continuous SpO2 monitoring.
- Oxygen (nasal prongs/face mask) to target SpO2 ≥90% (commonly 94–98% in high-resource settings).
- Parenteral antibiotics (WHO hospital care): ampicillin 50 mg/kg IV every 6 h + gentamicin 7.5 mg/kg IV/IM once daily (or ceftriaxone if local protocol/poor response). Consider macrolide if atypical features; add antistaphylococcal cover if pneumatoceles/empyema/post-viral severe disease.[1]
- Fluids carefully (avoid overload); antipyretic paracetamol 15 mg/kg PO/PR; nutrition/breastfeeding support.
- Investigations as available: CXR if hospitalised/complicated; blood culture; NPA viral PCR (RSV common under 1 year); HIV test if severe/recurrent/high prevalence.
- Reassess 48 h; if improving, step down to high-dose oral amoxicillin 80–90 mg/kg/day in 2 divided doses to complete 5–7 days total.[2]
- Complications: look for effusion/empyema (drain ± fibrinolysis), abscess, pneumothorax.
Prevention (exam bonus): PCV10/13, Hib conjugate, measles, influenza; exclusive breastfeeding 6 months; reduce indoor air pollution; hand hygiene; zinc/vitamin A per national guidance; timely care-seeking for fast breathing.
Common errors
- Treating indrawing as home oral therapy without oxygen assessment.
- Missing age-specific fast-breathing cut-offs.
- Using adult CURB-65 instead of WHO paediatric severity.
- No oxygen despite SpO2 88%.
- Forgetting vaccines in the prevention stem.
Examiner notes
- Reproduce WHO thresholds and three severity tiers verbatim.
- Give ampicillin + gentamicin doses and amoxicillin 80–90 mg/kg/day.
- Name leading pathogens: RSV (infants), S. pneumoniae (bacterial).
References2ShowHide
- [1]World Health Organization. Pocket Book of Hospital Care for Children, 2nd edition. WHO, 2013.PMID 24006557
- [2]Hazir T, et al. Ambulatory short-course high-dose oral amoxicillin for severe pneumonia. Lancet, 2008.PMID 18177775