Typical pneumonia  in children is primarily caused by bacterial pathogens, with Streptococcus pneumoniae (pneumococcus) being the most common across various pediatric age groups. This bacterium also commonly causes ear and sinus infections and, more rarely, bacterial meningitis—a serious brain infection. Thankfully, immunization against pneumococcus has drastically reduced its disease burden in children.

Clinically, pneumococcal pneumonia is characterized by the acute on- set of high fever, a deep productive wet cough, malaise, and sometimes respiratory distress. Upon auscultation, we may hear crackles and decreased breath sounds in areas of lung infection. On chest X-rays, typical pneumonia often appears as lobar consolidation, indicative of bacterial infection.

The incidence of pneumococcal pneumonia in children has greatly decreased due to the routine use of the Pneumococcal vaccine, currently known as Prevnar 20. Despite this reduction, pneumococcal pneumonia remains a threat, making prompt symptom recognition and management essential to reduce associated morbidity.

The common bacterial pathogens causing typical pneumonia in children vary by age. In neonates, Group B Streptococcus, Escherichia coli, and Listeria monocytogenes are prevalent. For infants and toddlers, Streptococcus pneumoniae and historically Haemophilus influenzae type b were common, though vaccination has significantly reduced both of these infections, particularly Haemophilus influenzae type b. In school-age children, Streptococcus pneumoniae remains the primary, although greatly reduced, cause of typical pneumonia.

The following are the most common causes of typical pneumonia:

1. Streptococcus pneumoniae: This is the most common bacterial cause of typical pneumonia in children.
2. Haemophilus influenzae type b (Hib): This bacterium was once a dreaded threat to all children causing meningitis, blood infection (sepsis), epiglottis (infection of the airway), otitis media and sinus- itis). It has now been virtually eradicated in the US due to vaccination. However, it has not been completely eradicated and infections like pneumonia with HiB still happen.
3. Moraxella catarrhalis: This bacterium causes ear infections, sinus infections, bronchitis and pneumonia in children. Moraxella catarrhalis infections are often exacerbated by viral infections that compromise the normal defense mechanisms of the respiratory tract.
4. Staphylococcus aureus: This bacterium which commonly causes skin and soft tissue infections like abscesses and impetigo, can also cause pneumonia, often following a viral respiratory infection. Staph pneumonia can be severe with the development of an empyema, which is an accumulation of pus within the pleural space, the area between the lungs and the chest wall. This condition is often a complication of pneumonia or lung infections, resulting from the invasion of Staph or other pathogens. Empyema can cause symptoms such as chest pain, fever, cough, and difficulty breathing. It typically requires medical intervention, which may include antibiotics and the surgical drainage of the pus, to prevent further complications and promote healing.

It’s important to differentiate between typical and atypical pneumonia, as the causes and treatments usually differ. Typical pneumonia is usually treated with amoxicillin unless there is a concern for a Staphylococcus aureus infection, in which case an anti-staph antibiotic like Clindamycin might be chosen.

Atypical pneumonia:  Patients with atypical pneumonia present with milder symptoms compared to typical pneumonia. Symptoms such as a gradual onset of a prolonged cough, low-grade fever, malaise, headache, and scratchy throat commonly occur with atypical pneumonia. Radiological findings may show patchy infiltrates and interstitial patterns rather than lobar consolidation.

Mycoplasma pneumoniae lung infection is often referred to as “walking pneumonia” because those affected can feel relatively well and continue their daily activities, unlike individuals with typical pneumonia who are often bedridden due to severe symptoms. Correctly diagnosing and managing atypical pneumonia is important, as it frequently requires different antibiotics compared to typical pneumonia. Mycoplasma infections typically respond better to macrolide antibiotics, such as azithromycin, whereas the first-line treatment for typical bacterial pneumonia is often amoxicillin.

Rarely, in newborn babies, chlamydial pneumonia can happen. Pregnant women with a sexually transmitted infection called chlamydia trachomatis can transmit the infection during birth. Neonatal chlamydial pneumonia usually becomes evident in newborns between 4 and 12 weeks of age. Initially, infants may present with rhinitis (nasal congestion) and then develop a distinctive staccato cough. Often, tachypnea (rapid breathing) and wheezing are also observed. Unlike many other types of pneumonia, fever is generally absent in these cases.



Early diagnosis and treatment are important to manage symptoms and prevent complications. If neonatal chlamydial pneumonia is suspected, it’s crucial for caregivers to seek medical evaluation for the newborn. Treatment usually involves appropriate antibiotic therapy, often with oral erythromycin.

Other forms of atypical pneumonia are tuberculosis and fungal pneumonia. A discussion of these topics is beyond the scope of this handbook.

Viral pneumonias, though not strictly categorized under typical or atypical bacterial causes, are common, especially in infants and young children. Respiratory Syncytial Virus (RSV) is the most common viral agent in infants that cause pneumonia, followed by influenza, parainfluenza, and adenoviruses. RSV bronchiolitis and pneumonia are the most common reason an infant is admitted to the hospital in the US.

Viral pneumonia is generally managed supportively unless bacterial super-infection is suspected.

Signs and Symptoms of Pneumonia:

Pneumonia is a concern if your child has:

1. High fever: Often, children will have a very high fever (104 degrees) with pneumonia that just doesn’t seem to go away.
2. Wet juicy cough: Children with pneumonia will often cough a lot with a very wet sounding juicy cough. Some cases of pneumonia however may not have a deep wet cough.
3. Trouble breathing: Some children with pneumonia begin to breath 204 faster than usual or start working harder to breathe. You might see them flaring their nostrils or see their chest pulling in with each breath. They may breathe faster than normal, toward 60 breaths in 60 seconds. If this happens seek medical attention right away.
4. Fatigue and Malaise: Some children with pneumonia might feel more tired than usual.
5. Chest pain: Some kids complain of chest or tummy pain or just not feel like eating much.
6. Newborn infants with pneumonia might present with trouble feeding.
7. Pneumonia may cause a bluish color of their skin called cyanosis, that’s a sign they’re not getting enough oxygen. Again, immediate medical help is needed for any child with cyanosis.

It’s important to obtain medical treatment if you notice these symptoms, especially if the fever isn’t going down with Tylenol or they’re having a lot of trouble breathing. If their lips or nails turn blue, if they be- come very sleepy and difficult to wake, don’t have much energy, show signs of dehydration like crying without tears or having fewer wet diapers, or vomit a lot and refuse food—these are signs you should seek medical help right away.