Pneumonia in children, fast breathing and when to go to hospital

Pneumonia is an infection of the lungs. In children, the key warning signs are cough or difficult breathing with fast breathing or the chest pulling in. Most children with mild pneumonia can be treated at home with antibiotics by mouth. Babies, and children with danger signs, need hospital care. Learning to count your child's breathing is one of the most useful skills a parent can have.

What is pneumonia?

Pneumonia is an infection that fills the tiny air sacs in the lungs with fluid and pus, so less oxygen gets into the blood.¹

It can be caused by bacteria or viruses. The most common bacterial causes in children are pneumococcus and Haemophilus influenzae type b (Hib), and the most common viral cause is respiratory syncytial virus (RSV).¹ Pneumonia is still a major cause of death in young children, and India carries a large share of the world's cases.²

What are the signs of pneumonia in a child?

The main signs are cough or difficulty breathing, together with fast breathing or the lower chest pulling in with each breath.¹

Fever is common but not always present, especially in young babies. Other signs include grunting, flaring of the nostrils, noisy breathing and tiredness. Very sick babies may stop feeding, become very sleepy, feel cold, or have fits.¹ No single sign is perfect. A review found that fast breathing and chest indrawing alone miss some cases and over-call others, so doctors combine several signs.³

How do I count my child's breathing rate?

Count the breaths for one full minute while your child is calm or asleep, by watching the tummy or chest rise.

1. Lift the vest or shirt so you can see the tummy clearly.
2. Use a watch or phone timer.
3. Count each rise of the tummy as one breath, for a full 60 seconds.
4. Do not count during crying, feeding or high fever if you can avoid it, as these raise the rate.
5. If the number is high, count again after a few minutes.

What breathing rate is too fast for a child?

These are the cut-offs used by WHO-based guidelines for fast breathing:

• Under 2 months: 60 breaths a minute or more.⁴
• 2 to 12 months: 50 breaths a minute or more.⁵
• 1 to 5 years: 40 breaths a minute or more.⁵

In a large study of sick babies under 2 months, a breathing rate of 60 or more was one of seven signs that predicted serious illness.⁴ If your child's count is above these numbers, see a doctor the same day.

What is chest indrawing?

Chest indrawing means the lower chest wall sucks inwards when the child breathes in, instead of moving out. It is a sign that the lungs are stiff and the child is working hard to breathe.¹

Look at the lower ribs while your child is calm and the chest is uncovered. A little pulling in between the ribs can happen with a blocked nose. A clear, deep pull at the bottom of the chest with every breath is not normal. In a baby under 2 months, severe chest indrawing is a danger sign.⁴

Is it pneumonia or just a cold or bronchiolitis?

A cold causes a runny nose and cough with normal, comfortable breathing. Pneumonia causes fast or hard breathing and a child who looks more unwell.

Bronchiolitis, a viral chest infection in babies, also causes fast breathing, often with wheeze. Wheeze is more common in viral infections.¹ Many children with wheeze and fast breathing do not need antibiotics. The doctor's examination sorts this out, which is why counting breaths and then seeing a doctor is the right order.

Does pneumonia always need a chest X-ray?

No. Most children with suspected pneumonia who are well enough to go home do not need an X-ray.

In a trial of 522 children aged 2 months to 5 years treated as outpatients, doing a chest X-ray did not speed up recovery. It did lead to more antibiotic use.⁶ Dr Dutta asks for an X-ray when a child is admitted, is very unwell, is not improving on treatment, or when she suspects a complication such as fluid around the lung.

Can my child be treated for pneumonia at home?

Yes, many children with pneumonia can be treated at home with antibiotics by mouth, if they are feeding well and have no danger signs.

WHO advises amoxicillin as the first choice, and most cases can be treated with oral antibiotics.¹ In a large trial in Pakistan, children aged 3 months to 5 years with severe pneumonia (chest indrawing) but no danger signs did as well with high-dose amoxicillin at home as with injections in hospital.⁷ Your doctor should review your child within 2 to 3 days, or sooner if things get worse.

How long should antibiotics be given for pneumonia?

Shorter courses work well for most children with uncomplicated pneumonia.

In the CAP-IT trial of over 800 children in the UK and Ireland, 3 days of amoxicillin worked as well as 7 days in terms of needing more antibiotics. Cough lasted slightly longer with the shorter course.⁸ Always give the dose and number of days your doctor prescribes, and do not stop early unless told to.

When does a child with pneumonia need hospital admission?

A child needs hospital care if there are danger signs, low oxygen, or if the child cannot drink or keep medicines down.

Very sick children may be unable to feed or drink, become unconscious, get cold, or have fits.¹ Vomiting everything, grunting and blue lips are also danger signs. In Dr Dutta's practice, every baby under 2 months with fast breathing is checked in hospital. In hospital, children may get oxygen, fluids and antibiotics by drip, with close watch on their breathing.

What is whooping cough and how is it different?

Whooping cough (pertussis) is a bacterial infection that causes long fits of coughing, sometimes followed by a "whoop" sound on breathing in, or by vomiting.

Between bouts the child may look well. Young babies often do not whoop. Instead they may go red or blue, stop breathing for a few seconds, or have trouble feeding. It hits young babies hardest: in England, cases and hospital admissions were highest in babies under 3 months.⁹ Vaccination against pertussis is one of the main ways to prevent pneumonia.¹ A baby with coughing fits or pauses in breathing needs a doctor the same day.

Which vaccines prevent pneumonia?

Vaccines against pneumococcus, Hib, measles and pertussis are the most effective way to prevent pneumonia in children.¹

A Cochrane review found the pneumococcal conjugate vaccine (PCV) prevented 80 percent of serious infections caused by the vaccine strains, and 27 percent of pneumonia seen on X-ray.¹⁰ In India, Hib is part of the pentavalent vaccine, and the government decided to roll out PCV nationwide in the free programme.¹¹

Why should I get the whooping cough vaccine in pregnancy?

A pertussis-containing vaccine (Tdap) given in pregnancy protects the newborn in the first weeks of life, before the baby's own vaccines start.

When England began vaccinating pregnant women, the vaccine was about 91 percent effective at preventing whooping cough in babies under 3 months.⁹ Ask your obstetrician about it in the later part of pregnancy. Your baby still needs all the DTP doses on time.

Does smoke from cooking or cigarettes cause pneumonia?

Yes. Smoke from cooking with solid fuels such as wood, coal, crop waste or cow dung raises a child's risk of pneumonia. A review of 24 studies found this risk was about 1.8 times higher in exposed children.¹²

Kerosene fumes, cigarette smoke, bidis, mosquito coils and incense also irritate a child's airways. Cook with LPG where possible, keep children out of the kitchen while cooking, open windows, and never smoke indoors. Crowded homes add to the risk.¹

How else can I protect my child from pneumonia?

Breastfeeding, good nutrition and handwashing all lower the risk.

A review found that children who were not breastfed had a higher risk of pneumonia illness and death in the first 2 years.¹³ Exclusive breastfeeding for the first 6 months is advised.¹ Keep up with vaccines and vitamin A doses under the government programme, and wash hands with soap before feeding your baby.

When should I take my child to hospital?

Go to hospital immediately if your child has any of these:

• Breathing rate above the cut-off for age, with the child looking unwell.
• Chest pulling in, grunting, or nostrils flaring with each breath.
• Blue or grey lips or tongue.
• Unable to drink or breastfeed, or vomiting everything.
• Unusual sleepiness, floppiness, or difficult to wake.
• A fit (convulsion).
• Pauses in breathing, or coughing fits with colour change in a baby.
• Any cough with fast breathing in a baby under 2 months.
• No improvement after 2 to 3 days of antibiotics, or getting worse.