Children with pneumonia may have a range of clinical presentations, depending on their age and the cause of the pneumonia. Children who have bacterial pneumonia usually become severely ill and show the following symptoms:

Fast or difficult breathing (see Table 35.2)
Cough
Fever and chills
Loss of appetite
Wheezing.

Adults with pneumonia also have fever, cough, and fast or difficult breathing.

Table 35.2 Estimating 'fast breathing' in children in different age groups.

If the child is aged:	The child has fast breathing if you count:
2 months to 12 months old	50 breaths or more per minute
12 months to 5 years old	40 breaths or more per minute

In severe cases of pneumonia, children under five-years-old may struggle to breathe and usually show chest in-drawing, which you can observe as drawing inwards or retracting of the lower chest (red arrows in Figure 35.8) during inhalation (taking air into the lungs).

Chest in-drawing during inspiration

Figure 35.8 Chest in-drawing during inspiration: the lower chest wall moves in sharply as the child breathes in. (Diagram: Dr Radmila Mileusnic)

Pneumonia in children and adults is classified into non-severe and severe pneumonia based on the features of the condition summarised in Box 35.4. This classification is very important because it determines what treatment is given to the patient (as you will see in Section 35.4.4).

A child with fast breathing, chest in-drawing or stridor should be immediately referred to hospital.

Box 35.4 Severe signs of pneumonia in children and adults

Children

Age less than 2 months
Presence of general danger signs (unable to drink or eat, lethargic or unconscious)
Chest in-drawing
Stridor (a harsh noise made during inhalation)
Respiratory rate exceeding the limits in Table 35.2.

Adults

Age 65 years or older
Respiratory rate equal to or greater than 30 breaths per minute
Presence of confusion.

If a child with pneumonia has fast breathing (Table 35.2), but no general danger signs, or chest in-drawing, or stridor, classify him/her as having non-severe pneumonia. Adults with pneumonia who do not have the severe signs given in Box 35.4, are also classified as having non-severe pneumonia.