Above, photo provided by Dr. Todd A. Florin. Right middle lobe pneumonia in an adolescent requiring hospitalization.
The question of disposition to home or hospital has been called the “most important management decision” in children with pneumonia in the British Thoracic Society pneumonia guidelines.1 For adults with pneumonia, rigorously derived severity scores assist with these decisions. The two most commonly used are the pneumonia severity index2 and the CURB-65 score.3 These scores, consisting of clinical findings and conventional laboratory tests, generally discriminate for mortality fairly well, though perform less well at predicting pneumonia complications.
For children, the evidence base for risk stratification is still in its infancy, particularly in high resource settings. In 2011, the Pediatric Infectious Diseases Society and Infectious Diseases Society of America published guidelines for the management of children with pneumonia.4 As no validated severity criteria existed for children, the guideline proposed a set of severity criteria for hospitalization adapted from the adult pneumonia guideline. When we examined how well these criteria performed in children, we found that more than half of those discharged safely from the ED met criteria for intensive care/continuous monitoring with only fair ability to predict the need for hospitalization, suggesting that more accurate pediatric risk stratification tools are needed.5