The two signs that most often separate pneumonia from an ordinary cough in a child under 5 are fast breathing and chest indrawing, where the lower chest sucks in each time your child breathes in. If your child also can’t drink or breastfeed, vomits everything, has a fit, is unusually drowsy or hard to wake, or makes a harsh noise when breathing in while calm, get medical help straight away.
Pneumonia is the single largest infectious cause of death in children worldwide. The World Health Organization (WHO) fact sheet on pneumonia reports that it killed 740,180 children under 5 in 2019, about 14% of all deaths in that age group. WHO says it can be prevented with simple measures and treated with low-cost medicine, and parents spotting the signs early is a big part of that.
How to tell if your child’s cough is pneumonia
Most coughs in small children come from colds and clear up on their own. Pneumonia is an infection deeper in the lungs, usually caused by bacteria such as Streptococcus pneumoniae and Hib, or by viruses such as respiratory syncytial virus (RSV). You can read more about the different types in our overview of pneumonia causes, diagnosis and treatment.
WHO describes a child under 5 who may have pneumonia as one with a cough or difficult breathing, with or without fever, plus either fast breathing or lower chest wall indrawing. Both can be checked at home without equipment.
Other clues that point towards pneumonia rather than a cold:
- The cough comes with breathing that looks like hard work, not only a runny or blocked nose.
- Your baby makes a grunting sound with each breath out. The NHS pneumonia page lists grunting in babies and wheezing in children as signs to watch.
- Your child is feeding or drinking much less than usual.
- The nostrils flare with each breath.
Fever is common but not guaranteed. Very young babies can have a serious chest infection with a normal or even low temperature.
Fast breathing: the breaths-per-minute cut-offs by age
Children breathe faster than adults, so “fast” depends on age. These are the cut-offs health workers use under WHO’s Integrated Management of Childhood Illness (IMCI) chart booklet. A count at or above the number counts as fast breathing.
| Child’s age | Fast breathing is (WHO IMCI) |
|---|---|
| Under 2 months | 60 breaths per minute or more |
| 2 months up to 12 months | 50 breaths per minute or more |
| 12 months up to 5 years | 40 breaths per minute or more |
Guidance differs slightly by country. The UK’s NICE guideline on fever in under 5s uses more than 60 breaths a minute for babies 0-5 months, more than 50 for 6-12 months and more than 40 for children over 12 months. NICE treats a rate above 60 at any age as a high-risk sign. If your count is near or above these figures, have your child checked.
How to count your child’s breathing at home
The WHO chart is clear that the child must be calm when you count. Crying, feeding or a fever spike all push the rate up, so a sleeping or quietly resting child gives the most useful number.
- Wait until your child is calm or asleep. Lift or loosen clothing so you can see the chest and tummy.
- Watch the belly or lower chest rather than listening. One rise plus one fall is one breath.
- Use a phone timer and count for a full 60 seconds. Don’t count for 15 seconds and multiply; babies breathe irregularly and short counts are misleading.
- If the number is at or above the cut-off for their age, wait a few minutes and count again. WHO advises repeating the count in young infants when it’s over 60.
- Write the number and the time down to show the doctor.
What chest indrawing looks like
Chest indrawing means the lower chest wall, just below the ribs, pulls inwards when your child breathes in. In a healthy child the chest and belly move out together on the in-breath. With indrawing, the belly may push out while the bottom of the ribcage sinks in.
Look for it with your child’s top off, in good light, while they’re calm. Indrawing that only appears during crying doesn’t count. Under WHO’s 2014 revised classification, a child aged 2-59 months with chest indrawing has pneumonia that needs antibiotics, so this always means a same-day visit to a doctor or clinic. In babies under 2 months, severe chest indrawing is treated as very severe disease that needs hospital care.
Get emergency help if you see any of these
Call your local emergency number (911 in the US, 999 in the UK, 112 in the EU and India) or go to the nearest emergency department if your child:
- Is struggling to breathe, gasping, or too breathless to cry, feed or talk
- Has pale, blue or blotchy skin, lips or tongue
- Can’t be woken, or feels floppy
- Has a fit (convulsion)
- Can’t drink or breastfeed at all, or vomits everything
- Makes a harsh, high-pitched noise breathing in (stridor) while calm
- Is under 2 months and breathing 60 or more times a minute, grunting, feeding poorly, has a temperature of 38°C (100.4°F) or above, or feels cold with a temperature under 35.5°C (95.9°F)
These come from WHO’s general danger signs and young-infant checklist, along with the NHS list of 999 signs. A child with any general danger sign is classed by WHO as having severe pneumonia or very severe disease and needs urgent referral to hospital.
When to see a doctor the same day
Book an urgent appointment, or go to a clinic today, if your child has a cough or trouble breathing and any of the following:
- A breathing count at or above the cut-off for their age
- Chest indrawing, nostril flaring or wheezing
- A baby under 3 months with a temperature of 38°C (100.4°F) or higher. NICE puts this group at high risk of serious illness.
- A baby aged 3-6 months with a temperature of 39°C (102.2°F) or higher
- Drinking much less than usual, or fewer wet nappies (diapers). Our guide to diarrhoea in children explains how to spot dehydration.
- A cough that’s getting worse after 3-4 days, or a fever that keeps returning
If your child has asthma, a flare-up can look a lot like a chest infection. Our post on pollution and asthma warning signs in children covers wheeze and asthma triggers in more detail.
What the doctor will do
Expect the doctor or nurse to count your child’s breathing, look for indrawing and listen to the chest. Many will also clip a small sensor called a pulse oximeter onto a finger or toe to measure oxygen levels. NICE lists an oxygen saturation of 95% or less on room air as a warning sign in a feverish child, and recommends oxygen when it falls below 92%. NICE also notes that some oximeters can overestimate oxygen levels in people with darker skin, so the reading is used alongside how your child looks.
A chest X-ray isn’t always part of the visit. WHO’s approach was built so health workers can classify pneumonia from simple signs (breathing rate, indrawing and danger signs) in places with little or no access to tests.
For treatment, WHO’s revised classification and treatment of childhood pneumonia (2014) recommends:
- Fast breathing and/or chest indrawing, no danger signs: oral amoxicillin given at home, dosed by your child’s weight, twice a day for five days. WHO allows three days for fast-breathing pneumonia alone in areas with low HIV rates.
- Any general danger sign: referral to hospital for injectable antibiotics (ampicillin or penicillin with gentamicin), plus oxygen and other support as needed.
Local guidelines in the US, UK and India may use different first choices or courses, so follow what your child’s doctor prescribes. Give every dose, even once your child perks up, and go back if they aren’t improving within 2-3 days or get worse at any point.
Vaccines and habits that lower the risk
WHO calls immunisation against Hib, pneumococcus, measles and whooping cough (pertussis) the most effective way to prevent pneumonia in children. The CDC’s pneumonia prevention page also lists flu, RSV, chickenpox (varicella) and COVID-19 vaccines, since those infections can lead to pneumonia too. Our post on chickenpox symptoms and home care covers that infection. Check your child’s record and catch up any missed doses.
In the UK, the NHS offers an RSV vaccine in pregnancy from 28 weeks to help protect babies after birth.
Beyond vaccines, WHO and CDC point to:
- Exclusive breastfeeding for the first 6 months
- Good nutrition, since undernourished children are at higher risk
- No smoking around children, and cutting indoor smoke from cooking or heating with wood, dung or other biomass fuels
- Regular handwashing and keeping sick family members away from babies where possible
Frequently asked questions
Can a child have pneumonia without a fever?
Yes. WHO describes childhood pneumonia as cough or difficult breathing with or without fever. Young babies may instead have a low temperature, poor feeding or unusual sleepiness. Count the breathing and check for indrawing whatever the thermometer says.
Is a breathing rate of 45 normal for my toddler?
For a child aged 12 months to 5 years, WHO counts 40 or more breaths a minute as fast breathing. A calm count of 45 is above that cut-off, so have your child checked the same day, even if they otherwise seem fine.
Can I treat my child’s pneumonia at home?
Many children with pneumonia are treated at home, but only after a health worker has examined them and prescribed antibiotics. Keep up fluids and feeds, keep the air smoke-free, and recheck breathing. Go back straight away if any danger sign appears.
Which viruses cause pneumonia in young children?
RSV is the most common viral cause, according to WHO. Flu, measles and other respiratory viruses, including HMPV (human metapneumovirus) can also lead to pneumonia.
How long does recovery take?
The NHS says most people with pneumonia improve in 2-4 weeks, and a cough or tiredness can linger after the fever settles. It also advises contacting your doctor if there’s no improvement after 2-3 days of antibiotics. Go back sooner if a danger sign appears.
This article is for general information and is not a substitute for advice from a doctor. If you have symptoms or a health condition, please consult a qualified healthcare professional.
