Defining Pneumonia Severity in Children A Delphi Study

Objectives: Although community-acquired pneumonia (CAP) is one of the most common infections in children, no standardized risk classification exists to guide management. The objective of this study was to develop expert consensus for factors associated with various degrees of disease severity in pediatric CAP. Methods: Using a web-based classical Delphi process, a multidisciplinary panel of 10 childhood pneumonia experts rated the degree of severity (mild, moderate, or severe) of clinical, radiographic, and laboratory factors, as well as outcomes relevant to pediatric pneumonia. Round 1 was open-ended, with panelists freely stating all characteristics they felt determined pneumonia severity. In rounds 2 to 4, panelists used a 9-point Likert scale (1–3, mild; 4–6, moderate; 7–9, severe) to rate severity for each item. Consensus was defined as 70% or greater agreement in ranking mild, moderate, or severe. Results: Panelists identified 318 factors or outcomes in round 1; the panel reached consensus for 286 (90%). The majority of items without consensus straddled levels of severity (eg, mild-moderate). Notable clinical factors with consensus included age, oxygen saturation, age-based respiratory rate, and gestational age. Severity classification consensus was also reached for specific imaging and laboratory findings. Need for and duration of hospitalization, supplemental oxygen/respiratory support, and intravenous fluids/ medications were considered important outcomes in classifying severity. Conclusions: This study presents factors deemed important for risk stratification in pediatric CAP by consensus of a multidisciplinary expert panel. This initial step toward identifying and formalizing severity criteria for CAP informs critical knowledge gaps and can be leveraged in future development of clinically meaningful risk stratification scores.