Childhood community-acquired pneumonia (CAP) is common, and recent data have shown that the number of children with severe CAP is increasing worldwide. Regardless of geographical area, severe cases are those at the highest risk of hospitalisation, prolonged hospitalisation and death, and therefore require prompt identification and the most effective treatment in order to reduce CAP-related morbidity and mortality. This review evaluates the available data concerning the diagnosis and treatment of severe and/or complicated cases of paediatric CAP in developed and developing countries. It also underlines the fact that any evidence-based recommendations require more research in various areas, including the aetiology of severe cases and the reasons for the complications, the better definition of first-choice antibiotic treatment and when surgery may be useful, and the role of chest physiotherapy.