Clinical signs and risk factors associated with pneumonia in children admitted to Goroka Hospital, Papua New Guinea

Clinical predictors of hypoxic pneumonia in children from the Eastern Highlands Province, Papua New Guinea: secondary analysis of two prospective observational studies

Background

Pneumonia is the leading cause of death in young children globally and is prevalent in the Papua New Guinea highlands. We investigated clinical predictors of hypoxic pneumonia to inform local treatment guidelines in this resource-limited setting.

Methods

Between 2013 and 2020, two consecutive prospective observational studies were undertaken enrolling children 0-4 years presenting with pneumonia to health-care facilities in Goroka Town, Eastern Highlands Province. Logistic regression models were developed to identify clinical predictors of hypoxic pneumonia (oxygen saturation <90% on presentation). Model performance was compared against established criteria to identify severe pneumonia.

Findings

There were 2067 cases of pneumonia; hypoxaemia was detected in 36.1%. The strongest independent predictors of hypoxic pneumonia were central cyanosis on examination (adjusted odds ratio [aOR] 5.14; 95% CI 3.47-7.60), reduced breath sounds (aOR 2.92; 95% CI 2.30-3.71), and nasal flaring or grunting (aOR 2.34; 95% CI 1.62-3.38). While the model developed to predict hypoxic pneumonia outperformed established pneumonia severity criteria, it was not sensitive enough to be clinically useful at this time.

Interpretation

Given signs and symptoms are unable to accurately detect hypoxia, all health care facilities should be equipped with pulse oximeters. However, for the health care worker without access to pulse oximetry, consideration of central cyanosis, reduced breath sounds, nasal flaring or grunting, age-specific tachycardia, wheezing, parent-reported drowsiness, or bronchial breathing as suggestive of hypoxaemic pneumonia, and thus severe disease, may prove useful in guiding management, hospital referral and use of oxygen therapy.

Funding

Funded by Pfizer Global and the Bill & Melinda Gates Foundation.

Aetiology and risks factors associated with the fatal outcomes of childhood pneumonia among hospitalised children in the Philippines from 2008 to 2016: a case series study

OBJECTIVE

Pneumonia remains the leading cause of hospitalisations and deaths among children aged <5 years. Diverse respiratory pathogens cause acute respiratory infections, including pneumonia. Here, we analysed viral and bacterial pathogens and risk factors associated with death of hospitalised children.

DESIGN

A 9-year case series study.

SETTING

Two secondary-care hospitals, one tertiary-care hospital and one research centre in the Philippines.

PARTICIPANTS

5054 children aged <5 years hospitalised with severe pneumonia.

METHODS

Nasopharyngeal swabs for virus identification, and venous blood samples for bacterial culture were collected. Demographic, clinical data and laboratory findings were collected at admission time. Logistic regression analyses were performed to identify the factors associated with death.

RESULTS

Of the enrolled patients, 57% (2876/5054) were males. The case fatality rate was 4.7% (238/5054), showing a decreasing trend during the study period (p<0.001). 55.0% of the patients who died were either moderately or severely underweight. Viruses were detected in 61.0% of the patients, with respiratory syncytial virus (27.0%) and rhinovirus (23.0%) being the most commonly detected viruses. In children aged 2-59 months, the risk factors significantly associated with death included age of 2-5 months, sensorial changes, severe malnutrition, grunting, central cyanosis, decreased breath sounds, tachypnoea, fever (≥38.5°C), saturation of peripheral oxygen <90%, infiltration, consolidation and pleural effusion on chest radiograph.Among the pathogens, adenovirus type 7, seasonal influenza A (H1N1) and positive blood culture for bacteria were significantly associated with death. Similar patterns were observed between the death cases and the aforementioned factors in children aged <2 months.

CONCLUSION

Malnutrition was the most common factor associated with death and addressing this issue may decrease the case fatality rate. In addition, chest radiographic examination and oxygen saturation measurement should be promoted in all hospitalised patients with pneumonia as well as bacteria detection to identify patients who are at risk of death.

Pneumonia mortality and healthcare utilization in young children in rural Bangladesh: a prospective verbal autopsy study

Background

The present study aimed to examine the risk factors for death due to pneumonia in young children and healthcare behaviors of the guardians for children in rural Bangladesh. A prospective autopsy study was conducted among guardians of children aged 4 weeks to 59 months in Mirzapur, Bangladesh, from 2008 to 2012.

Results

Pneumonia was the primary cause of death, accounting for 26.4% (n = 81) of all 307 deaths. Of the pneumonia deaths, 58% (n = 47) deaths occurred in younger infants (aged 4 weeks to < 6 months) and 24.7% (n = 20) in older infants (aged 6–11 months). The median duration of illness before pneumonia death was 8 days (interquartile range [IQR] 3–20 days). Prior to death, 91.4% (n = 74) children with pneumonia sought treatment, and of those who sought treatment, 52.7% (n = 39) sought treatment ≥ 2 days after the onset of disease. Younger infants of 4 weeks to < 6 months old were at 5.5-time (95% confidence interval [CI] 2.5, 12.0) and older infants aged 6–11 months were at 3-time (1.2, 7.5) greater risk of dying from pneumonia than older children aged 12–59 months. Children with a prolonged duration of illness (2–10 days) prior to death were at more risk for death by pneumonia than those who died from other causes (5.8 [2.1, 16.1]). Children who died from pneumonia sought treatment 3.4-time more than children who died from other causes. Delayed treatment seeking (≥ 2 days) behavior was 4.9-time more common in children who died from pneumonia than those who died from other causes. Children who died from pneumonia more often had access to care from multiple sources (5.7-time) than children who died from other causes.

Conclusions

Delay in seeking appropriate care and access to multiple sources for treatment are the underlying risk factors for pneumonia death in young children in Bangladesh. These results indicate the perplexity in guardians’ decisions to secure appropriate treatment for children with pneumonia. Therefore, it further underscores the importance of focusing on mass media coverage that can outline the benefits of seeking care early in the progression of pneumonia and the potential negative consequences of seeking care late.

Electronic supplementary material

The online version of this article (10.1186/s41182-018-0099-4) contains supplementary material, which is available to authorized users.

Prevalence and correlates of treatment failure among Kenyan children hospitalised with severe community-acquired pneumonia: a prospective study of the clinical effectiveness of WHO pneumonia case management guidelines

Objective

To determine the extent and pattern of treatment failure (TF) among children hospitalised with community-acquired pneumonia at a large tertiary hospital in Kenya.

Methods

We followed up children aged 2–59 months with WHO-defined severe pneumonia (SP) and very severe pneumonia (VSP) for up to 5 days for TF using two definitions: (i) documentation of pre-defined clinical signs resulting in change of treatment (ii) primary clinician's decision to change treatment with or without documentation of the same pre-defined clinical signs.

Results

We enrolled 385 children. The risk of TF varied between 1.8% (95% CI 0.4–5.1) and 12.4% (95% CI 7.9–18.4) for SP and 21.4% (95% CI 15.9–27) and 39.3% (95% CI 32.5–46.4) for VSP depending on the definition applied. Higher rates were associated with early changes in therapy by clinician in the absence of an obvious clinical rationale. Non-adherence to treatment guidelines was observed for 70/169 (41.4%) and 67/201 (33.3%) of children with SP and VSP, respectively. Among children with SP, adherence to treatment guidelines was associated with the presence of wheeze on initial assessment (P = 0.02), while clinician non-adherence to guideline-recommended treatments for VSP tended to occur in children with altered consciousness (P < 0.001). Using propensity score matching to account for imbalance in the distribution of baseline clinical characteristics among children with VSP revealed no difference in TF between those treated with the guideline-recommended regimen vs. more costly broad-spectrum alternatives [risk difference 0.37 (95% CI −0.84 to 0.51)].

Conclusion

Before revising current pneumonia case management guidelines, standardised definitions of TF and appropriate studies of treatment effectiveness of alternative regimens are required.

Objectif

Déterminer l'ampleur et les caractéristiques de l’échec du traitement (ET) chez les enfants hospitalisés avec une pneumonie acquise dans la communauté dans un grand hôpital tertiaire du Kenya.

Méthodes

Nous avons suivi des enfants âgés de 2 à 59 mois avec une pneumonie sévère (PS) et une pneumonie très sévère (PTS) telles que définies par l’OMS, sur un maximum de cinq jours pour l’ET, en utilisant deux définitions: (a) documentation des signes cliniques prédéfinis ayant entraîné un changement du traitement, (b) décision primaire du clinicien de changer de traitement avec ou sans documentation des mêmes signes cliniques prédéfinis.

Résultats

Nous avons recruté 385 enfants. Le risque d’ET variait de 1,8% (IC95%: 0,4 à 5,1) à 12,4% (IC95%: 7,9 à 18,4) pour la PS et de 21,4% (IC95%: 15,9 à 27) à 39,3% (IC95%: 32,5 à 46,4) pour la PTS selon la définition appliquée. Des taux plus élevés étaient associés à des changements précoces du traitement par le clinicien en l'absence d'une justification clinique évidente. Le non-respect des directives de traitement a été observé pour 70/169 (41,4%) et 67/201 (33,3%) enfants avec une PS et une PTS respectivement. Chez les enfants avec une PS, le respect des directives de traitement était associé avec la présence d'une respiration sifflante au cours l’évaluation initiale (P = 0,02) tandis que le non respect par les cliniciens des traitements recommandés pour la PTS tendait à se produire chez les enfants avec une altération de la conscience (P <0,001). L'utilisation du score de propension correspondant pour tenir compte du déséquilibre dans la répartition des caractéristiques cliniques de base chez les enfants avec une PTS n'a révélé aucune différence dans l’ET entre ceux traités avec le régime recommandé par les directives et ceux traités par des alternatives plus coûteuses à large spectre (différence de risque: 0,37 (IC95%: -0,84 à 0,51).

Conclusion

Avant la révision des directives actuelles de prise en charge des cas de pneumonie, des définitions standard d’ET et des études appropriées de l'efficacité des traitements alternatifs sont nécessaires.

Objetivo

Determinar la extensión y el patrón del fallo en el tratamiento (FT) en niños hospitalizados con una neumonía adquirida en la comunidad, ingresados en un gran hospital terciario de Kenia.

Métodos

Hemos seguido a niños con edades entre los 2-59 meses con una neumonía severa (NS) y neumonía muy severa (NMS) según definición de la OMS de hasta cinco días para FT utilizando dos definiciones: (a) documentación de signos clínicos pre-definidos que resultaron en un cambio de tratamiento (b) decisión del clínico principal de cambiar el tratamiento con o sin documentación de los mismos signos clínicos pre-definidos.

Resultados

Incluimos a 385 niños. El riesgo de FT varió entre un 1.8% (IC 95% 0.4 a 5.1) y 12.4% (IC 95% 7.9 a 18.4) para NS y 21.4% (IC 95% 15.9 a 27) y 39.3% (IC 95% 32.5 a 46.4) para NMS dependiendo de la definición que se aplicase. Unas mayores tasas estaban asociadas con cambios tempranos en la terapia por el clínico y en ausencia de un razonamiento clínico obvio. Se observaba una no adherencia a las guías de tratamiento en 70/169 (41.4%) y 67/201 (33.3%) de los niños con NS y NMS respectivamente. Entre los niños con SP, la adherencia a las guías de tratamiento estaba asociada con la presencia de sibilancias en la evaluación inicial (P=0.02) mientras que la no adherencia del clínico a los tratamientos recomendados por las guías para NMS tendían a ocurrir en niños con un estado alterado de consciencia (P<0.001). Utilizando el pareamiento por puntaje de propensión para equilibrar los grupos en la distribución de las características clínicas de base de los niños con NMS, se observó que no existían diferencias en FT entre aquellos tratados con el régimen recomendado por las guías versus alternativas más costosas de amplio espectro (diferencias de riesgo 0.37 (IC 95% -0.84 a 0.51).

Conclusión

Antes de revisar las actuales guías de manejo de casos de neumonía, se requieren definiciones estandarizadas de FT y estudios apropiados de la efectividad del tratamiento de regímenes alternativos.

Morbidity and outcome of severe respiratory syncytial virus infection

BACKGROUND

Respiratory syncytial virus (RSV) is the main cause of severe acute respiratory infection (SARI) in infants and young children. This study aimed to identify risk factors for intensive care unit (ICU) admission, prolonged length of stay (PLOS), and mortality in patients hospitalized with SARI caused by RSV.

METHODS

This prospective cohort study included children hospitalized with SARI (according to the World Health Organization definition) and whose laboratory results proved RSV infection during the period from February 2010 to May 2011.

RESULTS

Out of 240 enrolled patients, 24 patients (10%) were admitted to the ICU, 57 patients (24.3%) had a PLOS of >9 days and 12 patients (5%) died. The presence of cyanosis (P = 0.000; OR, 351.7) and lung consolidation (P = 0.006, OR, 9.3) were independent risk factors associated with ICU admission. The need for ICU admission (P = 0.000; OR, 6.1) and lung consolidation (P = 0.008, OR, 2.46) were independent risk factors associated with PLOS. The presence of an underlying congenital heart disease (P = 0.03, OR, 18.3), thrombocytopenia (P = 0.04, OR, 32.86) and mechanical ventilation (P = 0.000; OR, 449.4) were the only independent risk factors associated with mortality in our study.

CONCLUSIONS

Early recognition of risk factors for complicated RSV disease on admission prompts early interventions and early ICU admissions for these children.

The presence of clinical signs in malnourished infants with acute lower respiratory tract infections

OBJECTIVES

To determine the reliability of respiratory rate and subcostal retractions in diagnosing acute lower respiratory tract infection in malnourished children.

METHODS

One hundred forty-three children with acute lower respiratory tract infection were classified according to the Gomez classification as normal, mildly, moderately or severely malnourished. The presence of tachypnea, subcostal retractions and the sensitivity of either sign in identifying children with a clinical and radiological diagnosis of acute lower respiratory tract infection in each of the nutritional categories were evaluated and compared.

RESULTS

According to the Gomez classification, 21 (15%) of 143 subjects were severely malnourished, 40 (28%) were moderately malnourished, 38 (26%) were mildly malnourished and 44 (31%) were well nourished. The mean respiratory rates in subjects with normal nutrition and in mildly, moderately and severely malnourished subjects were 62.6+/-9.38 breaths/min, 61.3+/-5.57 breaths/min, 57.6+/-11.65 breaths/min and 49.9+/-9.04 breaths/min, respectively. The mean respiratory rate of those with normal nutrition was not significantly different from that of those with mild malnutrition (P>0.05), but there was a statistically significant difference between the normal subjects and both the moderately malnourished (P=0.03) and severely malnourished (P<0.001) subjects. Subcostal retraction was observed in 78% of total children, which represents 41 (93%) subjects with normal nutrition, 34 (89%) mildly malnourished subjects, 30 (75%) moderately malnourished subjects and 10 (47%) severely malnourished subjects. There was no statistically significant difference between the frequencies of subcostal retractions observed in children with normal nutrition and mildly malnourished children (P>0.05), but subcostal retraction frequencies were significantly lower both in moderately (P=0.03) and severely (P<0.001) malnourished children. Tachypnea frequency was also found to be significantly lower in moderately (P=0.04) and severely (P=0.03) malnourished children compared with the normal group. As a consequence, the sensitivity of the presence of both of these signs was found to be lower in these two groups. The coexistence rates of both findings were 95% for the patients with normal nutrition and 47% for the severely malnourished patients.

CONCLUSIONS

The current World Health Organization algorithm must be supported with other signs for the diagnosis of acute lower respiratory tract infection, especially in severely mal-nourished children.

Characteristics of radiographically diagnosed pneumonia in under-5 children in Salvador, Brazil

OBJECTIVE

To assess the association of demographic and clinical aspects with radiographically diagnosed pneumonia.

DESIGN

By active surveillance, the admitted pneumonia cases by the pediatrician on duty were identified in a 2 year period. Demographic, clinical and radiographic data were registered into standardized forms.

SETTING

A public university pediatric hospital in Salvador, Northeast Brazil.

PATIENTS

Children <5 years-old.

MAIN OUTCOME MEASURES

Radiographically diagnosed pneumonia based on detection of pulmonary infiltrate/ consolidation.

RESULTS

301 cases had the chest X-ray evaluated by a pediatric radiologist blinded to clinical information, among whom pulmonary infiltrate and consolidation were described in 161 (54%) and 119 (40%), respectively. Chest X-ray was read normal for 140 cases. Overall, the median age was 17 months (mean 20±14, range 12 days-59 months). Pulmonary infiltrate was less frequently described among patients aged under 1 year (41.3% vs 59.9%, P=0.002, OR [95% CI] = 0.47 [0.29-0.76]) and hyperinflation was significantly more frequent in this age group (27.9% vs 4.1%, P<0.001, OR [95% CI] = 9.14 [4.0-20.9]). By multiple logistic regression, fever on admission was independently associated with pulmonary infiltrate (OR [95% CI] = 1.68 [1.03-2.73]) or consolidation (1.79 [1.10-2.92]), wheezing was independently associated with absence of pulmonary infiltrate (0.53 [0.33-0.86]) or of consolidation (0.53 [0.33-0.87]). The positive likelihood ratio of fever on examination for pulmonary infiltrate and consolidation was 1.49 (95% CI:1.11-1.98) and 1.49 (95% CI: 1.14-1.94), respectively.

CONCLUSION

Presence of fever enhanced 2.5 times the chance of children hospitalized with lower respiratory tract disease to have radiographically diagnosed pneumonia.

Chloramphenicol versus ampicillin plus gentamicin for community acquired very severe pneumonia among children aged 2-59 months in low resource settings: multicentre randomised controlled trial (SPEAR study)

OBJECTIVE

To evaluate whether five days' treatment with injectable ampicillin plus gentamicin compared with chloramphenicol reduces treatment failure in children aged 2-59 months with community acquired very severe pneumonia in low resource settings.

DESIGN

Open label randomised controlled trial.

SETTING

Inpatient wards within tertiary care hospitals in Bangladesh, Ecuador, India, Mexico, Pakistan, Yemen, and Zambia.

PARTICIPANTS

Children aged 2-59 months with WHO defined very severe pneumonia.

INTERVENTION

Chloramphenicol versus a combination of ampicillin plus gentamicin.

MAIN OUTCOME MEASURES

Primary outcome measure was treatment failure at five days. Secondary outcomes were treatment failure defined similarly among all participants evaluated at 48 hours and at 10 and 21 days.

RESULTS

More children failed treatment with chloramphenicol at day 5 (16% v 11%; relative risk 1.43, 95% confidence interval 1.03 to 1.97) and also by days 10 and 21. Overall, 112 bacterial isolates were obtained from blood and lung aspirates in 110 children (11.5%), with the most common organisms being Staphylococcus aureus (n=47) and Streptococcus pneumoniae (n=22). In subgroup analysis, bacteraemia with any organism increased the risk of treatment failure at 21 days in the chloramphenicol group (2.09, 1.41 to 3.10) but not in the ampicillin plus gentamicin group (1.12, 0.59 to 2.13). Similarly, isolation of S pneumoniae increased the risk of treatment failure at day 21 (4.06, 2.73 to 6.03) and death (5.80, 2.62 to 12.85) in the chloramphenicol group but not in the ampicillin plus gentamicin group. No difference was found in treatment failure for children with S aureus bacteraemia in the two groups, but the power to detect a difference in this subgroup analysis was low. Independent predictors of treatment failure by multivariate analysis were hypoxaemia (oxygen saturation <90%), receiving chloramphenicol, being female, and poor immunisation status.

CONCLUSION

Injectable ampicillin plus gentamicin is superior to injectable chloramphenicol for the treatment of community acquired very severe pneumonia in children aged 2-59 months in low resource settings.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN39543942.

Case management of childhood pneumonia in developing countries

BACKGROUND

Pneumonia is a leading cause of morbidity and mortality in children worldwide. Appropriate management depends on accurate assessment of disease severity, and for the majority of children in developing countries the assessment is based on clinical signs alone. This article reviews recent evidence on clinical assessment and severity classification of pneumonia and reported results on the effectiveness of currently recommended treatments.

METHODS

Potential studies for inclusion were identified by Medline (1990-2006) search. The Oxford Center for Evidence Based Medicine criteria were used to describe the methodologic quality of selected studies.

RESULTS

In the included studies the sensitivity of current definitions of tachypnea for diagnosing radiologic pneumonia ranged from 72% to 94% with specificities between 38% and 99%; chest indrawing had reported sensitivities of between 46% and 78%. Data provide some support for the value of current clinical criteria for classifying pneumonia severity, with those meeting severe or very severe criteria being at considerably increased risk of death, hypoxemia or bacteremia. Results of randomized controlled trials report clinically defined improvement at 48 hours in at least 80% of children treated using recommended antibiotics. However, a limitation of these data may include inappropriate definitions of treatment failure.

CONCLUSION

Particularly with regard to severe pneumonia, issues that specifically need to be addressed are the adequacy of penicillin monotherapy, or oral amoxicillin or alternative antibiotics; the timing of introduction of high-dose trimethoprim-sulfamethoxazole in children at risk for or known to be infected by HIV and the value of pulse oximetry.

Acute lower respiratory infections among children hospitalized in Bangui, Central African Republic: toward a new case-management algorithm

To measure the performance of the current WHO algorithm in identifying children at higher risk of death, children aged 2-59 months who presented with cough and/or difficult breathing and were admitted into the paediatric hospital of Bangui (Central African Republic) during a 1-year period (1996/97) were investigated. Among children with subcostal indrawing, mortality and severity of oxygen desaturation were identical whether or not they also had tachypnoea. Among children with a 'severe pneumonia', those who also fulfilled the 'very severe disease' definition had a higher risk of death (31/132, 23.5%) than those who did not (12/106, 11.3%, P = 0.02). However, this 'very severe disease' definition did not predict death when used in children who did not have severe pneumonia. To identify variables that would better predict death, combinations of symptoms and signs were examined among the subgroup of children with indrawing. Nine combinations had both a sensitivity and specificity over 60%. 'Grunting and/or nasal flaring' had a sensitivity of 72% and a specificity of 66% in predicting death, and might be easier to use by primary health care personnel than other combinations. A new algorithm is proposed for the management of children aged 2-59 months presenting with cough and/or difficult breathing. The definition of pneumonia would be unchanged (tachypnoea). Severe pneumonia would remain defined on indrawing regardless of respiratory rate, except that indrawing should be lower chest wall and/or intercostal. In health facilities where intravenous antibiotics, chloramphenicol and/or oxygen are available, entry into a 'very severe pneumonia' category would be based on 'grunting and/or nasal flaring' among children with indrawing. In our study population, the mortality rates in the categories based on these definitions were 0.8% (1/127) in children with no pneumonia, 0.9% (1/116) in children with pneumonia, 7.7% (12/156) in children with severe pneumonia and 31.1% (33/106) in children with very severe pneumonia.

Risk factors for mortality among children hospitalized because of acute respiratory infections in Bangui, Central African Republic

BACKGROUND

Acute respiratory infections are the most common cause of death in children in developing countries. Little information is available on risk factors for mortality among African children presenting with symptoms compatible with acute respiratory infections.

OBJECTIVE

To identify risk factors for death among children hospitalized for respiratory complaints who satisfy the WHO clinical definition for pneumonia or severe pneumonia.

METHODS

Children <5 years of age who presented with cough and/or difficult breathing and were hospitalized in Bangui during a 1-year period were investigated for risk factors for mortality. The study population consisted of 395 children who satisfied the WHO clinical definition for pneumonia/severe pneumonia. The associations between death and demographic, nutritional, socioeconomic, laboratory and clinical variables were examined.

RESULTS

Of the 49 (12.4%) children who died, all but one had had indrawing of the chest which, in univariate analysis, was the risk factor most strongly associated with death [odds ratio, 22.99; 95% confidence interval (CI), 3.81 to 935.2]. In a multivariate model the independent risk factors for death were indrawing of the chest [adjusted odds ratio (AOR) 8.35, CI 1.04 to 66.82], hepatomegaly (AOR 6.72, CI 2.35 to 19.21), age between 2 and 11 months (AOR 6.37, CI 2.18 to 18.59), grunting (AOR 4.53, CI 1.96 to 10.45), a moderate/severe alteration of general status (AOR 3.23, CI 1.17 to 8.94) and acute malnutrition (AOR 2.74, CI 0.96 to 7.78).

CONCLUSIONS

These findings could be used in flow charts for the management of children with respiratory complaints to identify children at increased risk of death who need to receive aggressive therapy.

Potential interventions for the prevention of childhood pneumonia in developing countries: improving nutrition

Acute respiratory infections are the leading cause of childhood death in developing countries. Current efforts at mortality control focus on case management and immunization, but other preventive strategies may have a broader and more sustainable effect. This review, commissioned by the World Health Organization, examines the relations between pneumonia and nutritional factors and estimates the potential effect of nutritional interventions. Low birth weight, malnutrition (as assessed through anthropometry), and lack of breast-feeding appear to be important risk factors for childhood pneumonia, and nutritional interventions may have a sizeable effect in reducing deaths from pneumonia. For all regions except Latin America, interventions to prevent malnutrition and low birth weight look more promising than does breast-feeding promotion. In Latin America, breast-feeding promotion would have an effect similar to that of improving birth weights, whereas interventions to prevent malnutrition are likely to have less of an effect. These findings emphasize the need for tailoring interventions to specific national and even local conditions.

Clinical predictors of hypoxaemia in Gambian children with acute lower respiratory tract infection: prospective cohort study

OBJECTIVES

To determine clinical correlates and outcome of hypoxaemia in children admitted to hospital with an acute lower respiratory tract infection.

DESIGN

Prospective cohort study.

SETTING

Paediatric wards of the Royal Victoria Hospital and the hospital of the Medical Research Council's hospital in Banjul, the Gambia.

SUBJECTS

1072 of 42 848 children, aged 2 to 33 months, who were enrolled in a randomised trial of a Haemophilus influenzae type b vaccine in the western region of the Gambia, and who were admitted with an acute lower respiratory tract infection to two of three hospitals.

MAIN OUTCOME MEASURES

Prevalence of hypoxaemia, defined as an arterial oxygen saturation <90% recorded by pulse oximetry, and the relation between hypoxaemia and aetiological agents.

RESULTS

1072 children aged 2-33 months were enrolled. Sixty three (5.9%) had an arterial oxygen saturation <90%. A logistic regression model showed that cyanosis, a rapid respiratory rate, grunting, head nodding, an absence of a history of fever, and no spontaneous movement during examination were the best independent predictors of hypoxaemia. The presence of an inability to cry, head nodding, or a respiratory rate >/= 90 breaths/min formed the best predictors of hypoxaemia (sensitivity 70%, specificity 79%). Hypoxaemic children were five times more likely to die than non-hypoxaemic children. The presence of malaria parasitaemia had no effect on the prevalence of hypoxaemia or on its association with respiratory rate.

CONCLUSION

In children with an acute lower respiratory tract infection, simple physical signs that require minimal expertise to recognise can be used to determine oxygen therapy and to aid in screening for referral. The association between hypoxaemia and death highlights the need for early recognition of the condition and the potential benefit of treatment.

Cardiac failure in children with pneumonia in Papua New Guinea

BACKGROUND

Cardiac failure is suspected of contributing to mortality from pneumonia in children in developing countries, but its role has not been clearly defined.

METHODS

A convenience sample of 47 children admitted to Goroka Hospital in Papua New Guinea was studied prospectively with ultrasound, chest radiographs and assays of creatine kinase and lactate dehydrogenase. Results. Seven (15%) of the 47 children died. Of the 43 children who had a chest radiograph, 31 (72%) had severe or very severe pneumonia. No child had poor contractility of the heart on ultrasound examination or unequivocally raised cardiac isoenzymes; therefore no evidence of myocardial injury from sepsis was found. However, ultrasound examination showed dilatation of the right ventricle or hepatic veins in 12 (26%) of the children (both were dilated in 7 children) and 4 (33%) of these children died; this suggests that right ventricular cardiac failure secondary to pulmonary hypertension was present in 26% (95% confidence interval, 14 to 40%) of these children with severe pneumonia. Tachycardia was not associated with right ventricular dilatation on ultrasound, but 3 of the 4 children with more than 3 cm of liver palpable in the abdomen had right ventricular dilatation. Only 4 of the 12 children with right heart failure had hepatomegaly, tachycardia, raised jugular venous pressure or peripheral edema.

CONCLUSIONS

Right ventricular failure is common in children with severe pneumonia, and it is probably caused by pulmonary hypertension rather than septic toxemia. The clinical signs of heart failure are unreliable. There is no evidence that digoxin is effective treatment for right ventricular failure secondary to pulmonary hypertension.

Zinc supplementation reduces the incidence of acute lower respiratory infections in infants and preschool children: a double-blind, controlled trial

BACKGROUND

Increased acute lower respiratory infection incidence, severity, and mortality are associated with malnutrition, and reduced immunological competence may be a mechanism for this association. Because zinc deficiency results in impaired immunocompetence and zinc supplementation improves immune status, we hypothesized that zinc deficiency is associated with increased incidence and severity of acute lower respiratory infection.

METHODS

We evaluated the effect of daily supplementation with 10 mg of elemental zinc on the incidence and prevalence of acute lower respiratory infection in a double-blind, randomized, controlled trial in 609 children (zinc, n = 298; control, n = 311) 6 to 35 months of age. Supplementation and morbidity surveillance were done for 6 months.

RESULTS

After 120 days of supplementation, the percentage of children with plasma zinc concentrations <60 microg/dL decreased from 35.6% to 11.6% in the zinc group, whereas in the control group it increased from 36.8% to 43.6%. Zinc-supplemented children had 0.19 acute lower respiratory infection episodes/child/year compared with 0.35 episodes/child/year in the control children. After correction for correlation of data using generalized estimating equation regression methods, there was a reduction of 45% (95% confidence interval, 10% to 67%) in the incidence of acute lower respiratory infections in zinc-supplemented children.

CONCLUSIONS

A dietary zinc supplement resulted in a significant reduction in respiratory morbidity in preschool children. These findings suggest that interventions to improve zinc intake will improve the health and survival of children in developing countries.

Clinical characteristics and outcome of children aged under 5 years hospitalized with severe pneumonia in Yemen

A 1-year study of 529 Yemeni children under 5 years of age hospitalized for severe pneumonia was undertaken to define their clinical characteristics and to identify risk factors associated with death from pneumonia. There were 354 (66.9%) boys, 270 of the 529 (51%) were under 6 months of age and 457 (86.4%) were aged < or = 12 months. The clinical characteristics of the group were as follows. Boys constituted 70% of the group and under-1-year-olds 86%, weight-for-age was under 60% in 23%, clinical rickets was present in 50% and anaemia in 30% (30.1%). On admission, cyanosis was detected in 56%, heart failure in 21% and isolated hepatomegaly in 14%. Fifty-two children died (CFR 9.8%), of whom 25 (48%) were under 6 months of age and 20 (38.5%) were aged between 6 and 12 months. Only seven children aged over 1 year died from pneumonia. Weight-for-age less than 60%, rickets, haemoglobin < 10 g/dl, cyanosis and heart failure were associated with an increased risk of dying from severe pneumonia.

Predictors of hypoxaemia in hospital admissions with acute lower respiratory tract infection in a developing country

Since oxygen has to be given to most children in developing countries on the basis of clinical signs without performing blood gas analyses, possible clinical predictors of hypoxaemia were studied. Sixty nine children between the ages of 2 months and 5 years admitted to hospital with acute lower respiratory tract infection and an oxygen saturation (Sao2) < 90% were compared with 67 children matched for age and diagnosis from the same referral hospital with an Sao2 of 90% or above (control group 1), and 44 unreferred children admitted to a secondary care hospital with acute lower respiratory infection (control group 2). Using multiple logistic regression analysis, sleepiness, arousal, quality of cry, cyanosis, head nodding, decreased air entry, nasal flaring, and upper arm circumference were found to be independent predictors of hypoxaemia on comparison of the cases with control group 1. Using a simple model of cyanosis or head nodding or not crying, the sensitivity to predict hypoxaemia was 59%, and the specificity 94% and 93% compared to control groups 1 and 2, respectively; 80% of the children with an Sao2 < 80% were identified by the combination of these signs. Over half of the children with hypoxaemia could be identified with a combination of three signs: extreme respiratory distress, cyanosis, and severely compromised general status. Further prospective validation of this model with other datasets is warranted. No other signs improved the sensitivity without compromising specificity. If a higher sensitivity is required, pulse oximetry has to be used.

Clinical overlap between malaria and severe pneumonia in Africa children in hospital

Data collected from 200 children admitted to a hospital on the Kenyan coast who met a broad definition of severe acute respiratory infection (ARI) indicated that simple clinical signs alone are unable absolutely to distinguish severe ARI and severe malaria. However, laboratory data showed that marked differences exist in the pathophysiology of unequivocal malaria and unequivocal ARI. Children in the former group had a higher mean oxygen saturation (97 vs. 94, P < 0.001), mean blood urea level (5.3 vs. 1.9 mmol/L, P < 0.001) and geometric mean lactate level (4.5 vs. 2.1 mmol/L, P < 0.001), and lower mean haemoglobin level (5.3 vs. 9.0 g/dL, P < 0.001) and base excess (-9.4 vs. -2.6, P < 0.001) than those in the latter group. Using these discriminatory variables it was estimated that up to 45% of children admitted with respiratory signs indicative of severe ARI probably had malaria as the primary diagnosis. Radiological examination supported this conclusion, indicating that pneumonia characterized by consolidation was uncommon in children with respiratory signs and a high malarial parasitaemia (> or = 10,000/microliters). There is no specific radiological sign of severe malaria. In practice, all children with respiratory signs warranting hospital admission in a malaria endemic area should be treated for both malaria and ARI unless blood film examination excludes malaria. In those with malaria and clinical evidence of acidosis, but no crackles, antibodies may be withheld while appropriate treatment for dehydration and anaemia is given. However, if clinical improvement is not rapid, antibiotics should be started.

Interobserver variation in respiratory signs of severe malaria

Respiratory abnormalities are common presentations of malaria and acute respiratory tract infection, both of which are major causes of childhood mortality and morbidity in sub-Saharan Africa. Appropriate management depends on accurate assessment of disease severity which for the majority of children must be based on clinical signs alone. Choosing which signs best serve this purpose remains a considerable problem particularly in malaria endemic areas. As part of a prospective study to define clinical signs indicative of life threatening malaria video recordings were used to examine the level of agreement between clinicians for potentially important respiratory signs in 51 children. Overall agreement was good for recession, severe recession, and nasal flaring (kappa = 0.57, 0.50, and 0.60 respectively) and substantial for deep breathing and the summary impression of respiratory distress (kappa = 0.70 and 0.69 respectively). However, within this substantial variation in interpretation was apparent between individual observers from slight to almost perfect agreement (kappa values 0.10-0.92). Video is a useful tool to demonstrate interobserver variation and it may also allow training in recognition of signs and a means of standardising clinical signs between centres.

Hypoxia in childhood pneumonia: better detection and more oxygen needed in developing countries

Even though hypoxia is a major risk factor for death in children with acute respiratory infection in developing countries, oxygen is not part of first line treatment. Because oxygen is not readily available in developing countries it tends to be given to the most seriously ill children, whose outcome is poor. Oxygen might be useful if given earlier in the course of the disease. Clinical signs are not clear cut, however, though the presence of cyanosis and grunting together with a raised respiratory rate can significantly increase the detection of hypoxaemia. A simple oximeter would make detection easier, and oxygen concentrators are more cost effective than bottled oxygen. Ideally oxygen should be given to children in the early stages of clinical pneumonia to prevent deterioration.