Abstract
BackgroundPneumonia is the leading infectious cause of death in children aged under 5 years in low- and middle-income countries (LMICs). World Health Organization (WHO) pneumonia diagnosis guidelines rely on non-specific clinical features. We explore chest radiography (CXR) findings among select children in the Innovative Treatments in Pneumonia (ITIP) project in Malawi in relation to clinical outcomes.MethodsWhen clinically indicated, CXRs were obtained from ITIP-enrolled children aged 2 to 59 months with community-acquired pneumonia hospitalized with treatment failure or relapse. ITIP1 (fast-breathing pneumonia) and ITIP2 (chest-indrawing pneumonia) trials enrolled children with non-severe pneumonia while ITIP3 enrolled children excluded from ITIP1 and ITIP2 with severe pneumonia and/or selected comorbidities. A panel of trained pediatricians classified the CXRs using the standardized WHO CXR research methodology. We analyzed the relationship between CXR classifications, enrollee characteristics, and outcomes.ResultsBetween March 2016 and June 2018, of 114 CXRs obtained, 83 met analysis criteria with 62.7% (52/83) classified as having significant pathology per WHO standardized interpretation. ITIP3 (92.3%; 12/13) children had a higher proportion of CXRs with significant pathology compared to ITIP1 (57.1%, 12/21) and ITIP2 (57.1%, 28/49) (p-value = 0.008). The predominant pathological CXR reading was “other infiltrates only” in ITIP1 (83.3%, 10/12) and ITIP2 (71.4%, 20/28), while in ITIP3 it was “primary endpoint pneumonia”(66.7%, 8/12,; p-value = 0.008). The percent of CXRs with significant pathology among children clinically cured (60.6%, 40/66) vs those not clinically cured (70.6%, 12/17) at Day 14 was not significantly different (p-value = 0.58).ConclusionsIn this secondary analysis we observed that ITIP3 children with severe pneumonia and/or selected comorbidities had a higher frequency of CXRs with significant pathology, although these radiographic findings had limited relationship to Day 14 outcomes. The proportion of CXRs with “primary endpoint pneumonia” was low. These findings add to existing data that additional diagnostics and prognostics are important for improving the care of children with pneumonia in LMICs.Trial registrationITIP1, ITIP2, and ITIP3 were registered with ClinicalTrials.gov (NCT02760420, NCT02678195, and NCT02960919, respectively).
Highlights
Pneumonia is the leading infectious cause of death in children under the age of 5 years in low- and middleincome countries (LMICs) [1,2,3,4]
The Innovative Treatments in Pneumonia (ITIP) project consisted of three studies: ITIP1, a double-blind randomized controlled clinical trial evaluating 3 days of amoxicillin dispersible tablets (DT) versus placebo DT for non-severe fast-breathing pneumonia [21]; ITIP2, a double-blind randomized controlled clinical trial evaluating 5 versus 3 days of amoxicillin DT for non-severe chest-indrawing pneumonia [22]; and ITIP3, a prospective observational study of clinical outcomes among children with pneumonia who were excluded from ITIP1 and ITIP2 due to severe pneumonia and/or comorbidities such as HIV exposure or infection, severe malaria, severe acute malnutrition, and/or anemia with hemoglobin < 8 g/Dl [23]
Of the 83 enrolled ITIP children whose Chest radiography (CXR) were included in this analysis, 24.1% (21/83) were from ITIP1, 60.9% (49/83) were from ITIP2, and 14.9% (13/83) were from ITIP3 (Table 3)
Summary
Pneumonia is the leading infectious cause of death in children under the age of 5 years in low- and middleincome countries (LMICs) [1,2,3,4]. World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines used to diagnose pneumonia in resource-constrained settings rely on non-specific clinical features including cough, difficulty breathing, fast breathing-for-age and chest indrawing [5]. When imaging is clinically indicated in children with suspected pneumonia, chest radiography (CXR) has long been considered the reference standard [6, 7]. Compared to WHO IMCI-defined pneumonia, children with WHO CXR-confirmed pneumonia, are reported to have higher treatment failure rates, longer hospital stays, and higher morbidity and mortality in LMICs [9, 11,12,13,14,15]. With reports that children with pneumonia and abnormal CXRs have poorer outcomes, further data from subSaharan Africa that describes the indications for CXR imaging and the predictive value of CXR findings for pediatric outcomes appears prudent. We explore chest radiography (CXR) findings among select children in the Innovative Treatments in Pneumonia (ITIP) project in Malawi in relation to clinical outcomes
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
