Abstract
BackgroundRisks of death are high when children with pneumonia also have severe acute malnutrition (SAM) as a co-morbidity. However, there is limited published information on risk factors of death from pneumonia in SAM children. We evaluated clinically identifiable factors associated with death in under-five children who were hospitalized for the management of pneumonia and SAM.MethodsFor this unmatched case-control design, SAM children of either sex, aged 0–59 months, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) during April 2011 to July 2012 with radiological pneumonia were studied. The SAM children with pneumonia who had fatal outcome constituted the cases (n = 35), and randomly selected SAM children with pneumonia who survived constituted controls (n = 105).ResultsThe median (inter-quartile range) age (months) was comparable among the cases and the controls [8.0 (4.9, 11.0) vs. 9.7 (5.0, 18.0); p = 0.210)]. In logistic regression analysis, after adjusting for potential confounders, such as vomiting, abnormal mental status, and systolic hypotension (<70 mm of Hg) in absence of dehydration, fatal cases of severely malnourished under-five children with pneumonia were more often hypoxemic (OR = 23.15, 95% CI = 4.38–122.42), had clinical dehydration (some/severe) (OR = 9.48, 95% CI = 2.42–37.19), abdominal distension at admission (OR = 4.41, 95% CI = 1.12–16.52), and received blood transfusion (OR = 5.50, 95% CI = 1.21–24.99) for the management of crystalloid resistant systolic hypotension.Conclusion and SignificanceWe identified hypoxemia, clinical dehydration, and abdominal distension as the independent predictors of death in SAM children with pneumonia. SAM children with pneumonia who required blood transfusion for the management of crystalloid resistant systolic hypotension were also at risk for death. Thus, early identification and prompt management of these simple clinically recognizable predictors of death and discourage the use of blood transfusion for the management of crystalloid resistant systolic hypotension may help reduce deaths in such population.
Highlights
Over the last two decades, pneumonia remained the leading cause of global under-five childhood deaths [1,2], representing an estimated 1.4 million out of the total 7.6 million deaths in this population in 2010 [3]
The risk of death is high when children with pneumonia have the co-morbidity of severe acute malnutrition (SAM) [4,5] and has been reported to be 15 times higher compared to deaths in children who did not have SAM [6]
In resource constrained settings may be less confident in identifying clinical features for the diagnosis of pneumonia in SAM children and as a result they might offer only oral antibiotics following recent WHO recommendations if the SAM children do not have any complications [8]
Summary
Over the last two decades, pneumonia remained the leading cause of global under-five childhood deaths [1,2], representing an estimated 1.4 million out of the total 7.6 million deaths in this population in 2010 [3]. The subtle clinical signs and different etiology of pneumonia in SAM children may necessitate first dose of parenteral antibiotics before their referral to tertiary hospitals with the objectives to reduce morbidity and death. This management approach might not be feasible at every health care facility in resource limited settings due to lack of funds. From this perspective, identification of simple clinical cues for fatal outcome in SAM children with pneumonia may prove very useful to health professionals, health workers in making referral decisions.
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