Abstract
SummaryObjectiveCough or difficult breathing and an increased respiratory rate for their age are the commonest indications for outpatient antibiotic treatment in African children. We aimed to determine whether respiratory rate was likely to be transiently raised by a number of contextual factors in a busy clinic leading to inaccurate diagnosis.MethodsRespiratory rates were recorded in children aged 2–59 months presenting with cough or difficulty breathing to one of the two busy outpatient clinics and then repeated at 10‐min intervals over 1 h in a quiet setting.ResultsOne hundred and sixty‐seven children were enrolled with a mean age of 7.1 (SD ± 2.9) months in infants and 27.6 (SD ± 12.8) months in children aged 12–59 months. The mean respiratory rate declined from 42.3 and 33.6 breaths per minute (bpm) in the clinic to 39.1 and 32.6 bpm after 10 min in a quiet room and to 39.2 and 30.7 bpm (P < 0.001) after 60 min in younger and older children, respectively. This resulted in 11/13 (85%) infants and 2/15 (13%) older children being misclassified with non‐severe pneumonia. In a random effects linear regression model, the variability in respiratory rate within children (42%) was almost as much as the variability between children (58%). Changing the respiratory rates cut‐offs to higher thresholds resulted in a small reduction in the proportion of non‐severe pneumonia mis‐classifications in infants.ConclusionNoise and other contextual factors may cause a transient increase in respiratory rate and consequently misclassification of non‐severe pneumonia. However, this effect is less pronounced in older children than infants. Respiratory rate is a difficult sign to measure as the variation is large between and within children. More studies of the accuracy and utility of respiratory rate as a proxy for non‐severe pneumonia diagnosis in a busy clinic are needed.
Highlights
Pneumonia is the leading cause of death in young children causing an estimated 1.2 million deaths in children aged under 5 years worldwide, over 90% of which occur in resource-poor countries [1,2,3]
In Africa, the incidence of pneumonia in young children has been estimated at 0.28 episodes/child-year and an estimated 32% of these are due to bacterial infections where progression from early stages of pneumonia to severe and potentially fatal pneumonia might be prevented by antibiotic treatment taken early in the illness [4, 5]
A number of studies have demonstrated the association between raised respiratory rate (RR) and severe pneumonia, a finding that underpins the WHO-Integrated Management of Childhood Illness (IMCI) recommendation that children under the age of 5 years presenting with cough or difficult breathing and an increased RR for their age meet the IMCI criteria for ‘non-severe pneumonia’ and should receive antibiotic treatment [6]
Summary
Pneumonia is the leading cause of death in young children causing an estimated 1.2 million deaths in children aged under 5 years worldwide, over 90% of which occur in resource-poor countries [1,2,3]. In Africa, the incidence of pneumonia in young children has been estimated at 0.28 episodes/child-year and an estimated 32% of these are due to bacterial infections where progression from early stages of pneumonia to severe and potentially fatal pneumonia might be prevented by antibiotic treatment taken early in the illness [4, 5]. It is possible to count the respiratory rate during sleeping or feeding as the high respiratory rates tend to persist in a child with pneumonia. These IMCI strategies are appropriate to a scenario of high incidence of bacterial pneumonia, but a number of
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