Factors Predicting Mortality in Hospitalised Hiv-Negative Children with Lower-Chest-Wall Indrawing Pneumonia and Implications for Management

Abstract

Background: In 2013 the World Health Organization revised treatment guidelines for childhood pneumonia with lower chest wall indrawing (LCWI) to recommend home-based treatment rather than hospital admission. We analysed data from children hospitalized with LCWI pneumonia in the Pneumonia Etiology Research for Child Health (PERCH) study to identify sub-groups with high odds of mortality, who might continue to benefit from hospital management. Methods: PERCH enrolled 2189 HIV-negative children aged 2-59 months who were admitted to hospital with LCWI pneumonia between 2011-2014 in Kenya, Zambia, South Africa, Mali, The Gambia, Bangladesh, and Thailand. We analysed risk factors for mortality among these cases using logistic regression. Findings: Among 2189 cases with LCWI pneumonia, 76 (3·6%) died. Mortality was higher in infants compared to children 12-59 months of age (OR 2·03, 95%CI 1·05-3·93), in children with oxygen saturation <92% (3·33, 1·99-5·99), in HIV negative but exposed (4·59, 1·81-11·7), and in malnourished children (6·85, 3·22-14·6). Among all cases, 807 (40%) had hypoxaemia or HIV exposure, or were malnourished (mid-upper-arm circumference <125mm or low/ very low weight for age) while 65 (86%) of the 76 deaths observed had at least one of these characteristics. Interpretation: This study supports the suggestion that a subset of HIV-negative children with LCWI pneumonia, who are hypoxic, or malnourished or were born to HIV positive mothers, experience poorer outcomes than other children with chest-indrawing pneumonia and could benefit from hospital admission. Funding: This work was supported by The Bill & Melinda Gates Foundation [grant number 48968] Declaration of Interest: None to declare. Ethical Approval: The PERCH study was approved by the relevant ethics committees overseeing each site and by the Johns Hopkins Bloomberg School of Public Health ethics committee