Abstract
This Viewpoints article details our recommendation for the World Health Organization Integrated Management of Childhood Illness guidelines to consider additional referral or daily monitoring criteria for children with chest indrawing pneumonia in low-resource settings. We review chest indrawing physiology in children and relate this to the risk of adverse pneumonia outcomes. We believe there is sufficient evidence to support referring or daily monitoring of children with chest indrawing pneumonia and signs of severe respiratory distress, oxygen saturation <93% (when not at high altitude), moderate malnutrition, or an unknown human immunodeficiency virus (HIV) status in an HIV-endemic setting. Pulse oximetry screening should be routine and performed at the earliest point in the patient care pathway as possible. If outpatient clinics lack capacity to conduct pulse oximetry, nutritional assessment, or HIV testing, then we recommend considering referral to complete the evaluation. When referral is not possible, careful daily monitoring should be performed.
Highlights
The World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines provide the basis for treatment recommendations for children with pneumonia in most low-resource settings [1,2,3]
The IMCI guidelines were written for doctors, nurses, and other nonphysician clinicians working at first-level outpatient facilities in low-resource settings such as clinics, health centers, or outpatient departments of hospitals [1,2,3]
Given the association between chest indrawing, low lung compliance, and pneumonia, and the fact that chest indrawing can be observed without additional equipment, the WHO utilizes chest indrawing as a diagnostic sign for pneumonia
Summary
Outpatient Management of Children With World Health Organization Chest Indrawing Pneumonia: Implementation Risks and Proposed Solutions. The World Health Organization (WHO) Integrated Management of Childhood Illness (IMCI) guidelines provide the basis for treatment recommendations for children with pneumonia in most low-resource settings [1,2,3]. Unlike appropriately resourced and supervised clinical trials, effective guideline implementation in real-world settings hinges upon often inadequately trained, poorly supervised, and underresourced healthcare workers to correctly identify chest indrawing and exclude any accompanying clinical danger signs and underlying chronic illnesses that require hospitalization. We will discuss these issues here in this Viewpoint, revisiting evidence from the original studies that formed the basis of these guidelines to offer our alternative perspective. Represents the child’s attempt to generate additional positive end expiratory pressure and maintain lung volume
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