Chest Indrawing Research Articles

Point-of-care lung ultrasound in the diagnosis of childhood pneumonia.

Lung ultrasound is emerging as a rapid, simple and safe alternative for diagnosing pneumonia since it has a higher sensitivity than X-rays and lower radiation exposure than computerized tomography. This is a prospective observational study done at a tertiary care centre in Chennai to study the diagnostic utility of lung ultrasound in pneumonia. Children aged 1 month to 12 years who were admitted to the hospital with complaints of cough, fever and/or breathing difficulty and on examination had tachypnea and/or chest indrawing were included in the study. All children underwent chest X-rays which was a standard hospital protocol. At admission, an independent investigator who was blinded to the clinical and radiological features of the child performed lung ultrasound. In all children, the final diagnosis of pneumonia was made by another independent expert paediatrician on the basis of the clinical features and chest X-ray. The test characteristics of ultrasound and chest X-ray were compared against this gold standard of physician-diagnosed pneumonia. Out of the 252 children studied, 225 (89.3%) had pneumonia while the rest 27 (10.7%) had other diagnoses. Among the 225 children with pneumonia, 223 (99.1%) were detected by ultrasound while 157 (69.8%) were detected by chest X-ray. All the test characteristics such as sensitivity, specificity, positive and negative predictive values of ultrasound were higher than those of chest X-ray. The sensitivity and specificity of ultrasound to diagnose pneumonia were 99.11% and 81.48%, respectively, while the sensitivity and specificity of X-ray for the same were 69.77% and 74.07%, respectively. Overall diagnostic accuracy for chest ultrasonography was 97.22% (94.36% to 98.88%), whereas for chest radiography, it was found to be 70.24% (64.18% to 75.81%).While both modalities were able to diagnose pneumonia significantly, ultrasound had better strength of association (Cramer's V value = 0.849) than X-ray to the final diagnosis. Lung ultrasound can be employed as a point-of-care investigation to diagnose pneumonia in suspected cases and can even replace chest X-ray in such circumstances.

Clinical characteristics of pediatric patients with pneumonia and Streptococcus pneumoniae serotype distribution at Hai Phong Children’s Hospital, Vietnam

Streptococcus pneumoniae (S. pneumoniae) is a major cause of pneumonia in pediatric health concerns. Effective vaccination strategies depend on understanding serotype distribution and its correlation with clinical manifestations. This study aims to describe the serotype distribution of Streptococcus pneumoniae strains at Hai Phong Children’s Hospital, Vietnam. Conducted at Hai Phong Children’s Hospital in Vietnam from November 2022 to September 2023, our cross-sectional study enrolled 428 pediatric pneumonia patients. Nasopharyngeal fluid specimens were collected to isolate S. pneumoniae by culture and confirmed by Real-time PCR. S. pneumoniae serotyping was performed by realtime PCR. Medical records provided symptom and medical history data. Out of 428 samples, 66.8% tested positive for S. pneumoniae. Among confirmed cases by real-time PCR, 82.6% were typeable, with predominant serotypes being 6A/B (16.4%), 19F (14.9%), 15B/C (11.4%), 19A (11.0%), and 15A/15F (7.8%). Notably, 70.7% of strains belonged to vaccine-covered serotypes. Cough (96.5%), tachypnea (78.7%), fever (56.1%), and wheezing (52.8%) were the most frequent symptoms. Notably, cough, tachypnea, wheezing, and chest indrawing (29.0%) significantly correlated with pneumococcal pneumonia. Positive S. pneumoniae cultures also correlated with chest X-ray findings. Our study reveals a high prevalence of S. pneumoniae in pediatric patients with pneumonia in Vietnam. Insights into serotype distribution, clinical characteristics of pneumonia cases offer valuable guidance for optimizing vaccination programs and enhancing disease management.

Hypoxemia and its clinical predictors among children with respiratory distress admitted to the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

IntroductionHypoxemia is a common complication of childhood respiratory tract infections and non-respiratory infections. Hypoxemic children have a five-fold increased risk of death compared to children without hypoxemia. In addition, there is limited evidence about hypoxemia and clinical predictors in Ethiopia. Therefore, this study was conducted to assess the prevalence and clinical predictors of hypoxemia among children with respiratory distress admitted to the University of Gondar Comprehensive Specialized Hospital.MethodsAn institutional-based cross-sectional study was conducted from December 2020 to May 2021 in northwest Ethiopia. A total of 399 study participants were selected using systematic random sampling. The oxygen saturation of the child was measured using Masimo rad-5 pulse oximetry. SPSS version 21 software was used for statistical analysis.ResultIn this study, the prevalence of hypoxemia among children with respiratory distress was 63.5%. The clinical signs and symptoms significantly associated with hypoxemia were: head-nodding (AOR: 4.1, 95% CI: 1.81–9.28) and chest indrawing (AOR: 3.08, 95% CI: 1.32–7.16) which were considered statistically the risk factors for hypoxemia while inability to feed (AOR: 0.13, 95% CI: 0.02–0.77) was the protective factor for hypoxemia. The most sensitive predictors of hypoxemia were fast breathing with sensitivity (98.4%), nasal flaring (100.0%), chest indrawing (83.6%), and intercostal retraction (93.1%). The best specific predictors of hypoxemia were breathing difficulty with specificity (79.4%), inability to feed (100.0%), wheezing (83.0%), cyanosis (98.6%), impaired consciousness (94.2%), head-nodding (88.7%), and supra-sternal retraction (96.5%).Conclusion and recommendationThe prevalence of hypoxemia among children was high. The predictors of hypoxemia were the inability to feed, head nodding, and chest indrawing. It is recommended that the health care settings provide immediate care for the children with an inability to feed, head nodding, and chest indrawing. The policymakers better to focus on preventive strategies, particularly those with the most specific clinical predictors.

Understanding the outcome and management of children aged 2–59 months with chest indrawing pneumonia: a study protocol for an observational study in Ethiopia, India, Nigeria, Pakistan, Uganda and Zambia

IntroductionChildhood pneumonia is a leading cause of morbidity and mortality among children aged 2–59 months, particularly in low-income and middle-income countries (LMICs), where healthcare providers face significant challenges in diagnosing...

Medical Students' Clinical Knowledge of Integrated Management of Childhood Illness: A cross-sectional comparative study.

This study aimed to investigate and compare the clinical knowledge implications of the integrated management of childhood illness (IMCI) preservice education between pre-clerkship and junior clerkship medical students. This observational comparative cross-sectional study was conducted between June and August 2022 at Sultan Qaboos University, Muscat, Oman. A self-administered questionnaire was utilised and included questions on sociodemographic data, duration of IMCI preservice training, knowledge of the participants concerning the IMCI objectives and information on a range of childhood conditions. A total of 97 medical students were included in the study. The majority of students (42.3%) had received 2 lectures in IMCI preservice training. The role of the IMCI approach in reducing childhood morbidity and mortality was advocated by the majority of students (80.8% in the junior-clerkship [JCR] group and 73.3% in the pre-clerkship group). The awareness of the IMCI component of improving the health system was higher in JCR compared to pre-clerkship participants (P = 0.044). When compared to pre-clerkship students, the JCR participants demonstrated a slightly higher awareness of skin pinch (P = 0.038), chest indrawing (P = 0.008), anaemia assessment based on nail bed examination (P = 0.002), diagnostic assessment of malnutrition based on palm examination (P = 0.018), sucking capacity in breastfeeding (P = 0.025), and vaccines such as those for tuberculosis (P = 0.001), pneumococcal (P = 0.018) and rotavirus (P = 0.007). The majority of students displayed good IMCI knowledge and JCR students showed better knowledge compared to pre-clerkship candidates.

EFFECTS OF ACUTE MALNUTRITION ON THE RESULTS OF PNEUMONIA TREATMENT IN CHILDREN FROM 2 MONTHS TO 5 YEARS OLD

Background: Pneumonia is a very common disease in children, especially children under 5 years old, due to their immature immune system not being able to fight against environmental pathogens. Malnutrition affects the severity and outcome of pneumonia treatment. Objectives: 1) To describe the results of pneumonia treatment in acute malnutrition children from 2 months to 5 years old. 2) To determine the relationship between acute malnutrition and the results of pneumonia treatment in children from 2 months to 5 years old. Materials and method: 174 children with pneumonia with acute malnutrition from 2 months to 5 years old are receiving inpatient treatment at Can Tho Children's Hospital, Disease group: Children diagnosed with pneumonia according to the Ministry of Health 2014: Children with cough, fever accompanied by at least one of the signs of rapid breathing according to age, chest indrawing (the lower part of the chest indents during inhalation), or rales lung abnormalities (moisture rales, bronchial rales, crackles, etc.) [6]. AND children diagnosed with acute malnutrition according to the Ministry of Health 2016: Children have 1 of 2 anthropometric conditions: arm circumference (MUAC) or weight for height (CN/CC) lower than the normal threshold for age and gender (in which, severe malnutrition with MUAC<115 mm or CN/CC<-3SD, moderate malnutrition with 115mm≤MUAC<125mm or -3SD≤CN/CC<-2SD) [7]. Control group: children diagnosed with pneumonia without acute malnutrition. Disease control research. Results: Some characteristics after treatment: antibiotic combination was 28.2%, antibiotic change counted for 31.6%, respiratory support was 19.0%, intensive care unit transfer was 6.9%, curative treatment results was 98.7%. There is a significant correlation between acute malnutrition with pneumonia and the characteristics of treatment outcomes: severe pneumonia (p<0.001), combined with antibiotics (p<0.001), respiratory support (p=0.012) and transfer to Intensive Care Unit (p=0.017). Acute malnutrition with pneumonia was not significantly different from changing antibiotics (p<0.625) and death after treatment (p=0.560). Conclusion: Acute malnutrition is statistically significantly different from the severity of pneumonia, antibiotic combination, respiratory support, and transfer to the Intensive Care Unit.

Acute febrile illness in Kenya: Clinical characteristics and pathogens detected among patients hospitalized with fever, 2017-2019.

Acute febrile illness (AFI) is a common reason for healthcare seeking and hospitalization in Sub-Saharan Africa and is often presumed to be malaria. However, a broad range of pathogens cause fever, and more comprehensive data on AFI etiology can improve clinical management, prevent unnecessary prescriptions, and guide public health interventions. We conducted surveillance for AFI (temperature ≥38.0°C <14 days duration) among hospitalized patients of all ages at four sites in Kenya (Nairobi, Mombasa, Kakamega, and Kakuma). For cases of undifferentiated fever (UF), defined as AFI without diarrhea (≥3 loose stools in 24 hours) or lower respiratory tract symptoms (cough/difficulty breathing plus oxygen saturation <90% or [in children <5 years] chest indrawing), we tested venous blood with real-time PCR-based TaqMan array cards (TAC) for 17 viral, 8 bacterial, and 3 protozoal fever-causing pathogens. From June 2017 to March 2019, we enrolled 3,232 AFI cases; 2,529 (78.2%) were aged <5 years. Among 3,021 with outcome data, 131 (4.3%) cases died while in hospital, including 106/2,369 (4.5%) among those <5 years. Among 1,735 (53.7%) UF cases, blood was collected from 1,340 (77.2%) of which 1,314 (98.1%) were tested by TAC; 715 (54.4%) had no pathogens detected, including 147/196 (75.0%) of those aged <12 months. The most common pathogen detected was Plasmodium, as a single pathogen in 471 (35.8%) cases and in combination with other pathogens in 38 (2.9%). HIV was detected in 51 (3.8%) UF cases tested by TAC and was most common in adults (25/236 [10.6%] ages 18-49, 4/40 [10.0%] ages ≥50 years). Chikungunya virus was found in 30 (2.3%) UF cases, detected only in the Mombasa site. Malaria prevention and control efforts are critical for reducing the burden of AFI, and improved diagnostic testing is needed to provide better insight into non-malarial causes of fever. The high case fatality of AFI underscores the need to optimize diagnosis and appropriate management of AFI to the local epidemiology.

Identifying gaps in maternal knowledge and care-seeking for neonatal health: A mixed methods study in rural pregnant women.

Knowledge of neonatal danger signs is crucial for timely care-seeking and improved newborn survival. This study assessed this knowledge among pregnant women in rural western Gujarat. A mixed methods study was conducted among 390 pregnant women selected through a two-stage sampling procedure. Quantitative data were collected using a structured questionnaire. Qualitative data were gathered via in-depth interviews with 20 purposively sampled women. Logistic regression identified determinants of knowledge. Thematic analysis was done for qualitative data. The majority of women were young (220, 56.5% ≤25 years), literate (333, 85%), and from rural backgrounds (320, 82%). Overall, 232 (59.5%) knew about cord care, and 301 (77.2%) correctly identified breastfeeding initiation time. Recognition of key danger signs such as fever (311, 79.7%), vomiting (292, 74.8%), and jaundice (275, 70.5%) was high, but only 70 (18%) identified chest in-drawing. Multiparity (adjusted odds ratio (AOR): 1.4, 95% confidence interval (95% CI): 1.2-3.9), lower age (AOR: 3.8, 95% CI: 2.4-5.8), education (AOR: 3.1, 95% CI: 1.5-6.4), inadequate counseling (AOR: 2.2, 95% CI: 1.82-5.190), and normative delivery (AOR: 2.4, 95% CI: 1.16-5.006) were associated with poor knowledge. Qualitative findings revealed reliance on informal sources, family elders, and financial constraints as key barriers along with limited comprehension of some danger signs. Focused interventions via health workers, family members, and community platforms are needed to increase neonatal danger signs awareness among vulnerable women in the region to enable timely care-seeking.

Magnitude of Pneumonia and Bronchiolitis and Their Treatment Modalities Practiced in Under Five Children Attending a Tertiary Care Hospital

Background: Pneumonia is the leading cause of death globally among children younger than five years of age. Acute bronchiolitis is also a major public health problem throughout the world. Many children with pneumonia and bronchiolitis are not properly diagnosed, and overuse of antibiotics has led to increasing drug resistance. Objectives: To determine the magnitude of pneumonia and bronchiolitis and to study their treatment modalities practiced in under five children. Methods: This cross-sectional observational study was carried out in the Pediatric inpatient department and outpatient department of Rajshahi Medical college Hospital from October 2015 to March 2016. Total 373 cases between 1 month to 59 months of age with acute respiratory infection who fulfilled the inclusion criteria were enrolled in the study. The inclusion criteria were any child between 1 month to 59 months of age presented with respiratory symptoms including cough/runny nose or breathing difficulty as complained by the caregivers or having chest in-drawing. Detailed information was obtained through structured questionnaire and then analyzed. Results: In this study majority of the children 223 (59.78%) were under 12 months of age. There were 234 (62.73%) male and 139 (37.27%) female cases, male to female ratio being 1.68:1. Among studied children 217 (58.18%) were urban dwellers and 156 (41.82%) were from rural areas and majority of the children 268 (71.85%) came from lower socioeconomic strata. Out of 373 cases, pneumonia was diagnosed in 131(35.12%) cases, bronchiolitis in 88 (23.60%) cases and other acute respiratory tract infections in 154 (41.28%) cases. Most common antibiotic used for the treatment of both pneumonia and bronchiolitis was ceftriaxone in 34.35% and 25% cases respectively followed by other antibiotics and medications. Conclusion: It is concluded that pneumonia was found in 35.12% cases and bronchiolitis in 23.60% cases among the under five children attending a tertiary care hospital with acute respiratory infection. Majority were under 12 months of age, male children, residing in urban areas and coming from lower socioeconomic status. Ceftriaxone was the commonest antibiotic used in the treatment of both pneumonia and bronchiolitis. TAJ 2023; 36: No-2: 163-170

Commonly misdiagnosed round pneumonia in a child: a case report

Round pneumonia, a specific radiological finding in children, is often caused by Streptococcus pneumoniae; but it is easily misdiagnosed with some other diseases, causing many difficulties for clinicians. We described a case report of round pneumonia in a 9-year-old boy, with chest pain, following fever, productive cough, left-sided pulmonary consolidation syndrome, tachypnea, no chest indrawing, and a round homogenous lesion about 4 cm in diameter with a clear border in the left upper lobe position on chest X-ray. He was initially misdiagnosed as a lung tumor. He was correctly diagnosed with round pneumonia prior to pneumonectomy and was successfully treated with antibiotics. Therefore, it is important to carefully analyze round pneumonia cases that are often misdiagnosed, resulting in poor therapy.

Implication of the 2014 World Health Organization Integrated Management of Childhood Illness Pneumonia Guidelines with and without pulse oximetry use in Malawi: A retrospective cohort study.

Under-5 pneumonia mortality remains high in low-income countries. In 2014 the World Health Organization (WHO) advised that children with chest indrawing pneumonia, but without danger signs or peripheral oxygen saturation (SpO 2) < 90% be treated in the community, rather than hospitalized. In Malawi there is limited pulse oximetry availability. Secondary analysis of 13,413 under-5 pneumonia cases in Malawi. Pneumonia associated case fatality ratios (CFR) were calculated by disease severity under the assumptions of the 2005 and 2014 WHO Integrated Management of Childhood Illness (IMCI) guidelines, with and without pulse oximetry. We investigated if pulse oximetry readings were missing not at random (MNAR). The CFR of patients classified as having non-severe pneumonia per the 2014 IMCI guidelines doubled under the assumption that pulse oximetry was not available (1.5% without pulse oximetry vs 0.7% with pulse oximetry, P<0.001). When 2014 IMCI guidelines were applied with pulse oximetry and a SpO 2 < 90% as the threshold for referral and/or admission, the number of cases meeting hospitalization criteria decreased by 70.3%. Unrecorded pulse oximetry readings were MNAR with an adjusted odds for mortality of 4.9 (3.8, 6.3), similar to that of a SpO 2 < 90%. Although fewer girls were hospitalized, female sex was an independent mortality risk factor. In Malawi, implementation of the 2014 WHO IMCI pneumonia guidelines, without pulse oximetry, will miss high risk cases. Alternatively, implementation of pulse oximetry may result in a large reduction in hospitalization rates without significantly increasing non-severe pneumonia associated CFR if the inability to obtain a pulse oximetry reading is considered a WHO danger sign.

Health System Considerations for Community-Based Implementation of Automated Respiratory Counters to Identify Childhood Pneumonia in 5 Regions of Ethiopia: A Qualitative Study.

In Ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (RR) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. Our aim was to identify health system-level lessons from implementing two automated RR counters, Children's Automated Respiration Monitor (ChARM) by Phillips® and Rad-G by Masimo®, to provide considerations for integrating such devices into child health programmes and health systems. This study was part of an initiative called the Acute Respiratory Infection Diagnostic Aids (ARIDA). Key informant interviews (KIIs) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of Ethiopia. Data were analyzed in ATLAS.ti using thematic content analysis and themes were categorized using the Tanahashi bottleneck analysis. All participants recommended scaling up the ARIDA initiative nationally as part of Integrated Management of Newborn and Childhood Illness (IMNCI) in primary healthcare. Health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. Health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. Participants recommended increasing the number of devices distributed and health workers trained. Strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. While training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended. Automatic RR counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. However, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.

Profile and Outcome of Neonatal Respiratory Distress: A Single-center Study

Abstract Background: Respiratory distress (RD) is one of the common indications of hospitalisation in the neonatal intensive care unit. Due to recent advances in clinical diagnosis and treatment, there is a need for data on the current profile and outcome of neonatal RD (NRD). Aims: To determine the clinical presentation, causes, risk factors, severity, and outcome of NRD. Patients and Methods: All neonates who presented with signs of RD were enrolled. Neonatal data such as birth weight, mode of delivery, gestational age, saturation on room air, mode of oxygen therapy, and onset and severity of RD were noted in predesigned pro forma. The severity of RD in term and pre-term neonates was assessed by Downe’s score and Silverman–Anderson’s score, respectively. Relevant investigations and treatment were started as per standard protocol. Results: The most common cause of NRD was RD syndrome (29%). Chest indrawing was the most prevalent sign of RD (90.0%). There was no significant association of gestational age with the severity of RD (P = 0.140), but the birth weight was significantly associated with the severity of RD (P = 0.002). Severe RD was associated with extreme prematurity, meconium-stained amniotic fluid and birth weight of &lt;1.5 kg. The mortality rate was 12%, with meconium aspiration syndrome and RD syndrome being the common causes. Conclusions: Whatever the cause, RD can proceed to respiratory failure and death if it is not promptly diagnosed and treated. Therefore, any clinician providing care for neonates must be able to quickly identify the symptoms and degree of RD, distinguish between different aetiologies, and begin treatment plans to avoid future complications or mortality.

The Role of Zinc in Acute Bronchiolitis in children less than 2 years old

Background: Bronchiolitis is an acute respiratory illness which is the leading cause of respiratory distress in infancy and early childhood with its greatest morbidity in infants. Although zinc supplementation is effective in both preventing and treating pneumonia but its role in acute bronchiolitis has rarely been examined.&#x0D; Objective: To assess the effect of zinc sulfate to improve the clinical manifestations of acute bronchiolitis (Severe cases) in children less than 2 years of age.&#x0D; Materials and Methods: This was a double blind randomized clinical trial on 70 patients aged 2 to 23 months admitted in the Pediatric ward of Khwaja Yunus Ali Medical College and Hospital from September 2019 to September 2020 with the diagnosis of acute bronchiolitis. Patients were randomly divided equally into 2 groups: a case group was assigned oral zinc sulfate and the control group received placebo.&#x0D; Results: Mean age of case group was 174.63±98.7 days and control group 176.86±97.43 days ( p=0.924) with male predominance in both groups. Symptoms and signs of acute bronchiolitis (Severe cases) were compared between the 2 groups during admission and then at 24, 48 and 72 hours after initiation of treatment. No statistically significant differences were observed between the 2 groups in improvement of symptoms and signs including fever, fast breathing, chest indrawing and wheezing on 48 and 72 hours after treatment with zinc sulfate ( p&gt;0.05). The duration of hospitalization was 4.2±2.6 days in the case group and 4.4±2.2 days in the control group and this difference was not significant.&#x0D; Conclusion: The present study showed that zinc sulfate has no benefit in improving the clinical manifestations of acute bronchiolitis.&#x0D; Northern International Medical College Journal Vol. 12 No.2 Jan 2021, Page 535-538

A -2- month old child with Spinal Muscular Atrophy Type 1 with Pneumonia: A case report

Spinal muscular atrophy (SMA) is a autosomal recessive disease characterized by muscular weakness, hypotonia and atrophy. SMA is caused by mutation or deletion of the survivor motor neuron gene (SMN1), which is located in the telomere region of chromosome 5q13. Incidence of the disease is 1:6000-10000 newborn. Confirmatory diagnosis can be established by molecular genetic analysis. Here a 2- month- old female baby was admitted into the department of pediatrics of Sylhet Women’s Medical College Hospital with because of less movement of whole body for 1 month and repeated cough with respiratory distress for same duration. Baby was dyspneic, chest in drawing and crepitation was present over both lung fields. Signs of lower motor neuron lesions were present. It was confirmed by Polymerase chain reaction (PCR) for SMN gene. Final diagnosis was Spinal muscular atrophy with pneumonia. Symptomatic, Supportive and antibiotic treatment were given. Genetic counseling, regular respiratory follow up was advised.

Implication of the 2014 World Health Organization Integrated Management of Childhood Illness Pneumonia Guidelines with and without pulse oximetry use in Malawi: A retrospective cohort study

Background: Under-5 pneumonia mortality remains high in low-income countries. In 2014 the World Health Organization (WHO) advised that children with chest indrawing pneumonia, but without danger signs or peripheral oxygen saturation (SpO2) &lt; 90% be treated in the community, rather than hospitalized. In Malawi there is limited pulse oximetry availability. Methods: Secondary analysis of 13,413 under-5 pneumonia cases in Malawi. Pneumonia associated case fatality ratios (CFR) were calculated by disease severity under the assumptions of the 2005 and 2014 WHO Integrated Management of Childhood Illness (IMCI) guidelines, with and without pulse oximetry. We investigated if pulse oximetry readings were missing not at random (MNAR). Results: The CFR of patients classified as having non-severe pneumonia per the 2014 IMCI guidelines doubled under the assumption that pulse oximetry was not available (1.5% without pulse oximetry vs 0.7% with pulse oximetry, P&lt;0.001). When 2014 IMCI guidelines were applied with pulse oximetry and a SpO2 &lt; 90% as the threshold for referral and/or admission, the number of cases meeting hospitalization criteria decreased by 70.3%. Unrecorded pulse oximetry readings were MNAR with an adjusted odds for mortality of 4.9 (3.8, 6.3), similar to that of a SpO2 &lt; 90%. Although fewer girls were hospitalized, female sex was an independent mortality risk factor. Conclusions: In Malawi, implementation of the 2014 WHO IMCI pneumonia guidelines, without pulse oximetry, will miss high risk cases. Alternatively, implementation of pulse oximetry may result in a large reduction in hospitalization rates without significantly increasing non-severe pneumonia associated CFR if the inability to obtain a pulse oximetry reading is considered a WHO danger sign.

Acute Bronchiolitis in Term Newborns Following Relaxation in COVID-19 Appropriate Behavior

Abstract Objective Neonatal bronchiolitis is not well characterized. We studied the profile of acute bronchiolitis in term newborns during a respiratory syncytial virus (RSV) surge following relaxation in coronavirus disease 2019 (COVID-19) appropriate behavior. Methods This was a retrospective descriptive study performed in the neonatology division of a tertiary care pediatric hospital at Srinagar, Jammu and Kashmir, India. Term neonates (born at ≥37 completed gestational weeks) from 7 up to 28 days of life admitted with bronchiolitis over a 1-month period (November 2021) were included. Results Out of total 480 neonatal admissions over a month, 35 (7%) had acute bronchiolitis. Eight neonates were excluded. Out of 27 included neonates, 13 were males. Mean age at presentation was 20 days. All neonates were born at term (≥37 completed gestational weeks). Cough (26), rapid breathing (20), and lower chest indrawing (20) were the predominant presenting features. Median SPO2 was 87% (interquartile range 85–92%). Fourteen (52%) neonates needed admission to neonatal intensive care unit. Respiratory support was needed in the form of oxygen through nasal prongs in 24 (89%) newborns. Heated humidified high-flow nasal cannula (HHHFNC) and bubble continuous positive airway pressure were used in five neonates each. Two neonates were mechanically ventilated. The mean duration of the hospital stay was 6.2 days. All neonates survived. Conclusion A series of 27 term neonates with bronchiolitis during an RSV surge is reported in the aftermath of lifting of COVID-19 restrictions. Many of these neonates were sick enough to require significant respiratory support. The outcome was good in all neonates.

Oropharyngeal Mucocele as an Unusual Cause of Recurrent Pneumonia in a Young Infant

Background: Oral mucoceles, though frequently seen as asymptomatic lesions in young adults, very little is known about their existence in infants and the complications arising out of them in this age group. Clinical Description: A 4-month-old infant presented with a history of recurrent episodes of breathing difficulty since 15 days of life, every episode being managed as aspiration pneumonia. The child presented in the fifth such episode with tachypnea tachycardia and chest indrawing. Auscultation revealed bilateral crepitations and chest X-ray showed diffuse haziness in the bilateral chest predominantly in the right middle lobe, rest of the systemic examination being normal. Oral cavity examination showed a bluish globular bulge behind the tongue with surrounding congested mucosa and thick secretions. Management and Outcome: The baby was managed with respiratory support in the form of continuous positive airway pressure, intravenous antibiotics Piperacillin-Tazobactam, amikacin and metronidazole, and anti-reflux measures of oral Domperidone. Flexible laryngoscopy showed a cystic lesion behind the tongue and contrast-enhanced computerized tomography confirmed a hypodense lesion arising from the uvula suggestive of a mucocele. Excision of the oro-pharyngeal cystic lesion was done and the histopathological examination confirmed it to be a mucocele. The baby was gradually weaned off oxygen support and proper breastfeeding was re-established. Conclusion: This case creates awareness regarding the fact that an unsuspected oral mucocele may be the cause of recurrent respiratory symptoms in an infant, thereby reiterating the importance of oral examination even in young infants.

Viral Etiology and Clinical Characteristics of Acute Respiratory Tract Infections in Hospitalized Children in Southern Germany (2014-2018).

Viral acute respiratory tract infections (ARTIs) are a leading cause of hospitalization in infants and young children. During the winter seasons of 2014-2018, hospitalized children (<18 years) with symptoms of ARTI were prospectively included at the University Hospital Heidelberg, Germany. Nasopharyngeal swabs were obtained for multiplex molecular analysis of 10 groups of respiratory viruses, and clinical data were obtained using a standardized questionnaire. Of 1353 children included in this study, 1142 (84.4%) were positive for ≥1 viral pathogen. Virus monoinfection was detected in 797 (69.8%) children, whereas 345 (30.2%) children had coinfections with 2-4 viral pathogens. Respiratory syncytial virus (RSV), rhinovirus, and influenza virus were the main pathogens detected. RSV-positive children had significantly more often lower ARTIs, including symptoms of severe cough, wheezing, chest indrawing, tachypnea, and pulmonary rales. Hospitalized children aged <6 months represented the largest age group with detection of ≥1 viral pathogen (455/528 [86.2%] children). Coinfection was more frequent in younger children and, particularly for RSV with rhinovirus, significantly associated with more severe respiratory symptoms (P = .01). A better understanding of the etiology of viral ARTIs among hospitalized children plays a key role for future strategies in prevention, control, and treatment of respiratory viral infections.

What are the risk factors for death among children with pneumonia in low- and middle-income countries? A systematic review.

Knowledge of the risk factors for and causes of treatment failure and mortality in childhood pneumonia is important for prevention, diagnosis, and treatment at an individual and population level. This review aimed to identify the most important risk factors for mortality among children aged under ten years with pneumonia. We systematically searched MEDLINE, EMBASE, and PubMed for observational and interventional studies reporting risk factors for mortality in children (aged two months to nine years) in low- and middle-income countries (LMICs). We screened articles according to specified inclusion and exclusion criteria, assessed risk of bias using the EPHPP framework, and extracted data on demographic, clinical, and laboratory risk factors for death. We synthesized data descriptively and using Forest plots and did not attempt meta-analysis due to the heterogeneity in study design, definitions, and populations. We included 143 studies in this review. Hypoxaemia (low blood oxygen level), decreased conscious state, severe acute malnutrition, and the presence of an underlying chronic condition were the risk factors most strongly and consistently associated with increased mortality in children with pneumonia. Additional important clinical factors that were associated with mortality in the majority of studies included particular clinical signs (cyanosis, pallor, tachypnoea, chest indrawing, convulsions, diarrhoea), chronic comorbidities (anaemia, HIV infection, congenital heart disease, heart failure), as well as other non-severe forms of malnutrition. Important demographic factors associated with mortality in the majority of studies included age <12 months and inadequate immunisation. Important laboratory and investigation findings associated with mortality in the majority of studies included: confirmed Pneumocystis jirovecii pneumonia (PJP), consolidation on chest x-ray, pleural effusion on chest x-ray, and leukopenia. Several other demographic, clinical and laboratory findings were associated with mortality less consistently or in a small numbers of studies. Risk assessment for children with pneumonia should include routine evaluation for hypoxaemia (pulse oximetry), decreased conscious state (e.g. AVPU), malnutrition (severe, moderate, and stunting), and the presence of an underlying chronic condition as these are strongly and consistently associated with increased mortality. Other potentially useful risk factors include the presence of pallor or anaemia, chest indrawing, young age (<12 months), inadequate immunisation, and leukopenia.