Chest Indrawing Research Articles

Community case management of lower chest indrawing pneumonia with oral amoxicillin in children in Kenya.

To determine the accuracy and effectiveness of community health workers (CHWs) when compared to trained nurses for management of pneumonia in Kenyan children. In Homabay County in western Kenya, children 2-59months of age with lower chest indrawing pneumonia were identified, classified and treated by CHWs with oral amoxicillin (90mg/kg per day) for five days at home. Trained nurses visited the child within 24hours to verify diagnosis; and on day 4 and 14 to assess treatment outcomes. CHWs identified 1906 children with lower chest indrawing pneumonia. There was an 88.7% concordance in classification and treatment for lower chest indrawing pneumonia by CHWs compared to nurses. Children with moderate malnutrition (OR 1.68; 95% CI: 1.22-2.30), comorbidities such as diarrhoea or malaria (OR 1.55; 95% CI: 1.32-1.81) or an additional day of delay in care seeking (OR 1.06; 95% CI: 1.02-1.10) were more likely to have an incorrect classification of lower chest indrawing by the CHW. Comorbidity (OR 1.66; 95% CI: 1.12-2.48) and fast breathing (OR 4.66; 95% CI: 1.26-17.27) were significantly associated with treatment failure on day 14. CHWs can correctly manage lower chest indrawing pneumonia even in high-mortality settings, such as western Kenya, in sub-Saharan Africa.

Role of Antibiotic in Treatment of Bronchiolitis

Background: Acute bronchiolitis is a viral respiratory illness of infants and young children. It is characterized by coryzal symptoms followed by rapid onset of cough, wheeze, fever, tachypnea, chest recession and crepitation with radiological evidence of hyperinflation. Bronchiolitis occurs in first 2 years of age and is usually caused by respiratory syncytial virus. Objective: To find out the effectiveness of antibiotic in treatment of bronchiolitis.Methods: It was a randomized controlled trial carried out in Department of Paediatrics, Rajshahi Medical College Hospital, Rajshahi. 200 acute bronchiohtis patient admitted into paediatric ward of Rajshahi Medical College Hospital who fulfill inclusion criteria. Then relevant history and physical examination findings were recorded in data sheet. The even numbered patient was selected as control group and odd numbered patients as intervention group. The control group was receive supportive management and intervention group was receive lnj. Ceftriaxone 75mg/kg/day in for 5 days along with supportive management.Results: This study it was observed that bronchiolitis was more common in male. The age for peak incidence (75%) of bronchiolitis was 2-6 months. About 59% children presented with fever and all of them recovered from fever quickly before leaving hospital. At the time of admission 43% children had feeding difficulty, which improved steadily and similarly in both the groups. For days hours after admission 16% of antibiotic group and 15% of without antibiotic group had similar chest indrawing. Cough was the most common starting symptoms. None of the cases showed cyanosis and at the time of admission total 91% children had SpO2 <95%, after 4 days of admission 33%of antibiotic group and 14% of without antibiotic group still had SpO2 <95% but during discharge none of them had hypoxia. After 4 days of admission 17% of antibiotic group and 14% of without antibiotic group had crepitation and 6 days after discharge 1(1%) child of without antibiotic group and 2(2%) from antibiotic group still had crepitation. It was observed that hypertranslucency in 74% and hyperinflation in 64% in cases.Conclusion: This study shows antibiotics have no role in acute bronchiolitis management. Further multicenter study with larger sample size is recommended.TAJ 2013; 26: 43-47

Clinical Classification of Acute Respiratory Symptoms in a Sample of Under Five Years Children in Erbil City

Background: Pneumonia is an important cause of morbidity and mortality in developing countries. They are responsible for the death of more than two million children under five year of age every year10, 11. Objective: To find out the proportions of clinical types of respiratory tract infections, also to find out the factors that might be associated with severity of pneumonia and to compare the proportions of pneumonia between the hospital and primary health care centers attendees. Patients and Methods: Case series study conducted among 300 children aged two months to five years in the outpatient clinic of Raperin Teaching Hospital / Erbil and six primary health care centers(PHCCs)from the first of march 2017 to thirty of march 2018. The questioner was completed through direct interview. A chi square test of association was used to compare proportions. A p value equal or less than 0.05 was considered as statistically significant. Results: The majority of cases 42% of the patients were infant and 59% were male. Sever pneumonia was diagnosed in 7%, pneumonia 5% and no pneumonia 88%. all of the patients presented with the cough, wheeze 100% in sever pneumonia 86% in pneumonia, and 35% in other group, fever are high in all groups, lethargy was higher among sever pneumonia patients (81%), chest indrawing also high among those with sever pneumonia 76.2% and those with pneumonia was 73.3% while only 1.5% among other groups. also unable to drink in sever pneumonia was 81%. No association between the diagnosis of pneumonia and sever pneumonia with age, gender and residence. The prevalence of sever pneumonia was 12.5% among low socioeconomic status (SES), 2.2% among those of moderate socioeconomic status and 0% among high socioeconomic status.The prevalence of pneumonia and sever pneumonia were higher among those with family history of asthma and higher among those whose father was smoker. Also 13.3% of the hospital cases had severe pneumonia compared with 0.7% of the cases of the PHCCs. Regarding pneumonia, 4% of the hospital cases had pneumonia compared with 6% of the cases of PHCCs. Conclusion: This study showed significant association with wheezes, immunization, history of chronic illness, SES, family history of asthma and smoking in father. The majority of cases with sever pneumonia was higher among hospital cases compared with PHCC. and pneumonia cases were lesser in hospital compared with PHCC.

Methods for conducting a double-blind randomized controlled clinical trial of three days versus five days of amoxicillin dispersible tablets for chest indrawing childhood pneumonia among children two to 59\xa0months of age in Lilongwe, Malawi: a study protocol

BackgroundPneumonia is the leading infectious cause of death in children under 5 years of age around the globe. In addition to preventing pneumonia, there is a critical need to provide greater access to appropriate and effective treatment. Studies in Asia have evaluated the effectiveness of 3 days of oral amoxicillin for the treatment of fast-breathing pneumonia; however, further evidence is needed to determine if 3 days of oral amoxicillin is also effective for the treatment of chest indrawing pneumonia.MethodsThis is a double-blind, randomized, non-inferiority trial with the objective to assess the effectiveness of shorter duration amoxicillin dispersible tablet (DT) treatment of chest indrawing childhood pneumonia in a malaria-endemic region of Malawi. The primary objective of this study is to determine whether 3 days of treatment with oral amoxicillin DT in HIV-uninfected Malawian children two to 59 months of age with chest indrawing pneumonia is as effective as 5 days of treatment. The study will enroll 2000 children presenting to Kamuzu Central or Bwaila District Hospitals in Lilongwe, Malawi. Each child will be randomized to either 3 days of amoxicillin DT followed by 2 days of placebo DT or 5 days of amoxicillin DT. Children in the study will be hospitalized for 48 h after enrollment and will have scheduled study visits at Days 2, 4, 6 and 14. Treatment failure by Day 6 is the primary outcome. We hypothesize that the rates of treatment failure will be similar in both arms and that 3 days of treatment will be non-inferior to 5 days of amoxicillin DT for chest indrawing pneumonia using a relative non-inferiority margin of 1.5. This trial was approved by the Western Institutional Review Board and Malawi College of Medicine Research and Ethics Committee.DiscussionGiven the paucity of data from Africa, African-based research is necessary to establish appropriate duration of treatment with amoxicillin DT for chest indrawing childhood pneumonia in malaria-endemic settings in the region. An expanded evidence base will contribute to future iterations of World Health Organization Integrated Management of Childhood Illness guidelines.Trial registrationNCT02678195: Pre-results. Date registered February 9, 2016.

Clinical profile and radiological evaluation of severe pneumonia in children, age 2 months up to 5 years: a descriptive cross-sectional study

Acute respiratory illness, primarily pneumonia, is the main cause of mortality in children under five years in most developing countries - result in 1.9 million deaths each year. To reduce mortality from these diseases, WHO introduced case management guidelines based on simple clinical signs for diagnosing pneumonia followed by empirical treatment with antibiotics. For management purposes, pneumonia is subclassified according to its severity by using general danger sign, chest indrawing or fast breathing. But these factors are influenced by malaria, meningitis, hyperactive airway disorder, bronchiolitis and fever. So clinical profile and their chest radiographs were analyzed in children aged 2-59 months who presented to a health facility with severe pneumonia using WHO guidelines. The purpose was to observe the clinical profile, evaluate radiological features of severe pneumonia and also to correlate the efficacy of clinical criteria with that of radiological findings. The study was conducted under the department of Pediatrics, Mymensingh Medical College Hospital and the samples were collected from the Inpatient department of Pediatrics in this hospital. It was a cross sectional observational study. 100 consecutive samples were collected from mothers with their children aged 2-59 months who met the inclusion criteria. Out of 100 children 56 were male and 44 were female children and male female ratio was 1.3:1. Majority (66%) of the children were partially immunized, 37% children were fully immunized and only 7% children were unimmunized as per EPI schedule. 42% of the children were malnourished and 13% were severely malnourished. Regarding clinical presentation all the patients presented with fever with cough (100%), 88% with difficult breathing, 11% had wheeze and 25% presented with general danger signs. Among the physical signs' temperature raised in 92%, Chest indrawing in 88%, flaring of alaenasi 78%, central cyanosis in 15%, pallor in 28%, stridor in 3%, bulged fontanel in 2% cases and BCG scar present in 65% of the cases. Clinical diagnosis of the studied cases revealed bronchiolitis in 31%, lobar pneumonia in 23%, bronchopneumonia in 27%, asthma in 12% and pulmonary tuberculosis in 7% cases. Routine examination of blood revealed 70% children were mild to moderately pale, 63% leukocytosis, 52% neutrophilic leukocytosis, 15% lymphocytic leukocytosis, ESR was raised in 52% of cases. Chest X-ray showed normal skiagram in 36%, consolidation in 23%, bronchopneumonia in 16%, nonspecific infection in 17% and hilar lymphadenopathy in 7% cases. 12% patients responded with ampicillin alone, 30% required gentamicin in addition, 39% required cloxacillin in addition to ampicillin and gentamicin, only ceftriaxone in 12% and 7% cases required anti tubercular treatment. Steroid used in 30% cases and bronchodilator in 42% cases. Immediate hospital outcome of these patients showed 78% cases improved, 12% patients left hospital against medical advice and 8% patients died in the hospital.
 CBMJ 2018 July: Vol. 07 No. 02 P: 24-33

Radiological Findings of Pneumonia In Neonates Hospitalized in A Tertiary Care Hospital

Background: Pneumonia contributes to between 750,000 and 1.2 million neonatal deaths worldwide annually and neonatal pneumonia accounts for 10% of global child mortality. Chest radiography is the primary and most important imaging modality in the evaluation of neonatal pneumonia. The study was conducted to evaluate the common radiological findings of pneumonia among neonates to early diagnose the disease.Methodology: This prospective observational study was conducted in Dhaka Shishu (children) Hospital from April to September 2014. A total of 50 neonates admitted in the inpatient department were included who fulfilled the inclusion criteria’s like having difficult breathing, fast breathing>60 /min, severe chest indrawing, grunting, cyanosis, cough or fever. Diagnosis was confirmed by Chest X-ray. Positive X-ray findings like lobar or segmental consolidation, nodular or coarse patchy parenchymal infiltrate, diffuse haziness or granularity, air bronchogram were included into the study. X-ray changes were assessed.Results: Most commonly identified abnormality was patchy opacities (included nodular or coarse patchy opacities, diffuse haziness, air bronchogram), noted in 31(62.0%) cases. Followed by homogenous opacities (consolidation) were found in 19(38.0%) cases. Multifocal area involvement were found more 56.0 %(28) than single area. On right side radiological changes commonly noted, especially right upper zone involvement was the commonest 30 (66.0%). A comparison between severe and non- severe cases revealed that both types of opacities were found equally. But right sided Involvement was common in both groups.Conclusion: Multifocal patchy opacities were the most common radiological finding in cases of neonatal pneumonia. Pneumonia lesions were more common in the right lung among neonates and common site was right upper zone.Bangladesh J Child Health 2017; VOL 41 (3) :155-158

Abstract P-581: NON-INVASIVE VENTILATION WITH NASAL-PHARYNGEAL TUBE IN LIMITED RESOURCE: CASE SERIES

Aims & Objectives: Use of non-invasive ventilation (NIV) has increased in past years. Successful NIV requires compatible interface, however, NIV masks have not been widely available in our country so we tried alternative interface, albeit less effective because of potential leakage. Methods Case series Results Case 1. A 3-months-old baby, 3.6kg, was admitted with respiratory failure, pneumonia, and large PDA. She was intubated for 8 days then switched to NIV–pressure control (PC) mode (Servo-i) with ET tube 3.0 inserted 8 cm from nostril, respiratory rate (RR) 30x/minute, FiO2 40%, PIP 15/PEEP 6. Minute volume (MV) 0.6–0.9 L, PaO2 108.8, and PaCO2 32.7 were achieved without increased work of breathing. Case 2. A 4-months-old boy, 7.6kg, was admitted with pneumonia and respiratory failure. He had diaphoresis, chest indrawing, SaO2 90%, PaO2 33.2, and PaCO2 59.7, with 6 lpm oxygen (PaO2/FiO2 ratio 83). NIV–PC mode was started with ET tube 3.5 inserted 9 cm from nostril, RR 20x/minute, FiO2 65%, PIP 15/PEEP 5. His work of breathing was reduced significantly after NIV, RR was decreased from 60 to 30x/minute, and SaO2 was improved. Case 3. A 3.5-years-old boy, 15kg, admitted with dilated cardiomyopathy, cardiogenic shock, and increased work of breathing on 1 lpm nasal oxygen. NIV–PC was administered using ET tube 4.0, 12 cm depth, RR 30x/minute, FiO2 40%, PIP 15/PEEP 5. Chest wall retraction was diminished after NIV. Conclusions Despite of our limited resource, NIV showed promising results in respiratory failure and prevention of reintubation. Shortened ET tube might be used as alternative interface in pediatric NIV.

Predictors of mortality among hospitalized children with severe acute malnutrition: a prospective study from Uganda.

We determined the predictors of mortality among children admitted with severe acute malnutrition (SAM). This was a prospective study nested in a randomized trial among 6-59-month-old children admitted with SAM. Socio-demographic and medical history data were collected using questionnaires and clinical examination, anthropometry and laboratory tests were performed. They were monitored daily until discharge or death during hospitalization while receiving care according to national guidelines. Predictors of death were assessed using Cox regression. Of 400 children, 9.8% (n = 39) died during hospitalization. Predictors of mortality included diarrhoea at admission [hazard ratio [HR] 2.19, 95% confidence interval (CI): 1.06; 4.51], lack of appetite [HR 4.50, 95% CI: 1.76; 11.50], suspected sepsis [HR 2.23, 95% CI: 1.18; 4.24] and skin ulcers [HR 4.23, 95% CI: 1.26; 4.17]. Chest indrawing [HR 5.0, 95% CI: 1.53; 16.3], oxygen saturation below 94% [HR 3.92, 95% CI: 1.42; 10.83] and confirmed HIV infection [HR 3.62, 95% CI: 1.69; 7.77] also predicted higher mortality. Infections were major contributors to mortality. This underscores the need for improved prevention and management of these infections among children with severe malnutrition.

Safety, Effectiveness and Feasibility of Outpatient Management of Children with Pneumonia with Chest Indrawing at Port Moresby General Hospital, Papua New Guinea.

Implementing the World Health Organization (WHO) recommendations on home-based management of pneumonia with chest indrawing is challenging in many settings. In Papua New Guinea, 120 children presenting with the WHO definition of pneumonia were screened for danger signs, comorbidities and hypoxaemia using pulse oximetry; 117 were appropriate for home care. We taught mothers about danger signs and when to return, using structured teaching materials and a video. The children were given a single dose of intramuscular benzylpenicillin, then sent home on oral amoxicillin for 5 days, with follow-up at Days 2 and 6. During the course of treatment, five (4%) of the 117 children were admitted and 15 (13%) were lost to follow-up. There were no deaths. Treating children with pneumonia with chest indrawing but no danger signs is feasible as long as safeguards are in place—excluding high-risk patients, checking for danger signs and hypoxemia and providing education for mothers and follow-up.

Incidence and degree of hypoxaemia in Malawian infants under 2 months of age presenting to district hospitals and its correlation with mortality: a retrospective analysis

Abstract Background Pneumonia is a leading cause of death in Malawian infants under 2 months of age. Consensus defines hypoxaemia in infants as a peripheral capillary oxygen saturation (SpO 2 ) of less than 90%. We aimed to estimate the incidence and degree of hypoxaemia and its correlation with mortality in infants younger than 2 months presenting to district hospitals in Malawi. Methods We retrospectively analysed a child pneumonia surveillance dataset prospectively collected during routine care at seven hospitals in Malawi between 2011 and 2014. Infants aged 0–2 months with pneumonia according to 2012 WHO case management guidelines were included. We used logistic regression to determine correlation between degree of hypoxaemia and in-hospital death. Findings 1810 infant pneumonia admissions were analysed. The case fatality rate was 3·6% (n=65). SpO 2 could not be measured in 8·5% (n=154) of patients. Median SpO 2 was 96% (IQR 91–98). Infants for whom SpO2 measurement was successful versus unsuccessful had a similar prevalence of chest indrawing (85·6% vs 79·2%) and WHO danger signs (68·4% vs 61·0%; p=0·064), and the distribution of girls (40·9% vs 39·6%) was also comparable. Compared with infants with an SpO 2 of 93–100% (n=1160), infants with an SpO 2 of 90–92% (n=187) or 2 was not measurable (n=154) had a greatly increased adjusted odds of death compared with infants with a SpO2 of 93–100% (aOR 17·5, 95% CI 7·5–40·8). Interpretation The case definition of hypoxaemia in infants less than 2 months of age warrants re-evaluation. Infants with an SpO 2 of 90–92% have a higher odds of death than those with a SpO 2 of 93–100%. Infants for whom SpO 2 could not be measured, despite having similar demographic and physical examination findings, had a higher odds ratio for death than any other observed group. Interestingly, these infants had a lower rate of WHO danger signs, but probably had severe disease such as shock with diminished peripheral perfusion resulting in inability to measure SpO 2 . WHO danger signs may not adequately capture such physiological derangements. The inability to measure pulse oximetry is clinically meaningful in our setting. Implementation of compulsory SpO 2 measurement could result in improved referral rates and recognition of severe disease in infants younger than 2 months of age with pneumonia. Funding None.

Agreement Between Integrated Management of Childhood Illness and Final Diagnosis in Acute Respiratory Tract Infections.

To evaluate the agreement between integrated management of childhood illness (IMCI) and final diagnosis in patients presenting with cough at the second and third level health institutions. This cross-sectional study included 373 children aged 2-60 mo who presented with cough at the pediatric emergency and outpatient clinics in the Department of Pediatrics. After clinical examination of children, body temperature, respiratory rate, saturation, presence or absence of the chest indrawing, rales, wheezing and laryngeal stridor were recorded. Cases were categorized according to IMCI algorithm regarding the severity using the color code, such as red (urgent treatment), yellow (treatment in the hospital), or green (treatment at home). Final diagnosis after physical examination, laboratory analysis and chest X-ray was compared with the IMCI algorithm. Study agreement between IMCI classification and final diagnosis was 74.3% with kappa value 0.55 (moderate agreement). Similar agreement values were detected in both the second and third level health institutions. Health condition and gender did not affect agreement value. Agreement were found to be high in patients <24 mo of age (ĸ = 0.67), presence of fever and cough (ĸ = 0.54), tachypnea (ĸ = 0.93), chest indrawing (ĸ = 1.00) and oxygen saturation of <94%(ĸ = 0.90). Adding saturation level to the IMCI algorithmic diagnosis may increase agreement between IMCI classification and final diagnosis.

Clinical Profile of Neonatal Sepsis With Reference to Antibiotic Resistance

Introduction : Neonatal sepsis continues to be a major cause of morbidity and mortality in neonates. It is 30 per 1000 live births in India. The prevalence is more in preterm neonates.&#x0D; Objectives &#x0D; &#x0D; To describe the clinical and bacteriological spectrum in early onset sepsis and late onset sepsis.&#x0D; To describe the antibiotic resistance profile of bacteria causing early and late onset sepsis.&#x0D; To compare the risk factors and bacteriological spectrum in early onset and late onset sepsis.&#x0D; &#x0D; Setting: NICU of civil hospital Ahmedabad&#x0D; Study period: June 2016 to December 2016&#x0D; Design: retrospective cohort study&#x0D; Methods: all neonate admitted in NICU of civil hospital Ahmedabad during the abovementioned period were assessed.&#x0D; Inclusion criteria: presence of one or more of established clinical features like , (fever/hypothermia, poor feeding, poor activity, respiratory distress/apneic spells, hepatospleenomegaly, vomitting, abdominal distension, seizures, signs of either respiratory or circulatory dysfunction evidenced by tachycardia/bradycardia, capillary refill time&gt;3 seconds,, respiratory rate&gt;60/minute, chest indrawing and/or grunting)along with &gt;_2 of the following laboratory criteria(total blood leukocyte count&lt;5000 or&gt;15000, absolute neutrophil count(ANC)&lt;500 cells/mm3or &gt;1500 cells/mm3,C reactive protein (CRP)&gt;0.6microgram/ml, positive blood culture). Information assessed in a proforma. Cases were divided into early onset sepsis(EOS) (presenting in the first 72 hours) and late onset sepsis(LOS) (presenting after 72 hours). All cases were started on antibiotics and upgraded or stopped based on culture and sensitivity. Cases were followed to discharge/death.

Knowledge and health-seeking practices of mothers attending primary health-care centers in Baghdad Al-Karkh sector about danger signs in newborns

Background: High-risk neonate defines as one who requires more than the standard monitoring and care offered to a healthy term newborn infant; therefore, early detection of neonatal illness is an important step toward improving newborn survival. Objectives: The objective of this study is to assess the knowledge and health-seeking practices of mothers attending primary health-care centers about WHO recognized danger signs in newborns. Subjects and Methods: A cross-sectional study was carried out in primary health-care centers selected conveniently in Baghdad-Alkarkh district. Participants were 275 mothers of child-bearing age group selected conveniently; the data were collected during the period from March 1 to June 30, 2017. A general questionnaire used for the data collection. Results: About 81% of mothers in study sample listed three or more of the who recognized danger signs. About 71.7% of mothers tend to seek advice or treatment for the illness outside the home. The proportion of good knowledge and health-seeking practices was higher in (Educated, employee, mothers who had a history of antenatal care attendance with higher number of visits). There was no relationship between number of children and family support with seeking care outside the home. Mothers who had good knowledge of danger signs of their babies tend to seek care from health facilities more frequently 75%, and this relation was statistically significant, 61.2% of mothers who perceive illness in newborns delayed seeking advice or treatment outside the home, 66% not taking newborn to the health facilities because they expect self-resolution of the illness. There is good knowledge and perception of mothers toward some danger signs such as fever, poor feeding, and jaundice while fair toward others such as cold body, chest indrawing, and signs of local infections. Conclusion: There are good knowledge and perception of mothers about the WHO recognized danger signs in newborns; however, there is a gap between mothers' knowledge and their health-seeking behavior for sick newborn and explored their deep perceptions, constraints, and various treatments.

Clinical signs of hypoxaemia in children aged 2 months to 5 years with acute respiratory distress in Switzerland and Senegal

Background: Hypoxaemia is a predictor of pneumonia-related mortality. WHO published recommendations for oxygen therapy based on clinical signs which state that, when oxygen is plentiful, it should be given to children with central cyanosis, inability to drink, severe chest indrawing, RR >70 breaths/min, grunting with every breath (in young infants) or those who display head nodding. These guidelines, however, are based on a few studies only.Aim: To assess the accuracy of combinations of clinical signs which predict hypoxaemia in pre-school children aged 2 months to 5 years with acute respiratory distress in hospitals in Switzerland and Senegal.Methods: This observational study was conducted in four emergency units, two in Switzerland and two in Senegal. Patients aged 2 months to 5 years with acute respiratory distress were eligible for inclusion. Clinical signs were compared with transcutaneous blood saturation levels (SaO2).Results: About 111 children were assessed, 67 in Switzerland and 44 in Senegal. The prevalence of hypoxaemia was 13%. Twelve models of combined symptoms were analysed. The WHO model, for when oxygen supply is ample, had the highest diagnostic performance with a sensitivity of 0.93 and a specificity of 0.60.Conclusions: Clinical signs alone are unreliable for the detection of hypoxaemia. The current WHO model, for ample oxygen supply proved to be the best clinical predictor, although a great number of non-hypoxaemic children were unnecessarily treated because of the low specificity of this model.

Comparable outcomes among trial and nontrial participants in a clinical trial of antibiotics for childhood pneumonia: a retrospective cohort study

ObjectivesWe compared characteristics and outcomes of children enrolled in a randomized controlled trial (RCT) comparing oral amoxicillin and benzyl penicillin for the treatment of chest indrawing pneumonia vs. children who received routine care to determine the external validity of the trial results. Study Design and SettingA retrospective cohort study was conducted among children aged 2-59 months admitted in six Kenyan hospitals. Data for nontrial participants were extracted from inpatient records upon conclusion of the RCT. Mortality among trial vs. nontrial participants was compared in multivariate models. ResultsA total of 1,709 children were included, of whom 527 were enrolled in the RCT and 1,182 received routine care. History of a wheeze was more common among trial participants (35.4% vs. 11.2%; P < 0.01), while dehydration was more common among nontrial participants (8.6% vs. 5.9%; P = 0.05). Other patient characteristics were balanced between the two groups. Among those with available outcome data, 14/1,140 (1.2%) nontrial participants died compared to 4/527 (0.8%) enrolled in the trial (adjusted odds ratio, 0.7; 95% confidence interval: 0.2–2.1). ConclusionPatient characteristics were similar, and mortality was low among trial and nontrial participants. These findings support the revised World Health Organization treatment recommendations for chest indrawing pneumonia.

Etiology and Risk Factors Determining Poor Outcome of Severe Pneumonia in Under-Five Children.

To determine the etiology of severe pneumonia (pneumonia with chest indrawing) in under-five children, and to study the risk factors for poor outcomes viz., 'treatment failure', 'need for change in antibiotics', 'prolonged hospital stay', 'need for mechanical ventilation' and 'mortality.' Children (age 2 mo to 5 y) with pneumonia and chest drawing were enrolled prospectively from October 2012 through September 2013. Clinical history was recorded, and examination, anthropometry and investigations (including chest X-ray, blood culture and nasopharyngeal swab culture) were performed. Children were managed as per standard guidelines, and recovery outcomes were recorded in form of 'treatment failure' (defined as persistence of features of severe pneumonia after 72h or worsening of clinical condition before 72h), need for change of antibiotics and prolonged (>5 d) hospital stay. The associations between the clinical, anthropometric and diagnostic risk factors and the recovery outcomes were evaluated by univariate and multivariate logistic regression analysis. Out of 120 children enrolled in the study, 36 (42%) were culture positive (nasopharyngeal/blood); most common bacteria isolated were Streptococcal pneumoniae and Staphylococcal aureus, respectively. Treatment failure was seen in 15 (12.5%), 34 (28.3%) needed change of antibiotics, and 50 (41.6%) children required prolonged hospitalization. Low birth weight, overcrowding, general danger signs (lethargy/unable to drink), clinical rickets, crepitation, leukocytosis and positive blood culture were significant risk factors for treatment failure, prolonged hospital stay and antibiotics change. On multivariate logistic regression analysis, respiratory rate of >70/min (OR 19.94, 95%CI 1.42-280.29), lethargy/unconsciousness (OR 114.2, 95%CI 3.14-4147.92), and positive blood culture (OR 15.24, 95%CI 2.53-91.67) had more chances of treatment failure. Duration of hospital stay was prolonged in those who had inability to drink (OR 3.89, CI 1.37-10.99) or abnormal chest X-ray (OR 8.45, CI 3.56-20.04). Children with rickets (OR 3.69, CI 1.14-11.96), and those with abnormal chest X-ray (OR 9.66, CI 2.62-35.53) had a higher odds of change in antibiotics. Presence of wheeze was a protective factor for treatment failure (OR 0.03, CI 0.00-0.37) and change of antibiotics (OR 0.24, CI 0.07-0.74). Staphylococcus aureus and Streptococcus pneumoniae are the predominant organisms causing severe pneumonia in our setting. Children with risk factors such as respiratory rate>70/min, rickets, lethargy/unconsciousness, not able to drink, abnormal chest X-ray or positive blood culture are likely to have a delayed recovery or need of change of antibiotics, whereas those with wheeze are likely to recover faster with less chances of treatment failure.

Validity of Red Cell Distribution Width as a Predictor of Clinical Outcomes in Pediatric Patients Diagnosed With Pneumonia

SESSION TITLE: Pediatrics SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: To determine the validity of RDW in predicting clinical outcomes of pediatric patients with pneumonia at Philippine Heart Center METHODS: Medical records of all patients 1-18 years old admitted from January 1, 2013 to December 31, 2015 with pneumonia as one of the final diagnosis were retrieved. Demographic data, laboratory and clinical parameters such as, RDW, white blood cell (WBC) and presence of tachypnea, adventitious lung sounds, or chest in-drawing were recorded. Pneumonia was classified as community-acquired or hospital-acquired. The primary outcome of this study was in-hospital mortality, while the secondary outcome was development of complications that were absent upon initial presentation, such as (1) need for or prolonged mechanical ventilation, (2) need for or increased vasopressors, (3) admission or transfer to or prolonged pediatric intensive care unit (PICU) stay, (4) prolonged hospital stay, or (5) development of atelectasis, empyema thoracis, pleural effusion, sepsis, pneumothorax, or pulmonary abscess. Data analysis was done using Stata SE version 13. The accuracy of RDW in predicting mortality among pediatric patients with pneumonia were presented as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV). Homogeneity of characteristics between two groups were tested using independent t-test for quantitative variables and Fisher’s exact test for qualitative variables. Association between RDW and mortality were determined using logistic regression analysis. The level of significance was set at 0.05. RESULTS: There are 59 (50%) females and 57 (49.1%) males. The coexisting illnesses identified were congenital heart disease (37, 31.9%), bronchial asthma (15, 12.9%), and rheumatic heart disease (7, 6%). Most (84, 72.4%) of the patients were diagnosed with PCAP C. There is a significant association between high RDW value and development of complications (p<0.001) as well as non-survival (p<0.006) from pneumonia. Elevated RDW has a high specificity (94.7%) and sensitivity (60%) in identifying patients with pneumonia who will develop complications with a positive predictive value of 85.7% and a negative predictive value of 81.8%. In predicting in-hospital mortality, high RDW has a sensitivity of 66.7% and specificity of 79.4%, with a positive predictive value of 21.4% and a negative predictive value of 96.6%. CONCLUSIONS: Elevated RDW is significantly associated to mortality and development of complications among pediatric patients with pneumonia. It is both specific and sensitive as a prognostic tool for pneumonia and can be a valid and cost-efficient marker for pneumonia severity. CLINICAL IMPLICATIONS: Diagnostic tests such as C-reactive protein and erythrocyte sedimentation rate are used in the hospital setting in assessing treatment response in pediatric community-acquired pneumonia but these are not readily available in laboratories and would entail additional costs. The RDW, meanwhile, being part of a routine CBC, would be very useful and cost-efficient if proven to have clinical validity in predicting outcomes of pneumonia in children. DISCLOSURE: The following authors have nothing to disclose: Sherryl Jane Miranda No Product/Research Disclosure Information

Outpatient Management of Children With World Health Organization Chest Indrawing Pneumonia: Implementation Risks and Proposed Solutions.

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.

Predictive value of clinical and laboratory features for the main febrile diseases in children living in Tanzania: A prospective observational study.

BackgroundTo construct evidence-based guidelines for management of febrile illness, it is essential to identify clinical predictors for the main causes of fever, either to diagnose the disease when no laboratory test is available or to better target testing when a test is available. The objective was to investigate clinical predictors of several diseases in a cohort of febrile children attending outpatient clinics in Tanzania, whose diagnoses have been established after extensive clinical and laboratory workup.MethodFrom April to December 2008, 1005 consecutive children aged 2 months to 10 years with temperature ≥38°C attending two outpatient clinics in Dar es Salaam were included. Demographic characteristics, symptoms and signs, comorbidities, full blood count and liver enzyme level were investigated by bi- and multi-variate analyses (Chan, et al., 2008). To evaluate accuracy of combined predictors to construct algorithms, classification and regression tree (CART) analyses were also performed.Results62 variables were studied. Between 4 and 15 significant predictors to rule in (aLR+>1) or rule out (aLR+<1) the disease were found in the multivariate analysis for the 7 more frequent outcomes. For malaria, the strongest predictor was temperature ≥40°C (aLR+8.4, 95%CI 4.7–15), for typhoid abdominal tenderness (5.9,2.5–11), for urinary tract infection (UTI) age ≥3 years (0.20,0–0.50), for radiological pneumonia abnormal chest auscultation (4.3,2.8–6.1), for acute HHV6 infection dehydration (0.18,0–0.75), for bacterial disease (any type) chest indrawing (19,8.2–60) and for viral disease (any type) jaundice (0.28,0.16–0.41). Other clinically relevant and easy to assess predictors were also found: malaria could be ruled in by recent travel, typhoid by jaundice, radiological pneumonia by very fast breathing and UTI by fever duration of ≥4 days.The CART model for malaria included temperature, travel, jaundice and hepatomegaly (sensitivity 80%, specificity 64%); typhoid: age ≥2 years, jaundice, abdominal tenderness and adenopathy (46%,93%); UTI: age <2 years, temperature ≥40°C, low weight and pale nails (20%,96%); radiological pneumonia: very fast breathing, chest indrawing and leukocytosis (38%,97%); acute HHV6 infection: less than 2 years old, (no) dehydration, (no) jaundice and (no) rash (86%,51%); bacterial disease: chest indrawing, chronic condition, temperature ≥39.7°c and fever duration >3 days (45%,83%); viral disease: runny nose, cough and age <2 years (68%,76%).ConclusionA better understanding of the relative performance of these predictors might be of great help for clinicians to be able to better decide when to test, treat, refer or simply observe a sick child, in order to decrease morbidity and mortality, but also to avoid unnecessary antimicrobial prescription. These predictors have been used to construct a new algorithm for the management of childhood illnesses called ALMANACH.

Impact of the 13-Valent Pneumococcal Conjugate Vaccine on Clinical and Hypoxemic Childhood Pneumonia over Three Years in Central Malawi: An Observational Study.

BackgroundThe pneumococcal conjugate vaccine’s (PCV) impact on childhood pneumonia during programmatic conditions in Africa is poorly understood. Following PCV13 introduction in Malawi in November 2011, we evaluated the case burden and rates of childhood pneumonia.Methods and FindingsBetween January 1, 2012-June 30, 2014 we conducted active pneumonia surveillance in children <5 years at seven hospitals, 18 health centres, and with 38 community health workers in two districts, central Malawi. Eligible children had clinical pneumonia per Malawi guidelines, defined as fast breathing only, chest indrawing +/- fast breathing, or, ≥1 clinical danger sign. Since pulse oximetry was not in the Malawi guidelines, oxygenation <90% defined hypoxemic pneumonia, a distinct category from clinical pneumonia. We quantified the pneumonia case burden and rates in two ways. We compared the period immediately following vaccine introduction (early) to the period with >75% three-dose PCV13 coverage (post). We also used multivariable time-series regression, adjusting for autocorrelation and exploring seasonal variation and alternative model specifications in sensitivity analyses.The early versus post analysis showed an increase in cases and rates of total, fast breathing, and indrawing pneumonia and a decrease in danger sign and hypoxemic pneumonia, and pneumonia mortality. At 76% three-dose PCV13 coverage, versus 0%, the time-series model showed a non-significant increase in total cases (+47%, 95% CI: -13%, +149%, p = 0.154); fast breathing cases increased 135% (+39%, +297%, p = 0.001), however, hypoxemia fell 47% (-5%, -70%, p = 0.031) and hospital deaths decreased 36% (-1%, -58%, p = 0.047) in children <5 years. We observed a shift towards disease without danger signs, as the proportion of cases with danger signs decreased by 65% (-46%, -77%, p<0.0001). These results were generally robust to plausible alternative model specifications.ConclusionsThirty months after PCV13 introduction in Malawi, the health system burden and rates of the severest forms of childhood pneumonia, including hypoxemia and death, have markedly decreased.