Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance: a multi-hospital, retrospective, cohort study

Abstract

SummaryBackgroundManagement of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital.MethodsWe did a retrospective cohort study of children aged 2–59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia).FindingsWe assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1–6·8), mild to moderate pallor (3·4, 3·0–3·8), and weight-for-age Z score (WAZ) less than −3 SD (3·8, 3·4–4·3). Additional factors that were independently associated with death were: WAZ less than −2 to −3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more.InterpretationIn settings of high mortality, WAZ less than −3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making.FundingWellcome Trust.

Can chest x-ray predict pneumonia severity and its outcome in children aged 2 months - 5 years?

“…Patient presented after 7 days of symptoms of pneumonia also had more radiologically proven pneumonia compare to patient presented earlier, because as duration of disease increases change in lung parenchyma would be more reflected in x-ray films. 12,13 In present study also patient stayed more than 7 days in hospital having clinically as well as radiologically severe pneumonia as observed in other studies. 14 Right side lung involved more than left side because right bronchus is wider and shorter than left bronchus and chance of aspiration and invasion of bacteria is more in right lung compare to left lung and similar findings found radiologically.…”

Risk factors for death among children aged 5–14 years hospitalised with pneumonia: a retrospective cohort study in Kenya

“…We performed a separate analysis to explore the effect of nutritional status defined by weight-for-age z scores (WAZ) on clinical outcome (online supplementary material model 3 ). WAZ scores are often used to describe nutritional status in studies of children under 5 years,17 18 and these variables (weight and age) are well recorded in our data. We calculated WAZ scores using WHO child growth standards,19 excluding children over 10 years where there are no reference standards (WAZ scores are not reliable in the context of pubertal growth spurts) 19.…”

Predictive value of pulse oximetry for mortality in infants and children presenting to primary care with clinical pneumonia in rural Malawi: A data linkage study

“…The pre-2018 Malawi IMCI protocol identified 2-fold more (10/13 = 77%) of the HC patients who died within 7 days of outpatient diagnosis than the 2014 WHO IMCI protocol (5/13 = 38%). These data and recent data from hospitalised children in Kenya showed that in routine care settings, presence of chest indrawing may require referral in some high-mortality settings [ 30 ]. Because not much is known about other factors that influenced adverse outcomes in these children with chest indrawing, such as care seeking and appropriate and timely treatment, further research is required to examine the beneficial effects of hospitalisation of children with chest indrawing in routine settings.…”