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

Abstract

This review aimed to identify clinical, demographic, and investigation findings that are associated with treatment failure or mortality in children (aged two months to nine years) with pneumonia in LMICs. METHODSWe conducted a systematic search of medical databases MEDLINE, EMBASE, and PubMed (for recent studies not yet indexed on MEDLINE) for studies reporting on factors associated with child pneumonia mortality (August 30, 2020). We mapped search terms to medical subject headings where possible, using Boolean operators to combine searches into our final systematic search query. We used synonyms of "pneumonia", "mortality", and "child" to target our search strategy, with oversight from an experienced Health Service Librarian to ensure all relevant papers were identified. We also searched reference lists of all included references for eligible studies. Additional methodological detail, including the Medline search strategy, information sources and data collection processes are included in Text S1 in the Online Supplementary Document. Assessment of study eligibilityWe included observational and interventional studies from LMICs involving children aged 28 days to nine years with pneumonia and reporting data on risk factors for death. We focussed on studies published since 2010 to reflect current aetiology and diagnostic / treatment approaches and limited to English language. We included studies involving children older than five years of age as this is an important neglected child population but expected most studies to focus on the traditional under five-year population. Two reviewers (CW and MB) independently screened the titles and abstracts of all returned studies, obtained full text for studies that were screened in by either reviewer, then independently assessed them for inclusion. We resolved disagreements by discussion and, where appropriate, review by a third reviewer (HG). None of the reviewers were blind to the journal titles, study authors, or affiliated institutions.

Hypoxaemia and risk of death among children: rethinking oxygen saturation, risk-stratification, and the role of pulse oximetry in primary care

“…However, moderate hypoxaemia in the range of SpO 2 90–93% carried an increased odds of death, which is similar to findings from other studies that have reported general danger signs, severe malnutrition, or cyanosis conditions, which should almost always result in referral to a high-level facility. 6 Although severe hypoxaemia (SpO 2 <90%) should be a clear indication for referral and admission to a high-level facility, we suggest that moderate hypoxaemia (SpO 2 90–93%) and so-called failed readings should also be considered as clear cause for health-care worker concern and action. What this looks like will depend on the local context and capabilities of the health facility, with some primary care facilities able to offer day-care or short admissions with experienced oversight, giving health-care workers time to observe the child to see whether they are clinically stable, whereas other facilities without this capacity rely more on referral pathways to higher-level facilities.…”

“… 9 , 10 Data from children in hospital with pneumonia show that hypoxaemia on admission to hospital is the strongest predictor of death, with the risk of death varying between studies and settings, but proportional to the severity of hypoxaemia, and elevated even at moderate hypoxaemia of 90–93%. 6 Although the prevalence of hypoxaemia is decreased in non-pneumonia conditions, such as malaria and meningitis, the presence and severity of hypoxaemia is similarly associated with death, as hypoxaemic respiratory failure is a complication of many critical systemic illnesses. 11 , 12 , 13 , 14 , 15 …”

“…Recent WHO-commissioned reviews have further emphasised hypoxaemia as a major risk factor for death and highlighted the importance of pulse oximetry in risk stratification. 6 …”

Trends and spatial distribution of pneumonia admissions and deaths among children <5 years, Uganda, 2013–2021

“…It is unknown why this occurred, but it may be related to the 32% decline in new HIV infections between 2014 and 2015, which represented the largest decline in many years 26 . HIV is a key risk factor for pneumonia deaths among children <5 years linked and is associated with a 4-fold increased risk of pneumonia death 27 . Additional declines in pneumonia case-fatality rates even after 2015 might also reflect improvements in the quality of healthcare during the study period.…”

Association between indoor environmental risk factors and pneumonia among preschool children in Urumqi：A case-control study

“…This study conducted a comprehensive analysis of preschool children's pneumonia cases in Urumqi, focusing on the association with indoor environmental factors. Pediatric pneumonia remains a significant public health challenge, especially in low- and middle-income countries, where it continues to be one of the leading causes of child mortality [ [9] , [10] , [11] ]. Our findings align with global research, highlighting the substantial impact of indoor environmental factors, such as passive smoking, housing types, flooring materials, and dampness, on the incidence of pneumonia in children [ 5 ].…”