Nutritional status and diarrheal illness as independent risk factors for alveolar pneumonia

Dietary patterns and micronutrients in respiratory infections including COVID-19: a narrative review

BACKGROUND

COVID-19 is a pandemic caused by nCoV-2019, a new beta-coronavirus from Wuhan, China, that mainly affects the respiratory system and can be modulated by nutrition.

METHODS

This review aims to summarize the current literature on the association between dietary intake and serum levels of micronutrients, malnutrition, and dietary patterns and respiratory infections, including flu, pneumonia, and acute respiratory syndrome, with a focus on COVID-19. We searched for relevant articles in various databases and selected those that met our inclusion criteria.

RESULTS

Some studies suggest that dietary patterns, malnutrition, and certain nutrients such as vitamins D, E, A, iron, zinc, selenium, magnesium, omega-3 fatty acids, and fiber may have a significant role in preventing respiratory diseases, alleviating symptoms, and lowering mortality rates. However, the evidence is not consistent and conclusive, and more research is needed to clarify the mechanisms and the optimal doses of these dietary components. The impact of omega-3 and fiber on respiratory diseases has been mainly studied in children and adults, respectively, and few studies have examined the effect of dietary components on COVID-19 prevention, with a greater focus on vitamin D.

CONCLUSION

This review highlights the potential of nutrition as a modifiable factor in the prevention and management of respiratory infections and suggests some directions for future research. However, it also acknowledges the limitations of the existing literature, such as the heterogeneity of the study designs, populations, interventions, and outcomes, and the difficulty of isolating the effects of single nutrients from the complex interactions of the whole diet.

Role of vitamin D, serum zinc, and serum iron deficiency in community-acquired pneumonia in children

Background

Community-acquired pneumonia is a major cause of death among children. Inadequate nutrition disrupts the immune system and increases the susceptibility to infections. We aimed to evaluate the association between vitamin D, serum zinc, and iron, and pneumonia. A case-control study was conducted at the outpatient clinic and emergency room of Children’s Hospital. Thirty-one patients with community-acquired pneumonia and 36 healthy children (control group) underwent serum sampling for vitamin D, zinc, and iron.

Results

Most patients had mild form (n = 17, 54.8%). All patients survived and were discharged. The serum iron level showed a non-significant difference between pneumonia and control groups (p ˃ 0.05). TIBC, vitamin D, and serum zinc were significantly lower in the patient group than the control group (P value = 0.04, < 0.001, and 0.03, respectively). Vitamin D deficiency was highly associated with the severity of pneumonia (P value = 0.008).

Conclusion

Adequate serum zinc and vitamin D levels may be protective against infection with community-acquired pneumonia in children aged from 2 months to 5 years old, but not iron.

Risk Factors for Severe Pneumonia According to WHO 2005 Criteria Definition Among Children <5 Years of Age in Thai Binh, Vietnam: A Case-Control Study

Vietnam is one of the 15 countries where the prevalence of child pneumonia is highest. It is a major cause of admission in pediatric hospitals. However, little is known on the burden of severe pneumonia and their risk factors in children <5 years of age in Vietnam. A case–control study was conducted among children aged 2–59 months presenting with pneumonia at the Pediatric Provincial Hospital of Thai Binh. Cases were children with severe pneumonia while controls included those with non-severe pneumonia as defined by the World Health Organization (WHO) classification of 2005. Eighty-three cases and 83 controls were included. Sex ratio was 2.19. Children with severe pneumonia were significantly less likely to receive antibiotics preadmission compared to children with non-severe pneumonia [odds ratio (OR) = 0.16, 95% confidence interval (CI) = 0.06–0.42]. The main risk factors of severe pneumonia were a lack of immunization (OR = 4.77, 95% CI = 1.80–12.65), an exposure to cigarette smoke (OR = 3.87, 95% CI = 1.62–9.23), and having a mother with a low level of education. Children with severe pneumonia were 25 times more likely to present with associated measles with p < 0.0001 and five times more likely to present with diarrhea than children with non-severe pneumonia (p < 0.0001). Improving immunization coverage, educating parents about the risks of passive smoking and the recognition of respiratory distress signs, and facilitating early antibiotic access for infants with acute pulmonary disease should reduce the burden of such illnesses. To implement a national, multicenter study about pneumonia in children, more precise inclusion criteria should be chosen, including radiological and/or biological assessment.

Effects of Individual and Combined Water, Sanitation, Handwashing, and Nutritional Interventions on Child Respiratory Infections in Rural Kenya: A Cluster-Randomized Controlled Trial

Poor nutrition and hand hygiene are risk factors for acute respiratory infections (ARIs). Safe drinking water and sanitation can reduce exposure to pathogens and encourage healthy immune responses, reducing the risk of ARIs. Within a trial assessing impacts of water, sanitation, and handwashing (WASH), and nutritional interventions, we evaluated effects on ARIs. The WASH Benefits cluster-randomized trial enrolled pregnant women from Kenyan villages and evaluated health outcomes in children born to enrolled mothers 1 and 2 years after intervention delivery. Geographically adjacent clusters were block-randomized into a passive control (no promotional visits), a double-sized active control (monthly visits to measure mid–upper arm circumference), and six intervention groups: chlorinated drinking water (W), improved sanitation (S), handwashing with soap (H), combined WSH, improved nutrition (N) through counseling and lipid-based nutrient supplementation (LNS), and combined WSHN. The main outcome was the prevalence of ARI symptoms (cough, panting, wheezing, or difficulty breathing) in children younger than 3 years. Masking participants was not possible. Analyses were intention-to-treat. Between November 2012 and May 2014, 702 clusters were enrolled, including 6,960 (year 1) and 7,088 (year 2) children with ARI data. The cluster-level intra-cluster correlation coefficient for ARIs was 0.026 across both years. Water, sanitation, and handwashing interventions with behavior change messaging did not reduce ARIs. Nutrition counseling and LNS modestly reduced ARI symptoms compared with controls in year 1 [prevalence ratio (PR): 0.87, 95% confidence interval (CI): 0.77–0.99], but no effect in the combined WSHN group weakens this finding.

Poultry Ownership Associated with Increased Risk of Child Diarrhea: Cross-Sectional Evidence from Uganda

Domestic animals have been associated with enteric infections in young children and can also be carriers of respiratory viruses. We conducted a cross-sectional assessment of health outcomes in children aged < 5 years associated with animal presence among 793 rural households in Uganda. We recorded the 2-week prevalence of diarrhea and respiratory infections in children, and the number of cows, poultry, sheep/goats, and pigs in the household. We used generalized linear models with robust standard errors to estimate the prevalence ratio (PR) for diarrhea and respiratory infections associated with households owning the above- versus below-median number of animals. We conducted unadjusted and adjusted analyses controlling for socioeconomic, water, sanitation, and hygiene indicators. Children in households with the above-median number (> 5) of poultry had 83% higher diarrhea prevalence than those with ≤ 5 poultry (adjusted PR = 1.83 [1.04, 3.23], P = 0.04). Children in households with the above-median number (> 2) of cows had 48% lower prevalence of respiratory infection than those with ≤ 2 cows (adjusted PR = 0.52 [0.35, 0.76], P < 0.005). There were no other significant associations between domestic animals and child health. Studies should assess if barring chickens from indoor living quarters and sanitary disposal of chicken and other animal feces can reduce childhood zoonotic infections.

Relationships among Common Illness Symptoms and the Protective Effect of Breastfeeding in Early Childhood in MAL-ED: An Eight-Country Cohort Study

Children in low-income countries experience multiple illness symptoms in early childhood. Breastfeeding is protective against diarrhea and respiratory infections, and these illnesses are thought to be risk factors of one another, but these relationships have not been explored simultaneously. In the eight-site MAL-ED study, 1,731 infants were enrolled near birth and followed for 2 years. We collected symptoms and diet information through twice-weekly household visits. Poisson regression was used to determine if recent illness history was associated with incidence of diarrhea or acute lower respiratory infections (ALRI), accounting for exclusive breastfeeding. Recent diarrhea was associated with higher risk of incident diarrhea after the first 6 months of life (relative risk [RR] 1.10, 95% confidence interval [CI] 1.04, 1.16) and with higher risk of incident ALRI in the 3- to 5-month period (RR 1.23, 95% CI 1.03, 1.47). Fever was a consistent risk factor for both diarrhea and ALRI. Exclusive breastfeeding 0-6 months was protective against diarrhea (0-2 months: RR 0.39, 95% CI 0.32, 0.49; 3-5 months: RR 0.83, 95% CI 0.75, 0.93) and ALRI (3-5 months: RR 0.81, 95% CI 0.68, 0.98). Children with recent illness who were exclusively breastfed were half as likely as those not exclusively breastfed to experience diarrhea in the first 3 months of life. Recent illness was associated with greater risk of new illness, causing illnesses to cluster within children, indicating that specific illness-prevention programs may have benefits for preventing other childhood illnesses. The results also underscore the importance of exclusive breastfeeding in the first 6 months of life for disease prevention.

Cocontribution of Rotavirus and Pneumococcal Conjugate Vaccines to the Reduction of Pediatric Hospital Visits in Young Children

OBJECTIVE

To assess rotavirus vaccine and pneumococcal conjugate vaccines (PCVs) cumulative impact on the pediatric emergency department visits and hospitalization rates in children <2 years of age in southern Israel between April 2006 and March 2014.

STUDY DESIGN

This prospective, population-based observational study calculated the rates of rotavirus gastroenteritis (RVGE), non-RVGE, community-acquired alveolar pneumonia (CAAP), nonalveolar lower respiratory tract infection, and all-cause hospital visits. PCV7, PCV13, and rotavirus vaccination programs were implemented in Israel in July 2009, November 2010, and January 2011, respectively.

RESULTS

From 2006-2009 to 2013-2014, the rates of hospitilizations for RVGE, non-RVGE, CAAP, and nonalveolar lower respiratory tract infection decreased by 78%, 21%, 46%, and 7%, respectively. In outpatients, the respective decreases were 80%, 16%, 67%, and 14%. All-cause outpatient pediatric emergency department visits and hospitalization rates were reduced by 12% and 11%, respectively. During the peak season (October through March), RVGE, non-RVGE, CAAP, and nonalveolar lower respiratory tract infection hospitalization rates decreased significantly by 86%, 44.6%, 23.3%, and 10.5%, respectively. In outpatients, the respective decreases were 81.7%, 73.5%, 13.8%, and 10.7%. The proportion of RVGE and CAAP (grouped) of all-cause hospitalizations and outpatient pediatric ED visits decreased from 19.9% to 12.3% and from 6.9% to 1.8%, respectively.

CONCLUSIONS

Rotavirus vaccine and PCV introduction cocontributed to a rapid, considerable reduction in hospital burden in children <2 years of age. Because seasonalities of both diseases overlap, this reduction is particularly helpful in relieving burdens of disease and care during the most cumbersome morbidity season.

[Incidence of community-acquired infections of lower airways among infants]

OBJECTIVE

To estimate the incidence of community-acquired infections of the lower respiratory tract and the risk factors associated with its occurrence in infants, in their first year of life.

METHODS

A prospective cohort study of infants who were followed up during the first 12 months of life. Interviews were conducted with their mothers, and children were clinically monitored bimonthly to investigate the occurrence of the incidence density of community-acquired infections of the lower respiratory tract. Cox regression analysis was used to estimate the crude and adjusted relative risk of the variables associated with the outcome.

RESULTS

The mean age of the mothers was 26 years, 62% of them had more than 11 years of schooling, and 23.5 were at risk of social exclusion regarding economic income. The incidence density of pneumonia and bronchiolitis were, respectively, 0.51 and 3.10 episodes per 100 children-months. Children who had low birth weight (<2500g) were 5.96 (95%CI 1.75-20.40) times more likely to have pneumonia than infants weighing 2500g or over.

CONCLUSIONS

The incidence of acute lower respiratory tract infection in children was similar to that found in other studies. Only low birth weight was an independent risk factor for the occurrence of pneumonia.

Stunting is associated with poor outcomes in childhood pneumonia

OBJECTIVE

Stunting affects 26.7% of children worldwide, and little is known about its effects on the outcomes of childhood pneumonia. We evaluated the effect of stunting on the outcomes of pneumonia among children enrolled in two large clinical trials.

METHODS

We analysed data from two WHO and USAID-sponsored inpatient treatment trials, the Severe Pneumonia Evaluation Antimicrobial Research study (n = 958) and the Amoxicillin Penicillin Pneumonia International Study (n = 1702), which enrolled children aged 2-59 months across 16 sites in LMICs. We assessed the effect of stunting (height-for-age Z score < -2) on treatment outcome and time to resolution of hypoxaemic pneumonia.

RESULTS

Among 2542 (96%) children with valid data for height, 28% were stunted and 12.8% failed treatment by 5 days. The failure rate among stunted patients was 16.0% vs. 11.5% among non-stunted patients [unadjusted RR = 1.24 (95% CI 1.08, 1.41); adjusted RR = 1.28 (95% CI 1.10, 1.48)]. An inverse relationship was observed between height and failure rates, even among non-stunted children. Among 845 patients with hypoxaemic pneumonia, stunting was associated with a lower probability of normalisation of respiratory rate [HR = 0.63 (95% CI 0.52, 0.75)] and oxygen saturation [HR = 0.74 (95% CI 0.61, 0.89)].

CONCLUSIONS

Stunting increases the risk of treatment failure and is associated with a longer course of recovery in children with pneumonia. Strategies to decrease stunting may decrease the burden of adverse outcomes in childhood pneumonia in low-resource settings.

Diarrhea and health inequity among Indigenous children in Brazil: results from the First National Survey of Indigenous People's Health and Nutrition

BACKGROUND

Globally, diarrhea is the second leading cause of death among children under five. In Brazil, mortality due to diarrhea underwent a significant reduction in recent decades principally due to expansion of the primary healthcare network, use of oral rehydration therapy, reduced child undernutrition, and improved access to safe drinking water. The First National Survey of Indigenous People's Health and Nutrition in Brazil, conducted in 2008-2009, was the first survey based on a nationwide representative sample to study the prevalence of diarrhea and associated factors among Indigenous children in the country.

METHODS

The survey assessed the health and nutritional status of Indigenous children < 5 years of age based on a representative sample of major Brazilian geopolitical regions. A stratified probabilistic sampling was carried out for Indigenous villages. Within villages, children < 5 years of age in sampled households were included in the study. Interviews were based on a seven day recall period. Prevalence rates of acute diarrhea were calculated for independent variables and hierarchical multivariable analyses were conducted to assess associations.

RESULTS

Information on diarrhea was obtained for 5,828 children (95.1% of the total sample). The overall prevalence of diarrhea was 23.5%. Regional differences were observed, with the highest rate being in the North (38.1%). Higher risk of diarrhea was observed among younger children and those who had less maternal schooling, lower household socioeconomic status, undernutrition (weight-for-age deficit), presence of another child with diarrhea in the household, and occurrence of upper respiratory infection.

CONCLUSIONS

According to results of the First National Survey of Indigenous People's Health and Nutrition, almost a quarter of Indigenous children throughout the country had diarrhea during the previous week. This prevalence is substantially higher than that documented in 2006 for Brazilian children < 5 years generally (9.4%). Due to its exceedingly multicausal nature, the set of associated variables that remained associated with child diarrhea in the final multivariable model provide an excellent reflection of the diverse social and health inequities faced by Indigenous peoples in contemporary Brazil.

Does comorbidity increase the risk of mortality among children under 3 years of age?

OBJECTIVES

Diarrhoea and pneumonia remain leading causes of morbidity and mortality in children under 5 years of age. Little data is available to quantify the burden of comorbidity and the relationship between comorbid diarrhoea and pneumonia infections and mortality. We sought to quantify the relationship between comorbidity and risk of mortality among young children in two community-based studies conducted among South Asian children.

DESIGN

Secondary data analysis of two cohort studies.

PARTICIPANTS

We identified two cohort studies of children under 3 years of age with prospective morbidity at least once every 2 weeks and ongoing mortality surveillance.

OUTCOME MEASURES

We calculated the mortality risk for diarrhoea and acute lower respiratory infection (ALRI) episodes and further quantified the risk of mortality when both diseases occur at the same time using a semiparametric additive model.

RESULTS

Among Nepali children, the estimated additional risk of mortality for comorbid diarrhoea and ALRI was 0.0014 (-0.0033, 0.0060). Among South Indian children, the estimated additional risk of mortality for comorbid diarrhoea and ALRI was 0.0032 (-0.0098, 0.0162). This risk is in addition to the single infection risk of mortality observed among these children.

CONCLUSIONS

We observed an additional risk of mortality in children who experienced simultaneous diarrhoea and ALRI episodes though the CI was wide indicating low statistical support. Additional studies with adequate power to detect the increased risk of comorbidity on mortality are needed to improve confidence around the effect size estimate.

Risk factors for severe acute lower respiratory infections in children: a systematic review and meta-analysis

AIM

To identify the risk factors in children under five years of age for severe acute lower respiratory infections (ALRI), which are the leading cause of child mortality.

METHODS

We performed a systematic review of published literature available in the public domain. We conducted a quality assessment of all eligible studies according to GRADE criteria and performed a meta-analysis to report the odds ratios for all risk factors identified in these studies.

RESULTS

We identified 36 studies that investigated 19 risk factors for severe ALRI. Of these, 7 risk factors were significantly associated with severe ALRI in a consistent manner across studies, with the following meta-analysis estimates of odds ratios (with 95% confidence intervals): low birth weight 3.18 (1.02-9.90), lack of exclusive breastfeeding 2.34 (1.42-3.88), crowding - more than 7 persons per household 1.96 (1.53-2.52), exposure to indoor air pollution 1.57 (1.06-2.31), incomplete immunization 1.83 (1.32-2.52), undernutrition - weight-for-age less than 2 standard deviations 4.47 (2.10-9.49), and HIV infection 4.15 (2.57-9.74).

CONCLUSION

This study highlights the role of the above seven risk factors in the development of severe pneumonia in under-five children. In addition, it emphasizes the need for further studies investigating other potential risk factors. Since these risk factors are potentially preventable, health policies targeted at reducing their prevalence provide a basis for decreasing the burden of childhood pneumonia.

Diarrhea as a risk factor for acute lower respiratory tract infections among young children in low income settings

Background

Diarrhea and acute lower respiratory tract infections (ALRI) are leading causes of morbidity and mortality among children under 5 years of age. We sought to quantify the correlation of diarrhea and respiratory infections within an individual child and to determine if infection with one illness increases the risk of infection with the other during the same time period.

Methods

We quantified the likelihood of an ALRI and a diarrhea episode occurring during the same week compared to the likelihood of each occurring independently in two cohorts of children under 3 years of age using a bivariate probit regression model. We also quantified the likelihood of an ALRI episode conditioned on a child’s diarrhea history and the likelihood of a diarrhea episode conditioned on a child’s ALRI history using Cox Proportional Hazard models.

Results

In Indian and Nepali children, diarrhea and ALRI occurred simultaneously more than chance alone. Incidence of ALRI increased in both cohorts as the number of days with diarrhea in the prior 28 days increased; the greatest incident rate ratio was reported among children with 20 or more days of diarrhea (1.02, 95% confidence interval (CI) 1.01 – 1.03 in Nepal and 1.07, 95% CI 1.05 – 1.09 in South India). Incidence of diarrhea was affected differently by ALRI prevalence depending on season.

Conclusions

Diarrhea may be a direct risk factor for ALRI among children under 3 years of age. The risk of comorbidity increases as disease severity increases, providing additional rationale for prompt community case–management of both diarrhea and pneumonia.

Effect of recent diarrhoeal episodes on risk of pneumonia in children under the age of 5 years in Karachi, Pakistan

BACKGROUND

We assessed the association between the duration of diarrhoea and the risk ofpneumonia incidence among children <5 years of age.

METHODS

We analysed data from a cluster randomized controlled trial in Karachi, Pakistan, which assessed the effect of promoting hand washing with soap (antibacterial and plain) on child health. Field workers visited households with children <5 years of age weekly and asked primary caregivers if their child had diarrhoea, cough or difficulty breathing in the preceding week. We used the WHO clinical case definitions for diarrhoea and pneumonia.We used adjusted time-to-event analyses with cumulative diarrhoea prevalence over the previous 2 and 4 weeks as exposure and pneumonia as outcome. We calculated the attributable risk of pneumonia due to recent diarrhoea across the intervention groups.

RESULTS

873 households with children <5 years were visited. Children had an increased risk of pneumonia for every additional day of diarrhoea in the 2 weeks (1.06, 95% CI: 1.03-1.09) and 4 weeks (1.04, 95% CI: 1.03-1.06) prior to the week of pneumonia onset. The attributable risk of pneumonia cases due to recent exposure to diarrhoea was 6%. A lower associated pneumonia risk following diarrhoea was found in the control group: (3%) compared with soap groups (6% in antibacterial soap, 9% in plain soap).

CONCLUSION

Children <5 years of age are at an increased risk of pneumonia following recent diarrhoeal illness. Public health programmes that prevent diarrhoea may also reduce the burden of respiratory illnesses.

Childhood tuberculosis and malnutrition

Despite the burden of both malnutrition and tuberculosis in children worldwide, there are few studies on the mechanisms that underlie this relationship. From available research, it appears that malnutrition is a predictor of tuberculosis disease and is associated with worse outcomes. This is supported through several lines of evidence, including the role of vitamin D receptor genotypes, malnutrition's effects on immune development, respiratory infections among malnourished children, and limited work specifically on pediatric tuberculosis and malnutrition. Nutritional supplementation has yet to suggest significant benefits on the course of tuberculosis in children. There is a critical need for research on childhood tuberculosis, specifically on how nutritional status affects the risk and progression of tuberculosis and whether nutritional supplementation improves clinical outcomes or prevents disease.

Fatores associados às complicações em crianças pré-escolares com pneumonia adquirida na comunidade

OBJETIVO: Identificar os fatores socioeconômicos e clínicos associados à evolução para complicações em crianças internadas com pneumonia adquirida na comunidade (PAC). MÉTODOS: Estudo longitudinal prospectivo em crianças diagnosticadas com PAC (12-59 meses de idade) internadas em enfermarias gerais de pediatria de dois hospitais na região de Campinas (SP). Os critérios de exclusão foram ter fibrose cística, cardiopatia, malformação pulmonar, neuropatias e doenças genéticas. PAC foi diagnosticada por características clínicas e radiológicas. Os dados foram coletados dos prontuários médicos e por um questionário semiestruturado. Os sujeitos foram divididos em dois grupos (PAC complicada e não complicada). Foram comparadas variáveis socioeconômicas e clínicas, e foi realizada análise de regressão logística multivariada. RESULTADOS: Das 63 crianças incluídas, 29 e 34, respectivamente, apresentaram PAC não complicada e PAC complicada. Não houve diferenças estatisticamente significantes entre os grupos quanto a idade na admissão, idade gestacional, peso ao nascer, gênero ou variáveis socioeconômicas. Houve diferenças significantes entre os grupos em relação a pneumonia anterior (p = 0,03), antibioticoterapia prévia (p = 0,004), tempo de início da doença (p = 0,01), duração da febre antes da internação (p < 0,001), duração da antibioticoterapia (p < 0,001) e tempo de internação (p < 0,001). Na análise multivariada, somente permaneceu no modelo a duração da febre antes da internação (OR = 1,97; IC95%: 1,36-2,84; p < 0,001). CONCLUSÕES: Variáveis biológicas, com destaque para o tempo de febre anterior à internação, parecem estar associadas com a evolução para complicação em crianças com PAC.

Pneumonia and poverty: a prospective population-based study among children in Brazil

BACKGROUND

Children in developing country suffer the highest burden of pneumonia. However, few studies have evaluated associations between poverty and pneumonia.

METHODS

A prospective population-based study on pneumonia was carried out as part of the Latin America Epidemiological Assessment of Pneumococcus (LEAP study). Chest x-rays were obtained for children one to 35 months old with suspected pneumonia presenting to emergency care centers and hospital emergency rooms in Goiania, Brazil. Chest radiographs were evaluated according to WHO guidelines. Clustering of radiologically-confirmed pneumonia were evaluated using a Poisson-based spatial scan statistic. Associations between census socioeconomic indicators and pneumonia incidence rates were analyzed using generalized linear models.

RESULTS

From May, 2007 to May, 2009, chest radiographs were obtained from 11 521 children with clinical pneumonia; 3955 episodes were classified as radiologically-confirmed. Incidence rates were significantly higher in very low income areas (4825.2 per 105) compared to high income areas (1637.3 per 105). Spatial analysis identified clustering of confirmed pneumonia in Western (RR 1.78; p=0.001) and Southeast (RR 1.46; p=0.001) regions of the city, and clustering of hospitalized pneumonia in the Western region (RR 1.69; p=0.001). Lower income households and illiteracy were associated with pneumonia incidence.

CONCLUSIONS

In infants the risk of developing pneumonia is inversely associated with the head of household income and with the woman educational level. Areas with deprived socioeconomic conditions had higher incidence of pneumonia and should be targeted for high vaccination coverage.

Complicated community acquired pneumonia in children prior to the introduction of the pneumococcal conjugated vaccine

Increasing prevalence of pleural empyema (PE) complicating community acquired pneumonia (CAP) is reported worldwide. We compared hospitalized children with PE or non-purulent pleural effusion (NP-PEF) prior to the inclusion of the pneumococcal conjugated vaccine (PCV7) in the Israeli immunization schedule. We conducted a retrospective analysis of medical files of all children <18 y of age hospitalized with either PE or NP-PEF and CAP during 1990-2002. 75 children with NP-PEF and 37 with PE were identified. PE annual incidence increased from 0.5 in 1990 to 4.2 per 100,000 children in 2002. Higher WBC and absolute neutrophils counts were found in sera and pleural fluid of PE. The leading pathogens included Streptococcus pneumoniae (42%, all penicillin-susceptible) and Staphylococcus aureus (23%, all methicillin-susceptible). Blood cultures were positive only in children with PE (12/37, 32.4%). Patients with PE presented with higher respiratory rate and required longer hospitalization, more PICU admission, and more patients needed mechanical ventilation. PE prevalence increased in southern Israel during the study period. Streptococcus pneumoniae (62.5% serotype 1) was the most common pathogen causing PE before the introduction of PCV7. Future introduction of PCV7 or equivalents in the immunization schedule may impact clinical presentation and epidemic trends and will require future consideration.

The effect of passive smoking and breast feeding on serum antioxidant vitamin (A, C, E) levels in infants

AIM

Toxic substances in tobacco smoke are known to have negative effects on the antioxidant capacity of human body. In order to investigate the effect of passive smoking on serum antioxidant levels in infants, serum vitamin A, E, C levels and urinary cotinine/creatinine levels were measured in 254 infants at the age of 6 months.

METHODS

The information about infants' nutrition and exposure to tobacco smoke was obtained from the mothers by the help of a questionnaire. The infants were grouped according to both smoking status of mother and urinary cotinine/creatinine levels.

RESULTS

The mean serum vitamin A, C and E levels of infants of smoking mothers were significantly lower than those of non-smoking mothers (p < 0.05). Vitamin A, E and C levels were negatively correlated with urinary cotinine/creatinine levels (p < 0.05, r: -0.61, -0.42, -0.53, respectively). Multivariate analysis revealed independent factors determining the serum vitamin A, E and C levels of infants as maternal smoking and breast feeding (p < 0.05).

CONCLUSION

Tobacco smoke exposure of infants significantly decreases their serum antioxidant vitamin A, C and E levels. However, breast feeding may help to prevent the decrement of antioxidant vitamin levels of passive smoking infants.

Factors determining the outcome of children hospitalized with severe pneumonia

Background

Pneumonia is one of the leading causes of morbidity and mortality in under fives. We carried out a comprehensive study to identify factors influencing both mortality and morbidity for children less than 5 years of age hospitalized with severe pneumonia.

Methods

200 hospitalized children aged 2–60 months with World Health Organization (WHO) defined severe pneumonia were enrolled in the study. The children were managed using a standard protocol. They were closely followed up for need for change in antibiotics, prolonged hospital stay, need for mechanical ventilation and mortality. Data on the factors influencing the outcome were collected.

Results

Of 200 children enrolled in the study, 113 (56.5%) needed a change in antibiotics, 102 (51%) stayed for more than 5 days in the hospital, 41 (20.5%) needed mechanical ventilation and 21 (10.5%) died. On multivariate analysis, lack of exclusive breastfeeding [RR (95%CI) 2.63 (2.16–2.86)], overcrowding [RR (95%CI) 1.94 (1.35–2.38)] and an abnormal chest x-ray [RR (95%CI) 2.29 (1.22–3.44)] were associated with the need for change of antibiotics. Lack of exclusive breastfeeding [RR (95%CI) 2.56 (2.0–2.93)], overcrowding [RR (95%CI) 2.59 (1.78–3.23)] and an abnormal chest x-ray [RR (95%CI) 2.99 (1.65–4.38)] were identified as determinants for prolonged hospital stay. Head nodding [RR (95%CI) 8.34 (2.71–12.77)], altered sensorium [RR (95%CI) 5.44 (1.34–17.56)], abnormal leukocyte counts [RR (95%CI) 5.85(1.36–17.14)] and pallor [RR (95%C) 10.88 (2.95–20.40)] were associated with mortality. Head nodding (RR (95% CI) 4.73 (1.50–6.36)] and cyanosis (RR (95%CI) 5.06 (1.80–11.34)] were the determining factors for mechanical ventilation.

In radiographically confirmed pneumonia, the determining factors for change of antibiotics were: lack of exclusive breast feeding [RR (95% CI) 2.05 (1.69–2.2)] and low birth weight [RR (95% CI) 1.59 (1.1–1.89)]. For prolonged hospital stay, the factors identified were mothers' education less than graduation [RR (95% CI) 1.5 (1.19–1.7)], lack of exclusive breast feeding [RR (95% CI) 1.77 (1.19–2.09)] and oxygen saturation of < 90% at time of presentation [RR (95% CI) 2.06 (1.42–2.42)]. Determinants for mechanical ventilation were mothers' education less than graduation [RR (95% CI) 3.6 (1.15–6.3)] and cyanosis at presentation [RR (95% CI) 10.9 (1.56–18.9)]. For mortality, the only determinant was pallor [RR (95% CI) 10.54 (1.8–21.79)].

Conclusion

Children hospitalized with severe community acquired pneumonia [as defined by World Health Organization (WHO)] who had not received exclusive breast feeding, had stayed in an overcrowded homes and had an abnormal chest radiograph were more likely to fail to respond with primary antibiotic regimen and require change of antibiotics and prolonged hospital stay.

In children with radiographically confirmed pneumonia, lack of breast feeding and low birth weight was associated with need for change in antibiotics.

The association between antibiotic use in the community and nasopharyngeal carriage of antibiotic-resistant Streptococcus pneumoniae in Bedouin children

BACKGROUND

The objective of the study was to evaluate whether the increase in antibiotic-resistant Streptococcus pneumoniae carriage was associated with antibiotic use in the community in children in Southern Israel.

METHODS

All the prescriptions given to Bedouin children <5 years old enlisted in 2 sentinel primary pediatric clinics treating approximately 20% of the Bedouin pediatric population of this age range were recorded, from 1998 to 2005. Nasopharyngeal pneumococcal isolates obtained during the same period from healthy children <5 years old were collected and antibiotic susceptibility was determined.

RESULTS

A total of 1488 of 1927 (77.7%) cultures were positive for S. pneumoniae. The proportion of S. pneumoniae with penicillin minimal inhibitory concentration > or = 1.0 microg/mL increased from 8% to 21% (P < 0.01); resistance to clindamycin from 9% to 22%; resistance to erythromycin from 13% to 30%; resistance to tetracycline from 13% to 31%; and multidrug resistance from 16% to 30%. The total annual antibiotic prescription rates decreased by 19%, from 3867 to 3191 prescriptions per 1000 children (P < 0.001). This was mainly the result of a reduction in amoxicillin +/- clavulanate prescriptions (from 3046 to 2582; P < 0.001). Oral cephalosporin, erythromycin and penicillin prescription rates decreased significantly as well (P < 0.001) whereas azithromycin prescription rates increased significantly (P < 0.001).

CONCLUSIONS

We suggest that the increased carriage of S. pneumoniae resistant to multiple antibiotics is possibly associated to the increased azithromycin consumption. Reduction of total antibiotic use may not be sufficient as long as antibiotics with high potential to promote multidrug resistance, given their pharmacokinetics and pharmacodynamics characteristics, are widely used.