Stunting is associated with poor outcomes in childhood pneumonia

Time to recovery and its predictors among under-five children admitted with severe pneumonia in East Wallaga Zone public hospitals, western Ethiopia, 2023; a retrospective cohort study

BACKGROUND

Globally, pneumonia is one of the leading causes of morbidity and mortality as well as hospitalization burden for under-five children. Despite significant initiatives implemented to reduce morbidity and mortality from pneumonia in under-five children, little is known regarding the time to recovery and its predictors among under-five children admitted with severe pneumonia in Ethiopia. Hence, this study intended to estimate the median time to recovery and its predictors among under-five children admitted with severe pneumonia in East Wallaga zone public hospitals, western Ethiopia; 2023.

METHODS

An institution-based retrospective cohort study was conducted among 383 under-five children who were admitted with severe pneumonia in East Wallaga zone public hospitals from January 2017 to December 2022. A systematic sampling method was used to select eligible medical records. EpiData Version 4.6 was used to enter the data and analyzed using STATA Version 17.0. Cox-proportional hazard assumption test and model fitness were checked. Variables with P-value ˂ 0.25 at bivariable Cox regression analysis were selected for the multivariable Cox proportional model. A multivariable Cox regression model with 95% CI and Adjusted Hazard Ratio (AHR) was used to identify a significant predictor of time to recovery from severe pneumonia at a P-value < 0.05.

RESULTS

At the end of the follow-up, 356 observations were developed an event (recovered) with the median time to recovery of 4 days with IQR of 3-5 days. The overall incidence rate of recovery was 22.26 per 100 (95% CI: 20.07-24.70) person-days observations. Being rural residency (AHR: 0.75, 95% CI: 0.60-0.93), late presenters for seeking care (AHR = 0.70, 95% CI: 0.53-0.93), presence of danger sign at admission (AHR = 1.46, 95% CI: 1.15-1.83), and presence of comorbidity (AHR = 1.63, 95% CI, 1.31-2.04) were found to have a statistically significant association with prolonged recovery time.

CONCLUSION

The median time to recovery from severe pneumonia was long, and factors such as Residence, co-morbidity, presence of danger signs, and duration prior to seeking care were statistically significant predictors of recovery time from severe pneumonia. Hence, due attention has to be given to increasing the community's health-seeking behavior to visit health facility early and especial attention should be given for children with danger signs and comorbidity.

The Impact of Malnutrition on the Developing Lung and Long-Term Lung Health: A Narrative Review of Global Literature

Worldwide, over 2 billion children under the age of 5 experience stunting, wasting, or are underweight. Malnutrition contributes to 45% of all deaths in this age group (approximately 3.1 million deaths) [1]. Poverty, food insecurity, suboptimal feeding practices, climate change, and conflict are all contributing factors. Malnutrition causes significant respiratory problems, including increased risk of respiratory infections, impaired lung function, and increased risk of subsequent adult respiratory disease, including asthma, COPD, and lung cancer. Childhood malnutrition not only has serious consequences for children's health but it also has numerous consequences on wellbeing and educational attainment. Childhood malnutrition is a complex and multifaceted problem. However, by understanding and addressing the underlying causes, and investing in prevention and treatment programs, it is possible to maximize children's health and wellbeing on a global scale. This narrative review will focus on the impact of childhood malnutrition on lung development, the consequent respiratory disease, and what actions can be taken to reduce the burden of malnutrition on lung health.

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

Background

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.

Methods

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.

Findings

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.

Conclusions

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.

Validation of risk prediction for outcomes of severe community-acquired pneumonia among under-five children in Amhara region, Northwest Ethiopia

BACKGROUND

Globally there are over 1,400 cases of pneumonia per 100,000 children every year, where children in South Asia and Sub-Saharan Africa are disproportionately affected. Some of the cases develop poor treatment outcome (treatment failure or antibiotic change or staying longer in the hospital or death), while others develop good outcome during interventions. Although clinical decision-making is a key aspect of the interventions, there are limited tools such as risk scores to assist the clinical judgment in low-income settings. This study aimed to validate a prediction model and develop risk scores for poor outcomes of severe community-acquired pneumonia (SCAP).

METHODS

A cohort study was conducted among 539 under-five children hospitalized with SCAP. Data analysis was done using R version 4.0.5 software. A multivariable analysis was done. We developed a simplified risk score to facilitate clinical utility. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and calibration plot. Bootstrapping was used to validate all accuracy measures. A decision curve analysis was used to evaluate the clinical and public health utility of our model.

RESULTS

The incidence of poor outcomes of pneumonia was 151(28%) (95%CI: 24.2%-31.8%). Vaccination status, fever, pallor, unable to breastfeed, impaired consciousness, CBC abnormal, entered ICU, and vomiting remained in the reduced model. The AUC of the original model was 0.927, 95% (CI (0.90, 0.96), whereas the risk score model produced prediction accuracy of an AUC of 0.89 (95%CI: 0.853-0.922. Our decision curve analysis for the model provides a higher net benefit across ranges of threshold probabilities.

CONCLUSIONS

Our model has excellent discrimination and calibration performance. Similarly, the risk score model has excellent discrimination and calibration ability with an insignificant loss of accuracy from the original. The models can have the potential to improve care and treatment outcomes in the clinical settings.

Slow progress towards pneumonia control for children in low-and-middle income countries as measured by pneumonia indicators: A systematic review of the literature

Background

The integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD) has the goal of ending preventable childhood deaths from pneumonia and diarrhoea by 2025 with targets and indicators to monitor progress. The aim of this systematic review is to summarise how low-and-middle income countries (LMICs) reported pneumonia-specific GAPPD indicators at national and subnational levels and whether GAPPD targets have been achieved.

Methods

We searched MEDLINE, Embase, PubMed and Global Health Databases, and the World Health Organization (WHO) website. Publications/reports between 2015 and 2020 reporting on two or more GAPPD-pneumonia indicators from LMICs were included. Data prior to 2015 were included if available in the same report series. Quality of publications was assessed with the Quality Assessment Tool for Quantitative Studies. A narrative synthesis of the literature was performed to describe which countries and WHO regions were reporting on GAPPD indicators and progress in GAPPD coverage targets.

Results

Our search identified 17 publications/reports meeting inclusion criteria, with six from peer-reviewed publications. Data were available from 139 LMICs between 2010 and 2020, predominantly from Africa. Immunisation coverage rates were the indicators most commonly reported, followed by exclusive breastfeeding rates and pneumonia case management. Most GAPPD indicators were reported at the national level with minimal reporting at the subnational level. Immunisation coverage (Haemophilus influenzae, measles, diphtheria-tetanus-pertussis vaccines) in the WHO Europe, Americas and South-East Asia regions were meeting 90% coverage targets, while pneumococcal conjugate vaccine coverage lagged globally. The remaining GAPPD indicators (breastfeeding, pneumonia case management, antiretroviral prophylaxis, household air pollution) were not meeting GAPPD targets in LMICs. There was a strong negative correlation between pneumonia specific GAPPD coverage rates and under-five mortality (Pearson correlation coefficient range = -0.74, -0.79).

Conclusion

There is still substantial progress to be made in LMICs to achieve the 2025 GAPPD targets. Current GAPPD indicators along with country reporting mechanisms should be reviewed with consideration of adding undernutrition and access to oxygen therapy as important indicators which impact pneumonia outcomes. Further research on GAPPD indicators over longer time periods and at subnational levels can help identify high-risk populations for targeted pneumonia interventions.

Factors associated with community acquired severe pneumonia among under five children in Dhaka, Bangladesh: A case control analysis

Background

Pneumonia is the leading cause of death in children globally with the majority of these deaths observed in resource-limited settings. Globally, the annual incidence of clinical pneumonia in under-five children is approximately 152 million, mostly in the low- and middle-income countries. Of these, 8.7% progressed to severe pneumonia requiring hospitalization. However, data to predict children at the greatest risk to develop severe pneumonia from pneumonia are limited.

Method

Secondary data analysis was performed after extracting relevant data from a prospective cluster randomized controlled clinical trial; children of either sex, aged two months to five years with pneumonia or severe pneumonia acquired in the community were enrolled over a period of three years in 16 clusters in urban Dhaka city.

Results

The analysis comprised of 2,597 children aged 2–59 months. Of these, 904 and 1693 were categorized as pneumonia (controls) and severe pneumonia (cases), respectively based on WHO criteria. The median age of children was 9.2 months (inter quartile range, 5.1–17.1) and 1,576 (60%) were male. After adjustment for covariates, children with temperature ≥38°C, duration of illness ≥3 days, male sex, received prior medical care and severe stunting showed a significantly increased likelihood of developing severe pneumonia compared to those with pneumonia. Severe pneumonia in children occurred more often in older children who presented commonly from wealthy quintile families, and who often sought care from private facilities in urban settings.

Conclusion and recommendation

Male sex, longer duration of illness, fever, received prior medical care, and severe stunting were significantly associated with development of WHO-defined severe childhood pneumonia in our population. The results of this study may help to develop interventions target to reduce childhood morbidity and mortality of children suffering from severe pneumonia.

The distribution characteristics of intestinal microbiota in children with community-acquired pneumonia under five Years of age

Pneumonia is the leading cause of morbidity and mortality in children under five years of age worldwide. Over the past decades, studies have shown that the upper respiratory pathogens are closely related to the occurrence of pneumonia. However, the co-occurrence of gut microbiome dysbiosis may have clinical manifestation in the prognosis of childhood pneumonia. The aim of the present study is to investigate the differences in gut microbial communities between children's diagnosed community-acquired pneumonia (CAP) under five compared to healthy controls in Inner Mongolia. Fecal samples were collected from children with CAP and healthy controls (<5 years old) and the genomic microbiome 16S rRNA was amplified using the hypervariable V4 region and subjected to MiSeq Illumina sequencing, and then analyzed for microbiota composition and phenotype. Finally functional profiling was performed by KEGG pathways analyses. Our results revealed a gut microbiota dysbiosis in children with CAP. Distinct gut microbiome composition and structure were associated with childhood CAP between two age categories compared to healthy controls. In addition, the phylogenic phenotype's prediction was found to be significantly different between the groups. The prominent genera in age group of 0-3 were Bifidobacterium and Enterococcus. On the contrary, Escherichia-Shigella, Prevotella, Faecalibacterium and Enterobacter were remarkably decreased in most of the fecal samples from CAP patients in age group of 0-3 compared to the control. At the genus level, the CAP children in the age group of 4-5 showed an increase in the abundance of Escherichia/Shigella, Bifidobacterium, Streptococcus and Psychrobacter and, a decrease in the abundance of Faecalibacterium, Bacteroides, Lachnospiraceae and Ruminococcus compared with the matched healthy controls. Moreover, CAP children in both age groups exhibited distinct profiles in the KEGG functional analysis. Our data revealed that the gut microbiota differ between CAP patients and health children and certain gut microbial species are associated with CAP. Further research to identify specific microbial species which may contribute to the development CAP are merited. In addition, rectification of microbiota dysbiosis may provide supplemental benefits for treatment of the childhood CAP.

Assessing Comorbidity of Diarrhea and Acute Respiratory Infections in Children Under 5 Years: Evidence From Kenya's Demographic Health Survey 2014

Background: Kenya is one among the 15 countries that account for three-quarters of the global mortality burden due to diarrhea and respiratory tract infections (RTIs). Comorbidity of diarrhea and acute respiratory infection (ARI) can either be simultaneous (both occurring at the same time) or sequential (where the occurrence of one leads to the occurrence of the other. This study aimed to determine the shared risks that influence comorbidity of diarrhea and RTIs among Kenya's children younger than 5 years. Methods: The study entailed an analysis of secondary data from the Kenya Demographic Health Survey (DHS) 2014 using STATA Corp 2010. Descriptive analysis of independent variables and logistic regression model was used to analyze risk factors associated with comorbidity from diarrhea and ARI in children <5 years. Results: A total of 18 702 children <5 years were in the study out of whom 411 had comorbidity from diarrhea and ARI in the 2 weeks prior to the survey. Comorbidity peaked at 6 to 11 months (4.6%). Child's age between 6 and 11 months (adjusted odds ratio [aOR] = 3.48, 95% CI = 2.02-5.99) and caregivers with incomplete primary education (aOR = 1.66, 95% CI = 1.11-2.50) were associated with higher odds of comorbidity from diarrhea and ARI. The main determinants associated with lower odds of combined morbidity from diarrhea and ARI were high wealth quintile (aOR = 0.58, 95% CI = 0.39-0.85) and older aged caregivers (aOR = 0.47, 95% CI = 0.23-0.95). However, we found no association between nutritional status of a child, sex, residence, exclusive breastfeeding between 0 and 6 months, and combined morbidity from diarrhea and ARI. Conclusion: Programs aimed at reducing comorbidity should target children between 6 and 11 months and deliberate emphasis should be placed on addressing barriers to wealth and caregivers' education.

Birth size and early pneumonia predict linear growth among HIV-exposed uninfected infants

Stunting remains a global health priority, particularly in sub-Saharan Africa. Identifying determinants of linear growth in HIV-exposed uninfected (HEU) infants can inform interventions to prevent stunting in this vulnerable population. HIV-infected mothers and their uninfected infants were followed monthly from pregnancy to 12-month post-partum in Nairobi, Kenya. Mixed-effects models estimated the change in length-for-age z-score (LAZ) from birth to 12 months by environmental, maternal, and infant characteristics. Multivariable models included factors univariately associated with LAZ. Among 372 HEU infants, mean LAZ decreased from -0.54 (95% confidence interval [CI] [-0.67, -0.41]) to -1.09 (95% CI [-1.23, -0.96]) between 0 and 12 months. Declines in LAZ were associated with crowding (≥2 persons per room; adjusted difference [AD] in 0-12 month change: -0.46; 95% CI [-0.87, -0.05]), use of a pit latrine versus a flush toilet (AD: -0.29; 95% CI [-0.57, -0.02]), and early infant pneumonia (AD: -1.14; 95% CI [-1.99, -0.29]). Infants with low birthweight (<2,500 g; AD: 1.08; 95% CI [0.40, 1.76]) and birth stunting (AD: 1.11; 95% CI [0.45, 1.78]) experienced improved linear growth. By 12 months of age, 46 infants were stunted, of whom 11 (24%) were stunted at birth. Of the 34 infants stunted at birth with an available 12-month LAZ, 68% were not stunted at 12 months. Some low birthweight and birth-stunted HEU infants had significant linear growth recovery. Early infant pneumonia and household environment predicted poor linear growth and may identify a subgroup of HEU infants for whom to provide growth-promoting interventions.

Air pollution control and the occurrence of acute respiratory illness in school children of Quito, Ecuador

Because of air quality management and control, traffic-related air pollution has declined in Quito, Ecuador. We evaluated the effect of a city-wide 5-year air pollution control program on the occurrence of acute respiratory illness (ARI). We compared two studies conducted at the same location in Quito: in 2000, 2 years before the policy to control vehicle emission was introduced, and in 2007. Each study involved ~ 730 children aged 6-12 years, observed for 15 weeks. We examined associations between carboxyhemoglobin (COHb) serum concentration-an exposure proxy for carbon monoxide (CO)-ambient CO, and ARI in both cohorts. In 2007, we found a 48% reduction in the ARI incidence (RR 0.52; 95% CI 0.45-0.62, p < 0.0001), and 92% decrease in the percentage of children with COHb > 2.5% as compared to the 2000 study. We found no association between COHb concentrations above the safe level of 2.5% and the ARI incidence (p = 0.736). The decline in air pollution due to vehicle emissions control was associated with a lower incidence of respiratory illness in school children.

Risk factors associated with nasopharyngeal carriage and density of Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus in young children living in Indonesia

Background

Potentially pathogenic bacteria Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus are commonly carried in the nasopharynx of young children. Host and environmental factors have been linked with pathogen carriage, and in many studies rural children have higher carriage rates than their urban counterparts. There are few published data on what factors contribute to increased pathogen density. The objectives of this study were to identify risk factors for nasopharyngeal carriage and density of S. pneumoniae, H. influenzae, M. catarrhalis, and S. aureus in young children in Indonesia.

Methods

Risk factor analysis was done using data on bacterial carriage and participant characteristics from a cross-sectional study that enrolled 302 children aged 12–24 months living in urban or semi-rural areas of Indonesia. Associations between host factors and odds of pathogen carriage were explored using logistic regression. Characteristics identified to be independent predictors of carriage by univariable analysis, as well as those that differed between urban and semi-rural participants, were included in multivariable models. Risk factors for increased pathogen density were identified using linear regression analysis.

Results

No differences in carriage prevalence between urban and semi-rural children were observed. Multiple children under the age of 5 years in the household (< 5y) and upper respiratory tract infection (URTI) symptoms were associated with S. pneumoniae carriage, with adjusted odds ratios (aOR) of 2.17 (95% CI 1.13, 4.12) and 2.28 (95% CI 1.15, 4.50), respectively. There was some evidence that URTI symptoms (aOR 1.94 [95% CI 1.00, 3.75]) were associated with carriage of M. catarrhalis. Children with URTI symptoms (p = 0.002), and low parental income (p = 0.011) had higher S. pneumoniae density, whereas older age was associated with lower S. pneumoniae density (p = 0.009). URTI symptoms were also associated with higher M. catarrahlis density (p = 0.035). Low maternal education (p = 0.039) and multiple children < 5y (p = 0.021) were positively associated with H. influenzae density, and semi-rural residence was associated with higher S. aureus density (p < 0.001).

Conclusions

This study provides a detailed assessment of risk factors associated with carriage of clinically-relevant bacteria in Indonesian children, and new data on host factors associated with pathogen density.

Electronic supplementary material

The online version of this article (10.1186/s41479-018-0058-1) contains supplementary material, which is available to authorized users.

Pneumonia in HIV-exposed and Infected Children and Association With Malnutrition

We evaluated the association between HIV exposed-uninfected (HEU) status, malnutrition and risk of death in Ugandan children hospitalized with pneumonia. Both HIV exposure and infection were associated with lower anthropometric indices on univariate analysis, and mid-upper arm circumference was significantly associated with overall mortality (odds ratio (OR), 0.96) in a multivariable model. HIV infection (OR 5.0) but not HEU status was associated with overall mortality. Malnutrition may contribute to poor pneumonia outcomes among HIV-infected and HEU children requiring hospitalization.

Impact of contaminated household environment on stunting in children aged 12-59 months in Burkina Faso

BACKGROUND

Stunting affects 165 million children worldwide, with repercussions on their survival and development. A contaminated environment is likely to contribute to stunting: frequent faecal-oral transmission possibly causes environmental enteropathy, a chronic inflammatory disorder that may contribute to faltering growth in children. This study's objective was to assess the effect of contaminated environment on stunting in Burkina Faso, where stunting prevalence is persistently high.

METHODS

Panel study of children aged 1-5 years in Kaya. Household socioeconomic characteristics, food needs and sanitary conditions were measured once, and child growth every year (2011-2014). Using multiple correspondence analysis and 12 questions and observations on water, sanitation, hygiene behaviours, yard cleanliness and animal proximity, we constructed a 'contaminated environment' index as a proxy of faecal-oral transmission exposure. Analysis was performed using a generalised structural equation model (SEM), adjusting for repeat observations and hierarchical data.

RESULTS

Stunting (<2 SD height-for-age) prevalence was 29% among 3121 children (median (IQR) age 36 (25-48) months). Environment contamination was widespread, particularly in rural and peri-urban areas, and was associated with stunting (prevalence ratio 1.30; p=0.008), controlling for sex, age, survey year, setting, mother's education, father's occupation, household food security and wealth. This association was significant for children of all ages (1-5 years) and settings. Lower contamination and higher food security had effects of comparable magnitude.

CONCLUSIONS

Environment contamination can be at least as influential as nutritional components in the pathway to stunting. There is a rationale for including interventions to reduce environment contamination in stunting prevention programmes.

Effect of pregnancy intention, postnatal depressive symptoms and social support on early childhood stunting: findings from India

BACKGROUND

According to United Nation Children's Fund, it has been estimated that worldwide about 165 million children were stunted in 2012 and India alone accounts for 38 % of global burden of stunting. This study aims to examine the effect of pregnancy intention and maternal postnatal depressive symptoms on early childhood stunting in India. We hypothesized that effect of pregnancy intention and postnatal depressive symptoms were mediated by social support.

METHODS

We used data from the first wave of Young Lives Study India. Multivariate logistic regression models (using generalized estimation equation) were used to examine the effect of pregnancy intention and postnatal depressive symptoms on early childhood stunting among children aged 5-21 months. The analysis included 1833 children (out of 2011 sample children) that had complete information on pregnancy intention, maternal depression and other variables.

RESULTS

Bivariate results indicate that a higher percent of children born after unintended pregnancy (40 %) were stunted than children of intended pregnancy (26 %). Likewise, the proportion of stunted children was also higher among women with high postnatal depressive symptoms (35 %) than the low level of depression (24 %). Results of multivariate logistic regression model indicate that children born after unintended pregnancy were significantly more likely to be stunted than children born after intended pregnancy (AOR: 1.76, CI: 1.25, 2.48). Similarly, early childhood stunting was also associated with maternal postnatal depressive symptoms (AOR: 1.53, CI: 1.21, 1.92). Moreover, the effect of pregnancy intention and postnatal depressive symptoms on early childhood stunting were not mediated by social support.

CONCLUSIONS

The findings of this study provide conclusive evidence regarding consequences of pregnancy intention and postnatal depressive symptoms on early childhood stunting in India. Therefore, there is a need to identify the women with unintended pregnancy and incorporate the promotion of mental health into their national reproductive and child health programme.