In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset

OBJECTIVES

We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors.

METHODS

We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors.

RESULTS

Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32).

CONCLUSION

Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

Video based non-contact monitoring of respiratory rate and chest indrawing in children with pneumonia

OBJECTIVE

Pneumonia is the single largest cause of death in children worldwide due to infectious diseases. According to WHO guidelines, fast breathing and chest indrawing are the key indicators of pneumonia in children requiring antibiotic treatments. The aim of this study was to develop a video-based novel method for simultaneous monitoring of respiratory rate and chest indrawing without upsetting babies.

APPROACH

Respiratory signals, corresponding to periodic movements of chest-abdominal walls during breathing, were extracted by analyzing RGB (red, green, blue) components in video frames captured by a smartphone camera. Respiratory rate was then obtained by applying fast fourier transform on the de-noised respiratory signal. Chest indrawing was detected by analysing relative phases of regional chest-abdominal wall mobility. The performance of the developed algorithm was evaluated on both healthy and pneumonia children.

MAIN RESULTS

The proposed method can measure respiratory rate with an overall mean absolute error of 1.8 bpm in the range 18-105 bpm. Phase difference between regional chest wall movements in the chest indrawing (pneumonia) cases was found to be 143±23.9 degrees, which was significantly higher than that in the healthy cases 52.3 ±32.6 degrees (p<0.001).

SIGNIFICANCE

Being non-intrusive and non-subjective, this computer-aided method can be useful in the monitoring for respiratory rate and chest indrawing for the diagnosis of pneumonia and its severity in children.

Fast-breathing vs chest-indrawing childhood pneumonia: baseline characteristics

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Comparison of fast-breathing vs chest-indrawing community-acquired pneumonia.

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Male and younger children appear more vulnerable to chest-indrawing pneumonia.

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Understanding sex-, age-, and nutrition-related differences informs interventions.

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

AIM

To determine the accuracy and effectiveness of community health workers (CHWs) when compared to trained nurses for management of pneumonia in Kenyan children.

METHODS

In Homabay County in western Kenya, children 2-59 months of age with lower chest indrawing pneumonia were identified, classified and treated by CHWs with oral amoxicillin (90 mg/kg per day) for five days at home. Trained nurses visited the child within 24 hours to verify diagnosis; and on day 4 and 14 to assess treatment outcomes.

RESULTS

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.

CONCLUSION

CHWs can correctly manage lower chest indrawing pneumonia even in high-mortality settings, such as western Kenya, in sub-Saharan Africa.

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 months of age in Lilongwe, Malawi: a study protocol

Background

Pneumonia 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.

Methods

This 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.

Discussion

Given 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 registration

NCT02678195: Pre-results. Date registered February 9, 2016.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3379-z) contains supplementary material, which is available to authorized users.