Patients and Methods
The study was conducted at The Children’s Hospital, Pakistan Institute of Medical Sciences, Islamabad. This is a referral centre for a large population in and around the twin cities of Islamabad and Rawalpindi.
All children with pneumoma admitted between December 1992, -February 1993, were studied prospectively. This is the peak season for ARI in this region, Children 2-24 months old presenting with cough and/or difficult breathing were assessed and classified according to National AR! Control Programme guidelines13,14. Seventy-seven fulfilled the criteria of severe pneumonia, 17 very severe pneumonia and 6 simple pneumonia. Six children with simple pneumonia were admitted because they had not responded to initial oral anti-microbial therapy.
History of illness, parental education, socio-economic status, feeding, vaccination, medications taken before admission for current illness was recorded on a proforma. Physical examination, laboratory investigations and radiological examination were also performed. Nutritional status was determined according to Gomez classification. Underlying congenital and other, abnormalities were also investigated. A pediatric radiologist, blinded to the clinical diagnosis reviewed the roentgenogram.
Children with severe pneumonia were treated with parenteral ampicillin 200 mg/kg/day and those with very severe pneumonia with parenteral chloramphenicol 100 mg/kg/day sixhourly. Afterimprovement, they were switched over to oral amoxycillin in cases of severe and oral chloramphenical in very severe pneumonia to complete 10 days14.
If a child deteriorated or did not improve clinically within 48 hours, a change in antimicrobial therapy was made according to the NARI guidelines14. An earlier change in therapy was made on the basis of clinical judgement.
Feeding Practices: a) Exclusively breast fed: given breast milk and vitamins only; b) predominantly breast fed: given breast milk and other non-milk liquids; c) mixed fed: given both breast milk and other milk; d) never breast fed: never given breast milk; e) initially breast fed: bottle feeding at the time of admission but for an initial short period after birth, given breast milk.
Gainfully employed: Any work for which the respondent gets financial renumeration,
Illiterate: One who has not attended a formal school. Primary: One who has completed 5 grades ma school. Secondary: Who has completed upto 10 grades. College: Who has completed 12 or more grades.
Umvariate analysis was carried out for clinical characteristics and bivariate analysis for clinical severity of pneumonia, nutritional factors and radiological diagnosis. Chi square test was used for testing statistical significance for bivariate analysis.
This study shows that NARI Standard Case Management is effective in in-patient treatment of pneumonia. The guidelines for management of pneumonia, severe pneumonia and very severe pneumonia are simple and applicable in a tertiaiy care hospital as well as at the primary care facilities16. Pneumonia in developing countries and in Pakistan as well, is mainly of bacterial etiology17,18 and needs treatment with appropriate antibiotics. There has been a trend among physicians in developing countries to treat pneumonia with variety of antibiotics, occasionally with more than one antibiotic at a time19,20. Probably this polypharmacy is due to poor knowledge about etiology of pneumonia and also due to lack of confidence in one single antimicrobial drug. Prior to admission most of the children had received antibiotics in orni or injectable form, mostly given inappropriately. This shows the misuse of antibiotics in the communily. Other studies have also shown inadequate and inappropriate use of antibiotics in ARJ21,22. The children in our study had received antibiotics ranging from penicillin to cephalosporin. The use of inexpensive antibiotics like cotrimoxazole, penicillin and chioramphenicol in ARI standard case management inpneumonias has been shown to be effective16,20,23,24. The simple, effective and low cost standard case management guidelines are needed as much in the hospitals as in the isolated primary health care centres and poor communities.
When antibiotics were used in our admitted patients, according to NARI standard case management guidelines in appropriate dose, majority of children responded regardless to prior use of antibiotics.
We also compared the conventional clinical method of auscultation for diagnosis of pneumoma with NARI diagnostic criteria of fast breathing, chest indrawing and other danger signs. The NARI assessment protocol was compared with the traditional clinical examination, looking for signs of respiratory distress and listening to crackles and ralesonauscultation. The accuracy of diagnostic criteria of NARI protocol was as sensitive as traditional methods of diagnosis. The NARI protocol was simpler to follow and it also classified pneumonia into various stages according to the severity of disease. This helped indecision making during the case management. A number of workers have found these clinical signs to be reliable predictors of pneumonia and severe pneumonia25-27.
Radiology has been considered important in the diagnosis of pneumonia. In our study fewer than two third of the children had radiological evidence of pneumonia, though clinical criteria for diagnosis of pneumonia were fulfilled. This shows that chest radiography is not as sensitive and essential a criterion for diagnosis of pneumonia as the simple clinical signs like fast breathing and lower chest inclrawing26-29. Radiological changes appear later than the development of sensitive simple signs like fast breathing25,26. So, if diagnosis is only based on radiological evidence, it would possibly result in higher mothidity and mortality by virtue of increased severity of disease because radiological changes may take time to develop.
Young age is particularly a risk factor for developing pneumonia30-33. Half of the children in this study also were below 6 months of age and almost two third were under one year of age.
The impact of nutritional factors was also evaluated. Breast feeding in developing countries is not merely baby friendly but is essential for child survival. The superiority of human milk and breast feeding over formula and bottle is well documented34,35. Breast fed children have lower risk of ARI mothidity and mortality7,36. On the contrary few workers like Leventhal37, Bauchner38 and Hakansson39 found a minimal protective effect of breast feeding. Victora6, Lapage8 and Launer40 found that breast fed children had a lower incidence of ARI6,8,40. Chen et al found the protective effect of breast feeding greater for respiratory infections than for gasteoenteritis41 . Breast. feeding protects against viral pneumonia as well42. In our study very small number of children were exclusively breast fed and a significant number of children with pneumonia were suboptimally breast fed. This shows beneficial effect of breast feeding. However, because of the small sample size and the study design we were unable to assess exact relationship between breast feeding practices and severity of disease.
High incidence of ARI in lower socio-economic status has been described43-44. Poor socio-economic group are also related to poor housing conditions. Low literacy and poverty also contributes to the severity of pneumonia because these parents may bring their children late to the hospital resulting in delay of appropriate treatment. Majority of our patients belonged to lower socio-economic groups and their ,thothers were illiterate. Illness in this gmup of children was more severe and hospitaistay was also longer. Severity of disease in our study was less in children brought within 3 days of illness. Response to treatment in chidi brought early, was good and hospital stay Was short. Early health care seeking behaviour and recognition of signs of pneumonia should fonn an integral part of the future communications strategy for the NARl in the future.
Malnutrition is recognized as an important risk factor for developing pneumonia45-47. In our study, majority of the children were well nourished. The children who were malnourished had also not been breast fed and their duration of stay in hospital was longer than of well nourished children.
We conclude that NARI antibiotic therapy recommended for severe pneumonia and very severe pneumonia is effective. NARI programme standard case management guidelines for the small hospitals work for a tertiary care facility like ours. Use of simple clinical signs like fast breathing, lower chest indrawing and danger signs are an efficient way of diagnosing and classifying pneumonia.
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