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May 1996, Volume 46, Issue 5

Original Article

Clinical, Nutritional and Radiological Features of Pneumonia

Muhammad Hamid  ( The Children’s Hospital, Pakistan Institute of Medical Sciences, G-8/3, Islamabad. )
Shamim A. Qazi  ( The Children’s Hospital, Pakistan Institute of Medical Sciences, G-8/3, Islamabad. )
Mushtaq A. Khan  ( The Children’s Hospital, Pakistan Institute of Medical Sciences, G-8/3, Islamabad. )


From December, 1992 to February, 1993,100 consecutively admitted children between 2-24 months of age with pneumonia were studied. They were diagnosed and treated according to the National ARI Control Programme case management guidelines. Of the total, 74 were under one year of age. Seventeen children had very severe pneumonia, 77 severe pneumonia and 6 simple pneumonia. Sixty children had radiologi­cal evidence of pneumonia, 89 responded to standard recommended treatment and only 11% required a change of therapy. There were no deaths. Only 6 mothers of these 100 children had practiced exclusive breast feeding. Low socioeconomic status, illiteracy and malnutrition were the other risk factors. In this study all types of pneumonia were more common in children under one year of age and radiology did not appear to be essential for its diagnosis. The National AR! Control guidelines for diagnosis and manage­ment of hospitalized children are simple, useful and effective (JPMA 46:95, 1996).


Pneumonia is the leading cause of childhood moibidity and mortality globally1. In 1990 acute respiratory infections (ARI) killed 4.3 million children under 5 years of age2. Approximately 10,000 children die from pneumonia every day - more than the deaths from diarrhoea or measles3,4. The higherprevalence of some risk factors in developing countries predisposes children to pneumonia3,4. Among these risk factors are young age5, lack of breast feeding6-8 malnutrition9, poor vaccination status10 and some congenital anomalies11. All these influence host immunity and defence.
The World Health Organization (WHO) has developed a protocol for management of AR! in children12 which has been adapted by the National ARI Control Programme of Pakistan13,14. Early recognition andproper case management are the mainstay of these guidelines for reduction of mortality and mothidity from pneumonia15.
The objective of this study was to determine the effectiveness of National AR! (NARI) Control Programme guidelines for management of pneumonia in in-patients and to assess some risk factors related to severity and prognosis of pneumonia.

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.
Statistical analysis
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.


Of 100 children included in this study, majority (66%) were males under one year of age (74%). Most (80°4) children belonged to lower socioeconomic groups (incom­eRs.3000/month). Fifty-seven percent mothers were illiterate and 8% were gainfully employed (Table 1).

Table II shows the clinical characteristics of pneumonia patients. Only 28% children came to the hospital within 3 days of illness. Eighty-six percent had received antibiotics in some + form, prior to admission. Majority (66%) of the children were well nourished and 43% were fully vaccinated. Fast breathing was the main complaint whichcorrelated well withthe clinical examination (84%). Lower chest indrawing was present in 94% and 17% had additional danger signs. Ninety-seven percent had crackles and 3% had bronchial breathing on auscultation. Eighty- nine percent improved with NARI Standard Case Management and only 11% needed a change in therapy. Of these 11%, 1 child had pyopneumothomx, 5 associated hypotoma, cerebral palsy, Gaucher disease and severe undernutrition. Whereas, other five children did not have any associated illness.

Table III shows the comparison of radiological and clinical diagnosis. There was radiological evidence of pneu­monia in 60% children. Fifty percent had bronchopneumonia, 9% lobar pneumonia and one pyopneumothomx. Total leuco­cyte count was less than 11,000/cm3 in 56% cases.
The feeding pattern of 100 children is shown in Table IV.

Exclusive breast feeding was practiced by only 6 of mothers while 75 gave non-milk fluids after birth. Twenty-four mothers had stopped breast feeding; of these 8, (3 3%) mothers did so before their children were two months of age, 4(17%) stopped between 2 and 4 months of age and the other 12(50%) did so between 4 and 6 months of age. When supplementary food practices were inquired. 67% reported giving biscuits and sometimes banana upto the age of one year and generally avoided the “family pot”.


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.


1. Chretien, J., Holland. W., Macklem, P. et a!. Acute respiratory infections in children: A Global Public Health Problem (editorial). N. Engi. J.Med., 1984;3 10:982-4.
2. Campbell, H. Acute respiratory infections are main killers ofunder 5s. Br. Med. J., 1992,304:335.
3. Monto. AS. Coordination ofepidemiological studies of respiratory infections. Pediatr. Res,, 1983; 17:1062-4.
4. A Programme for controlling acute respiratory infections in children: Memoran­dum from WHO meeting. Bull. WHO., 1984;62:47-58.
5. Glezen. W.P. and Denny, W.F Epidemiology of acute lower respiratory diseases in children. N. Engi. J. Med., 1973;28 8:498- 505.
6. Victora, C. G., Smith, PG., Vaughan, IF. eta!. Evidence of protection by breast feeding against infant deaths from infectious diseases in Brazil. Lancet, 1987;ii:319-22.
7. Watkins, C.J., Leeder, S.R. and Corkhill, R.T The relationship between breast and bottle feeding and respiratory illness in the first year of life. J. Epidemiol. Community Health, 1979;33:1 80- 182.
8. Lapage, P., Munyakazi, C. and Hennart, P: Breast feeding and hospital mortality in children inRwanda. Lancet, 1981 ,ii:409- 411.
9. Rochester, D.F, and Esan, SA. Malnutrition and respiratory system. Chest, 1984;85:411-415.
10. World Health Organizaiton, Case management ofARI in children in developing countries. Report of a working group meeting, WHO, Geneva, 1984.
11. Sunakom, P., Chunchit, L., Niltawat, S: et al. Epidemiology ofacuterespiratory infections in young children from Thailand. Pediatr. Infect. Dis. J., 1990;9:873­77.
12. World Health Organization. Acute respiratory infections in children: Case management in small hospitals in developing countries. A manual for doctors and other senior health workers, WHO programme for control of acute respiratory infections, Geneva, WHO/ART, 1991.
13. Government of Pakistan. Management of the young child with an acute respiratory infection, Islamabad Federal ART cell, Federal Ministry of Health, Government of Pakistan, 1991.
14. Government of Pakistan. Acute respiratory infections in children: Case management in small hospital in developing countries. A manual fordoctors and other senior health workers. Islamabad, Federal ART Cell, Federal Ministry of Health, Government ofPakistan, 1991.
15. Pio, A. Acute respiratory infection in children in developing countries: An international point of view. Pediatr. Infect. Dis. J., 1986;5: 179-82.
16. Khan, MA., Qazi, S.A., Rehman, G.N.. et at. A community study ot the application of WHO ARI management guidelines in Pakistan. Ann. Trop. Pediatr., 1993;13:73-78.
17. Shann, F. Etiology of severe pneumonia in children in developing countries. Pediatr. Infect. Dis. J., 1986;5:247-52.
18. Ghafoor, A., Nomani, N.K., Ishaq, Z. et al. Diagnosis ofacute towerrespiratory tract infections in children in Rawalpindi and Islamabad, Pakistan. Rev Infect. Dis., 1 990;1 2 (Suppl 8):S907- S914.
19. Maitai, C.K. and Watkins, W.M. A surveyofoutpatient prescriptions dispensed in Kenyatta National Hospital. East Afr. Med. J., 1980;58:641-645.
20. Narain, J.P. and Sharma, TD. Acute respiratory infections in Kangra district: magnitude and current treatment practices. Indian J. Pediatr., 1987;54:441-444.
21. Hussain, MM., Glass, R. I. and Khan M.R. Antibiotic use in rural community in Bangladesh. Int. J. Epidemiol., 1982;11:402-405.
22. Abbott, GD., Fergusson, D.M. and Horwood, LJ. General practitioner prescribing practices for childhood respiratory infection. NZ Med. J., 1982;95:185-188.
23. Shann, F., Linneman, V. and Gratten, M. Serum concentrations ofPenicillin after intramuscular administration ofProcaine, Benzyl and benethamine Penicillin in Children with pneumonia. J. Pediatr., 1987;110:299-302.
24. Shann, F, Barker, J. and Poore, P. Chloramphenicol aloneversus chiorampheni­cot plus penicillins for severe pneumonia in children. Lancet, 1985 ;2:684-686.
25. Campbell, H., Byass, P. and Greenwood, B.M. Simple clinical signs for diagnosis of acute lower respiratory infections. Lancet, 1988;ii:742-43.
26. Cherian, T, John, T.J., Simoes, E. et al. Evaluation of simple clinical signs for the diagnosis of acute lower respiratory tract infection. Lancet, 1988;ii:125-28.
27. Campbell, H., Byass, P., Lamont, A.C. et al. Assessment of clinical criteria for identification of severe acute lower respiratory tract infections in children. Lancet, 1989;i:297-299.
28. Alario, A.J., Mc-Carthy, P.L., Markowits, R. at al. Usefulness of chest radiographs in children with acute lower respiratory tract disease. J. Pediatr., 1987;111 :187-193.
29. Leventhal, J.M. Clinical predictors of pneumonia as a guide to ordering chest roentgenogram. Clin. Pediatr., 1982;21 ;730-34.
30. Berman, S., Duenas, A., Bcdoya, A. et al. Acute lower respiratory tract illnesses in Call, Colombia: A two-year ambulatory study. Pediatrics, 1983;71:210-18.
31. Borrero. I.. Fajardo, L., Bcdoya, A. etal. Acute respiratory tract infections in a birth cohort of children through 17 months of life. Cali, Colombia. Rev.In­fect.Dis.. 1990;12(Suppl 8):S950-S956.
32. Mc-Connocnie, K.M., Hall, C.B. ana BarKer, w.ri. Lower respiratory tracr illness in the first two years of life: Epidemiologic patterns and costs in a suburban pediatric practice. Am. J. Public Health, 1988;78:34-39.
33. Denny, F.W. and Clyde, WA. Acute lower respiratory tract infecitons in non-hospitalized children. J. Pediatr., 1986;108:635-646.
34. Jellife, D.B. and Jelliffe, E.F. Breast is best modernmeaning. N. EngI. J. Med., 1977;297:912-915.
35. Welsh, J.K. and May, J.T. Anti-infective properties of breast milk. J. Pediatr., 1979;94:1-9.
36. Jason, 3M, Nieburg, P., Mark, J.S. Mortality and infectious disease associated with infant feeding practices in developing countries. J. Pediatr., 1984;74:702-727.
37. Leventhal, J.M, Shapiro, ED., Aten, C.B. et at. Does breast feeding protect against infections in infants less than 3 months of age? Pediatrics, 1 986;78:896­ 903.
38. Bauchner, H., Leventhal, J.M. and Shapiro, ED. Studies of breast feeding and infections. How Good is the evidence? JAMA., 1986;256:887-92.
39. Hakansson, A. and Carisson, B. Maternal Cigarette Smoking, breast feedingand respiratory infections in infancy. Scand. J. Prim. Health Care, 1992;10:60-5.
40. Launer, L.J., Habicht, J.P. and Kardjate, S. Breast feeding protects infants in Indonesia against illness and weight loss due to illness. Am. J. Epidemiol., 1990;131:322-31.
41. Chen, Y., Yu, S. and Li, W. X Artificial feeding and hospitalization in the first 18 months of life. Pediatrics, 1988;81 :58-62.
42. Pullan, C., Toms, G.L., Martin, A.J. et at. Breast feeding and respiratory syncytial virus infection. Br. Med. J., 1980;281:1034-1036.
43. Victora, C.G., Smith, PG., Barros, F.C. et at. Risk factors for death dueto respiratory infections among Brazilian infants. Int. J. Epidemiol., 1989;18:918-925.
44. Vathanophas, K., Sangchai, R., Raktham, S. eta!. A community study of acute respiratory tract infections in Thai children, Rev. Infect. Dis., 1990;12 (supp8):S957-65.
45. Tupasi. I.E., Velmonte, M.A., Sanvictores, MEG. et at. Determinants of morbidity and mortality due to acute respiratory infections: Implications for intervention. J. Infect. Dis., 1988;157:615-23.
46. James, J.W., Longitudinal study of the morbidity of diarrhoeal and respiratory infections in malnourished children. Am. J. Clin. Nutr.. 1972;25:690-94.
47. Tupasi, T.E., Mangubat, NV., Sunico, M.E.S. et at. Malnutrition and acute respiratory tract infections in Filipino Children. Rev. Infect. Dis., 1990;12(Suppl 8):S1047-S 1054.

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