Factors determining the outcome of children hospitalized with severe pneumonia

Abstract

BackgroundPneumonia 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.Methods200 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.ResultsOf 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)].ConclusionChildren 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.

Risk factors for mortality in children hospitalized with pneumonia

“…Presence of co-morbidities, in this study particularly diarrhea and HIV, has been reported as an important risk factor for severe pneumonia in areas with high prevalence of HIV [4]. These observations support a thorough clinical assessment at the time of admission to pick up underlying co-morbidities in order to provide optimum treatment for these specific conditions.…”

“…Significant independent predictors of mortality in children with pneumonia reported earlier by several prospective studies relate to host characteristics (age less than 1 year, lack of exclusive breastfeeding), severity of infection (severe roentgenogram changes, leukocytosis, bandemia), worsening of clinical condition, and hypoxemia (inability to feed, grunting, head nodding, respiratory rate >70/minute, severe chest indrawing, cyanosis), severe malnutrition (weight for age Z score <-3) and associated co-morbidities like diarrhea and HIV [1][2][3][4].…”

Kematian Akibat Pneumonia Berat pada Anak Balita

“…Case fatality rate pneumonia yang mendapat perawatan di rumah sakit sebesar 8,7-47%. Faktor prediktor yang meningkatkan kematian pneumonia antara lain head nodding, penurunan kesadaran, pucat, serta leukosit abnormal, 8 namun faktor risiko tersebut masih berbeda antara penelitian satu dan yang lainnya.…”

“…8 menunjukkan head nooding, penurunan kesadaran, nilai leukosit abnormal, dan juga pucat merupakan faktor risiko kematian pneumonia anak usia <5 tahun, sedangkan kelainan jantung bawaan, diare, dan malnutrisi merupakan faktor yang meningkatkan lama perawatan di rumah sakit, penggantian antibiotik, serta penggunaan ventilator mekanik. Penelitian yang dilakukan oleh Nantanda dkk.…”

“…Hasil yang sama juga dilaporkan pada penelitian terdahulu. 8 Beberapa penelitian lain anak yang tidak mendapat ASI meningkatkan kejadian pneumonia berat sebesar 1,5-2,6 kali dan dapat meningkatkan penggunaan ventilator, serta meningkatkan kematian sebesar 3,2-5,7 kali. 8 Malnutrisi terutama malnutrisi yang berat menunjukkan OR 16,5; 95%IK 4,2-65,5; juga mengingkatkan kematian pada pneumonia oleh karena penurunan respons imun terhadap infeksi.…”