Which children with chest-indrawing pneumonia can be safely treated at home, and under what conditions is it safe to do so? A systematic review of evidence from low- and middle-income countries

Abstract

Background WHO pneumonia guidelines recommend that children (aged 2-59 months) with chest indrawing pneumonia and without any “general danger sign” can be treated with oral amoxicillin without hospital admission. This recommendation was based on trial data from limited contexts whose generalisability is unclear. This review aimed to identify which children with chest-indrawing pneumonia in low- and middle-income countries can be safely treated at home, and under what conditions is it safe to do so. Methods We searched MEDLINE, EMBASE, and PubMed for observational and interventional studies of home-based management of children (aged 28 days to four years) with chest-indrawing pneumonia in low- or middle-income countries. Results We included 14 studies, including seven randomised trials, from a variety of urban and rural contexts in 11 countries. Two community-based and two hospital-based trials in Pakistan and India found that home treatment of chest-indrawing pneumonia was associated with similar or superior treatment outcomes to hospital admission. Evidence from trials (n = 3) and observational (n = 6) studies in these and other countries confirms the acceptability and feasibility of home management of chest-indrawing pneumonia in low-risk cases, so long as safeguards are in place. Risk assessment includes clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia, or HIV. Pulse oximetry is a critical risk-assessment tool that is currently not widely available and can identify severely ill patients with hypoxaemia otherwise possibly missed by clinical assessment alone. Additional safeguards include caregiver understanding and ability to return for review. Conclusions Home treatment of chest-indrawing pneumonia can be safe but should only be recommended for children confirmed to be low-risk and in contexts where appropriate care and safety measures are in place.

Defining the role of host biomarkers in the diagnosis and prognosis of the severity of childhood pneumonia: a prospective cohort study

“…Most cases of childhood pneumonia can be successfully managed at home 1 , 2 . In remote locations of many low- and middle-income countries (LMICs), where accessing hospital-level care may incur substantial cost, community-based care is often preferred by families 3 .…”

“…In remote locations of many low- and middle-income countries (LMICs), where accessing hospital-level care may incur substantial cost, community-based care is often preferred by families 3 . However, pneumonia remains the leading cause of death and disability for young children living in LMICs and clear criteria for the safe outpatient management of pneumonia are required 2 , 4 , 5 .…”

Randomised controlled trials in child and adolescent health in 2023

“…At the other end of the ALRI spectrum, home management of what WHO calls ‘chest indrawing’ ALRI can be effective, but again is only safe in certain contexts. To be safe there needs to be a system of risk assessment including clinical danger signs, oxygen saturation, and the presence of comorbidities such as undernutrition, anaemia or HIV, and parental understanding of when to return and ability to do so 16 17…”