International Emergency Medicine
Oxygen Saturation Can Predict Pediatric Pneumonia in a Resource-Limited Setting

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Abstract

Background

The World Health Organization (WHO) recommends using age-specific respiratory rates for diagnosing pneumonia in children. Past studies have evaluated the WHO criteria with mixed results.

Objective

We examined the accuracy of clinical and laboratory factors for diagnosing pediatric pneumonia in resource-limited settings.

Methods

We conducted a retrospective chart review of children under 5 years of age presenting with respiratory complaints to three rural hospitals in Rwanda who had received a chest radiograph. Data were collected on the presence or absence of 31 historical, clinical, and laboratory signs. Chest radiographs were interpreted by pediatric radiologists as the gold standard for diagnosing pneumonia. Overall correlation and test characteristics were calculated for each categorical variable as compared to the gold standard. For continuous variables, we created receiver operating characteristic (ROC) curves to determine their accuracy for predicting pneumonia.

Results

Between May 2011 and April 2012, data were collected from 147 charts of children with respiratory complaints. Approximately 58% of our sample had radiologist-diagnosed pneumonia. Of the categorical variables, a negative blood smear for malaria (χ2 = 6.21, p = 0.013) and the absence of history of asthma (χ2 = 4.48, p = 0.034) were statistically associated with pneumonia. Of the continuous variables, only oxygen saturation had a statistically significant area under the ROC curve (AUC) of 0.675 (95% confidence interval [CI] 0.581–0.769 and p = 0.001). Respiratory rate had an AUC of 0.528 (95% CI 0.428–0.627 and p = 0.588).

Conclusion

Oxygen saturation was the best clinical predictor for pediatric pneumonia and should be further studied in a prospective sample of children with respiratory symptoms in a resource-limited setting.

Introduction

Pneumonia kills more children under the age of 5 years than any other illness; it is responsible for over two million pediatric deaths each year (1). In the developing world, about 29% of children under 5 years of age, or about 151 million children each year, will develop clinical pneumonia. Nearly 10% of those, or 14 million children, will go on to have severe disease requiring hospitalization (1). Over 97% of new pneumonia cases each year occur among children living in low- and middle-income countries, and nearly two-thirds of those cases are in children living in Southeast Asia and sub-Saharan Africa (1). Because it is the primary cause for one in every five child deaths, prompt identification and treatment of pneumonia remains integral to achieving the fourth Millennium Development Goal of reducing the under-5 mortality by two-thirds before 2015.

To address the disease burden caused by pneumonia and other common childhood diseases such as malnutrition, diarrhea, and malaria, the World Health Organization (WHO) released the Integrated Management of Childhood Illnesses (IMCI) guidelines to establish a standardized protocol for the diagnosis and management of common and often fatal pediatric diseases (2). Given that in most resource-limited settings where child mortality remains high and access to advanced diagnostic modalities such as chest radiography are often limited, the IMCI guidelines appropriately focus on simple clinical measures for diagnosing and treating these common pediatric diseases. Although a recent evaluation of the impact of IMCI in five countries found relatively consistent improvements in health worker skills, community knowledge, and care-seeking behavior with the implementation of IMCI, the studies were mixed with regards to improvements in child mortality 3, 4, 5, 6, 7. Although the IMCI guidelines have proved to be both an effective and cost-effective tool for improving pediatric care in resource-limited settings, there is still room for further improvement and refinement of the guidelines to bring about more significant reductions in child mortality.

Specifically with regards to pneumonia, the IMCI guidelines recommend separating children with cough or difficulty breathing into one of three categories: children with chest indrawing (subcostal retractions) should be considered to have severe pneumonia; children with rapid respiratory rate (tachypnea) alone should be treated as having non-severe pneumonia; and children without tachypnea should be treated as having no pneumonia (essentially as having a viral upper respiratory infection). According to the IMCI guidelines, children with severe pneumonia should be given intravenous antibiotics and admitted to a hospital; children with non-severe pneumonia should be treated as outpatients with oral antibiotics; and children with no pneumonia should be treated as outpatients without antibiotics (2).

As part of a preliminary analysis for a larger study to develop a clinical prediction rule for pediatric pneumonia, we conducted a retrospective chart review of children under 5 presenting with respiratory complaints to three rural hospitals in Rwanda. We developed a list of candidate clinical variables that were associated with our outcome of interest: the presence of pneumonia on chest radiograph. Based on our review of the literature and experience treating children with respiratory disease in rural Rwanda, we hypothesized that other clinical signs and symptoms, including oxygen saturation, may be better predictors of pneumonia in children than respiratory rate alone.

Section snippets

Study Design

We conducted a retrospective chart review of children admitted with respiratory complaints (cough or difficulty breathing) to three rural hospitals in Rwanda. The research was approved by both the Rwanda National Ethics Committee and the Lifespan (Rhode Island Hospital) Institutional Review Board, both of which waived informed consent for this study given its retrospective nature and the difficulty in contacting rural villagers up to a year after their child's admission to the hospital.

Setting

This

Demographics

We identified 178 charts of children admitted to the pediatric wards of our three study hospitals between May 2011 and April 2012. Of these charts, 147 (87%) were for children under age 5 years who received chest radiographs, and we limited our analysis to this group. The median age of children in our sample was 10 months, and 51% were male. All three districts were about evenly represented, with 32% from Kayonza District, 26% from Kirehe District, and 42% from Burera District. Figure 1

Discussion

The accuracy and reliability of respiratory rate and other clinical indicators for the diagnosis of pneumonia is of far more than just academic importance; the use of inaccurate or unreliable means for diagnosing pneumonia in children can have significant negative impacts on both the effectiveness and cost-effectiveness of pediatric care in resource-limited settings. For instance, the low specificity of respiratory rate alone for diagnosing pneumonia in certain settings can mean that many

Conclusion

Pneumonia is a major cause of morbidity and mortality among children in resource-limited settings. Currently, the IMCI guidelines rely on respiratory rate as the primary indicator of pneumonia in children and advise initiating or withholding treatment based on this variable alone. However, the low specificity of respiratory rate may lead to overtreatment with antibiotics while missing other important diagnoses in children, and the low sensitivity dictates that antibiotics may be withheld from

Acknowledgments

We would like to thank the Rwanda Ministry of Health and Partners in Health/Inshuti Mu Buzima for their support of this project.

References (25)

  • S.E. Arifeen et al.

    Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial

    Lancet

    (2009)
  • I. Rudan et al.

    Epidemiology and etiology of childhood pneumonia

    Bull World Health Organ

    (2008)
  • Integrated management of childhood illness

    (2005)
  • J. Amaral et al.

    Effect of Integrated Management of Childhood Illness (IMCI) on health worker performance in Northeast-Brazil

    Cad Saude Publica

    (2004)
  • J. Bryce et al.

    Programmatic pathways to child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness

    Health Policy Plan

    (2005)
  • L. Huicho et al.

    Implementation of the Integrated Management of Childhood Illness strategy in Peru and its association with health indicators: an ecological analysis

    Health Policy Plan

    (2005)
  • J. Armstrong Schellenberg et al.

    The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania

    Health Policy Plan

    (2004)
  • Rwanda demographic and health survey 2010

    (2011)
  • T. Cherian et al.

    Standardized interpretation of paediatric chest radiographs for the diagnosis of pneumonia in epidemiological studies

    Bull World Health Organ

    (2005)
  • P. Margolis et al.

    The rational clinical examination. Does this infant have pneumonia?

    JAMA

    (1998)
  • T. Puumalainen et al.

    Clinical case review: a method to improve identification of true clinical and radiographic pneumonia in children meeting the World Health Organization definition for pneumonia

    BMC Infect Dis

    (2008)
  • S. Shah et al.

    Lack of predictive value of tachypnea in the diagnosis of pneumonia in children

    Pediatr Infect Dis J

    (2010)
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