Evaluation of risk factors for morbidity and mortality in children aged 1 month- 6 years presenting with lower respiratory tract infection to a referral hospital


  • Shambhavi Tewary Department of Paediatrics, Peerless Hospitex Hospital and Research Centre, Kolkata, West Bengal, India https://orcid.org/0000-0001-6778-168X
  • Sanjukta De Department of Paediatrics, Peerless Hospitex Hospital and Research Centre, Kolkata, West Bengal, India
  • Papiya Khawash Department of Paediatrics, Peerless Hospitex Hospital and Research Centre, Kolkata, West Bengal, India




LRTI, RISC score, Scoring model, Diagnostic criteria for pneumonia


Background: Acute lower respiratory tract infection (LRTI) is the single largest cause of death in children in most developing countries. It can be prevented by simple interventions and treated with low-cost medication and care. Hence we undertook this study with the aim to assess the severity of LRTI in children using the respiratory index of severity in children (RISC) scoring system and to evaluate the prognosis of these children using this scoring model and to evaluate which are the risk factors that consistently predict mortality and morbidity in LRTI in young children.

Methods: It was a prospective observational study which included 104 children aged 1 month-6 years presenting with LRTI. Data was collected using a pre-coded proforma and analysed using R 2.6.2 (2008-02-08) and Microsoft excel.

Results: The risk factors for adverse outcome in children with LRTI were age <6 months, refusal of feeds, hypoxemia (SpO2 <90% in room air), and positive chest X-ray findings for prolonged hospitalization, age <6 months for need for assisted ventilation. 62.79% of children with a RISC score of ≤0, were managed as outpatients and all children with a RISC score of ≥3 required hospitalization, of which, 88.89% required prolonged hospitalization and 19.4% required ventilation.

Conclusions: A high RISC score (≥3) can determine poor outcome in children with LRTI with high specificity and sensitivity. This study may be used to limit hospital referrals to those most in need, especially in resource limited regions, thereby improving the number of children receiving appropriate treatment.


Kabra SK. Acute lower respiratory tract infection. In: Paul VK, Bagga A, editors. Ghai Essential Paediatrics. 8th edition. New Delhi: CBS publishers. 2013;376-8.

Grant JP. The State of the World's Children. New York, Oxford University Press. 1994;20.

World Health Organisation. World Health Statistics Geneva WHO. 2010. Available at: http://www.who. int/whosis/whostat 2010.pdf. Accessed on 14 November 2013.

Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008;86(5):408-16.

Khan AJ, Khan JA, Akbar, Addiss DG. Acute respiratory infections in children: A case management intervention in Abbottabad District, Pakistan. Bull World Health Organ.1990;68:577-85.

Bang A, Bang R, Tale O, Sontakke P, Solanki J, Wargantiwar R, et al. Reduction in pneumonia mortality and total childhood mortality by means of community-based intervention trial in Gadchiroli, India. Lancet. 1990;336(8709):201-6.

Tiewsoh K, Lodha R, Pandey RM, Broor S, Kalaivani M, Kabra SK. Factors determining the outcome of children hospitalized with severe pneumonia. BMC Pediatr. 2009;9:15.

Sehgal V, Sethi GR, Sachdev HP, Satyanarayana L. Predictors of mortality in subjects hospitalized with acute lower respiratory tract infections. Indian Pediatr.1997;34:213-9.

Ramachandran P, Nedunchelian K, Vengatesan A, Suresh S. Risk factors for mortality in community-acquired pneumonia among children aged 1–59 months admitted in a referral hospital. Indian Pediatr. 2012;49(11):889-95.

World Health Organization. Integrated management of childhood illness chart booklet. Geneva: WHO. 2014. Available at: http://apps.who.int/iris/ bitstream/10665/104772/16/9789241506823_Chartbook_eng.pdf. Accessed on 16 December 2014.

Chowdhury E, El Arifeen S, Rahman M, Hoque D, Hossain M, Begum K, et al. Care at first-level facilities for children with severe pneumonia in Bangladesh: a cohort study. Lancet. 2008;372(9641):822-30.

Simoes EA, Peterson S, Gamatie Y, Kisanga FS, Mukasa G, et al. Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult. Bull World Health Organ. 2003;81:522-31.

Mosleh H. Accuracy of Risk Assessment Tool in Predicting Pneumonia’s Outcome among Egyptian Children: Hospital Based Study. Br J Med Med Res. 2013;3(4):2276-87.

Reed C, Madhi SA, Klugman KP, Kuwanda L, Ortiz JR, Finelli L, Fry AM. Development of the Respiratory Index of Severity in Children (RISC) score among young children with respiratory infections in South Africa. PLoS One. 2012;7(1):e27793.

Cardoso MRA, Carvalho CMN, Ferrero F, Alves FM, Cousens SN. Adding fever to WHO criteria for diagnosing pneumonia enhances the ability to identify pneumonia cases among wheezing children. Arch Dis Child. 2011;96(1):58-61.

Subhi R, Adamson M, Campbell H, Weber M, Smith K, Duke T. The prevalence of hypoxemia among ill children in developing countries: a systematic review. Lancet Infect Dis. 2009;9(4):219-27.

Djelantik IG, Gessner BD, Sutanto A, Steinhoff M, Linehan M, Moulton LH, et al. Case fatality proportions and predictive factors for mortality among children hospitalized with severe pneumonia in a rural developing country setting. J Trop Pediatr. 2003;49(6):327-32.

Graham SM, English M, Hazir T, Enarson P, Duke T. Challenges to improving case management of childhood pneumonia at health facilities in resource-limited settings. Bull World Health Organ. 2008;86:349-55.

Weber MW, Mulholland EK. Pulse oximetry in developing countries. Lancet. 1998;351:1589.

Maina J. Performance of a modified respiratory index of severity in children score to predict poor outcomes in children admitted with lower respiratory tract infections at Kenya National Hospital. The 10th International Congress of Tropical Pediatrics. Nairobi, Kenya. 2014.

Aujesky D, Fine M. The Pneumonia Severity Index: A Decade after the Initial Derivation and Validation. Clin Infect Dis. 2008;47(S3):S133-9.

Barsam FJ, Borges GS, Severino AB, de Mello LM, da Silva AS, Nunes AA. Factors associated with community-acquired pneumonia in hospitalised children and adolescents aged 6 months to 13 years old. Eur J Pediatr. 2013;172(4):493-9.

Suwanjutha S, Ruandkanchanasetr S, ChantarojanasiniT, Ttotrakitya S. Risk factors associated with morbidity and mortality of pneumonia in children under 5 years. Southeast Asian J Trop Med Public Health. 1994;25(1):60-6.

Patwari AK. Risk Factors for Mortality in Children Hospitalized with Pneumonia. Indian Pediatr 2012;49(11):869-70.

Kumar A, Saha E, Patra D. Outcome of Acute Lower Respiratory Tract Infection in Children. Indian Medical Gazzette. 2011;394-9.

Broor S, Pandey RM, Ghosh M, Maitreyi RS, Lodha R, Singhal T, Kabra SK. Risk factors for severe acute lower respiratory tract infection in under-five children. Indian Pediatr. 2001;38:1361-9.

Roy P, Sen PK, Das KB, Chakraborty AK. Acute respiratory infections in children admitted in a hospital of Calcutta. Indian J Public Health. 1991;35(3):67-70.

Agrawal PB, Shendurnikar N, Shastri NJ. Host factors and pneumonia in hospitalized children. J Indian Med Assoc. 1995;93(7):271-2.

World Health Organization. Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. Geneva, WHO. 2001. Available at: http://apps.who.int/iris/bitstream/ 10665/66956/1/WHO_V_and_B_01.35.pdf. Accessed on 16 December 2014.

Swingler G, Hussey G, Zwarenstein M. Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children. Lancet. 1998;351(9100):404-8.

Swingler G. Observer variation in chest radiography of acute lower respiratory infections in children: a systematic review. BMC Med Imaging. 2001;1(1).

Shah S, Bachur R, Kim D, Neuman M. Lack of Predictive Value of Tachypnea in the Diagnosis of Pneumonia in Children. Pediatr Infect Dis J. 2010;29(5):406-9.

Sachdev HP, Vasanthi B, Satyanarayana L, Puri RK . Simple predictors to differentiate acute asthma from ARI in children: implications for refining case management in the ARI Control Programme. Indian Pediatr. 1994;31(10):1251-9.

Ayieko P, English M. Case management of childhood pneumonia in developing countries. Pediatr Infect Dis J. 2007;26:432-40.

Kumar N, Singh N, Locham KK, Garg R, Sarwa D. Clinical Evaluation of Acute Respiratory Distress and Chest Wheezing in Infants. Indian Pediatr. 2002;39:478-83.

Hazir T, Qazi S, Nisar YB, Ansari S, Maqbool S, et al. Assessment and management of children aged 1–59 months presenting with wheeze, fast breathing, and/or lower chest indrawing; results of a multicentre descriptive study in Pakistan. Arch Dis Child. 2004;;89:1049-54.

Bleeker S, Moll H, Steyerberg E, Donders A, Derksen-Lubsen G, Grobbee D, et al. External validation is necessary in prediction research. J Clin Epidemiol. 2003;56(9):826-32.






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