Performance of WHO-defined clinical criteria for diagnosing pneumonia in children with severe acute malnutrition

Sarita Hathila; Varinder Singh

doi:10.18203/2349-3291.ijcp20263312

Authors

Sarita Hathila Department of Pediatrics, Ram Manohar Lohia Hospitals, New Delhi, India
Varinder Singh Department of Pediatrics, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India

DOI:

https://doi.org/10.18203/2349-3291.ijcp20263312

Keywords:

Severe acute malnutrition, Pneumonia, Under-five children, Respiratory rate, Fast breathing, World Health Organization

Abstract

Background: Severe acute malnutrition (SAM) and pneumonia are major contributors to childhood morbidity and mortality, particularly in developing countries. Malnourished children often exhibit a blunted inflammatory response, resulting in atypical clinical presentations that may delay the diagnosis of pneumonia. Evidence regarding the performance of the World Health Organization (WHO)-recommended respiratory rate cut-offs for diagnosing pneumonia in children with SAM remains limited. This study aimed to evaluate the diagnostic performance of WHO-defined clinical criteria for pneumonia among under-five children with severe acute malnutrition.

Methods: This prospective hospital-based observational study included 95 children aged 2–59 months with severe acute malnutrition who were admitted with suspected pneumonia. Chest radiography was performed in all participants. Seventy-five children with radiologically confirmed pneumonia were considered cases, while 20 children without radiological evidence of pneumonia served as controls. The diagnostic performance of WHO-defined fast breathing was evaluated by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratios.

Results: WHO-defined fast breathing demonstrated a sensitivity of 77.3% (95% CI: 66.2–86.2%) and a specificity of 40.0% (95% CI: 19.1–64.0%) for diagnosing radiologically confirmed pneumonia in children with SAM. The positive predictive value was 82.9%, while the negative predictive value was 32.0%. Overall diagnostic accuracy was 69.5%.

Conclusions: WHO-defined respiratory rate criteria retain acceptable sensitivity for identifying pneumonia in children with severe acute malnutrition. The findings support the continued use of WHO clinical criteria in resource-limited settings; however, larger multicenter studies are warranted to further validate their diagnostic performance in this high-risk population.

References

Mathew JL, Patwari AK, Gupta P, Shah D, Gera T, Gogia S, et al. Acute respiratory infection and pneumonia in India: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India. Indian Pediatr. 2011;48(3):191-218.

Garenne M, Ronsmans C, Campbell H. The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries. World Health Stat Q. 1992;45:180-91.

Hug L, Alexander M, You D, Alkema L; UN Inter-agency Group for Child Mortality Estimation. National, regional, and global levels and trends in neonatal mortality between 1990 and 2017, with scenario-based projections to 2030: a systematic analysis. Lancet Glob Health. 2019;7(6):672.

Chisti MJ, Tebruegge M, La Vincente S, Graham SM, Duke T. Pneumonia in severely malnourished children in developing countries: mortality risk, aetiology and validity of WHO clinical signs: a systematic review. Trop Med Int Health. 2009;14(10):1173-89.

Mathur A, Tahilramani G, Makhija S, Devgan V. Burden of severe acute malnutrition in under-five children (2-59 months) admitted in a tertiary care hospital of Delhi. J Trop Pediatr. 2018;64(1):45-50.

Chowdhury F, Shahid ASMSB, Ghosh PK, Rahman M, Hassan MZ, Akhtar Z, et al. Viral etiology of pneumonia among severely malnourished under-five children in an urban hospital, Bangladesh. PLoS One. 2020;15(2):54.

Tupasi TE, Mangubat NV, Sunico ME, Magdangal DM, Navarro EE, Leonor ZA, et al. Malnutrition and acute respiratory tract infections in Filipino children. Rev Infect Dis. 1990;12(8):297.

Spooner V, Barker J, Tulloch S, Lehmann D, Marshall TF, Kajoi M, et al. Clinical signs and risk factors associated with pneumonia in children admitted to Goroka Hospital, Papua New Guinea. J Trop Pediatr. 1989;35(6):295-300.

Cherian T, Steinhoff MC, Simoes EA, John TJ. Clinical signs of acute lower respiratory tract infections in malnourished infants and children. Pediatr Infect Dis J. 1997;16(5):490-4.

Mulholland EK, Simoes EA, Costales MO, McGrath EJ, Manalac EM, Gove S. Standardized diagnosis of pneumonia in developing countries. Pediatr Infect Dis J. 1992;11(2):77-8.

Shann F, Hart K, Thomas D. Acute lower respiratory tract infections in children: possible criteria for selection of patients for antibiotic therapy and hospital admission. Bull World Health Organ. 1984;62(5):749-53.

Harari M, Spooner V, Meisner S, Carney M, Shann F, De Campo J. Clinical signs of pneumonia in children. Lancet. 1991;338(8772):928-30.

Corniola RS, Suskind DL, Lewinter-Suskind L, Murthy KK, Suskind RM. The malnourished child. In: Suskind RM, Lewinter-Suskind L, editors. Textbook of Pediatric Nutrition. New York: Raven Press. 2010.

Chisti MJ, Ahmed T, Faruque ASG, Salam MA. Clinical and laboratory features of radiologic pneumonia in severely malnourished infants attending an urban diarrhoea treatment centre in Bangladesh. Pediatr Infect Dis J. 2010;29(2):174-7.

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(5):349-55.

Falade AG, Tschäppeler H, Greenwood BM, Mulholland EK. Use of simple clinical signs to predict pneumonia in young Gambian children: the influence of malnutrition. Bull World Health Organ. 1995;73(3):299-304.

Aref GH, Osman MZ, Zaki A, Amer MA, Hanna SS. Clinical and radiologic study of the frequency and presentation of chest infection in children with severe protein-energy malnutrition. J Egypt Public Health Assoc. 1992;67(5-6):655-73.

Wafula EM, Ngamau DW, Onyango FE, Mirza NM, Njeru EK. X-ray diagnosable pneumonia in children with severe malnutrition at Kenyatta National Hospital. East Afr Med J. 1998;75(10):567-70.