Factors predicting mortality in hospitalised HIV-negative children with lower-chest-wall indrawing pneumonia and
Katherine E Gallagher1,2, Juliet O Awori2, Maria D Knoll3
1Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Insights
New guidelines for childhood pneumonia recommend home treatment, but this study found that hypoxemia, malnutrition, or HIV exposure significantly increase mortality risk in children with lower chest wall indrawing pneumonia. These high-risk children require continued hospital management for better outcomes.
Area of Science:
- Pediatric Infectious Diseases
- Global Child Health
- Respiratory Medicine
Background:
- The World Health Organization (WHO) updated childhood pneumonia treatment guidelines in 2012, advocating for home-based management for cases with lower chest wall indrawing (LCWI) but no 'danger signs'.
- This shift aimed to reduce healthcare burden but may overlook specific subgroups of children with LCWI pneumonia who remain at high risk of mortality.
- The Pneumonia Etiology Research for Child Health (PERCH) study provides data to re-evaluate risk stratification for hospitalized LCWI pneumonia cases.
Purpose of the Study:
- To identify subgroups of children hospitalized with LCWI pneumonia who have a high risk of mortality.
- To compare the effectiveness of the 2012 WHO guidelines versus an alternative risk stratification model in identifying children who died.
- To inform clinical practice regarding the appropriate level of care for children with LCWI pneumonia.
Main Methods:
- Analysis of data from 2189 HIV-negative children aged 2-59 months hospitalized with LCWI pneumonia across multiple countries (2011-2014).
- Utilized predictive logistic regression to identify risk factors associated with mortality.
- Defined malnutrition as mid-upper-arm circumference <125mm or weight-for-age z-score <-2.
Main Results:
- Overall mortality was 3.6% (76/2189).
- Key mortality risk factors identified: oxygen saturation <92% (aOR 3.33), HIV-exposed status (aOR 4.59), moderate/severe malnutrition (aOR 6.85), and younger age.
- A model incorporating hypoxemia, HIV exposure, or malnutrition identified 86% of deaths (65/76) and 40% of all LCWI pneumonia cases, significantly outperforming the 2012 WHO criteria (which identified 66% of deaths).
Conclusions:
- The study supports enhanced risk stratification for children with LCWI pneumonia beyond current WHO guidelines.
- Children presenting with hypoxemia, malnutrition, or born to HIV-positive mothers face poorer outcomes and warrant continued hospital management.
- Prioritizing the identification of these risk factors is crucial to prevent community-based management for high-risk infants and improve child survival rates.
Introduction:
In 2012, the World Health Organization revised treatment guidelines for childhood pneumonia with lower chest wall indrawing (LCWI) but no 'danger signs', to recommend home-based treatment. We analysed data from children hospitalized with LCWI pneumonia in the Pneumonia Etiology Research for Child Health (PERCH) study to identify sub-groups with high odds of mortality, who might continue to benefit from hospital management but may not be admitted by staff implementing the 2012 guidelines. We compare the proportion of deaths identified using the criteria in the 2012 guidelines, and the proportion of deaths identified using an alternative set of criteria from our model.
Methods:
PERCH enrolled a cohort of 2189 HIV-negative children aged 2-59 months who were admitted to hospital with LCWI pneumonia (without obvious cyanosis, inability to feed, vomiting, convulsions, lethargy or head nodding) between 2011-2014 in Kenya, Zambia, South Africa, Mali, The Gambia, Bangladesh, and Thailand. We analysed risk factors for mortality among these cases using predictive logistic regression. Malnutrition was defined as mid-upper-arm circumference <125mm or weight-for-age z-score <-2.
Results:
Among 2189 cases, 76 (3·6%) died. Mortality was associated with oxygen saturation <92% (aOR 3·33, 1·99-5·99), HIV negative but exposed status (4·59, 1·81-11·7), moderate or severe malnutrition (6·85, 3·22-14·6) and younger age (infants compared to children 12-59 months old, OR 2·03, 95%CI 1·05-3·93). At least one of three risk factors: hypoxaemia, HIV exposure, or malnutrition identified 807 children in this population, 40% of LCWI pneumonia cases and identified 86% of the children who died in hospital (65/76). Risk factors identified using the 2012 WHO treatment guidelines identified 66% of the children who died in hospital (n = 50/76).
Conclusions:
Although it focuses on treatment failure in hospital, this study supports the proposal for better risk stratification of children with LCWI pneumonia. Those who have hypoxaemia, any malnutrition or those who were born to HIV positive mothers, experience poorer outcomes than other children with LCWI pneumonia. Consistent identification of these risk factors should be prioritised and children with at least one of these risk factors should not be managed in the community.
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