Clinical And Epidemiological Of Severe And Very Severe Pneumonia In Infants And Children

Clinical And Epidemiological Of Severe And Very Severe Pneumonia In Infants And ChildrenSumber: Medicinus Agustus 2020  vol. 33 issue 2Hedi Mustiko MD, Retno Asih Setyoningrum MDDepartment of Pediatrics Faculty of Medicine Universitas Airlangga/Soetomo General Academic Hospital Surabaya-Indonesia 

Abstract 

Background: Childhood pneumonia is a leading cause of mortality and morbidity in developing countries.  World Health Organization  (WHO) stated that pneumonia is the cause of mortality of around 1.2 million children under 5 years per year. The high incidence of very  severe pneumonia cases with preventable risk factors become the background of this study.Purpose: The aim of our study was to describe clinical and epidemiological characteristics of severe and very severe pneumonia in  infants and children.Methods: This is a descriptive cross-sectional study. The study were conducted from January 2017 to December 2018. We obtained  clinical and demographic data of each patient based on medical records.The diagnosis of pneumonia was made clinically based on the  Indonesian Ministry of Health criteria. Prematurity was defined as babies born with gestational age less than 37 weeks, low birth weight  was defined as babies with birth weight less than 2500 grams. The nutritional status of children is clinically and anthropometrically  evaluated using 2006 WHO curve of weight-by-age.Results: A total of 465 patients were diagnosed with pneumonia during 48 months study. 212 patients were excluded and 253 pneumonia  patients met the inclusion criteria, 140 patients with very severe pneumonia and 113 patients with severe pneumonia. Among 253  patients, 141 were boys. 125 patients were 2-5 months of age. 71 patients were born with low birth weight and 62 patients had history of  preterm birth. There were 86 patients receiving exclusive breastfeeding and 138 patients with complete immunization status. There were  131 patients with moderate and severe malnutrition, and 127 patients with comorbidity factors. 94 patients developed pneumonia with  suspected bacterial causative agents.Conclusion: Lower age, prematurity, low birth weight, poor nutritional status, exclusive breastfeeding, comorbidities, and suspected  bacterial causative agents are common characteristics of severe and very severe pneumonia in infants and children in Dr. Soetomo  Surabaya.Keywords: Pneumonia, very severe, characteristic, descriptive epidemiology

Introduction 

Childhood pneumonia is a leading cause of mortality and morbidity in developing countries.1  World Health Organization (WHO) declares  pneumonia as the cause of mortality of around 1.2 million children under 5 years per year.2  The incidence of pneumonia in children under  5 years of age is 150 million cases per year, worldwide.3  About 7-13% of pneumonia are very severe pneumonia. Based on the 2012  Indonesian Demographic Health Survey (Survei Demografi dan Kesehatan Indonesia/SDKI), the under-five years mortality rate due to  pneumonia in Indonesia was 40 per 1000 live births.4

Characteristics identification of severe and very severe pneumonia can be used as a predictor of pneumonia cases. It can be useful in  the management and evaluation of patients as well as a function of community therapy.5  A study in Egypt showed that maternal age  and education, vaccination status, indoor air pollution and exposure to cigarette smoke are factors that affecting the incidence of severe  pneumonia in infants and children.6  Study by Sudarwati, et al. at Hasan Sadikin Hospital Bandung showed that malnutrition, prematurity  and the presence of comorbidities such as infection with Human Immunodeficiency Virus (HIV), congenital heart disease, cerebral palsy,  and tuberculosis are factors that affect the incidence of pneumonia in children with high mortality rates.7

The aim of our study was to describe clinical and epidemiological characteristics of severe and very severe pneumonia in infants and  children in Dr. Soetomo Hospital, Surabaya.

Methods 

1. Patients 

The study was carried out on 2-59 months old children with severe and very severe pneumonia admitted in Respirology Ward and  Pediatric Intensive Care Unit (PICU), Department of Pediatrics Dr. Soetomo Hospital, Surabaya from January 2017-December 2018. The  patients were excluded if they had hospital acquired pneumonia, tuberculosis, aspiration pneumonia and incomplete medical data record.

2. Methods 

This is a descriptive cross-sectional study. The study were conducted from January 2017 to December 2018. Ethical Committee in Health  Research Dr. Soetomo General Hospital Surabaya approved the protocol of this study with ethical clearance number 1536/KEPK/IX/2019.  Clinical and demographic data of every patient was obtained from medical records.

3. Operational Definition 

Diagnosis of pneumonia was made clinically based on the Indonesian Ministry of Health criteria. Diagnosis was confirmed by chest  radiological examination and then classified into severe pneumonia and very severe pneumonia. Prematurity was defined as babies born  with gestational age less than 37 weeks, low birth weight was defined as babies with birth weight less than 2500 grams. The nutritional  status of children is clinically and anthropometrically evaluated using the 2006 WHO curve of weight-by-age. The suspected causative  agent for pneumonia was assessed using the Bacterial Pneumonia Score, suspected bacterial causative agents is stated if the BPS value  was >4.

4. Statistical Analysis 

SPSS ver. 12.0 was used for statistical analysis. The variables in nominal or ordinal scale were expressed as frequency distributions.  For contingency analysis, the Chi-square test or Fisher’s exact test was used, assuming a significance level of 0.05 to reject the null  hypothesis.

Results 

A total of 465 patients were diagnosed with pneumonia during 48 months study. 212 patients were excluded and 253 pneumonia patients  met the inclusion criteria, 140 patients with very severe pneumonia and 113 patients with severe pneumonia. The characteristic of subject  are showed in Table 1.

Sample of this study consisted of 141 boys and 112 girls. 125 patients were in 2-5 months of age. Patients with history of LBW birth  were 71 patients and 62 patients had history of preterm birth. 86 patients were exclusively breastfed and 138 patients had complete  vaccination status. There were 131 patients with moderate and severe malnutrition, and 127 patients with comorbidities. 17 patients  had mothers under 19 years of age. There were 19 patients with family income below Rp. 825.000 per month. 32 patients have mothers  with primary education and 31 patients live at home with 7 or more family members. 94 patients developed pneumonia with suspected  bacterial causative agents.

Discussion 

In this study, diagnosis of pneumonia is made based on clinical and radiological criteria established by Indonesian Ministry of Health.  Among these patients, 44.6% were classified as severe cases and 55.4% were classified as very severe cases.  

With regard to the sociodemographic variables, majority of the children were under 2 years of age, which is consistent with other studies  that indicated low age as a risk factor for pneumonia and highlighted the anatomical peculiarities of the airways and immunological  immaturity in this group.8 

Study by Sonego et al. of 12,279 pediatric patients showed that children under 2 months of age had significant relationship with an  increased risk of death from Acute Lower Respiratory Infections with an odds ratio (OR) of 5.22 (1.70-16.03).9  However, because of the  large number of nursing children in the study, a group in which suspected nonbacterial respiratory infections are frequent, it is difficult to  differentiate nonbacterial and bacterial pneumonia, and therefore some patients diagnosed with CAP may have had viral infections that  were treated as bacterial pneumonia.

Family income with minimum wage and low maternal education levels reflect the low socioeconomic status of the population studied and  are known as risk factors for pneumonia.10 Study by Murray et al. showed a significant relationship between socioeconomic status and  the incidence of very severe pneumonia with OR 2.8 (95% CI 1.1-7) for the high-income group compared to the low-income group.11 The  profile of the study population may have contributed to the delay in seeking medical care, considering that 7.2% of the children had their  first consultation. Delay in seeking medical care implies worse prognosis of pneumonia.

As observed in Table 1, 51.8% of the children hospitalized due to pneumonia had low or very low weight for their age according to this  ratio. The association between malnutrition and infectious diseases is well documented, and most of our patients were malnourished.  This finding can be attributed to socioeconomic condition in Indonesia. A study indicated that a low weight-for-age was associated with  severe lower respiratory infections in developing countries.12 A metaanalysis by Jackson et al. from six developing countries also reported  a significant relationship between malnutrition and the risk of severe acute LRTI using multivariate analysis with an OR metaestimate of  4.5 (95% CI 2.1 to 9.5).13

WHO recommends the expansion of the vaccination to decrease the incidence of pneumonia in children. A metaanalysis by Jackson et  al. in five developing countries also reported a significant relationship between incomplete vaccination status and the incidence of severe  acute LRTI with an OR metaestimate of 1.8 (95% CI 1.3-2.5).13

A metaanalysis of several randomized clinical trials showed a decrease in pneumonia cases both clinically and radiologically after the  introduction of the pneumococcal conjugate vaccine (PCV).14 Despite relatively high vaccination coverage in Indonesia, the percentage of  children categorized as unvaccinated in this study (45.5%) deserves attention to re-assess the data. 

Conflicts of Interest No potential conflicts of interest in this study were reported.

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