Acute Lower Respiratory Tract Infections in Children: Possible Criteria for Selection of Patients for Antibiotic Therapy and Hospital Admission
Shann, Frank, Hart, Kate, Thomas, David, Bulletin of the World Health Organization
Acute lower respiratory tract infections cause considerable morbidity and mortality, particularly in children in the less developed countries (1). From 1970 to 1979 at Goroka Base Hospital, in the Eastern Highlands of Papua New Guinea, pneumonia was responsible for 29% of the 18 605 paediatric admissions, and for 31% of the 1040 deaths of children in the hospital.
Since 1974, standard treatment protocols have been widely used in the management of diseases of children in Papua New Guinea--a slightly modified version of the current protocol for the management of cough is shown in Fig. 1. Simple and effective standard treatments for common diseases are essential if optimum use is to be made of the limited resources available for health care in the less developed countries, and whatever protocols are used should be carefully evaluated.
[FIGURE 1 OMITTED]
Criteria for the use of antibiotics and for admission to hospital with acute lower respiratory tract infections should be carefully defined, particularly when patients are managed by primary health workers. At present, it is not known which clinical findings in lower respiratory tract infections can best predict the outcome or the need for antibiotics, nor which signs can most reliably be elicited by primary health workers. The present study investigated this problem, based on the clinical findings in children in Goroka who had acute lower respiratory tract infections of varying degrees of severity.
MATERIALS AND METHODS
We prospectively studied 200 children who were brought to the Goroka Hospital outpatient department with cough. Only children who had not had prior treatment were studied. The first 100 of the 200 children with cough were paired with 100 age-matched controls without cough. In addition, 50 children admitted to Goroka Hospital with pneumonia were studied. Thus, a total of 350 children were studied. In each case, a record was made of age, diagnosis, respiratory rate (in most cases with the child awake but quiet), chest indrawing (sternal recession), cyanosis, wheeze, pulse rate, liver size, crepitations, and forehead skin temperature (using the Fever Scan (a)). The mother was asked if her child was breathless and whether he was feeding normally.
Of the 200 paediatric outpatients with cough, 115 (58%) had a respiratory rate greater than 40/min, 87 (44%) had a temperature greater than 37.5[degrees]C, 74 (37%) were said by the mother to be breathless, 73 (37%) had a respiratory rate greater than 50/min, 67 (34%) had crepitations, 17 (9%) were said by the mother to be feeding poorly, 16 (8%) had a pulse rate greater than 160, 7 (4%) had a liver edge palpable more than 2 cm below the costal margin in the mid-clavicular line, 4 (2%) had chest indrawing (all four had crepitations as well), one child was wheezing, and no child was cyanosed. Since the midpoint between the mean respiratory rates in children with and without crepitations was 50.3 breaths per minute (Table 1), this respiratory rate is likely to give the lowest number of false positive plus false negative results in predicting the presence or absence of crepitations (2). Table 1 shows that the child's age had little effect on the respiratory rate that best predicted the presence or absence of crepitations. A detailed analysis of the data on respiratory rate, temperature, and the mother's impression of breathlessness in the child is shown in Table 2.
Table 3 shows the respiratory rate by age in 300 outpatients: the 200 children with cough referred to in Table 2 and, in addition, 100 age-matched controls without cough. Among the 151 children aged 0-11 months, proportionately more of the 44 children with cough and crepitations had a fast respiratory rate than the 107 children who did not have crepitations ([chi square] 38.270, 2df, P < 0.001). Among the 149 children aged 12 months or more, proportionately more of the 23 children with crepitations were breathing fast than the 126 children without crepitations ([chi square] 27. …