Hedi Mustiko MD, Retno Asih Setyoningrum MD
Department 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.
Table 1. Characteristics of Children with Severe and Very Severe Pneumonia
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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Sumber: Medicinus Agustus 2020 vol. 33 issue 2