The Definition of Pneumonia, the Assessment of Severity, and Clinical Standardization in the Pneumonia Etiology Research for Child Health Study

To develop a case definition for the Pneumonia Etiology Research for Child Health (PERCH) project, we sought a widely acceptable classification that was linked to existing pneumonia research and focused on very severe cases. We began with the World Health Organization’s classification of severe/very severe pneumonia and refined it through literature reviews and a 2-stage process of expert consultation. PERCH will study hospitalized children, aged 1–59 months, with pneumonia who present with cough or difficulty breathing and have either severe pneumonia (lower chest wall indrawing) or very severe pneumonia (central cyanosis, difficulty breastfeeding/drinking, vomiting everything, convulsions, lethargy, unconsciousness, or head nodding). It will exclude patients with recent hospitalization and children with wheeze whose indrawing resolves after bronchodilator therapy. The PERCH investigators agreed upon standard interpretations of the symptoms and signs. These will be maintained by a clinical standardization monitor who conducts repeated instruction at each site and by recurrent local training and testing

Clinical signs that predict severe illness in children under age 2 months: a multicentre study.

BACKGROUND: Neonatal illness, particularly in the first week of life, is a leading cause of death worldwide. Improving identification of young infants who require referral for severe illness is of major public-health importance. METHODS: Infants under 2 months of age brought with illness to health facilities in Bangladesh, Bolivia, Ghana, India, Pakistan, and South Africa were recruited in two age-groups: 0-6 days and 7-59 days. A trained health worker recorded 31 symptoms and clinical signs. An expert paediatrician assessed each case independently for severe illness that required hospital admission. We examined the sensitivity, specificity, and odds ratio (OR) for each symptom and sign individually and combined into algorithms to assess their value for predicting severe illness, excluding jaundice. FINDINGS: 3177 children aged 0-6 days and 5712 infants aged 7-59 days were enrolled. 12 symptoms or signs predicted severe illness in the first week of life: history of difficulty feeding (OR 10.0, 95% CI, 6.9-14.5), history of convulsions (15.4, 6.4-37.2), lethargy (3.5, 1.7-7.1), movement only when stimulated (6.9, 3.0-15.5), respiratory rate of 60 breaths per minute or more (2.7, 1.9-3.8), grunting (2.9, 1.1-7.5), severe chest indrawing (8.9, 4.0-20.1), temperature of 37.5 degrees C or more (3.4, 2.4-4.9) or below 35.5 degrees C (9.2, 4.6-18.6), prolonged capillary refill (10.5, 5.1-21.7), cyanosis (13.7, 1.6-116.5), and stiff limbs (15.1, 2.2-105.9). A decision rule requiring the presence of any one sign had high sensitivity (87%) and specificity (74%). After we reduced the algorithm to seven signs (history of difficulty feeding, history of convulsions, movement only when stimulated, respiratory rate of 60 breaths per minute or more, severe chest indrawing, temperature of 37.5 degrees C or more or below 35.5 degrees C), mainly on the basis of prevalence of each sign or symptom, sensitivity (85%) and specificity (75%) were much the same. These seven signs also did well in 7-59-day-old infants (sensitivity 74%, specificity 79%). INTERPRETATION: A single simple algorithm could be recommended for identifying severe illness in infants aged 0-2 months who are brought to health facilities. Further research is needed on screening newborn children for illness in the community during routine home visits

Neonatal severe bacterial infection impairment estimates in South Asia, sub-Saharan Africa, and Latin America for 2010.

BACKGROUND: Survivors of neonatal infections are at risk of neurodevelopmental impairment (NDI), a burden not previously systematically quantified and yet important for program priority setting. Systematic reviews and meta-analyses were undertaken and applied in a three-step compartmental model to estimate NDI cases after severe neonatal bacterial infection in South Asia, sub-Saharan Africa, and Latin America in neonates of >32 wk gestation (or >1,500 g). METHODS: We estimated cases of sepsis, meningitis, pneumonia, or no severe bacterial infection from among estimated cases of possible severe bacterial infection ((pSBI) step 1). We applied respective case fatality risks ((CFRs) step 2) and the NDI risk among survivors (step 3). For neonatal tetanus, incidence estimates were based on the estimated deaths, CFRs, and risk of subsequent NDI. RESULTS: For 2010, we estimated 1.7 million (uncertainty range: 1.1-2.4 million) cases of neonatal sepsis, 200,000 (21,000-350,000) cases of meningitis, 510,000 cases (150,000-930,000) of pneumonia, and 79,000 cases (70,000-930,000) of tetanus in neonates >32 wk gestation (or >1,500 g). Among the survivors, we estimated moderate to severe NDI after neonatal meningitis in 23% (95% confidence interval: 19-26%) of survivors, 18,000 (2,700-35,000) cases, and after neonatal tetanus in 16% (6-27%), 4,700 cases (1,700-8,900). CONCLUSION: Data are lacking for impairment after neonatal sepsis and pneumonia, especially among those of >32 wk gestation. Improved recognition and treatment of pSBI will reduce neonatal mortality. Lack of follow-up data for survivors of severe bacterial infections, particularly sepsis, was striking. Given the high incidence of sepsis, even minor NDI would be of major public health importance. Prevention of neonatal infection, improved case management, and support for children with NDI are all important strategies, currently receiving limited policy attention

Monitoring respiration in wheezy preschool children by pulse oximetry plethysmogram analysis

The aim of this study was to investigate whether respiratory information can be derived from pulse oximetry plethysmogram (pleth) recordings in acutely wheezy preschool children. A digital pulse oximeter was connected via 'Bluetooth' to a notebook computer in order to acquire pleth data. Low pass filtering and frequency analysis were used to derive respiratory rate from the pleth trace; the ratio of heart rate to respiratory rate (HR/RR) was also calculated. Recordings were obtained during acute wheezy episodes in 18 children of median age 31 months and follow-up recordings from 16 of the children were obtained when they were wheeze-free. For the acutely wheezy children, frequency analysis of the pleth waveform was within 10 breaths/min of clinical assessment in 25 of 29 recordings in 15 children. For the follow-up measurements, frequency analysis of the pleth waveform showed similarly good agreement in recordings on 15 of the 16 children. Respiratory rate was higher (p < 0.001), and HR/RR ratio was lower (p = 0.03) during acute wheeze than at follow-up. This study suggests that respiratory rate can be derived from pleth traces in wheezy preschool children