(2018) Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance : a multi-hospital, retrospective, cohort study. The Lancet Global Health, 6 (1). e74-e83. doi:10.1016/S2214-109X(17)30448-5

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Abstract

Background:
Management of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital.

Methods:
We did a retrospective cohort study of children aged 2–59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia).

Findings:
We assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1–6·8), mild to moderate pallor (3·4, 3·0–3·8), and weight-for-age Z score (WAZ) less than −3 SD (3·8, 3·4–4·3). Additional factors that were independently associated with death were: WAZ less than −2 to −3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more.

Interpretation:
In settings of high mortality, WAZ less than −3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making.

Item Type:	Journal Article
Subjects:	R Medicine > RJ Pediatrics > RJ101 Child Health. Child health services
Divisions:	Faculty of Medicine > Warwick Medical School > Health Sciences Faculty of Medicine > Warwick Medical School > Health Sciences > Population, Evidence & Technologies (PET) Faculty of Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Pneumonia in children -- Diagnosis -- Standards, World Health Organization
Journal or Publication Title:	The Lancet Global Health
Publisher:	The Lancet Publishing Group
ISSN:	2214-109X
Official Date:	3 January 2018
Dates:	Date Event 3 January 2018 Published 18 December 2017 Accepted 23 September 2017 Submitted
Date of first compliant deposit:	20 March 2018
Volume:	6
Number:	1
Page Range:	e74-e83
DOI:	10.1016/S2214-109X(17)30448-5
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
RIOXX Funder/Project Grant:	Project/Grant ID RIOXX Funder Name Funder ID Research Fellowship Wellcome Trust http://dx.doi.org/10.13039/100004440 Strategic Award Wellcome Trust http://dx.doi.org/10.13039/100004440 UNSPECIFIED [NIHR] National Institute for Health Research http://dx.doi.org/10.13039/501100000272
Open Access Version:	Publisher

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