Letters to the Editor

Indian Pediatrics 2001; 38: 307-308  

Physical Signs in Children with Pneumonia

Pneumonia is one of the major causes of death in children <5 years of age in most developing countries. Majority of fatal cases are attributable to bacterial infection. Several studies have demonstrated that in children with cough, tachypnea is probably the best indicator of the need for starting antibiotic treatment by primary health workers. The World Health Organization (WHO) has recommended guidelines for case manage-ment of acute respiratory infections in developing countries based on tachypnea as a criterion for diagnosing pneumonia in children aged <5 year(1). In some of those studies, children with wheezing were excluded, in others the effect of wheezing was not described in the analysis, and in another just one child was wheezing. However, wheezing has been described in children with pneumonia caused by Streptococcus pneu-monia or Haemophilus influenzae(2), or in children with mixed bacterial-viral lower respiratory infection(3).

In Salvador, Northeast Brazil, from September 1997 to October 1999, 1999 cases of radiologically diagnosed pneumonia were prospectively identified at the Emergency Room (ER) of the Pediatric Center Professor Hosannah de Oliveira, a University Hospital, and at the Pediatric ER of the Alianca Hospital, a private setting. Respiratory, aus-cultatory findings, other clinical information and chest X-ray results were evaluated by the primary pediatrician.

The median age was 1.8 years (mean 2.7 ± 2.7 yr, range 8 days to 14.5 years). There were 55.0% males and 45.0% females. Wheezing was reported in 46.6% of the cases. Table 1 shows the results of stratified analysis of respiratory rates.

The differences of respiratory rate means between children with wheezing and children without wheezing were significant when patients were aged >2 months and the mean and 95% Confidence Intervals were over the cutoff limits (Table 1) recommended by WHO in the Program for the Control of Respiratory Infection in developing coun-tries(1). These observations in Brazilian children are in agreement with the results from other studies where tachypnea is present in 50 to 75% of children aged <5 years with pneumonia. In older children (>5 years of age), normal respiratory rates vary between 15 and 25 breaths per minutes(5). Therefore, from our data (Table 1), we agree with Korppi(4) that the cutoff limit of respiratory rate for definition of tachypnea for the purpose of diagnosing pneumonia in this latter group of patients may be 30 when facilities are limited.

Table I - Stratified Analysis of Respiratory Rates from Child with Pneumonia

This study was supported by the Pan American Health Organization.

Cristiana M.C. Nascimento-Carvalho
Department of Pediatrics,
Faculty of Medicine,
Federal University of Bahia,
Rua Prof. Aristides Novis,
No. 105/1201B-Salvador, Bahia,
Brazil CEP 40210-730
E-mail: [email protected]

1. World Health Organization. Case Manage-ment of Acute Respiratory Infections in Developing Countries: Report of a Working Group Meeting. Document WHO/RSD/85.15 Rev 1. Geneva, World Health Organization.

2. Ghafoor A, Nomani NK, Isha1q Z, Zaidi SZ, Anwar F, Burny MI, et al. Diagnoses of acute lower respiratory tract infections in childen in Rawalpindi and Islambad, Pakistan Rev Infect Dis 1990; 12(S8): S907-S914.

3. Korppi M, Leinonen M, Koskela M, Makela PH, Launiala K. et al. Bacterial coinfection in children hospitalized with respiratory syncy-tial virus infections. Pediatr Infect Dis J 1989; 8: 687-692.

4. Korppi M. Physical signs in childhood pneu-monia. Pediatr Infect Dis J 1995; 14: 405-406.

5. Klein JO. Bacterial pneumonias. In: Textbook of Pediatr Infectious Diseases. Feigin RD, Cherry JD. Philadelphia, W.B. Saunders Co, 1998; pp 273-284.