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In this issue of Indian Pediatrics, the
study by Fountoura, et al. [1] compares the evolution of symptoms
and signs among children with non-severe lower respiratory tract
infection, with and without radiological pneumonia. The authors conclude
that persistence of fever or tachypnea up to the second day of
amoxicillin treatment is predictive of radiographically diagnosed
pneumonia among children with non-severe lower respiratory tract
disease. The sincere attempt of the authors in finding out clinical
predictors of radiologically diagnosed pneumonia is appreciated.
However, there are a few ambiguities in the diagnosis
of non-severe lower respiratory infection, viz., the inclusion
and exclusion criteria and the radiological diagnostic criteria. Cases
with consolidation and pleural effusion, atelectasis, hyperventilation
on chest radiograph; clinical findings of difficulty in breathing (68%),
vomiting (47.6%), wheezing (29.8%), chest retraction (2.69%), inability
to drink (8.8%; 6.8 % among pneumonia and 2.0 % among children with
normal chest radiograph) were also observed in children who were
considered as "non-severe LRI", which is unacceptable. On recruitment,
pneumonia was said to be defined by the respiratory complaints, lower
respiratory tract findings, and radiographic presence of pulmonary
infiltrates at admission read by pediatrician on duty. This does not
explain the fact that a significant proportion of chest radiographs
(40.9%), were found to be normal!
There are a few controversies also observed in this
study. Without attempting to identify the exact etiology of pneumonia,
amoxicillin was administered. This we presume would have been given
orally. With 45.8% of children having vomiting, its effectiveness is
also questionable. Good response to therapy could be due to the fact
that most of the LRI in this series may have been due to viruses, which
is also evidenced by normal chest X-ray in 40.9% of cases where
antibiotics may not have any role. The exact results of clinical
effectiveness of amoxicillin in community acquired pneumonia in their
set-up should have been mentioned, which has a bearing on the evolution
of symptoms and signs. When the WHO recommendation is 3-5 days of
antibiotic therapy for non severe pneumonia [2], unwarranted
administration for 10 days can lead to related adverse events,
escalation of cost and emergence of drug-resistance.
Since the study aims to study the evolution of
symptoms and signs among radiologically diagnosed pneumonia compared to
those who had normal radiograph, recruiting cases with full blown
picture of pneumonia plus pulmonary infiltrates on radiograph is not
ideal. The "inception cohort" should have been assembled with suspected
cases of pneumonia very early in the course, i.e. from the 1st
day of illness itself and followed up for evolution of symptoms and
signs. The outcome of this study, namely the persistence of fever or
tachypnea up to the 2nd day
of amoxicillin treatment predicting radiographically diagnosed pneumonia
among non-severe lower respiratory tract infections does not help, as we
are interested in symptoms or signs which could predict the indications
for radiograph in a case of non-severe lower respiratory tract when they
report very early, i.e. even on the first day of illness itself,
which is the need of the hour (second day of amoxicillin treatment does
not mean that the illness is of two days duration only). Radiographic
pulmonary infiltrates do not distinguish viral from bacterial pneumonia
[3], on which the physician’s attention is focused as the
next step in the management of pneumonia. In the end, there is a query
about the exact utility of this study: whether it tries to assess the
indications for initial and repeat chest radiograph during the course of
pneumonia, or, it determines the duration of antibiotic treatment, or it
determines the severity and evolution of radiographically diagnosed
pneumonia
In view of all these limitations, the authenticity of
conclusion and utility of this study observations are questionable. A
prospective study with a definite objective, properly assembled
"inception cohort" and a robust methodology would be ideal.
Competing interests: None stated; Funding:
Nil
References
1. Fontoura MS, Matutino AR, Silva CC, Santana MC,
Nobre-Bastos M, Oliveira F, et al. Differences in evolution of
children with non-severe acute lower respiratory treat infection with
and with outradiologically diagnosed pneumonia. Indian Pediatr.
2012;49:363-9.
2. Grant GB, Campbell H, Dowell SF, Graham SM,
Klugman KP, Mulholland EK, et al. Recommendations for treatment
of childhood non-severe pneumonia. Lancet Infect Dis. 2009;9:185-96.
3. Swingler GH. The radiologic differentiation between
bacterial and virus lower respiratory infection in children: a
systematic literature review. Clin Pediatr. 2000;39: 627-33.
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