Acute lower respiratory infections among children hospitalized in Bangui, Central African Republic: toward a new case-management algorithm

To measure the performance of the current WHO algorithm in identifying chil dren at higher risk of death, children aged 2-59 months who presented with cough and/or difficult breathing and were admitted into the paediatric hosp ital of Bangui (Central African Republic) during a 1-year period (1996/97) were investigated. Among children with subcostal indrawing, mortality and s everity of oxygen desaturation were identical whether or not they also had tachypnoea. Among children with a 'severe pneumonia', those who also fulfil led the 'very severe disease' definition had a higher risk of death (31/132 , 23.5%) than those who did not (12/106, 11.3%, P = 0.02). However, this 'v ery severe disease' definition did not predict death when used in children who did not have severe pneumonia. To identify variables that would better predict death, combinations of symptoms and signs were examined among the s ubgroup of children with indrawing. Nine combinations had both a sensitivit y and specificity over 60%. 'Grunting and/or nasal flaring' had a sensitivi ty of 72% and a specificity of 66% in predicting death, and might be easier to use by primary health care personnel than other combinations. A new alg orithm is proposed for the management of children aged 2-59 months presenti ng with cough and/or difficult breathing. The definition of pneumonia would be unchanged (tachypnoea). Severe pneumonia would remain defined on indraw ing regardless of respiratory rate, except that indrawing should be lower c hest wall and/or intercostal. In health facilities where intravenous antibi otics, chloramphenicol and/or oxygen are available, entry into a 'very seve re pneumonia' category would be based on 'grunting and/or nasal flaring' am ong children with indrawing. In our study population, the mortality rates i n the categories based on these definitions were 0.8% (1/127) in children w ith no pneumonia, 0.9% (1/116) in children with pneumonia, 7.7% (12/156) in children with severe pneumonia and 31.1% (33/106) in children with very se vere pneumonia.