No. PAEDIATRICS 200 -200 Date:Place: Bellary

Dr. HONNAPPA G.M.IN SERVICE POST GRADUATE STUDENT IN MD PAEDIATRICS,DEPT OF PAEDIATRICS,V.I.M.S., BELLARY.KARNATAKA.PIN: 583 104.

To

THE PRINCIPALVijayanagar Institute of Medical Sciences,BELLARY.

THROUGH PROPER CHANNEL

Respected Sir,

Sub: Registration and Forwarding of dissertation topic.***

In accordance with the above cited topic I the undersigned studying in PG

Course in Pediatrics has been allotted the dissertation topic “HEMATOLOGICAL,

CLINICAL, EPIDEMIOLOGICAL AND RADIOLOGICAL STUDY OF SEVERE

PNEUMONIA IN CHILDREN” CHILDREN ADMITTED IN HQH/VIMS

HOSPTIAL, BELLARY” from December-2007 to December-2008 under the

guidance of Dr. M. Lakshminarayana Reddy, Associate Professor Department of

Pediatrics, V.I.M.S., Bellary.

I request you to kindly forward the dissertation topic in the prescribed form to

the university for approval.

Thanking you,

Signature of the Guide Yours faithfully,

Dr. M. LAKSHMI NARAYANA REDDY,Associate Professor,Department of Pediatrics, (DR. HONNAPPA G.M.)V.I.M.S., Bellary.

From Place: BellaryDate:

The Prof. & Head of Department,Department of Pediatrics,VIMS, BELLARY.

ToTHE REGISTRAR,Rajiv Gandhi University of Health Sciences,BANGALORE.

THROUGH PROPER CHANNEL

Respected Sir,

As per the regulation of the University for Registration of Dissertation topic

the following post Graduate student in MD (Pediatrics) has been allotted the

dissertation topic as follows by the official registration committee of all qualified and

eligible guides of the Department of Pediatrics.

Name Topic GuideDR. HONNAPPA G.M.In Service: Post Graduate

Student in Pediatrics,V.I.M.S., BELLARY.

HEMATOLOGICAL, CLINICAL,

EPIDEMIOLOGICAL & RADIOLOGICAL STUDY OF SEVERE PNEUMONIA IN CHILDREN ADMITTED IN HQH/VIMS HOSPITAL,

BELLARY.

DR. M. LAKSHMI NARAYANA REDDY

Associate Prof. Pediatrics,Department of Pediatrics,

VIMS, BELLARY.

Therefore I kindly request you to communicate the acceptance of dissertation

topic allotted to the Post Graduate Student at an early date.

Thanking you,Signature of the Guide

Yours faithfully

Dr. M. LAKSHMI NARAYANA REDDY,

Associate Prof. of Pediatrics,Department of Pediatrics,

VIMS, BELLARY.

Dr. VEERASHANKAR,Professor & Head of the Department,

Department of Pediatrics, BELLARY.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE KARNATAKA,

ANNEXURE-II

SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.

1. Name of the Candidate and Address(in block letters)

DR. HONNAPPA G.M.IN SERVICE: POST GRADUATE STUDENT IN PEDIATRICS, V.I.M.S., BELLARY. KARNATAKA, PIN 583 104.

2. Name of the Institution VIJAYANAGARA INSTITUTE OFMEDICAL SCIENCES, BELLARY.

3. Course of Study and Subject MD IN PEDIATRICS

4. Date of Admission to course 25-05-2007.

5. Title of the topic “HEMATOLOGICAL, CLINICAL, EPIDEMIOLOGICAL &

RADIOLOGICAL STUDY OF SEVERE PNEUMONIA IN CHILDREN ADMITTED IN HQH/VIMS

HOSPITAL, BELLARY.

6 Brief Resume of the Intended Work6.1 NEED FOR THE STUDY.Infections of the respiratory tract are perhaps the most common human ailment.

While they are a source of discomfort, disability and loss of time for most adults,

they are a substantial cause of morbidity and mortality in young children.1

Acute respiratory infections (ARI) are one of the commonest causes of

death in children in developing countries. It is responsible for an estimated 4

million deaths worldwide. Almost all ARI deaths in young children are due to

acute lower respiratory tract infections (ALRTI), mostly pneumonia.2

Modernization, industrialization and urbanization are now posed with the

problem of increase in ARI morbidly and mortality. It is clear that future health of

children depends on preventing, diagnosing, treating and or limiting ALRTI.

The utility of simple clinical signs like rapid breathing and chest in drawing

to diagnose pneumonia in infants and young children has been well established.

The use of these clinical signs in the early detection and treatment of children with

pneumonia by primary health care workers forms the basis for the case

management strategy formulated by the World Health organization (WHO) to

control and morbidity.3

Empirical antibiotic therapy for pneumonia is the commonly accepted

practice world wide as the etiology of pneumoni in children is difficult to

establish. Clinical and radiological criteria do not accurately reflect the etiology

of childhood pneumonia.4

ARI can be preventable. However socio environmental factors are acting

as major obstacles in prevention of ARI. The epidemiological information

regarding risk factors and management is scanty. A large gap exists in our

knowledge about these factors, which needs to be fulfilled by systematic studies.

The present study is designed to clinically evaluate children with

pneumonia, correlate it with hematological, radiological findings, to identify the

risk factors and to study the efficacy of various antibiotics that are used routinely

in our sector.

6.2 REVIEW OF LIITERATURE

PNEUMONIAPROBLEM STATEMENT: 1.5

ARI is responsible for 19% of all deaths in children below five years of age

and 8.2% of all disability as measured by Disability Adjusted Life Years (DALY).

It is estimated that Bangladesh, India, Indonesia and Nepal together account

for 40% of the global ARI mortality. About 90% of ARI deaths are due to

pneumonia, which is usually bacterial in origin. The incidence of pneumonia in

developed countries may be as low as 3-4%, its incidence in developing countries

range between 20-30%.

On an average, children below five years of age suffer 5 episodes of ARI per

child per year. ARI is responsible for about 30-50% of visits to health facilities and

for about 20-40% of admissions to hospitals.

In India, ARI is one of the major reasons for which children are brought to

the hospitals and health facilities. According to WHO estimates, respiratory

infections caused about 9.87 lakh deaths in India of which 9.69 lakh deaths were

due to ALRTI.

Hospital records from states with high infant mortality rates show that, 13%

of inpatient deaths in pediatric wards are due to ALRTI. The proportion of death

due to ALRTI in the community is much higher as many children die at home. The

reason for high case fatality may be that children are either not brought to the

hospitals or brought too late.

The standard case management of ARI and prevention of deaths due to

pneumonia is now an integral part of Reproductive and Child Health programme

(RCH).

Many studies have been done in the past to know the magnitude, etiology,

risk factors and out come of pneumonia in young children.

Mishra S et al6 studied the results of ARI control programme in 100

hospitalized children. All cases with severe pneumonia survived. A mortality of

7.7% was seen in case of very severe pneumonia. 6 patients were treated as cases

of staphylococcal pneumonia, out of which one died. The duration of stay in

hospital was significantly less in cases of severe pneumonia (4.21 + 1.59 days) as

compared to very severe pneumonia (9.35 + 2.39 days). The data from this study

suggest that the treatment protocol of the ARI control programme for hospitalized

children is reasonably effective and can be implemented.

Gupta D et al7 in their hospital based prospective study have found fast

breathing as most useful sign predicting pneumonia in all age groups. Cut off

points at 50 breaths / min for infants including neonates, 40 breaths/ min for

children aged 12-35 months and 30 breaths / min for children aged 36- 60 months

indicated presence of pneumonia. They also found that, crepitations on auscultation

were found to have good correlation with presence of radiological pneumonia.

Kumar N et al8 clinically evaluated acute respiratory distress and chest

wheezing in infants. They found that presence of fever >1000F, neutrophilia and

opacities on chest X ray point to the diagnosis of bronchopneumonia in an infant

with respiratory distress and chest wheezing. They also found that absence of fever

with normal leukocyte count or lymphocytosis point towards bronchiolitis in infants

with respiratory distress and chest wheezing.

Drummond P. et al9 did a prospective study on etiology and most useful

diagnostic tests for community acquired pneumonia in children. They isolated

pathogens in 60% of cases. Viral infection accounted for 71% of the cases

diagnosed. Group A streptococcus was the most common bacterial agent with a

low incidence of both Mycoplasma pneumoniae and Streptococcus pneumoniae.

Pneumococal pneumonia was the most common bacterial cause of pneumonia in

children under 2 years. Inflammatory markers and chest X-ray inflitrates did not

differentiate viral from bacterial pneumonia. They also found that serology and

viral immunofluoroscence were the most useful diagnostic tests.

Hamid M et al10 conducted a study on clinical, nutritional and radiological

features of pneumonia. They found that 17 children had severe pneumonia, 77

children very severe pneumonia and 6 simple pneumonia. 60% had radiological

evidence of pneumonia. 89% responded to standard recommended treatment and

only 11% required a change of therapy. Lack of breast feeding, low socio

economic status, illiteracy and malnutrition were the significant risk factors. They

concluded that the national ARI control guidelines for diagnosis and management

of hospitalized children are simple, useful and effective.

Heaton P et al11 have conducted a study to determine whether chest

radiography was clinically useful in the follow up of uncomplicated pneumonia.

93% of children had radiological evidence of pneumonia. 63% of children were

followed up both clinically and radiologically between four and six weeks after

discharge. 90% had no abnormal symptoms or signs and had normal chest

radiographs. 10% showed either slight resolution or no change from the admission

films. Thus they concluded that, in cases of uncomplicated pneumonia, follow up

chest radiography should be deferred until at least four weeks after discharge, and is

not indicated if symptoms and signs are absent.

Zukin DD et al12 correlated pulmonary signs and symptoms with chest

radiographs in the pediatric age group. They found that the sign with highest

positive and negative predictive value for the presence of any radiographic

abnormalities was tachypnoea. Absence of fever suggests absence of pneumonia,

while chest examination findings other than wheezing cough, prolonged expiration,

or rhonchi significantly increased the likeihood of pneumonia. Thus they

concluded that physical examination findings could help the clinician determine the

need for chest radiography in the pediatric emergency patient.

Davies HD et al13 conducted a study to determine the reliability of detecting

features and making diagnosis of lower respiratory infections from chest

radiograms in young infants. The examined features were hyperinflation,

peribronchial thickening, perihilar linear opacities, atelectasis and consolidation.

They noticed that there is variation in interobserver and intraobserver agreement

among radiologists on the radiographic features used for diagnosis. They

concluded that the presence of consolidation highly correlated with a diagnosis of

air space disease.

Kabra SK et al14 studied the etiology of ALRTI in under five children by

non-invasive methods. They identified etiological agents in 94% of the patients.

Viruses were isolated from nasopharyngeal aspirate in 38% bacteria from blood

cultures in 16%, Mycoplasma in 24% and Chilamydia in 11%. They concluded that

noninvasive methods are useful in identifying etiological agents in severe ALRTI.

Broor S et al15 studied the risk factors for severe ALRTI in under five

children. They concluded that lack of breast feeding, upper respiratory tract

infection in mother, upper respiratory tract infection in siblings, severe

malnutrition, cooking fuel other than liquid petroleum gas, inappropriate

immunization for age and history of ALRTI in the family were significant risk

factors.

Rahman MM et al16 studied the prevalence of acute respiratory tract

infection and its risk factors among under five children in a rural community. The

prevalence or ARI was 58.7%, with mean number of episodes of ARI being 1.75

per child per year. The risk factors were malnutrition, illiteracy, poverty,

overcrowding ad parental smoking. Thus they concluded that there is need for

research aimed at health system to determine the most appropriate approaches to

control ARI and thus could be utilized to strengthen the ARI control programme.

Kaushik PV et al17 studied the relationship between ARI and malnutrition.

They found that 57.5% suffered from PEM with 78.6% of children aged between

12-14 months had PEM. The incidence of ARI increased as the nutritional status

deteriorated. These findings confirm the synergistic action between ARI and

malnutrition. They concluded that there is a need to strengthen the quality, quantity

and accessibility of nutritional services particularly promotion of breast-feeding and

vitamin A supplementation.

Kirkwood BR et al18 described the background and framework for a

systematic review of potential interventions for preventing pneumonia among under

fives in developing countries. According to them immunization, improving

nutrition, reducing environmental pollution, case management and chemo

prophylaxis, reducing transmission of pathogens and improving child care practices

are the potential intervention areas for reducing pneumonia morbidity or mortality

among under fives.

Deivanayagam N et al19 conducted a case control study of identify the risk

factors for death among hospitalized children with acute pneumonia. They found

that young infants, malnutrition, severity of pneumonia and presence of congenital

malformation are important risk factors for fatal pneumonia.

Sehgal V et al20 predicted mortality in subjects hospitalized with ALRTI.

They found that mortality was inversely related to age with case fatality rate being

31.25%, 14.6% and 3.12% in children less than 2 months, 2-12 months and 12-60

months of age. They concluded that hurried breathing, cough, fever and poor

feeding were statistically significant for ALRTI. According to them, age less than

one year, inability to feed, altered sensorium, presence of respiratory distress and

underlying congenital heart disease are significant independent predictors of

mortality.

6.3 OBJECTIVES OF THE STUDY

AIMS AND OBJECTIVES OF THE STUDY

1) To study the hematological, clinical, epidemiological and radiological

features of severe pneumonia in children.

2) To identify the risk factors associated with severe pneumonia.

3) To correlate clinical findings with radiological and bacteriological

examination.

4) To known the choice of antibiotic for severe pneumonia.

7 Material And Methods7.1 SOURCE OF DATA

This is prospective clinical study of severe pneumonia in children admitted

in the Head Quarters Hospital and V.I.M.S. Hospital, Bellary, during the period of

December-2007 to December-2008.

7.2 METHOD OF COLLECTION OF DATA

INCLUSION CRITERIA

Children in the age group of one month to five years with clinical features

of severe pneumonia as per WHO recommendations for the control of ARI were

included.

EXCLUSION CRITERIA:

Children with congenital anomalies of heart and lungs, anatomical defects

like cleft lip and cleft palate, immunocompromised states like human

immunodeficiency virus infection (HIV) and infants less than one month of age

were excluded from the study.

A detailed history of the relevant symptoms such as fever, cough, rapid

breathing, refusal of feeds, wheezing etc. was taken.

TECHYPNOEA:

Based on WHO ARI criteria, children were considered tachypnoeic if

Respiratory rate (RR);

- RR > 60 in < 2 months

- RR > 50 in 2 months – 1 yr.

- RR > 40 in 1 yr – 5 yrs.

A detailed examination of each child including anthropometry, general

physical examination, general condition of the child, respiratory rate (counted over

one minute), presence of fever and other signs such as syanosis and pallor.

Detailed systemic examination of the respiratory, cardiovascular and central

nervous system. Associated illness such as septicemia, meningitis and congestive

cardic failure if present have to be noted. Socio economic history regarding the

type of house (Pucca or Kutcha), family size (over crowding), sanitary facilities

and fuel used for cooking (LPG or non LPG). Socio economic status classified

according to modified Prasad’s classification. Other pertinent information such as

immunization status (Immunized, partially immunized or unimmunized), feeding

practices and degree of malnutrition (IAP classification).

According to WHO ARI criteria, children were classified into two groups:

severe pneumonia and very severe pneumonia.

ANTIBIOTICS 1. First line antibiotics:- Ampicilline with Gentamicin.2. Second line antibiotics:- Amoxycilline clavulanic acid with amikacin.3. Others :- Cloxacillin. Cefotaxime/Ceftriaxone with Amikacin.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS. IF SO PLEASE DESCRIBE BRIEFLY.

Routine Investigations like Hb, TC, DC, ESR. Chest X-ray in all children, follow up X-ray in relevant cases. Blood culture in relevant cases. Pleural Fluid Analysis / Culture in relevant cases.

7.4 HAS ETHICAL CLEARANCE OBTAINED FROM YOURINSTITUTION IN CASE OF 7.3?

Yes Ethical clearance has been obtained from the VIMS Institutional ethics committee, Bellary.

8 LIST OF TEXT BOOK REFERENCES

a) TEXT BOOK REFERENCES1. Park K. Acute respiratory infections. In: Park’s text book of preventive

and social medicine, 19th Ediction, Jabalpur, M/s Banarasidas Bhanot

publishers, 2007, 132-38. PP-142 -148.

2. Sectish TC and Prober CG. Pneumonia. In Behrman RE, Kleigman

RM, Jensan HB (Editors): Nelson Textbook of Pediatrics, Philadelphia,

Saunders, 2007; 18th Edition-Volume-II PP 1795 – 1803.

3. Pneumonia. In Ghai OP, Gupta P. Paul VK (Editors): Ghai Essential

Pediatrics, 6th edition, Delhi; Dr. Ghai Delhi, 2005; PP 348 – 367.

4. Balachandran A. Somu N. Subramanayam L: Pneumonia in children. In

Somu N. Subramanayam L (Editors): Essentials of Pediatric

pulmonology, Madras, M/s. Siva & Co, 1996, pp 63-72.

5. Mahajan SC and Sachdev HPS. ARI control programme. In Patwari

AK, Sachdev HPS (Editors): Frantiers in Social Pediatrics, New Delhi,

Jaypee Brothers, 1998; PP 285-298.

6. Narain S. Acute Pneumonia. In Suraj Gupte (Editor): Recent Advances

in Pediatrics (Special Volume 14): Criticare Pediatrics, New Delhi,

Jaypee Brothers, 2004: pp220-37.

7. Glezen WP. Viral Pneumonia. In Chernick V. Boat TF (Editors):

Kendig’s disorders of the respiratory tract in children, 6 th edition,

Philadelphia, W.B. Saunders, 1998: pp518-25.

b) JOURNAL REFERENCES

1. World Health Organization Programme for the control of acute

respiratory infections. Acute Respiratory Infections in children: Case

Management in small hospitals in developing countries. A manual for

doctors and other senior health workers, Geneva, WHO, 1990.

WHO.ARI.90.5.

2. World Health Organization programme for the control of acute

respiratory infections. Technical basis for the WHO recommendations

on management of pneumonia in children at first level health facilities.

Geneva, WHO, 1991; WHO. ARI.91.20.

3. Jadavji T, Law B, Lebel MH, Kennedy WA, Gold R, Wang EEL. A

practical guide for the diagnosis and treatment of pediatric pneumonia.

Can Med Assoc J 1997; 156 (Suppl):S703-11.

4. Kabra SK, Verma IC. Acute lower respiratory tract infection: The

forgotten pandemic. Indian J Pediatr 1999; 66: 873-75.

5. Mishra S. Kumar H, Anand VK, Patwari AK, Sharma D. ARI control

programme: results in hospitalized children. J Trop Pediatr

1993;39:288-92.

6. Gupta D. Mishra S. Chaturvedi P. Fast breathing in the diagnosis of

pneumonia – a reassessment. J Trop Pediatr 1996; 42: 196-99.

7. Kumar N. Singh N. Locham KK. Garg R. Sarwal D. Clinical Evaluation

of acute respiratory distress and chest wheezing in infants. Indian

Pediatr 2002; 39: 478-83.

8. Drummond P. Clark J. Wheeler J. Galloway A. Freeman R. Cant A.

Community acquired pneumonia – a prospective UK study. Arch Dis

child 2000; 83:408-12.

9. Hamid M. Qazi SA. Khan MA. Clincal, nutritional and radiological

features of pneumonia. J Pak Med Assoc 1996; 46: 95-99.

10. Heaton P. Arthur K. The utility of chest radiography in the follow up of

pneumonia. N Z Med J 1998; 111:315-17.

11. Zukin DD, Hoffman JR, Cleveland RH, Kushner DC, Herman TE.

Correlation of pulmonary signs and symptoms with chest radiographs in

the pediatric age group. Ann Emerg Med 1986; 15: 792-96.

12. Kabra SK. Lodha R. Broor S. Chaudhary R. Ghosh M and Maitreyi RS.

Etiology of Acute Lower Respiratory Tract Infection. Indian J Pediatr

2003; 70:33-36.

13. Kirwood BR, Gove S. Rogers S. Lob-Levyt J. Arthur P. Campbell H.

Potential interventions for the prevention of childhood pneumonia in

developing countries: a systematic review. Bulletin WHO 1995; 73:793-

98.

14. Deivanayagam N. Nedunchelian K. Ramaswamy S. Sudhandirakannan,

Ratnam SR. Risk Factors for fatal pneumonia: A case control study.

India Pediatr 1992; 29:1529-32.

15. Dhar GM. An epidemiological approach to the understanding and

control of acute respiratory infections in Indian Children. Indian J

Matern Child Health 1992; 3:4-7.

16. Lichenstein R. Suggs AH. Campbell J. Pediatric Pneumonia. Emerg

Med Clin N Am 2003; 21:437-51.

17. Reddaiah VP and Kapoor SK. Acute respiratory infections in under

fives: Experience at comprehensive rural health services project

hospital, Ballabgarh. Indian J Community Med 1995; 20: 1-4.

18. Palafox M. Guiscafre H. Reyes H. Mufioz O. Martinez H. Diagnositc

value of tachypnoea in pneumonia defined radiologically. Arch Dis

Child 2000; 82:41-45.

19. Bahl R. Mishra S. Sharma D. Singhal A. Kumari S. A bacteriological

study in hospitalized children with pneumonia. Am Trop Pediatr 1995;

15:173-77.

20. MacIntyre CR, McIntyre PB, Cagney M. Community-based estimates

of incidence and risk factors for childhood pneumonia in Western

Sydney. Epidemiol Infect 2003; 131:1091-96.

21. Shah N. Raman Kutty V. Premila PG. Sathy N. Risk factors for severe

pneumania in children in South Kerala: a hospital-based case-control

study. J Trop Pediatr 1994; 40:201-06.

22. Suwanjutha S. Ruangkanchanasetr S. Chantarojanasiri T. Hotrakitya S.

Risk factors associated with morbidity and mortality of pneumonia in

Thai children under 5 years. Southeast Asian J Trop Med Public Health

1994; 25:60-66.

9 SIGNATURE OF THECANDIDATE

10 REMARKS OF THE GUIDE RECOMMENDED AND FORWARDED

11 NAME AND DESIGNATION OF

11.1 GUIDE Dr. M. LAKSHMINARAYANA REDDYASSOCIATE PROF. DEPARTMENT OF PEDIATRICS, VIMS, BELLARY.

11.2 SIGNATURE

11.3 CO-GUIDE (IF ANY)

11.4 SIGNATURE

11.5 HEAD OF THEDEPARTMENT

Dr. VEERASHANKARPROFESSOR & H.O.D.DEPT. OF PEDIATRICS,VIMS, BELLARY.

11.6 SIGNATURE

12 12.1 REMARKS OF THECHAIRMAN ANDPRINCIPAL

RECOMMENDED AND FORWARDEDFOR NEEDFUL

12.2 SIGNATURE

PROFORMA

Name: I.P. No: D.O.A.:

Age: Hospital: D.O.D.:

History Duration Number of days of follow up.

1 2 3 4 5 6 Etc

Cough

Fever

Hurried Breathing

Chest In Drawing

Wheeze

Stridor

Refusal of Feeds

Cyanosis/Convulsions

AlteredSensorium/Coma

Past History of LRTI:

Family History of LRTI:

Immunization History:

Wt: Ht:

Grade of Malnutrition (IAP):

Systemic examination:

Respiratory System:

Respiratory Rate:

Breath Sounds:

Added Sounds:

Cardio Vascular System:

Per Abdomen:

Central Nervous System:

CONCLUSION: SEVERE PNEUMONIA/ VERY SEVERE PNEUMONIA

Epidemiology:

Type of family:

Number of members in family:

Over crowding:

Type of house:

Fuel for cooking:

Sanitation:

Socio economic status:

Modified Prasad’s Classification grade:

Investigations:

Hb%

TC:

DC:

ESR:

Chest X-ray: Followup X-ray:

Blood culture:

Pleural fluid analysis:

Management:

Supportive Care:

Antibiotics:- First line antibiotics:- Ampicilline with Gentamicin.

Second line antibiotics:- Amoxycilline clavulanic acid with amikacin.

Others :- Cloxacillin. Cefotaxime/Ceftriaxone with Amikacin.

Duration:

Change of Antibiotics/Added:

Response.

Oral Antibiotics at discharge:

Result: