CERTIFICATE BY THE GUIDE

STUDY ON ACUTE ILLNESS OBSERVATION SCALE (AIOS) AND ITS EFFICACY IN DIAGNOSING AND MANAGING CHILDREN OF 2 TO 60

MONTHS WITH ACUTE RESPIRATORY ILLNESS Dissertation submitted to

THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI

In partial fulfillment of regulations for award of the degree of

M.D.PAEDIATICS BRANCH- VII DEPARTMENT OF PAEDIATRICS,

GOVERNMENT KILPAUK MEDICAL COLLEGE, CHENNAI - 10

THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI-TAMILNADU

MAY 2020

BONAFIDE CERTIFICATE

This is to certify that this dissertation entitled “STUDY ON ACUTE ILLNESS OBSERVATION SCALE (AIOS) AND ITS EFFICACY IN DIAGNOSING AND MANAGING CHILDREN OF 2 TO 60 MONTHS WITH ACUTE RESPIRATORY ILLNESS ” is the original and bonafide work done by Dr. AARTHY.R.V under the guidance of Prof. Dr.K.SUGUNA, M.D., DCH., Professor, Department of Paediatrics, Government Kilpauk Medical College &

Hospital and Govt. Royapettah Hospital, Chennai – 600 014, during the tenure of his course in M.D. Paediatrics from May-2017 to May-2020 held under the rules and regulations of the Tamil Nadu Dr. M.G.R Medical University, Guindy, Chennai – 600 032, in partial fulfilment for the award of the degree of M.D Branch VII Paediatrics.

Prof. Dr.K.SUGUNA, M.D.,DCH, Professor of Paediatrics,

Department of Paediatrics, Govt. Kilpauk Medical College/

Govt Royapettah Hospital Chennai-600 014

Prof.Dr.V.E.VIVEKANANDAN,M.D,DCH., Professor and Head,

Department of Paediatrics, Govt. Kilpauk Medical College, Chennai- 600 010.

Prof. Dr. P.VASANTHAMANI, MD., DGO., MNAMS., DCPSY., MBA

DEAN

Government Kilpauk Medical College & Hospital, Chennai – 600 010.

Date :

Place : Chennai

CERTIFICATE BY THE GUIDE

This is to certify that this dissertation titled “STUDY ON ACUTE ILLNESS OBSERVATION SCALE(AIOS) AND ITS EFFICACY IN DIAGNOSING AND MANAGING CHILDREN OF 2 TO 60 MONTHS WITH ACUTE RESPIRATORY ILLNESS” is the original and bonafide work done by

Dr.AARTHY.R.V under my guidance and supervision at the Govt. Royapettah Hospital & Govt. Kilpauk Medical College & Hospital, Chennai – 600 010, during the tenure of his course in M.D. Pediatrics from May-2017 to May-2020 held under the regulation of the Tamil Nadu Dr. M.G.R. Medical University, Guindy, Chennai – 600 032.

Prof. K.SUGUNA, M.D, DCH.,

Professor and Chief,

Department of Pediatrics, Govt. Kilpauk Medical College,

Govt. Royapettah Hospital, Chennai- 600 010.

Date :

Pace : Chennai

DECLARATION BY THE CANDIDATE

I solemnly declare that this dissertation titled “STUDY ON ACUTE ILLNESS OBSERVATION SCALE(AIOS) AND ITS EFFICACY IN DIAGNOSING AND MANAGING CHILDREN OF 2 TO 60 MONTHS WITH ACUTE

RESPIRATORY ILLNESS‖ is the original and bonafide work done by me at the Govt. Royapettah Hospital & Govt. Kilpauk Medical College & Hospital,

Chennai – 14.

This is submitted to the Tamilnadu Dr. M. G. R. Medical University, Chennai in partial fulfilment of the rules and regulations for the award of M.D. Degree in PAEDIATRICS, BRANCH VII

Signature by the candidate Dr.AARTHY.R.V

Date :

Pace : Chennai

CERTIFICATE - II

This is to certify that this dissertation work titled “STUDY ON ACUTE ILLNESS OBSERVATION SCALE(AIOS) AND ITS EFFICACY IN

DIAGNOSING AND MANAGING CHILDREN OF 2 TO 60 MONTHS WITH ACUTE RESPIRATORY ILLNESS” of the candidate Dr.AARTHY.R.V, post graduate in PAEDIATRICS with registration Number 201717151 for the award of M.D. PAEDIATRICS in the Branch VII. I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion pages and result shows 14%

percentage of plagiarism in the dissertation.

Signature of the Guide

Prof.Dr.K.SUGUNA, M.D., DCH, Professor of Paediatrics,

Dept. of Paediatrics

Govt. Kilpauk Medical College Govt. Royapettah Hospital Chennai-600 014

Date :

Pace : Chennai

ACKNOWLEDGEMENT

It gives me immense pleasure to express my sincere thanks and deep gratitude to my Dean, Prof. Dr. P. VASANTHAMANI, M.D.,DGO., for permitting me to utilise the infrastructure and resources needed to conduct this study in Government Kilpauk Medical College & Government Royapettah Hospital.

I express my sincere gratitude to Prof. Dr. T.ARUNA, M.D., Vice Principal for her support to conduct this study.

I would like to thank Prof. Dr. MANI. M.S., Director and Medical

Superintendent of Govt. Royapettah Hospital for allowing me to utilize the hospital facilities for the study.

I take this opportunity to express my heartfelt gratitude to my guide Prof Dr. K. SUGUNA, M.D., DCH., Professor and Chief, Department of Pediatrics,

Govt. Kilpauk Medical College & Hospital & Govt. Royapettah Hospital, Chennai for her keen interest, guidance, constant encouragement, and valuable suggestions throughout this study. Her constant motivation and support were the key factors for the construction of this study. I am extremely grateful to her.

I sincerely thank my HOD, Prof. Dr. V.E. VIVEKANANDHAN, M.D., DCH., for his support. I would like to thank my professors Prof. Dr. DEVIMEENAKSHI, M.D., and Prof. Dr. SRIDEVI NAARAAYAN, M.D., for their support.

I sincerely thank Prof. K. GOPINATHAN, MDRD, DNB, Department of Radiology at Govt. Roypaettah Hospital for allowing me to use the facilities for the investigation and providing his valuable opinion.

I extend my gratitude to my Assistant Professors Dr. NANDHINI BALAJI, DCH,DNB., and Dr. K. PREETHI, M.D., for their guidance and constant imputs throughout this study. I would like to thank all my Assistant Professors,

Dr. C.CHANDRASEKARAN, M.D., Dr. A.S. NOOR HUZZAIR, DCH., Dr. SREE NANDHINI, M.D., for their support and guidance.

I also thank Dr. BHARATHI SELVAM, DMRD.,MDRD., Assistant Professor in Department of Radiology, Govt. Royapettah Hospital for his guidance.

I am grateful to my fellow postgraduates, interns and staff nurses of Department of Paediatrics, Govt. Royapettah Hospital, who were an immense help.

I would also like to thank all the children and their parents who participated in the study.

CONTENTS

S.NO TITLE PAGE NO.

1. INTRODUCTION 1

2. REVIEW OF LITERATURE 17

3. NEED OF THE STUDY 30

4. AIMS AND OBJECTIVES 31

5. SUBJECTS AND METHODS 32

6. OBSERVATION AND ANALYSIS 36

7. RESULTS 38

8. DISCUSSION 70

9. CONCLUSION 74

10. SUMMARY 75

11. LIMITATIONS 76

12. BIBLIOGRAPHY 13. ANNEXURES

ABBREVIATIONS PROFORMA CONSENT FORM

URKUND PLAGIARISM ANALYSIS REPORT ETHICAL COMMITTEE CLEARANCE FORM MASTER CHART

KEY TO MASTER CHART

1

INTRODUCTION

Paediatric respiratory disease remains an important cause of morbidity in both the developing and the developed world. It has become the most common reason for parents taking their children to see the clinician, and to the emergency department with a paediatric medical problem⁶.

EPIDEMIOLOGY

Globally, in 2000, nearly 10 million children died before reaching their fifth

birthday . Though despite significant progress made by the global community in reducing the child mortality by nearly 40%, the under – 5 mortality was more than 5.7 million worldwide in 2016.¹ Two common, yet largely preventable diseases that claim more child lives than any others are Pneumonia and Diarrhea which is responsible for nearly one in every four under-5 deaths.^(2,3)

Fig . Under 5 deaths worldwide

2

Of these Pneumonia accounts for 14% of all deaths of children under 5 years old, killing approximately 1 million children in 2015. Pneumonia affects children and families all over the world, but is most prevalent in South Asia and sub-Saharan Africa.

About Fifteen countries account for more than three quarter of all pediatric deaths from pneumonia.

Fig.2 Prevalance of diseases in under 5

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And sadely India ranks number one in Global Mortality Rank in Pneumonia Deaths in Under- 5 children.¹⁶ In India about 45 million episodes are

estimated annually accounting for 6.6 million hospitalizations, which contribute to 24%

national disease burden with 0.37million deaths annually.

Fig .3 Distribution of Pneumonia in children worldwide

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Though the average annual rate of reduction in under-five mortality has accelerated— from 1.2 percent a year over 1990–1995 to 3.9 percent over 2005–

2012—but still remains insufficient to reach MDG 4. The reason for the decline is probably due to the introduction of antibiotics, vaccines, improved access to healthcare in rural areas of developing countries and the introduction of pneumococcal conjugate vaccines were also important contributors to the further reductions in pneumonia-related deaths achieved over the past decade.

ACUTE RESPIRATORY INFECTION:

This includes any infection of the upper or lower respiratory tract, as defined by the International Classification of Diseases. Acute lower respiratory infections are those that affect the airways below the epiglottis and include severe infections, such as pneumonia. Pneumonia accounts for a significant proportion of the disease burden attributed to acute lower respiratory infections.⁵

Community acquired pneumonia (CAP) refers to an infection of the lung by a variety of microorganisms acquired from the community, resulting in

inflammation of the lung tissue. It is typically presents with fever and respiratory symptoms such as cough and tachypnoea, but symptoms may not be specific in young children. Radiographic changes play a major role in confirming the diagnosis.

It contributes as an important cause of death in children throughout the world, especially in developing countries. The groups at highest risk of long term morbidity and mortality include infants (low birth weight or premature), those who are

5

immunosuppressed, and those who have other underlying conditions such as malnutrition or congenital heart disease.

Despite pneumonia being a condition commonly encountered by clinicians, uncertainty prevails over the diagnosis, investigation, and treatment of the disease. In developed countries it can be verified by the radiological finding of Consolidation. In the developing world a more practical term- acute lower respiratory tract infection is

preferred, keeping in .mind the difficulties in obtaining an X-ray.⁴

The British Thoracic Society (BTS) and WHO have published clinical guidelines which provide evidence based .management of CAP⁴. The guidelines recognize, however, that there are still some recommendations based on consensus opinion due to the lack of available evidence.

ETIOLOGY

Variety of organisms may be the cause of CAP (table 1).

Identification of the causative organism would aid treatment but accurate, fast,

affordable, and widely available diagnostic methods are still awaited. There is a current wide belief that the causative organisms vary according to the age of the child, where viruses being most common in children under 5 years old. Respiratory syncitial virus (RSV, most common in the very young), parainfluenza virus, adenovirus, influenza virus, and more recent metapneumovirus virus have all been identified in this age group.

6

Table-1 Causative pathogen among different age groups

Age Common Causes Less Common Causes Birth to 20 days

3 Weeks to 3 Months

4 Months to 5 Years

5 Years to Adolescence

Bacteria

Escherichia coli Group B Streptococci Listeria monocytogens

Bacteria

Chlamydia trachomatis S.Pneumoniae

Viruses Adenovirus Influenza virus

Parainfluenzavirus 1,2,3 Respiratory Syncytial Viruses

Bacteria

Chlamydia pneumonia Mycoplasma pneumoniae Viruses

Adenovirus Influenza virus Para influenza virus Rhinovirus, RSV Bacteria

C. Pneumoniae M.Pneumoniae S.Pneumoniae

Bacteria

Anaerobic Organisms Group D streptococci Haemophilus influenza Streptococcus pneumonia Urea plasma ureolyticum Viruses

Cytomegalo virus Herpes simplex Bacteria

Bordetella pertusis H.Influenzae

Moraxella catarrhalis Staph.aurius

U.Urealyticum Viruses

Cytomegalovirus Bacteria

H.Influenzae1 M.Catarrhalis.

M.tuberculosis N. meningitis S.aureus Viruses

Varicella-Zoster Bacteria

H.Influenza Legionella M.tuberculosis S.aureus Viruses

Epstein-Barr virus Para influenza Rhinovirus

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Other viruses isolated in children with pneumonia include rhinovirus, varicella zoster virus, herpes simplex virus and enteroviruses, cytomegalovirus, new viruses like Human metapneumovirus⁷ and human bocavirus⁸ has recently been isolated.

Overall, they appear to account for 30-67% of CAP cases in childhood and are more frequently identified in children aged <1 year than in those aged >2 years (77% vs 59%)^9,7.

Although viral infections (especially RSV) are more commonly found in younger children, bacteria are also isolated in up to 25% of children aged <2 years, along with an co infection with a virus in upto half of these.⁹

S pneumoniae is the most common bacteria causing pneumonia in childhood.

S pneumoniae causes about one-third of radiologically confirmed pneumonia among children aged <2 years. Pneumococcal serotypes are important, with serotypes 14, 6B, 19F and 23F being implicated more frequently in IPD (invasive pneumococcal disease) and serotype 1 in empyema⁴ .Pneumonia caused by group A streptococci¹⁵ and S aureus¹⁰ are more likely than pneumococcal in worsening to paediatric intensive care or empyema.

Chlamydia and Mycoplasma species have been more commonly encountered in older children^11,13 However, Block et al¹⁴ studied the incidence of M pneumonia and C pneumoniae infections to be comparable in all age groups between 3 and 12 years. In particular, the finding of a 23% incidence of M pneumoniae infection and 23% of C pneumoniae infection in children aged 3-4 years is high. Studies by Baer et al¹² supported this noting a 22% incidence of M pneumoniae in children aged 1-3 years.

8

There are also studies that support the preponderance of particular organisms in different age groups. For example, a Finnish study¹¹ found that in children less than 5 years, the incidence of S. pneumoniae infection was 8.6/1000 per year and mycoplasma 1.7/1000 per year. In children aged from 5–15 years, the incidence of S pneumoniae dropped to 5.4/1000, while that of mycoplasma rose to 6.6/1000.

However, the study by Clark et al¹² did not support this finding; in their study the mean age of the children with mycoplasma infection was 3.5 years. Apart from S pneumoniae and mycoplasma, other organisms that need to be mentioned include Chlamydia trachomatis, Bordetella pertussis, Staphylococcal aureus, and Mycobacterium tuberculosis.

Although most cases of pneumonia are caused by microorganisms, noninfectious causes include aspiration (of food or gastric acid, foreign bodies,

hydrocarbons, and lipoid substances), hypersensitivity reactions and drug- or radiation- induced pneumonitis.¹⁷

DIAGNOSIS

Infants and Childrens may present with different types clinical symptoms and signs such as fever, cough, and breathlessness. Some children may present with Fever of unknown origin and may not have any respiratory symptoms or signs.

Children may also present with abdominal pain and/or vomiting and even headache. Few infants may suffer convulsions, lethargy, feeding problems, unconsciousness,

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hypothermia¹⁹. Children with symptoms of upper respiratory disease and generalised wheeze with low-grade fever mostly not have pneumonia.

To guide first-level (based on community clinics) health-care workers in management of pneumonia .in developing countries, WHO recommends a diagnostic algorithm¹⁸ that takes considers clinical signs that are relatively easy to assess, .including age-specific respiratory rates, lower chest indrawing, and several danger signs such as lethargy, cyanosis and inability to feed without radiologica confirmation.

The World Health Organization (WHO) defines Pneumonia as cough or difficult breathing and age-adjusted tachypnea:

Table 2 : Age adjusted Tachypnea definition by WHO

< 2 Months >60 breaths/min

2 – 12 Months >50 breaths/ min

>12 Months >40 breaths / min

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WHO algorithm stresses the importance of tachypnoea (table 2) as an indicator of pneumonia. Palafox²⁰ found that tachypnoea (as defined by WHO) had a 74% sensitivity and 67% specificity for radiologically defined pneumonia. An increase in the age-specific respiratory .rate or tachypnoea has been linked to treatment failure in children with severe pneumonia in the developing world²². Although tachypnoea in infants with pneumonia may relate with presence of hypoxemia, tachypnoea may also be due to fever, dehydration, or any concurrent metabolic acidosis. Clinicians must be aware about fact that, the absence of tachypnoea does not necessarily mean the absence of pneumonia²¹.

The signs like nasal flaring and grunting increase the chance of pneumonia, but their absence cannot be taken as a rule out criteria of pneumonia²⁰. Other signs that correlate to the severity of pneumonia are chest in-drawing, lethargy and cyanosis. Noises such as rales, crackles or rhonchi alone are not sensitive or specific indicator of pneumonia.

High fever in young children (aged u.p to 3 years) is also a sign of pneumonia^{23, 24}. A temperature >38.5°C is a sign of bacterial pneumonia⁴. The BTS guidelines had suggested that in children less than 3 years old features of fever >38.5°C, chest recession with respiratory rate of more than 50 suggests pneumonia. Breathing difficulty itself is a more reliable marker in older children.

11

Pneumococcal pneumonia starts with .fever and tachypnoea. Cough is not a initial feature as alveoli have very few cough receptors. Cough begins not until lysis occurs and debris irritates cough receptors in the airways. Non-respiratory symptoms, such as arthralgia and headache, might also suggest mycoplasma infection^25. Hence many studies emphasise the importance of history of fever and breathlessness and the signs of tachypnoea, indrawing and ‗toxic‘ or ‗sick‘ look.

CRITERIA FOR ADMISSION

The most important decision in planning the management of CAP is whether to treat the child as OP or refer and admit for tertiary level care. This decision can be obtained by an accurate assessment of the severity of illness at presentation and the assessment of the illness prognosis.

The summary of the recommendations^4,18,26 from the BTS, WHO and Paediatric Accident and Emergency .Research Group guidelines to help clinicians to decide which children may need admission to hospital.

INDICATION FOR ADMISSION TO HOSPITAL

 Oxygen saturation < 92%

 RR > 70/ Min, > 50/min in older children

 Tachycardia disproportionate for level of fever;

 Prolonged CRT >2 s;

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 Difficulty in breathing;

 Grunting and Apnea;

 Feeding difficulty;

 Signs of dehydration;

 Chest indrawing, nasal flaring

LABORATORY AND SEROLOGICAL DIAGNOSIS

A variety of laboraory tests are currently used in combination with the clinical assessment to diagnose pneumonia. The utility of white blood count (WBC) , ESR, procalcitonin (PCT), Cytokines, C reactive protein (CRP) count individually and also in combination. But, none of these combinations was sufficiently sensitive or specific to differentiate bacterial Pneumonia (specifically pneumococcal) from viral pneumonia.

Though many hospitals routinely take blood cultures, they have a low yield for identification of the organism(s)^27,28. Moreover, they take 2 to 3 days for a positive result and are not much helpful in deciding initial antibiotic prescribing. It is not recommended that .blood cultures are taken in the community setting, although within the hospital setting the .BTS guidelines still recommend that they are performed⁴.

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Nasopharyngeal aspirate for viral immune fluorescence & viral antigen detection may be useful in identifying the causative virus but not much helpful on the immediate management of the patient. These tests are highly sensitive and help to identify RSV or other viral etilogy positive children so that they can be isolated.

Pleural fluid cultures though often show no growth, with just 9% of 47 cultures positive .in a UK study. Most of the children would have received antibiotics prior the aspiration of pleural fluid.

Diagnosis based on Radiology

Initially chest X Ray was considered one of the gold standard method for diagnosing pneumonia. However, there is poor variation between radiologists about what radiological changes constitute the pneumonia. Along with that, there is problem in variation of reporting CXRs between radiologists. Davies et al²⁹ studied the CXRs of 40 infants age less than 6 months admitted with LRI and showed that there are variation in intra-observer and inter-observer findings among radiologists.

Inorder to overcome the difficulties with CXR interpretation WHO developed a tool to standardize the reporting of CXR of pneumonia. This system

classifies CXR as .normal appearance, infiltrates/nonend point consolidation or endpoint consolidation.

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End-point consolidation is defined as a dense opacity that may be a ^.fluffy consolidation of a portion o.r whole of a lobe/ of the entire lung, often with air bronchograms and sometimes associated with pleural effusion.

Other (non-end-point) infiltrate is defined as linear and patchy densities (interstitial infiltrate) in a ^.lacy pattern involving both lungs, suggesting peribronchial thickening with multiple areas of atelectasis. Lung inflation may be normal or increased. It also includes minor patchy ^.infiltrates and small areas of atelectasis which is difficult to distinguish from consolidation .in children.

Although consolidation is a reliable marker for diagnosing

pneumonia, it does not merely indicate a bacterial infection. This was demonstrated in a study by Virkki et al³⁰. In the study, 254 children were assessed for etiology and

radiological changes; only 72% with alveolar .infiltrates had a bacterial infection. In children with viral pneumonia 50% had alveolar changes. Observing the group with interstitial changes, half of them had evidence of viral infection and the other half of them had bacterial infection.

Guidelines for Chest Radiography as per BTS (update 2011)^4, and IDSAare,

 CXR should not be a choice of routine investigation in children suspected of CAP.

 Those who are treated as Out Patients should not be advised CXR

 Lateral Xray is not to be performed routinely.

 CXR – PA view or lateral view should be taken in those suspected to have complications like Pleural effusion.

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 For those who don‘t .show improvement or there is clinical deterioration within 48 – 72 hrs after starting antibiotic therapy.

 Follow up CXR is not needed routinely except for those with severe consolidation, collapse or recurrent pnenumonia.

MANAGEMENT OF PNEUMONIA

The decision in managing the disease for the physician depends on the severity of the illness.

When do we need to provide oxygen therapy?

Not all hypoxic or cyanosed infants need oxygen therapy. Those with O2 saturation <

92% while breathing room air need to be treated with oxygen through any mode in order to maintain o2 saturation above 92%

Who needs fluid therapy?

Children who are diagnosed to have severe disease with inability to drink or with danger signs like vomiting may require intravenous fluid therapy. It is necessary to monitor in case of any electrolye imbalance.

ANTIBIOTIC THERAPY

The main problem in the management of pneumonia comes when the decision regarding the antibiotics is to be sought.

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The physician should decide,

 Whether to start on antibiotics or not?

 If yes, which antibiotic to start?

 Whether to start it as Oral or IV?

 How long .should it be given?

As an suggestion to the above questions, there was a study conducted by Friis et al³² where a randomized controlled trial was done allocating children with

Pneumonia to receive either Placebo or antibiotics. There was no difference seen between the two groups in the course of acute disease or with development of pulmonary

complications. However, 15 of 64 children in the placebo group were in need of antibiotics.

Based on the guidelines of BTS⁴ Update 2011, it is suggested that

 All children with proper and clear diagnosis of pneumonia should be started on antibiotics

 Children less than 2 years with mild symptoms of LRI usually don‘t have pneumonia and does not need to be started on antibiotics, but may need if symptoms persists.

CHOICE OF ANTIBIOTICS

The choice of antibiotic is mostly empirical, based on the chance of likely organism from etiological studies and also considering the age. The most

17

common cause of bacterial pneumonia in children is S .pneumoniae. Resistance of S pneumoniae to penicillin is .increasing but still remains as the main choice. The BTS guidelines henceforth suggest oral amoxicillin or as parentral Ampicillin and gentamycin as first line treatment in children < 5 years, with co-amoxiclav,

erythromycin, clarithromycin, cefaclor and azithromycin, cefotaxime, ceftriaxone or cefuroxime as alternatives.

How to administer the antibiotic of choice?

The BTS guidelines suggest that the antibiotics administered orally are safe .and effective for children presenting even with severe CAP and IV antibiotics should be reserved for those children with severe symptoms / signs or those children who are unable to tolerate oral antibiotics.

How long to continue the antibiotics?

There is currently little study to indicate the appropriate duration of time that a child with CAP should be given antibiotics. Oral antibiotics are usually prescribed for 5 to 7 days, but treatment duration may be increased to 10 days in case of severe infections (depending on the antibiotic which is used). This practice depends on the individual clinician.

COMPLICATIONS OF PNEUMONIA

Most children diagnosed CAP improve without any sequelae or complications. However, a small proportion of children develops complications which needs to be treated.

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TABLE 3^31,4. Complications of CAP

FOLLOW UP

After discharge from the hospital, some clinicians follow the child for X rays resolution at 6–8 weeks. But the need for this has been questioned and not needed unless PULMONARY COMPLICATIONS

Pleural effusion/ empyema

Lung abscess Pneumothorax

Bronchopleural fistula Necrotising Pneumonia Acute Respiratory Failure

METASTATIC COMPLICATIONS

Meningitis

Central nervous system abscess Pericarditis

Endocarditis Osteomyelitis Septic Arthritis

SYSTEMIC COMPLICATIONS

SIRS/ Sepsis HUS

TREATMENT FAILURE by Antibiotic Resistance

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the child continues to remain symptomatic or has lobar collapse / ‗‗round pneumonia‘‘, it is not recommended^33,34.

NEED FOR PREVENTION AND VACCINATION According to the IDSA guidelines ^31, it is suggested that

 Childrens should be vaccinated with vaccines for bacterial pathogens like H.

Influenza type B, S. Pneumonia and Pertusis.

 Infants with high risk, should be given immune prophylaxis with RSV – specific monoclonal antibody.

INTEGRATED MANAGEMENT OF NEONATAL AND CHILDHOOD ILLNESS (IMNCI)

The Integrated Management of Neonatal and Childhood Illness (IMNCI) is the Indian strategy of the WHO-UNICEF generic Integrated Management of Childhood Illness (IMCI) and is the core of newborn and child health modality under Reproductive Child Health II & National Rural Health Mission.UNICEF developed IMNCI in 1992 along with the World Health Organization (WHO) aiming on the prevention, or early diagnosis and treatment of the major childhood diseases.

It provides an integrated approach for standard management of major conditions of childhood morbidity and mortality like Pneumonia, Malnutrition, Neonatal problems Diarrhea, Measles and Malaria in the OP settings. Apart from focusing on treatment, it strategy provides the opportunity to emphasize on the prevention of illness

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through proper education on the importance of immunization, nutrient supplementation, and improved nutrition – especially breast feeding, oral rehydration therapy (ORT) and infant feeding.

IMNCI Process

Integrated case management is based on the case detection using simple clinical signs & research-based treatment. As it uses few clinical signs as possible.

IMNCI uses three basic steps in managing every condition.

 ASSESS

 CLASSIFY

 TREAT ACCORDINGLY

Initially the Community Health Worker checks for the presence of danger signs

& confirms the presence of main symptoms pertaining to cough/difficult breathing, malaria, fever, ear infections, diarrhea /dehydration and malnutrition. Following which the assessment of immunization status & vitamin A supplementation are done.

Later, Classify the severity of the child using a colour-coded triage system.

Hence, Pink colour is an indication for urgent referral; the Yellow colour stands for initiation of specific treatment as OP, and Green colour indicates home- based management & follow-up.

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Treatment is determined according to the colour-coded classification

Fig. 4 IMNCI algorithm for pneumonia

• Convulsions

• Lethargy/unconsciousness

• Inability to drink/breastfeed

• Vomiting

Check for danger signs

• Cough/ Difficulty in breathing

• Fever / Diarrhea with Dehydration

• Ear Problem

Assess for Main symptoms

• Nutrition & Feeding Problems

• Immunization

Assess

• Identify other associated problems.

Assess

• Classify and treat accordingly.

Classify

URGENT REFERRAL TREAT AS OP HOME MANAGEMENT

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RECENT IMCI CLASSIFICATION OF SEVERITY OF PNEUMONIA Table. 4 IMNCI classification of Pneumonia

SIGNS CLASSIFIED AS PREFERRED TREATMENT

(Urgent pre referral treatment are in bold)

 Any dangerous signs/

 Chest indrawings /

 Stidor in a calm child

SEVERE

PNEUMONIA OR VERY SEVERE DISEASE

 Administer the first dose of antibiotics

 Refer to a tertiary centre

 Fast Breathing PNEUMONIA  Give Cotrimoxazole for 5 days

 Safe remedy to soothe the throat and to relieve the cough

 Advice the mother about when to return immediately

 Follow up after 2 days

 No signs of

Pneumonia or very severe disease

NO PNEUMONIA:

COUGH / COLD

 If cough persists for more than 21 days needs assessment

 To start on safe remedy to soothe the throat and to relieve cough

 Inform the mother about when to return immediately

 To come for follow up after 5 days or if symptoms persist.

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ACUTE ILLNESS OBSERVATION SCALE

Though IMNCI strategy is more effective in classifying and managing pneumonia, if supplemented by an illness assessing scoring system used along the context to primary care setting that can quickly assess the severity of illness at all levels from onset to recovery. In this view, use of AIOS- illness severity scale

developed by P.L. McCarthy – using simple observations(based on hydration, hydration, toxic look) instead of complex symptomatology, aiming for wholeness rather details and encompassing the entire not just t^.he ends of sickness continuum. It is a three point scale fo^.r six ordinal variables and the total score ranges from 6-30. It is a validated index of^. assessing risk of serious bacterial infection in children 60 months or younger presenting with febrile illnesses.

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ACUTE ILLNESS OBSERVATION SCALE³⁵ - composition and. score description 1 = Normal, 3 = Moderate Impairment, 5 = Severe Impairment

Table. 5. AIOS

VARIABLES SCORE = 1 SCORE = 3 SCORE = 5

Quality of cry

Strong cry with normal

tone or contented

and not crying

Whimpering or sobbing Weak cry/moaning or high pitched cry

Reaction to stimulation to

parent

Cries briefly and stops or

is content and not

crying

Cries on and off Cries continuously or responds hardly

When awake,

stays awake, or if stimulated

while sleeping, awakens quickly

Closes eyes for short period when awake or awakens when stimulated for long

time

Fast asleep or not arousable

Color

Pink Pale

extremities/acrocyanosis

Pale/cyanotic/

mottled/ashen

Normal skin

and eyes and moist mucous membranes

Normal skin and eyes, mouth slightly dry

Poor recoiling of skin, mucous

membrane dry and or eyes

social overtunes

Smiles or alerts

Smiles for a brief period or alerts briefly

No smile, anxious face, no

expressions or

not alert

25

REVIEW OF THE LITERATURE

McCarthy PL et al³⁶ conducted a study between Nov 1, 1980 and March 1, 1981 in order to find a valid and reliable observation data for assessing prior to history and physical examination, using a 14 scaled item which was scored simultaneously by an attending physician, residents & nurses prior to history & physical examination on 312 febrile children less than 2 years seen consecutively in a Primary Care Emergency Room & in one private practice. Of the 312 children, 37 had serious illness. Multiple regression analysis which based on patients seen by at least. one attending physician in Primary Care. Center revealed six items (quality of cry, reaction to the parents, state variation, color, .hydration status, and. response to social overtures) that were .significant and independent predictors of. serious illness (multiple R = 0.63). The. observed

agreement for these six items between two attending physicians who saw 1/3 of the patients ranged from 88% - 97%. A discriminate function. analysis revealed that these^. six items when used together had a. specificity of 88% & sensitivity of 77% for serious illness. ^.Individual scores for each of the following 6 key items were added to yield a total. score for each patient. The .sensitivity of the six-item model for .serious illness when combined with .history and physical examination was .92%.

Bharati Bhavaneet et al³⁷ conducted a study in the remote hilly areas in Shimla of Himachal Pradhesh, in the objective of validating AIOS in severe pneumonia in the perspective of IMNCI Strategy and recent evidence favoring the use of oral antibiotics by which showed that those children scored abnormally on AIOS (>10) .had significantly

26

higher frequency of .severe tachypnea (P>0.01)., marked recession (P>05), & grunting (P-0.01) while the frequency of inability to drink .reached statistical significance.

(P<0.05) only for those children who scored 16 on AIOS. Also the study showed that higher the. scores on AIOS, longer it. took for tachypnea to reduce (P<01), and as well as subside (P-01) & hospital stay was also prolonged. (P<01). Although not of much significant, scores also seemed to positively correlate with the time taken for fever to subside (P<10).

Lingaraj H. Mulage et al⁴² conducted a descriptive epidemiological study in Kempegowda Institute of Medical Sciences, Karnataka in children between 2 – 60 months with clinical features of pneumonia^. as per WHO recommendations. IMNCI &

Acute Illness Observation Scale (AIOS) scoring was applied on each subject. to assess the severity of CAP. Study proved scoring has good internal consistency & external validity. They also correlates well with the clinical signs, abnormal X ray findings., initial SpO2 reading., predicting & therapeutic decision taken by the. physician and clinical outcomes. Comparing with IMNCI, sensitivity of AIOS in detecting illness severity in pneumonia group was very proved to be high but with a poor specificity, but in very severe pneumonia its sensitivity was poor in spite of having very high specificity.

Domenic V et al ³⁷ along with Paul L. McCarthy conducted a study from The

Departments of Pediatrics & psychiatry, Yale University .School of Medicine in 1991.

The purpose of this .study was to investigate to what. extent selected adverse

demographic., clinical, and psychosocial data. measured at the two-week well child visit

27

could. predict poorer reliability of .mothers' judgments during the acute illness episodes over the next thirty two months. The study was a randomized trial. of the Acute Illness Observation Scales(AIOS)., 369 mothers participated, 183 were in the intervention group using the AIOS and 186 were in the control group using a. three point global assessment scale. .There were 704 acute illnesses judged simultaneously & independently by

mothers the pediatricians. Standard Pearson r correlations was performed between the independent. variables, taken singly and in. all possible combinations, and . the

dependent variable, reliability of the mother‘s judgments as measured. by weighted kappa (kw). Analyses was performed separately for all the first, second, and third acute .illness visits to control for. any "practice effect" (analysis .1). As control for the

consistency of observers, the 1^st , 2^nd , and 3^rd visits of mothers with 3 visits were also analyzed (analysis 2.). Depending on the visit .number, adverse demographic, clinical, &

psychosocial characteristics did correlate. with poorer reliability independent of group assignment. .The results support the untoward impact. that adverse demographic, clinical,

& psychosocial factors have on the mother‘s clinical judgment. .These data may assist the pediatricians in identifying the parents who might benefit .from more intensive teaching and support about. acute illness episodes in their children.

Clark JE, Hammal D, .Spencer D, Hampton. F³⁸ conducted a study to describe the spectrum of. clinical features & management of community acquired pneumonia in UK from the Department of. Paediatric Infectious .Disease, Newcastle General .Hospital, Newcastle, UK. They .prospectively . recorded clinical details for all the children with

28

possible. pneumonia and chest X ray (CXR) changes .in 13 hospitals in the North of .England between 2001 & 2002. 89% of 711. children presenting to hospital with

pneumonia. were admitted; 96% received antibiotics., 70% had Intravenously ., 20% had lobar CXR. changes, 3% empyema and 4% required intensive care. Respiratory rate (RR), hypoxia & dyspnoea all correlated with each other & prompted appropriate interventions. Admission in children was .independently associated with RR., oxygen saturation, lobar CXR. changes and pyrexia. Children > 1 year old with perihilar changes in CXR more often had severe. disease (p = 0.001). Initial IV antibiotics were associated with CXR lobar changes in infants & children and with dyspnoea, pyrexia & pleural effusion in children. Cefuroxime was the. most often used IV antibiotic in 61%. Oral antibiotics were penicillin in 258 (46%), macrolide in 192 (34%) & cephalosporin in 117 (21%).

M. Weber, S. Usen, A. Palmer, S. Jaffar, and E Mulholl⁴⁰ studied the clinical

predictors of hypoxemia in Medical Research Council Laboratories, Fajara, The Gambia in 1996. About 69 children between the ages of 2 months to 5 years admitted to the hospital with acute LRI and with oxygen saturation (.SaO2) < 90% were compared with.

67 children matched for the age and diagnosis from the same hospital with an SaO2 of.

90% or above (control group 1), & 44 unreferred children admitted to a. secondary care hospital with. acute LRI (control group 2). Using multiple logistic .regression analysis, sleepiness, arousal., quality of cry, cyanosis., head nodding, nasal flaring, decreased air entry & upper arm circumference were found to be .independent predictors of hypoxemia

29

when. cases were compared to the control group 1. Using a simple model of. cyanosis or not crying or head nodding, the sensitivity of predicting hypoxemia was 59%, & the specificity was 94% and 93% compared to the control groups 1 and 2 respectively;

about 80% of the children with SaO2 < 80% were .identified by the combination of these signs.

Addo-.Yobo E, Chisaka, N. .Hassan M, Hibberd P. .Lozano JM. Jeena P et al⁴¹. conducted a randomized controlled trials (RCTs) & quasi RCTs comparing the 2 ways of giving antibiotics. in the treatment of pneumonia..

Campbell in 1988 compared oral cotrimoxazole. versus intramuscular penicillin followed. by an oral antibiotic in 134 children.. There was similar recovery in both the groups at follow up.

APPIS Group in 2004 evaluated 1702 patients, in comparing oral amoxicillin vs intravenous penicillin for 2 days. They showed equivalence. in effectiveness & safety in both treatments.

30

NEED FOR THE STUDY

In India Pneumonia is responsible for the high morbidity and mortality amongst children less than 5 years. It is essential to formulate the criteria to triage,

classify and treat or refer the children in developing countries. The strategy developed by IMNCI seeks to reduce the morbidity and mortality in children by improving the

management of illness in family and community practices. It relies on case detection by using simple clinical assessment and research based treatment.

Various studies have been conducted throughout the world, as also in India in proving the effectiveness of IMCI in case detection and management of childhood illness. Though IMCI had been showed to be effective in managing childhood

pneumonia, it would be more effective if been supplemented by an illness assessment scale aiming at helping the primary care setting in quickly assessing the severity.

In the view of the above context, AIOS system developed by P.L. McCarthy a generic illness severity scoring system uses 6 easily observed parameters are shown to be a sensitive indicator of illness in children. Using the Acute illness observation scale can also be rationalized with the curative services of the hospital management.

Very few studies had been conducted in India in measuring the effectiveness of Acute Illness Observation Scale scoring system in management of Pneumonia in

children less than 5 years. With this background the present will be conducted to prove the effectiveness of AIOS in diagnosing and managing pneumonia in children, especially in large populated southern India like Tamil Nadu.

31

AIM OF THE STUDY

To validate the effectiveness of Acute illness observation scale in predicting the severity of the illness and to describe the efficacy of AIOS in determining the initial therapeutic modalities and clinical outcome of the children.

32

METHODOLOGY STUDY DESIGN

Descriptive epidemiological study.

STUDY PERIOD

March 2018 – February 2019 STUDY POPULATION

Children aged 2 months to 60 months STUDY SETTING

Govt. Royapettah Hospital/ KMC, Chennai, Tamilnadu, a tertiary care hospital SAMPLE SIZE

Based on the prevalence of Pneumonia from the study by Bhavneet Bharti et al, Sample size (N) is calculated using the formula:

N = z² pq/L² where Z (Relative Coefficient) at 95% confidence level = 1.96 P is the prevalence (p = 52.3%)

Q = (100 – p) i.e. q = 47.7, L is the relative Precision N = 1.96 x 1.96 x 52.3 x 47.7 / 225

N = 42.5

33

Allowing a 10% non response rate, the minimum sample size is 47.

Sample size is estimated to be minimum of 47 patients.

INCLUSION CRITERIA

Children between 2 months to 60 months presenting to OPD with fever , cough and difficult breathing less than 2 weeks with any of the following signs:

 Fast breathing - 2 Months –12 months >50 breaths/mt 12 Months –5 years >40breaths/mt

 Chest in drawing

 Stridor in calm child

 Lethargy

 Convulsion

 Grunting

 Inability to drink

EXCLUSION CRITERIA 1. Duration of illness >2 weeks 2. Known case of Asthma

3. Any underlying cardiac diseases..

4. Other conditions like IEM, Chronic Lung Disease etc.

34

5. Neurological conditions like Developmental delay, neurodegenerative disorders.

METHOD:

1. Children between 2 months to 60 months attending OP with suspected pneumonia, if satisfying the criteria of inclusion were enrolled as the study group and were admitted ,and classified according to IMNCI based on severity assessment.

2. All the children with the following signs and symptoms were admitted for study purpose, for which parental consent was obtained.

3.On day 1 AIOS Scoring was done using the 6 parameters and given scoring as 1 for normal, 3 for moderate and 5 for severe disease , with final score ranging from 6 to 30 depending on the severity, in a reasonably quite state by a single observer. Similarly, AIOS scoring was done and followed for respiratory parameters to determine the outcome of illness on Day 5, where the outcome will be compared with the initial score on Day 1.

4. Pulse oxy meter reading of each patient were recorded.

5. Vital signs including respiratory rate were collected and documented.

6. At the time of admission, complete blood count, Chest X ray were done within 24 hrs.

7. Interpretation of Chest X Ray was done by a radiologist who was blinded about the study.

35

8. Treatment were decided according to the initial AIOS score at presentation, where children with score more than 16 were started on IV antibiotics and nasal oxygen and intravenous fluid depending on the respiratory distress. Rest of the children were treated according to the IMNCI protocol.

9. The children were followed up until discharge from the hospital.

36

OBSERVATION & ANALYSIS

50 children who satisfied the inclusion criteria were enrolled in the study. Statistical analysis was done using SPSS computer software. Continuous data are being analysed and denoted with mean and standard deviation (SD). Microsoft Excel and Microsoft Word was used to form the tables and charts.

The following analysis methods were used:

 Chi square test

Significant figures:

Significance - [ P value:0.01<.P ≤ 0.05]

The following statistical analysis are presented as following

 General. Characteristics.

1. Demographic^. characteristics 2. Clinical^. Features

3. Investigations.

4. Treatment and^. course of the illness.

37

 AIOS and its correlation

i) Score distribution in the study group

ii) Individual item analysis among the study group iii) Correlation with clinical signs

iv) Correlation with the investigations v) Correlation with the treatment

38

RESULTS

GENERAL CHARACTERISTICS 1) Demographic Characteristics

 AGE:

Table .1 Age distribution in the study group

AGE NUMBER PERCENTAGE

2 – 12 mon 18 36

13 – 36 mon 24 48

37 – 60 mon 8 16

TOTAL 50 100%

A total of 50 children were enrolled in the study, age ranging from 2 months to 60 months. ^. Children in the age group 13 – 36 months were more affected (48%).

39

Fig.1 Age distribution in the study group

0 5 10 15 20 25 30 35 40 45 50

2-12 m 12-36mon > 36

18

24

8 36

48

16

Number Percentage

40

 SEX

Table 2. Sex distribution among the study group

Among 50 children under study, males were 31(62%) & females were 19 (38%), male (62%) incidence was higher than the females (38%). Male: female ratio was 1.63:1.

Figure. 2 Sex distribution in the study population

62%

38%

Male Female

SEX NUMBER PERCENTAGE

MALE 31 62%

FEMALE 19 38%

TOTAL 50 100%

41

 Nutritional analysis

While considering the nutritional status, majority of children were between 3^rd and 15^th percentile (32%), while children below 3^rd percentile were 14% and children above 97^th percentile according to WHO were 4%.

Figure. 3 Weight for age percentile distribution among the children.

0 5 10 15 20 25 30 35

<3rd 3-15th 15-50th 50-85th 85-97th

7

16

11

14

2 14

32

22

28

4

NUMBER PERCENTAGE

42

2) Clinical Features

Table. 3 Common presenting complaints.

Symptoms Mean duration(days) SD

Fever 1.84 0.71

Cough 2.52 0.81

Breathlessness 1.5 0.5

Children who presented to out patient department with complaints of fever, cough and breathlessness were enrolled into the study. The mean duration of the presenting complaints are tabulated below.

43

 Danger signs noted in the population.

Table 4. danger signs in the study group

DANGER SIGNS NUMBER PERCENTAGE

Lethargy

20 40

Inability to drink

9 18

Grunt

10 20

Convulsion

0 0

Among the danger signs, majority of the children had lethargy (40%), while inability to drink (18%) and grunt (20%) were least common. None of the children had convulsions

44

 VITAL SIGNS

 Table.5 Common signs and duration

Symptoms Mean SD Range

Respiratory rate/mt 52 8.2 40-75

Temperature(°C) 38.2 0.63 37.2-40

Heart rate/mt 117.42 11.6 99-140

Systolic BP(mmHg) 89 6.4 70-100

Diastolic BP(mmHg) 58.2 4 50-65

In regards to vitals, the mean respiratory rate was 52 (SD – 8.2), and mean temperature was 38.2, and heart rate was 117.42.

45

 Respiratory Morbidity Parameters Table 6. Respiratory parameters

Respiratory Signs Total %

Respiratory Rate 40 – 50 23 46

51 – 60 16 32

>60 11 22

Subcostal / Intercostal Recession 30 60

Grunt 10 20

Cyanosis 1 2

Convulsion 0 0

Inability to drink 9 18

Abnormal Capillary refill time 1 2

Decreased breath sound 13 26

Bronchial Breathing 8 16

Crepitations 10 20

Wheeze 11 22

Vocal Resonance Increased 8 16

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All children with tachypnea were admitted, where about 46% of children had respiratory rate between 40-50, while 22% of children had respiratory rate more than 60. Intercostal/subcostal retractions were also found in about 60% of cases, with grunt in 20% cases, cyanosis in 1 children, inability to drink in 18% of cases.

Abnormal breath sounds like crepitations were found in 10 (20%) children, wheeze in 11 children, decreased breath sound were found in 13 children (26%).

Fig.4 Respiratory Parameters among the study group

0 10 20 30 40 50 60 70 80 90 100

Number Percentage

47

 INVESTIGATIONS

 Pulse Oximetry

Table. 7 Spo2 distribution among the study group

Pulse oximetry reading was done on the children at

admission, day 2 and day 5. Children with spO2 less than 85, was found to have cyanosis, and only 1 child had cyanosis with saturation 83%, and 68% children were having

saturation between 86-92% and remaining 30% were having saturation more than 92%.

SpO2 Number Percentage

< 85 1 2

86 – 92 34 68

>92 15 30

TOTAL 50 100

48

Fig.5 Spo2 rate among the children 2%

68%

30%

SpO2

< 85 86 - 92

> 92

49

 Chest X ray

Table .8 CXR finding among the study group

CXR Finding Number Percentage

Normal 20 40%

Infiltrates 22 44%

Consolidation 8 16%

Chest X ray was done in all subjects at the time of admission. Normal findings were seen in about 40% children, abnormal in 30 children, where infiltrates found in 22 children (56%), and consolidation was seen in 16% of children.

50

Fig 6. CXR distribution

40%

44%

16%

Chest X Ray findings

Normal Infiltrates Consolidation

51

 OTHER INVESTIGATIONS Table. 9 Blood investigations

INVESTIGATIONS NUMBER PERCENTAGE

Leucocytosis 17 34

Among the other investigations, leukocytosis was seen in 17 children (34%), where the total count more than 11000 was considered leukocytosis.

 DIAGNOSIS

Table.10 diagnosis according to IMNCI

According to IMNCI classification, of the total 50 children, 20%

of them (10), had fever, cough, tachypnea and was diagnosed pneumonia, while the remaining 80% (40) had distress along with retractions or grunt or lethargy and was diagnosed as Severe Pneumonia.

DIAGNOSIS NUMBER PERCENTAGE

PNEUMONIA 10 20%

SEVERE PNEUMONIA/

40 80%

52

Fig. 7 IMNCI diagnosis

20%

80%

IMNCI Diagnosis

PNEUMONIA SEVERE PNEUMONIA

53

 TREATMENT AND COURSE OF ILLNESS

Table.11 Treatment required for the subjects

TREATMENT DONE NUMBER PERCENTAGE

ANTIBIOTICS ORAL 9 18%

INTRAVENOUS 41 82%

NASAL O2 33 66%

INTRAVENOUS FLUIDS 32 64%

NEBULISATION 12 24%

MECHANICAL VENTILATION 1 2%

COMPLICATION 1 2%

During their course of management, (2%) 1 child was so

severely affected that the child needed mechanical ventilation for respiratory failure and 1 child (2% ) needed inotropic support for shock management. Nasal Oxygen was

administered for 66% (33/50) of cases in view of severe respiratory distress.

Majority of children, about (32/50) 64% of them required maintenance intravenous fluids because of respiratory distress and/or dehydration and/or refusal of

54

feeds. Parenteral antibiotics were administered in majority(82%) of patients while remaining were treated with oral antimicrobial(18%).

During the hospital stay 1 child (2% ) developed complication in the form of shock. About 60% of children had hospital stay between 6 – 14 days, with range 5 – 12, and mean duration of stay was 6.78 days and all were discharged after treatment.

No deaths were encountered during the course of the illness.

Fig. 8 Treatment done for the subjects

0 5 10 15 20 25 30 35 40

45 41

9

33 32

12

1 1

Treatment & Course of illness

Number

55

AIOS and its associations with the illness

Acute illness observation scale (AIOS) is a generic illness severity scale developed by P.L. McCarthy. AIOS is a 3 point scale for six ordinal variables and total score range from 6-30. The composition and scoring pattern of AIOS scale with its clinical

significance are presented in table.

Table. 12 AIOS parameters

SCALE Acute Illness Observation Scale

VARIABLES INCLUDED Quality of cry

Response to parent stimulation State variation

Color Hydration

Response to social overtures

SCORE INTEPRETATION Each item scored as normal(1)

Moderate(3) & severe Impairment(5)

TOTAL SCORE 6= best score

30= worst physical score

CHANCE OF ILLNESS Score≤10 : 2-3%

Score 11-15 : 26%

Score ≥16 : 92%

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1. Score correlation among the study population.

Table 13 AIOS score at admission X2 value =1.36 , df=4. P value >0.05 not significant

In our study, about 42% of children scored abnormally (≥ 16) at the initial presentation, while about 20% children scored between 11 – 15 and 38%

children scored near normal (≤ 10). Majority of children between age group 12 – 36 months scored abnormally (≥ 16) at the initial presentation. Mean score at the initial presentation is 14.56.

AIOS SCORE On day 1

≤10 11-15 ≥16

N % N %

2-12 years 18 6 31.6

%

4 40 8 38.1%

12-36 years 24 9 47.4

%

4 40 11 52.4%

> 36 years 8 4 21.1

%

2 20 2 9.5%

Total 19 10 21

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2. Individual AIOS variables correlation Table.14 Individual variable analysis

ITEMS NORMAL SCORE (=1) ABNORMAL SCORE (=3or5)

Quality of cry 19 (38%) 31 (62%)

Response to parent stimulation

12 (24%) 38 (76%)

State variation 17 (34%) 33 (66%)

Colour 47 (94%) 3 (6%)

Hydration 39 (78%) 11 (22%)

Response to social overtunes

1 (2%) 49 (98%)

In the individual item analysis of AIOS, 94% and 78% of affected children scored normally for variables ―color‖ and ―hydration status‖ respectively. In contrast majority of children showed worst score in the variable ―response to social overtures.

At the initial presentation, of the 50 children, 19 of them showed normal score for quality of cry, while 62% of children (31) showed abnormal scrore 3/5. In view of

response to parent stimulation, where abnormal score was seen 76%(38) of children. 66%

children scored abnormal for state variation, while majority of children had normal score in variables like colour and hydration. But almost majority of children (49) 98% showed worst score for social overtunes.

58

Table. 15 Symptoms correlation with the AIOS

When comparing the respiratory morbidities of the children with the scores during their initial presentation, children scoring more than 10, had marked significance with lethargy (p<0.05,11.4) and grunt(11.45, p<0.05), while inability to drink and convulsion, does not show much significance(p>0.05). Higher scores thus found to be significantly correlating with clinical features of Pneumonia.

Symptoms

AIOS

10 11-15 >16 Chi

square, P value

N % N % N %

Breathlessness 50 19 100 10 100 21 100 -

Lethargy

Yes 20 5 26.3 1 10 14 66.7 11.45

;<0.05*

No 30 14 73.7 9 90 7 33.3

Grunt

Yes 10 1 5.3 0 9 42.9 11.45

;<0.05*

No 40 18 94.7 10 10 12 57.1

Inability to drink 1 0 9

Yes 9 1 5.2 3 30 5 23 2.3

>0.05

No 41 18 94.8 7 10 16 76.1

Convulsion ---

No 50 19 100 10 100 21 100

Tachypneic 50 19 100 10 100 21 100 -

Total 19 10 21

59

Table. 16 AIOS correlation with signs

AIOS

10 11-15 >16 Chi

square, P value Cyanosis

1.4 df=2

>0.05

Yes 1 0 0 1 4.8

CRT

<3 Sec 49 19 100 10 100 20 95.2 1.4 df=2

>0.05

>3 sec 1 0 0 1 4.8

Decreased Breath Sound

Yes 13 0 0 13 100

;<0.05*

No 37 19 100 10 100 8 66.7

Wheeze 1 0

Yes 11 5 26.3 2 20 4 19 0.83

>0.05

No 39 14 73.7 8 80 17 81

Crepitations 12.4

<0.05*

Yes 10 0 1 10 9 42.9

No 40 19 100 9 90 12 57.1

Bronchial Breathing

(<0.05*)

Yes 8 0 0 0 8 38.1 13.4,

Vocal Resonance (<0.05*)

Increased 8 0 0 0 0 8 38.1 13.1