Age specific fast breathing in under-five diarrheal children in an urban hospital: Acidosis or pneumonia?

BACKGROUND: Children with diarrhea often present with fast breathing due to metabolic acidosis from dehydration. On the other hand, age specific fast breathing is the cornerstone for the diagnosis of pneumonia following classification of pneumonia recommended by the World Health Organization (WHO). Correction of metabolic acidosis by rehydrating the diarrheal children requires time, which delays early initiation of appropriate antimicrobials for pneumonia and thereby increases the risk of deaths. We need to further investigate the simple clinical features other than fast breathing which might help us in earliest diagnosis of pneumonia in children with diarrhea Thus, the objective of our study was to identify other contributing clinical features that may independently help for early diagnosis of pneumonia in diarrheal children who present with age specific fast breathing. METHODS: This was an unmatched case-control study. Diarrheal children aged 0–59 months, admitted to Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) during January 2014 to December 2014 having age specific fast breathing (<2 month ≥60 breath/min, 2–11 months ≥50 breaths/min, >11–59 months ≥40 breaths/min) were studied. The study children with clinical and radiological pneumonia constituted the cases (n = 276) and those without pneumonia constituted the controls (n = 446). Comparison of clinical features and outcomes between the cases and the controls was made. RESULTS: The distribution of acidosis among the cases and the controls was comparable (35% vs. 41%, p = 0.12). The cases had proportionately higher deaths compared to the controls, however, the difference was not statistically significant (3% vs. 1%; p = 0.23). In logistic regression analysis after adjusting for potential confounders, the cases were independently associated with cough (OR = 62.19, 95% CI = 27.79–139.19; p<0.01) and chest wall indrawing (OR = 31.05, 95%CI = 13.43–71.82; p<0.01) and less often had severe acute malnutrition (OR = 0.33, 95%CI = 0.13–0.79; p<0.01). The sensitivity and specificity of cough were 83% (78–87%) and 93% (91–96%). The sensitivity and specificity for lower chest wall indrawing were 65% (59–71%) and 95% (93–97%). However, the sensitivity and specificity of cough and lower chest wall indrawing combined were 94% (89–97%) and 99% (97–100%). CONCLUSION AND SIGNIFICANCE: Thus, diarrheal children having fast breathing who present with cough and/or lower chest wall indrawing, irrespective of presence or absence of metabolic acidosis, are more likely to have radiological pneumonia. The results underscore the importance of early identification of these simple clinical features that may help to minimize potential delay due to rehydration in initiating prompt treatment of pneumonia in order to reduce fatal consequences in such children.