ORIGINAL

Niger J Paed 2013; 40 (2): 150 –153

Yilgwan CS

John C

Abok I I

Pattern of acute respiratory

infections in hospitalized children

under five years of age in Jos

Nigeria

Okolo SN

DOI:http://dx.doi.org/10.4314/njp.v40i2,8

Accepted: 19th September 2012

Abstract Background: Acute res-

piratory infections are the com-

monest cause of acute morbidity in

children especially those under five

in the developing countries. Clini-

cal diagnosis is of utmost impor-

tance considering the unavailability

of radiological and microbiological

services in most primary care set-

tings in most developing countries.

Methodology: Thirty nine children

with symptoms of acute respiratory

infection attending our emergency

room over a one year period were

recruited. Each had a CXR and

blood culture ordered by the at-

tending physician on admission.

=25.6+19.1, Males = 13.8+14.2,

t=2.2, p=0.03). Bronchiolitis was

the commonest ARI seen in infants,

tonsillitis in children beyond in-

fancy while pneumonia was seen in

all age groups. The cardinal feature

of each disease entity was Fever,

cough, breathlessness, tachycardia

and hypoxemia in those with Pneu-

monia; Catarrh, nasal congestion

and tachypnoea in those with bron-

chiolitis, while fever and vomiting

were seen in those with pharyngo-

tonsilitis.

Conclusion: This review highlights

the common ARI in our setting.

Efforts need to be intensified on the

identification of children with ARI

in the children emergency room

with the aim of prompt and appro-

priate management in order to meet

the MDG targets.

Yilgwan CS

(

)

John C, Abok I I, Okolo SN

Department of Paediatrics

University of Jos

Nigeria.

Email: yilgwan@hotmail.com,

yilgwanc@unijos.edu.ng

Tel: +2348180310979

Results: Thirty nine subjects were

admitted with ARI with a hospital

prevalence of 43.5/1000 person per

year (39/897). Mean age was

1

8.75+17.23 mo, (Females

Introduction

While the use of pulse oximetry has been deployed in

several centres, its application and interpretation remains

a challenge.

We sort therefore to examine the pattern of ARI in our

environment, vis-a-vis age, sex, anthropometric find-

ings, clinical symptoms and signs and pulse oximetry

reading in ARI as seen in our hospital.

Acute respiratory infections are the commonest cause of

acute morbidity in children_,e₂specially those under five

1

in the developing countries. Viral and bacterial organ-

isms have been i_,m₄ plicated as causative agents for most

3

ARI in children. Most diagnosis of ARI is made in the

presence of clinical features and where available also

radiolog_,₅ical appearances especially in the case of Pneu-

4

monia. However, radiological services in most cases

are only available in tertiary care facilities with few radi-

ologists available for specialist interpretation of films.

Patients and methods

6

,7

This then makes clinical diagnosis imperative and of

utmost importance considering the high burden and the

case fatal₈it_,₉y rate for children with ARI in developing

countries. There are features that are highly suggestive

Thirty nine children with symptoms of acute respiratory

infection attending the emergency room of the Jos uni-

versity teaching hospital over a one year period were

recruited. Each had a CXR ordered by the attending

physician on admission. All children with symptoms of

ARI necessitating admission were recruited. However

subjects with cardiovascular, pulmonary, or neurological

congenital defects, or if 6weeks and below as well as

those with chronic respiratory tract disorders or diseases

(R)

of ARI and have been defined by WHO in the ARI

1

0

case management for primary health care providers.

While this is very useful, few applications exist to dis-

tinguish the various forms of ARI-pneumonia. Bron-

chiolitis and others like pharyngotonsilitis.

1

51

while 3(27.3%) had pharyngotonsillitis. In the age group

6 month and above, all 9(100%) were seen with pneu-

were excluded.

3

Informed consent was sought from care givers of all

eligible children and only those who consented to par-

ticipate in this study were recruited into the study. All

children were evaluated by the attending physicians (1

of 4 of the investigators)

monia while none were seen with either bronchiolitis or

tonsillitis.

Frequency of common symptom encountered

Data was collected using a standardised questionnaire

which included information such as cough, fast breath-

ing/rapid breathing, fever or hypothermia, nasal conges-

tion, catarrh or vomiting. Axillary temperature and the

status of the child (quiet or fussy/crying) were recorded.

Hypoxaemia detected using pulse oximetric readings

Fever was found in all the children with pneumonia and

tonsillitis but only present in 25% of those children seen

with bronchiolitis.

Cough was a prominent symptom seen in 80% of chil-

dren with pneumonia, while only 20% of those with

bronchiolitis and none of those with tonsillitis presented

with cough.

Breathlessness was seen in 75% of the children with

pneumonia, while 25% of children with bronchiolitis

and none of those with tonsillitis had breathlessness.

Catarrh was seen in 100% of those children with bron-

chiolitis while none of the children with pneumonia or

pharyngotonsilitis had catarrh.

Vomiting was seen in only those children with pneumo-

nia (25%) and those with tonsillitis (50%). This is as

shown in table1

(

SaO2) measured three times using a Nellcor N10 oxime-

ter with an adhesive sensor attached to the child's index

finger was noted.

A complete chest examination was done. The presence

of nasal flaring, retractions, wheezing or grunting was

established with the child's chest naked, and the respira-

tory rate was determined by counting the respiratory

movements for one minute. Auscultation for breath

sound character and quality was done while the presence

of abnormal respiratory sounds (crepitations, rhonchi,

reduced breath sounds) were also recorded. All cases of

ARI had chest radiograph against which we compared

the clinical features being studied. Children with a his-

tory of rapid breathing, a history of difficulty drinking,

tachypnoea ( respiratory rate greater than 40 breaths/

minute for children older than 12 months, and greater 50

breaths/minute for children aged 3-12

months),wheezing, nasal flaring, or chest in drawing in

the presence of a pulmonary parenchymal density com-

patible with pneumonia on chest radiograph as inter-

preted by the paediatric radiologist were defined as hav-

ing pneumonia. While those with painful swallowing,

vomiting and pharyngeal hyperaemia and exudates in

the tonsilar crypts were classified as tonsillitis.

Table 1: Frequency of symptoms encountered by morbidity

type

%

of children

Symptom

Fever

Pneumonia

Tonsillitis Bronchiolitis

100

80

100

25

0

Cough

Breathlessness

Catarrh

75

0

25

0

20

100

80

Nasal congestion

0

Vomiting

25

50

0

Cardiorespiratory parameters

Data so generated was analysed using the Stata IC 10

statistical software.

The mean respiratory rate by age was 47±13.5

(

range=30-80) for those aged 0-11 months, 33.6±6.9

range=22-48), for those age 12-35 months and

3

5.8±10.5 (range=24-52) for those age 36-60 months.

Results

When stratified by diagnosis, the mean respiratory rate

was 54.6±8.77 in children with bronchiolitis, 51.0±14.1

in those with pneumonia and 34.0±8.99 in those with

acute tonsillitis.

During the study period, a total of 113 children were

admitted into the unit, out of which 78 (69.0%) were

children 5years and below. From this, 39(50%) were

diagnosed with acute respiratory tract infection. Males

were 22(59.0%) and Females 16(41.0%).

Mean age was18.75mo+17.23, (Females =25.6+19.1,

Males = 13.8+14.2, t=2.2, p=0.03). The 0-11months old

accounted for 48.7% (19) of the patients seen. This was

followed by the 12-36 month group with 28.2% (11)

while the 36-60 month old group were 23.1 % (9).

The mean oxygen saturation by age was 96.3±2.08

(

range=92-99) for those age 0-11 months, 95.8±4.8

range=82-98), for those age 12-35 months and 96.6±1.9

range=93-99) for those age 36-60 months. When strati-

fied by diagnosis, the mean oxygen saturation was

9

7.8±0.71% in those with bronchiolitis, 95.5±3.40% in

those with pneumonia and 97.5±0.55% in those with

acute tonsillitis.

Patient distribution by diagnosis of ARI

The mean pulse rate by age was 131.5±22.5 (range=98-

Of the 19 infants seen, aged 0-11 months, 8(42.1%) each

had bronchiolitis and pneumonia, while 3(15.8%) had

pharyngotonsillitis. Similarly, among the 12-36mo olds

seen, none had bronchiolitis, 8(72.7%) had pneumonia

1

62) for those age 0-11 months, 121.0±17.4 (range=100-

53), for those age 12-35 months and 136.0±28.6

(

range=160-168) for those age 36-60 months. When

stratified by diagnosis, the mean pulse rate was

1

52

1

bronchiolitis, pneumonia and tonsillitis respectively.

This is shown in table 2

22.0±24.7, 134.4±23.2 and 117.3±14.3 in those with

cough been predominant features in pneumonia while

cough and catarrh were more frequent in bronchiolitis.

Pharyngotonsilitis had more of fever and vomiting and

less cough. Reports have shown bronchiolitis to be com-

monly associate₂₀d with nasal congestion, catarrh and

breathlessness. The course of bronchiolitis is usually

variable and dynamic ranging from transient events such

as nasal blockade to progressive respiratory distress

from lower respiratory tract inflamma₂t₀i_,₂o₁n and obstruc-

Table 2: Cardio-respiratory parameters by morbidity of

Subjects

Diagnosis

RR

SO2

PR

Bronchiolitis 44.6±8.77 97.8±0.71 122.0±24.7

Pneumonia

Tonsillitis

41.0±14.1 95.5±3.40 134.4±23.2

34.0±8.99 97.5±0.55 117.3±14.3

tion. As reported by other researchers

fever was not

a common feature of bronchiolitis in our study. How-

ever, we did not find cou₀gh as a prominent symptom

Commonest features of ARI

2

unlike what Fattouh et al reported in Egypt. Since all

our patients with bronchiolitis were younger than 6

months where cough is not so prominent with respira-

tory infections, it is not surprising that fewer than 25

percent of our children reported cough as a symptom.

The cardinal feature of each disease entity was Fever

(

100%), cough (80%), breathlessness (75%), tachycardia

and hypoxemia in those with Pneumonia. Catarrh

100%), nasal congestion (80%) and tachypnea(80%) in

those with bronchiolitis. Fever (100%) and vomiting

100%) in those with pharyngotonsilitis. (Table 1 and 2)

(

On the other hand, that we found pharyngotonsilitis as-

sociated₂commonly with fever and vomiting is not sur-

(

2

prising. Though pharyngotonsilitis is an acute respira-

tory infection, its onset is sudden and usually character-

ized by symptoms of fever and sore throat, naus₂ea, vom-

Discussions

2

iting, headache, and rarely, abdominal pain. Cough

and breathlessness are not prominent features especially

since it is an upper tract infection without the usual lung

parenchyma inflammation and the lower tract obstruc-

tion seen in pneumonia and other lower tract infections.

Clinical features and aetiologies of ARI differ from age

to age and so also the pat₁te₁rns of the different ARI

within the same age group. Typical features of ARI

include but are not limited to cough, breathlessness, ca-

tarrh, fever etc. Differences in features are seen in de-

gree of respiratory distresses, hypoxaemia and age of

In general, pneumonia was more associated with hypox-

aemia than bronchio₃litis and pharyngotonsilitis similar

1

2

typical presentation. This was amply demonstrated in

our study.

2

to what Shann et al, in Papua New Guinea reported in

their clinical assessment of ARI in children an₀d the

1

WHO clinical criteria for the diagnosis of ARI. Like

I₁₃n_,₁₄this study we found, as has been reported severally

bronchiolitis in infancy, pharyngotonsilitis in older

children and pneumonia cutting across all age groups as

well a_,₁s₅ being the commonest ARI in our environ-

2

3

the Shann study , the present study made use of the

added clinical finding of crepitations in the diagnosis of

pneumonia. Crepitations had been demonstrated to give

an added strength in the diagnosis of pneumonia.

1

ment. Younger children especially infants are predis-

posed to viral bronchiolitis because placentally transmit-

ted anti-RSV maternal antibody, even if present in high

conce₆ntration, provides partial but incomplete protec-

1

Conclusion

tion. On the other hand, pneumonia is caused by a

5,7

wide range of organism with most been virulent. Be-

sides, the absence of vaccine against the common under

five causes of pneumonia in our national immunization

schedule is a significant contributor to the high preva-

lence₁₇of pneumonia found in children under five years

old.

This study showed that the commonest acute respiratory

infections encountered in our emergency room were

pneumonia, bronchiolitis and pharyngotonsilitis. Bron-

chiolitis is a frequent infection in infants while pharyn-

gotonsilitis occur commonly in children beyond infancy.

On the other hand, pneumonia cuts across all age group.

Furthermore, the common features seen in the emer-

gency room associated with pneumonia were cough,

breathlessness, tachycardia and hypoxemia while bron-

chiolitis was more commonly associated with infancy,

breathlessness, catarrh, and nasal congestion. Pharyngo-

tonsilitis was seen in association with fever and

We also found a higher proportion of infants compared

with other age groups presenting with ARI similar to

previous reports where infants have been shown to be

generally more predisposed to infections as a result of

their relatively immature adaptive im₈mune system com-

1

pared to older children and adults. Also, degradation

vomiting.

of maternal antibodies, cessation of breastfeeding, and

been at child-care centres increases the r₉isk of infections

1

Limitation

especially respiratory tract infections. It is thus not

surprising that even in this study the proportion of chil-

dren with ARI decreased with age.

The small sample size here will preclude drawing hasty

inferences however our findings still give some insight

on the current problem as seen in our facility. Secondly,

Typical features seen in each entity showed fever and

1

53

our studied population consisted of only children admit-

ted in the EPU rather than the whole paediatric cases

seen in the facility with a diagnosis of ARI. Since most

ARI will be mild and may not necessarily be admitted,

that group seen in the outpatient clinic will be invariably

missed.

Acknowledgement

We sincerely appreciate the Nursing staff in the unit and

our residents who helped in patient management

Conflict of interest: None

Funding: None

Reference

1

.

Oyejide CO, Osinusi K. Acute

respiratory tract infection in chil-

dren in Idikan Community, Ibadan,

Nigeria:severity, risk factors, and

frequency of occurrence. Reviews

of Infectious Diseases 1990; 12:

S1042–1046.

Rudan I, Tomaskovic L, Boschi-

Pinto C, Campbell H: Global esti-

mate of the incidence of clinical

pneumonia among children under

five years of age. Bull WHO 2004;

9. Williams BG, Gouws E, Boschi-

17. Effect of a conjugate pneumococ-

cal vaccine on the occurrence of

respiratory infections and antibi-

otic use in day-care center atten-

dees. Pediatr Infect Dis J,

Pinto C, Bryce J, Dye C: Estimates

of worldwide distribution of child

deaths from acute respiratory in-

fections. Lancet Infect Dis 2002, 2

(1):25-32.

10. World Health Organization. Tech-

nical basis for the WHO recom-

mendations on the management of

pneumonia in children at first level

health facilities. Geneva: World

Health Organization, 1991. (WHO/

ARI/91.20).

11. Ohiaeri CN, Akinsulie OA and

Renner JK. Pattern of presentation

and risk factors of acute respira-

tory infection in under five old in

Mushin local government area of

Lagos State. Nig Ot J Hosp med

2003;13:24-26.

12. Lozano JM.Epidemiology of hy-

poxaemia in children with acute

lower respiratory infection Int J

Tuberc Lung Dis 5(6):496–504

13. Koch A, Mølbak K, Homøe

P,Sørensen P, Hjuler T, Ehmer M

Risk Factors for Acute Respiratory

Tract Infections in Young

2001;20:951-958

18. Dahl MS, Tessin I, Trollfors B.

Invasive group B streptococcal

infections in Sweden: Incidence,

predisposing factors and progno-

sis. Int J Infect Dis 2003;7:113-9.

19. Nafstad P, Brunekreef B, Skrondal

A, and Nystad W.Early respiratory

infections, asthma and allergy: 10

year follow up of the Oslo birth

cohort. Pediatrics 2005;116;e255

20. Fattouh AM, Mansi YA, El-anany

MG, El-kholy AA and El-karaksy

HA. Acute lower respiratory tract

infection due to respiratory

2

3

.

8

2:895-903.

Robertson SE, Roca A, Pedro P et

al. Respiratory syncytial virus

infection: denominator-based stud-

ies in Indonesia, Mozambique,

Nigeria and South Africa. Bull-

WHO 2004; 82: 914–922.

Klig JE, Chen L. Lower respiratory

infections in children. Current

Opinion in Pediatrics 2003; 15:

4

5

.

syncytial virus in a group of Egyp-

tian children under 5 years of age

Italian Journal of Pediatrics 2011;

37:14-20

1

21–126.

Tagbo, BN, AC Ude. Use of clini-

cal parameters other than respira-

tory rate in predicting pneumonia

in under five children in Enugu,

Nigeria. J Coll Med 2001; 6: 116-

21. Nokes DJ, et al. Respiratory

syncytial virus epidemiology in a

birth cohort from Kilifi district,

Kenya: infection during the first

year of life. Journal of Infectious

Diseases 2004; 190: 1828–32.

22. Brooks I. Diagnosis and manage-

ment of pharyngotonsilitis. Israeli

Journal of Emergency Medicine

2008;8:26-34

23. Shann F, Hart K, Thomas D. Acute

lower respiratory tract infections in

children: possible criteria for se-

lection of patients for antibiotic

therapy and hospital admission.

1984. Bull WHO. 2003; 81(4): 301

–305.

1

19

Greenlandic Children. Am J Epide-

miol 2003;158:374–384

6

.

Redd SC, Patrick E, Vreuls R,

Metsing M, Moteetee M. Compari-

son of the clinical and radiographic

diagnosis of paediatric pneumonia.

Trans R Soc Trop Med Hyg. 1994

May-Jun;88(3):307-10

14. Selwyn BJ. The epidemiology of

acute respiratory tract infection in

young children: comparison of

findings from several developing

countries. Coordinated Data Group

of BOSTID Researchers. Rev In-

fect Dis 1990;12(suppl 8):870–88

7

8

.

Rudan I, Boschi-Pinto C, Biloglav

Z, Mulholland K, Campbell H:

Epidemiology and etiology of

childhood pneumonia. Bull WHO

1

5. Monto AS. Studies of the commu-

nity and family: acute respiratory

illness and infection. Epidemiol

Rev 1994;16:351–73.

2

008, 86:408-416B.

1

6. Odisho SM , Al-Bana AS, Yaas-

sen NY. Detection of Respiratory

syncytial virus infection in a sam-

ple of infants in Iraq. Iraqi J Med

Sci, 2009; VOL.7 (4):11-19

Simoes AF, Cherian T, Chow J,

Shahid-Salles S, Laxminarayan R,

John TJ: Acute Respiratory Infec-

tions in Children. Disease Control

Priorities in Developing Countries

Washington: Oxford University

Press, second 2006.