Co morbidities in children hospitalized for community acquired pneumonia in Maiduguri Nigeria.html

Niger J Paed 2015; 42 (1): 51 – 54

ORIGINAL

Mustapha MG

Co-morbidities in children

Ashir GM

Elechi HA

hospitalized for community

Rabasa AI

acquired pneumonia in

Alhaji MA

Maiduguri, Nigeria

Farouk AG

DOI:http://dx.doi.org/10.4314/njp.v42i1,11

Accepted: 4th November 2014

Abstract: Background: Pneumo-

five; 107 (93%), 65(56.5%) were

nia is one of the commonest

males, 101 (87.8%) had one or

Mustapha MG

(

)

causes of morbidity and mortality

multiple co morbidities, with about

Ashir GM, Elechi HA, Rabasa AI

in children, especially in develop-

half of them 58 (50.4%) afflicted

Alhaji MA, Farouk AG

ing countries. These children are

by malaria. Pre admission medica-

Department of Paediatrics, University

of Maiduguri Teaching Hospital,

also at risk of other morbidities,

tion was commoner for orthodox

Maiduguri, Nigeria.

thus, increasing the morbidity and

than traditional medication. No

Email: mgofama@gmail.com

mortality.

significant difference in mortality

Objective: This study was con-

outcome was however noticed

ducted to examine the prevalence

between children with

and pattern of co-morbidities in

co-morbidity and those without co-

children admitted for community

morbidity, p > 0.05.

acquired pneumonia (CAP) in

Conclusion: The occurrence of co-

Maiduguri.

morbid conditions among children

Methodology: All children admit-

hospitalized for CAP in Maiduguri

ted into the Emergency Paediatric

is common; however, the presence

Unit (EPU) of the University of

of co-morbidity did not signifi-

Maiduguri

Teaching

Hospital

cantly affect the mortality outcome

(UMTH), Maiduguri, in 2011,

of their management. It is recom-

with CAP were prospectively

mended that the presence of co-

followed until discharge or death.

morbidity be actively looked for in

The children were evaluated for

children hospitalized for pneumo-

co-morbidities clinically and by

nia, so as to effect holistic treat-

examination of appropriate speci-

ment, and improve the outcome of

men where necessary.

management.

Result: A total of 115 children

aged one month to 14 years were

Key words: Pneumonia, Children.

admitted for CAP during the

Co-morbidity, Maiduguri, Mortal-

study period. While majority of

ity outcome

the children studied were under-

Introduction

also put these children at risk of other morbidities like

malnutrition, malaria, diarrhoeal disease and measles

Pneumonia is one of the commonest causes of childhood

among others. The colossal contribution of these ill-

morbidity and mortality, especially in developing coun-

nesses to U-5 morbidity and mortality operating either

tries . It is estimated that six million out of the global

1-4

singly or in combination has been highlighted in the

156 million episodes of clinical pneumonia per year

recent World Health Organization (WHO) publication

on integrated management of childhood illnesses . The

occurs in under-5 (U-5) children in Nigeria, (0.33 epi-

sodes per child-year in Africa). Pneumonia accounts for

importance of holistic management of children with

approximately four million deaths of children world-

multiple morbidities, especially the in-patients cannot be

wide and two-thirds of the global pneumonia deaths

over emphasized. This is because, in-patients provide

were concentrated in 10 developing countries; Nigeria

ample opportunities to the physicians to evaluate and

(204, 000 deaths) only second to India (408, 000 deaths)

where necessary carry out investigations to arrive at an

among others

2, 3

. The risk factors for the high burden of

additional diagnosis or an alternative primary diagnosis.

pneumonia in the developing countries are overcrowd-

Previous studies in Nigeria showed that co-morbidities

ing, lack of exclusive breast feeding, low birth weight

were not only common, but worsen the outcome of

patients with pneumonia . This study was conducted to

6,7

and limited access to health care services. These factors

examine the prevalence and pattern of co-morbidities

48(41.7%)had no medication before admission. Names

(not complications) in children admitted for community

of drugs given to 29(25.2%)children were not given,

acquired pneumonia (CAP), defined as pneumonia in a

while 9(7.8%), 5(4.3%) and 4(3.4%) children were

previously healthy person who acquired the infection

given ampiclox, cefuroxime and cotrimoxazole respec-

outside a hospital . Pre-hospitalization treatment modali-

tively. Combinations of drugs were given to 6(5.2%)

ties by care givers and the outcome of management of

children and the remaining 2(1.7%) children had gen-

these children were also studied.

tamicin injections. The outcome of management with

respect to the different morbidities is shown in table 2.

Table 2: Co morbidity Treatment outcome in children

Methodology

hospitalized for Community Acquired

Pneumonia.

Outcome

Co-morbidity

Discharged

*DAMA

Died

All children admitted into the EPU of the University of

Maiduguri Teaching Hospital (UMTH), Maiduguri, in

None

2011, with fever, cough, fast breathing, chest wall in-

Malaria

drawing or additional features of CAP formed the study

Malnutrition

group. These children were evaluated for other morbid-

Meningitis

ities as guided by the clinical findings and followed up

Urinary tract infection

until discharge or death. The diagnosis of co-morbidities

Sickle cell disease

among the patients was made clinically and by examina-

Congenital heart disease

tion of appropriate specimens where necessary. Children

HIV infection

NB: *DAMA: Discharged against medical advice, p = 0.659.

aged one month to 14 years fulfilled the inclusion crite-

ria. Pre-admission medications given to the children

were also obtained from the care givers. Data generated

In spite of the occurrence of co-morbidities, no signifi-

was entered into a computer data base (Microsoft excel

cant difference in mortality was however found between

office version 2007, Washington) and analyzed using

children with co-morbidity and those without, p = 0.659

SPSS version 16. Results were expressed in proportions

or percentages. A comparison for difference between

children with or without co-morbidities was done using

Discussion

Fisher-Exact test. A p-value of < 0.05 was considered

significant.

Infections in general and pneumonia in particular, are

common causes of U-5 morbidity and mortality. The

high rate of co-morbidity among children with pneumo-

nia found in this study is similar to previous reports .

5-7

Results

For example in a study conducted in Ogun State Nigeria,

30% of the children with malaria also had pneumonia,

There were a total of 115 children with pneumonia aged

furthermore, 23% of all children enrolled satisfied the

one month to 14 years with pneumonia. Majority of the

criteria for both malaria and pneumonia . The chal-

children studied were U-5(107, 93%), 65(56.5%) were

lenges of diagnosis and management of children with

males. One hundred and one (87.8%) children had one

malaria and pneumonia co-morbidity was highlighted

or more co morbidities, with over half of them 58

earlier in a hospital based study in Mozambique . Ma-

(50.4%) afflicted by malaria, table 1.

laria, especially when severe results in respiratory symp-

toms and signs; thus mimicking pneumonia. This under-

Table 1: Frequency distribution of co-morbidities in hospital-

scores the importance of holistic approach in patient

ized children for pneumonia

management such as search for alternate diagnosis or co

Co morbidities

Frequency (percent)

-morbidity. Although, the likelihood of over diagnosis

Malaria

58 (50.4)

of malaria as a result of positive blood film parasitaemia

was discussed earlier in Africa , where malaria was

Malnutrition

28 (24.3)

Meningitis

8 (7.0)

reported to be frequently over-diagnosed and results in

Urinary tract infection

8 (7.0)

failure to treat other life-threatening conditions, how-

Sickle cell disease

6 (5.2)

ever, in clinical setting; especially among the ill children

HIV infection

2 (1.7)

with symptoms and signs suggestive of malaria, such

Congenital heart disease

2 (1.7)

positive blood film parasitaemia are not ignored despite

None

14 (12.2)

the presence of other confirmed morbidity. These pa-

Note: Multiple morbidities were found in 11 children, total

tients thus, deserved to be treated for malaria as a matter

number of children was 115

of urgency.

Review of pre-admission medication showed that

The relatively high proportion of pneumonia among the

55(47.8%)of children were given orthodox medications,

malnourished children and vice versa was previously

reported in Nigerian studies . It has been shown that

6,7

2(1.7%)had only traditional medications and 6(5.2%)

had both traditional and orthodox medications. Medica-

the epidemiology, clinical features, aetiologic agents,

tion detail was not available in 4(3.5%) children, while

treatment outcome of pneumonia among the malnour-

ished children may be different from that of the well

included. Most HIV infected children in developing

nourished children

3,4,13

. Pneumonia and infection in gen-

countries become symptomatic soon after birth or at

presentation

22,23

eral result in malnutrition through the induction of ano-

, and may not qualify for the CAP crite-

rexia, vomiting, and pyrexia with increased metabolism

ria.

and negative nitrogen balance . Although malnutrition

is usually a chronic event, acute events such as infec-

The administration of treatment, usually in form of

tions also result in malnutrition in children; thus the

drugs to children at home before resorting to hospital or

term severe acute malnutrition (SAM). Pneumonia usu-

in-patient care is a common practice. Although majority

ally resolves within few days of commencement of treat-

of the mothers gave one form of treatment or another to

ment, but sometimes, it may take a longer course, de-

their children, substantial proportion did not attempt

pending on the aetiologic pathogen, promptness and

treatment before presentation. The fact that most moth-

adequacy of treatment, and more importantly if associ-

ers did not know the names of drugs given to their

ated with complications. On the other hand, malnutrition

wards, lack of pre-admission medication details in many

can predispose to infection through lowered immunity .

of them and patronage of traditional treatment may per-

Although, the possibility of the predisposition to pneu-

haps be due to maternal ignorance or illiteracy. Other-

monia by malnutrition and vice versa was highlighted

wise, detailed history of drugs administered during an

above, the two can independently occur in a child, as co-

acute illness like pneumonia may not be difficult to re-

morbidity. Malnutrition poses challenges in the diagno-

call. Although, the details of the mothers’ education was

sis and treatment of children with infections, as there is

not part of this study, previous studies in the same com-

substantial variation in epidemiology, aetiologic agents

munity suggest high rate of maternal ignorance and illit-

eracy . Even though some of the children had antibiot-

and clinical findings of infection in the setting of malnu-

trition . This challenge is in addition to the background

ics before presentation, adequate improvement was not

social problems, high cost of treatment and longer hos-

recorded; thus the admission. The lack of response was

pital stay commonly found in the management of mal-

probably because the children had severe pneumonia

nourished children that may be responsible for the high

requiring hospitalization, improper administration of

rate of DAMA among the malnourished children

16,17

medication or the presence of co-morbidity, or the chil-

dren had viral pneumonia. Ill children with pneumonia

The occurrence of urinary tract infection (UTI) among

sometimes require in addition to antibiotics fluid, intra-

the patients may be a coincidental clinical finding as

venous medications, oxygen and other supportive treat-

pneumonia and UTI do not share common aetiologic

ment which cannot be delivered safely on out-patient

agents. Likewise the origin of UTI is usually an ascend-

basis.

ing infection, as haematogeneous origin of UTI is rare

except in early infancy or neonatal period . However,

Although the study population was not large, the lack of

the same may not be said for meningitis as the two im-

significant statistical difference in mortality outcome of

portant agents causing pneumonia are also known to

the children may be due to the fact that majority of the

cause meningitis; S. pneumoniae and H. influenza . How-

children with co-morbidities were identified and neces-

ever, it is difficult to speculate that the same agents

sary treatment administered. The importance of identify-

caused pneumonia and meningitis in the children stud-

ing co-morbidities goes beyond treatment during the

ied, as the detection of the aetiologic agents for the

period of hospitalization, but also for proper follow up

pneumonia was not part of what this study sought to

treatment, counseling etc.

determine. Meningitis can occur as a result of haemato-

While the proportion of malaria and malnutrition among

genous metastatic/embolic complication of pneumonia .

children hospitalized for pneumonia in Maiduguri was

Either UTI or meningitis, or both can also occur in a

high, the proportion of other co-morbidities in these

patient as part of septicaemic illness from pneumonia.

children was relatively low. We therefore recommend

that all children hospitalized for pneumonia be screened

Although, SCD has been shown to be an important risk

for malaria, and be evaluated for other co morbid condi-

factor for pneumonia, with increased incidence and

tions in order to provide a holistic management.

severity , the proportion of children with SCD in this

and earlier study in Ilorin , Nigeria was modest. How-

ever, it is critical to note that, a significant overlap exists

between the features of pneumonia and acute chest syn-

Acknowledgement

drome .

The very low proportion of children with HIV infection

We wish to acknowledge Professor H Yusuph for pains-

in this study should not be construed as if it is not an

takingly going through the manuscript despite his tight

important co-morbid condition with pneumonia, but

schedule.

indeed, a significant risk and a usual co-morbid condi-

tion . Apart from invasive bacterial pneumonia, HIV

1,3

infected children are also at risk of lymphoid interstitial

Conflict of Interest: None

pneumonia, Pneumocystis jiroveci pneumonia and tuber-

Source of Funding: None

culous pneumonia. The paucity of HIV infected children

in the study group is due to nature of the patients

studied, as only children that met CAP criteria were

References

Theodore CS, Charles GP. Pneu-

10. Kingsley NU, Olufemi BA, Ade-

17. Correia MITD, Waitzberg DL. The

monia. In: Kliegman RM, Behr-

mola AT. Clinical overlap between

impact of malnutrition on morbid-

man RE, Jerson HB, Eds. Nelson

malaria and pneumonia: can ma-

ity, mortality, length of hospital

Textbook of Paediatrics, 17 Edi-

laria rapid diagnostic test play a

stay and costs evaluated through a

tion, Saunders Philadelphia, USA.

role? J Infect Dev Ctries 2011; 5

multivariate model analysis. Clini-

2004:1432-1435.

(3):199-203.

cal Nutrition 2003; 22(3): 235–

Fagule D, Adedoyin MA, Nzeh

11. Bassat Q, Machevo S, O’Cal-

239.

DA. Childhood pneumonia in the

laghan-Gordo C, Sigaúque B,

18. JA Owa. Urinary tract infection in

University of Ilorin Teaching Hos-

Morais L, Díez-Padrisa N , et al .

children. In: Azubuike JC and

pital. Niger JPaed 1987; 14(3

Distinguishing Malaria from Se-

Nkanginieme KEO, Eds. Paediat-

&4): 73-78

vere Pneumonia among Hospital-

rics and Child Health in Tropical

Region 2 Edition, African Educa-

Igor R, Cynthia B, Zrinka B, Kim

ized Children who Fulfilled Inte-

M, Harry C. Epidemiology and

grated Management of Childhood

tion Services, Owerri, Nigeria.

etiology of childhood pneumonia.

Illness Criteria for Both Diseases:

2007: 280-287

Bull World Health Organ 2008; 86

A Hospital-Based Study in Mo-

19. Bradley JS, Byington CL, Shah SS,

(5): 408-416.

zambique. Am. J. Trop. Med. Hyg

Alverson B, Carter ER, Harrison

Stephen MG, Mike E, Tabish H,

2011, 85(4): 626 – 634.

C, et al . The Management of Com-

Penny E, Trevor D. Challenges to

12. Samson G, Charles RJCN, James

munity-Acquired Pneumonia in

improving case management of

AB. Over-Diagnosis and Co-

Infants and Children Older Than 3

childhood pneumonia at health

Morbidity of Severe Malaria in

Months of Age: Clinical Practice

facilities in resource-limited set-

African Children: A Guide for

Guidelines by the Pediatric Infec-

tings. Bull World Health Organ

Clinicians. Am. J. Trop. Med. Hyg

tious Diseases Society and the

2008; 86: 349–355.

2007; 77(6): 6–13.

Infectious Diseases Society of

WHO. Recommendations for man-

13. Falade AG, Tschappeler H, Green-

America. Clin Infect Dis 2011, 1-

agement of common childhood

wood BM, Mulholland EK.Use of

52.

conditions: evidence for technical

simple clinical signs to predict

20. De Ceulaer K, McMullen KW,

update of pocket book recommen-

pneumonia in young Gambian

Maude GH, Keatinge R, Serjeant

dations: newborn conditions, dys-

children: the influence of malnutri-

GR. Pneumonia in young children

entery, pneumonia, oxygen use

tion. Bulletin of the World Health

with homozygous sickle cell dis-

and delivery, common causes of

Organization, 1995, 73 (3): 299-

ease: risk and clinical features. Eur

fever, severe acute malnutrition

304.

J Pediatr. 1985;144(3):255-8.

and supportive care. ISBN 978 92

14. Rodrgíuez L, Cervantes E, Ortiz R.

21. Gladwin MT, Vichinsky E. Mecha-

4 150282 5; 2012, 1-161.

Malnutrition and Gastrointestinal

nisms of Disease: Pulmonary Com-

Olowu AO, Njokanma FO. Pneu-

and Respiratory Infections in Chil-

plications of Sickle Cell Disease. N

monia in Sagamu. Niger J Paed

dren: A Public Health Problem.

Engl J Med 2008; 359: 2254-65

1993;20 (3): 49-54.

Int. J. Environ. Res. Public Health

22. Nigeria Institute of Medical Re-

Fagbule D, Adedoyin MA. Clini-

2011, (8):1174-1205.

search. Training Manual for Doc-

cal predictors of outcome in child-

15. Chisti MJ, Tebruegge M, La Vin-

tors on the use of Antiretroviral

hood pneumonia. Niger J Paed

cente S, Graham SM, Duke T.

drugs in Nigeria. First Edition,

1990; 17(2): 37-41.

Pneumonia in severely malnour-

2005.

Ostapchuk M, Roberts DM, Haddy

ished children in developing coun-

23. Fetuga MB, Ogunfowora OB,

R. Community acquired pneumo-

tries – mortality risk, aetiology and

Oyegunle VN, Thanni LOA. A

nia in infants and children. Am

validity of WHO clinical signs: a

Ten-year Review of Paediatric

Fam Physician. 2004 Sep 1; 70(5):

systematic review. Tropical Medi-

HIV/AIDS among hospitalized

899-908.

cine and International Health

children in a Nigerian Teaching

Lionel AM, Thomas JM, Ronald

2009, 14 (10 ): 1173–1189.

Hospital. Niger J Paed 2005; 32

FG, Anthony WC, Robert HH and

16. MA Alhaji, H Ahmed, Mustapha

(3) 29-32.

the Canadian Community-

MG, GM Ashir. Discharge from

24. Mustapha MG, SS Ifah, GM Ashir.

Acquired Pneumonia Working

hospital against medical advice

Knowledge, Attitude and Practices

Group. Canadian Guidelines for

among paediatric patients in

of Mothers on Home Management

the Initial Management of Com-

Azare. Sahel Med J 2009; 12(1):10

of Childhood Acute Watery Diar-

munity-Acquired Pneumonia: An

-12.

rhoea in Maiduguri, Borno state,

Evidence-Based Update by the

Nigeria. Niger Med J 2008; 49 (1):

Canadian Infectious Diseases So-

5-8.

ciety and the Canadian Thoracic

Society. Clin Infect Dis 2000; 31:

383–421.