ORIGINAL

Niger J Paed 2013; 40 (1): 30 –33

Mustapha MG

Ashir GM

Alhaji MA

Rabasa AI

Ibrahim BA

Mustapha Z

Presentation, complications and

management outcome of community

acquired pneumonia in hospitalized

children in Maiduguri, Nigeria.

DOI:http://dx.doi.org/10.4314/njp.v40i1.5

Accepted: 10th June 2012

Abstract Background: Pneumonia studied. The commonest clinical

remains a leading cause of U-5 features were fever, cough, tachyp-

morbidity and mortality in develop- noea and dyspnoea. Radiographic

ing countries like Nigeria. This evidence of pneumonia was found

study was conducted to determine in 84 (94.4%) of cases. Dehydration

the clinical presentation, complica- and congestive cardiac failure

tions and factors contributing to (CCF) were the commonest compli-

mortality in the hospitalized chil- cations encountered. Eight (9.0%)

dren with community acquired children died, seven of whom had

pneumonia (CAP) in Maiduguri, complications of pneumonia. The

Mustapha MG

(

)

Ashir GM, Alhaji MA, Rabasa AI,

Ibrahim BA.

Department of Paediatrics,

Mustapha Z

Department of Radiology,

University of Maiduguri Teaching

Hospital, Maiduguri, Nigeria.

PMB 1414, Maiduguri.

Tel: +2348038087639

Nigeria.

rate of occurrence of complications,

Methods: Children younger than 14 radiographic pattern of pneumonia

years admitted into the Emergency and outcome of treatment did not

Paediatric Unit of the University of significantly differ statistically in

Maiduguri Teaching Hospital the different age groups; p = 0.135,

Email: mgofama@yahoo.com

(

UMTH), Maiduguri, in 2011 with 0.622 and 0.167 respectively.

the diagnosis of community ac- Conclusion: While dehydration and

quired pneumonia were followed up CCF were found to be commonest

until discharge or death. Chest ra- complications, mortality was com-

diographs were read by radiologists. moner among the male infants hos-

Results: Eighty nine children aged pitalized for pneumonia.

two months to 14 years were

Introduction

children in addition to the presentation of children with

CAP in Maiduguri was prospectively studied with spe-

Community acquired pneumonia (CAP) is one the com-

monest lower respiratory tract infection of children with

unparalleled morbidity and mortali_-t₅y, especially in de-

cial reference to different age groups.

1

veloping countries, like Nigeria. Explanations prof-

fered for the high burden of pneumonia in the develop-

ing economies include overcrowding, malnutrition, lack

of exclusive breast feeding, low birth weight and l_-₈imited

Methodology

5

access to curative health services among others. Intra-

The study was carried out in the University of

Maiduguri Teaching Hospital (UMTH), Maiduguri,

North-eastern Nigeria. The UMTH renders specialised

services to the people of North-eastern Nigeria, Repub-

lics of Cameroon, Chad and Niger. All children admit-

ted into the Emergency Paediatric Unit of the UMTH, in

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

drawing who₁₀q_-₁u₂alified diagnosis of CAP formed the

thoracic and extra-thoracic complications of pneumonia

such as pleural effusion, air leak syndrome, heart failure

and septicaemia among others increase the pneumonia

morbidity and mortality. This is in spite of the efforts by

the World Health Organization (WHO) and other United

Nation bodies over the years in promoting and advocat-

ing many diagnostic and treatment guidelines, not only

for the management of pneumonia, but the entire acute

respiratory infections (ARI) in general.

study group.

A study Proforma with the demo-

graphic details, clinical features, complications of pneu-

monia and treatment outcome was filled for each eligi-

ble child. These children were followed up until dis-

charge or death. Chest radiographs were read and re-

ported by radiologists. Chest radiographic evidence of

Pneumonia _,d₉eaths occur both at home and in the hospi-

3

tal setting. Complications of pneumonia and factors

contributing to pneumonia mortality in the hospitalized

3

1

pneumonia includes homogeneous opacity and/or patchy

infiltrates of the lung parenchyma consistent with con-

solidation with or without other radiographic features of

pneumonia. Children with incompletely filled records

and those who did not have chest radiograph were ex-

cluded. Children found to have HIV infection, hospital

acquired pneumonia or aspiration pneumonia were also

excluded.

Dehydration and congestive cardiac failure were the

most prevalent complications (Table 3). No complica-

tion was detected in 43 (48.3%) of the children studied.

Chest radiographs of 84 (94.4%) of the children were

suggestive of pneumonia; the remaining five were re-

ported as normal, (Table 3). While 81(91%) of the pa-

tients recovered and were discharged home, the outcome

was fatal in eight of them (Table 3). The prevalence of

complications, radiographic pattern of pneumonia and

outcome of treatment did not significantly differ signifi-

cantly in the different age groups; p = 0.135, 0.622 and

0.167 respectively. Further analysis of the eight fatal

cases revealed that four had convulsions and three had

CCF as complication. However, no complication was

identified in the remaining child. Although, the mortal-

ity rate among the males and females was seven and one

respectively, no significant statistical difference was

found (p = 0.140).

Data generated was entered into a computer and ana-

lyzed using SPSS version 16. Results were given in pro-

portions, percentages and tables. Comparisons between

groups were done with appropriate chi-square test and a

p-value of < 0.05 was considered significant.

Results

Table 3: Age related complications, radiographic

Eighty nine of the children admitted for pneumonia met

the study criteria, 26 did not and thus excluded. The age

ranged from two months to 14 years and the mean age

pattern and outcome of treatment of CAP.

Age group (months)

1 to 6

n = 24

7 to 12 > 12 to 59

n = 27 n = 33

≥ 60

n = 5

(

SD) was 18.44 (128.76) months. The male to female

ratio was 1.5:1, but the male to female ratio was 5:1 in

the age group 1-6 months. Eighty four (94.4%) of the

children were U-5. The age and sex distribution of the

children is shown in table 1.

Complications

CCF

Seizures

Dehydration

Pyothorax

Hydropneumothorax 0 (0.0)

7(29.2) 5 (18.5) 6 (18.2)

4 (16.7) 3 (11.1) 1(3.0)

6 (25.0) 9 (33.3) 12 (36.4)

0(0.0)

0(.0)

0(0.0)

1(20.0)

0(0.0)

0 (0.0)

2 (7.4)

0 (0.0)

1(3.0)

Table 1: Age group and sex distribution of the study

population

None

Chest radiographic finding

9 (37.5) 11(40.7) 17(51.5) 4(80.0)

Bronchopneumonia 22(91.6) 24(88.9) 29(87.9) 4(80.0)

Sex

Male (%)

Lobar pneumonia

Normal radiograph

Outcome

1(4.2) 3(11.1)

1(4.2) 0(0.0)

1(3.0) 0(0.0)

3(9.1) 1(20.0)

Age (months)

Female (%) Total (%)

1

7

-6

-12

20(22.47)

13(14.60)

4(4.49)

24(26.96)

27(30.33)

33(37.07)

5(5.61)

Recovered

Died

19(79.2) 25(92.6) 32(97.0) 5(100)

5(20.8) 2(7.4) 1(3.0) 0(0.0)

14(15.73)

>

12-59

59

Total

19(21.34) 14(15.73)

>

2(2.24)

3(3.37)

54(60.7)

35(39.3)

89(100.00)

Note: Some children had more than one complication, H pneumoth:

Hydropneumothorax.

CCF: congestive cardiac failure

Clinical features at admission showed that cough and

fast breathing were found in 98.8% of the children, table

2

. Five, four and eight care givers were not sure of prior

history of common cold, history of contact with person

s) with common cold and history of prior exposure to

Discussion

(

cold weather respectively.

The importance of pneumonia in particular and ARI in

general to public health and especially in children can-

not be over emphasized. The fact that the majority of the

patients were U-5, underlines the significant contribu-

tion of pneumonia to U₁-_,5₂_,₈m_,₁₀orbidity, similar to observa-

Table 2: Frequency of clinical features in study patients

Clinical Feature

No of patients (per cent)

tions made previously.

The preponderance of in-

Fever

Cough

Fast breathing

History of recent common cold

Contact with individual with common cold

History of exposure to cold weather

Poor appetite

Vomiting

Diarrhoea

84(94.4)

88(99.8)

36(40.4)

13(14.6)

24(26.9)

67(75.3)

49(55.1)

48(53.9)

89(100)

44(49.4)

7(7.8)

fants in general and that of males among the children

younger than six months in this study, may be attributed

to the incomplete development of the immune system

and ₁t₃h_,₁e₄ increased risks to infection of the males of this

age.

Fever, cough and fast breathing found in major-

ity of children in this study are the hallmark for the

clinic₂a_,₁l₅diagnosis of pneumonia, especially in chil-

dren. Anorexia, vomiting and diarrhoea, although not

specific respiratory symptoms, are usual₂ly_,₁₅found in chil-

dren with pneumonia as earlier reported.

Dypsnoea

Hepatomegaly

Splenomegaly

3

2

These symptoms occur due to the systemic inflamma-

tory effect of pneumonia.

the accuracy of the interpretations of chest radiographs,

and when should chest radiography be ordered in pa-

2

0

tients with pneumonia still remains unresolved. Some

authors have reported it to be less sensitive than high

Majority of the subjects had complications directly at-

tributable to pneumonia. This calls for a deliberate look

for such complications in children with pneumonia. De-

hydration was the commonest complication encountered

but it is not usually reported as a common complication

of pneumonia. This may be due to the fact that most

authors lay emphasis on the direct and local complica-

tions of pneumonia. Dehydration in children with pneu-

monia in the present study may be due to increased in-

sensible fluid loss; through the skin and the airways.

This is important as majority of the subjects were in-

fants; who are known to have high total body water,

which makes them at risk of increased fluid loss.

Diarrhoea, vomiting and poor intake found in significant

proportion of the children studied can all contribute to

dehydration. Small body size compared to relative large

body surface area of the children (over half of children

studied younger than 12 months), also predisposes them

increased fluid loss and thus dehydration. Another factor

contributing to dehydration in the study patients is the

weather effect of Maiduguri. Like other Sahel regions of

the world Maiduguri is generally dry, sunny, and hot

with low humidity; these factors contribute to fluid loss

via several mechanisms.

2

0

resolution CT scans in detecting pulmonary infiltrates.

In a study of 2000 children with WHO non severe pneu-

monia; children with fast breathing, an outrageous 82%

2

1

were reported to have normal chest radiographs, com-

pared to only 5.6% obtained in this study. This is proba-

bly because the categories of patients studied were dif-

ferent. In this study, all the children met the WHO crite-

ria for severe or very severe pneumonia, which perhaps

explains the high proportion of children with radiologi-

cal evidence of pneumonia.

While a normal chest radiograph does not exclude pneu-

monia₂as it may not detect early changes of the dis-

2

ease, the presence of other clinical features of pneumo-

nia in addition to fast breathing may provide a better

assessment of the child for pneumonia, as fast breathing

in a coughing child could be explained by many disease

conditions. Of 75 children with pneumonia, Fagbule et

2

al found patchy consolidation and punctuate perihilar

opacities in 33 and 12 children, while lobar consolida-

tion and normal chest radiographs were found in nine

and two children respectively. That study was done in

hospitalized children like the present study, thus, the

similarity of radiographic findings. The high prevalence

of bronchopneumonia in younger children compa₁r₆ed to

older ones seen in this study was reported earlier. This

may perhaps be due to the less ability of the younger

children compared to older ones or adults in localizing

infection.

Congestive cardiac failure (CCF) is a common compli-

2

cation of pneumonia seen in this study. Fagbule et al ,

reported a CCF prevalence of up to 46%, in a study con-

ducted at Ilorin Teaching Hospital. Other authors have

also reported CCF to be one₈_,o₁₆f_,₁₇the common complica-

tion pneumonia in children.

Pulmonary hyperten-

sion manifesting as cor pulmonale, as quoted by Shan et

al may be the cause of heart failure in children with

pneumonia. Other causes are pericarditis and myocardi-

tis.

The mortality of hospitalized children with pneumonia

in the present st₂u_,₇dy of 9% is similar to 10% and 10.5%

earlier reported, The high proportion of complications

among the dead children calls for the need to actively

and deliberately look for such complications in all hos-

pitalized children. Similar to the finding in the present

study, Fagbule and Adedoyin earlier reported the high

rate of mortality in the young and in children with com-

plications of pneumonia. The high rate of mortality

among the infants in the present study may be as a result

of the combination of complications in addition to t₁h₄e

sub optimal state of immunity in the younger children.

1

8

While the low prevalence of pyothorax and pneum_,₁o₆tho-

2

rax in this study is similar to previous reports, few

cite seizures as a common complication of pneumonia;

probably because it is extra-thoracic. Convulsion; an

acute encephalopathy in children with pneumonia in the

present study may be due to febrile convulsion. It can

also be a feature of sepsis manifesting as multi-organ

dysfunction (MOD) in general or can arise from a secon-

dary meningitis following embolic phenomena from

pneumonia. Olowu and Njokanma reported febrile con-

vulsion as the most prevalent complication of pneumo-

2

3

Although, the clinical diagnosis of pneumonia is simple,

complications and deaths are common especially among

the male hospitalized children. Certain predisposing

factors and important complications of pneumonia such

as septicaemia, septic embolic phenomena, syndrome of

inappropriate anti diuretic hormone secretion were not

looked for in this study, perhaps due to their occult oc-

currence. We recommend that complications such as

dehydration and CCF be looked for in all children hospi-

talized for pneumonia.

1

6

nia following CCF and metabolic acidosis. Although

there was no significant difference of the prevalence of

complications and age in this study, it was reported that

the prevalence of complic₁a₉tions of pneumonia is in-

versely proportional to age.

While the chest radiograph is the standard diagnostic

investigation for pneumonia, the issue of sensitivity of

chest radiography in detecting pulmonary infiltrates,

3

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