Clinical management critical to reduce deaths from pneumonia in malnourished children

Muhammad Zahir Hassan Nabil

Pneumonia remains a common cause of death in children with severe acute malnutrition (SAM). Recent icddr,b research has shown that many of these deaths occur after the children received treatment for SAM and recovered.

Pneumonia, a leading infectious disease that kills one child under the age of 5 every 35 seconds worldwide, is claiming the lives of more children than from HIV, TB, Zika, Ebola and malaria combined. Children with SAM are more prone to suffer from infectious illnesses particularly pneumonia because of their compromised immune status.

On World Pneumonia Day we recognise that the burden for Bangladesh remains high as 15% of the 118,000 deceased children under 5 died of pneumonia last year in the country.

A child with her mother at icddr,b's Dhaka hospital. Photo: icddr,b / Shehzad Noorani


“Management of pneumonia in severely malnourished children is critically important in reducing deaths in such children. However the causes are not well described in medical literature,” says icddr,b scientist Dr Jobayer Chisti, also head of clinical research at icddr,b hospitals, clinical lead, ICU and consultant physician of respiratory ward at icddr,b’s Dhaka hospital.

According to existing icddr,b research spanning the last two decades, it has been well established1,2,3 that prevalence of pneumonia in SAM children is common and deaths in this group are high, says icddr,b’s senior director of nutrition and clinical services Dr Tahmeed Ahmed, who has headed many studies in this area.

icddr,b researchers followed up children with SAM and pneumonia receiving treatment for SAM and findings have indicated that 8.7% of these children died within 3 months of discharge from the hospital. Evidence suggests that these post-discharge deaths were associated with new respiratory or gastrointestinal symptoms.

“Clinical signs are relatively poor predictors of pneumonia in such children,” says Dr Chisti. Children who died have shown new episodes of respiratory symptoms, fever or diarrhoea, with symptoms lasting only 3-5 days prior to death. This leaves little time for warning or treatment.

Another icddr,b study suggests that pneumonic SAM children who displayed WHO-defined danger signs of severe pneumonia more often had treatment failure and a fatal outcome compared to those without the danger signs.

A malnourished child with pneumonia at intensive care unit, icddr,b. Photo: icddr,b / Shehzad Noorani


However, currently the WHO does not recommend any specific change in treatment in hospitalised severely malnourished children who also have pneumonia. The WHO-recommended choice of antibiotics in severely malnourished children with signs of pneumonia and severe pneumonia is the same.

Data are limited to evaluate the role of WHO recommended antibiotics in such children. “A number of our ongoing studies are attempting to evaluate the outcome of WHO recommended management of pneumonia in severely malnourished children,” says Dr Chisti.

A cross country study with icddr,b titled “The Childhood Acute Illness & Nutrition Network (CHAIN)” will attempt to build the evidence base for care of acutely ill, undernourished children in limited resource settings. Another ongoing descriptive study is investigating the origin and causes of pneumonia and associated outcome in severely malnourished children who received treatment at icddr,b hospital.

Currently, there is no randomised trial to re-evaluate WHO-recommended antibiotics treatment in such children, mentions Dr Chisti. icddr,b researchers are also evaluating efficacy of other combination of antibiotics in comparison to the existing WHO-recommended treatment in SAM children with danger signs of severe pneumonia.

These studies are expected to contribute to a more appropriate treatment for severely malnourished children with pneumonia and improve clinical management of these children.