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482 La Revue de Santé de la Méditerranée orientale, Vol.

10, N o 4/5, 2004

Detection of pneumonia among

children under six years by clinical
H. Shamo’on,1 A. Hawamdah,1 R. Haddadin1 and S. Jmeian 2

ABSTRACT To determine the most useful clinical symptoms and signs for detection of pneumonia in children,
we carried out a prospective clinical study at Queen Alia Hospital, Amman, on 147 children admitted between
August 2002 and January 2003 with clinical pneumonia. All the children had chest X-rays, which were read
by the same radiologist. The most sensitive and specific signs and symptoms for prediction of pneumonia
were coughing, tachypnoea (respiratory rate > 50/min) and chest wall indrawing. We found that presence of
tachypnoea and lower chest wall indrawing can detect most cases of pneumonia. If all clinical signs are
negative, chest X-ray findings are unlikely to be positive.

Dépistage de la pneumonie chez des enfants de moins de six ans par évaluation clinique
RÉSUMÉ Afin de déterminer les symptômes et les signes cliniques les plus utiles pour le dépistage de la
pneumonie chez l’enfant, nous avons réalisé une étude clinique prospective à l’hôpital Reine Alia d’Amman
chez 147 enfants hospitalisés entre août 2002 et janvier 2003 pour un épisode de pneumonie avec diagnos-
tic clinique. Tous les enfants ont eu des radiographies pulmonaires interprétées par le même radiologue. La
toux, la tachypnée (rythme respiratoire > 50/min) et le tirage respiratoire étaient les signes et les symptômes
les plus sensibles et les plus spécifiques pour prédire une pneumonie. Nous avons trouvé que la présence
de tachypnée et d’un tirage sous-sternal permet de dépister la plupart des cas de pneumonie. Si tous les
signes cliniques sont négatifs, il est peu probable que les résultats de la radiographie pulmonaire soient

Department of Paediatrics; 2Ear, Nose and Throat Department, Queen Alia Military Hospital, Royal
Medical Services, Amman, Jordan.
Received: 09/12/03; accepted: 17/03/04
Eastern Mediterranean Health Journal, Vol. 10, Nos 4/5, 2004 483

Introduction man (suburban areas) but does not always

have radiology facilities available. The pae-
Acute lower respiratory tract illness diatrician admitted all cases on a clinical
(ALRI) is common among children seen in basis according to World Health Organiza-
primary care [1], and accounts for slightly tion criteria: cough with tachypnoea (respi-
less than 50% of deaths in children under 1 ratory rate > 50/min in infants or > 40/min
year and about 20% of deaths in all hospi- in older children), indrawing or wheezing.
talized children under 15 years [2]. The respiratory rate was counted for a full
The physical differences between the minute after lowering the temperature (us-
chests of children and adults account for ing cold compresses or paracetamol) to
some of the differences in physical signs < 38 °C rectally or 37.5 °C axillary and be-
[3]. Small children find it difficult to take fore the routine extraction of blood.
large breaths, so crackles and wheezes All children admitted were examined by
which may be expected only during such a a specialist in paediatrics and the same ear,
manoeuvre will not be heard. In ALRI, nose and throat specialist to exclude severe
when the history and physical examination upper respiratory tract infection and all had
suggest the same diagnosis, chest radiogra- chest X-rays which were assessed by the
phy is rarely necessary; when the 2 are in- same radiologist. No clinical findings were
consistent, then a radiograph may be written on the X-ray request.
helpful [4]. The identification of signs such Exclusion criteria from the study were
as rapid breathing and chest retraction is children with immune deficiency, those
very important in deciding who needs ex- known to have asthma, history of foreign
pensive treatment and who does not [5]. body aspiration or chemical pneumonitis,
Also important is the decision to refer a children with failure to thrive and malnutri-
child to hospital, which may be many miles tion, and children with severe upper res-
away for many people living in rural areas piratory tract infection. Malnourished chil-
in developing countries. dren were excluded because tachypnoea
Our aim was to emphasize the impor- and lower chest wall indrawing are not suf-
tance of using simple clinical signs such as ficiently sensitive as predictors of pneumo-
respiratory rate and chest wall indrawing in nia in these children [6].
detecting ALRI, especially pneumonia, in The 147 patients in our study were di-
children. vided into 2 groups according to the chest
X-ray findings: those having lobar pneumo-
nia or bronchopneumonia in 1 or more
Methods lobes, and those having normal or hyperin-
flated chest X-rays. The clinical signs and
We did a prospective clinical observation
symptoms of the 2 groups were analysed
study at Queen Alia Military Hospital, Am-
and compared with the radiological evi-
man, Jordan over a 6-month period (Au-
dence of pneumonia (gold standard) and
gust 2002–January 2003) for all children their sensitivity and specificity calculated.
below 6 years of age admitted with clinical
pneumonia (most cases admitted were be-
low this age). All patients were admitted via Results
the outpatient clinic at Marqa, which is
about 20 km from the hospital. This clinic Our study included 147 children admitted
sees patients from areas surrounding Am- with clinical pneumonia, 72 (49%) male
484 La Revue de Santé de la Méditerranée orientale, Vol. 10, N o 4/5, 2004

and 75 (51%) female. The ages of the chil- rax) and 3 had pleural effusion. There were
dren were: 1–12 months 92 (63%), 13–36 no deaths.
months 47 (32%) and 37–72 months 8
(5%). Mean duration of admission was 5
days for the first and second age groups Discussion
and 2 days for the third age group.
In developing countries, the case fatality
From the chest X-ray findings, 40 chil-
rate from ALRI in children could to be re-
dren (27%) had lobar pneumonia in 1 or 2
duced if the most serious forms of ALRI
lobes and 50 children (34%) had broncho-
were identified and dealt with appropriately.
pneumonia, a total of 90 children (61%)
Our study showed that the most sensi-
with pneumonia diagnosed on a radiological
tive symptom was cough 98%, with 70%
basis. Fifty-seven children (39%) had nor-
specificity. The most sensitive signs in de-
mal or hyperinflated chest X-rays. A family
creasing order were: tachypnoea (99%),
history of bronchial asthma or allergy was
chest wall indrawing (88%), and fever
discovered in 15 children (10%).
(78%), while the most specific were tachy-
Table 1 shows the overall frequency of
pnoea (88%) followed by chest wall in-
symptoms and signs of pneumonia and Ta-
drawing (77%).
ble 2 shows their sensitivity and specificity
Anadol found that tachypnoea had a
compared with radiology results (gold
specificity of 99% and a sensitivity of 61%
standard). Cough, fever, tachypnoea and
and was the most important sign in diag-
chest indrawing were the most frequently
nosing pneumonia [7]. Another study
observed signs and symptoms, while tac-
showed that the best screen for pneumonia
hypnoea was both the most sensitive
was the presence of fever along with
(99%) and most specific (88%) sign of
tachypnoea [8]. A study done in China
pneumonia and cough the most sensitive
showed that tachypnoea was more reliable
(98%) symptom. Most of the children
than auscultation in predicting pneumonia
(146) received antibiotics; 2 patients need-
ed a respirator (1 developed pneumotho-
Most of our children were infants, so in
our study clinical signs appear to predict
pneumonia in infants more reliably than in
Table 1 Frequency of symptoms and signs in older children. A study done by Redd et al.
children with pneumonia (n = 147) comparing the clinical and radiological di-
agnosis of pneumonia found that children
Clinical sign or symptom No. %
with a radiographic diagnosis tended to
Cough 105 71 have been ill longer and to be older because
Fever 103 70 mothers may have tended to take febrile
Tachypnoea 96 65
children with mild ALRI to the health centre
or hospital more often than non-febrile chil-
Chest indrawing 92 63
dren with mild ALRI [10]. In the absence
Poor feeding 79 54 of respiratory signs, febrile infants are un-
Grunting 79 54 likely to have abnormal chest radiography
Diminished air entry 58 40 [11,12].
Crepitation 52 35 Wheezing was found in 33% of the chil-
Wheezes 49 33 dren in our study and was not a useful sign
Eastern Mediterranean Health Journal, Vol. 10, Nos 4/5, 2004 485

Table 2 Sensitivity and specificity of clinical symptoms and signs at

presentation for predicting pneumonia

Clinical sign or Chest X-ray Sensitivity Specificity

symptom Pneumonia Normal or (%) (%)
detected hyperinflated
(n = 90) (n = 57)
No. positive for No. positive for
symptom/sign symptom/sign

Tachypnoea 89 7 99 88
Cough 88 17 98 70
Chest indrawing 79 13 88 77
Fever 70 33 78 42
Poor feeding 52 27 58 53
Grunting 52 27 58 53
Diminished air entry 30 28 33 51
Crepitation 27 25 30 56
Wheezes 20 29 22 49

for determining pneumonia in children. this was the case in our study. Subcostal or
This is in agreement with a study done by intercostal recessions (difficulty in breath-
Mahabee-Gittens et al., who found that in ing) are generally more often seen in infants
wheezy infants and toddlers, grunting than in older children because the chest
along with oxygen saturation is highly spe- wall is more compliant than that of the old-
cific and can be used to help diagnose er child.
pneumonia in wheezing infants and tod- The most useful single factor for ruling
dlers [13]. out pneumonia in an infant is the absence of
We did not differentiate ALRI from tachypnoea [18]. We found that tachyp-
bronchial asthma so it is possible that chil- noea and chest wall indrawing in the pres-
dren were overtreated for ALRI and under- ence of cough can help the clinician to
treated for asthma. In regions where determine the need for chest radiography in
wheezing illness is prevalent, the specifici- the paediatric emergency clinic. A study
ty of the World Health Organization pneu- done in Brazil showed that the clinical
monia algorithm is reduced and this may symptoms taken together contribute more
lead to unnecessary use of antibiotics or than the signs and are on a par with X-ray
underutilization of bronchodilators [14]. in importance [19]. Another study found
Simple physical signs that require minimal that age-specific respiratory rate (recom-
expertise to recognize can be used to deter- mended by the World Health Organization,
mine oxygen therapy and to aid in screen- with or without chest wall indrawing) is a
ing for referral [15–17]. sensitive and specific indicator of pneumo-
There may be poor agreement, even nia in almost all age groups [20]. Careful
among experienced physicians, on the attention to specific clinical factors and use
presence of rales in young children, and of adjunct radiographs and laboratory tests
486 La Revue de Santé de la Méditerranée orientale, Vol. 10, N o 4/5, 2004

should guide physicians in selection of anti- Conclusions

biotics and decisions regarding hospitaliza-
tion [21]. Initial observation of the infant may be the
The employment of simple clinical cri- most critical component for the diagnosis
teria gives a good indication of pneumonia of pneumonia.
and can decrease unnecessary referral and Tachypnoea is the most valuable of the
admissions to hospital and thus result in individual clinical signs for prediction of
cost-savings. radiological pneumonia and can be a sensi-
Most of the children in our study re- tive and reasonably specific indicator of
ceived antibiotics, which appear to be used respiratory infection.
in a high percentage of cases, even if inap- The absence of tachypnoea and chest
propriate for the condition, because these wall indrawing can safely be used to reduce
clinical signs do not distinguish viral from the number of chest X-rays ordered for
bacterial pneumonia, nor do chest X-ray, children under investigation. These find-
temperature measurement or duration of ings have relevance for assessment proto-
fever [22]. cols and resulting treatment decisions
Our study justifies the premise that when chest X-ray is not routinely available.
pneumonia case detection does not require These methods for pneumonia case de-
auscultation, chest X-ray or laboratory tection could be taught to primary care
testing, and that observation of the respira- physicians, nurses and even mothers, al-
tory rate and lower chest wall indrawing lowing them to seek medical advice early.
are the key elements of assessment in This would lead to a decrease in the pneu-
young children. monia mortality rate in children.

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