Evaluación de dos métodos estandarizados de interpretación de radiografías de tórax en niños con neumonía / Evaluation of two standarized methods for chest radiographs interpretation in children with pneumonia

Objetivos. Evaluar la capacidad diagnóstica del método de interpretación radiográfico de la Organización Mundial de la Salud (OMS) para identificar neumonía bacteriana en niños y comparar su desempeño con otro método similar. Población, material y métodos. Radiografías de tórax de pacientes menores de 5 años de edad hospitalizados por neumonía con etiología confirmada (bacteriana o viral), fueron evaluadas por 3 observadores (pediatra [P], neumonólogo [N] y radiólogo[R]) según los métodos de OMS y Khamapirad. Se seleccionaron un puntaje OMS= 1 y un Khamapirad ≥2 para definir neumonía radiológica, presumiblemente bacteriana. Se evaluó asociación entre cada puntaje y etiología por χ2. Se calculó sensibilidad(S), especificidad (E) y valores predictivos positivo (VPP) y negativo (VPN) para predecir neumonía deetiología bacteriana confirmada. Se calculó el acuerdo interobservador (coeficiente kappa).Resultados. Se evaluaron 108 radiografías (87 neumonías virales y 21 bacterianas). Un puntaje OMS= 1,en la evaluación de P, se asoció con etiología bacteriana (p <0,001; OR= 6,4; IC 95 por ciento= 1,6-29,7), alcanzando S= 85 por ciento, E= 51 por ciento, VPP= 30 por ciento, VPN= 93 por ciento. Un puntaje Khamapirad ≥2, se asoció con etiología bacteriana(p= 0,0008; OR= 6,31; IC95 por ciento= 1,8-24,4), alcanzando S= 80 por ciento, E= 59 por ciento, VPP= 32 por ciento, VPN= 92 por ciento. Al evaluar las con etiología bacteriana confirmada, el acuerdo interobservador fue ligeramente superior con métodoOMS (P contra N= 0,82, P contra R= 0,69, N contra R= 0,85) que con Khamapirad (P contra N= 0,48, Pcontra R= 0,69, N contra R= 0,82).Conclusiones. Ambos métodos mostraron similar capacidad diagnóstica para identificar neumonía bacteriana. El método OMS es más simple y mostrómejor acuerdo interobservador.

Acute respiratory infections control in the context of the IMCI strategy in the Americas

As infecções respiratórias agudas (IRA) são importante causa de morbidade e mortalidade em menores de cinco anos. Importantes contrates são observados em relação a isto nos diferentes países das Américas, e também entre regiôes ou estados de um mesmo país. A morbidade está associada a vários fatores, especialmente com a situação nutricional das pacientes e o tempo de aleitamento materno. Também as caracteríosticas dos cuidados prestados a essas crianças durante a doença são essenciais, com destaque para a percepção dos pais ou responsáveis em relação à doença, os cuidados que os mesmos prestam à criança durante a doença, a preocupação em decidir e consultar os serviços de saúde, a forma em que esses cuidados são oferecidos pelos serviços de saúde e em que as orientações são cumpridas em casa. Especial preocupação deve existir em relação à resistência bacteriana aos antibióticos, sendo um problema crescente na América, com uma média de 26,1 por cento de resistência do Streptococcus pneumoniae à penicilina. Os antibióticos são freqüentemente utilizados de forma irresponsável com 70 por cento das crianças com IRA recebendo-os desnecessariamente. Controlar as IRA tem-se tornado prioridade. Intervenções preventivas como as atuais vacinas conjugadas para Haemophilus influenzae e Streptococcus pneumoniae, e o manejo padronizado de casos, como proposto pela estratégia Atenção Integrada a doenças Prevalentes na Infância (AIDPI), aparecem como os mais importantes passos para este problema de Saúde Pública.

Effects of socioeconomic status on presentation with acute lower respiratory tract disease in children in Salvador, Northeast Brazil.

Two different socioeconomic groups of children with pneumonia were studied, and their clinical and demographic aspects were evaluated. The diagnosis of pneumonia was based on findings of cough and tachypnea, or on crackles on auscultation or on radiologically confirmed infiltrate. This was a prospective cross-sectional study conducted at the Professor Hosannah de Oliveira Pediatric Center, which cares for children of lower socioeconomic status (PHOPC), and at one private hospital which cares for children from middle to high socioeconomic status (Aliança Hospital, AH). Demographics and clinical differences were assessed by the Pearson chi-square test or Fisher's exact test as appropriate; means of continuous variables were compared by Mann-Whitney U-test. In a 26-month period, 3,431 cases were recruited. The 2,476 cases identified at the PHOPC were younger than the 955 identified at AH (2.2 +/- 2.3 vs. 4.5 +/- 3.1 years, P < 0.0001) and had higher scores for severity (3.5 +/- 1.5 vs. 2.7 +/- 1.7, P < 0.0001), duration of hospitalization (days) (10.9 +/- 12.1 vs. 6.2 +/- 7, P < 0.0001), frequency of tobacco smoker in the household (48% vs. 31%, P < 0.0001), cardiopathy (15.3% vs. 5.9%, P = 0.003), fever (44.4% vs. 36.3%, P = 0.0001), tachypnea (67.6% vs. 32.3%, P < 0.0001), crackles (69.5% vs. 64.9%, P = 0.02), somnolence (19.9% vs. 10.4%, P < 0.0001), malnutrition (13.7% vs. 5%, P < 0.0001), hospitalization rate (27.4% vs. 22.5%, P = 0.003), and death (0.9% vs. 0.1%, P = 0.009). However, other features were more frequent among AH cases: parent's university level of education (38.2% vs. 1.0%, P < 0.0001), underlying chronic illness (40.6% vs. 28.5%, P < 0.0001), asthma (62.7% vs. 50.8%, P = 0.01), rhinitis (9.2% vs. 0.4%, P < 0.0001), previous use of antibiotics (34.3% vs. 27.1%, P = 0.001), and wheezing (53.1% vs. 42.2%, P < 0.0001). Children of lower socioeconomic status have more serious lower respiratory tract disease, whereas children with pneumonia of middle to high socioeconomic status have more allergic diseases (rhinitis, asthma) and wheezing.

Childhood pneumonia: clinical aspects associated with hospitalization or death

OBJECTIVE: To determine which available information at an Emergency Room (ER) consultation is associated with hospitalization or death among children with pneumonia. DESIGN: Prospective cohort study. SETTING: The ER of one university and one private hospital. MEASUREMENT: Using stepwise logistic regression we analyzed factors that showed a univariate association. MAIN RESULTS: Of 2,970 cases, the median age was 1.83 years (range 2 days to 14.5 yrs, mean 2.76 +/- 2.72 yrs); 25.8 were hospitalized and 0.8 died. Age (2-11 mos, OR 0.4 [0.2-0.6]; 12-59 mos, OR 0.2 [0.1-0.4]; > or = 5 yrs, OR 0.1 [0.08-0.3]), malnutrition (OR 2.0 [1.4-2.7]), underlying chronic illness (OR 1.4 [1.1-1.8]), tachypnea (OR 1.8 [1.4-2.4]), chest indrawing (OR 1.7 [1.4-2.2]), and somnolence (OR 1.8 [1.4-2.4]) were associated with hospitalization and age (2-11 mos, OR 0.3 [0.08-0.8]; > or = 12 mos, OR 0.06 [0.02-0.2]), malnutrition (OR 3.1 [1.2-7.7]) and underlying chronic illness (OR 4.3 [1.6-11.0]) were associated with death in the multivariate analysis. CONCLUSIONS: Several clinical aspects may be used in assessing need for hospitalization (i.e. young age, malnutrition, underlying chronic illness, tachypnea, chest indrawing and somnolence) for children with pneumonia seen at the ER. Individual intrinsic factors such as age, malnutrition and underlying chronic illness were independently associated with death. Pneumonia should be considered a treatable disease and complete recovery can be achieved in the majority of the cases.

Integrated management of childhood illness (IMCI): an innovative vision for child health care

A estratégia de Atençäo Integrada às Doenças Prevalentes da Infância (AIDPI), desenvolvida pela Organizaçäo Mundial da Saúde (OMS), Organizaçäo Panamericana da Saúde (OPAS) e Fundo das Naçöes Unidas para à Infância (UNICEF), incorpora as experiências prévias de programas para tratar as principais doenças infantis, acrescentando aspectos preventivos e de promoçäo à saúde. Nesta nova visäo, outorga papéis fundamentais à família, à comunidade e ao trabalhador de saúde que desenvolve o seu trabalho no primeiro nível de atençäo. A estratégia visa principalmente diminuir as taxas de mortalidade infantil em países e regiöes onde elas ainda säo muito elevadas, com cifras acima de 40 por 1.000 nascidos vivos, situaçöes em que as pneumonias, diarréias, desnutriçäo e outras doenças evitáveis säo as principais causas de óbito. Pretende também mudar o perfil da demanda ambulatorial dando ênfase a atividades preventivas de alto impacto, como educaçäo em saúde, imunizaçöes e promoçäo ao aleitamento materno. Permite ainda ao trabalhador de saúde fazer a detecçäo precoce de sinais de perigo em doenças graves, assim como avaliar e tratar, de forma adequada, os problemas de saúde mais freqüentes, ao mesmo tempo que educa as famílias em relaçäo aos cuidados a serem oferecidos em casa.

Perspectivas en el control de enfermedades en los niños: atención integrada a las enfermedades prevalentes de la infancia / Perspectives of diseases control in children: integrated management of childhood illness

La mortalidad en niños menores de 5 años continúa siendo un problema prioritario en la mayoría de los paises de la Region de las Américas. A pesar del suceso de las principales campañas de asistencia pediatrica de la decada de 80, tales como los programas ampliados de vacunas, infecciones respiratorias agudas o enfermedades diarreicas agudas, los resultados aún no son satisfactorios. Buscando mejorar el impacto de estas intervenciones, durante la decada de 90 la Organización Panamericana de la Salud, Organización Mundial de la Salud. OPS, OMS y United Nations Children's Fund (UNICEF) desarrollaron la estratégia de Atención Integrada a las Enfermedades Prevalentes de la Infancia (AIEPI) que pretende disminuir mas aún esta mortalidad con accciones preventivas y curativas que enfocan la atención del niño como un todo, identificando rapidamente los niños gravemente enfermos, racionaliza el uso de medicamentos y aprovecha la consulta para realizar prevención y promoción de salud, especialmente en el ámbito familiar y comunitario. Esta nueva estratégia incorpora una visión global del proceso salud y enfermedad, con beneficios directos para el niño, su familia y su comunidad.

Community acquired Pneumonia among pediatric outpatients in Salvador, northeast Brazil, with emphasis on the role of pneumococcus

Pneumonia is one of the leading causes of hospitalization and death among children in developing counties,, and mortality due to pneumoniae has been associated with S. pneumoniae infection. This investigation was designed to describe the antimicrobial susceptibility and serotype patterns of pneumococcal strains recovered from the blood of children with community-acquired pneumonia (CAP) and to acess the clinical findings of pneumococcal bacteremic patients with pneumonia. In a 26 month prospective study, blood cultures were obtained as often as possible from children(<16 years of age) diagnosed with CAP in two emergency rooms. Antimicrobial drug susceptibility tests and serotyping were performed when pneumococcus was identified. We studied 3,431 cases and cultured blood samples from 65.5 percent of those. Pneumococcus was recovered from 0.8 percent of the blood samples. The differences in age, somnolence, wheezing and hospitalization among children with and without pneumococcal bacteremia were statistically significant. Pneumococcal bacteremia was age-related (mean 1.63 +1.55; median 0.92) and associated with somnolence and hospitalization among children with CAP. One strain was recovered from pleural fluid. Penicillin resistance was detected in 21.0 percent(4/19) of the strains at an intermediate level, whereas 63.0 percent of the strains were resistant to trimethoprim-sulfamethoxazole. The most common serotypes were 14 and 6B, and these serotypes included the resistant strains. Eight of our 18 isolates from blood were of types included in the heptavalent conjugate pneumococcal vaccine, recently licensed in the USA.