Alwadhi, V; Dewan, P; Malhotra, RK; Shah, D; Gupta, P
OBJECTIVE: To compare the performance of respiratory rate and other clinical signs against pulse oximetry for predicting hypoxia in children with Severe pneumonia/Very severe disease as per integrated management of neonatal and childhood illness (IMNCI) classification.
DESIGN: Cross-sectional study.
SETTING: Pediatric emergency department of a tertiary-care hospital in Delhi, India.
SUBJECTS: 112 hospitalized children (2 mo - 5 y) with Severe pneumonia/Very severe disease as per IMNCI classification.
METHODS: Respiratory rate was recorded at enrolment, along with other clinical signs and symptoms. Oxygen saturation (SpO2) was measured by a pulse oximeter. Clinical predictors of hypoxia (SpO2 <90%) and their combinations (index test) were evaluated for their sensitivity, specificity, positive predictive value and negative predictive value for diagnosis of hypoxia, against pulse oximetry (reference test).
RESULTS: Hypoxia was present in 57 (50.9%) children. Presence of tachypnea, head nodding, irritability, inability to drink/breastfeed, vomiting, and altered sensorium was significantly associated with hypoxia (P<0.05). Multiple logistic regression revealed that age-specific tachypnea (respiratory cut-offs of ≥70/min and ≥60/min in children aged 2-12 mo and ≥12 mo respectively), head nodding, and inability to drink/breastfeed were independent predictors for hypoxia in under-five children with severe/very severe disease, with sensitivity of 70.2%, 50.9% and 75.4%, respectively; and specificity of 88.9%, 96.4%, and 90.9%, respectively. When all three predictors were used in conjunction, the sensitivity increased to 91.2% and specificity was 81.8%.
CONCLUSIONS: No single clinical sign can perform as well as pulse oximetry for predicting hypoxia in children with severe pneumonia. In settings where pulse oximetry is not available, combination of signs, age-specific tachypnea (respiratory cut-offs of ≥70/min and ≥60/min in children aged 2-12 months and ≥12 months, respectively), head nodding, and inability to drink/breastfeed can be used for admission and oxygen therapy in children with pneumonia.