The current WHO recommendations for the case management of acute respiratory infections (ARI) in children aged 2 months to 5 years in developing countries use fast breathing (respiratory rate of > or = 50 per minute in children under 12 months and > or = 40 in children aged 12 months to 5 years) and lower chest wall indrawing to determine which child is likely to have pneumonia and should therefore receive antibiotics. We have evaluated these and other physical signs in 487 malnourished children and 255 well nourished children who presented with a cough or breathing difficulty. Pneumonia, defined as definite radiological pneumonia or probable radiological pneumonia associated with crackles on auscultation, was present in 145 (30%) of the malnourished children and 68 (26%) of the well nourished children. The respiratory rate predicted pneumonia equally well in the two groups, but to achieve an appropriate sensitivity and specificity the respiratory rate cut-off required in malnourished children was approximately 5 breaths per minute less than that in well nourished children. Intercostal indrawing was more common and lower chest wall indrawing was less common in the malnourished children, with or without pneumonia. These results suggest that fast breathing, as defined at present by WHO, and lower chest wall indrawing are not sufficiently sensistive as predictors of pneumonia in malnourished children. As the latter are a high-risk group, we should like to recommend that children with malnutrition who present with a cough, fast breathing or difficult breathing should be treated with antibiotics.
PIP: During November 1990-March 1992 in The Gambia, data on 487 malnourished children (85% of all malnourished children presenting at the clinic) were compared with data on 255 well-nourished children. All the children presented at the outpatient clinic of the Medical Research Council Hospital at Fajara with respiratory symptoms. The purpose was to assess the power of various widely used clinical signs as predictors of pneumonia, which was defined as radiological pneumonia or probable radiological pneumonia associated with crackles on auscultation. 30% of the malnourished children and 26% of the well-nourished children were diagnosed with pneumonia. History of cough, fast breathing, and difficult breathing were significant predictors of pneumonia in malnourished children (p 0.001 for cough; p 0.01 for fast and difficult breathing) while only difficult breathing was a significant predictor in well-nourished children (p 0.01). The durations of all presenting symptoms of malnourished children were significantly longer than those of well-nourished children (p 0.001). Children with pneumonia in both the malnourished and well-nourished groups had a significantly higher mean respiratory rate than did those without pneumonia (51.3 vs. 37 and 58 vs. 41.7 breaths/minute, respectively; p 0.001 for both). Fast breathing had a sensitivity of 61% and 79% and a specificity of 79% and 65% for malnourished and well-nourished children, respectively. The required respiratory rate for malnourished children stood about 5 breaths/minute less than that for well-nourished children. Findings indicate that fast breathing (= or 50/minute for infants and = or 40/minute for 1-5 year olds) and lower chest wall indrawing are not sensitive predictors of pneumonia in malnourished children. Since they are a high risk group, malnourished children with a cough or fast or difficult breathing should be treated with antibiotics.