15 December 2011

WHO Guidelines for Childhood Pneumonia in Developing Countries

            Acute pneumonia remains the leading cause of death in children throughout the world, killing 1.6 million children each year, the vast majority in developing countries.  Some 20+y years ago the World Health Organization developed a set of guidelines for pneumonia management designed for community settings in developing countries.  The aim was to reduce pneumonia related deaths.  These guidelines were later incorporated into the WHO Integrated Management of Childhood Illness Guidelines., designed both for primary care and hospital based case management.
            These guidelines call for diagnosis on the basis of three signs, cough, rapid breathing, and lower chest in drawing or retractions.  Cases are then separated into not severe, severe, and very severe, based on the degree of difficulty.  Not severe cases are treated locally by the community health worker with either amoxicillin or co-trimoxazole.  Those with severe or very severe pneumonia are referred to the nearest health facility for treatment with injectable antibiotics.  This approach does not distinguish between viral and bacterial causes, nor does it clearly separate pneumonia from other causes of respiratory distress, notably bronchiolitis in infants, or croup.  Concerns over differentiating pneumonia from reactive airway disease (asthma) have persuaded WHO to add a trial of a bronchodilator with those children with audible wheezing to the guidelines.  Widespread use of these guidelines has created a clearer plan for the community health worker.  A number of extensive studies have demonstrated a 25-50% reduction in mortality in those third world settings that adopt the guidelines.  Some studies have shown that treatment of severe pneumonia at home with antibiotics under the guidelines is as effective as referral to the regional center, and resolves the often difficult problems of transportation and follow-up.
Ref:  Graham, S.M. et al.  Challenges to Improving Case Management of Childhood Pneumonia at health Facilities in Resource Limited Settings:  Bull World Health Org  86, May 2007
Submitted by Roger Boe MD.

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