Childhood Pneumonia in Low and Middle Income Countries: Burden, Prevention and Management

Pneumonia is the leading cause of morbidity and mortality in children under five years of age worldwide. The burden of childhood pneumonia occurs predominantly in low or middle income countries. Despite recent advances in management and preventative strategies, high rates of treatment failure and case fatality continue to occur in children in such countries.

To review the current evidence on the epidemiology and management of childhood pneumonia in low and middle income countries.

Direct search of Medline database from 1995 to date through Pubmed was conducted. Search terms included: (pneumonia OR lower respiratory tract infections OR lower respiratory infections OR ARI) AND child. Search was restricted to English articles. In addition reference lists of selected studies were reviewed for relevant information.

Major findings accounting for the high burden include delayed health seeking, poor access to health care, poorly resourced health care systems, inadequate immunisation programs and lack of availability of oxygen delivery systems. The burden of pneumonia deaths has also been increased by the paediatric HIV epidemic in sub-Saharan Africa. Effective preventive interventions include exclusive breastfeeding, optimizing nutrition, reduction of indoor air pollution and immunisations. Wider availability of new immunisations particularly pneumococcal conjugate vaccine can substantially reduce pneumonia incidence. Prophylactic trimethoprim- sulphamethoxazole and antiretroviral therapy are important strategies to prevent pneumonia in HIV infected children, and wider implementation of these is still needed. The most effective treatment strategy remains case management guidelines as contained in the Integrated Management of Childhood Illness program. Case management efficacy is dependent on timely access to health facilities, on health worker ability to recognise and treat pneumonia or severe pneumonia and on availability of appropriate antibiotics and functioning referral pathways. In areas of high HIV prevalence, guidelines must be adapted to broaden antimicrobial coverage including treatment for Pneumocystis jirovecii pneumonia. Monitoring of hypoxia with pulse oximetry and appropriate oxygen delivery systems are still not widely available and should be prioritized in pneumonia management programs.

Improved access to preventive and management strategies is urgently needed to reduce the burden of childhood pneumonia in resource limited settings. Further research on childhood pneumonia is needed to delineate the burden of specific pathogens, to develop better diagnostic tests and to improve current management and preventive strategies.