Turkiye Klinikleri Journal of Pediatrics

.: ORIGINAL RESEARCH
Factors Affecting Acute Respiratory Rate Change Among Under-Five Children Hospitalized with Severe Pneumonia: A Longitudinal Study
Ağır Pnömoni Nedeniyle Hospitalize Edilen Beş Yaş Altındaki Çocuklarda Akut Solunum Hızı Değişikliğini Etkileyen Faktörler: Boylamsal Bir Çalışma
Muluwerk Ayele DEREBEa, Awoke Seyoum TEGEGNEa, Haile Mekonnen FENTAa
aDepartment of Statistics, Bahir Dar University, Ethiopia
Turkiye Klinikleri J Pediatr. 2022;31(2):74-84
doi: 10.5336/pediatr.2021-83974
Article Language: EN
Full Text
ABSTRACT
 Objective: About one-third of all childhood deaths are due to Pneumonia with high respiratory rate/acute respiratory infections. Respiratory rate is used as a preliminary health indicator in the diagnosis and progression of Pneumonia. The current study was conducted to identify factors associated with tachypnea. Material and Methods: Quasi-Poisson modeling using generalized linear mixed-effects (GLM) and multiple logistic regressions models were used to analyze the study variable. The data were extracted from each patient's hospital chart. Parameter estimation was conducted using penalized quasi-likelihood estimation. Results: Four-hundred, fifty-three Pneumonia patients under-five years of age were included in the study. From the main effects, body temperature (adjusted rate ratio (ARR= 1.01, p<0.001), length of hospital stay (ARR=0.92, p<0.001), previous cough history (ARR= 1.03, p=0.0135), and season (summer: ARR= 0.98, p=0.0021; autumn: ARR=0.99952, p=0.0032; spring: ARR= 0.90, p=0.02) had a significant effect on variation of acute respiratory rate in Pneumonia patients. Interaction effects that were significant for the variable of interest included visiting times with family disease history, age with breast feeding history, and length of hospital stay with previous disease history. Conclusion: Certain groups of Pneumonia patients (those with high temperature, previous disease history, and family disease history) need special intervention to reduce the risk of acute respiratory rate in Pneumonia patients. Parents should be educated to follow up their children for health checks whenever breathing rate becomes fast or increases. Special attention should be given to patients with a previous disease history, family disease history, and those hospitalised during the winter season.

Keywords: Acute respiratory rate; generalized linear mixed model; pneumonia; under-five children; Ethiopia
ÖZET
 Amaç: Tüm çocukluk ölümlerinin yaklaşık üçte biri yüksek solunum hızlı pnömoni/akut solunum yolu enfeksiyonları nedeniyle meydana gelmektedir. Solunum hızı, pnömoninin tanısı ve ilerlemesi için bir ön sağlık göstergesi olarak kullanılmaktadır. Bu çalışma, Kuzey- Batı Etiyopya'daki Felege Hiwot Başvuru Hastanesinde pnömoni ile hastaneye yatırılan beş yaşın altındaki çocuklarda takipne ile ilişkili faktörleri belirlemek amacıyla yapılmıştır. Gereç ve Yöntemler: Çalışma değişkenini analiz etmek için genelleştirilmiş doğrusal karışık etkiler ve çoklu lojistik regresyon modelleri kullanan Quasi-Poisson modellemesi kullanılmıştır. Veriler, hastaların hastane kayıtlarından elde edilmiştir. Parametre tahmini, penalize yarı-olabilirlik tahmini kullanılarak yapılmıştır. Bulgular: Çalışmaya 5 yaşın altında 453 pnömoni hastası alınmıştır. Ana etkilerden vücut ısısı [ayarlanmış hız oranı (ARR)=1.01, p<0.001], hastanede kalış süresi (ARR=0.92, p<0.001), önceki öksürük öyküsü (ARR=1.03, p=0.0135) ve mevsim (yaz: ARR=0.98, p=0.0021; sonbahar: ARR=0.99952, p=0.0032; ilkbahar: ARR=0.90, p=0.02) pnömoni hastalarında akut solunum hızı varyasyonu üzerinde anlamlı bir etkiye sahipti. İlgilenilen değişken için anlamlı olan etkileşim etkileri arasında aile öyküsü ile ziyaret süreleri, emzirme öyküsü ile yaş ve önceki hastalık nedeniyle hastanede kalış süresi yer almaktadır. Sonuç: Bazı pnömoni hasta grupları (yüksek ateşi, önceki hastalık öyküsü ve ailede hastalık öyküsü olanlar) akut solunum hızı riskini azaltmak için özel müdahaleye ihtiyaç duyarlar. Anne-babalar, solunum hızı hızlandığında veya arttığında çocuklarını sağlık kontrolleri için takip etmeleri konusunda eğitilmelidir. Daha önce hastalık öyküsü olan, ailesinde hastalık öyküsü olan ve kış mevsiminde hastaneye yatırılan hastalara özel dikkat gösterilmelidir.

Anahtar Kelimeler: Akut solunum hızı; genelleştirilmiş doğrusal karma model; pnömoni; beş yaşından küçük çocuklar; Etiyopya
REFERENCES:
  1. Izurieta HS, Thompson WW, Kramarz P, Shay DK, Davis RL, DeStefano F, et al. Influenza and the rates of hospitalization for respiratory disease among infants and young children. N Engl J Med. 2000;342(4):232-9. [Crossref]  [PubMed] 
  2. Maganga ER. Pneumonia case fatality rate in children under-five: understanding variations in district hospitals in Malawi. Norway: Department of General Practice and Community Medicine, Faculty of Medicine University of Oslo; 2004. [Link] 
  3. Garenne M, Ronsmans C, Campbell H. The magnitude of mortality from acute respiratory infections in children under 5 years in developing countries. World Health Stat Q. 1992;45(2-3):180-91. [PubMed] 
  4. World Health Organization. Health situation analysis in the African region: atlas of health statistics. Africa: World Health Organization (WHO); 2011. [Link] 
  5. Cebey-López M, Salas A. Recognising the asymptomatic enemy. Lancet Infec Dis. 2021;21(3):305-6. [Crossref]  [PubMed]  [PMC] 
  6. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the sustainable development goals. Lancet. 2016;388(10063):3027-35. [Crossref]  [PubMed]  [PMC] 
  7. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361(9376):2226-34. [Crossref]  [PubMed] 
  8. World Health Organization. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: World Health Organization; 2015.
  9. Legesse H, Degefie T, Hiluf M, Sime K, Tesfaye C, Abebe H, et al. National scale-up of integrated community case management in rural Ethiopia: implementation and early lessons learned. Ethiop Med J. 2014;52 Suppl 3:15-26. [PubMed] 
  10. Graham NM. The epidemiology of acute respiratory infections in children and adults: a global perspective. Epidemiol Rev. 1990;12:149-78. [Crossref]  [PubMed] 
  11. UNICEF, World Health Organization, World Bank. State of the World's Vaccines and Immunization. 3rd ed. Geneva: World Health Organization; 2009. [Link] 
  12. Wingerter SL, Bachur RG, Monuteaux MC, Neuman MI. Application of the world health organization criteria to predict radiographic pneumonia in a us-based pediatric emergency department. Pediatr Infect Dis J. 2012;31(6):561-4. [Crossref]  [PubMed] 
  13. Fatmi Z, White F. A comparison of 'cough and cold'and pneumonia: risk factors for pneumonia in children under 5 years revisited. Int J Infect Dis. 2002;6(4):294-301. [Crossref]  [PubMed] 
  14. Smith KR, Samet JM, Romieu I, Bruce N. Indoor air pollution in developing countries and acute lower respiratory infections in children. Thorax. 2000;55(6):518-32. [Crossref]  [PubMed]  [PMC] 
  15. Pomat WS, Smith TA, Sanders RC, Witt CS, Montgomery J, Lehmann D, et al. Levels of anti-pneumococcal antibodies in young children in Papua New Guinea. Epidemiol Infect. 1993;111(1):109-19. [Crossref]  [PubMed]  [PMC] 
  16. Amhara Regional State. Budget Brief Amhara Regional State 2007/08-2015/16. Ethiopia: United Nations Children's Fund (UNICEF); 2018. [Link] 
  17. Cameron AC, Trivedi PK. Regression Analysis of Count Data. Vol. 53. 2nd ed. Cambridge: Cambridge University Press; 2013.
  18. Cameron AC, Johansson P. Count data regression using series expansions: with applications. Journal of Applied Econometrics. 1997;12(3):203-23. [Crossref] 
  19. Cochran WG. Sampling Techniques. 3rd ed. New York: John Wiley & Sons; 2007.
  20. Zalacain R, Torres A, Celis R, Blanquer J, Aspa J, Esteban L, et al. Community-acquired pneumonia in the elderly: Spanish multicentre study. Eur Respir J. 2003;21(2):294-302. [Crossref]  [PubMed] 
  21. Marston BJ, Plouffe JF, File TM. Prognosis and outcomes of patients with community-acquired pneumonia. JAMA.1996;275(2):134-41. [Crossref]  [PubMed] 
  22. Thomas Jr CF, Limper AH. Pneumocystis pneumonia. N Engl J Med. 2004;350(24):2487-98. [Crossref]  [PubMed] 
  23. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336(4):243-50. [Crossref]  [PubMed] 
  24. McCullagh P, Nelder JA. Generalized Linear Models, No. 37 in Monograph on Statistics and Applied Probability. 2nd ed. Boca Raton; London; New York: Chapman & Hall; 1989.
  25. Pan W. Akaike's information criterion in generalized estimating equations. Biometrics. 2001;57(1):120-5. [Crossref]  [PubMed] 
  26. Asparouhov T, Muthen B. Bayesian Analysis of Latent Variable Models Using Mplus; 2010a. Tihomir Asparouhov and Bengt Muth'en Version 5. [Link] 
  27. Seyoum A, Ndlovu P, Zewotir T. Quasi-Poisson versus negative binomial regression models in identifying factors affecting initial Cd4 cell count change due to antiretroviral therapy administered to hiv-positive adults in North-West Ethiopia (Amhara Region). AIDS Res Ther. 2016;13:36. [Crossref]  [PubMed]  [PMC] 
  28. Lanata CF, Rudan I, Boschi-Pinto C, Tomaskovic L, Cherian T, Weber M, et al. Methodological and quality issues in epidemiological studies of acute lower respiratory infections in children in developing countries. Int J Epidemiol. 2004;33(6):1362-72. [Crossref]  [PubMed] 
  29. Khan AJ, Hussain H, Omer SB, Chaudry S, Ali S, Khan A, et al. High incidence of childhood pneumonia at high altitudes in Pakistan: a longitudinal cohort study. Bull World Health Organ. 2009;87(3):193-9. [Crossref]  [PubMed]  [PMC] 
  30. de Andrade ALSS, de Andrade JG, Martelli CMT, Almeida e Silva S, de Oliveira RM, Neves Costa MS, et al. Effectiveness of haemophilus influenzae b conjugate vaccine on childhood pneumonia: a case-control study in Brazil. Int J Epidemiol. 2004;33(1):173-81. [Crossref]  [PubMed] 
  31. Brown KH, Stallings RY, de Kanashiro HC, de Romana GL, Black RE. Effects of common illnesses on infants' energy intakes from breast milk and other foods during longitudinal community-based studies in Huascar (Lima), Peru. Am J Clin Nutr. 1990;52(6):1005-13. [Crossref]  [PubMed] 
  32. Tupasi TE, Mangubat NV, Sunico ME, Magdangal DM, Navarro EE, Leonor ZA, et al. Malnutrition and acute respiratory tract infections in filipino children. Rev Infect Dis. 1990;12 Suppl 8:S1047-54. [Crossref]  [PubMed] 

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