ArticlesClinical features for diagnosis of pneumonia in children younger than 5 years: a systematic review and meta-analysis
Introduction
In developing countries, pneumonia is the largest cause of deaths in children younger than 5 years.1 Early identification and treatment of patients with pneumonia cases is fundamental to reduce mortality. Identification of which pneumonia cases need antibiotic treatment among the large number of children presenting with respiratory symptoms is a challenge because cough is reported in two thirds of children attending outpatient facilities in low-income countries.2 Chest radiograph, the current gold standard for pneumonia diagnosis,3 is not available in resource-poor settings where the burden of disease is the highest. Even when available, chest radiograph cannot be done for all coughing children because of the very high frequency of this complaint and the potential long-term effects of exposure to x-rays. Therefore, clinical predictors are used to identify children who should receive an antibiotic drug or undergo assessment by chest radiograph.
Since the late 1980s, pneumonia diagnosis in developing countries has relied on the presence of cough, fast breathing, and chest indrawing, as recommended by WHO.4, 5 This recommendation was based on studies published in the late 1980s and validated by other studies in the 1990s. Since then, no major innovation has been made in pneumonia diagnosis and no accurate point-of-care test is available to identify children who would benefit from antibiotics. With the rapid spread of antibiotic resistance worldwide, there is rising concern about overprescription of antibiotics resulting from insufficient specificity of the WHO criteria used to classify acute respiratory infections.6, 7
Here, we assess the diagnostic value of clinical signs and symptoms in identification of children younger than 5 years (excluding infants <2 months) with radiological pneumonia. This evaluation might help to generate more accurate clinical scores from which to make decisions about the necessity of further investigation by chest radiograph or antibiotic treatment for children presenting with respiratory symptoms in low-resource ambulatory care facilities.
Section snippets
Search strategy
We did a systematic literature search in Medline (PubMed), Embase (Ovid), and the Cochrane Database of Systematic Reviews (CDSR), without date or language restrictions. We did our first search on Sept 30, 2013, with an update on Nov 6, 2014. In Medline, we used the following search terms: “pneumonia”[MeSH terms] in combination with: “predictive value of tests”[MeSH terms] OR “sensitivity and specificity”[MeSH terms] OR “reproducibility of results”[MeSH terms] OR “diagnostic test” OR “diagnostic
Results
Our search identified 1839 papers. Through the study selection process (figure 1), 18 articles12, 13, 14, 15, 16, 17, 18, 19 were included in the review and underwent quality assessment using QUADAS-2 (detailed assessment of individual studies is available in the appendix). One of the included articles reported on two separate surveys done in different health facilities in the same country but using the same procedures;15 data were extracted separately and counted as two distinct studies. Table
Discussion
To our knowledge, our Article is the first systematic review with meta-analysis of clinical predictors of pneumonia in children. The comprehensive search, unimpeded by date, country, or language restrictions, allowed the consideration of large amounts of data, compared with previous reviews.7, 30, 34, 35 We considered only data from children aged younger than 5 years, allowing better targeting of the population of interest. Methodological quality was assessed in duplicate and based on a-priori
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