6. Brief Resume of the Intented Work

6. BRIEF RESUME OF THE INTENTED WORK

INTRODUCTION

‘Knowing is not enough; we must apply.

Willing is not enough; we must do.’

Johann Wolfgang

WHO estimated that every year 73% of the 10 million children die before they reach their 5th birthday and the major causes are pneumonia (19%), diarrhoea (18%), neonatal pneumonia or sepsis (10%), malaria (8%), preterm delivery (10%), and birth asphyxia (8%). In this pneumonia is the leading cause of morbidity and common cause of death in children below five years.1

The World Pneumonia Day on 2nd November, a programme launched by the World Health Organisation and UNICEF with the aims to save more than 5 million children from dying of the disease by 2015. To fight with pneumonia nearly 100 leading organization from around world joined forced to recognize the first annual World Pneumonia Day on November 2nd and urge governments to take step to fight pneumonia the world’s leading killer of young children.2

Pneumonia is an inflammation of the pulmonary parenchyma, is common in childhood but occur more frequently in infancy and early childhood. Pneumonia affects both genders equally. It is more common in winter and rainy season. Clinically, pneumonia may occur either as a primary disease or as a complication of another illness. Although most cases of pneumonia are caused by micro-organisms, non-infectious causes include aspiration of food or gastric acid, foreign bodies, hydrocarbons and lipid substances, hypersensitivity reaction and drugs or radiation induced pneumonia.3

A study show that the leading risk factors contributing to pneumonia incidence are low birth weight, malnutrition vitamin A deficiency, lack of breast feeding, passive smoking, poor socioeconomic status, large family size, family history of bronchitis, advanced birth order, over crowding, young age, indoor and outdoor pollution and lack of measles immunization.4

Pneumonia can be classified according to morphology, etiologic agent, or clinical form. Although morphologic classification is typically used, the most common classification based on the etiologic agent that is viral, bacterial, and mycoplasmal or aspiration of foreign substances.Another classification is as follow-5

1.  Hospital acquired pneumonia : pneumococcal pneumonia

Streptococcal pneumonia

Staphylococcal pneumonia

Haemophillus pneumonia

2. Community acquired pneumonia : Chlamydial pneumonia

Viral pneumonia

Children with pneumonia may have a range of symptom depending on their age and the cause of the infection. Bacterial pneumonia usually causes children to become severely ill with high fever and rapid breathing. Viral infection, however, often come on gradually and may worsen over time. Some common symptom in pneumonia in children and infant include rapid or difficult breathing, cough, fever, chills, headache, loss of appetite and wheezing. Children under five with severe cases of pneumonia may struggle to breath, with their chest moving in or retracting during inhalation. Young infants may suffer convulsions, unconsciousness, hypothermia, lethargy and feeding problems.6

Three essential steps are needed to reduce deaths among children under five with pneumonia are recognize a child is sick, seek appropriate care, and treat appropriately with antibiotics. For this it is important to increase the knowledge of the mothers who is the first care provider as well as observer of child.

6.1 NEED FOR THE STUDY

Everyday million of parents seek health care for their sick children, taking them to hospital, health centres, pharmacists, doctors and traditional healers. Each year more then ten million children die before they reach their fifth birthday. Seven in ten of these deaths are due to five preventable and treatable conditions: pneumonia, diarrhoea, malaria, measles and malnutrition and often to a combination of these conditions.7

Pneumonia is the leading cause of mortality and a common cause of morbidity in children below five years of age. In developing countries pneumonia alone kills 3 million children every year. It is responsible for 19 percent of all deaths in children below five years of age.8

A comparative study showed that the incidence of pneumonia in children less than 5 years is estimated to be 0.29 episodes per child-year in developing and 0.05 episode per child-year in developed countries. This translate into about 156 million new episodes each year worldwide, of which 151 million episodes are in developing world. Most cases occur in India (43million), China (21 million), and Pakistan (10 million), with additional high number in Bangladesh, Indonesia and Nigeria (6 million each). Of all community cases, 7-13% are severe enough to be life- threatening and require hospitalization.4

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A study was conducted to investigate the epidemiology and disease burden of childhood pneumonia in Taiwan from 1997 to 2004. Result showed that the average annual incidence of hospitalized pneumonia in children under 5 years old and for infants was 3,965 and 4,984 out of 100,000, respectively. Boys were more likely to be affected than girls (male to female risk ratio 1.27, P<O.001). In children below the age of 5 years old, mortality due to pneumonia was 6.7 per 100,000 per year for children and accounted for 4.2% of the total deaths in this population. It suggested that, Taiwan has high incidence of pneumonia which is four times that of developed countries (1.6- 1.8 episodes per 100,000 children- year).9

It was reported on 22 December 2008 in The Telegraph that Bengal has recorded the highest number of child deaths from pneumococcal diseases in the past two years. According to experts, pneumococcus bacteria causes more than 80% of the pneumonia-related deaths. The Central Bureau of Health Intelligence data shown that in 2006, 1,151 died of pneumonia in the state. The figure was 620 the next year, again highest in the countary.10

An epidemiological study was conducted in rural and urban area of west Tripura dist showed that incidence of ARI was 23% in urban area and 17.65% in the rural area, an over all mean incidence of 20.23%. The incidence of pneumonia was 16/1000 children and 5/1000 children in rural area, respectively, with the incidence of pneumonia highest among infants.11

A case control study undertaken in 400 children under 5 years in South Kerala, India, to identify the risk factors for severe pneumonia. Cases were in patient with pneumonia as ascertained by WHO criteria, while controls were out patients with non severe acute respiratory infections. Only four from many probable risk factors emerged as being significant they are young age, immunization, delayed weaning and sharing bedroom. The significant factors on univarite analysis were parental education, environmental pollution, discontinuation of breastfeeding in young infants, malnutrition, hypovitaminosis A, low birth weight, previous history of severe ARI, unresponsiveness to earlier treatment, and use of non allopathic medicine. Correction of these factors can probably reduce mortality due to pneumonia.12

Several risk factors for acquiring respiratory infection in developing countries, such as poverty, family size and household crowding have been linked to the risk of developing pneumonia, where as the forme also may be influenced by birth spacing and nutritional factors, the latter is consistent findings in developed and developing countries. Sanitation influences many health outcomes and might affect the risk of developing pneumonia directly or indirectly.13

The incidence of pneumonia and bronchitis has been studied in 2205 infants over first year of life. In the same period their parents’ smoking habits and respiratory symptoms were recommended annually. Those factors shows that both the environmental and host are very important to lead pneumonia occurrence in child, and almost of risk factors of pneumonia among under five children are in the family.14

Preventing children from developing pneumonia in the first place is important for reducing deaths. Prevention efforts include many well known child survival interventions including immunizing children a (especially with measles, HIb and pneumococcal conjugate vaccine) ensuring adequate nutrition (including zinc intake and breast feeding) and that reducing indoor air pollution may also play a role. But once child develops pneumonia, prompt treatment with full course of effective antibiotic is life saving because most severe cases are caused by bacterial pathogens. And since access to health services is limited in many developing countries, prompt treatment may also require training health workers to diagnose and treat children with pneumonia in the community.15

Community mothers mentioned a wide range of illness concepts in relation to breathing problems. Although the terminology was not Clear-cut, caretaker especially mothers were very articulate about the breathing problems and their explanations were consistent both within and between the different group. This shows that mother/ caretakers’ knowledge could be important in preventing and assessing pneumonia among children in family. At least, mother’s knowledge can be very important factor in reducing the occurrence of pneumonia in children under five years of age.

Mothers as a immediate caretaker of children could easily identify the unusual breathing patterns or problem in their children. Improving mother’s knowledge on pneumonia by identifying its early signs in their children will be of great importance in preventing this hazardous disease.

The investigator has also experienced a wide range of questions by mothers related to breathing problem during her clinical experience in paediatric ward. Here an attempt is made to design a structured teaching programme on pneumonia and its prevention to enhance the knowledge of mothers with concept, prevention is better than cure.

6.2 REVIEW OF LITRATURE

‘Literature adds to reality, it does not simply describe it. It enriches the necessary competencies that daily life requires and provides; and in this respect, it irrigates the deserts that our lives have already become.’

C.S.Lewis

The review of literature is presented in the following order:

·  Pneumonia

·  Mothers knowledge

·  Sign and symptoms

·  Risk factors of the pneumonia

·  Pneumonia prevention

Pneumonia

A study was conducted by a group of paediatricians to evaluate which disease entities the W.H.O definition actually captures and what is the probable aetiology of respiratory infection. Result showed that among the 12,194 children enrolled to the vaccine study recorded 1,195 disease episodes leading to hospitalization which fulfilled the W.H.O criteria for pneumonia. In total, 34% of these episodes showed radiographic evidence of pneumonia and 11% were classified as definitive or probable bacterial pneumonia. Over 95% of episodes of W.H.O defined severe pneumonia (with chest indrawing) had an acute respiratory infection as final diagnoses. This suggested that the W.H.O definition for severe pneumonia shows high specificity for acute lower respiratory infection and provides a tool to compare the total burden of respiratory infections in different setting.16

An epidemiologic study was done to determine the risk factors for the enhancement of acute respiratory infection. The subjects were 531 children in which 74% were younger than one year old. And the data was collected by samples of pharyngeal swabs were obtained from children with ARI. The result revealed Bronchopneumonias constituted 66.39 of the cases. In total 357 agents were isolated 35% corresponding to bacteria in pure culture and 11.6% only virus. The bacteria were: Haemophilus influenza (12.4%), Streptococcus pneumoniae (11%), Staphylococcus aureus (9%) and Klebsiella pneumoniae (6.3%), Mychoplasma pneumoniae was identified in 5 children and M. hominis in 3. Adenoviruses were isolated in 98 patients, parainfluenza in 19, respiratory syncytial virus in 4, influenza in 1 and picornavirus in 2. It was confirmed that babies under 12 months are more susceptible to bacterial pneumonia.17

Mother’s knowledge

A cross-sectional study was done with the aim to assess the Peruvian mothers’ knowledge and recognition of pneumonia in children under 5 years of age, the mothers’ attitude toward seeking medical help. For this 501 mothers were selected randomly from low income communities and were interviewed between June and august 2000. The result showed that about 84% of mothers knew the pneumonia 58.7% indicated that pneumonia caused by lack of parental care, 28.9% believed that virus causes the disease, 80% picked rapid breathing and/or chest retraction as possible sign and symptom of pneumonia and 69.3%of these mothers ready to take their child to closest health centre if they thought their child had pneumonia. It showed that Peruvian mothers can recognize pneumonia but still efforts needed to educate Peruvian mothers about the causes, recognition of the sign, and treatment of pneumonia.18

A study was conducted by Department of Paediatric, Kalawati Saran Children Hospital, New Delhi on 200 mothers of children under five years of age having lower respiratory tract infection were interviewed with the help of pretested unstructured questionnaire to know the danger signs perceived by her in a child suffering from pneumonia and the home remedies used by them before seeking medical help. ‘Pasli Chalna’ and refusal feed were the most common symptom perceived as dangerous. ‘Pasli Chalna’ correlated with retraction in 91.1% and fast breathing in 8.1% cases. Honey (25%) and ginger (27%) were the most common remedies used for relief of cough. Self advised medications were used by 24%mothers and majority (58.4%) gained this knowledge from mass media.19

A cross-sectional descriptive study was conducted on 78 mothers and 16 health workers were interviewed using structured questionnaires to determine factors contributing to high mortality caused by pneumonia among children under 5 years of age in Kalabo District. Result showed that knowledge about the disease and its treatment is inadequate, both in health workers and in mothers. Low birth weight and distance contribute to high mortality. It showed that the community should be educated to recognize the sign and symptom of pneumonia and to understand the importance of early and adequate treatment.20

A health facility-based study conducted to assess the knowledge of mothers regarding recognition of pneumonia in their pre-school children. 400 women were interviewed using a pre-tested structured questionnaire. 61% recognise pneumonia by difficult breathing, 42% by fast breathing and 26% by severe cough. Few mothers mentioned sign suggestive of chest indrawing (8.5%) and central cynosis (1%).A substantial number of mother s (51%) perceived fast breathing to be indication of severe pneumonia, a sizeable number (87.5%) were unsure that late sign such as chest indrawing and central cynosis suggested severe disease, it is concluded that maternal recognition of pneumonia in children is at best modest while knowledge of signs indicating severe disease is poor.21

Signs and symptom of pneumonia

A prospective study conducted to determine simplified clinical signs predictive of pneumonia in children between 2 month and 5 years of age, and to test the validity of the signs recommended by the WHO, clinical findings were correlated with X-ray evidence of pneumonia in 854 children, 400 with pneumonia and 454 with upper respiratory infections (no pneumonia). A respiratory rate of > or = 50/min in infants 2-6 month of age,> or = 40/min in children 7-35 months, and > or = 35/min in children > or = 36 months was the best discriminator of radiological evidence of pneumonia. Use of a respiratory rate of > or = 40/min resulted in a 14%, 19% and 32% loss of sensitivity with little gain in specific age groups 7-11 months, 12-35 months and > or = 36 months respectively. The age-specific respiratory rate (recommended by W.H.O) and/or chest indrawing, history of rapid or difficult breathing and/or chest indrawing, and nasal flaring were also sensitive and specific indicators of pneumonia in almost all age group studied.22