title: Pneumonia in severely malnourished children in developing countries - mortality risk, aetiology and validity of WHO clinical signs: a systematic review.
abstract: OBJECTIVE
  To quantify the degree by which moderate and severe degrees of malnutrition increase the mortality risk in pneumonia, to identify potential differences in the aetiology of pneumonia between children with and without severe malnutrition, and to evaluate the validity of WHO-recommended clinical signs (age-specific fast breathing and chest wall indrawing) for the diagnosis of pneumonia in severely malnourished children.
  
  
  METHODS
  Systematic search of the existing literature using a variety of databases (Medline, EMBASE, the Web of Science, Scopus and CINAHL).
  
  
  RESULTS
  Mortality risk: Sixteen relevant studies were identified, which universally showed that children with pneumonia and moderate or severe malnutrition are at higher risk of death. For severe malnutrition, reported relative risks ranged from 2.9 to 121.2; odds ratios ranged from 2.5 to 15.1. For moderate malnutrition, relative risks ranged from 1.2 to 36.5. Aetiology: Eleven studies evaluated the aetiology of pneumonia in severely malnourished children. Commonly isolated bacterial pathogens were Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, and Haemophilus influenzae. The spectrum and frequency of organisms differed from those reported in children without severe malnutrition. There are very few data on the role of respiratory viruses and tuberculosis. Clinical signs: Four studies investigating the validity of clinical signs showed that WHO-recommended clinical signs were less sensitive as predictors of radiographic pneumonia in severely malnourished children.
  
  
  CONCLUSIONS
  Pneumonia and malnutrition are two of the biggest killers in childhood. Guidelines for the care of children with pneumonia and malnutrition need to take into account this strong and often lethal association if they are to contribute to the UN Millennium Development Goal 4, aiming for substantial reductions in childhood mortality. Additional data regarding the optimal diagnostic approach to and management of pneumonia and malnutrition are required from regions where death from these two diseases is common.
authors.affiliation: Clinical Science Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
authors.forename: Mohammod Jobayer
authors.initials: MJ
authors.lastname: Chisti
authors.forename: Marc
authors.initials: M
authors.lastname: Tebruegge
authors.forename: Sophie
authors.initials: S
authors.lastname: La Vincente
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Graham
authors.forename: Trevor
authors.initials: T
authors.lastname: Duke
mesh_terms: D002664:Child Nutritional Physiological Phenomena; D002675:Child, Preschool; D003906:Developing Countries; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D044342:Malnutrition / Q000150:complications / Q000401:mortality* / Q000517:prevention & control; D016017:Odds Ratio; D011014:Pneumonia / Q000209:etiology / Q000401:mortality* / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D011502:Protein-Energy Malnutrition / Q000150:complications / Q000401:mortality / Q000517:prevention & control; D012307:Risk Factors; D012720:Severity of Illness Index