Passive smoke exposure increases the risk of lower respiratory infection (LRI) in infants, but the extensive literature on this association has not been systematically reviewed for nearly ten years. The aim of this paper is to provide an updated systematic review and meta-analysis of studies of the association between passive smoking and LRI, and with diagnostic subcategories including bronchiolitis, in infants aged two years and under. We searched MEDLINE and EMBASE (to November 2010), reference lists from publications and abstracts from major conference proceedings to identify all relevant publications. Random effect pooled odds ratios (OR) with 95% confidence intervals (CI) were estimated. We identified 60 studies suitable for inclusion in the meta-analysis. Smoking by either parent or other household members significantly increased the risk of LRI; odds ratios (OR) were 1.22 (95% CI 1.10 to 1.35) for paternal smoking, 1.62 (95% CI 1.38 to 1.89) if both parents smoked, and 1.54 (95% CI 1.40 to 1.69) for any household member smoking. Pre-natal maternal smoking (OR 1.24, 95% CI 1.11 to 1.38) had a weaker effect than post-natal smoking (OR 1.58, 95% CI 1.45 to 1.73). The strongest effect was on bronchiolitis, where the risk of any household smoking was increased by an OR of 2.51 (95% CI 1.96 to 3.21). Passive smoking in the family home is a major influence on the risk of LRI in infants, and especially on bronchiolitis. Risk is particularly strong in relation to post-natal maternal smoking. Strategies to prevent passive smoke exposure in young children are an urgent public and child health priority.

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We carried out bibliographic searches in PubMed and Embase.com for the period from 1996 to 2008 with the aim of reviewing the scientific literature on the relationship between various sources of indoor air pollution and the respiratory health of children under the age of five. Those studies that included adjusted correlation measurements for the most important confounding variables and which had an adequate population size were considered to be more relevant. The results concerning the relationship between gas energy sources and children's respiratory health were heterogeneous. Indoor air pollution from biomass combustion in the poorest countries was found to be an important risk factor for lower respiratory tract infections. Solvents involved in redecorating, DYI work, painting, and so forth, were found to be related to an increased risk for general respiratory problems. The distribution of papers depending on the pollution source showed a clear relationship with life-style and the level of development.

PURPOSE OF REVIEW Indoor air pollution (IAP) resulting from the use of solid fuel for cooking and heating is a significant public health concern in developing countries. Recent studies have attempted to better characterize the epidemiology of IAP in respiratory diseases and develop technologies for reducing this IAP exposure. RECENT FINDINGS Evidence showed that IAP resulting from solid fuel smoke is a causative or contributory factor to acute respiratory infection, chronic obstructive lung disease, asthma, lung cancer and tuberculosis. Evidence also showed that health education, improvements in household ventilation and area distribution, improvements in stoves and changes of the fuels for cooking and heating can reduce IAP. SUMMARY Evidence of impacts of IAP on respiratory system disease is strong. Although some technologies can improve indoor air quality in households, improving it in households is still an urgent and high-priority task. Longitudinal studies using different methods of exposure assessment that include both chemical measurements and activity data, with longer follow-up and larger samples, are needed. Any program for the prevention of IAP must be based on what is acceptable to the community, and the effects of the intervention must be evaluated.

BACKGROUND Pneumonia is one of the leading causes of morbidity and mortality in under fives. We carried out a comprehensive study to identify factors influencing both mortality and morbidity for children less than 5 years of age hospitalized with severe pneumonia. METHODS 200 hospitalized children aged 2-60 months with World Health Organization (WHO) defined severe pneumonia were enrolled in the study. The children were managed using a standard protocol. They were closely followed up for need for change in antibiotics, prolonged hospital stay, need for mechanical ventilation and mortality. Data on the factors influencing the outcome were collected. RESULTS Of 200 children enrolled in the study, 113 (56.5%) needed a change in antibiotics, 102 (51%) stayed for more than 5 days in the hospital, 41 (20.5%) needed mechanical ventilation and 21 (10.5%) died. On multivariate analysis, lack of exclusive breastfeeding [RR (95%CI) 2.63 (2.16-2.86)], overcrowding [RR (95%CI) 1.94 (1.35-2.38)] and an abnormal chest x-ray [RR (95%CI) 2.29 (1.22-3.44)] were associated with the need for change of antibiotics. Lack of exclusive breastfeeding [RR (95%CI) 2.56 (2.0-2.93)], overcrowding [RR (95%CI) 2.59 (1.78-3.23)] and an abnormal chest x-ray [RR (95%CI) 2.99 (1.65-4.38)] were identified as determinants for prolonged hospital stay. Head nodding [RR (95%CI) 8.34 (2.71-12.77)], altered sensorium [RR (95%CI) 5.44 (1.34-17.56)], abnormal leukocyte counts [RR (95%CI) 5.85(1.36-17.14)] and pallor [RR (95%C) 10.88 (2.95-20.40)] were associated with mortality. Head nodding (RR (95% CI) 4.73 (1.50-6.36)] and cyanosis (RR (95%CI) 5.06 (1.80-11.34)] were the determining factors for mechanical ventilation. In radiographically confirmed pneumonia, the determining factors for change of antibiotics were: lack of exclusive breast feeding [RR (95% CI) 2.05 (1.69-2.2)] and low birth weight [RR (95% CI) 1.59 (1.1-1.89)]. For prolonged hospital stay, the factors identified were mothers' education less than graduation [RR (95% CI) 1.5 (1.19-1.7)], lack of exclusive breast feeding [RR (95% CI) 1.77 (1.19-2.09)] and oxygen saturation of < 90% at time of presentation [RR (95% CI) 2.06 (1.42-2.42)]. Determinants for mechanical ventilation were mothers' education less than graduation [RR (95% CI) 3.6 (1.15-6.3)] and cyanosis at presentation [RR (95% CI) 10.9 (1.56-18.9)]. For mortality, the only determinant was pallor [RR (95% CI) 10.54 (1.8-21.79)]. CONCLUSION Children hospitalized with severe community acquired pneumonia [as defined by World Health Organization (WHO)] who had not received exclusive breast feeding, had stayed in an overcrowded homes and had an abnormal chest radiograph were more likely to fail to respond with primary antibiotic regimen and require change of antibiotics and prolonged hospital stay. In children with radiographically confirmed pneumonia, lack of breast feeding and low birth weight was associated with need for change in antibiotics.

Acute lower respiratory tract infection (ALRTI) is a common illness, but there have been relatively few studies of the bacterial etiology in developing countries. Nasopharyngeal aspirates of 70 children under 10 years of age with ALRTI were cultured for aerobic bacterial pathogens. Klebsiella pneumoniae was the commonest organism (32.2%) isolated followed by S. pneumoniae (10%), E. coli (10%), P. aeruginosa (5.7%), S. aureus (2.8%) and H. influenzae (1.4%). There were significantly more bacterial pathogens isolated in children <1 year of age (73.7%) than in those > 1 year of age (56.2%)(P=0.03). A shift in spectrum from Gram-positive cocci to Gram negative bacilli in ALRTI was observed in our study.

BACKGROUND The association between environmental tobacco smoking (ETS) and childhood pneumonia has not been established in developed or developing countries. A study was conducted to assess the effect and impact of ETS exposure on pneumonia among children in central Vietnam. METHODS A population-based large-scale cross-sectional survey was conducted covering all residents of 33 communes in Khanh Hoa Province, the central part of Vietnam. Information on demographics, socioeconomic status and house environment, including smoking status of each household member, was collected from householders. Hospital admissions for pneumonia among children aged <5 years in each household in the previous 12 months were recorded based on caregiver's report. RESULTS A total of 353 525 individuals living in 75 828 households were identified in the study areas. Of these, 24 781 (7.0%) were aged <5 years. The prevalence of ETS was 70.5% and the period prevalence of hospital admissions for pneumonia was 2.6%. Multiple logistic regression analysis showed that exposure to ETS was independently associated with hospital admissions for pneumonia (adjusted odds ratio 1.55, 95% CI 1.25 to 1.92). The prevalence of tobacco smoking was higher among men than women (51.5% vs 1.5%). It is estimated that 28.7% of childhood pneumonia in this community is attributable to ETS. CONCLUSIONS Children in Vietnam are exposed to substantial levels of ETS which results in 44 000 excess hospital admissions due to pneumonia each year among children aged <5 years.

We compared the socio-demographic and clinical outcomes as predictors in severely ill hospitalized under-five diarrheal children with and without pneumonia. We studied 496 under-five children with diarrhea admitted to the Special Care Ward (SCW) of Dhaka Hospital of International Center for Diarrheal Disease Research, Bangladesh from 1999 to 2004. Children with pneumonia, in addition to their diarrhea, constituted the study group (cases), and those who did not have pneumonia constituted the comparison (control) group. The individual predictors of pneumonia in children were a history of cough (OR 2.19, 95% CI 1.30-3.72, p=0.002), fever (OR 1.73, 95% CI 1.19-2.53, p=0.003), and rapid breathing (OR 2.45, 95% CI 1.49-4.03, p<0.001). Hypothermia (6% vs 2%; p=0.02), hyponatremia (41% vs 27%; p=0.003) and dehydrating diarrhea (81% vs 69%, p=0.003) were more frequent in control children. On logistic regression analyses, the case fatality among children with pneumonia was nearly two times (OR, 1.88 CI, 1.12-3.15, p= 0.02) than that of controls. Formulation of guidelines and implementation of a more comprehensive approach to managing pneumonia among severely ill diarrheal children is necessary to reduce childhood deaths in Bangladesh.

Reduction of indoor air pollution (IAP) exposure from solid fuel use is a potentially important intervention for childhood pneumonia prevention. This review updates a prior meta-analysis and investigates whether risk varies by etiological agent and pneumonia severity among children aged less than 5 years who are exposed to unprocessed solid fuels. Searches were made of electronic databases (including Africa, China and Latin America) without language restriction. Search terms covered all sources of IAP and wide-ranging descriptions of acute lower respiratory infections, including viral and bacterial agents. From 5317 studies in the main electronic databases (plus 307 African and Latin American, and 588 Chinese studies, in separate databases), 25 were included in the review and 24 were suitable for meta-analysis. Due to substantial statistical heterogeneity, random effects models were used. The overall pooled odds ratio was 1.78 (95% confidence interval, CI: 1.45-2.18), almost unchanged at 1.79 (95% CI: 1.26-2.21) after exclusion of studies with low exposure prevalence (< 15%) and one high outlier. There was evidence of publication bias, and the implications for the results are explored. Sensitivity subanalyses assessed the impact of control selection, adjustment for confounding, exposure and outcome assessment, and age, but no strong effects were identified. Evidence on respiratory syncytial virus was conflicting, while risk for severe or fatal pneumonia was similar to or higher than that for all pneumonia. Despite heterogeneity, this analysis demonstrated sufficient consistency to conclude that risk of pneumonia in young children is increased by exposure to unprocessed solid fuels by a factor of 1.8. Greater efforts are now required to implement effective interventions.

OBJECTIVES To identify factors associated with developing severe respiratory syncytial virus (RSV) pneumonia and their commonality with all-cause lower respiratory tract infection (LRTI), in order to isolate those risk factors specifically associated with RSV-LRTI and identify targets for control. METHODS A birth cohort of rural Kenyan children was intensively monitored for acute respiratory infection (ARI) over three RSV epidemics. RSV was diagnosed by immunofluorescence of nasal washings collected at each ARI episode. Cox regression was used to determine the relative risk of disease for a range of co-factors. RESULTS A total of 469 children provided 937 years of follow-up, and experienced 857 all-cause LRTI, 362 RSV-ARI and 92 RSV-LRTI episodes. Factors associated with RSV-LRTI, but not RSV-ARI, were severe stunting (z-score < or =-2, RR 1.7 95%CI 1.1-2.8), crowding (increased number of children, RR 2.6, 1.0-6.5) and number of siblings under 6 years (RR 2.0, 1.2-3.4). Moderate and severe stunting (z-score < or =-1), crowding and a sibling aged over 5 years sleeping in the same room as the index child were associated with increased risk of all-cause LRTI, whereas higher educational level of the primary caretaker was associated with protection. CONCLUSION We identify factors related to host nutritional status (stunting) and contact intensity (crowding, siblings) which are distinguishable in their association with RSV severe disease in infant and young child. These factors are broadly in common with those associated with all-cause LRTI. The results support targeted strategies for prevention.

Two hundred children below five years of age hospitalized with a clinical diagnosis of acute severe lower respiratory tract infection were enrolled in the study. Nasopharyngeal (NP) aspirate was collected for viral isolation by centrifugation enhanced culture technique. Viruses were isolated from 89 NP aspirates. Clinical features of these 89 children were compared with 111 children whose NP aspirates were negative for viruses. There was significantly higher incidence of breathlessness and rhonchi in children whose nasopharyngeal aspirates yielded virus. Sensitivity,specificity, positive and negative predictive values of breathlessness for severe viral ALRTI were 98%, 10.8%, 46.8% and 85%, respectively. The values for rhonchi were 60%, 56.8%, 58.2%, and 74.1%, respectively. It is concluded that clinical features do not have desirable sensitivity and specificity for identification of ALRTI due to viral etiology.

OBJECTIVE To identify pathogens responsible for acute severe lower respiratory tract infection (ALRTI) in under five children by non-invasive methods. METHOD 95 children hospitalized with acute severe lower respiratory tract infection were investigated for identification of viruses, bacteria, chlamydia or mycoplasma by nasopharyngeal aspirates, blood culture and serology. RESULT Etiological agents could be identified in 94% of the patients. Viruses from NP aspirate could be isolated in 36 (38%), bacterial isolates from blood cultures in 15 (16%); mycoplasma was identified in 23 (24%) and chlamydia in 10 (11%) by serological tests; mixed infections were present in 8 (8%) patients. CONCLUSION Noninvasive methods can be useful in identifying etiological agents in severe ALRTI.

Metered dose inhaler (MDI) with spacer is the preferred method for administration of aerosolized medications in pediatric asthma. The expense of commercial spacers limits their use and indigenous alternatives have therefore been developed. Information on the clinical efficacy of home-made spacers is limited. This study was conducted to compare the efficacy of a valve-less home-made spacer with a commercial spacer in delivering salbutamol via MDI in acute asthma. Asthmatic children aged 5-15 years who presented with an acute exacerbation to the pediatric chest clinic of a tertiary care hospital were enrolled in a single blinded randomized parallel group study. The study patients received 10 puffs of salbutamol (100 microg/puff) via MDI-home-made spacer or MDI-commercial spacer. Pre and post inhalation measurements of peak expiratory flow rate (PEFR), oxygen saturation (SaO2), respiratory rate (RR), pulse rate (PR) were made and compared. Sixty children were enrolled in the study, 31 were administered salbutamol via the home-made spacer and 29 via the commercial spacer. The median increase in PEFR was similar in both the groups (20.8% vs 22.2%, p=0.4), clinical improvement being satisfactory in all patients. The valve-less home-made spacer is equally efficacious and cheaper than the commercial spacer in administering bronchodilators in acute exacerbations of asthma. Further studies on the efficacy of home-made spacer in delivery of inhaled steroids are needed.

BACKGROUND Acute respiratory tract infection (ARI) is the major cause of morbidity and mortality in young children in developing countries. Information on viral aetiology in ARI in India is very limited. OBJECTIVE The aim of the study was to define the role of viruses in acute lower respiratory tract infections (ALRTI) in children in India using centrifugation enhanced cultures followed by indirect immunofluorescence (IIF). STUDY DESIGN Nasopharyngeal aspirates (NPAs) were collected from children from September 1995 to April 1997, attending paediatric clinic of All India Institute of Medical Sciences (AIIMS) with symptoms of ALRTI. Virus isolation was done by centrifugation enhanced cultures using HEp-2, LLC-MK2 and MDCK cells. The viruses were identified at 24-48 h post inoculation by IIF staining using monoclonal antibodies to respiratory syncytial virus (RSV), parainfluenza virus (PIV), influenza virus and adenovirus. RESULTS Of 200 NPA samples, 89 (44.5%) were positive for one or more viral pathogens. RSV was detected in 34 (17%) of all ALRTI cases followed by influenza viruses in 29 (14.5%), PIVs in 23 (11.5%) and adenoviruses in three (1.5%). In 79 children with bronchiolitis, RSV was most frequently isolated (25%) pathogen, while in bronchopneumonia cases (101) the most common viral pathogen was influenza virus (17%). In eight cases (4%) of ALRTI dual infections were detected. In 100 NPA specimens IIF staining on direct cell smears was carried out and viruses were detected in only 17%. RSV and influenza virus infection peaked from September to December, where as PIV infections were more frequent from January to April. CONCLUSION Respiratory viruses accounted for 44.5% of cases of ALRTI in India and the results of viral aetiology could be given in 24-48 h using centrifugation enhanced cultures. RSV was the most common viral agent associated with ALRTI in children under 5 years of age with greater association with bronchiolitis.

An epidemic of dengue haemorrhagic fever (DHF) occurred in Delhi in 1996. A total of 240 children between the age of 4 months to 13 years of either sex, admitted in one hospital, were evaluated. Two hundred and sixteen (90%) children were from Delhi. A clinical diagnosis of dengue fever (DF) was made in 25 (10%), dengue fever with unusual bleeding (DFB) in 22 (9%), DHF in 80 (33%) and dengue shock syndrome (DSS) in 113 (47%) of the children strictly according to the WHO classification. The age peaked at 8 years. There was no association between various grades of severity of illness and age-groups though girls suffered from more severe illness. No association between severity of malnutrition and severity of illness was observed. Tourniquet test was positive in 40% with DF, 18% with DFB, 62% with DHF and 64% with DSS. In DSS haematemesis was present in 55 (49%), epistaxis in 39 (35%), melaena in 27 (24%) and ecchymosis in 34 (30%) patients. Children diagnosed as DFB had haematemesis and epistaxis in 12 (55%) and 10 (45%) respectively. Intravenous fluid requirement was clearly less in DFB patients than in DHF/DSS patients. Unusual clinical features in the form of jaundice were present in 7 (6%), hepatic encephalopathy in 6 (5%) and dengue encephalopathy in 6 (5%) patients. Dengue 2 virus was isolated from 10 of the 50 patients for whom viral culture was done on C6/36 clone of Aedes albopictus cell line. Eighteen patients suffering from DSS died giving an overall case fatality of 7.5%. The mortality rate in DHF/DSS was 9.3%. It is further suggested that DFB is a distinct entity. Most patients could be classified by the WHO classification if a retrospective packed cell volume was used to assess haemoconcentration. We suggest that development of area-specific criteria for diagnosis and management is desirable.

BACKGROUND Pneumonia is the leading cause of mortality in children. In developing countries, pneumonia is usually caused by bacterial pathogens. The early administration of empirical antibiotics improves the patients' clinical outcomes. There are currently no systematic reviews of clinical trials on this subject. OBJECTIVES To identify effective antibiotic drug therapy for community acquired pneumonia (CAP) in children by comparing various antibiotics. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library, Issue 4, 2005), MEDLINE (OVID)(1966 to January 2006) and EMBASE (WebSPIRS)(1990 to September 2005). There were no language restrictions. SELECTION CRITERIA Randomized controlled trials (RCTs) in children of either sex, which compared at least two antibiotics for CAP in hospital or ambulatory settings. DATA COLLECTION AND ANALYSIS Data from full articles of selected studies were independently extracted by two authors. MAIN RESULTS The review of these studies suggests that for treatment of pneumonia, co-trimoxazole is inferior in efficacy to both amoxycillin (failure rates odds ratio (OR) 1.33; 95% CI 1.05 to 1.67) and procaine penicillin (cure rates OR 2.64; 95% CI 1.57 to 4.45). Penicillin in conjunction with gentamycin was better than chloramphenicol alone (re-hospitalization rates OR 1.61; 95% CI 1.02 to 2.55). Co-amoxyclavulanic acid was better than amoxycillin alone (cure rates OR 10.44; 95% CI 2.85 to 38.21). There was no differences between injectable penicillin and oral amoxycillin (failure rates OR 1.03; 95% CI 0.81 to 1.31); azithromycin and erythromycin (cure rates OR 1.17; 95% CI 0.70 to 1.95); cefpodoxime and amoxycillin (cure rates OR 0.69; 95% CI 0.18 to 2.60); or azithromycin and co-amoxyclavulanic acid (cure rates OR 1.02; 95% CI 0.54 to 1.95, failure rates OR 1.42; 95% CI 0.43 to 4.66). AUTHORS' CONCLUSIONS There were many studies each investigating multiple antibiotics with different methodologies. For treatment of ambulatory patients with CAP, amoxycillin was better than co-trimoxazole; there was no difference between azithromycin and erythromycin, or between cefpodoxime and co-amoxyclavulanic acid. For hospitalized patients, procaine penicillin was better than co-trimoxazole; and the combination of penicillin and gentamycin was better than chloramphenicol alone. Injectable penicillin and oral amoxycillin had similar failure rates. For the rest of the antibiotics there were only single studies available. There is a need for more studies with large patient populations and similar methodologies in order to compare newer antibiotics.

OBJECTIVE To compare cultures throat swab after physiotherapy with results of sputum culture in identification of lower airway pathogens in children with cystic fibrosis. METHODS 387 samples of sputum cough swabs, throat swab and throat swab after physiotherapy were collected from 48 patients of cystic fibrosis and cultured for aerobic bacteria. The results of cultures of cough swabs, throat swab and throat swab after physiotherapy were compared with results of sputum culture. RESULTS There was good concordance between culture results of sputum and other methods. Over all concordance was 70%, 81% and 92% with cough swab, throat swab and throat swab after physiotherapy. Sensitivity for isolation of Pseudomonas aeruginosa by throat swab, cough swab and throat swab after physiotherapy was 40%, 42% and 82% respectively. Specificity for isolation of Pseudomonas by throat swab, cough swab and throat swab after physiotherapy was 99%, 100% and 99% respectively. Sensitivity for isolation of Staphylococcus aureus by throat swab, cough swab and throat swab after physiotherapy was 57%, 50% and 100% respectively. Specificity for isolation of Staphylococcus by throat swab, cough swab and throat swab after physiotherapy was 99% for all these methods. CONCLUSION It is concluded that throat swab after physiotherapy in a child with CF can be used reliably for identification of lower airway pathogens.

OBJECTIVE To document clinical profile of cystic fibrosis (CF) in Indian children and the prevalence of delta F508 mutation in these patients. DESIGN Observational study. Setting:Pediatric chest clinic in an urban tertiary care center in north India. PERIOD OF STUDY: July 1995 to June 2002. METHODS Clinical features of 120 children diagnosed as CF by quantitative pilocarpine iontophoresis were recorded. A polymerase chain reaction based test for identification of delta F 508 mutation was performed on all children. RESULTS Out of 3500 new cases registered in Pediatric Chest Clinic during this period 120,(3.5%) children were diagnosed as CF. Origin of parents of patients traced from almost all the States of north India. Family history suggestive of CF was present in 41 (34%) and consanguinity in 19 (61%) patients. Common clinical manifestations at the time of presentation included recurrent or persistent pneumonia in 118 (98%), failure to thrive in 108 (90%), malabsorption in 96 (80%), history of meconium ileus in 10 (8%), and rectal prolapse was present in 16 (13%). History of salt craving, salty taste on kissing and skin rashes was present in 5 patients each. 49(41%) patients were severely malnourished. Nasal polyposis was present in 5 (4%) patients. Examination of chest revealed evidence of hyperinflation in 100 (83%), kyphosis 20 (17%), crepitations 110 (92%), wheezing 40 (25%) and bronchial breathing in 20 (17%) patients. Average clinical CF scores were 51 (95%; CI 20-80). 48 (40%) patients had a CF score of LT40. Pseudomonas spp was cultured from respiratory secretions of 51 (42%), Staphylococcus spp in 18 (15%), Klebsiella spp in 8 (7%) and Hemophilus influenzae in 2 (2%) patients. Delta F508 mutation was positive in 45 chromosomes out of 240 tested. Patients originated from Pakistan had more frequency of delta F508 mutations. CONCLUSIONS Cystic fibrosis does occur in Indian children; clinical features are classical. Diagnosis is often delayed and the disease is advanced in most patients at the time of diagnosis. Frequency of Delta F508 mutation is 19% i.e., less than that seen in Caucasian population. There is need to create awareness about occurrence of CF in Indian children.

An indigenously developed method for sweat collection and titration method for estimation of chloride was validated. The mean difference in estimated chloride value from the known strength of saline in 50 samples was -1.04 +/- 4.13 mEq/L (95% CI:-0.07 to 2.28). The mean difference in the estimated chloride values between two observers when the test was performed on known strengths of saline solution was -2.5 +/- 4.24 mEq/L (95% CI:-3.67 to 1.33). The inter observer variability between two observers when the test was performed on sweat samples obtained from 50 individuals was -1.12 +/- 4.34 mEq/L (95% CI:-2.23 to 0.8 ). Sweat weight of more than 100 mg could be collected in first attempt in 602 of 757 (80%) patient with an average sweat weight of 230 mg. This inexpensive method of sweat collection and chloride estimation has acceptable accuracy and repeatability and can be used in resource poor setting for making a diagnosis of cystic fibrosis.

Pneumonia is the leading cause of mortality and a common cause of morbidity in children below five years of age. Commonly, pneumonia is caused by bacterial agents. The diagnosis of pneumonia is usually made on clinical features. A child with tachypnea with no chest in-drawing or difficulty in feeding is labeled as pneumonia. Presence of chest in-drawing, difficulty in speech, feeding or cyanosis classifies a child as suffering from severe or very severe pneumonia. Factors that may help in selection of appropriate antibiotics include: knowledge of etiological agents, sensitivity of pathogens to antibiotics, severity of the disease, immune status, nutritional status, previous antimicrobial usages, history of hospitalization, duration of illness, associated complications and cost and safety of antibiotics. For selection of antibiotics pneumonia can be classified in two major categories (a) community acquired, without risk factors, and (b) pneumonia with risk factors. Both these can be further classified as non severe and severe illness. A community acquired pneumonia in a child between 2 months -60 months without risk factors for resistant or atypical organism may be treated with amoxicillin. The alternative to amoxicillin includes oral cephalosporins and cotrimoxazole. In pneumonia with presence of risk factors the antibiotics are decided on basis of individual patients characteristics. A child with non-severe pneumonia should be treated with oral cefuroxime or amoxicillin clavulinic acid for a period of 7-14 days.

Background. Upper respiratory tract infections (URTIs) are common in children. The cause of URTIs is usually viral, but parents' attitudes often contribute to inappropriate prescription of antibiotics, promoting antibiotic resistance. The objective of this study was to identify possible risk factors associated with antibiotic misuse in Greece, a country with high levels of antibiotic use and antibiotic resistance. Methods. A knowledge-attitude-practice (KAP) questionnaire was developed and distributed to Greek parents caring for children who were 5-6 years old, between January and July of the same school year. Results. The sample of the study contained 5312 parents from all geographic areas of Greece. The risk factors of being a father, having low education, having immigrant status, being a single parent, having low income, having <2 or >3 children, living in the islands, and being without experience in recurrent URTIs were significantly associated to inadequate knowledge, inappropriate attitudes, and wrong practices. Conclusions. This study has identified the main groups of parents that should be targeted in future intervention programs.

BACKGROUND The purpose of this study is to determine whether elderly subjects with severe brain atrophy, which is associated with neurodegeneration and difficulty swallowing (dysphagia), are more susceptible to lower respiratory tract infections (LRTI), including pneumonia. METHODS The severity of brain atrophy was assessed by computed tomography in 51 nursing home residents aged 60-96 years. The incidence of LRTI, defined by body temperature ≥ 38.0°C, presence of two or more respiratory symptoms, and use of antibiotics, was determined over 4 years. The incidence of LRTI was compared according to the severity and type of brain atrophy. RESULTS The incidence rate ratio of LRTI was significantly higher (odds ratio 4.60, 95% confidence interval 1.18-17.93, fully adjusted P = 0.028) and the time to the first episode of LRTI was significantly shorter (log-rank test, P = 0.019) in subjects with severe brain atrophy in any lobe. Frontal and parietal lobe atrophy was associated with a significantly increased risk of LRTI, while temporal lobe atrophy, ventricular dilatation, and diffuse white matter lesions did not influence the risk of LRTI. CONCLUSION Elderly subjects with severe brain atrophy are more susceptible to LRTI, possibly as a result of neurodegeneration causing dysphagia and silent aspiration. Assessing the severity of brain atrophy might be useful to identify subjects at increased risk of respiratory infections in a prospective manner.

Acute respiratory tract infections (ARTI) are the most common cause of childhood morbidity and an important public health problem. The aim of this study was to identify the significant risk factors for ARTI in children. The study took place in Ivankovo which is a rural area of Eastern Slavonia and with small socio-economic differences. The study population were 159 children who were 3-5 years old at the time of the study, and who were registrated at doctor's office Ivankovo. The study was conducted retrospectively through a questionnaire from January 2008 to December 2008. The risk factors studied were the gender, breastfeeding history, any atopic manifestation in the form of atopic eczema, rhinoconjuctivitis and/or asthma, the size of the family, parents smoking habits and main form of childcare. The number of ARTI requiring the consultation of a doctor throughout 2007 were measured; and whether ARTI had been treated with antibiotic or there were recommendation for symptomatic treatment only. Results of this research show that the risk factor for consulting a doctor because ofARTI in children was passive exposure to cigarette-smoke. For receiving antibiotics because of ARTI in children, the risk factors were passive exposure to cigarette-smoke and atopic manifestation. By giving the available evidence, parents must be told that ceasing smoking offers a significant opportunity to reduce the risk of ARTI in their children.

In contrast to its 'preventive role', no consensus has evolved for the therapeutic role of zinc in pneumonia in children. We conducted a meta-analysis to find the therapeutic role of zinc in children <5 years of age hospitalised for severe acute lower respiratory tract infection (ALRTI). A comprehensive search was performed of the major electronic databases. Randomised controlled trials (RCTs) comparing treatment with zinc versus placebo were included. Seven RCTs (1066 subjects) conducted in developing countries were eligible for inclusion. There was no significant difference between the two groups regarding the time of resolution of severe illness (standardised mean difference (SMD)-0.15 (95% confidence interval (CI)-0.5, 0.2; p=0.4)) and duration of hospitalisation (SMD -0.29 (95% CI -0.68,-0.09; p=0.13)). No significant difference between the two groups was also noted for other parameters (duration of resolution of hypoxia, chest indrawing or tachypnoea, change of antibiotics and treatment failure rates). The adverse events were not significant. To conclude, present available data do not support the efficacy of zinc in treatment of severe ALRTI.

BACKGROUND : Human rhinovirus (HRV) species C (HRV-C) have been associated with frequent and severe acute lower respiratory infections and asthma in hospitalized children. The prevalence of HRV-C among healthy children and whether this varies with ethnicity is unknown. OBJECTIVE : To describe the prevalence of HRV species and their associations with demographic, environmental and socioeconomic factors in healthy Aboriginal and non-Aboriginal children. METHODS : Respiratory viruses and bacteria were identified in 1006 nasopharyngeal aspirates collected from a cohort of 79 Aboriginal and 88 non-Aboriginal Western Australian children before 2 years of age. HRV-positive nasopharyngeal aspirates were typed for HRV species and genotypes. Longitudinal growth models incorporating generalized estimating equations were used to investigate associations between HRV species and potential risk factors. RESULTS : Of the 159 typed specimens, we identified 83 (52.2%) human rhinovirus species A (HRV-A), 26 (16.4%), human rhinovirus species B and 50 (31.4%) HRV-C. HRV-C was associated with upper respiratory symptoms in Aboriginal (odds ratio, 3.77; 95% confidence interval:1.05-13.55) and non-Aboriginal children (odds ratio, 5.85; 95% confidence interval: 2.33-14.66). HRV-A and HRV-C were associated with carriage of respiratory bacteria. In Aboriginal children, HRV-A was more common in the summer and in those whose mothers were employed prior to delivery. In non-Aboriginal children, day-care attendance and exclusive breast-feeding at age 6-8 weeks were associated with detection of HRV-A, and gestational smoking with detection of HRV-C. CONCLUSIONS : Factors associated with the presence of HRV differ between Aboriginal and non-Aboriginal children. In contrast to HRV-A, HRV-C is associated with upper respiratory symptoms suggesting that HRV-C is likely to be implicated in respiratory illness.

In this study, we aimed to estimate the prevalence of growth failure and identify the risk factors for this health problem in infants under two years old in Tehran, Iran. Using a cluster sampling method, 2182 infants' health files were randomly selected from eight health centers in Tehran. Growth failure was defined as a decrease in a child's weight (minimum 50 grams) at each attendance compared to the previous evaluation. The prevalence rate was between 0.05% and 6.2% at the different measurements. The regression analysis revealed that the presence of diarrhea [odds ratio (OR): 4.01, 95% confidence interval (CI):(3.50, 4.60)], respiratory infections [OR: 4.95, 95% CI:(4.40, 5.57)] and urinary tract infections [OR: 6.35, 95%CI:(3.97, 10.18)], as well as discontinuation of breast-feeding [OR: 10.91, 95%CI:(7.82, 15.23)], teething [OR: 4.14, 95% CI:(3.61, 4.75)] and complementary feeding [OR: 9.58, 95% CI:(6.48, 14.18)] were the significant risk factors for growth failure. Generally, our study showed a high prevalence of growth failure in infants less than two years in Tehran. More efforts are needed for promoting the knowledge level of mothers and healthcare providers to control this health problem in Iran.

OBJECTIVE to assess the role of oropharyngeal dysphagia (OD) as a risk factor for malnutrition and/or lower respiratory tract infection (LRTI) in the independently-living population of 70 years and over. DESIGN a population-based cohort study. Subjects and setting: persons 70 years and over in the community (non-institutionalised) were randomly selected from primary care databases. MEASUREMENTS the volume-viscosity swallow test (V-VST) was administered by trained physicians at baseline to identify subjects with clinical signs of OD and impaired safety or efficacy of swallow. At the one year follow-up visit, hand grip, functional capacity (Barthel score), nutritional status (mini nutritional assessment, MNA) and LRTI (clinical notes) were assessed. RESULTS two hundred and fifty-four subjects were recruited (46.5% female; mean age, 78 years) and 90% of them (227) were re-evaluated one year later. Annual incidence of 'malnutrition or at risk of malnutrition'(MNA <23.5) was 18.6% in those with basal signs of OD and 12.3% in those without basal signs of OD (P = 0.296). However, prevalent cases of 'malnutrition or at risk of malnutrition' at follow up were associated with basal OD (OR = 2.72; P = 0.010), as well as with basal signs of impaired efficacy of swallow (OR = 2.73; P = 0.015). Otherwise, LRTI's annual incidence was higher in subjects with basal signs of impaired safety of swallow in comparison with subjects without such signs (40.0 versus 21.8%; P = 0.030; OR = 2.39). CONCLUSIONS OD is a risk factor for malnutrition and LRTI in independently living older subjects. These results suggest that older persons should be routinely screened and treated for OD to avoid nutritional and respiratory complications.

BACKGROUND Higher prevalence rates of acute respiratory tract infections (ARTIs) have been described in Australian and Canadian indigenous populations than in nonindigenous age-matched counterparts. Few studies on ARTIs in South American indigenous populations have been published. We performed a cross-sectional survey to describe the prevalence of upper respiratory tract infections and acute lower respiratory tract infections (ALRTIs) and associations with malnutrition and immunization status. METHODS From December 1, 2009 to May 31, 2010, 487 Warao Amerindian children 0 to 59 months of age living in the Delta Amacuro in Venezuela were included in a cross-sectional survey. Data were obtained through parent questionnaires, vaccination cards, and physical examinations including anthropometric measurements. RESULTS Of the 487 children, 47% presented with an ARTI. Of these, 60% had upper respiratory tract infections and 40% were ALRTI. Immunization coverage was low, with only 27% of all children presenting a vaccination card being fully immunized. The prevalence of malnutrition was high (52%), with stunting (height-for-age <-2 standard deviations) being the most frequent presentation affecting 45% of children. ARTI and ALRTI prevalence diminished with increasing age (odds ratio for ALRTI in children 25-59 months of age vs. children younger than 12 months, 0.49; 95% confidence interval, 0.26-0.93). Furthermore, significant differences in ARTI prevalence were seen between villages. No significant associations between immunization status or malnutrition and ARTI or ALRTI prevalence were identified. CONCLUSIONS A high prevalence of ARTIs and chronic malnutrition in combination with a low immunization status highlights the need for an integrated approach to improve the health status of indigenous Venezuelan children.

BACKGROUND Ambient air pollution and malnutrition, particularly anemia, are risk factors for pneumonia, a leading cause of death in children under five. We simultaneously assessed these risk factors in Quito, Ecuador. METHODS In 2005, we studied two socioeconomically similar neighborhoods in Quito: Lucha de los Pobres (LP) and Jaime Roldos (JR). LP had relatively high levels of air pollution (annual median PM2.5 = 20.4 μg/m3; NO2 = 29.5 μg/m3) compared to JR (annual median PM2.5 = 15.3 μg/m3; NO2 = 16.6 μg/m3). We enrolled 408 children from LP (more polluted) and 413 children from JR (less polluted). All subjects were aged 18-42 months. We obtained medical histories of prior physician visits and hospitalizations during the previous year, anthropometric nutrition data, hemoglobin levels, and hemoglobin oxygen saturation via oximetry. RESULTS In anemic children, higher pollution exposure was significantly associated with pneumonia hospitalization (OR = 6.82, 95%CI = 1.45-32.00; P = 0.015). In non-anemic children, no difference in hospitalizations by pollution exposure status was detected (OR = 1.04, NS). Children exposed to higher levels of air pollution had more pneumonia hospitalizations (OR = 3.68, 1.09-12.44; P = 0.036), total respiratory illness (OR = 2.93, 95% CI 1.92-4.47; P < 0.001), stunting (OR = 1.88, 1.36-2.60; P < 0.001) and anemia (OR = 1.45, 1.09-1.93; P = 0.013) compared to children exposed to lower levels of air pollution. Also, children exposed to higher levels of air pollution had significantly lower oxygen saturation (92.2% ± 2.6% vs. 95.8% ± 2.2%; P < 0.0001), consistent with air pollution related dyshemoglobinemia. CONCLUSIONS Ambient air pollution is associated with rates of hospitalization for pneumonia and with physician's consultations for acute respiratory infections. Anemia may interact with air pollution to increase pneumonia hospitalizations. If confirmed in larger studies, improving nutrition-related anemia, as well as decreasing the levels of air pollution in Quito, may reduce pneumonia incidence.

Chest radiographs are often used to support the decision to use antibiotics in children aged <5 years with moderate to severe lower acute respiratory infection (ARI). This study aimed to evaluate inter-observer agreement in the interpretation of chest radiographs of children with suspected lower ARI. Three experienced paediatric sub-specialists: a radiologist, an intensivist and a pulmonologist were provided with basic clinical information on each of 48 cases, but the individual standardized evaluations were blinded for clinical diagnoses and for the assessment by the other two specialists. While for specific radiographic findings Kappa agreement values revealed considerable variation, agreement was higher (fair to substantial) on overall diagnostic impression. These findings reiterate that radiographs of children with a clinical suspicion of lower ARI are a limited but potentially useful resource for case management.