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Paediatr Child Health Vol 8 No 2 February 2003 83

ORIGINAL ARTICLE

The presence of clinical signs in

malnourished infants with acutelower respiratory tract infections

Nafiye Urgancý MD, Tuðçin Polat MD, Nuri Özer MD, Nimet Kayaalp MD

Clinic of Pediatrics, Þi Þ li Etfal Hospital, Istanbul, TurkeyCorrespondence and reprints: Dr Nafiye Urgancý , Dereboyu cad, Cudi Efendi sok. Pinyal apt, No 3/6 Ortaköy-Istanbul, Turkey.

Telephone +90-212-212-3262, fax +90-216-522-2222, e-mail nafiyeurganci@yahoo.com

N Urganc1, T Polat, N Özer, N Kayaalp. The presence ofclinical signs in malnourished infants with acute lower

respiratory tract infections. Paediatr Child Health2003;8(2):83-86.

OBJECTIVES: To determine the reliability of respiratory rateand subcostal retractions in diagnosing acute lower respiratory

tract infection in malnourished children.

METHODS: One hundred forty-three children with acute lowerrespiratory tract infection were classified according to the Gomez

classification as normal, mildly, moderately or severely malnour-

ished. The presence of tachypnea, subcostal retractions and the

sensitivity of either sign in identifying children with a clinical

and radiological diagnosis of acute lower respiratory tract infec-

tion in each of the nutritional categories were evaluated and

compared.

RESULTS: According to the Gomez classification, 21 (15%) of 143 subjects were severely malnourished, 40 (28%) were moder-ately malnourished, 38 (26%) were mildly malnourished and 44

(31%) were well nourished. The mean respiratory rates in sub-

jects with normal nutrition and in mildly, moderately and severe-

ly malnourished subjects were 62.6±9.38 breaths/min, 61.3±5.57

breaths/min, 57.6±11.65 breaths/min and 49.9±9.04 breaths/min,

respectively. The mean respiratory rate of those with normal

nutrition was not significantly different from that of those with

mild malnutrition (P>0.05), but there was a statistically signifi-

cant difference between the normal subjects and both the moder-

ately malnourished (P=0.03) and severely malnourished

(P0.05), but

subcostal retraction frequencies were significantly lower both in

moderately (P=0.03) and severely (P

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était de 62,6±9,38 respirations/min, de 61,3±5,57 respirations/min, de

57,6±11,65 respirations/min et de 49,9±9,04 respirations/min. Le rythme

respiratoire moyen des enfants présentant une nutrition normale n’était

pas sensiblement différent de celui des enfants présentant une malnutri-

tion légère (P>0,05), mais on remarquait une différence statistiquement

importante entre les sujets normaux et tant les sujets modérément malnu-

tris (P=0,03) que les sujets gravement malnutris (P0,05), mais la fréquence du

tirage intercostal était sensiblement inférieure à la fois chez les enfants

modérément malnutris (P=0,03) et chez les enfants gravement malnutris

(P

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than 60 breaths/min in infants younger than two months of 

age, respiratory rate greater than 50 breaths/min in infantsbetween the ages of two and 12 months and respiratory rategreater than 40 breaths/min in infants older than

12 months, or the presence of either sign (8,9).Chest x-rays were obtained from all patients, and were

evaluated by a paediatric radiologist at our hospital who wasblind to the subjects’ clinical histories and the purpose for

which the x-rays were taken.The sensitivity and specificity of tachypnea, subcostal

retractions and the presence of either sign in clinical and

radiological diagnosis of ALRTI were determined in each of the nutritional categories and compared with each other.

Statistically, the discrete clinical signs between childrenwith different nutritional states were compared by using χ2

test. Continuous variables were compared by usingStudent’s t test. Analyses were performed using SSPS 10.0for Windows (SSPS Inc, USA).

RESULTSThe study was completed with 143 subjects (70 boys [49%]

and 73 girls [51%]) with a median age of 7.8±5.9 months.According to the Gomez classification, 21 (15%) sub-jects were severely malnourished, 40 (28%) were moderate-ly malnourished, 38 (26%) were mildly malnourished and

44 (31%) were well nourished.The mean respiratory rates in subjects with normal

nutrition and in mildly, moderately and severely malnour-ished subjects were 62.6±9.38 breaths/min, 61.3±5.57

breaths/min, 57.6±11.65 breaths/min and 49.9±9.04breaths/min, respectively. The mean respiratory rate of patients with normal nutrition (62.6±9.38 breaths/min)

was not significantly different from that of those with mildmalnutrition (P>0.05) but there was a statistically signifi-

cant difference between the normal subjects and both themoderately malnourished (P=0.03) and severely malnour-

ished (P0.05), but subcostal retraction frequencies were signifi-

cantly lower both in moderately (P=0.03) and severely(P0.05 32 (0.84) >0.05 35 (0.92) >0.05

Moderately malnourished 40 30 (0.75) 0.04 27 (0.67) 0.03 32 (0.80) 0.04

Severely malnourished 21 10 (0.47)

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signs for management (8,9). However, the reliability of these clinical findings in malnourished children has not

been evaluated. The responses of malnourished children toinfections may differ from those of well-nourished children

(4). In a study conducted in Gambia by Falade et al (5), itwas concluded that the lower limiting values of respiratoryrates in malnourished children with pneumonia must be

five breaths less per minute than the respiratory rates in

well-nourished children. In the same study, intercostalretractions were reported to be less in malnourished chil-dren (5).

In our study, we detected tachypnea-limiting values tobe higher than the values reported by the WHO, only in52% of patients, especially in the severely malnourished

group. In addition, we did not detect any subcostal retrac-tion in 53% of those cases, as shown in Figure 1, which dis-

plays the respiration rates per age.We observed that the average respiratory rates in mal-

nourished children were decreased with respect to thedegree of malnutrition, and this difference was more promi-nent in cases with severe malnutrition. Likewise, subcostal

retraction was found to be less frequent in cases with severemalnutrition. Coexistance of tachypnea and subcostal

retractions was also found to be less frequent in severelymalnourished children with ALRTIs.

We can explain these results by decreased rates of pro-tein synthesis and breakdown, and the consequent loss of 

muscle power in malnourished children.WHO studies that found the clinical signs of ALRTI to

be different in malnourished children than in well-nour-

ished children were found to conflict both with our findings

and the literature (4,5).Respiratory rates in malnourished children with ALRTIs

were found to be lower than the limit tachypnea values rec-

ommended by the WHO, at least in children younger thansix months of age (Figure 1).

If it is considered that the death rates from pneumonia

are higher in the first six months of life, especially in devel-oping countries, it is evident that as well as the criteria of 

the WHO, other criteria must be followed to be able todiagnose ALRTIs, and to provide an efficient and fast treat-

ment of hypoxia (22).As a result, we consider that, in diagnosing ALRTIs

especially in cases with malnutrition, supporting criteria

must be used in addition to the WHO criteria, rather thanchanging the algorithms of the WHO.

Urgancý et al

Paediatr Child Health Vol 8 No 2 February 200386

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