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Pediatrics |

High Altitude and Anemia Predict Treatment Failure in Children With Very Severe Pneumonia

Peter Moschovis*, MD; Salem Banajeh, MD; William MacLeod, DSc; Samir Saha, PhD; Douglas Hayden, MA; David Christiani, MD; Greta Mino, MD; Mathuram Santosham, MD; Donald Thea, MD; Shamim Qazi, MD; Patricia Hibberd, MD
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Massachusetts General Hospital/Harvard Medical School, Boston, MA


Chest. 2012;142(4_MeetingAbstracts):764A. doi:10.1378/chest.1389872
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Abstract

SESSION TYPE: Pediatric Critical Care

PRESENTED ON: Sunday, October 21, 2012 at 01:15 PM - 02:45 PM

PURPOSE: Pneumonia is the leading cause of mortality in children under five years of age in developing nations. Factors that affect tissue delivery of oxygen (DO2) may contribute to severity of illness on presentation and treatment outcomes. We examined the effect of two of these factors, high altitude and anemia, on clinical severity at presentation and treatment outcomes in young children with WHO-classified very severe pneumonia.

METHODS: We analyzed data from the Severe Pneumonia Evaluation Antimicrobial Research (SPEAR) study, a multinational WHO-funded RCT of chloramphenicol vs. ampicillin/gentamicin for very severe pneumonia among children 2-59 mo. in low-resource settings. The trial enrolled 958 children in 8 sites at varying elevations, classified as high (≥ 2,000m) or low altitude (< 2,000m). Differences in clinical characteristics were compared using Student's T test and Pearson's chi-square. The effect of hemoglobin at high vs. low altitude was assessed using multivariate regression, adjusting for potential confounders and study site.

RESULTS: Children at high altitude had significantly lower mean SpO2 on presentation (71% vs. 88%, p < .0001), higher proportion of cyanosis (94% vs. 8%, p < .0001), lower systolic blood pressure (86 mm Hg vs. 93 mm Hg, p < .0001), and higher mean hemoglobin (10.5 vs. 9.8, p < .0001). Interaction was observed between high altitude and hemoglobin (p = 0.001), indicating a different effect of hemoglobin at high and low altitudes. After adjusting for potential confounders, a lower hemoglobin predicted treatment failure at high altitude (RR = 0.68 [0.53, 0.86]) but not at low altitude. For every 1g/dL increase in hemoglobin, the risk of treatment failure was found to decrease by 32%.

CONCLUSIONS: Children at high altitude present with significantly more severe hypoxemia and cyanosis than children at low altitude. Lower hemoglobin at high altitude increases the risk of treatment failure.

CLINICAL IMPLICATIONS: Treatment of anemia should be a high priority in children at high altitude, and could reduce morbidity and mortality from very severe pneumonia.

DISCLOSURE: The following authors have nothing to disclose: Peter Moschovis, Salem Banajeh, William MacLeod, Samir Saha, Douglas Hayden, David Christiani, Greta Mino, Mathuram Santosham, Donald Thea, Shamim Qazi, Patricia Hibberd

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Massachusetts General Hospital/Harvard Medical School, Boston, MA

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