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Original article
1
Clinical Sciences Division,
ICDDR,B, Mohakhali, Dhaka,
Bangladesh; 2 Radda MCH-FP
Centre, Mirpur, Dhaka,
Bangladesh; 3 University of
Basel, 4031 Basel, Switzerland
Correspondence to:
Dr H Ashraf, Clinical Sciences
Division, ICDDR,B, 68 Shaheed
Tajuddin Ahmed Sharani,
Mohakhali, Dhaka 1212,
Bangladesh; ashrafh@icddrb.
org
Accepted 30 August 2007
Published Online First
5 September 2007
490
Day-care management of severe and very severe
pneumonia, without associated co-morbidities such
as severe malnutrition, in an urban health clinic in
Dhaka, Bangladesh
H Ashraf,1 S A Jahan,1 N H Alam,1 R Mahmud,1 S M Kamal,2 M A Salam,1 N Gyr3
ABSTRACT
Background: Management of severe and very severe
pneumonia in children relies on hospital-based treatment,
but practical barriers often prevent children in areas with
the highest rates from receiving hospital care.
Objective: To develop and prospectively evaluate a day-
care clinic approach, which provided antibiotics, feeding
and supportive care during the day with continued care
provided by parents at home, as an effective alternative to
hospitalisation.
Methods: Children aged 2–59 months with severe or
very severe pneumonia without associated co-morbidities,
denied admission to hospital because of lack of beds,
were enrolled at Radda Clinic, Dhaka and received
antibiotics, feeding and supportive care from 08:00 to
17:00 every day, while mothers were educated on
continuation of care at home during the night.
Results: From June 2003 to May 2005, 251 children
were enrolled. Severe and very severe pneumonia was
present in 189 (75%) and 62 (25%) children, respectively,
and 143 (57%) were hypoxaemic with a mean (SD)
oxygen saturation of 93 (4)%, which increased to 98 (3)%
on oxygen therapy. The mean (SD) day-care period was 7
(2) days. Successful management was possible in 234
children (93% (95% CI 89% to 96%)), but 11 (4.4% (95%
CI 2.5% to 7.7%)) had to be referred to hospital, and six
(2.4% (95% CI 1.1% to 5.1%)) discontinued treatment.
There were no deaths during the day-care study period;
however, four children (1.6% (95% CI 0.6% to 4.0%)) died
during the 3-month follow-up period, and 11 (4.4% (95%
CI 2.5% to 7.7%)) required hospital admission.
Conclusion: Severe and very severe pneumonia in
children without associated co-morbidities such as severe
malnutrition can be successfully managed at day-care
clinics.
Acute lower respiratory tract infections, particu-
larly pneumonia, are the leading cause of childhood
morbidity and death in developing countries such
as Bangladesh.1 Acute respiratory tract infec-
tion causes more than 2 million child deaths
worldwide each year, mostly from pneumonia,
and 90% of them occur in less-developed coun-
tries.2–4 Recent estimates suggest that 1.9 million
(95% CI 1.6 million to 2.2 million) children died
from acute respiratory tract infection throughout
the world in 2000, and 70% of them occurred in
Africa and Southeast Asia.5 In Bangladesh, acute
lower respiratory tract infections account for
25% of deaths in the under 5 age group and 40%
of all infantile deaths.6 Depending on clinical
presentation, pneumonia can be classified as very
severe, severe or non-severe, with specific treat-
ment guidelines available for each.7–10 It is recom-
mended that children with severe or very severe
pneumonia be hospitalised for supportive treat-
ment, including suction, oxygen therapy for
hypoxaemia, fluid and nutritional management,
and close monitoring.7–10 In Bangladesh, there are
not enough hospital beds for admission of all severe
and very severe cases of pneumonia. In addition,
hospitalisation may not be possible because of the
inability of parents to visit the hospital. It is
therefore important to provide institutional care
for children who cannot be hospitalised. A pro-
spective observational study was conducted to
examine the feasibility of day-care-facility-based,
modified primary care as an alternative for children
denied hospital admission who would otherwise be
sent home.
METHODS
Setting
This was a collaborative study involving the
ICDDR,B, Radda Maternal and Child Health
(MCH)-Family Planning (FP) Centre (Radda
Clinic), and the University of Basel, Switzerland.
The study was approved by the research and
ethical review committees of ICDDR,B, and was
conducted from June 2003 to May 2005 at the
Radda Clinic, Mirpur, Section 10, Dhaka, about
5 km from the Dhaka Hospital, ICDDR,B. The
Radda Clinic is a non-governmental organisation
which has provided MCH services since 1974 in the
Mirpur area of the metropolitan Dhaka City
Corporation with a population of about 1.5
million. It operates from 08:00 to 16:00 daily,
except for weekends and holidays, and provides
primary care for common childhood illnesses,
including pneumonia, on an outpatient basis.
After triage, children with severe or very severe
pneumonia are referred to either the Institute of
Child Health and Shishu Sasthya Foundation
Hospital (ICHSH) or the Dhaka Shishu Hospital
(DSH) for admission; however, many cannot be
admitted because of shortage of beds. The ICHSH
and DSH are about 1 and 3 km, respectively, from
the Radda Clinic. Adequate space for 12 beds in
two separate rooms was established at the clinic.
Additional staff, comprising a doctor, two nurses,
and four health workers, were hired to operate the
clinic every day of the week to provide care for
children from 08:00 to 17:00, remaining on call
Arch Dis Child 2008;93:490–494. doi:10.1136/adc.2007.118877
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beyond these hours. The health workers were trained to prepare
and administer diets to the children, and educate and motivate
mothers to comply with treatments and follow-up. Provisions
for oxygen therapy and electric suction therapy, a pulse
oximeter and a weighing scale were made available at the clinic.
Inclusion and exclusion criteria
Children of either sex aged 2–59 months with severe or very
severe pneumonia according to WHO criteria (box 1),7–10 who
had been refused admission to ICHSH and DSH because of lack
of beds after proper referral, were enrolled in the study after
parental consent had been obtained. Health workers accom-
panied the children during referral to ICHSH/DSH, and also
brought them back to the Radda Clinic after refusal of
admission. Children with a history of taking antibiotics for
pneumonia during the illness and those with associated co-
morbidities such as tuberculosis, congenital heart disease
(CHD), bronchiolitis, bronchial asthma, severe malnutrition
(,23 weight-for-age Z score), sepsis, hypoglycaemia, convul-
sion and meningitis were not enrolled. Children who lived a
long distance (.5 km) from the clinic and those who presented
late in the day (after 14:30) were also excluded from the study.
Case management
Parents brought their children to the Radda Clinic at 08:00 and
took them home at 17:00 seven days a week. Thick secretions in
the throat and nostrils were removed by gentle suction with an
electric suction machine. Oxygen saturation was routinely
measured in every child after enrolment in the study before any
oxygen therapy was given. Oxygen was administered via nasal
cannulae to all hypoxaemic children with oxygen saturation
,95%11 in room air, as recorded by the pulse oximeter. Oxygen
saturation was routinely monitored in every hypoxaemic child
receiving oxygen therapy at intervals of 30 min to 2 h,
depending on the patient’s condition, until oxygen saturation
remained stable at >95% in room air. It was rechecked during
oxygen therapy as well as after removal of oxygen for 2–5 min.
Children who were still hypoxaemic at 17:00 were referred to
Dhaka Hospital, ICDDR,B or ICHSH for admission and
continued care.
All children received an intramuscular injection of ceftriaxone
once a day at a dose of 75–100 mg/kg for at least 5 days, as it
has been used successfully for outpatient treatment of the most
severe bacterial pneumonia in children and because of its single
daily dose which can easily be administered during daily clinic
visits.12
Feeding of the children had two components, one at the clinic
and the other at home during the night. Infants (7–11 months)
and children received a locally produced milk-based diet (milk-suji;
Box 1 Clinical definitions
Severe pneumonia
c Cough or difficult breathing
c Fast breathing
c Lower chest wall indrawing
c No danger signs
Very severe pneumonia
c Cough or difficult breathing
c Danger signs (eg, cyanosis, convulsions, abnormally sleepy/
difficult to wake, stridor in calm child, inability to drink, severe
clinical malnutrition)
Arch Dis Child 2008;93:490–494. doi:10.1136/adc.2007.118877
Original article
67 kcal/100 ml and 1.4 g protein/100 ml) every 2 h with at least
four feeds administered between 08:00 and 17:00 at the clinic.
Breast feeding was continued for breastfed children, and infant
formula (68 kcal/100 ml and 1.5 g protein/100 ml) was given to
non-breastfed infants aged 2–6 months. Mothers were provided
with three or four feeds of milk-suji/infant formula in a hot pot to
feed their children at night. No child received nasogastric tube
feeding at the clinic or at home during the night.
Children who failed to attend in the morning were visited at
home by a health worker, who brought them back to the clinic.
The above management continued every day until there was
clinical improvement, defined as the child becoming afebrile, no
fast breathing, no lower chest wall indrawing, no danger signs,
and no rales on auscultation. After successful management,
children were discharged from the clinic with advice for follow-
up. Those who failed to improve with day-care management were
referred to Dhaka Hospital, ICDDR,B or DSH for admission.
Follow-up
Parents were asked to bring their children to the Radda Clinic
every 2 weeks for a period of 3 months for examination by the
study doctor. Children who failed to attend a follow-up date
were visited at home by a health worker and brought back to
the clinic. During follow-up visits, morbidity (respiratory,
diarrhoeal, or other) data were collected, treatment advice was
given, and anthropometric indices were recorded. Any child
who developed pneumonia, diarrhoea, or other complications
requiring hospitalisation during follow-up visits were referred to
Dhaka Hospital, ICDDR,B or DSH.
Data analysis
Success of day-care management was defined as improvement
in clinical condition without referral to hospital, full compliance
with the day-care management until recovery, without pre-
mature discontinuation of the study for any reason, and not
dying during the study. All data were collected on case report
forms, edited, entered into a personal computer, and analysed
using statistical software (SPSS V10; SPSS Inc, Chicago, Illinois,
USA). The main outcome measures of the study were the
proportion of successes and failures of day-care management
with 95% CI. Other outcome measures were proportion (with
95% CI) of patients requiring referral to hospital, and
proportion (with 95% CI) discontinuing the study prematurely
without fulfilling the criteria for success.
RESULTS
A total of 557 children were screened, 306 of whom were not
enrolled in the study for various reasons (fig 1). Of the 306
children not enrolled, seven did not have pneumonia, 92 had
pneumonia (non-severe), 70 had severe pneumonia, 57 had very
severe pneumonia according to the WHO criteria,7–10 and the
remaining 80 had bronchiolitis according to the clinical
assessment of the study doctor and the paediatricians working
at the ICHSH and Radda Clinic. The 70 children with severe
pneumonia were not enrolled because 13 refused to give
consent, 14 had contagious diseases such as measles and
pulmonary tuberculosis, 13 had previously received antibiotic
treatment, nine had CHD, nine lived a long way from the clinic,
eight presented late in the day, two were less than 1 month old,
and two had no identified cause. The 57 children with very
severe pneumonia were not enrolled because 48 were severely
malnourished, three were less than 1 month old, one presented
late in the day, three had CHD, and two had no specific reason.
491
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Original article
Figure 1 Trial profile. VSD, ventricular
septal defect.
A total of 251 children with severe or very severe pneumonia
were enrolled at the Radda Clinic from the Mirpur and
surrounding communities. Tables 1 and 2 show the baseline
and clinical characteristics, respectively, of the study children.
On examination, 143 (57%) children were hypoxaemic, with a
mean (SD) oxygen saturation of 93 (4)% in room air, which was
corrected by oxygen therapy to 98 (3)% (table 2). The mean
(SD) duration of oxygen therapy required to correct hypox-
aemia was 3 h 40 min (1 hour 45 min). Of the 143 children
with hypoxaemia, only three required referral to the Dhaka
Hospital, ICDDR,B, and one to the ICHSH, as they remained
hypoxaemic at the end of the first day of enrolment (17:00) at
the Radda Clinic.
Day-care management was successful in 234 children (93%
(95% CI 89% to 96%)). Of the remaining 17 children (7% (95%
CI 4.3% to 10.6%)), 11 (4.4% (95% CI 2.5% to 7.7%)) required
referral to hospital and six (2.4% (95% CI 1.1% to 5.1%))
discontinued treatment (table 3). Reasons for referral to
hospital were mostly respiratory distress with hypoxaemia in
10 and heart failure secondary to ventricular septal defect
(VSD) in one (fig 1). Reasons for withdrawing from the study
were: two families left the city; one family moved to live
.5 km from the clinic; one family had a sick child at home;
one mother could not spare time from work; one family
withdrew for personal reasons (fig 1). There were no deaths
during the day-care period, but four children (1.6% (95% CI
492
0.6% to 4%)) died during the 3-month follow-up period: two
at the Dhaka Hospital, ICDDR,B, one each due to very severe
pneumonia with hypoxaemia and hospital-acquired sepsis; the
cause of death of two children could not be determined as they
died at home and the information was collected long after the
events occurred. Of the 234 children successfully discharged,
11 (4.7% (95% CI 2.6% to 8.2%)) were referred to hospital
during the 3-month follow-up period because of respiratory
distress with hypoxaemia in five, VSD with cyanosis in two,
and one child each with severe pallor (haemoglobin = 7.8 g/
100 ml), pulmonary tuberculosis, vesical calculus, and pneu-
monia with severe malnutrition. The VSD cases were not
diagnosed clinically on enrolment as the children had
additional respiratory sounds due to severe respiratory distress
that masked the cardiac murmurs, which became evident on
subsequent days. Diagnosis of pulmonary tuberculosis in one
child and development of severe malnutrition in another
occurred during the follow-up period.
DISCUSSION
The results clearly show that a select group of children
with severe or very severe pneumonia, without associated co-
morbidities such as severe malnutrition, can be safely managed
on a day-care basis in resource-poor countries where hospital
beds are scarce, such as Bangladesh.
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Original article

Table 1 Baseline characteristics of the study children Table 2 Clinical characteristics of the study children
Severe Very severe Severe Very severe
pneumonia pneumonia Total pneumonia pneumonia Total
Characteristic (n = 189) (n = 62) (n = 251) Characteristic (n = 189) (n = 62) (n = 251)

Source of patients Duration of cough (days) 6.08 (4.54) 5.97 (3.70) 6.05 (4.34)
Radda Clinic 172 (91) 54 (87) 226 (90) Temperature (uC) 37.9 (0.8) 38.1 (0.9) 38.0 (0.9)
ICHSH 17 (9) 8 (13) 25 (10) Temperature >38uC 79 (42%) 32 (52%) 111 (44%)
Male 123 (65) 36 (58) 159 (63) Duration of fever (days) 3.17 (2.73) 4.18 (3.16) 3.42 (2.87)
Age (months)* 7 (6) 6 (8) 7 (7) Pulse rate/min 152 (16) 154 (14) 154 (15)
Infants (2–11 months) 157 (83) 55 (89) 212 (84) Pulse rate .160/min 47 (25%) 14 (23%) 61 (24%)
12–59 months 32 (17) 7 (11) 39 (16) Respiratory rate/min 62 (8) 66 (9) 63 (8)
Breastfed 170 (90) 58 (93) 228 (91) Respiratory rate >40/min 189 (100%) 62 (100%) 251 (100%)
History Duration of rapid breathing (days) 2.64 (2.43) 2.35 (1.94) 2.56 (2.32)
Cough 189 (100) 60 (97) 249 (99) Lower chest wall indrawing 186 (98%) 59 (95%) 245 (98%)
Fever 167 (88) 56 (90) 223 (89) Duration of lower chest wall 2.4 (2.4) 2.2 (2.0) 2.33 (2.34)
Difficulty in breathing 64 (34) 20 (32) 84 (33) indrawing (days)
Rapid (fast) breathing 125 (66) 44 (71) 169 (67) Vesicular breath sound 179 (95%) 55 (89%) 234 (93%)
Lower chest wall indrawing 122 (65) 42 (68) 164 (65) Bronchial breath sound 0 3 (5%) 3 (1.2%)
Inability to drink{ 0 39 (63) 39 (16) Rales/crepitation on auscultation 189 (100%) 60 (97%) 249 (99%)
Stop feeding well{ 0 10 (16) 10 (4) Hepatomegaly (liver palpable .2 cm) 63 (33%) 25 (40%) 88 (35%)
Cyanosis{ 0 1 (1.6) 1 (0.4) Oxygen saturation (%) 94 (4) 92 (4) 93 (4)
Stridor in calm child{ 0 3 (5) 3 (1.2) Oxygen saturation after oxygen 98 (3) 98 (2) 98 (3)
therapy (%)
Abnormally sleepy/difficult to 0 13 (21) 13 (5)
wake{ Duration of ceftriaxone therapy (days) 7 (2) 7 (2) 7 (2)
Vomiting 4 (2) 5 (8) 9 (3.6) Duration of clinic stay (days) 7 (2) 7 (2) 7 (2)
Diarrhoea 7 (4) 2 (3) 9 (3.6) Duration of clinic stay .10 days 12 (7%) 1 (1.6%) 13 (5%)
Weight (kg)* 6.1 (1.8) 5.5 (1.7) 6 (1.8) Values are mean (SD) or number (%).
Height (cm)* 63 (8) 60 (8) 63 (8)
Weight-for-age Z score* 21.34 (1.38) 21.4 (1.3) 21.36 (1.37) management could not be directly compared with hospital
Weight-for-height Z score* 20.56 (0.98) 20.38 (0.93) 20.52 (0.97)
care. The absence of a true control group weakens any
Unless otherwise indicated, values are number (%). conclusions drawn, but the use of a control group would not
*Mean (SD).
{Danger signs of very severe pneumonia (four children had two danger signs of very
have been ethical under the circumstances.13 14 Our encouraging
severe pneumonia). results suggest the need for a randomised, controlled clinical
ICHSH, Institute of Child Health and Shishu Sasthya Foundation Hospital. trial to prove or disprove them. Any future randomised,
controlled clinical trial should include a component to assess
the cost-effectiveness of the interventions, as this would be
The main advantages of the day-care model evaluated in this important in selecting the intervention for wider implementa-
study are: (a) it is an attractive alternative because of easy tion in national programmes. Such a study is ongoing at the
replication at most urban and rural outpatient clinics and day- Radda Clinic and ICHSH as the two primary sites for day-care
care centres, with slight modification of the existing staffing, management and inpatient management, respectively, of
including adequate training, motivation and provision of some children with severe pneumonia.
logistic support; (b) lower cost than hospitalisation. However,
the logistics and acquisition of supplies would require additional CONCLUSIONS
funding, which clinics may find difficult to acquire. The results of this study indicate that severe and very severe
That none of the children who were managed solely on a day- pneumonia without associated co-morbidities such as severe
care basis died is very reassuring; however, this may be, at least malnutrition in children can be successfully managed on a day-
in part, related to exclusion of children with associated co- care basis at established day-care clinics, if adequately trained
morbidities such as severe malnutrition, sepsis, hypoglycaemia,
convulsion, meningitis, CHD and tuberculosis according to
Table 3 Outcome in the study children
protocol guidelines. Children were recruited from the outpatient
Severe Very severe
department of the Radda Clinic, leading to a selection bias, as
pneumonia pneumonia Total
the more sick children reported directly to a hospital. Our study Characteristic (n = 189) (n = 62) (n = 251) OR p Value
children were managed by adequately trained research staff who
Success 177 (94) 57 (92) 234 (93) 1.29 0.41
were under greater supervision than normal and thus likely to
Failure 12 (6) 5 (8) 17 (7) 0.77 0.41
have been more motivated and worked with greater dedication.
Referred to hospital 8 (4) 3 (5) 11 (4.4) 0.87 0.53
A better staff to patient ratio than normal may also have played Discontinued 4 (2) 2 (3) 6 (2.4) 0.65 0.46
a role in a country where the ratio is usually sub-optimal. treatment
Our high success rate can be explained by the possibility of Death during 3-month 3 (1.6) 1 (1.6) 4 (1.6) 0.98 0.68
less severity of illness, as only 57% of the children were follow-up period*
hypoxaemic. These received oxygen therapy for a few hours, Referred to hospital 6 (3) 5 (8) 11 (5) 0.37 0.10
during 3-month follow-up
and most were no longer hypoxaemic by the end of the first day period (out of 234
(17:00) and went home. successful cases)
A major limitation of our study is that this was not a Values are number (%).
randomised controlled trial, and thus the efficacy of the *NB: no infants died during the day-care period.

Arch Dis Child 2008;93:490–494. doi:10.1136/adc.2007.118877 493

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Original article
What is already known on this topic
c Hospitalisation of children with severe or very severe
pneumonia is recommended for supportive treatment including
oropharyngeal or nasopharyngeal suction, oxygen therapy for
hypoxaemia, fluid and nutritional management, and close
monitoring.
c In developing countries such as Bangladesh, there are not
enough hospital beds for all severe and very severe cases of
pneumonia. In addition, hospitalisation may not be possible
because of the inability of parents to visit because of long
distances to travel or financial or other domestic reasons, such
as the need to care for siblings at home and the need for the
mother to work.
c It is therefore important to provide institutional care for
children who cannot be hospitalised, at least until stabilisation
of their acute condition.
and motivated staff and the necessary logistic support can be
made available. The death of four children and referral of an
additional 11 children during the 3-month follow-up period
indicates the importance of follow-up for early detection of
medical problems to prevent deaths.
Acknowledgements: We are grateful to Drs Prashant Chhajed, Md Yunus,
Mahbubur Rahman, Khalequzzaman and Wasif Ali Khan for their excellent review of
the manuscript.
Funding: The study was funded by the Swiss Agency for Development and
Cooperation (SDC), Bern, the Gastrointestinal Research Foundation, Liestal, and the
University of Basel, Switzerland. ICDDR,B acknowledges with gratitude the
commitment of the above donors to the centre’s research efforts.
Competing interests: None.
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Arch Dis Child 2008;93:490–494. doi:10.1136/adc.2007.118877
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Day-care management of severe and very

severe pneumonia, without associated
co-morbidities such as severe malnutrition,
in an urban health clinic in Dhaka,
Bangladesh
H Ashraf, S A Jahan, N H Alam, R Mahmud, S M Kamal, M A Salam and
N Gyr

Arch Dis Child 2008 93: 490-494 originally published online September 5,
2007
doi: 10.1136/adc.2007.118877

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