Determine the Severity of Acute Respiratory Infections by Using Pediatric Respiratory Severity Score (PRESS) in Children Visiting Federal Govt. Polyclinic hospital, Islamabad

Objective: To determine the severity of acute respiratory infections in children by using Pediatric Respiratory Severity Score (PRESS). Methodology: This descriptive cross sectional study was conducted at the outpatient and emergency paediatric department of the Federal Govt. Polyclinic hospital, Islamabad, from October 2017 to December 2019. One hundred and seventeen children with acute respiratory infections were enrolled in the study by a non-probability sampling technique. Epidemiologic variables of interest included age, sex, and breastfeeding or not. Clinical variables of interest included respiratory rate, use of accessory respiratory muscle, wheeze on auscultation, and oxygen saturation at room air. PRESS assessed tachypnea, wheezing, accessory muscle use, SpO2 and feeding difficulties with each component given a score of 0 or 1, and the total score were categorized as a mild(0-1), moderate (2-3) or severe(4-5). Results: Out of 117 children, 98 (83.8%) belonged to the age group > 2 months– 12 months, while 19 (16.2%) belonged to the age group > 12 months– 24 months. Among them, 17 (14.5%) were mild, 53 (45.3%) were moderate, and 47 (40.2%) were severe according to their severity of respiratory distress. The hospitalization rate for moderate infection was 84.9% while 100% for severe infection and none of the patient with mild infection was hospitalized (p<0.001). Conclusion: Early assessment by simple bedside technique will help in managing the respiratory distress according to its severity, reducing the undue investigation and improving the outcome of illness. Moreover it can be easily administered at primary health care facilities for triage of pediatric patients with respiratory distress.


In trodu ction
Acute respiratory infections (ARI) are a leading cause of morbidity and mortality in under-five children worldwide. 1 About 6.6 million children less than 5 years of age die every year in the world; 95% of them in lowincome countries and one third of the total deaths being due to ARI. 2 In Pakistan the childhood mortality rate is 67 deaths per 1000 live births and there are 640,000 deaths per year associated with pneumonia that is a severe form of acute respiratory infection. 3 The trend of deaths associated with pneumonia has declined to 14% in 2018 from 16% reported in 2013. 4 Acute respiratory infection can involve upper, middle or lower parts of respiratory system. Infection limited to ear, nose and throat are usually mild in nature, but when lungs Original Article are involved, acute respiratory infection takes the severe form of pneumonia which can be life-threatening in infants. Sometimes in high-risk children with low immunity and other associated comorbidities, even the mild infection can take form of severe illness. 5 Both bacteria and viruses can cause acute respiratory infection but in young children the most common cause of acute respiratory infection is viral in nature. Acute respiratory viral infections commonly present with tachypnea, wheezing, cyanosis, respiratory distress and decreased feeding which may reflect the severity of illness. 6 Therefore, it is crucial to treat the acute respiratory infections timely to prevent the complications and burden of disease among young children.
There are many tools and scoring systems developed to predict the severity of acute respiratory infection in peadiatric population. 7-8 Among various tools, Pediatric Respiratory Severity Score (PRESS) is a validated clinical tool that can be very helpful in assessing the severity of illness in children with acute respiratory illnesses. [9][10] This tool utilizes clinical characteristics and clinical investigations to calculate the score which reflects the severity of illness. It is important to identify the high-risk children who are suffering from severe illness in order to provide them with appropriate and timely management. [11][12] The objective of the current study was to assess the severity of acute respiratory illness using a peadiatric respiratory severity score among children in a tertiary care hospital. Another objective was to determine the association of hospital admission, length of stay, and outcome with disease severity.

Meth odo log y
This study was carried out at the Department of Pediatric, Federal Govt. Polyclinic Hospital, Islamabad from October 2017 to December 2019. We enrolled 117 children who visited outpatient and emergency of Pediatric department because of acute respiratory symptoms. A written informed consent was obtained from parents. The study was approved by Ethical committee of the hospital.
Inclusion criteria comprised of age >2 months to <24 months, acute respiratory infections in the form of fever, cough, wheeze, increase work of breathing, feeding difficulty and first-time reporting to the hospital. Exclusion criteria comprised of cardiac disease (Congenital and acquired heart disease), anatomic airway defect, neuromuscular disease, immunodeficiency, recurrent wheeze or asthma and chronic lung disease. Sample size was based on 7% prevalence of respiratory tract infection. The minimum required sample size of 100 children with respiratory distress was calculated at 95% confidence level and 80% study power.
Data was collected on five components using PRESS namely respiratory rate, wheezing accessory muscle use, SPO2 and feeding difficulty. Respiratory rate more than upper limits for age were considered as per WHO guidelines. Wheezing was defined as high pitched whistling sound on auscultation, use of accessory muscles including nasal flaring, head bobbing, grunting, subcostal and intercostal recessions. Oxygen saturation was monitored by pulse oximeter categorized as >95% and <95%. Feeding difficulty was defined as <50-75% of usual feed. Complete blood count, C-Reactive protein (qualitative) and X Ray Chest were done. Treatment and disease management for mild, moderate and severe illness was provided in accordance with the WHO guidelines. [13][14] Study data was analyzed using IBM SPSS (version 23.0) data management software. Data was checked for normality by histograms using normality curves and Shapiro Wilk statistical test. Continuous data was presented as mean and standard deviation whereas the categorical data was presented as frequency and percentage. Quantitative variables were compared using student's t-test, chi-square test was used to compare qualitative variables while ANOVA was applied for qualitative variables with more than two categories. A pvalue of less than 0.05 was considered to be statistically significant in this study.

Results
There were 117 children enrolled in the study, out of which 68 (58.1%) and 49 (41.9%) were males and females respectively. Majority of the children, 98 (83.8%) belonged to age group of 2 -12 months whereas remaining 19 (16.2%) had age group of 12 -24 months.

Discussion
The Pediatric Respiratory Severity Score is a significant bedside clinical method to assess the severity of patients with respiratory distress, and the tool was reported to be used in many other similar studies. [15][16][17][18] The most commonly reported sign and symptom was wheezing and    In our study, we observed that positive CRP test and positive chest x-ray were not significantly different among mild, moderate, and severe infection groups.
Similarly, blood test results for total leukocyte count, hemoglobin level, platelets, lymphocytes and neutrophils count were also not significantly different with respect to the severity of infection. Similar insignificant associations were reported by studies conducted by Yumiko Miyaji. 11 One of the limitations in our study was that the study was conducted in only one center and there was low enrollment of mild cases due to loss follow up.

Conclu sion
Early assessment by simple bedside technique will help in managing the respiratory distress according to its severity, reducing the undue investigation and improving the outcome of illness. Moreover, it can be easily administered at primary health care facilities for triage of pediatric patients with respiratory distress.