Clinical Profile , Radiological Resolution and Risk Factors Associated with Community Acquired Pneumonia : Correspondence

Not present

1.The authors state that all children from two month to 16 years with clinically diagnosed and radiologically confi rmed cases of pneumonia were included in this study.The accurate diagnosis of pneumonia in children remains an important yet diffi cult clinical problem and chest radiograph remains the diagnostic test of choice in tertiary care centres 2,3 .The diagnosis of clinical pneumonia in developing countries is mainly based on the WHO recommendation with the presence of cough, fast breathing and chest indrawing 4 .The authors have not mentioned which diagnostic criteria they have considered in this study to diagnose clinical pneumonia.Again, using the WHO criteria may overestimate the diagnosis of actual pneumonia while the specifi city of diagnosing pneumonia using WHO criteria is low 5 .It would have been more informative to the readers, if the authors had provided measures taken to exclude pneumonia like illnesses (like bronchiolitis, asthma and cardiac diseases).In the methodology section, whether only clinical pneumonia or clinical pneumonia along with radiological pneumonia were included in the study needs further clarifi cation.Further, elaboration on criteria for the diagnosis of clinical and radiological pneumonia along with exclusion of other pneumonia like conditions would benefi t the readers.
2. Regarding the diagnosis done by chest x-ray, the authors have not mentioned how was radiological pneumonia confi rmed (either by the treating paediatrician or a radiologist).In radiological diagnosis, both intra-observer and inter-observer variabilities have ranged from 20 to 25% 6 .Therefore, it is suggested that x-ray should be read by a paediatrician/radiologist who is blinded with the clinical features of pneumonia.If the above criteria is not fulfi lled, there are high chances of observer bias.The readers would be keen to know regarding the radiological diagnosis of pneumonia in this study.6. Haemophilus infl uenza type-b (HiB) and pneumococcal (PCV) vaccines have been introduced in the national immunization schedule of Nepal.It has been seen that the introduction of these vaccines have signifi cantly reduced the radiologically confi rmed pneumonia 9,10 .The vaccination status of all the children enrolled would defi nitely provide important information to the readers regarding the radiological resolution of pneumonia in the present study.

Response from Author
1.The diagnosis of clinical pneumonia in developing countries is mainly based on the WHO recommendation which we also used to diagnose clinical pneumonia, however including the WHO criteria alone would lead to over overestimation and diagnosis of Pneumonia.So we only included those clinical pneumonia that was proved by radiological assessment in this study.Pneumonia like illness was excluded by careful history and by chest x-ray.
2. X-ray should were read by radiologists who were blinded with the clinical features of pneumonia.
3.Even though the respiratory rate and retraction were not mention it on table, we recorded the retraction and RR in each cases for Downes Score only.
4. In assessing the respiratory distress in children, apart from the WHO criteria we had also taken reference of the Downes score for evaluation of respiratory distress in paediatric population.Even though this is not the standard, we had to use some practical method to assess the improvement everyday and before discharge.It has not been mentioned in result or discussion section.
5. We agree to the mistake done in the Perform which showed headache in two infants of 11 and 12 month age.
7. According to WHO, fast breathing and retractionare important criteria to diagnose pneumonia.Presence of retraction has a specifi city of about 98% in diagnosing pneumonia7.The readers would be keen to know what proportion of pneumonia cases had fast breathing and retraction.