Clinical signs, symptoms or findings of the Household Air Pollution Intervention Network pneumonia definition
| Cough | Caregiver indicating the child has cough or the direct observation of the child coughing, defined as expelling air from the lung with a loud sound to clear the airway of fluids, secretions or other materials. |
| Difficulty breathing | Breathing characterised by the caregiver as abnormal or the direct observation or measurement of the child having any of the following characteristics. Tachypnoea: manually measured respiratory rate ≥60 breaths per min in children aged <2 months and ≥50 breaths per min in children aged 2–11 months. Head nodding: the head consistently moves upward and downward in synchrony with respiration. Nasal flaring: consistent and repetitive outward movement of the lateral aspect of the nares during inspiration. Audible wheeze: a harsh, high-pitched noise made during expiration. Stridor when calm: a harsh, high-pitched noise made during inspiration. Grunting: repetitive “eh” sounds, usually short in duration, during early expiration. Tracheal tugging: when the soft tissue over the trachea immediately superior to the sternum consistently pulls inward during inspiration. Intercostal retractions: when the tissue between the ribs consistently pulls inward during inspiration. Chest indrawing: the child's tissue below the lower chest wall retracts with almost every breath observed over a 1-min period (i.e. may not retract during periods of movement). |
| Danger signs | |
| General danger signs for children <2 months old | |
| Tachypnoea | Direct observation of a respiratory rate ≥60 breaths per min. |
| Unable to feed well | Caregiver indicates that the infant is taking significantly less breastmilk or formula than usual due to the illness. |
| Not moving or moves only when stimulated | Direct observation of an infant not moving spontaneously unless the child is stimulated by noise or touch. |
| Convulsions | Direct observation or the caregiver indicates that the child has had repetitive stiffening of the arms and legs as the muscles contract. May occur with consciousness or not be able to respond to spoken directions. Sometimes described as “fits” or “spasms.” |
| Grunting | Direct observation of the child making repetitive “eh” sounds during early expiration. |
| Severe chest indrawing | Direct observation of the child's tissue below the lower chest wall retracting with every breath observed over a 1-min period. |
| Fever or low body temperature | Direct measurement of a tympanic temperature ≥38°C defines fever. Direct measurement of a tympanic temperature <35.5°C defines low body temperature. |
| General danger signs for children ≥2 months old | |
| Unable to drink or breastfeed | The direct observation of the child's inability or refusal to suck or swallow when offered a drink or breastmilk. |
| Persistent vomiting | The direct observation of the child's inability to hold anything down (i.e. what goes down comes back up). Definition excludes vomiting with the ability to hold some fluids down. |
| Convulsions | Direct observation or the caregiver indicates that the child has had repetitive stiffening of the arms and legs as the muscles contract. May occur with consciousness or not be able to respond to spoken directions. Sometimes described as “fits” or “spasms.” |
| Stridor | Direct observation of the child making a harsh high-pitched noise during inspiration. |
| Lethargic or unconscious | Direct observation of the child's inability to be awakened or not being awake or alert. This child has no response when touched, shaken or addressed. |
| Objective signs | |
| Hypoxaemia | Direct measurement or medical chart abstraction of an oxygen saturation ≤92% in Guatemala, India or Rwanda, or ≤86% in Peru using the Rad G (Masimo, Irvine, CA, USA) or abstracted from the medical chart. |
| Or if the child is directly observed or documented to be on any of the following: CPAP or BiPAP or ventilator support (intubated and mechanically ventilated) or high-flow nasal cannula. | |
| Imaging | |
| Chest radiography | The definition of primary endpoint pneumonia on radiography is either: a dense opacification that is at least one posterior rib plus one rib space in size, or any size opacification, any density plus silhouette sign, or a pleural effusion at the lateral chest wall or costophrenic angle(s), spatially associated with primary endpoint or other opacification or obliterates the hemithorax. To be a positive silhouette sign, the silhouette must obscure the heart border or diaphragm and result in border loss that is one posterior rib plus one rib space in size. |
| LUS | Primary endpoint pneumonia on LUS is defined as the presence of artefacts consistent with either a consolidation that measures ≥1 cm, or a pleural effusion with any of the following: any size consolidation, three or more B-lines or presence of air bronchograms [33, 34]. |
CPAP: continuous positive airway pressure; BiPAP: bilevel positive airway pressure; LUS: lung ultrasound.