Outcome and management of 2–59-month-old Nigerian children with chest indrawing pneumonia at primary-level healthcare facilities: a prospective cohort study

Background
In 2012, World Health Organization (WHO) recommended outpatient oral amoxicillin for children aged 2–59 months with chest indrawing pneumonia without general danger signs, based on randomised trials. We assessed mortality and case management for such children routinely managed at primary healthcare centres (PHCs) in Lagos, Nigeria.

Methods
This prospective observational cohort study (September 2021–September 2023) was conducted in Ikorodu Local Government Area (LGA), nested within the Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) Lagos study across 16 PHCs. PHC healthcare workers (HCWs) trained in Integrated Management of Childhood Illness (IMCI) provided routine care, while INSPIRING staff independently assessed eligibility using IMCI criteria. The primary outcome was the 14-day case fatality rate (CFR) among children with chest indrawing pneumonia without general danger signs; secondary outcomes included antibiotic use, treatment adherence, and referral practices.

Results
PHC HCW identified 24 chest indrawing cases, while INSPIRING staff diagnosed 247 cases, including 19 of the 24 identified by PHC HCWs. Among those followed up (n = 16), the CFR was 6.3% (n/N = 1/16; 95% confidence interval (CI) = 0.2–30.2) for PHC HCW identified cases; with the same death identified by INSPIRING staff (n/N = 1/197; CFR = 0.5%). The single event in each cohort, and high loss to follow-up, imply that these CFR estimates are statistically fragile and should be interpreted as indicative only. Only 4% (n/N = 1/24) of children received routine care aligned with IMCI protocols. Of those prescribed antibiotics, 50% (n/N = 4/8) completed the full course, and just 1 of the 6 of referred children was admitted to hospital.

Conclusions
PHC HCWs rarely diagnosed chest indrawing pneumonia, and one-third of the patients were lost to follow up leading to a smaller than expected sample and therefore an imprecise CFR. Improving HCW capacity to identify and manage pneumonia, alongside strengthening IMCI implementation, is critical to reducing preventable child deaths in this setting.