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The etiology of acute lower respiratory tract infection (ALRI) was identified in 235 (43.8%) of 537 hospitalized children less than 5 years of age. Clinical evidence of measles was found in 258 (48.0%) patients, of whom 59 had a second viral infection. A viral agent was identified in an additional 121 patients, so that a total of 379 (70.6%) had viral infections. After measles, respiratory syncytial virus was the most common respiratory virus. Bacteremia was noted in 72 children (13.4%), occurring as frequently in children with measles (14.8%) as in those without (12.1%); Haemophilus influenzae and Salmonella typhi were predominant in the former, and H. influenzae, Staphylococcus aureus, and Streptococcus pneumoniae were prominent in the latter. The presence of bacterial antigen in urine was not helpful in identifying bacterial infection. Extrapulmonary and intrapleural complications, concomitant measles, complicated ALRI, female gender, and malnutrition were associated with increased mortality among children with ALRI. The importance of measles immunization, vitamin A supplementation for alleviation of defects associated with malnutrition, and timely antimicrobial therapy is emphasized.

Clinicopathologic correlations for 71 cases of fatal pneumonia in children were determined. The mechanism of death for these patients was multifactorial. Severe pneumonia alone accounted for 11 deaths (15.5%). Pneumonia associated with sepsis occurred in 42 children (59.2%). Heart failure (8.5%), hypovolemia (4.2%), and nosocomial infection (12.6%) were also seen in children with fatal acute lower respiratory tract infection. Extensive consolidation, squamous metaplasia, and hyaline membranes were present in the lungs of these children. Patients with severe disease must receive, in addition to antibiotics for acute episodes, individualized intensive respiratory and supportive care. Since these types of care are not available in poor communities, vaccination against measles and vitamin A supplementation for malnourished children may ameliorate the conditions that appear to predispose these children to severe or fatal disease.

The impact of malnutrition on morbidity and mortality associated with acute respiratory tract infection (ARI) was studied in Filipino children less than 5 years old. Malnutrition measured by weight-for-age Z-scores of less than -3 SD and less than -2 SD from the National Center for Health Statistics median reference population was associated with the following significant relative risks of morbidity: 1.24 (95% confidence interval [CI] = 1.14, 1.34) and 1.14 (95% CI = 1.08, 1.19), respectively, for ARI; and 1.9 (95% CI = 1.46, 2.39) and 1.2 (95% CI = 1.03, 1.47), respectively, for acute lower respiratory tract infection (ALRI). These risk ratios remained significant when adjusted for age, crowding, and parental smoking. Malnourished children with severe ALRI also had a mortality risk two to three times higher than that of healthy children. This risk remained significant even when adjusted for significant predictors of mortality, including clinical complications, concurrent measles, severe infections, and female gender; and for clinical factors, including extent of pneumonic infiltrates, dehydration, and hepatic enlargement. These findings underscore the importance of nutritional intervention in the control of morbidity and mortality among patients with ARI.

The diagnosis and epidemiology of acute respiratory tract infection (ARI) in 199 children less than 5 years old were investigated in Manila. As part of this study, children who were treated at one of two outpatient clinics for cough of less than 3 weeks' duration were studied to test the validity of the use of a respiratory rate (RR) of greater than 50/minute for identifying ARI of a severity necessitating treatment with antibiotics. In the first population, in which 69% of the children had radiologically confirmed pneumonia, the sensitivity of a RR of greater than 50/minute was 54%, the specificity was 84%, the false-positive rate was 16%, and the false-negative rate was 46%. In the second population, in which 29% of the children had pneumonia, the sensitivity and positive predictive values were low. The validity of a RR of greater than 50/minute may vary in populations with different prevalences of ARI.

Histopathologic studies and isolation of virus and bacteria in culture were carried out for 71 children less than 5 years of age with fatal pneumonia. A potential microbial etiology was identified for 61 children (86%): bacteria for 19 (27%), virus for 16 (23%), and virus plus bacteria for 26 (37%). Staphylococcus was the most prevalent pathogen, alone or in combination with other organisms, followed by Pseudomonas aeruginosa. Viral infection may predispose to bacterial infection in some children. A correlation of clinical course, results of cultures, and morphologic changes revealed cofactors that may have contributed to a fatal outcome. Lung abscess, pericarditis, myocarditis, endocarditis, and meningitis were associated with bacterial infection. Many patients in this study had severe bronchopneumonia, with a high prevalence of complications such as abscess (62%), atelectasis (40%), pericarditis (28%), and empyema (7%). Such complications added to multiple infections, measles, and malnutrition contributed to the fatal outcome in these children.