University of Medicine, Mandalay

CLINICO-SOCIAL FACTORS
AND
SEVERITY OF PNEUMONIA IN CHILDREN

A Protocol Submitted for

Degree of Master of Medical Science (Pediatrics)

Khaing Moh Moh Zin

MBBS
2017
 University of Medicine, Mandalay

CLINICO-SOCIAL FACTORS
AND
SEVERITY OF PNEUMONIA IN CHILDREN

Khaing Moh Moh Zin

MBBS
2017
 CONTENTS

Page
LIST OF TABLES iii
LISTS OF FIGURES iv
LIST OF ABBREVIATIONS v
1 INTRODUCTION 1
1.1 Background Information 1
1.2 Justification 2
2 LITERATURE REVIEW 3
2.1 Acute Respiratory Tract Infection (ARI) 3
2.2 Acute Lower Respiratory Tract Infection (ALRI) 4
2.3 Relationship between Clinico-social Factors and
Severity of Pneumonia in Children  5
3 OBJECTIVES 12
3.1 General Objective 12
3.2 Specific Objectives 12
4 METHODOLOGY 13
4.1 Study Design 13
4.2 Study Sites 13
4.3 Study Period 13
4.4 Reference Population 13
4.5 Study Population 13
4.6 Selection Criteria 13
4.7 Sample Size Determination 14
4.8 Detailed Procedure 15
4.9 Data Processing and Analysis 15
4.10 Operational Definitions 15
4.11 Flow Chart 18
5 ETHICAL CONSIDERATIONS 19
6 TIME SCHEDULE 20
7 REFERENCES 21
Appendices 23
I. Pro forma 23
II. Dummy Tables 26
III. Informed Consent (Myanmar and English) 31
IV. WHO/NCHS Normalized Reference Weight-for-height 39
V. Classification of the Severity of Pneumonia 43
VI. Classification of Malnutrition 44
VII. Current EPI immunization schedule in Myanmar 45
VIII. Figures 46
 iii

LISTS OF TABLES

No. Page
1. Frequency distribution of cases according to severity of pneumonia 26
2. Frequency distribution of children with pneumonia according to
socio-demographic factors 26
3. Frequency distribution of children with pneumonia according to
environmental factors 26
4. Frequency distribution of children with pneumonia according to
nutritional factors 27
5. Frequency distribution children with pneumonia according to
immunization status and delay first medical contact 27
6. Relationship between age and severity of pneumonia 27
7. Relationship between sex and severity of pneumonia 27
8. Relationship between mother’s education level and severity of pneumonia 28
9. Relationship between residency and severity of pneumonia 28
10. Relationship between smoking in family members and
severity of pneumonia 28
11. Relationship between exposure to indoor air pollutants and
severity of pneumonia 29
12. Relationship between exclusive breast feeding and severity of pneumonia 29
13. Relationship between malnutrition and severity of pneumonia 29
14. Relationship between immunization status and severity of pneumonia 29
15. Relationship between delay first medical contact and severity of pneumonia 30
 iv

LISTS OF FIGURES

No. Page
1. Baby weighing machine 46
2. Beam type weighing machine 46
3. Pulse oximeter 47
 v

LISTS OF ABBREVIATIONS

ALRI = Acute Lower Respiratory Tract Infections

ARI = Acute Respiratory Tract Infections
AURI = Acute Upper Respiratory Tract Infections
BCG = Bacillus Calmette Guerin
DOH = Department of Health
DPT = Diphtheria, Pertussis and Tetanus
EPI = Expanded Programme of Immunization
ETS = Environmental Tobacco Smoking
GAPP = Global Action Plan for Prevention and Control of Pneumonia
Hep B = Hepatitis B vaccine
Hib = H influrenzae serotype B infection
IAP = Indoor Air Pollution
LRI = Lower Respiratory Tract Infections
OPV = Oral Polio Vaccine
PCV = Pneumococcal conjugate vaccine
PM 2.5 = Particulate matter less than 2.5 micrometer
SD = Standard Deviation
UNICEF = United Nations Children’s Fund
URI = Upper Respiratory Tract Infections
US = United States
WHO = World Health Organization
 1

1 INTRODUCTION

1.1 Background Information

Pneumonia is the single largest infectious cause of death in children

worldwide. Pneumonia killed 920,000 children under the age of 5 in 2015, accounting
for 16% of all deaths of children under five years old. Pneumonia affects children and
families everywhere, but the majority of deaths occur in South-East Asia and sub-
Saharan Africa (WHO, 2016).
In Myanmar, under five mortality survey found that 27% of post neonatal
deaths (aged 1-59 months) were due to pneumonia (DOH, 2013). According to annual
statistical report of Medical Records Department, Mandalay Children Hospital (2015),
ARI constitutes 8 % of total admissions with case fatality rate of 1.5%. Therefore,
prevention of pneumonia is an essential component of a strategy to reduce under five
mortality.
In 2007, WHO and UNICEF integrated Global Action Plan for Prevention and
Control of Pneumonia (GAPP) to accelerate pneumonia control in the context of
integrated interventions for child survival. The goal is to see a drop in deaths from
pneumonia to fewer than 3 children in 1000 live births by 2025. Effective
interventions to reduce pneumonia deaths are available but reach too few children.
More than a million lives could be saved if prevention and treatment interventions
were implemented universally (WHO, 2009).
Savitha et al. made a comparative study between 104 acute lower respiratory
tract infection cases fulfilling WHO criteria for pneumonia in the age group of 1
month to 5yr and 104 healthy control children in the same age group in 2006. They
found that parental illiteracy, lack of exclusive breast feeding, malnutrition, partial
immunization and using smoke producing fuel were significant risk factors for acute
lower respiratory tract infections.
In 2009, the study done by Karalanglin et al. based on factors determining the
outcome of severe pneumonia in 2-60 months children reveled that mother’s
education less than graduation, lack of exclusive breast feeding, incomplete
 2

immunization, cooking with solid fuel, smoking by father and delay first medical
contact were significantly associated with adverse outcome of pneumonia.
In 2016, Kumar et al. made hospital based case series study on 200 ALRI
cases in the age group of 2 months to 5 years for clinical profile and outcome of
ALRI. They found that period of exclusive breast feeding and parental smoking were
significantly associated with severity of pneumonia.
There are many clinico-social factors associated with pneumonia that are
amenable to correct. Therefore, control of reversible clinico-social factors could help
in reducing the severity, morbidity and mortality of pneumonia in children.

1.2 Justification

ARI is one of the most common childhood illness and leading cause of
morbidity and mortality in children under five years of age, worldwide. The majority
of ARI deaths are due to pneumonia. Therefore, pneumonia is a major health problem
of public health in community. There are many clinico-social factors associated with
pneumonia. In order to reduce the burden of disease, a thorough knowledge of
clinico-social factors is necessary.
Among these factors, lack of exclusive breast feeding, malnutrition, incomplete
immunization, mother’s education level, exposure to indoor air pollutants, smoking in
family members and delay first medical contact are reversible factors. Identifying and
effective interventions such as promoting exclusive breastfeeding and adequate
nutrition, expanding vaccine coverage, reducing indoor air pollution and seeking
medical care for a child with suspected pneumonia can help in protection and
prevention of pneumonia.
This study will be conducted to evaluate the relationship between clinico-
social factors and different severity of pneumonia in children. It is aimed that this
study will give some useful information to health care personnel in reducing severity,
morbidity and mortality of pneumonia in under five children.
 3

2 LITERATURE REVIEW

2.1 Acute Respiratory Tract Infection (ARI)

Acute respiratory tract infections (ARI) are classified as upper respiratory tract
infections (URI) or lower respiratory tract infections (LRI). The upper respiratory
tract consists of the airways from the nostrils to the vocal cords in the larynx,
including the paranasal sinuses and the middle ear. The lower respiratory tract covers
the continuation of the airways from the trachea and bronchi to the bronchioles and
the alveoli (WHO, 1994).
WHO suggested that ALRI is responsible for 20% of deaths in under five
children which account for more than 2 million under five children dying of ARI
annually, of which 90% occur in developing countries (Kumar et al., 2016). Control
of ARI is a major problem of public health in developing countries where the immune
systems of children are weak because of malnutrition and infectious diseases (Farhad
et al., 2013).
In 1995, the Department of Health carried out a nationwide under five
mortality survey and the result showed that pneumonia was number one killer of
under five children in Myanmar (DOH, 1995).
In 2013, diseases of post neonatal deaths (age 1 to 59 months) were identified,
ARI ranked first with 27%, other conditions with 18%, diarrhoea and non-
communicable disease third with 15%, injuries with 12%, measles with 6%, malaria
with 4%, meningitis/encephalitis with 3% and pertussis with 1%.
According to annual statistical report of Medical Records Department,
Mandalay Children Hospital, ARI constitute 10 % of total admissions with case
fatality rate of 5 % in 2009 and 8% of total admission with 1.5 % of case fatality rate
in 2015.
 4

2.2 Acute Lower Respiratory Tract Infection (ALRI)

Clinical syndromes included in ALRI are epiglottitis, laryngitis,

laryngotracheitis, bronchitis, bronchiolitis and pneumonia (WHO, 1994). Pneumonia
and bronchiolitis are considered to be the major components of ALRI that account for
the global burden of disease from acute respiratory infections among young children.
Pneumonia is the leading cause of death in children under five years of age, being
responsible for 16% of all deaths in this age category (WHO, 2016).

2.2.1 Pneumonia

Pneumonia is a form of acute respiratory infection that affects the lungs. The
lungs are made up of small sacs called alveoli, which fill with air when a healthy
person breathes. When an individual has pneumonia, the alveoli are filled with pus
and fluid, which makes breathing painful and limits oxygen intake (WHO, 2016).

2.2.2 Classification of the severity of pneumonia (WHO Pocket Book of

Hospital Care for Children, 20013)

For the children between two months and five years of age, pneumonia is
classified as severe pneumonia, pneumonia and no pneumonia on the basis of clinical
features.

Classification Sign or symptom

Severe pneumonia Cough or difficulty in breathing, plus at least one
of the following:
 Oxygen saturation <90 % or central cyanosis
 Severe respiratory distress (e.g. granting, very
severe chest indrawing, head nodding)
 Signs of pneumonia with a general danger sign
( inability to breastfeed or drink, lethargy or
reduced level of consciousness, convulsion)
In addition, some or all of the other signs of
pneumonia may be present.
Pneumonia  Fast breathing
 5

≥ 50 breaths/minutes in a child aged 2-11 months

≥ 40 breaths/minutes in a child aged 1-5 years
and/or
 chest indrawing (i.e. lower chest wall goes in when
the child breathes in)
No pneumonia, cough or  No signs of pneumonia or severe pneumonia
cold

2.3 Relationship between Clinico-social Factors and Severity of

Pneumonia in Children

2.3.1 Socio-demographic factors and severity of pneumonia in children

Age
The hospital based study enrolling ARI among children under five years old
attending Tirikit General Teaching Hospital done by Thamer and Ban in 2006
demonstrated that first year of life was significantly associated with pneumonia
severity. But there was no significant association between age and ALRI severity in a
study done in India aged between 2 months to 5 years for clinical profile and outcome
of ALRTI (Kumar et al., 2016).

Sex
The study done in Brazil among children with pneumonia < 2 years of age
showed that the risk of pneumonia was almost twice as great for boys as girls (Victora
et al., 1994). But, there was no significance between sex and pneumonia severity in a
study done in India aged between 2 months to 5 years for clinical profile and outcome
of ALRTI (Kumar et al., 2016).

Mother’s education level

 6

Mother’s illiteracy was significantly associated with ALRI in a study done in

India for modifiable risk factors for ALRI (Savitha et al., 2007). Parental education
played an important role to differentiate ARI among children where education has
negative impact with ARI. It could be that educated parents were more aware about
their child health, cared for their children properly, knew how to take prevention to
avoid coughing, to reduce spread of infection and subsequently reduce the risk of
ARI, immunized their children properly and gave warm closes to the child if it was
cold (Kazi, 2008).
There was a highly significant association between the mother’s education
level and ARI severity (Thamer & Ban, 2006). The study done on factors determining
the outcome of pneumonia in children shown that mother’s education less than
graduation was also significantly associated with adverse outcome (Karalanglin et al.,
2009).

Residency
The hospital based study enrolling ARI among children under five years old
attending Tirikit General Teaching Hospital done by Thamer and Ban in 2006
demonstrated that rural residency was significantly associated with pneumonia
severity. This may be explained by the fact that cases of severe ARI residing in rural
areas are usually referred to hospital for admission, while less severe cases are usually
treated in primary areas.

2.3.2 Environmental Factors and severity of pneumonia in children

Exposure to indoor air pollutants

Majority of under five children, being young spend most of their time with
their mothers doing household cooking, thus getting more exposed to biomass fuel
pollution and it was a significant environmental risk factor of ALRI (Savitha et al.,
2007).
Indoor Air Pollution (IAP) is a part of the major determinant of childhood
pneumonia in developing countries where solid fuels are used for cooking and
heating. Crop residues, dung, wood, and coal are widely used globally, perhaps
accounting for about half of all fuels used daily to cook meals. Smoke from household
 7

solid fuels is a complex mixture which contains many relevant components from a
toxicologic perspective. Sustained exposure to air pollutants produces chronic
inflammation and then infections might become more severe (Smith et al., 2000).
The exposure to the smoke of mosquito coils pose significant acute and
chronic health risks .Burning of one mosquito coil would release the same amount of
particulate matter <2.5 micrometer in diameter; PM 2.5 mass as burning 75-137
cigarrettes. These submicrometer particles can reach the lower respiratory tract.
Toxicologic effects of mosquito coil smoke on rats include focal deciliation of the
tracheal epithelium, metaplasis of epithelial cells, and morphologic alteration of the
alveolar macrophages (Liu et al., 2003).

Smoking in family members

Environmental tobacco smoking (ETS) is another indoor pollutant that reduces
local defense mechanisms and predisposes children to respiratory illness (Savitha et
al., 2007).
A population-based large-scale cross-sectional survey was conducted over
353,525 individuals to find an association of environmental tobacco smoking (ETS)
exposure with an increased risk of hospital admissions for pneumonia in children
under five years of age in Vietnam covering all residents of 33 communes in Khanh
Hoa Province, the central part of Vietnam. Out of 353,525 individuals, 24,781 (7%)
were aged <5 years. The prevalence of ETS was 70.5% and the period prevalence of
hospital admissions for pneumonia was 2.6%. The study showed that exposure to ETS
was independently associated with hospital admissions for pneumonia.
It is estimated that 28.7% of childhood pneumonia in this community is
attributable to ETS. ETS is the most preventable risk factor for admission to hospital
with pneumonia among children under five years. It indicates a need for smoking
prevention and cessation efforts in order to reduce the prevalence of ETS exposure
among children (Suzuki et al., 2009).
The study done by Kumar et al. on 200 ALRI cases in the age group of 2
months to 5 years for clinical profile and outcome of ALRI in 2016 showed that
parental smoking was significantly associated with severity of pneumonia.

2.3.3 Nutritional Factors and severity of pneumonia in children

 8

Exclusive breastfeeding
Currently, most national and international authorities, including the American
Academy of Pediatrics, American Academy of Family Physicians, WHO and United
Nations Children’s Fund recommend 6 months of exclusive breastfeeding (Chantry
et al., 2006).
In a prospective study in the slums of Dhaka city in Bangladesh, 1,677 infants
were followed up from birth till 12 months of their age by visiting 5 more times for
anthropometric measurements and infant-feeding information. Verbal autopsy, based
on a structured questionnaire, was used for assigning causes to the 180 reported
deaths. Compared to exclusive breast-feeding in the first four months of life, partial or
no breast-feeding was associated with 2.30-fold higher risk of infant deaths and 2.48-
fold higher risk of deaths due to ARI (Arifeen et al., 2001).
Secondary analysis of data from the National Health and Nutrition
Examination Survey III, a nationally representative cross-sectional home survey
conducted from 1988 to 1994 in the United States, was performed on 2277 children
aged 6 to<24 months, revealed statistically significant increased risk for both
pneumonia and recurrent otitis media in those who were fully breastfed for 4 to
<6months compared with >6months.These findings support current recommendations
that infants should receive only breast milk for the first 6 months of life (Chantry et
al., 2006).
High coverage with optimal breastfeeding practices has potentially the single
largest impact on child survival of all preventive intervention. The exclusive
breastfeeding rate in developing countries is only 36% and estimated 34 million infant
are not exclusively breastfed. Breastmilk provides all of the nutrients, vitamins and
minerals an infant needs for growth for the first six months and no other liquid or food
are needed.
Breastmilk carries antibodies form the mother that helps combat disease,
which breastmilk substitutes cannot contain. In addition, breastmilk contains digestive
enzymes which breastmilk substitutes do not contain. In the first six months of life,
non-breastfed infants were 15 times more likely to die from ARI (Benefits of
Breastfeeding, 2012).
 9

In 2006, Thamer and Ban made a hospital based longitudinal study based on
epidemiology of ARI among under five children reveled that there was a highly
statistical significant association between ARI severity and type of feeding. Period of
exclusive breast feeding was significantly associated with severity of pneumonia
(Kumar et al., 2016).

Malnutrition
Malnutrition was the most important risk factor for childhood pneumonia
severe enough for a mother to take her child to hospital. The risk of pneumonia
increased as the value of the Z-score decreased (Fonseca et al., 1996).
Overall malnutrition is associated with a two to three fold increase in mortality
from ALRI. It is well known that malnourished children have defective cell mediated
immunity secondary to thymolymphatic depletion leading to severe gram negative
infections and sepsis. They may also have qualitatively abnormal immunoglobulin,
and impairment of key enzymes involved in bactericidal action of leucocytes (Savitha
et al., 2007).
Malnourished children are at significantly higher risk of suffering from ARI
compared with healthy children. This child malnutrition may be a combined effect of
insufficient and improper food intake, improper treatment and care provided during
and after sickness, lowered immune response and the potential for repeated suffering
of infection from different diseases (Kazi, 2008).
Children with pneumonia and moderate or severe malnutrition are at higher
risk of death than well-nourished children with pneumonia (Chisti et al., 2009). There
was a highly significant association between undernourished children and ARI
severity in under five children (Thamer and Ban, 2006).

WHO Classification of malnutrition

The assessment of nutritional status according to weight for height (or length),
height (or length) for age and oedema is summarized in the following table. Also
shown are the criteria for classifying severe malnutrition as “oedematous”, “severely
wasted” or “severely stunted”. Reference values for weight for height or length are
given in Appendix IV. Children whose weight for height is below −3 SD or less than
70% of the median of the US National Centre for Health Statistics of WHO
 10

International reference values (termed “severely wasted”), or who have symmetrical

oedema involving at least the feet (termed “oedematous malnutrition”) are severely
malnourished.

Classification of malnutrition (WHO Geneva, 1999)

Symmetrical oedema
Weight for height
Height for age
Classification
Moderate malnutrition Severe malnutrition (type)
No Yes
(oedematous malnutrition)
-3 ≤ SD score < -2 < -3 SD score (70%)
(70-79%) (severe wasting)
-3 ≤ SD score < -2 < -3 SD score (85%)
(85-89%) (severe stunting)

2.3.4 Immunization status and severity of pneumonia in children

Infectious diseases are a major cause of morbidity and mortality in children.

One of the most cost effective and easy methods for child survival is immunization.
In May 1974, WHO officially launched a global immunization programme
known as Expanded Programme of Immunization (EPI) to protect all the children of
the world against six vaccine preventable diseases by the year 2000 (Yadav et al.,
2006). In Myanmar, EPI was launched in 1978. OPV and Measles vaccine introduced
in 1987. Hib pentavalent (DPT, Hib, Hep B) vaccine was introduced in 2012 and PCV
was introduced in July 2016. According to EPI in Myanmar, immunization of children
against nine serious but preventable diseases (tuberculosis, diphtheria, pertussis,
tetanus, hepatitis B, H influrenzae serotype B infection, pneumococcal diseases,
poliomyelitis, and measles) has been a cornerstone of the child health care system.
Immunization against Hib, pneumococcous, measles and whooping cough
(pertussis) is the most effective way to prevent pneumonia. Children with no history
of immunization for DPT (diphtheria, pertussis and tetanus) and measles vaccine are
also at high risk with 2.7 times more risk of having ARI (Deb, 1998).
A hospital based observational study was undertaken in one hundred seventy
six under five years old children who attended the pediatric outpatient department
with a history of acute onset of respiratory illness in the period of one month in J. J.
 11

Hospital in Mumbai city to evaluate the morbidity of ARI with regards to

epidemiological factors including immunization.
Acute respiratory tract infections were more commonly seen in non-
immunized and partially immunized patients than in fully immunized patients (Kanchi
& Kakeri, 2005). There was a highly significant association between immunization
status and ARI severity in under five children (Thamer and Ban, 2006).

2.3.5 Delay first medical contact and severity of pneumonia in children

It is important for caregivers to seek appropriate care for a child with

suspected pneumonia. Appropriate care, as defined by WHO and UNICEF includes
providers that can correctly diagnosed and treat pneumonia, such as hospitals, health
centres, dispensaries, community health workers, maternal and child health clinics,
outreach clinics, and physicians’ private offices.
In 2009, the study done by Karalanglin et al. based on factors determining the
outcome of severe pneumonia in 2-60 months children reveled that delay first
medical contact was significantly associated with adverse outcome of pneumonia.
 12

3 OBJECTIVES

3.1 General Objective

To study the clinico-social factors and severity of pneumonia in children

3.2 Specific Objectives

1. To describe the severity of pneumonia in children

2. To describe the socio-demographic factors in children with pneumonia
3. To describe the environmental factors in children with pneumonia
4. To describe the nutritional factors in children with pneumonia
5. To describe the immunization status and delay first medical contact in children
with pneumonia
6. To determine the relationship between clinico-social factors and severity of
pneumonia in children
 13

4 METHODOLOGY

4.1 Study Design

Hospital based cross-sectional descriptive study

4.2 Study Site

Medical Units I, II and III at 550 Bedded Mandalay Children Hospital (MCH)

4.3 Study Period

One year from 1st January 2018 to 31st December 2018

4.4 Reference Population

Children with pneumonia

4.5 Study Population

Children aged 2 months to 5 years hospitalized with pneumonia at Medical

Units I, II and III of 550 Bedded Mandalay Children Hospital

4.6 Selection Criteria

4.6.1 Inclusion criteria

2 months to 5 years old children hospitalized with pneumonia

 14

4.6.2 Exclusion criteria

1. Children with known congenital heart diseases

2. Known syndromic babies (e.g. Down syndrome, Turner syndrome)
3. Children with known neuromuscular disorders (e.g. Cerebral palsy, spinal
mascular atrophy, myasthenia gravis)

4.7 Sample Size Determination

4.7.1 Sample size calculation

Sample size is calculated by estimating the population proportion

(prevalence) with specified absolute precision.

(z (1-α/2))2 p (1-p)
Sample size (n) =
d2

Anticipated proportion (p) of very severe pneumonia = 21 % = 0.21 (Reference:

Kumar et al., 2016)
d = 5% = 0.05 (assumption)
α = 0.05 (set value)
z (1-α/2) = 1.96 (from z table)
n = 255
In this study, minimal required sample size is 255.
Therefore, 260 of samples will be collected.

4.7.2 Sampling procedure

From children aged 2 months to 5 years with pneumonia, 26 children per

month will be collected for the first 10 months and 2 months will be reserved. The
first 26 children with pneumonia admitted to Medical Units of 550 Bedded Mandalay
Children Hospital on admission days in every month according to inclusion and
exclusion criteria during the study period will be selected.
 15

4.8 Detailed Procedure

This study will be conducted in children aged between 2 months to 5years

with pneumonia that fulfill the selection criteria attending at 550 bedded Mandalay
Children Hospital during the study period. The written informed consent will be
obtained from the parents or guardians of the children after explaining detailed
procedure and nature of the study. History taking, thorough physical examination and
measurement of weight and height will be done.
Assessment of pneumonia severity will be done and categorized into
pneumonia and severe pneumonia according to WHO Pocket Book of Hospital Care
for Children, 2013. The clinico-social factors will be collected by interview method,
using the pre-structured questionnaires.
The parents of the child or the guardians will be interviewed by the researcher
herself to get the information. History of immunization will be elicited from parents
and guardians and verified by checking the written document wherever available.

4.9 Data Processing and Analysis

Data will be collected by using pro forma. Data entry will be done by using
spread sheet. Data summarization for description will be done by showing frequency
distribution tables. In this study, Chi square test will be applied to analyze categorical
data and the p value of less than 0.05 will be considered statistically significant.

4.10 Operational Definitions

Clinico-social factors
Socio-demographic factors, environmental factors, nutritional factors,
immunization status and delay first medical contact

Delay first medical contact

Medical contact (such as hospitals, health centres, dispensaries, community
health workers, maternal and child health clinics, outreach clinics, and physicians’
private offices that can provide correct diagnosis and treat pneumonia) >3 days of
onset of illness
 16

Environmental factors
Smoking in family members and cooking with solid fuel

Exclusive breast feeding

The child had never been given any food and liquid other than breast milk up
to 6 months of age.

Immunization status

Complete for age

If he/she had received all vaccinations due for his/her age according to
EPI

Incomplete for age

If he/she had not received all vaccinations due for his/her age
according to EPI

Indoor air pollutants

Smoke from burning of crop residues, dung, wood, coal and mosquito coil

Malnutrition
Weight for height < - 2 standard deviation

Nutritional factors
Exclusive breast feeding and malnutrition

Pneumonia
Cough or difficulty in breathing, plus
 Fast breathing
≥ 50 breaths/minutes in a child aged 2-11 months
≥ 40 breaths/minutes in a child aged 1-5 years and/or
 chest indrawing (i.e. lower chest wall goes in when the child breathes in)
 17

Residency

Rural
Villages

Urban
Wards

Severe pneumonia
Cough or difficulty in breathing, plus at least one of the following:
 Oxygen saturation <90 % or central cyanosis
 Severe respiratory distress (e.g. granting, very severe chest indrawing, head
nodding)
 Signs of pneumonia with a general danger sign
( inability to breastfeed or drink, lethargy or reduced level of consciousness,
convulsion)
In addition, some or all of the other signs of pneumonia may be present.

Socio-demographic factors
Age, sex, mother’s education level and residency
 18

4.11 Flow Chart

Children aged between 2 months to five years with pneumonia

Exclude according to exclusion

criteria

Informed consent
nnnnnnnnnnnnnnnnnn

Assessment of severity of
Pneumonia (pneumonia and
severe pneumonia) according to
WHO Pocket Book of Hospital
Care for Children, 2013

Data collection of clinico-social

factors (Age, sex, mother’s
education level, residency,
exposure to indoor air pollutants,
smoking in family members,
exclusive breast feeding,
malnutrition, immunization status
and delay first medical contact)

Relationship between severity of pneumonia and clinico-social

factors

Data Processing and Analysis

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5 ETHICAL CONSIDERATIONS

Necessary information will be explained to the parents or guardian before they

give consent to participate in the research. The decision to take part or not in the study
will be completely their own without any form of intimidation, inducement or undue
influence. The participants also have the right to withdraw their child from the
research at any time without in any way affecting the medical care of the child.
Written informed consent of the parents/guardians will be obtained after
thorough explanation of the purpose of the study. The study will be done under
supervision of a well-experienced pediatrician. There will be neither charge nor
incentive for participant. No new drugs will be administered and no treatment will be
restricted for the purpose of study. The results of the study will be used only for the
health care and research purpose.
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Mar       

2019
Feb          
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2018 Jun          
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6. TIME SCHEDULE

Jan          
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Sep          
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2017

Jul          
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Data processing analysis
Protocol assessment
Protocol writing

Data collection

Report writing
Activities

5
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7 REFERENCES

Arifeen, S, Black, RE, Antelman, G, Baqui, A, Caulfield, L & Becker, S 2001,

‘Exclusive Breastfeeding Reduces Acute Respiratory Infection and Diarrhea
Deaths Among Infants in Dhaka Slums’, American Academy of Pediatrics
vol.108,no.4, pp. 67-69.
Chantry, CJ, Howard, CR & Auinger, P 2006, ‘Full Breastfeeding Duration and
Associated Decrease in Respiratory Tract Infection in US Children’, Pediatrics
vol.117, no.2, pp. 425-432.
Chisti, MJ, TEbruegge, M, Vincnte, SL, Graham, SM, & Duke, T 2009, ‘Pneumonia
in severely malnourished children in developing countries’,Tropical Medicine
& International Health,vol 14(10),pp. 1173-1189.
Deb, SK 1998, ‘ Acute respiratory disease survey in Tripura in case of children below
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and Practice of Mother Regarding Acute Respiratory Tract Infection in
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accessed 21 Oct 2010.
 22

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‘Clinical profile and outcome of acute lower respiratory tract infection in
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 23

APPENDICES

I. Pro forma

I. Title CLINICO-SOCIAL FACTORS AND SEVERITY OF

PNEUMONIA IN CHILDREN

Code No. Date.

II. Personal Identification

(1) Age
(2) Sex
(3) Weight
(4) Height
(5) Weight for height

III. Assessment of severity of pneumonia according to WHO Pocket Book of

Hospital Care for Children, 2013

Yes No
(1) Fever
(2) Cough or difficulty in breathing
(3) Respiratory rate ……….rate/min
(4) Fast breathing
(5) Chest indrawing
(6) Central cyanosis
(7) Oxygen saturation on pulse oximetry ………..%
(8) Severe respiratory distress
- granting
- Very severe chest indrawing
- Head nodding
 24

(9) Danger sign - Inability to breastfeed or drink

- Lethargy
- Reduced level of consciousness
- Convulsion

IV. Classification of severity of pneumonia according to WHO Pocket Book of

Hospital Care for Children, 2013
Severe pneumonia
Pneumonia

V. Data collection of clinico-social factors

(1) Socio-demographic factors

Mother’s education level - Primary school and below

- Middle and high school
- University and above
Residency - Urban
- Rural

(2) Environmental Factors

Smoking in family members - Present

- Absent
Exposure to indoor air pollutants - Present
- Absent
(3) Nutritional Factors

Exclusive breast feeding - Present

- Absent
Malnutrition - Present
- Absent
 25

(4) Immunization Status

Complete
Incomplete

(5) Delay first-medical contact

Present
Absent
 26

II. Dummy Tables

Table 1. Frequency distribution of cases according to severity of pneumonia

Cases No Percent
Severe pneumonia
Pneumonia
Total

Table 2. Frequency distribution of children with pneumonia according to socio-

demographic factors
Socio-demographic factors No %
Age 2-12 months
>12-60 months
Sex Male
Female
Mother’s education Primary school and
level below
Middle and high
school
University and
above
Residency Urban
Rural

Table 3. Frequency distribution of children with pneumonia according to

environmental factors
Environmental factors No %
Smoking in family Present
Absent
members
Exposure to indoor Present
Absent
air pollutants

Table 4. Frequency distribution of children with pneumonia according to nutritional

factors
Nutritional factors No %
Exclusive breast Present
Absent
feeding
Malnutrition Present
 27

Absent

Table 5. Frequency distribution children with pneumonia according to immunization

status and delay first medical contact
Factors No %
Immunization Complete
Incomplete
status
Delay first medical Present
Absent
contact

Table 6. Relationship between age and severity of pneumonia

Age Severe pneumonia Pneumonia Total
No % No % No %
2-12 months
>12-60 months
Total
X2 = p=

Table 7. Relationship between sex and severity of pneumonia

Sex Severe pneumonia Pneumonia Total
No % No % No %
Male
Femle
Total
X2 = p=
 28

Table 8. Relationship between mother’s education level and severity of pneumonia

Mother’s education Severe pneumonia Pneumonia Total
level No % No % No %
Primary school and
below
Middle and high
school
University and
above
Total
X2 = p=

Table 9. Relationship between residency and severity of pneumonia

Residency Severe pneumonia Pneumonia Total
No % No % No %
Urban
Rural
Total
X2 = p=

Table 10. Relationship between smoking in family members and severity of

pneumonia
Smoking in family Severe pneumonia Pneumonia Total
members No % No % No %
Present
Absent
Total
X2 = p=

Table 11. Relationship between exposure to indoor air pollutants and severity of
pneumonia
Exposure to indoor Severe pneumonia Pneumonia Total
air pollutants No % No % No %
Present
Absent
 29

Total
X2 = p=

Table 12. Relationship between exclusive breast feeding and severity of pneumonia
Exclusive breast Severe pneumonia Pneumonia Total
feeding No % No % No %
Present
Absent
Total
X2 = p=

Table 13. Relationship between malnutrition and severity of pneumonia

Malnutrition Severe pneumonia Pneumonia Total
No % No % No %
Present
Absent
Total
X2 = p=

Table 14. Relationship between immunization status and severity of pneumonia

Immunization Severe pneumonia Pneumonia Total
status No % No % No %
Complete
Incomplete
Total
X2 = p=

Table 15. Relationship between delay first medical contact and severity of
pneumonia
Delay first medical Severe pneumonia Pneumonia Total
contact No % No % No %
Present
Absent
Total
X2 = p=
 30

III. Informed Consent (Myanmar & English)

သု ေတသနတြင္ ပါ၀င္ရန္ သေဘာတူ ညီခ်က္ ေပးျခင္း

ရက္စြဲ။
_______________
(က) သု ေတသနႏွင့္ပတ္သက္ေသာ အခ်က္အ လက္မ်ား

(၁) သု ေတသနဧ။္ အမည္

သု ေတသန၏အမည္မွာ အဆု တ္ေရာင္ေရာဂါရွိေသာ ကေလးမ်ား၏ က်န္းမာေရးႏွင့္ လူ မွုေရးဆို င္ရာ
အခ်က္အ လက္မ်ား ႏွင့္ အဆု တ္ေရာင္ေရာဂါ၏ ျပင္းထန္မႈကို ေလ့ လာျခင္းျဖစ္ပါသည္။

(၂) သု ေတသနျပဳ လု ပ္သူ

သု ေတသနကို ျပဳလု ပ္သူမွာ ေဆးတကၠသို လ္ မႏၱေလး၊ ကေလးက်န္းမာပညာဌာန မွ ဘြဲ႕လြန္
ေက်ာင္းသူ ေဒါက္တ ာခို င္မို့မို့ ဇင္ ျဖစ္ပါသည္။

(၃) သု ေတသန ျပဳလု ပ္မည္ ့ အဖြဲ႕ အစည္း

သု ေတသနကို ေဆးတကၠသို လ္ မႏၱေလး၊ ကေလးက်န္းမာ ပညာဌာနမွ ဦးစီးျပဳလု ပ္မည္ ျဖစ္ပါသည္။

(၄) နိဒါန္း
သု ေတသနမွာ အသက္၂လမွ ၅ႏွစ္ၾကားအရြယ္ရွိ အဆု တ္ေရာင္ေရာဂါရွိေသာ ကေလးမ်ား၏ က်န္း
မာေရးႏွင့္ လူ မွုေရးဆို င္ရာ အခ်က္အ လက္မ်ားႏွင့္ အဆု တ္ေရာင္ေရာဂါ၏ ျပင္းထန္မႈကု ိ ေလ့ လာေသာ
သု ေတသနျဖစ္သည္။

(၅) သု ေတသနဧ။္ ရည္႐ြယ္ ခ်က္ မ်ား

အသက္၂လမွ ၅ႏွစ္ၾကားအရြယ္ရွိ အဆု တ္ေရာင္ေရာဂါရွိေသာ ကေလးမ်ား၏ က်န္းမာေရးႏွင့္ လူ
မွုေရးဆို င္ရာ အခ်က္အ လက္မ်ားႏွင့္ အဆု တ္ေရာင္ေရာဂါ၏ ျပင္းထန္မႈ ဆက္စပ္ပုံကု ိ ေလ့ လာျခင္းျဖစ္သည္။
(၆) သု ေတသနဧ။္ နည္းစနစ္
သု ေတသန နည္းစနစ္မွာ ေဆးရံ ု အေျချပဳ သရု ပ္ေဖာ္ သု ေတသနနည္း ျဖစ္ပါသည္။

(၇) ပါဝင္မည္ ့ သူ မ်ားႏွင္ ့ ေ႐ြ းခ်ယ္ မွဳ

သု ေတသနတြင္ အသက္၂လမွ၅ႏွစ္ၾကားအရြယ္ရွိ အဆု တ္ေရာင္ေရာဂါရွိေသာ ကေလးမ်ား ပါ၀င္မည္
ျဖစ္ပါသည္။

(၈) လု ပ္ေဆာင္မည္ ့ လု ပ္ငန္းစဥ္မ်ား

သု ေတသနတြင္ ပါ၀င္ရန္ အခ်က္အ လက္မ်ားႏွင့္ ကို က္ညီေသာ အသက္၂လမွ ၅ ႏွစ္ၾကား အဆု တ္ေရာ
င္ေရာဂါရိွေသာ ကေလးမ်ားကို ေရြးခ်ယ္ပါမည္။ မိဘ (သို ႔မဟု တ္) အု ပ္ထိန္းသူ အား သု ေတသန အေၾကာင္း ရွင္း
လင္းေျပာျပၿပီးေနာက္ သေဘာတူ ညီခ်က္ ရယူ ပါမည္။ ထို ႔ေနာက္ ကေလး၏ေရာဂါရာဇ၀င္ကို စစ္ေဆးေ
 31

မးျမန္းျခင္း၊ စမ္းသပ္ျခင္း၊ ကို ယ္အေ လးခ်ိန္ခ်ိန္ျခင္း၊ အရပ္တိုင္းျခင္း၊ ေရာဂါႏွင့္သက္ဆိုင္ေသာ က်န္းမာေရးႏွင့္ လူ

မွုေရးဆို င္ရာ အခ်က္အ လက္မ်ား ေမးျမန္းျခင္း စသည္တို႕ ပါ၀င္မည္ျဖစ္ပါသည္။

(၉) သု ေတသန ျပဳ လု ပ္မည္ ့ ကာလ

ဤသု ေတသနအတြက္ ပါ၀င္သူတစ္ဦးအတြက္ ၾကာျမင့္ခ်ိန္ကာလ မိနစ္ (၂၀) မွ မိနစ္ (၄၀) အတြင္း
သာ ၾကာမည္ျဖစ္ပါသည္။

(၁၀) ေဘးထြက္ ဆို းက်ိဳးမ်ား

ထိခို က္နစ္နာမွဳ ၊ ေဘးထြက္ဆိုးက်ိဳးမ်ား မရွိပါ။

(၁၁) သု ေတသနမွ ရရွိမည္ ့ အက်ိဳးေက်းဇူ းမ်ား

သု ေတသနမွရရွိေသာ အခ်က္အ လက္မ်ားသည္ အဆု တ္ေရာင္ေရာဂါ၏ ျပင္းထန္မွုကို ကာကြယ္ျခင္း၊ ေ
ရာဂါျဖစ္ပြါးမွုႏွင့္ ေသဆံ ု းမွု တို့ကို ေလွ်ာ့ ခ်ျခင္းကု ိ အေထာက္ကူျပဳႏို င္မည္ျဖစ္ပါသည္။

(၁၂) ပါဝင္ သူ လူ နာမ်ား ရရွိမည္ ့ အက်ိဳး ေက်းဇူ း မ်ား

သု ေတသနတြင္ ပါ၀င္ကူညီရန္ သေဘာတူ လက္ခံ သည့္ လူ နာမ်ားအေနျဖင့္ ေငြေရးေၾကးေရးအက်ိုး
အျမတ္ တစ္စံ ု တစ္ရာရရွိမည္မဟု တ္သကဲ့ သို့ သု ေတသနတြင္ ပါ၀င္ျခင္းမရွိလွ်င္လဲ ေဆး၀ါးကု သမွုတြင္ မည္သို့မွ ် ထိခို
က္ေစမည္ မဟု တ္္ပါ္။

(၁၃) သု ေတသန မွရရွိမည့္ ရလဒ္မ်ား

သု ေတသနမွ ရရွိမည့္ ရလဒ္မ်ားမွာ အဆု တ္ေရာင္ေရာဂါရွိေသာ ကေလးမ်ား၏ က်န္းမာေရးႏွင့္ လူ
မွုေရးဆို င္ရာ အခ်က္အ လက္မ်ားသည္ အဆု တ္ေရာင္ေရာဂါျပင္းထန္မွုအေပၚ သက္ေရာက္မွုရွိပံ ု ကို ေလ့ လာ သိရွိႏို င္မ
ည္ ျဖစ္ပါသည္။

(၁၄) သု ေတသန ရလဒ္ မ်ား ထိန္းသိမ္းမွဳ

သု ေတသနရလဒ္မ်ားကို ပါ၀င္သူတို ႕၏ ကို ယ္ေရးကို ယ္တ ာ အခ်က္အ လက္မ်ား အမည္ေဖာ္ျပျခင္း မရွိဘဲ ကု ဒ္နံ ပါတ္စ
နစ္ျဖင့္ေသခ်ာစြာ သိမ္းဆည္းထားမည္ ျဖစ္ပါသည္။

(၁၅) သု ေတသန ရလဒ္မ်ားျဖန္႔ေဝမွဳ

အေျဖရလဒ္မ်ားကို ကု သမွဳေပးေသာ တာ၀န္ခံ ဆရာ၀န္အား အသိေပးမည္ျဖစ္ျပီး လူ နာမွ သိလို လွ်င္လ
ည္းေျပာျပပါမည္။အေျဖရလဒ္မ်ားကို လွ်ိဳ႕၀ွက္ထ ားမည္ျဖစ္ၿပီး သု ေတသန ဆို င္ရာ ေဆြးေႏြးတင္ျပ
ခ်က္မ်ားႏွင့္ ေဆးပညာ ဂ်ာနယ္မ်ားတြ င္သာ အသုံ းျပဳပါမည္။

(၁၆) ျငင္းပယ္ႏို င္ခြင္ ့

 32

ဤသု ေတသနလု ပ္င န္းတြင္ပါ၀င္ရန္ မိမိသေဘာအေလ်ာက္ လြတ္လပ္စြာ ဆုံ းျဖတ္ႏို င္ ပါသည္။ သု ေတသန
လု ပ္င န္းမွ မိမိသေဘာအေလ်ာက္ မည္သ ည့္အခ်ိန္တြင္မဆို ႏွဳတ္ထြ က္ခြင့္ရွိပါသည္။ သု ေတသနလု ပ္င န္းတြင္ မပါ၀င္ေသာ္လည္း
လူ နာ၏ က်န္းမာေရး ေစာင့္ေရွာက္မွဳအား မထိခို က္ေစပါ။

(၁၇) ဆက္သြယ္ ေမးျမန္းႏို င္သူ

မိဘ (သို ႔မဟု တ္) အု ပ္ထိန္းသူ သည္ ဤသု ေတသနႏွင့္ပတ္သတ္၍ မရွင္းလင္းသည္မ်ားရွိပါက ကြ်န္မေဒါက္တာ
ခို င္မို႔မို ႔ဇင္၊ ဘြဲ႕လြန္ေက်ာင္းသူ ၊ ကေလးက်န္းမာပညာဌာန ၊ ေဆးတကၠသို လ္ မႏၲ ေလး ၊ ဖု န္းနံ ပါတ္ ၀၉

-၄၀၁၅၁၇၂၉၃ ကို ဆက္သြယ္ ေမးျမန္းႏို င္ပါသည္။

 33

(ခ) သေဘာတူ ညီခ်က္ပုံစံ

ကြ်န္ေတာ္ /ကြ်န္မသည္ အထက္ပါ သေဘာတူ ညီမွဳ ပုံ စံ ကို ဖတ္ရွဳၿပီးျဖစ္ပါသည္။ မရွင္းလင္းသည္ မ်ား
ကို လည္း သု ေတသနျပဳသူ ႏွင့္ နားလည္သ ည္အ ထိ ေဆြးေႏြးၿပီးျဖစ္သည္။ ဤသေဘာတူ ညီခ်က္မွာ မိမိဆႏၵအလ်ာ
က္ သေဘာတူ ခြင့္ျပဳျခင္း ျဖစ္ပါသည္။ သု ေတသနႏွင့္ပတ္သက္သ ည့္ ရည္ရြယ္ခ်က္မ်ား၊ လု ပ္င န္းစဥ္မ်ား၊ အက်ိဳးေက်းဇူ း
မ်ားကို လည္း ေကာင္းစြာသိရွိၿပီး ျဖစ္ပါသည္။ ေမးျမန္းလို သည္မ်ားရွိပါက သု ေတသနျပဳသူ ကို ေခၚယူ ေမးျ
မန္းႏို င္သည္ကိုလည္း သိရွိပါသည္။ ေမးျမန္းခြင့္လည္းရရွိပါသည္။ သိလို သည္မ်ားကို ေမးျမန္းၿပီးလည္းျဖစ္ပါသ
ည္။ ေမးျမန္းသည္မ်ားကို လည္း သု ေတသနျပဳသူ က ေကာင္းစြာနားလည္သေဘာေပါက္သည္အ ထိ ေျဖၾကားၿ
ပီးျဖစ္ပါသည္။ အထက္ အေၾကာင္းအရာမ်ား အားလုံ းကို ေကာင္းစြာသိရွိနားလည္သေဘာေပါက္ၿပီး ပါ၀င္မွဳကို
မိဘ (သို ႔မဟု တ္) အု ပ္ထိမ္းသူ ၏ သေဘာအေလ်ာက္ ခြင့္ျပဳျခင္း ျဖစ္ပါသည္။

သေဘာတူ ညီခ်က္ေပးသူ
လက္မွတ္ ------------------------------
အမည္ ------------------------------
ႏို င္ငံ သားစီစစ္ေရးကဒ္ ------------------------------ ၀ဲလက္မ လက္ေဗြ
ေနရပ္ ------------------------------ (စာမတတ္သူအတြက္ )

အသိသက္ေသ
လက္မွတ္ ------------------------------
အမည္ ------------------------------
ရာထူ း ------------------------------
ဌာန ------------------------------

သု ေတသနျပဳလု ပ္သူ
လက္မွတ္ ------------------------------
အမည္ ေဒါက္တ ာ ခို င္မို႔မို ႔ဇင္

(ဂ)သု ေတသနျပဳသူ ၏ခံ ၀န္ခ်က္

သု ေတသနျပဳသူ သည္ သု ေတသနႏွင့္ ပတ္သက္သ ည့္ ဆို းက်ိဳး၊ ေကာင္းက်ိဳးမ်ားကို သု ေတသန တြင္
ပါ၀င္သည့္ လူ မ်ားအား ေမးျမန္းခြင့္ေပးၿပီး ၄င္းတို ႔ေကာင္းစြာ နားလည္သေ ဘာေပါက္သ ည္အ ထိ ဖတ္ၾကားၿပီး
ေျဖၾကားၿပီး ျဖစ္ပါသည္။ သိရွိလို သည့္ အျခားေသာ အခ်က္အ လက္မ်ားကို လည္း ပါ၀င္သူမ်ား ေကာင္းစြာ နားလ
ည္ သည္အ ထိ ေျဖၾကားၿပီးျဖစ္ပါသည္။

လက္မွတ္ ------------------------------ ဖု န္း - ၀၉-၄၀၁၅၁၇၂၉၃

ေဒါက္တ ာ ခို င္မို႔မို ႔ဇင္ အီးေမးလ္ …mohmohzin87@gmail.com

(A) Informed consent form

1. Title of research
clinic-social factors and severity of pneumonia in children

2. Researcher
Dr Khaing Moh Moh Zin, Post graduate student, Department of Pediatrics,
University of Medicine , Mandalay

3. Organization
 34

Department of Pediatrics, University of Medicine, Mandalay

4. Introduction
To study the clinico-social factors and severity of pneumonia in children aged
between 2 months to 5years

5. Purposes of this study

This study is conducted to compare the relationship between clinico-social
factors and severity of pneumonia in children with pneumonia aged between 2
months to 5years

6. Research design
Hospital based cross-sectional descriptive study

7. Selection criteria
Children aged 2 months to 5 years hospitalized with pneumonia at Paediatric
Unit Units I, II and III 550 Bedded Mandalay Children Hospital will be included.

8. Procedures
This study will be conducted in children aged between 2 months to 5years
with pneumonia that fulfill the selection criteria attending at 550 bedded Mandalay
Children Hospital during the study period. The written informed consent will be
obtained from the parents or guardians of the children after explaining detailed
procedure and nature of the study. History taking, thorough physical examination and
measurement of weight and height will be done. The clinico-social factors will be
collected by interview method, using the pre-structured questionnaires.

9. Duration of the study

Nearly 20 to 40 min for each participant.

10. Potential risks of participants

There will be no serious risks or any other complications.

11. Potential benefits of the study

 35

By participating in this study, there will be able to give information for

protection of severity of pneumonia and reduction of morbidity, and mortality of
pneumonia.

12. Incentives
There will be no extra cost and no financial gain for the participant by
participating in this research study.

13. The result of the study

The result is expected to find out the effect of clinic-social factors on
pneumonia severity.

14. Confidentiality
The participant’s name will never be expressed and coding system will be
used instead. The data from this research will be kept confidentially and will be used
only for research purpose.

15. Sharing of the results

The results will be informed to the attending doctor and the patient if he/she
wants to know. The results will be disclosed only in the educational discussion and
presentation. These data will not be published in public news journals except medical
journals.

16. Right to refuse

The participants or parents can decide independently whether to participate in
this research or not by themselves. Although the participant or parents do not
participate in this study, it will have no effect on the treatment that they are receiving.
Moreover, the participants can withdraw from this study at any time if the parents
wish to do so.

17. Who to contact

The parents or guardians may ask any time if they have any question about
the research and they may contact me: Dr Khaing Moh Moh Zin, Post graduate
 36

student, Department of Pediatrics, University of Medicine, Mandalay, Phone 09-

401517293.
 37

(B) Patient consent form

I have read this consent form. I have already discussed it with the investigator
to my satisfaction. I understand that my permission is voluntary. I know enough
about the purpose, methods, risks and possible benefits of the study. I know that I
can call the investigator if I have any question. I have a chance to ask questions. I
feel that all of my questions have been answered to my satisfaction.
I was well informed about the research. I understand the procedure of research
well. I consent voluntarily for my child/ my relative participation as participant in this
research.

Signature of patient or guardian

Finger print of left thumb
(For illiterate person)
Name …………………
Identification Card ………………….
Address …………………
Signature of witness
Name …………………
Rank …………………
Department …………………
Signature of researcher
Name Dr……………..

(C) Statement by researcher / person taking consent

I have accurately read out the information sheet to the potential participant /
parent of the potential participant. In addition to information in this consent form, I
have offered an opportunity for further explanation of the risks and discomforts,
which are or may be associated with this study. I also answered any further questions
relating to it.

Signature ………. Hand phone 09-401517293

Dr Khaing Moh Moh Zin email…mohmohzin87@gmail.com
 38

IV. WHO/NCHS Normalized Reference Weight-for-height

39
40
41
 42

V. Classification of the Severity of pneumonia (WHO Pocket Book of

Hospital Care for Children, 20013)

Classification Sign or symptom

Severe pneumonia Cough or difficulty in breathing, plus at least one
of the following:
 Oxygen saturation <90 % or central cyanosis
 Severe respiratory distress (e.g. granting, very
severe chest indrawing, head nodding)
 Signs of pneumonia with a general danger sign
( inability to breastfeed or drink, lethargy or
reduced level of consciousness, convulsion)
In addition, some or all of the other signs of
pneumonia may be present.
Pneumonia  Fast breathing
≥ 50 breaths/minutes in a child aged 2-11 months
≥ 40 breaths/minutes in a child aged 1-5 years
and/or
 chest indrawing
No pneumonia, cough or  No signs of pneumonia or severe pneumonia
cold

VI. Classification of Malnutrition (WHO Geneva, 1999)

 43

Classification
Moderate malnutrition Severe malnutrition (type)
Symmetrical oedema No Yes
(oedematous malnutrition)
Weight for height -3 ≤ SD score < -2 < -3 SD score (70%)
(70-79%) (severe wasting)
Height for age -3 ≤ SD score < -2 < -3 SD score (85%)
(85-89%) (severe stunting)

VII. Current EPI Immunization Schedule in Myanmar

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 44

&uf &uf uf
tonf;a&mif tom;0g (bD) arG;p
bDpD*sD arG;p^(2)v
qHkqdkY? Muufn§m? yxr (2)v
'kwd, (4)v
ar;cdkif? tonf;a&mif tom;0g
wwd, (6)v
(bD)? OD;aESmuf
tajr§;a&mif? (ig;rsKd;pyf
umuG,faq;)
jyif;xef tqkwfa&mif yxr (2)v
(yDpDAD)
jyif;xef tqkwfa&mif 'kwd, (4)v
(yDpDAD)
jyif;xef tqkwfa&mif wwd, (6)v
(yDpDAD)
ydkvD,dk yxr (2)v
ydkvD,dk 'kwd, (4)v
ydkvD,dkumuG,faq;xdk;aq; (4)v
ydkvD,dk wwd, (6)v
0ufouf? *sdKufodk; (9)v
0ufouf (1)ESpfcGJ
 45

VIII. Figures

Figure 1. Baby weighing machine

Figure 2. Beam type weighing machine

 46

Figure 3. Pulse oximeter