Pneumonia in Children: to Win in Battle against the Forgotten Killer

By: Madeleine Ramdhani Jasin, Pediatric Respirologist, Indonesian Pediatric Society 

This has been a continuing battle since ancient times. Pneumonia, or is commonly known as a lung inflammation or “radang paru” in Indonesian, has been described since 400 BC, and it has been progressing over the years in prevalence and mortality. During the 1990s, there were four events of the pandemic related to pneumonia which led to high mortality. Though pneumonia has been around for centuries, this disease is still looming as one of the deadliest infections in children globally, including in Indonesia. Even in surviving children, pneumonia may lead to complications that might disturb the growth and development of our future generation. However, many still have not realized that pneumonia is a preventable disease! Morbidity and mortality of Indonesian children due to pneumonia can be avoided through various measures performed by parents, regulated, and reinforced by the government. 

Pneumonia is defined as inflammation of the lung parenchyma due to pathogenic microorganisms, mostly due to viruses and bacteria, leading to shortness of breath as a result of lack of oxygen in the lungs. Thus, signs and symptoms of pneumonia are characteristic of the pathophysiology, children affected with this disease are breathing faster than normal, show signs of chest muscle retraction, and are lethargic when it gets more severe. Delay in noticing the symptoms will lead to delay in medical intervention and proper treatment, and subsequent mortality. World Health Organization and UNICEF have announced that pneumonia is the leading cause of childhood mortality, more than diarrhea, malaria, and measles. It is reported that one child dies of pneumonia every 39 seconds! In Indonesia, data from the 2018 Basic Health Survey (Riskesdas) shows that the prevalence of pneumonia increased to 2% (from 1.85% in 2013). Data from the Ministry of Health, among toddlers, pneumonia is just behind diarrhea as a cause of mortality in Indonesia. This disease claims more lives of children than any other infectious disease, thus coining the name of pneumonia as the forgotten killer. One death of a child is too many due to this disease, then what is the recipe for how to tackle pneumonia? 

The blueprint of how to tackle childhood pneumonia has been planned by global and national stakeholders, the World Health Organization, and UNICEF, and adopted by the Indonesian Ministry of Health. Nevertheless, the problem is always in the implementation and reinforcement. Pneumonia is a disease that can be reduced in burden by three inter-relating aspects of protection, prevention, also good diagnosis, and treatment. The three trifecta holds the key to winning the battle against childhood pneumonia, yet every aspect has its caveat. 

The first strategy is protecting the children by providing adequate nutrition and improving breastfeeding. Childhood malnutrition is related to higher pneumonia prevalence and is frequently associated with fatal outcomes. Stunting, which has been the subject of intervention for the government, is defined as short in stature due to undernutrition. If a child with stunting is ill with pneumonia, more risk of a fatal outcome is met. The prevalence of stunting children in 2021 is 24.4%, and the government has made a commitment to reduce the prevalence by at least 3% in 2022. If the goal is met, the burden of pneumonia mortality will fall subsequently. Another protection aspect is optimal breastfeeding practices is also a critical factor for reducing pneumonia among infants and young children. The practice of exclusive breastfeeding during the first six months of life and continued breastfeeding until 24 months of age is an important practice that has been studied to reduce pneumonia. Thus, this practice needs to be promoted and educated to mothers, with the provision of medical personnel for optimal benefit to protect children. 

Prevention always holds the key to decreasing the burden of mortality and morbidity of diseases. In childhood pneumonia, prevention lies in increasing immunity against pneumonia-causing pathogens by increasing immunization coverage, reducing risk factors for pneumonia, and increasing access to water sanitation and hygiene. Pneumonia due to viruses and bacteria can be prevented by immunization, and with high coverage to establish herd immunity. In addition to compulsory immunization for children that have been performed in Indonesia, since 2021, the Ministry of Health has added pneumococcal immunization in children which is planned to be nationally implemented in 2022. Streptococcus pneumonia is among the most common bacteria causing childhood pneumonia, thus this measure if reinforced optimally will reduce the burden of the disease. The challenge to the implementation of immunization has been the coverage in the community. From 2012-2019, basic compulsory immunization in children under 5 years old met the target, however, there was decreasing in coverage in 2020-2021, probably related to COVID -19 pandemic which has caused disruption in many aspects, including in healthcare. Reinforcing immunization in children is a big responsibility to be shared among many stakeholders, the Ministry of Health as the decision maker and regulator, the medical community and health care facilities, vaccine manufacturers, professional societies, such as the Indonesian Pediatric Society, and the community groups to continually promote the importance of immunization. Another important measure in prevention is reducing cigarette smoke exposure and air pollution, due to its effect on lung damage leading to the lungs being more prone to infection. The cigarette-free zone as implemented by the Ministry of Health is a good start, 321 cities/districts (62.5%) have implemented a cigarette-free zone in Indonesia, and promoting more cities/districts to join this strategy for better results. 

The third is diagnosis and treatment, by providing easy healthcare access, quality service, and universal healthcare coverage. Prompt diagnosis and timely treatment are critical to impose a better prognosis. Parents or caregivers must be educated on how to recognize signs and symptoms of pneumonia, such as increased respiratory rate, chest muscle retraction, and nasal flare. By recognizing early, parents may take their children early for evaluation of pneumonia, hence medical treatment can start soon. Easy healthcare access reaching farther to the remote area in Indonesia grants for fair distribution of medical personnel and facility. Comprehensive management of ill toddlers or 

Manajemen Terpadu Balita Sakit is used by midwives and nurses, under a doctor’s supervision, to diagnose and treat infectious diseases, one of which is pneumonia, in limited areas. The measures of providing even distribution of medical personnel and facility should be the focus of the government to prevent severe disease and fatality. 

The strategy for winning the battle against pneumonia in children is clear and has an evidence-based approach. However, like many other plans and regulations in Indonesia, the implementation and reinforcement remain a challenging aspect, as well as monitoring and evaluation. Commitment from the government in determining regulations that always push forwards the health of Indonesian children is needed. Investing in immunization and its’ distribution, promoting clean air from cigarette smoke and pollution, encouraging exclusive breastfeeding, and providing access to good nutrition, health care access and facilities are the means to end pneumonia as a childhood silent killer. Other stakeholders, from professional societies such as the Indonesian Pediatric Society, to the community foundations, hold the responsibility to help the implementation of the right policy, control the execution of programs and involve in monitoring as well as evaluation. If one child’s death due to pneumonia is too many, so losing this battle is never an option!

The trifecta to tackle pneumonia (taken from Global action for Pneumonia and Diarrhoea). 

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