The World Health Organisation's (WHO) guidelines for treatment of pneumonia in children under one year in Africa are inadequate and need revision, conclude authors of an Article published in this week's edition of TheLancet.

Lisa McNally, Centre for International Health and Development, Institute of Child Health, University College London, UK and colleagues from University of KwaZulu-Natal, South Africa, measured predictors of treatment failure and causes of non-responsive pneumonia in 358 children under five years old admitted to hospital with severe pneumonia in Durban, South Africa.

Each child was treated with a standard antimicrobial regimen of benzylpenicillin and gentamicin, plus a high dose of trimethoprim-sulfamethoxazole for infants under one year, as per the current WHO guidelines. However, these guidelines were published before the HIV pandemic swept through Africa.

Despite receiving these drugs 43% of the children under one (who represented 70 per cent of the study) had failed treatment by 48 hours, and a further 6% failed subsequently. Rates of treatment failure were higher in infants who were HIV infected or HIV exposed, uninfected. Polymicrobial infections were also found to be an important factor in treatment failure and were found in 70% of children investigated for treatment failure, irrespective of HIV status.

The authors say: "Polymicrobial disease is a key predictor of treatment failure and there is a need for rapid low cost diagnostic methods to assist clinicians."

Dr McNally and her team also raise the issue of the increasing importance of HIV-exposed yet uninfected children as a public health concern. Such children, who are born to HIV infected mothers yet have not contracted the disease, still have weaker immune systems during the first year of life - a possible cause for this is reduced transplacental transfer of protective antibodies to the foetus during pregnancy.

Thus whilst the widespread roll-out of prevention of mother to child HIV transmission strategies will reduce the number of pneumonia infected children admitted to hospital, the raised risk in HIV-exposed, uninfected children will assume increasing importance.

The authors conclude: "For children younger than one year, the present guidelines for treatment of severe pneumonia are inadequate because of high failure rates in infants born to HIV-infected mothers, and these guidelines need to be revised."

In an accompanying comment, Dr Mark Steinhoff and Dr Robert Black, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA, say: "Achieving the Millennium Development Goal for child survival will require a new co-ordinated effort of research and implementation to prevent and control childhood pneumonia. This need is now urgent and the effort must be aimed at disease reduction in areas with low or high prevalences of HIV infection."

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Contact: Lisa McNally
Lancet