Pneumonia is a leading cause of morbidity and mortality in children under five years of age. Recent estimates from the World Health Organization (WHO) suggest that pneumonia constitutes 20% of mortality in the specified age group, leading to 3 million fatalities per year. Recent estimates reveal that pneumonia constitutes 13% of deaths among children under five in India and 24% of the National Burden of Disease.[1–3]World Health Organization (WHO) initiated the Acute Respiratory Infection (ARI) control campaign, leading to a reduction in the infant mortality rate by 10.7 (4.8–16.7) deaths per 1000 live births. Factors associated with increased mortality include maternal youth, paternal educational shortcomings, child age, delayed hospitalization with cyanosis, altered consciousness, grunting, concurrent chest in drawing, hepatomegaly, acute malnutrition, inability to consume fluids, accompanying diarrhoea or cardiac conditions, anaemia, rickets, and lack of breastfeeding. [4–6] Risk factors include inadequate exclusive breastfeeding, low birth weight, under nutrition, overcrowding and lack of measles vaccination are also associated with pneumonia. Traditional health care methods may be categorized into four main types: useful, damaging, innocuous, and of uncertain efficacy. A variety of traditional health methods for infant care are advantageous and based on solid scientific evidence and reasoning. [7,8]Customs and traditions are rigorously adhered in several South Indian households, both in rural and urban settings. Certain established child-rearing traditions are being promoted by elders and are historically adhered. Even the educated urban elite are to some degree, influenced by the older women of their families and communities. Community data indicates a significant impact of diverse cultural practices on the incidence of childhood illness and mortality. [9]. Thus this study was conducted to study the clinical presentation, predisposing risk factors and outcome of pneumonia in children aged 2 to 60 months admitted to a tertiary care hospital

Study design: Observational prospective hospital-based study, conducted in department of Paediatrics, ACSR Government Medical College, Nellore for over a period of 1 year after obtaining institutional ethical clearance. Children with fever, cough, difficult breathing for less than 2 weeks and with clinical features of pneumonia admitted in ICU and wards will be included in the study as per the sample size obtained. Statistical analysis was performed using Microsoft windows Excel and SPSS 21.0 version. Results are expressed as mean±standard deviation and proportions in percentage form. The Chi-square test and linear regression analysis was done to investigate the relationship between traditional practices and pneumonia outcomes

Table 1: Socio-demographic characteristics of Study participants VARIABLE FREQUENCY PERCENTAGE Age group 2 - 12 Months 135 67.5 13 - 60 Months 65 32.5 Gender Male 111 55.5 Female 89 44.5 Locality Rural 171 85.5 Urban 29 14.5 Mothers Education Illiterate 118 59.0 Literate 82 41.0 Indigenous substances No 159 79.5 Yes 41 20.5 Immunization Status No 19 9.5 Partial 41 20.5 Yes 140 70.0 Breast feeding No 29 14.5 Yes 171 85.5 Congenital Heart Disease No 186 93.0 Yes 14 7.0 Table 2: Outcome of Patients Outcome: Out of the 200 children included in the study, 182 children (91%) improved and were discharged, while 18 children (9%) died during the course of treatment. This reflects the overall mortality rate within the study population. Outcome Frequency Percent Death 18 9.0 Improved 182 91.0 Total 200 100.0 Table 4: Association of Traditional Practices, Indigenous Substances, Immunization Status, Breastfeeding, Congenital Heart Disease and Nutritional Status with Duration of ICU Stay Association of Traditional Practices, Indigenous Substances, Immunization Status, Breastfeeding, Congenital Heart Disease and Nutritional Status with Duration of ICU Stay ICU care Total Greater than > 48 hrs Less than < 48 hrs Indigenous Substances No Count 42 117 Chi square: 55.569 % within Indigenous Substances 26.40% 73.60% Yes Count 34 4 P<0.001 % within Indigenous Substances 90.20% 9.80% Immunization Status No Count 18 1 Chi square: 46.387 % within Immunization given or not 94.70% 5.30% Partial Count 26 15 % within Immunization given or not 63.40% 36.60% Yes Count 35 105 P<0.001 % within Immunization given or not 25.00% 75.00% Breast Feeding No Count 18 11 Chi square: 7.229 % within Breast feeds 62.10% 37.90% Yes Count 61 110 P=0.007 % within Breast feeds 35.70% 64.30% Congenital Heart Disease No Count 67 119 Chi square: 13.454 % within Congenital Heart Disease 36.00% 64.00% Yes Count 12 2 P<0.001 % within Congenital Heart Disease 85.70% 14.30%

In the present study, which assessed 200 children aged 2 to 60 months diagnosed with pneumonia, several key demographic and clinical insights emerged which is similar to the study by Vinaykumar N et al.[10] The age- wise distribution revealed that a substantial proportion, 67.5%, belonged to the 2–12 months category, while the remaining 32.5% were in the 13–60 months group. This indicates that infants are more vulnerable to pneumonia, which is consistent with global epidemiological patterns.[11] The study showed a slight male predominance, with 55.5% male children and 44.5% female. A striking observation was that 85.5% of the study population came from rural areas, underscoring the need for targeted public health interventions in rural settings.[12] The education level of mothers indicated a concerning pattern, with 59% of mothers being illiterate, which may indirectly affect timely health- seeking behavior and child care practices.[13] Nutritional status data revealed high levels of malnutrition, with only 6.5% of children having normal nutrition, while 93.5% had varying grades of malnutrition where, 23 children (11.5%) with Grade I, 69 children (34.5%) with Grade II, 62 children (31%) with Grade III, and 33 children (16.5%) with Grade IV.[14, 15]In terms of putative risk factors for pneumonia, traditional practices were reported by 24% of families and 20.5% of children were exposed to indigenous substances. Both of which were later shown to be significantly associated with poor outcomes.[16] Immunization coverage was relatively good, with 70% of children being fully immunized, though 9.5% were not immunized at all. Breastfeeding practices were commendable with 85.5% of children having been breastfed. Only 7% of children were diagnosed with congenital heart disease, yet this factor emerged as a significant determinant in various clinical outcomes. In the same way an Indonesian case–control study (ages 10–59 months) found that children with incomplete basic immunizations had a 4.47‑fold increased odds of pneumonia (OR 4.47; 95 % CI 2.22–8.99) compared to fully immunized children.[17] These risk factors serve as critical indicators for public health planning and parent education. Clinically, 57.5% of children had fever for less than 48 hours, while 42.5% experienced prolonged fever. Most children required oxygen supplementation for less than 48 hours (63%), while a significant proportion needed it for longer durations. Difficulty in taking feeds, a marker of severity, was observed in 64% for less than 48 hours and 36% for more extended periods. Intravenous fluids were administered for less than 48 hours in 60% of cases, whereas 40% required extended IV therapy. ICU care was required in over half the cases (60.5%) for under 48 hours, but 39.5% needed intensive care for longer durations. Notably 40.5% of children needed second-line antibiotic treatment, whereas 59.5% managed without second-line antibiotics, suggesting variability in severity and treatment response. Complications were rare, occurring in only one child (0.5%), indicating good clinical management protocols.The clinical outcome analysis revealed that 91% of children improved and were discharged, while 9% succumbed to the disease. Factors influencing prolonged ICU stay included the use of traditional practices (81.3% of such cases required ICU stay >48 hrs), exposure to indigenous substances (90.2%), and lack of immunization (94.7%). These associations were statistically significant (p<0.001), demonstrating that cultural and behavioural practices, along with immunization status, play crucial roles in influencing disease severity and recovery. Breastfeeding status also showed a significant association with ICU stay (p=0.007), with non-breastfed children more likely to require prolonged ICU support. Congenital heart disease was another strong determinant (p<0.001), with 85.7% of affected children needing ICU care for more than 48 hours. Nutritional status played a vital role; children with Grade IV malnutrition had the longest ICU stays (81.8%), and a clear trend was observed wherein the severity of malnutrition corresponded with longer ICU requirements (p<0.001). [18]

In conclusion, the study provides a vital contribution to the existing literature on childhood pneumonia, particularly within rural and resource-limited settings. By identifying key risk factors and correlating them with treatment requirements and outcomes, it highlights areas for targeted intervention. Future research should aim at exploring the effectiveness of community-based health education programs, strategies to improve vaccination uptake and longitudinal studies assessing long- term respiratory outcomes in children affected by severe pneumonia. The findings underscore the need for a multidisciplinary and preventive approach to pediatric respiratory health where, clinical care is reinforced by public health strategies and community engagement.

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