European Journal of Cardiovascular Medicine

Pleural effusion represents a significant clinical challenge in the pediatric population, characterized by the accumulation of fluid in the pleural space between the visceral and parietal pleura.^[1,2] This condition may arise as a primary manifestation or secondary to various underlying pathologies, including infectious, inflammatory, malignant, and systemic disorders.^[3] The global incidence of pediatric pleural effusion has been reported to range from 0.4 to 6 per 1000 hospital admissions, with higher prevalence in developing countries.^[4,5]

The etiological spectrum of pleural effusion in children differs markedly from adults, with parapneumonic effusions and empyema constituting approximately 50-70% of cases.^[6] Other common causes include tuberculosis, malignancies, and rheumatological disorders.^[7] The clinical presentation varies widely depending on the underlying etiology, volume of effusion, and rapidity of accumulation, often presenting diagnostic and therapeutic challenges to pediatricians.^[8,9]

Management approaches for pediatric pleural effusion have evolved significantly over the past two decades, transitioning from conservative medical management to more aggressive interventional strategies.^[10,11] The therapeutic options range from simple thoracentesis to chest tube drainage, intrapleural fibrinolytics, VATS (Video-Assisted Thoracoscopic Surgery), and open decortication.^[12,13] Despite these advancements, there remains considerable debate regarding the optimal timing and selection of these interventions, particularly in resource-limited settings.^[14]

Recent guidelines from international societies have attempted to standardize the approach to pediatric pleural effusion; however, regional variations in pathogen distribution, antimicrobial resistance patterns, and healthcare resource availability necessitate context-specific studies.^[15,16] Additionally, the emergence of novel pathogens and changing resistance profiles has further complicated the management paradigm.^[17]

In this context, studying the clinical profile and management modalities of pleural effusion in children becomes crucial for developing evidence-based protocols tailored to specific populations. This study aims to analyze the demographic characteristics, clinical presentations, etiological factors, diagnostic approaches, and therapeutic interventions in children with pleural effusion, with special emphasis on treatment outcomes and prognostic indicators.^[18,19]

AIMS AND OBJECTIVES

The aim of this study is to investigate the incidence, clinical presentation, and clinico-etiological correlation of pleural effusion. It seeks to analyze various management modalities and their correlation with underlying etiological factors. Additionally, the study aims to evaluate early outcomes in patients with pleural effusion to gain insights into effective treatment approaches and prognosis

Study Design

This study is a prospective observational study conducted at a tertiary care hospital attached to a medical college. The study was carried out over a period of one year, from March 2018 to March 2019.

Inclusion and Exclusion Criteria

The study included children aged more than 28 days and less than 12 years with radiological evidence of pleural effusion. Neonates and children aged above 12 years were excluded from the study. With informed written consent, patients were evaluated using a pre-written proforma. Diagnosis of pleural effusion was made through routine radiological investigations, including chest roentgenogram and ultrasonography. Further evaluation, including routine blood investigations, sputum analysis, cultures, and pleural fluid study (where necessary), was conducted to determine the underlying etiology.

Data Collection Method

Data for this study were collected using a structured pre-written proforma after obtaining informed written consent from the participants' guardians. The proforma included detailed demographic information, clinical history, presenting symptoms, past medical and family history, socio-economic status, birth and immunization history, developmental milestones, diet history, and anthropometric measurements. Routine radiological investigations, such as chest roentgenogram and ultrasonography, were used to diagnose pleural effusion, while additional investigations, including blood tests, sputum analysis, cultures, and pleural fluid examination, were conducted to determine the underlying etiology. Systemic examination covered respiratory, cardiovascular, gastrointestinal, and central nervous system evaluations. The treatment modalities included specific management, supportive care, intercostal drainage tube insertion, thoracotomy, dietary support, and physiotherapy. Early outcomes were documented, including discharge status, DAMA (Discharge Against Medical Advice), absconding, or mortality.

Table 1 shows that 2.34% of pediatric hospital admissions had pleural effusion, indicating its relatively rare occurrence but significant clinical impact.

Table 2 shows the majority (45.3%) of affected children were between 1 and 5 years, correlating with pneumonia being common in this age group. The majority (45.3%) of affected children were between 1 and 5 years old, correlating with pneumonia being common in this age group.

Male predominance (55.1%), suggesting gender-based health-seeking behaviour differences in Table 3.

Table 4 shows the highest cases in rainy and winter seasons, consistent with increased respiratory infections during these periods.

Table 5 compares the most patients were from lower socioeconomic classes (71.5%), emphasizing poor hygiene, nutrition, and healthcare access as contributing factors.

Table 6 shows that 74.7% of children were malnourished, highlighting the role of poor nutrition in disease susceptibility.

Pleural effusion in pediatric patients is commonly secondary to infections, primarily pneumonia. In the present study, the incidence of pleural effusion was found to be 2.34% of total hospital admissions, consistent with global epidemiological patterns.

Age and Gender Distribution

The study revealed that the majority of cases occurred in the 1-5 years age group (45.3%). This finding aligns with studies by Kumar P. et al. and Hasan M. et al., which also observed a higher incidence in younger children due to their susceptibility to infections, particularly pneumonia.^[20,21] A slight male predominance (55.1%) was observed, which can be attributed to differences in health-seeking behavior and potential biological factors.

Seasonal Variation

Pleural effusion cases peaked in the rainy (30%) and winter (27%) seasons, likely due to increased respiratory infections. This trend aligns with findings by Soares et al., who reported higher rates of respiratory illnesses and subsequent pleural effusion in similar climatic conditions.^[22]

Socioeconomic and Nutritional Impact

A significant proportion (71.5%) of affected children belonged to lower socioeconomic strata, highlighting the impact of poor hygiene, malnutrition, and inadequate healthcare access. The nutritional status assessment showed that 74.7% of children were malnourished, which is known to increase susceptibility to infections and delay recovery.^[21]

Clinical Presentation

The most common presenting symptoms were fever (93.6%), cough (91.9%), and breathlessness (77.9%). This is consistent with studies conducted by Kumar P. et al. and Soares et al., where fever and cough were the most prevalent complaints.^[21,22]

Management and Outcomes

Medical management was the mainstay of treatment (69.5%), with 24.5% of patients requiring ICD and 5.9% undergoing surgical intervention. The need for surgical intervention was associated with increased mortality (35.7%), indicating the severity of disease in these cases. Similar findings were reported by Munir S. et al. and Iqbal Z. et al., where advanced cases required invasive management with poorer outcomes.^[23,24]

Etiology and Microbiological Findings

Pneumonia was the leading cause of pleural effusion (58.1%), followed by congestive cardiac failure (19.9%). Bacterial cultures revealed Staphylococcus aureus as the most commonly isolated organism (17.8%), followed by Streptococcus pneumoniae (9.6%). These findings correspond with those of Iqbal Z. et al. and Dass R. et al., who also identified Gram-positive cocci as the predominant pathogens.^[24,25]

Limitations

This study has several limitations. Adolescents above 12 years of age were not included, restricting its applicability to older pediatric populations. The small sample size limits the ability to draw definitive conclusions or generalize findings to the broader population. Additionally, the microbiology lab lacked the capability to identify causative organisms in cases of atypical or viral pneumonia, which could have improved specific management and outcomes. As the study was conducted at a tertiary care referral center receiving patients from multiple states, it does not accurately reflect the true epidemiological distribution of pleural effusion. Furthermore, newer management modalities such as intrapleural fibrinolytic injection and VATS were not included, which may have impacted the treatment approach and patient outcomes.

This study analyzed 236 pediatric cases of pleural effusion, with an incidence of 2.36%. The most affected age group was 1–5 years, with a male-to-female ratio of 1.23:1. Fever, cough, and tachypnea were the most common symptoms, with the right lung predominantly involved. Most cases had minimal effusion, and pleural fluid aspiration was done in severe cases. Post-pneumonia effusion was the leading cause, with Staphylococcus aureus and Streptococcus pneumoniae as the most frequently isolated organisms. While most patients were managed conservatively, 30.9% required surgical intervention. Early diagnosis and targeted management remain crucial for better outcomes.

1. Light RW. Pleural effusions. Med Clin North Am 2011;95(6):1055-70.
2. Sahn SA. The pathophysiology of pleural effusions. Annu Rev Med 2010;61:248-56.
3. Molnar TF. Current surgical treatment of thoracic empyema in adults. Eur J Cardiothorac Surg 2007;32(3):422-30.
4. Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax 2005;60(Suppl 1):i1-21.
5. Singh M, Singh SK, Chowdhary SK. Management of empyema thoracic in children. Indian Pediatr 2002;39(2):145-57.
6. Islam S, Calkins CM, Goldin AB, et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg 2012;47(11):2101-10.
7. Chakravorty I, Oldfield W, Gomeran N. Pleural effusion: diagnosis, management and new developments. Postgrad Med J 2006;82(973):638-42.
8. Mishra OP, Das BK, Jain AK, et al. Clinico-bacteriological study of empyema thoracis in children. J Trop Pediatr 1993;39(6):380-1.
9. Proesmans M, De Boeck K. Clinical practice: treatment of childhood empyema. Eur J Pediatr 2009;168(6):639-45.
10. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53(7):e25-76.
11. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009;44(1):106-11.
12. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006;174(2):221-7.
13. Avansino JR, Goldman B, Sawin RS, et al. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics 2005;115(6):1652-9.
14. Mahant S, Cohen E, Weinstein M, et al. Video-assisted thorascopic surgery vs chest drain with fibrinolytics for the treatment of pleural empyema in children: a systematic review of randomized controlled trials. Arch Pediatr Adolesc Med 2010;164(2):201-3.
15. Strachan RE, Jaffe A. Assessment of the burden of paediatric empyema in Australia. J Paediatr Child Health 2009;45(7-8):431-6.
16. Krenke K, Urbankowska E, Urbankowski T, et al. Clinical characteristics of 323 children with parapneumonic pleural effusion and pleural empyema due to community acquired pneumonia. J Infect Chemother 2016;22(5):292-7.
17. Elemraid MA, Thomas MF, Blain AP, et al. Risk factors for the development of pleural empyema in children. Pediatr Pulmonol 2015;50(7):721-6.
18. Wu PS, Huang LM, Chang IS, et al. The epidemiology of hospitalized children with pneumococcal/lobar pneumonia and empyema from 1997 to 2004 in Taiwan. Eur J Pediatr 2010;169(7):861-6.
19. Chibuk TK, Robinson JL, Hartfield DS. Pediatric complicated pneumonia and parapneumonic pleural effusion: a retrospective review of thoracoscopic management. J Pediatr Surg 2010;45(8):1587-92.
20. Hasan M, Islam MR, Martin A, et al. Clinical profile of children with pleural effusion admitted in a tertiary care hospital in Bangladesh. J Shaheed Suhrawardy Med Coll 2012;4(1):7-9.
21. Kumar P, Sunilbala K, Sharma D, et A study of the clinico-etiological profile and outcome of pleural effusion in children of age 0-12 year. IOSR Journal of Dental and Medical Sciences 2020;19(1):18-23.
22. Soares P, Barreira J, Pissarra S. Pediatric parapneumonic pleural effusions: experience in a university central hospital. Portuguese Journal of Pulmonology (English Edition) 2009;15(2):241-59.
23. Munir S, Qiass N, Safdar W. Frequency of various causes of pleural effusion: a study conducted on children with age up to 5 years. Theoretical & Applied Science 2018(10):597-601.
24. Iqbal Z, Khan SA, Ullah Z, Alam J, et al. Causes and outcome of pleural effusion in children in a tertiary care hospital of Peshawar, Pakistan. J Postgrad Med Inst 2019;33(3):199-203.
25. Dass R, Deka NM, Barman H, et al. Empyema thoracis: analysis of 150 cases from a tertiary care centre in North East The Indian Journal of Pediatrics 2011;78(11):1371-7.