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Original Article
ABSTRACT
Objective. Acute respiratory infection is a leading cause of morbidity and mortality in under five children in developing countries.
Hence, the present study was undertaken to identify various modifiable risk factors for acute lower respiratory tract infections
(ALRI) in children aged 1 mth to 5 yr.
Methods. 104 ALRI cases fulfilling WHO criteria for pneumonia, in the age group of 1 mth to 5 yr were interrogated for potential
modifiable risk factors as per a predesigned proforma. 104 healthy control children in the same age group were also interrogated.
Results. The significant sociodemographic risk factors were parental illiteracy, low socioeconomic status, overcrowding and
partial immunization, [p value <0.05 in all]. Significant nutritional risk factors were administration of prelacteal feeds, early
weaning, anemia, rickets and malnutrition, [p value <0.05 in all]. Significant environmental risk factors were use of kerosene
lamps, biomass fuel pollution and lack of ventilation [p value <0.05 in all]. On logistic regression analysis, partial immunization,
overcrowding and malnutrition were found to be significant risk factors.
Conclusion. The present study has identified various socio-demographic, nutritional and environmental modifiable risk factors
for ALRI which can be tackled by effective education of the community and appropriate initiatives taken by the government.
[Indian J Pediatr 2007; 74 (5) : 477-482] E-mail : savvvy6 2002@yahoo.co.in
Children with acute respiratory infections account for 20% to 40% of the children attending outpatient clinics and 12%
of these risk factors related to acquisition of ALRI will
to 35% of admissions of children into hospitals.1 It is
help in its prevention, through effective health education
estimated that 500 to 900 million acute respiratory
of the community and appropriate initiatives taken by the
infection episodes occur per year in developing
government, leading to a healthy community and a
countries.2 Also, about 5 million under five children die of
healthy nation as a whole. The authors therefore,
acute respiratory infection annually, of which 90% occur
undertook this study to identify the various modifiable
in developing countries.2 Acute lower respiratory tract
risk factors for acute lower respiratory tract infection in
infection (ALRI) is a leading cause of mortality in under
under five children.
five children in developing countries.3
The international consultation on control of acute
respiratory infections, December 1991 reported that there
are links between environmental risk factors (such as
smoke, outdoor air pollution, indoor pollution, passive
smoking, overcrowding) and risk factors in the child
(such as low birth weight, malnutrition, measles, breast
feeding and vitamin A deficiency) with acute
respiratory infections. Many of these risk factors are
amenable to corrective measures. Therefore, knowledge
56
M.R. Savitha et al
and more than 40/min in 12 mth to 5 yr of age, the
duration of illness being less than 30 days. The presence
of lower chest wall indrawing was taken as evidence of
severe pneumonia. The presence of refusal of feeds ,
central cyanosis, lethargy or convulsions was taken as
evidence of very severe pneumonia.4 Controls included
in the study were healthy children between 1 month to 5
yr of age who were normal siblings of admitted children
for non respiratory complaints during the study period.
Children with a clinical diagnosis of Bronchial asthma
(based on history of repeated episodes of wheeze with
rapid response to bronchodilator therapy, positive family
history of bronchial asthma) and children with any
underlying chronic illness were excluded from the study.
Verbal, informed consent of the childs carer was
obtained in both cases and controls. For both cases &
controls a detailed history and physical examination was
done according to a predesigned proforma to elicit
various potential risk factors. Age of the child was
recorded in completed months and age of parents in
completed yr. A detailed history of relevant symptoms
like fever, cough, rapid breathing, chest retraction, refusal
of feeds, lethargy, wheezing etc., was taken. Past history
of similar complaints was also taken. History of
immunization was elicited from parents and verified by
checking the documents wherever available. History of
breastfeeding and weaning was recorded. Dietary intake
of child prior to current illness was calculated by 24 hr
Dietary recall method. History of upper respiratory tract
infection in the family members in the preceding 2 wk
was recorded. History of smoking by various family
members and details of cooking fuel used was recorded.
Details of the housing conditions were also obtained.
Socioeconomic status grading was done according to
modified kuppuswamys classification.
A detailed examination of each child was done.
Respiratory rate and heart rate were measured for one
minute, when the child was quiet. A detailed
anthropometry was done and malnutrition was graded
according to Indian academy of Pediatrics classification.
Severity of respiratory distress was assessed in each child.
Anemia and other signs of vitamin deficiencies were
recorded. A detailed systemic examination was done in
both cases and controls. Routine hematological, urine
and stool investigations were done in all cases and
specific investigations were done as per requirement of
individual cases.
RESULTS
In this study 104 ALRI cases were compared with 104
normal controls. Majority of children were infants with
their age distributions comparable between the two
groups with male preponderance in both the groups
(Table 1). When other sociodemographic variables were
compared between the two groups (table 1), there were
significantly higher number of illiterate mothers in cases
as compared to controls (63.46% vs 19.23%) (p value
<0.001). Similarly, significantly more fathers were
illiterate in cases as compared to controls (59.62% vs 25%)
(p value <0.001). Inappropriate immunization for age
was significantly associated with ALRI (21.15% vs 7.69%)
(p value<0.001). Also, Families having more than two
underfive children at home, were significantly associated
with ALRI (30.77% vs 11.54%) (p value<0.001).
Similarly, overcrowding5 was also significantly associated
with ALRI (91.35% vs 20.19%) (p value <0.001). Also,
more ALRI cases were from lower and upper lower class
as compared to controls (93.26% vs 62.5%) (p
TABLE 1. Sociodemographic Variables in Alri Cases and Controls
Variables
1. Age
<1YR
1-3yr
3-5Yr
2. Sex
Male
Female
3. Mothers Literacy
Illiterate
Primary/High school
PUC
Graduate
4. Fathers Literacy
Illiterate
Primary/High school
PUC
Graduate
5. Immunization
Complete for age
Incomplete for age
6. No. of underfive
children at home
<2
>2
7. Overcrowding
Present
Absent
8. Socioeconomic class
Lower Class
Upper Lower Class
Lower middle class
Upper Middle Class
9. Family H/o URI
Infection
Alri Cases
(n=104)
No.[%]
Controls
(n=104)
No.[%]
65 [62.5%]
31 [29.8%]
8 [7.7%]
77 [74.04%]
18 [17.31%]
9 [8.65%]
67 [64.42%]
37 [35.58%]
54 [51.92%]
50 [48.08%]
66 [63.46%]
36 [34.62%]
2 [4.81%]
0
20 [19.23%]
55 [52.88%]
15 [14.42]
14 [13.46]
<0.001
62 [59.62%] 26 [25%]
38 [36.54%] 40 [38.46%]
3 [2.88%]
23 [22.12%]
1 [0.96%]
15 [14.42%]
<0.001
82 [78.85%]
22 [21.15%]
96 [92.3%]
8 [7.69%]
<0.001
72 [69.23%]
32 [30.77%]
92 [88.46%]
12 [11.54%]
<0.001
95 [91.35%]
9 [8.65%]
21 [20.19%]
83 [79.81%]
<0.001
62 [59.62%] 26 [25%]
35 [33.65%] 39 [37.5%]
6 [5.77%]
24 [23.08%]
1 [0.96%]
15 [14.42%]
<0.001
9 [8.65%)
P Value
- Nil
57
Alri Cases
(n=104)
No.[%]
1. Prelacteal feeds
Given
33 (31.73)
Not given
71 (68.27)
2. Weaning
<4 months
39 (37.5)
4months-6months
44 (42.31)
>6 months
21 (20.19)
3. Anemia
Present
80 (76.92)
Absent
24 (23.08)
4. Rickets
Present
30 (28.85)
Absent
74 (71.15)
5. Malnutrition
Absent
45 (16.14)
Gr I & II
37 (62.71)
Gr III & IV
22 (21.15)
6. Birth Weight
<2.5 Kg
9 (8.65)
7. Vitamin A deficiency
Present
4 (3.85)
Controls
(n=104)
No.[%]
P Value
4 (3.85)
100 (96.15)
<0.05
14 (13.46)
84 (80.77)
6 (5.77)
<0.01
7 (6.73)
97 (93.27)
<0.01
4 (3.85)
100 (96.15)
<0.01
101 (97.12)
3 (2.88%)
- Nil
<0.01
Variables
1. Type of Floor
Mud
Cow Dung
Cement
2. Windows
Present
Absent
3. Lighting
Kerosene lamps
Electricity
4. Fuel used
Firewood
Cow dung
Kerosene
LPG
5. Kitchen
Separate
Not separate
6. Family H/o Smoking
Present
Absent
- Nil
Alri Cases
(n=104)
No.[%]
Controls
(n=104)
No.[%]
P Value
25 (24.04)
39 (37.5)
40 (38.46)
11 (10.58)
1 (0.96)
92 (88.46)
<0.05
70 (67.3)
34 (32.7)
99 (95.19)
5 (4.8)
<0.001
38 (36.54)
66 (63.46)
3 (2.88)
101 (97.11)
<0.001
95 (91.35)
2 (1.92)
5 (4.8)
2 (1.92)
31 (29.8)
26 (25)
47 (45.19)
<0.001
89 (85.58)
15 (14.42)
104 (100)
76 (73.08)
28 (26.92)
38 (36.54)
66 (63.46)
>0.05
11 (10.58)
1
2
3
Adjusted
Odds Ratio
95% CI
P Value
0.001-0.035
2.578-55.720
1.063-45.290
0.000
0.002
0.043
58
M.R. Savitha et al
overcrowding.6 Probably low SES leads to less access to
social, human and material resources leading to more of
infections.
The authors also observed that partially immunized
children were more prone for ALRI as compared to upto
date immunized children. Similar results were found by
Broor S et al.7 This is probably because mothers utilizing
immunization services are better aware of health care
facilities and probably seek early consultation for illness
of their children, which probably avoids severe illness.
Also, immunization against certain diseases like measles,
H. influenza type b may protect the child against ALRI.
Another significant risk factor in our study was
overcrowding. Also, families with more than two
children at home were more at risk for ALRI.
Overcrowding contributes to the transmission of
infections through respiratory droplets. Similar results
were found in other studies. 2,8 A study from Brazil 9
showed that after adjustment for socioeconomic and
environmental factors, the presence of three or more
children under five years of age in the household was
associated with a 2.5 fold increase in pneumonia
mortality.
NUTRITIONAL VARIABLES
The administration of prelacteal feeds and early weaning
before 4 mth of age was significantly associated with
ALRI in the present study. Similar results were found in
other studies.7 Colostrum contains antibodies against
Respiratory synctial virus and also a high concentration
of C3, IgA and lactoferrin which protect against gram
negative organisms. 10 In a study on ALRI specific
mortality relative to breastfed infants, those, who also
received artificial milk had a risk of 1.6 and non-breast
fed infants, a risk of 3.6. 11 Among children hospitalized
with pneumonia in Rwanda, breast feeding was
associated with a 50% reduction in case fatality.12
Anemia was a significant risk factor for ALRI in the
present study. Not many studies have stressed on the
role of anemia in ALRI. The role of anemia in infection is
debated extensively. The proposed pathophysiologic
basis for increased risk of infection are- neutrophils have
a decreased capacity to kill staph.aureus due to decreased
myeloperoxidase activity. Both the proportion and
absolute number of circulating T cells are reduced and
also they have defective DNA synthesis due to decreased
ribonucleotide reductase activity.13
Presence of Rickets was a significant risk factor for
ALRI in the present study which was similar to other
studies. 14 Humoral immunodeficiency is known in
rickets, mainly in the form of dysgammaglobinemia, poor
antibody response, defective opsonisation and killing.15
480
59
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
CONCLUSIONS
The present study identified many modifiable risk factors
for ALRI. The significant sociodemographic risk factors
were parental illiteracy, low socioeconomic status,
overcrowding and partial immunization. The significant
nutritional risk factors were administration of prelacteal
feeds, early weaning, anemia, rickets and malnutrition.
The significant environmental risk factors were use of
mud/cow dung flooring, kerosene lamps, biomass fuel
pollution and lack of ventilation. On logistic regression
analysis, partial immunization, overcrowding and
malnutrition remained as significant independent risk
factors for ALRI.
The above risk factors can be tackled through effective
health education of the community and appropriate
initiatives taken by the government leading to a healthy
community and a healthy nation as a whole.
REFERENCES
1. A programme for controlling acute respiratory infections in
14.
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M.R. Savitha et al
21. Smith KR, Samet JM, Romieu I, Bruce N. Indoor air pollution
in developing countries and acute lower respiratory infections
in children. Thorax 2000; 55: 518-531.
22. Sharma S, Sethi GR, Rohtagi A, Chaudhary A,Shankar R,
Bapna JS et al. Indoor air quality and acute lower respiratory
tract infection. Indian Environ Health Perspect 1998; 106: 291
297.
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