ABSTRACT
Background:
Acute respiratory infections (ARIs) are the single greatest cause of death among children throughout the world. They are responsible every year for the deaths of 4.3 million children under 5 years of age worldwide. Community- or hospital-based surveys for finding out the prevalence and various factors associated with ARI are very few, especially in urban areas. Also, surveys to study the use of vaccines in preventing ARIs are scarce. Hence, we studied ARI in children aged 1 year to 5 years in a tertiary care hospital in Kerala. The aim was to determine the frequency of ARIs in the last 1 year in children aged 1 year to 5 years, attending the immunization clinic at Lourdes Hospital, Kochi, and assess the selected epidemiological, socio-demographic, nutritional and immunization factors associated with ARIs in the study group.
Methods:
Children attending the immunization clinic at a tertiary care hospital, Kochi, in the age group of 1 year to 5 years were selected. A brief introduction was given to the mother/caregiver of the child regarding the purpose of the study and was asked to fill out the questionnaire. Informed consent was taken. For the study, ARI is defined as the presence of one or more of the following: cough, running nose, blocked nose, sore throat, difficulty breathing, or ear problems; with or without fever. Results were analyzed.
Results:
Mother was the caregiver in 67% of the cases. When the caregiver was the mother, ARI is found to be less. Among those mothers who had no formal education, 100% of their children got ARI. Children whose caregivers were 30 years and older had lesser ARI. The proportion of children with ARIs was more with a history of respiratory infection among family members (parents/siblings) compared to those with no such history. The occurrence of ARI was more frequent in rural compared to urban areas. There is a significant proportion of ARI in non-exclusively breastfed infants, bottle feeding, and early initiation of complementary feeding. Children with a history of exposure to cigarette smoke had an increased occurrence of ARI. Similar results followed for exposure to biomass fuel and exposure to cold and rain. Children who were not immunized to vaccines-pneumococcal, Hib, measles, vitamin A, showed a higher occurrence of ARI compared to immunization.
Conclusion:
The studies regarding factors influencing ARI are relatively rare in an urban setting, thus this calls for more studies in urban areas. Health education can change the healthcare-seeking behavior and attitude of parents for preventing ARI-related deaths. Family physicians can play a significant role by educating caregivers of children and giving timely services. Promoting and ensuring exclusive breastfeeding practices, timely weaning after 6 months, and avoidance of bottle feeds can dramatically decrease the episodes of ARI.
Keywords: 1 year to 5 years, acute respiratory infections, bottle feeding, complementary feeding, cough, exclusive breastfeeding, fever, immunization, pneumonia, running nose, Vitamin A supplementation
Introduction
Infections of the respiratory tract are perhaps the most common human ailment. Although they are a source of discomfort, disability, and loss of time for most adults, they are a substantial cause of morbidity and mortality in young children.[1] Acute respiratory infections (ARIs) are the single greatest cause of death among children throughout the world. They are responsible every year for the deaths of 4.3 million children under 5 years of age worldwide, which represents 21.3% of all deaths in this age group.[2,3]
It is estimated that at least 300 million episodes of ARIs occur in India every year, out of which about 30 to 60 million are moderate to severe ARI. Hospital records from states with high infant mortality rates show that up to 13% of inpatient deaths in pediatric wards are due to ARIs. The proportion of death due to ARIs in the community is much higher as many children die at home.[4]
Childhood ARI is thus an important public health problem in India and a multitude of social and environmental factors are linked to ARI morbidity and mortality. ARI is a major public health problem among children in Kerala. Even though Kerala accounts for only 2.7% of India’s population, 17.5% of total cases of ARI reported in India during 2014 were from Kerala.[5]
However, community- or hospital-based surveys for finding out the prevalence and various factors associated with ARI are very few,[5] especially in urban areas. Also, surveys to study the use of vaccines in preventing ARI are scarce. Many optional vaccines are now listed under the immunization schedule, and their efficacy in preventing the complications of ARI has not been studied much. Knowledge about factors related to ARIs in children can contribute to interventions that can reduce the burden of the disease.
It is in this setting, a new reading, such as in the study proposed, regarding the prevalence of ARI in the community, assessment of risk factors, and practice of preventive strategies and knowledge stands relevant.
The population in the urban areas is a heterogeneous conglomerate of all castes, creeds, and religions with a diversified lifestyle. In addition, the risk factors for childhood ARI are also present with respect to feeding practices, nutritional, and immunization status.
Factors related to the higher prevalence of ARI are lack of education of the mother, lack of exclusive breastfeeding, nutritional status, immunization status, female sex, personal hygiene, and overcrowding.[6,7]
An assessment of modifiable risk factors for acute lower respiratory tract infections in under-five children has shown a significant association of acute lower respiratory tract infection with social class, families with more than two under-five children at home, immunization, family history of respiratory infections, family history of smoking, infants with a history of LBW, and the presence of malnutrition.[7]
Thus, this study is narrowed down to children in the urban population, of age group 1 year to 5 years in a tertiary care hospital in Kerala, as opposed to various studies in a similar setting for better assessment of the factors and practices associated with an ARI.
The aim of the study was to determine the frequency of ARIs in the last 1 year in children aged 1 year to 5 years, attending an immunization clinic at a tertiary hospital and assess the selected epidemiological, socio-demographic, nutritional, and immunization factors associated with ARIs in the study group.
Materials and Methods
Study population
The study was done on children in the age group of 1 to 5 years attending an immunization clinic in Lourdes Hospital, a tertiary care hospital in Kochi, Kerala, India.
Study type: Cross-sectional study
Study time: October 2019 to March 2021
Sample size: 100.
Inclusion criteria
Children between the age of 1 year and 5 years attending the immunization clinic of Lourdes Hospital in the stipulated study period.
Exclusion criteria
Children with a clinical or confirmed diagnosis of bronchial asthma, congenital heart disease, pulmonary tuberculosis, cystic fibrosis, immunodeficiency, aspiration pneumonia, foreign body inhalation, and any other chronic illness.
Methodology
A simple random sampling was done. A brief introduction was given to the mother/caregiver of the child regarding the purpose of the study. After receiving their informed consent, a pre-tested, semi-structured validated questionnaire, was administered to mothers/caregivers to elicit information on socio-demographic, environmental, nutritional, and immunization characteristics and practices. To assess the frequency of ARI, details of ARI episodes in the last 1 year are included in the questionnaire.
For the study, ARI is defined as the presence of one or more of the following: cough, running nose, blocked nose, sore throat, difficulty in breathing, or ear problems; with or without fever.
Statistical methods
All data were entered in Excel 2010 and statistical analysis was performed using the statistical software SPSS 25.0. Data are expressed as numbers (with percentages) and mean values (with standard deviations). Differences between groups were analyzed with the independent sample t-test (Student’s t-test) for mean and Pearson’s Chi-square test/Fisher’s exact test for proportions. Results were defined as statistically significant when the P value (two-sided) was less than 0.05.
Ethical considerations
No interventions or investigations were done, hence no financial burden was incurred on participants. Information was collected solely using the questionnaire, which was given to the caregivers of children participating in the study. Informed consent was taken. Ethical and Scientific committe acceptance forms were uploaded during submission of manuscript (29.08.2019).
Results
The proportion of children with ARI in the study population was 60%, which was higher compared to other studies in the same age group. In our study, of the total 100 study subjects who participated, 52% were males and 48% were females. The incidence of ARI was comparable in male and female children (59.62% and 60.42%, respectively).
The caregivers and ARI
Mother was the caregiver in 67% of the cases. Children whose caregivers were 30 years and older had lesser ARI (52%), whereas children whose caregivers were younger (less than 30 years) had more ARI occurrence (62.67%). However, the relation was not statistically significant. The majority of mothers in the study group had at least secondary education. Among those mothers who had no formal education, 100% of their children got ARI.
ARI when parents or siblings had a similar history
The proportion of children with ARI was more with a history of respiratory infection among parents compared to those with no such history (P-value = 0.000) [Picture 1]. Similar results followed when siblings were previously affected by ARI (P-value = 0.000) [Picture 2].
Picture 1.
Relation between History of ARI in parents and Occurrence of ARI in children
Picture 2.
Relation between History of ARI in Siblings and Occurrence of ARI in children
Relation with breastfeeding and bottle feeding
There is a significant proportion of ARI in non-exclusively breastfed infants (82.35%), compared to exclusively breastfed infants (48.48%). (P-value = 0.001) [Picture 3]. Initiation of complementary feeding earlier than 4 months (in non-exclusively breastfed infants) was associated with increased ARI (P-value = 0.048). A significant association could be derived between bottle feeding and the incidence of ARI. Children who were bottle-fed showed a higher (66.23%) occurrence of ARI compared to non–bottle-fed babies (39.13%) (P-value = 0.020) [Picture 4].
Picture 3.
Relation between Breastfeeding and Occurrence of ARI in children
Picture 4.
Relation between Bottle feeding and Occurrence of ARI in children
Relation with immunization
Children who were not immunized to the measles and Hib vaccines showed a higher (80%) occurrence of ARI compared to immunized (58.95%) children with no statistical significance. Similarly, children who were not immunized with the pneumococcal vaccine showed a higher (65%) occurrence of ARI compared to those immunized (58.75%). The relation is not statistically significant [Picture 5]. Vitamin A supplementation was taken by 99% of children under study. One child who did not take the supplement developed an ARI episode. Though 100% of children with no vitamin A supplementation developed ARI, it is not statistically significant.
Picture 5.
Relation between Immunisation with Pneumococcal Vaccine and Occurrence of ARI in children
Sociodemographic and environmental factors
The occurrence of ARI was more frequent in rural (85%) compared to urban areas (53.75%) (P value = 0. 011).
Children with a history of exposure to cigarette smoke (73.17%) had an increased occurrence of ARI compared to non-exposure to cigarette smoke (50.85%) (P-value = 0.025) [Picture 6]. Children with exposure to biomass fuel had a higher chance of getting ARI (61.97%) compared to non-exposure to biomass fuel (55.17%). However, there was no statistical significance for the relation. Exposure to cold and rain revealed interesting results. Children with a history of exposure to cold and rain had a higher chance of getting ARI (71.05%) compared to the others (53.23%). However, there was no statistical significance for the relation.
Picture 6.
Relation between Cigarette smoke and Occurrence of ARI in children
Discussion
In our study, of the total 100 study subjects who participated, 52% were males and 48% were females.
Out of 100 children who participated, 60% of children had ARI and the rest (40%) did not have an ARI in the specified period. The incidence of ARI was comparable in male and female children, i.e., 59.62% and 60.42%, respectively.
Mother/caregiver and ARI
It was found that the mother was the caregiver in 67% of the cases. In 66.67% of children with ARI, the caregiver was not their mother. However, the relation was not statistically significant.
Among women who had only primary education, 75% of children got ARI and 25% did not get ARI. Among those who had no formal education, 100% of children got ARI. However, with a P value of more than 0.05, the results were not statistically significant. The study aligns with the article published by Mutalik et al.[6] in 2018 to find the association of maternal education and socioeconomic status with the knowledge, attitude, and practice of her child with respect to the development of ARI.
Children whose caregivers were 30 years and older had a lesser occurrence of ARI (52%), whereas children whose caregivers were younger (less than 30 years) had more occurrence of ARI (62.67%). However, the results were not statistically significant. This was consistent with a study on risk factors for ARI among under-five children in Bangladesh by Azadin 2009.[8]
When we compared the occurrence of ARI with the history of an ARI in siblings preceding the episode, it was found with great statistical significance that the incidence of ARI was found to be higher (100%) when there was a history of ARI in siblings as compared to no history of ARI in sibling preceding this episode.
A similar relation was derived when parents or caretakers had the disease. This is similar to the study conducted by Savitha et al.[9] There was a significant association between the history of family members who had a respiratory infection and ARI among under-five children residing in the same house. Children spending more time with their family and the indoor hygiene practices of the family members could contribute to this association.
Socio-demography and ARI
The relation between the place of residence and ARI revealed that ARI was more frequent in rural areas (85%) compared to urban areas (53.75%). The study population, though primarily urban (80%), had a 20% rural population too. This study contradicts the study done by Deb in 1996.[10] The annual attack rate of ARI was higher in urban compared to rural areas. Probably because of more reporting of cases.
Feeding practices and ARI
It was found that in both children with and without ARI, the majority were breastfed until 6 months of age. The percentage of children breastfed less than 6 months was comparable in both groups. In this study, there is a significant proportion of ARI in non-exclusively breastfed infants (82.35%), compared to exclusively breastfed infants (48.48%). A study was conducted by Azad et al.[7] in which lack of exclusive breastfeeding for 6 months was associated with ARI episodes. The protective effect of exclusive breastfeeding has been demonstrated in different other studies as well.
In those who were not exclusively breastfed, complementary feeds were started at varying intervals, we divided the period into two, as less than 4 months and more than 4 months. The study revealed that a significant proportion of children who were initiated on complementary feeding less than 4 months had a higher occurrence of ARI (92%). Similar results were seen in studies done by Savitha et al. in Mysore in 2007.[11]
A strong association was also seen between the use of bottle feeds and the occurrence of ARI. Also, 66.23% used bottle feeds and developed ARI. Similar studies were done by Deb in 1996.[10]
Immunization and ARI
Children who were not immunized to the measles and Hib vaccines showed a higher (80%) occurrence of ARI compared to immunized (58.95%) children. This corresponds to a study done by Arun et al.,[12] where a significant association was found between ARI and immunization. It was the least in children who were fully immunized (12.5%) as compared to unimmunized children (26%).
Similarly, children who were not immunized with the pneumococcal vaccine showed a higher (65%) occurrence of ARI compared to those immunized (58.75%). The relation is not significant.
Vitamin A supplementation was taken by 99% of children under study. Though 100% of children with no vitamin A supplementation developed ARI, it is not statistically significant. Vitamin A deficiency was related to the prevalence of ARI in a study conducted by Azad in 2009.[8]
Environmental factors and ARI
It was found that exposure to biomass fuel is linked to ARI. Children with exposure to biomass fuel have a higher chance of getting ARI (61.97%) compared to non-exposure to biomass fuel (55.17%). A study done by Azad et al. in 2018 in Kolkata[7] showed the use of biomass fuel to have a significant association with ARI.
Also, children with a history of exposure to cold and rain had a higher chance of getting ARI (71.05%) compared to the others (53.23%). This is further supported by a study done by Kartasasmita and Demedts.[13]
The study also revealed an interesting relationship between exposure to cigarette smoke and ARI. Children with a history of exposure to cigarette smoke (73.17%) have an increased occurrence of ARI compared to non-exposure to cigarette smoke (50.85%). This aligns with the study conducted by Savitha and Gopalakrishnan in 2018.[9]
The limitations of the study are that it is confined only to the study of the frequency of ARI and associated factors. Since Cross sectional study, causal association cannot be derived.The socio-demographic and other associated factors were self-reported by parents of the study population, hence may suffer from over- and under-reporting and recall bias. This study survey was cross-sectional and hence no causal inferences can be made.
Conclusion
Mother was the caregiver in 67% of the cases. When the caregiver was the mother, ARI is found to be less. Children whose caregivers were 30 years and older had lesser ARI. The proportion of children with ARI was more with a history of respiratory infection among family members (parents/siblings) compared to those with no such history. There is a significant proportion of ARI in non-exclusively breastfed infants, bottle feeding, and early initiation of complementary feeding. Children with a history of exposure to cigarette smoke, biomass fuel, and exposure to cold and rain had an increased occurrence of ARI. Children who were not immunized to vaccines-pneumococcal, Hib, measles, and vitamin A, showed a higher occurrence of ARI compared to those immunized.
Studies regarding factors influencing ARI are relatively rare in an urban setting, thus this calls for more studies in urban areas. Family physicians can play a significant role by educating caregivers of children and giving timely services. Promoting immunization and ensuring exclusive breastfeeding practices, timely weaning after 6 months, and avoidance of bottle feeds can dramatically decrease the episodes of ARI.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.World Health Organization. Acute respiratory infections in children:case management in small hospitals in developing countries, a manual for doctors and other senior health workers. World Health Organization. 1990 [Google Scholar]
- 2.World Health Organization. Programme for Control of Acute Respiratory Infections:interim programme report, 1992. World Health Organization; 1993. [Google Scholar]
- 3.World Health Organization. Childhood pneumonia:strategies to meet the challenge, proceedings of the First International Consultation on the Control of Acute Respiratory Infections (ICCARI [meeting held in Washington, 11-13 December 1991]. InChildhood pneumonia:strategies to meet the challenge, proceedings of the First International Consultation on the Control of Acute Respiratory Infections (ICCARI [meeting held in Washington, 11-13 December 1991] 1992 [Google Scholar]
- 4.Rahman MM, Rahman AM. Prevalence of acute respiratory tract infection and its risk factors in under-five children. Bangladesh Med ResCounc Bull. 1997;23:47–50. [PubMed] [Google Scholar]
- 5.Sebastian SR. Epidemiology of acute respiratory infections among under-fives in a rural community of Trivandrum district, Kerala. Int J Community Med Public Health. 2018;5:3459–63. [Google Scholar]
- 6.Mutalik AV, Raje VV. Association of maternal education and socioeconomic status with knowledge, attitude, and practise of her child regarding acute respiratory infections. Int J MedSciPublic Health. 2018;7:29–34. [Google Scholar]
- 7.Azad SM, Bannerji R, Ray J, Mitra M, Mukherjee A, Biyani G. Assessment of modifiable risk factors for acute lower Respiratory tract infections in under-five children. Indian J Child Health. 2018;5:376–80. [Google Scholar]
- 8.Azad KMAK. Risk factors for acute respiratory infections (ARI) among under-five children in Bangladesh. JSci Res. 2009;1:72–81. [Google Scholar]
- 9.Savitha AK, Gopalakrishnan S. Determinants of acute respiratory infections among under-five children in a rural area of Tamil Nadu, India. JFam MedPrim Care. 2018;7:1268–73. doi: 10.4103/jfmpc.jfmpc_131_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Deb SK. Acute respiratory disease survey in Tripura in case of children below five years of age. J Indian Med Assoc. 1998;96:111–6. [PubMed] [Google Scholar]
- 11.Savitha MR, Nandeeshwara SB, Kumar MP, Raju CK. Modifiable risk factors for acute lower respiratory tract infections. Indian JPediatr. 2007;74:477–82. doi: 10.1007/s12098-007-0081-3. [DOI] [PubMed] [Google Scholar]
- 12.Arun A, Gupta P, Sachan B, Srivsatava JP. Study on prevalence of acute respiratory tract infections (ARI) in under-five children in Lucknow district. Natl J Med Res. 2014;4:298–302. [Google Scholar]
- 13.Kartasasmita CB, Demedts M. Risk factors for acute respiratory infections in under-five children. PaediatrIndones. 1995;35:65–77. doi: 10.1093/tropej/38.3.127. [DOI] [PubMed] [Google Scholar]