International Journal of Contemporary Pediatrics

Srinivasa S et al. Int J Contemp Pediatr. 2018 Mar;5(2):456-461

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20180535
Original Research Article

A study on distribution pattern of lower respiratory tract infections in

children under 5 years in a tertiary care centre
Srinivasa S, Shruthi Patel*

Department of Pediatrics, KIMS Bangalore, Karnataka, India

Received: 26 December 2017

Accepted: 27 January 2018

*Correspondence:
Dr. Shruthi Patel,
E-mail: shruthi13p@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Respiratory infections are the leading cause of mortality in children below 5 years in India as well as
worldwide. 16% mortality in children below 5 years is attributed to lower respiratory tract infection. Various factors
influence the occurrence of the disease like environmental factors, lack of immunization, malnutrition. Present study
was conducted to know the distribution pattern of lower respiratory tract infections, common pathogens associated
with respiratory infections and risk factors associated with it.
Methods: This study was conducted in Department of Pediatrics, KIMS Bangalore for a period of 1 year from
January 2016 to December 2016. Total of 172 children admitted to ward and ICU with history suggestive of
respiratory infection were included in the study after excluding congenital heart problems, congenital lung problems
and immunodeficiency state.
Results: In the present study, male predominance (59.3%) was observed. The incidence of respiratory tract infection
was 17.5%. The common pathogen isolated was streptococcus pneumoniae. Most common respiratory infections
included bronchopneumonia followed by bronchiolitis, croup, and lobar pneumonia. The common symptoms were
cough, fever and hurried breathing. Anemia was observed in majority of them.
Conclusion: Respiratory infections if timely managed, the mortality associated with it can be reduced. Pneumonia is
a major killer disease in children below 5 years in India. Understanding the symptoms and signs and time of referral
to tertiary centre not only reduces the mortality but it also reduces morbidity. So, it is important to create awareness
among the health care personnel regarding common age of presentation of various types of respiratory infection and
warning sign.

Keywords: Anemia, Lower respiratory tract infections, Pneumonia

INTRODUCTION

Acute lower respiratory tract infection is the leading In paediatric patients, respiratory infections can be life
cause of mortality and one of the common causes of threatening if not treated. The incidence of acute
morbidity in children under-five years of age. Respiratory respiratory infection is high in developing countries than
infections are heterogeneous and complex group of in developed countries.2 The higher incidence is attributed
diseases caused by wide range of pathogens-virus, crowding, HIV burden, low birth weight and the lack of
bacteria or fungi. Lower respiratory tract includes the pneumococcal and measles immunization.3-6 Also zinc
trachea, bronchi, bronchioles and alveoli. Pneumonia and vitamin A deficiency, poor maternal education, and
killed 9,20,136 children under 5 in 2015, accounting for living in polluted areas are the other contributing factors.
16% of all deaths of children under 5-year old.1 Though etiology is often undetermined in a clinical

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 Srinivasa S et al. Int J Contemp Pediatr. 2018 Mar;5(2):456-461

situation, the most common agents causing pneumonia in recovery or death. Those with signs of severe respiratory
children are Streptococcus pneumonia, Hemophilus distress were admitted to PICU and followed there
influenzae and to some extent Staphylococcus aureus. accordingly. A detailed history was taken, with a special
Bronchiolitis is also a leading cause of mortality in focus on past history, family history, diet history,
children. RSV is implicated in most of the cases. The immunization status of the child and socio-economic
other viruses include parainfluenza virus 1, 2 and 3, status. A detailed examination was done once child
adenovirus and influenza virus. stabilized for protein malnutrition and vitamin
deficiencies.
Studies have shown the importance of social factors for
ARI mortality and morbidity, like family size, education Basic blood test like complete blood counts, CRP and
level, and density in the residence.7-9 Thus it’s very chest X ray was done in all cases. Results were tabulated
important to focus on social factors while considering and analyzed. Other investigation pertaining to
preventive measures. It has been reported that problem of respiratory system like throat swab for culture and
ARI is more in urban areas, slums than compared to rural sensitivity, sputum/gastric aspirate for gram stain/AFB
areas.10 Costs attributable to lower respiratory tract stain, pleural fluid for routine analysis, culture and
infection in both outpatient and inpatient settings are an sensitivity were sent. Other test like Mantoux test, CT
important burden on national healthcare budgets. Thorax, BAL fluid for analysis sent in selected cases.

It is important to emphasize on modifiable risk factors All cases were followed till recovery or death. Data was
like breast feeding, overcrowding, undernutrition, entered in a Microsoft excel spread sheet and data was
delayed weaning and prelacteal feeding while analyzed accordingly.
approaching cases of LRTI. Further IMNCI has classified
as no pneumonia, pneumonia, severe pneumonia, very RESULTS
severe pneumonia based on respiratory rate according to
age, presence or absence of chest retraction and general Out of 172 cases, 97 cases (56.4%) were boys, 75 cases
status of the patient. Treatment option includes oral (43.6%) were girls. There is a slight male predominance
antibiotics, sick cases needs hospital admission, IV observed as shown in Figure 1. Figure 2 represents age
antibiotics and other supportive care measures like wise distribution of study subjects, 31 cases (18%)
oxygen/ventilator support, ICD drainage. between 1 month and 6 months, 83 cases (48%) were
between 6 months and 2 years, 58 cases (34%) were
Respiratory infections are major concern in children and between 2 years and 5 years. As we can observe in Figure
adolescents. Frequent chest infections are not only 2, majority of cases in our study were between 6 months
economic burden to parents, it also adds to missing and 2 years.
school days. This study was undertaken to know the
distribution pattern of lower respiratory tract infection
and associated risk factor along with identification of Boys
bacterial agents associated with it.
43.60%
56.40%
METHODS Girls

This is a prospective observational hospital-based study

conducted in the Department of Paediatrics,
Kempegowda Institute of Medical Sciences, Bangalore
between January 2016 and December 2016. Children
aged between 1month to 5 years who presented with Figure 1: Sex wise distribution.
symptoms and signs of Lower respiratory tract infection
and chest x ray findings consistent with lower respiratory 60 54
infection were included in this study. Further those 50
children with known congenital heart disease, congenital 40 29 32
lung diseases, immunodeficient states, neuromuscular or 26
30 20
skeletal disorders were excluded from the study. Consent 20 11
was taken from parents/guardians. Totally 172 cases met 10
our inclusion criteria. 0
1-6 months 6 month-2 2-5 year
In each case presenting complaints like fever, cough, year
hurried breathing was documented. Examination finding Boys Girls
including signs of respiratory distress like tachypnoea,
nasal flaring, chest retraction, oxygen requirement and
presence of crackles/decreased breath sounds were noted. Figure 2: Age wise distribution.
Each of this signs and symptoms were followed till

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 Srinivasa S et al. Int J Contemp Pediatr. 2018 Mar;5(2):456-461

Table 1 shows symptom wise distribution of cases with Figure 3 showing socioeconomic status of the family
respect to age groups. 90% of the cases in the age group indicating majority of the children (46%) presented with
below 6 months had hurried breathing followed by not ALRTI belongs to lower socioeconomic group which
feeding (87%), fever (81%). In children between 6 includes 79 cases, followed by middle class 65 cases
months and 2 years, 96% cases had fever followed by (38%), only 28 cases (16%) belonging to upper class
hurried breathing (90%), cough (65%), breathlessness were observed in the present study.
(61%), not feeding (41%). Children between 2 and 5 year
had fever and cough in all cases followed by hurried Table 3: Nutritional status of study subjects.
breathing (77%), breathlessness (50%).
No. of cases (%)
Table 1: Symptom wise distribution of ARI. Boys Girls Total
Normal 52 46 98 (57%)
1 to 6 6 months PEM-1 19 22 41 (24%)
Symptoms 2-5 year
months to 2 year PEM-2 10 13 23 (13%)
25 cases 80 cases 58 cases PEM-3 03 08 11 (6%)
Fever
(81%) (96%) (100%) PEM-4 None None None
2 cases 54 cases 58 cases
Cough
(6%) (65%) (100%) Table 3 shows the nutritional status of children, 98 cases
Hurried 28 cases 75 cases 45 cases showed no signs of protein energy malnutrition (PEM),
breathing (90%) (90%) (77%) 41 cases had Grade 1 PEM, 23 cases had Grade 2 PEM,
Not feeding 27 cases 34 cases 02 cases 11 cases had Grade 3 PEM. Majority of the children with
well (87%) (41%) (3.4%) PEM belongs to low socioeconomic status. Exclusive
Chest 20 cases 51 cases 29 cases breast feeding was found in 121 cases (70%), remaining
indrawing (64%) (61%) (50%) cases either baby was on formula feeds along with EBM
or on formula feeds only. Delayed weaning observed in
Table 2 shows signs of Acute lower respiratory tract 18% of the cases.
infection, majority of the children in our study had
respiratory distress (94%) i.e., tachypnoea, nasal flaring, Table 4: Immunization status of children.
intercostal retractions followed by pallor (78%),
hepatomegaly (44%), altered conscious (6%) due to Immunisation status No.of cases(%)
hypoxia, cyanosis was observed in 3% of cases. BCG 172 (100%)
DPT 172 (100%)
Table 2: Distribution of signs in study subjects. Measels/MR/MMR 172 (100%)
PCV-10 10 (6%)
Signs No. of cases (%) PCV-13 25 (15%)
Pallor 135 (78%) No vaccination Nil
Respiratory distress 162 (94%)
Hepatomegaly 76 (44%) Table 4 shows the immunization status of the children, all
Altered conscious 10 (6%) cases received vaccine according to National
Cyanosis 6 (3%) immunization schedule. We also elicited vaccination
status regarding pneumococcal vaccine. 10 cases received
PCV-10 and 25 cases received PCV-13.

Table 5 shows the distribution pattern of Acute

16% Respiratory infection (ARI), 73 cases of
46% bronchopneumonia were reported, 28 cases of
bronchiolitis, 22 cases of croup and lobar pneumonia
each were seen. 9 cases of pneumonia with
38% parapneumonic effusion, 11 cases of wheeze associated
LRTI, 4 cases of empyema thoracic and 3 cases of
tuberculosis were noted our study. Different types of LRI
presenting at various ages also shown in Table 5.

Table 6 shows investigations, anaemia noted in 135 cases

(78.5%), further grading of anaemia done according to
Lower class Middle class Upper class WHO guidelines. 53% of cases found to have mild
anaemia, 31% of cases moderate anaemia and 16% of the
cases severe anaemia. Further total WBC count listed as
Figure 3: Socioeconomic status. shown in Table-6, 50% of cases had total count between

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5000 and 10000 cells/cumm, 29% of cases had counts isolates showed staphylococcus aureus organism in this
more than 15000 cells/cumm, 21% of cases had counts case.
below 5000 cells/cumm. Further tuberculin test was done
in selective cases and was positive in 57% of cases. DISCUSSION

Table 5: Distribution pattern of Acute Respiratory Childhood respiratory infections are of major concern in
Infection (ARI). developing countries. The incidence of respiratory
infection in our study was 17.5%. Another study done by
6 Paramesh et al reported 12.85% incidence in their
Types of LRTI
1 to 6 months 2-5 Total study.11 Various factors contribute to incidence like age
months -2 year (%) group selection for a study, seasonal variation and
years presence of risk factors in a community. There was slight
22 male predominance observed in our study. The study
Croup 03 13 06
(14%) done by Udaya et al which includes children less than 18
73 years also showed male predominance.12 Other study
Bronchopneumonia 19 35 19 done by Savitha et al, Yosif et al, Broor et al also showed
(42%)
22 male predominance in their study. The higher incidence
Lobar pneumonia Nil 11 11 in boys is probably attributed to early seeking of medical
(14%)
28 advice.13-15
Bronchiolitis 09 16 03
(17%)
03 The most common age group in this study was 6 months
Tuberculosis Nil 01 02 to 2 years followed by 2 to 5year. Whereas China AS et
(1%)
11 al reported 2 months to 1 year as common age group in
WALRTI Nil 04 07 their study.16 Similarly Varhanophas et al reported 1 to 5
(6%)
year as most common age group in their study.17 The
Pneumonia with 09
Nil 02 07 most common presenting symptom varied with different
effusiom (5%)
age group, below 6 months infants mostly presented with
04
Empyema thoracis Nil 01 03 hurried breathing followed by not feeding well and fever.
(1%) However, in the age group between 6 months and 2-year,
fever, hurried breathing and cough was observed and
Table 6: Distribution of study subjects on basis of between 2 year and 5 years, fever and cough were
investigations. predominant. This is comparable with other studies
where Kabra et al, Kumar et al showed cough and fever
Anaemia No. of cases (%) as predominant symptom.18,19 Other study done in Nepal
Mild 71 (53%) by Rijal P et al reported fever and cough as predominant
Moderate 42 (31%) symptom.20
Severe 22 (16%)
Total count (cells/cumm) In our study, pallor, respiratory distress was the
Less than 5000 37 (21%) predominant sign followed by hepatomegaly. These
5000-15000 86 (50%) findings are inconsistent with Kumar AMK et al, they
More than 15000 49 (29%) reported tachypnoea and chest retraction are the
Tuberculin test % of cases predominant sign.21 Ramkrishna and Harish showed
Positive 57% anaemia is a risk factor for LRTI Anaemia was found in
78.5% of cases.22 LRTI was predominant in low
Negative 43%
socioeconomic status in our study. This can be probably
attributed to overcrowding, malnutrition, lack of hygiene,
Among the organisms isolated, the most common educational status. Munagala VK et al also reported
pathogen was streptococcus pneumonia followed by higher number of cases in low economic status.23 PEM-1
klebsiella. The other organisms were staphylococcus is observed in 24% of the cases. Mungala VK et al
aureus and H. influenza. 3 cases of Tuberculosis reported 35% of grade-1 PEM in their study.23 Contrary
diagnosed from gastric aspirate sample sent for gene x to this Sonego M reported Grade-3 PEM as a major risk
pert. Out of 4 cases of empyema thoracis, pleural fluid factor.24
analysis showed staphylococcus in 2 cases, streptococcus
in 1 case and klebsiella species in 1 case. Majority of Exclusive breast feeding reported in 70% of the cases.
cases were sensitive to amoxicillin-clavulanic acid, Lack of breast feeding is an independent risk factor for
piperacillin-tazobactum and vancomycin. pneumonia. Exclusive breast feeding and continuation till
24 months are critical in reducing burden of
The incidence of LRTI in the present study found to be pneumonia.25-27 Savitha et al and Broor et al reported
17.5%. Out of 172 cases, only 1 case died because of early weaning before 4 months of age in 37.5% and
sepsis with pneumonia being the focus. The culture 39.4% of children were significantly associated with

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 Srinivasa S et al. Int J Contemp Pediatr. 2018 Mar;5(2):456-461

LRTI. The immunisation status is very important. Lack of aetiology and validity of WHO clinical signs: A
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