55

Original Article

Modifiable Risk Factors for Acute Lower Respiratory

Tract Infections
M.R. Savitha, S.B. Nandeeshwara, M.J. Pradeep Kumar, Farhan-ul-haque and C.K. Raju
Department of Pediatrics, Government Medical College, Mysore, India
[Received February 23, 2006; Accepted February 15, 2007]

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

Key words : Acute lower respiratory tract infection; Risk factors

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

Correspondence and Reprint requests : Dr. M.R. Savitha, No. 79/

A,4 th Main, Maruthi Temple Road, Saraswathipuram, Mysore
570 009 (Karnataka), India; Phone-0821-2341891; Mobile: 9844066497

Indian Journal of Pediatrics, Volume 74May, 2007

MATERIALS AND METHODS

The present study is a prospective case control study
conducted from March 2005 to August 2005 at
Cheluvamba Hospital, attached to Government Medical
College, Mysore which is a teaching hospital and a
referral centre. Children in the age group of 1 month to 5
yr admitted with acute lower respiratory tract infection
during the study period were enrolled in the study as
cases. A case of ALRI is defined as presence of cough
with fast breathing of more than 60/min in less than 2
mth of age, more than 50/min in 2 mth to 12 mth of age
477

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.

STATISTICAL METHODS USED

Chi square test was used. P value <0.05 was taken as
significant. P value <0.001 was taken as highly
significant. Logistic Regression Methods was done using
SPSS version 14.0 (evaluation review).
478

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

Indian Journal of Pediatrics, Volume 74May, 2007

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Modifiable Risk Factors for Acute Lower Respiratory Tract Infections

value<0.001). Family history of upper respiratory tract
infection in the preceding two weeks was present in
8.65% cases as compared to none of the controls.
Among the nutritional variables compared between
cases and controls (Table 2), early weaning before 4 mth
of age had a significant association with ALRI (37.5% vs
13.46%) (p< 0.01). Similarly 31.73% cases had
administered prelacteal feeds as compared to 3.85% of
controls. Also, anemia was present in 76.92% of cases as
compared to 6.73% of controls and Rickets was present in
28.85% of cases and only 3.85% of controls (p<0.01).
Malnutrition was present in 83.86% of cases as compared
to 2.88% of controls (p<0.01). However, there was no
significant association between Vitamin A deficiency, low
birth weight, and pneumonia.
TABLE 2. Nutritional Variables in Alri Cases and Controls
Variables

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

Among the environmental variables compared

between cases and controls (Table 3), 61.54% of cases had
either mud or cowdung flooring in their house as
compared to 11.54% of controls, which was statistically
significant (p<0.05). 32.7% of ALRI cases did not have
any windows in their house as compared to 4.8% of
controls (p<0.001). 36.54% of ALRI cases used kerosene
lamps as the lighting source as compared to 2.88% of
controls where electricity was the mode of lighting
(p<0.001). Cooking fuel other than liquid petroleum gas
was strongly associated with ALRI (98.07% in cases vs
54.8% in controls) (p<0.001). Added to this, 14.42% cases
did not have a separate kitchen and they cooked their
food in the living place as compared to none of the
controls. Family history of smoking was seen in 73.08% of
cases as compared to 36.5% of controls, however, this was
not statistically significant.

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

TABLE 4. Risk Factors For Acute Lower Respiratory Tract

Infection Using Logistic Regression Methods

Sl. Risk Factors

No.

11 (10.58)

Indian Journal of Pediatrics, Volume 74May, 2007

TABLE 3. Environmental Variables in Alri Cases and Controls

1
2
3

Adjusted
Odds Ratio

Partial immunization 0.006

Overcrowding
11.985
Malnutrition
6.939

95% CI

P Value

0.001-0.035
2.578-55.720
1.063-45.290

0.000
0.002
0.043

Of the 104 cases with pneumonia, 12.51% cases had

pneumonia, 82.69% cases had severe pneumonia and
4.8% cases very severe pneumonia. There was past H/O
pneumonia in 14.42% of cases. 5 Cases had past H/O
Pneumonia in the siblings of which, 2 sibling deaths had
occurred due to pneumonia. Of the 104 cases with
Pneumonia 2 infants with very severe Pneumonia died.
DISCUSSION
The various risk factors for ALRI were broadly classified
under 3 headings-sociodemographic variables, nutritional
variables and environmental variables. The age and sex
distributions were comparable between cases and
controls.
SOCIODEMOGRAPHIC VARIABLES
Among the sociodemographic variables both maternal
and paternal illiteracy and low socioeconomic status(SES)
were significantly associated with ALRI. Similar results
were found by Cunha AL et al even after adjusting for
other risk factors like nutritional status and
479

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

Presence of malnutrition was significantly associated

with ALRI in the present study, similar to other studies.7
A study in the philippines included age stratified risks in
children less than 23 mth of age and reported highest risk
of death from ALRI due to malnutrition among those
aged 12-22 mth.16
A study in New Delhi revealed severe malnutrition as
the predictor of mortality in ALRI in 2 wk to 5 yrs old
children.17 Overall malnutrition is associated with a two
to three fold increase in mortality from ALRI. 18 It is well
known that malnourished children have defective cell
mediated immunity secondary to thymolymphatic
depletion leading to severe gram negative infections and
sepsis. They may also have qualitatively abnormal
immunoglobulin, and impairment of key enzymes
involved in bactericidal action of leucocytes.19
In the present study vitamin A deficiency was not
significantly associated with ALRI. Although Vitamin
A supplements reduce overall childhood mortality in
areas where deficiency is present, no reduction in ALRI
morbidity or mortality has been shown.20
Environmental Variables
Air pollutants increase the incidence of ALRI by
adversely affecting nonspecific host defenses like
filtration, mucociliary apparatus etc, and specific host
defenses like cellular and humoral immunity.21
In the present study there was a significant association
between mud/cow dung flooring with ALRI. Similar
results were found by Sikolia et al.2 Mud floors tend to
break up and cause dirt and cannot be easily washed,
clear and dry and also they get dampened easily. Cracks
and crevices which are common in these type of floors
lead to breeding of insects and harborage of dust.
In nearly 1/3rd of cases kerosene lamps were the main
modes of lighting source. These are a potential source of
emission of harmful particulate matter (<2.5) like
polycyclic aromatic hydrocarbons, aliphatic
hydrocarbons, nitrated hydrocarbons etc., which as they
are small, are inhaled deep into lungs, leading to greater
severity of illness.22
93.2% of ALRI cases used, biomass fuels like firewood,
cow dung as fuel for cooking. These biomass fuels are
burnt in simple stoves with very incomplete combustion
generating a lot of toxic products that adversely affect
specific and nonspecific local defenses of the respiratory
tract.7,21 Majority of under five children, being young
spend most of their time with their mothers doing
household cooking, thus getting more exposed to
biomass fuel pollution. Added on to this, about 14.42%
cases did not have a separate kitchen and cooking was
done in the living Place, leading to bulk of emissions
being released into the living area. Further, nearly 1/3rd
cases did not have any windows in their house. This ill
Indian Journal of Pediatrics, Volume 74May, 2007

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Modifiable Risk Factors for Acute Lower Respiratory Tract Infections

ventilation further aggravated the effects of indoor
pollutants.
Environmental tobacco smoke (ETS) is another indoor
pollutant that reduces local defense mechanisms and
predisposes children to respiratory illness. 8,23, 24 In the
present study family history of smoking was not
statistically significant. This may be because, majority of
smokers in the families were fathers and the exposure of
children due to smoking by fathers may be limited
because of relatively greater time spent by fathers outside
the house.
On reanalyzing data using logistic regression methods,
partial immunization, overcrowding and malnutrition
remained as major independent risk factors for
pneumonia. (Table 4).
As children were constantly exposed to the above risk
factors, 14.42% of cases also complained of past attacks of
pneumonia and 5 cases had history of sibling pneumonia
with 2 sibling deaths.
However, the present study had certain limitations
As the present study was a hospital based study,
hospitalized cases may not be representative of all ALRI
cases in the community. This needs an extensive
population based research. 25 Also the authors used a
questionnaire measure to assess risk factors. This has a
sensitivity of 82% and a specificity of 79% and some
misclassification of the outcome may have occurred.
Thirdly in view of ALRI having marked periodicity,
studies on ALRI should last for at least one yr. 25 The
present study was done over a period of six mth.

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.
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Indian Journal of Pediatrics, Volume 74May, 2007