Acute Respiratory Infections (ARI) alongwith malnutrition are the major causes of morbidity and mortality in children of developing countries. While the magnitude of the problem of Acute Respiratory Infections and its implications were not recognized until recently, major developing countries have now realized the need to focus attention on this problem. In our country too, ARIs constitute a serious health problem. They are responsible for 20-30% of death amongst under 5 years of age and mortality in this age group constitutes nearly 47% of total mortality in India. The morbidity 3-7 attacks of illness per year, due to ARIs are already significant. The magnitude of problem is also well documented by health services statistics. ARIs are the cause for 30-50% of paediatrics outpatient department. These figures are a result of complex interplay of socio-economic, educational, nutritional, environmental factors.

In the past few years, there has been a significant progress in our understanding of the problem of ARIs and their susceptibility to intervention in our country. Today, many deaths can be prevented since supportive and effective antibiotic treatment can be made available. Existing experience has consolidated into simple case management plans that could be handled by trained community workers through present public health care infrastructure.

This urban based hospital study is carried out to study children attending paediatric OPD in one month with ARIs with special reference to socio-economic factors, immunization, clinical features, predisposing factors associated with illness and outcome measures.

Aims and Objectives

1. To assess the possible impact of Socio-economic factors on Acute Respiratory Infections in children under 5 years of age group.
2. To assess the impact of immunization on ARI in children under 5 years of age group.
3. To assess the possible impact of Anaemia on ARI in children under 5 years of age group.

An observation study was undertaken for one month in J. J. Hospital which is a major teaching hospital in Mumbai city to evaluate the morbidity of ARI with regards to its incidence, aetiology, symptomatology, physical findings associated illness, socioeconomic factors, immunization and sample size was considered.

One hundred seventy six children under five who attended the paediatric outpatient department with a history of acute onset of respiratory illness in the period of one month were screened for this purpose. At the initial encounter a detailed history was recorded. Besides the name, age, sex, patient's income was inquired to establish the socioeconomic status by using Kuppuswamy Index. The detailed history and symptomatology of children under 5 years of age were taken up from the parents especially mothers who were accompanying patients. The detailed symptomatology of the present illness was noted with reference to fever, cough, breathlessness, chest pain and haemoptysis.

A past history of aspiration of foreign body or vomitus, nasal or ear discharge, recurrent cold was considered significantly. A history of asthma was documented. The presence or absence of a family history of asthma and allergic manifestations were noted.

Patients in contact with a person either within the family or vicinity having prolonged cough, that is, more than 3 weeks, continuous low-grade fever, haemoptysis or diagnosed tuberculosis infection were excluded from the series.

The details of Immunization were inquired and relation of ARI with nonimmunized patients was found out. Weight of under five was taken by using simple weighing machines.

Subsequently a detailed physical examination was carried out. The patient's vital parameters were quickly assessed with special reference to temperature, respiratory rate. The weight measures of the patients were taken and the patients were classified according to Indian Academy of Paediatrics classification of the state of nutrition. Among other general examination findings, special importance was given to the presence of pallor, clubbing, ear discharge and tonsillar enlargement.

On systemic examination, alongwith other systems a detailed examination of the respiratory system was carried out with special reference to respiratory rate, distress, specific physical findings within the chest to locate the site and type of pathology.

According to Haemoglobin levels the patients were further grouped as mild, moderately and severely anaemic.

Follow up of children under five with ARI was not considered for the study.

 Data Analysis ® This was done by,

1. Calculating the percentages
2. Applying the Chi-square test
3. Finding S.E. of difference between the two proportions. The results are presented in the subsequent sections.

Acute Respiratory tract infections in children less than 5 years of age constitute a common clinical problem encountered in day to day practice. The contribution of these infections to childhood morbidity and mortality is significant. Data regarding the incidence, environmental/aetiological factors and response to therapy have not been clearly elucidated in developing countries. More studies are required to examine all aspects of ARI.

The present study was conducted with a view to examine the children less than 5 years of age with ARI attending the paediatrics out patient department with special reference to socioeconomic factors, immunization status, malnutrition and clinical presentation.

 Age wise distribution showed that 104 out of 176 patients were between the age group of 1-5 years. Out of which 58 suffered from URTI and 46 suffered from LRTI.
However, 72(40.9%) patients were less than 1 year of age. Out of them 40 were suffering from URTI and 32 were suffering from LRTI.

Thus more number of children between the age group of 1-5 years suffered from ARI than infants less than 1 year of age. Also URTI was more common than LRTI.

Out of 176 patients 102 (58%) were males and 74 (42%) were females. Thus, there was a slight preponderance of male patients. Ratio of male to female was 1.4:1. Male patients seem to have greater susceptibility to ARI as compared to female patients which is proved in our study. Similar findings were observed in Huges et al,1 but the ratio is slightly lesser than Huges et al1 (1.8:1).

Out of 176 patients which were observed in the present study, 52(29.55%) suffered from mild ARI i.e. cough; 76(43.18%) suffered from moderate ARI i.e cough and breathlessness and 48(27.27%) suffered from severe ARI i.e above symptoms along with in drawing of chest and difficulty in swallowing fluid according to the National ARI Control Programme.2

As far as the nutritional status in the patients of ARI in present study is concerned, 132 (75%) patients had malnutrition according to Indian Academy of Paediatrics.2
Out of 176 patients 44 (25%) children were of average nutrition.44 (25%) children had grade-I malnutrition; 42 (23.9%) children had grade-II malnutrition; 38 (21.6%) children had grade-III malnutrition and 8 (4.5%) children had grade-IV malnutrition which were advised for hospitalization.

This study was comparable to the study done by Gulati et al.3 The severity of undernourished state also correlated well with severity of respiratory infections. Studies have documented increased susceptibility of malnourished children to respiratory infections.37

Socio Economic Status of the patients was classified according to modified Kuppuswamy scale5 into five groups. Our study shows that greater majority that is 88.62% of patients came from very low (20), low (72) and lower middle (64) socio economic status.

None of the parents had per capita income more than 3000 rupees per month. Among patients the socio economic status, ARI was seen more because of low standard of living, unfavourable domestic and peridomestic environment viz. overcrowding, increased spread of airborne diseases, lack of sufficient sunlight, lack of sufficient air-exchange which is due to ill ventilated room. This is comparable to the study done by Gulati et al3 and Ballard T.J.

This study shows that out of 176 patients who were eligible for B.C.G vaccine, 145 (82.4%) were immunized against B.C.G. Out of 106 eligible patients only 25 (23.6%) patients were immunized against D.P.T and O.P.V. i.e. triple-polio vaccine.

Out of 78 eligible patients 20(25.6%) were immunized against measles. Out of 70 eligible patients for Booster-1, 20 were given Booster-1 dose and only 4 out of 37 eligible patients for Booster-II were given 2nd Booster dose. This clearly indicates that incidence of ARI is more in non-immunized and partially immunized under five children than in fully immunized under five children.

Thus this highlights the need for immunization as a national priority to reduce morbidity and mortality due to ARI.

• Most of the ARIs occurred in children below the age of 5 years (59.1%) than infants (40.9%).
• It was observed that more male children suffered from acute respiratory tract infections than female children.
• Acute respiratory tract infections were more common in children belonging to the lower socio-economic status with a large family and poor nutrition.
• The severity of acute respiratory tract infections was correlated with the degree of malnutrition.
• Acute respiratory tract infections were more commonly seen in non-immunized and partially immunized patients than in fully immunized patients.
• Out of 176 patients 9.09% had mild anaemia, 56.81% had moderate anaemia and 34.1% had severe anaemia.
• Cough, breathlessness and fever were the common symptoms.
• Clinically, majority of the children had a respiratory rate more than 50/min. which formed a reliable clinical marker.

Acute respiratory tract infections in the paediatrics age group especially among the children less than 5 years of age can be prevented provided appropriate preventive measures are adopted by the parents.

Pertaining to the study, and in general, the recommendations are as follows:

• Health education of the mothers about breast feeding.
• Supplement of proper weaning food at the appropriate age of the child.
• Full immunization of the child along with the Booster doses.
• Awareness of personal and domestic hygiene.
• Safe storage of drinking water, which prevent the water-borne diseases viz. diarrhoea, because diarrhoea decreases the immunity of child resulting into susceptibility to ARI.
• Prompt health check-up of the child which is helpful for early diagnosis and treatment of ARI.
• Education to the mother about care during acute respiratory tract infections.
• Health education of mother about the nutrition of the child.