Breif Communication Published on December 30, 2023

 

Vitamin D Deficiency among Children Aged 1-5 Years with Severe Pneumonia in comparison to Healthy Controls

Anupama Thankaa, Gopika Sekhara, Mili Thomasa, Elizabeth KEb

a. Department of Pediatrics, Ananthapuri Hospital & Research Institute, Thiruvananthapuram;
b. Department of Pediatrics, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari District*

Abstract

Background: Vitamin D Deficiency is on the rise and the effect of Vitamin D deficiency in various diseases like respiratory illness is being increasingly recognized. Hence this study was planned.

Objectives: To asses Dietary pattern, sun exposure, place of residence, Immunization status, anthropometry and Vitamin D levels among children-aged-1-5 years with severe pneumonia in comparison to healthy controls and find the association between Vitamin D deficiency and severe pneumonia.

Methods: Relevant parameters were assessed among 33 children with pneumonia and 33 healthy controls. Vitamin D was assessed using CLIA and was categorized into Normal (>30 ng/ml), Insufficient (20-19 ng/ml) and Deficient (<20 ng/ml) and both insufficient and deficient were included in low Vitamin D category. The data analyzed using SPSS version 24.

Results: Children belonged to Middle and Upper Lower Socio-Economic status. Mean age, gender, and Immunization status were comparable in both groups. 73% among cases and 49% controls were from rural setting. Malnutrition was more in the pneumonia group. Exclusive breastfeeding rate during first 6 months was lower than Kerala NFHS 5 data of 55%. Milk and Egg exclusion diet was noted in 12% and there was a significant association between exclusion diet and low Vitamin D status (P-0.015). Adequate sun exposure was noted in only 18% in the total children, 15% cases and 21% controls. 91% with adequate sun exposure had normal Vitamin D levels. The mean Vitamin D level was (34.13+ 14.01) ng/ml in cases Vs. (36.14 + 9.48) ng/ml in controls. Among the total children, 36% had low Vitamin D level and 6% were in the deficient category. Proportion of children with low Vitamin D were significantly more among cases than controls (51.5% vs 21.2%: P- 0.011).

Conclusions: Dietary pattern, sun exposure and Vitamin D levels were suboptimum among the study children. Exclusion diets and reduced sun exposure were associated with low Vitamin D levels. Those with severe pneumonia had significantly lower Vitamin D levels compared to normal control children. Hence a closer look at this public health problem is recommended in order to optimize dietary pattern, sun exposure and Vitamin D Status among children in health and diseases.

 

Introduction & Rationale

Currently vitamin D Deficiency is on the increase and is now recognized as a Lifestyle related disease. The skeletal and extra-skeletal manifestations of Vitamin D deficiency and excess are important public health challenges.1 Vitamin D sufficiency is recommended for prevention of various diseases, including respiratory diseases. Frequent respiratory infections are common among under-five children. Hence, this study was undertaken.

This research paper investigates the factors associated with Vitamin D deficiency and the association between Vitamin D deficiency and severe pneumonia in children aged 1-5 years. Vitamin D is the most under diagnosed and untreated deficiency. This utilizes a sample size of 33 cases and 33 controls based on a study by Li W et al.2 Vitamin D status is categorized as deficiency (<20 ng/ml), insufficiency (21-29 ng/ml), and normal (30-80 ng/ml), with serum 25 (OH) vitamin D measured by CLIA.3 Pneumonia is considered as the leading cause of under 5 mortality in the world.4 Severe pneumonia is defined as fever, cough along with danger signs or stridor in a calm child (WHO Classification).

Objectives

  1. To assess dietary pattern, sun exposure, place of residence, anthropometry and Vitamin D levels using CLIA in children aged 1-5-years with severe pneumonia in comparison with an age and sex-matched healthy control group.
  2. To find the association between Vitamin D deficiency and severity of pneumonia.

Methodology

The sample size was calculated based on study by Li W et al,2 aiming to explore the relationship between vitamin D levels and severe pneumonia in children aged 1-5 years. Relevant parameters were assessed among 33 children with pneumonia and 33 healthy controls, selected by Non-Random sampling, enrolling consecutive cases and controls. Detailed clinical history and investigation reports were recorded using a standardized proforma. Vitamin D was assessed using CLIA and was categorized into Normal (>30 ng/ml), Insufficient (20-19 ng/ml) and Deficient (<20 ng/ml). Both insufficient and deficient were included in low Vitamin D category. This study was conducted over 20 months in the Tertiary Care Centre in Kerala. Nutritional status was evaluated using anthropometric measurements, including weight-for-age, height-for-age, and weight-for-height. Dietary patterns were assessed using food frequency questionnaires. Sun exposure and outdoor activities were also documented.

Quantitative Variables were expressed as mean and standard deviation. Qualitative variables were expressed as frequency and percentage. Comparison of continuous variable between two group were analysed by student t test. Association between qualitative variables were analysed by Chi square test. A p- value <0.05 was considered statistically significant. Data was analysed using SPSS version 24.

Results

The children belonged to Middle and Upper Lower Socio-Economic status. 73% among cases and 49% controls were from rural setting. Mean age, gender, and Immunization status were comparable in both groups. The Mean age of cases and controls in our study was (2.7 years ± 1.1) and (3.3 years ± 1.2) respectively. Male to Female ratio was 23:10 in cases and 20:13 in controls. Entire study population was fully immunized for age (100%) according to National Immunization schedule. In this study, 42.4% of cases and 36.4% of controls were on exclusive breast feeding during first 6 months. Malnutrition was more in the pneumonia group. Breastfeeding rate was less than the NFHS - 5 FACT SHEET Kerala data,5 where 55.5% were exclusively breast fed. Exclusion of Milk and Egg in the diet was noted in 12% and there was a significant association between exclusion diet and low Vitamin D status (P-0.015). The baseline parameters in the study are summarised in table 1. Both cases and controls lacked adequate sun exposure.  Only 15.2% among cases and 21.2% among controls had exposure of >1 hour/day. This was not statistically significant. Adequate sun exposure was noted in only 18% in the total children. 91% with adequate sun exposure had normal Vitamin D levels (Table 2). Mean Vitamin D level was (34.13+14.01) ng/ml in cases Vs. (36.14 + 9.48) ng/ml in controls. Among the total children, 36% had low Vitamin D level and 6% were in the deficient category. Proportion of children with low Vitamin D were significantly more among cases than controls (51.5% vs. 21.2%: P- 0.011). Vitamin D status among cases and controls is depicted in Table 3.

Discussion

The sample size of 33 cases and 33 controls ensured a robust analysis. Exclusion diet and inadequate sun exposure are important causes for vitamin D deficiency. In Kerala as per Comprehensive National Nutrition Survey - CNNS 2016-20186 among 2-4 years 40.7% children were excluding dairy products and 53% were excluding egg from their diet, which is more than what was observed in the study. Gordon CM et al7 in his study on Prevalence of Vitamin D deficiency among healthy adolescents found out that 4.6% children were Vitamin D deficient and 42 % had low vitamin D level, compared to 6% and 36% respectively in this study. The findings of the study conducted by Garg D et al8 reported statistically significant difference between cases with pneumonia and controls, with respect to vitamin D deficiency and insufficiency, which is in accordance with this study. In their study, 47.5% cases showed low vitamin D compared to 22.5 % controls. There are clinical and molecular evidences that vitamin D supplementation reduces the rate of respiratory tract infections.9,10,11  In a previous study from the same region, association between Vitamin D deficiency and severity of pneumonia among children has been reported.12

Conclusion

Vitamin D insufficiency and deficiency was significantly more in those with severe pneumonia, compared to controls. Inadequate sunlight exposure, lack of Vitamin D rich food (egg/milk) in diet were associated with low Vitamin D levels. Adequate sunlight exposure and inclusion of Vitamin D rich diet should be encouraged.

The findings of the study recommend targeted public health interventions addressing vitamin D deficiency and its potential impact on respiratory health.

Limitations

Only a larger sample size can increase generalizability of the study. Effect of confounders like air pollution, nutritional sufficiency was not included in the study.

End Notes

Author Information

  1. Dr Anupama Thanka, Department of Pediatrics, Ananthapuri Hospital & Research Institute, Thiruvananthapuram
  2. Dr Gopika Sekhar, Department of Pediatrics, Ananthapuri Hospital & Research Institute, Thiruvananthapuram. 
  3. Dr Mili Thomas, Department of Pediatrics, Ananthapuri Hospital & Research Institute, Thiruvananthapuram.
  4. Dr Elizabeth KE, Department of Pediatrics, Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari District.

Conflicts of Interest: None.

Financial Support: Nil. The Kit to undertake Vitamin D level was provided by the investigators.

The support from the Hospital management and the cooperation from the children and their parents are gratefully acknowledged.

References

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