Effect of immunonutritional status,healthcare factors,and lifestyle on acute respiratory infections among under-5 children in Bangladesh

Abstract

Introduction:

Acute respiratory infection is a major cause of death for under-5 children in Bangladesh. We aimed to analyze the effect of immunonutritional status, healthcare factors, and lifestyle on the incidence of acute respiratory infection among under-5 children taking individual-level and contextual-level risk factors into consideration.

Methods:

This study recruited 200 children suffering from acute respiratory infection and 100 healthy controls matched by age, sex, and sociodemographic profile. Serum antioxidant vitamin A (retinol), vitamin C (ascorbic acid), and vitamin E (α-tocopherol) were assessed along with the impact of vaccination, socioeconomic factors, and Z-score on the incidence of acute respiratory infection.

Results:

Serum antioxidant vitamins were significantly lower in the acute respiratory infection children compared to the non–acute respiratory infection group. Vitamin A was found to be significantly high in acute respiratory infection children who were breastfed for more than 1 year. Vitamin E levels were found to be significantly higher in the acute respiratory infection children who were immunized. Compared to the children living in tin-shed house or huts, serum vitamin E level increased in those acute respiratory infection children who resided in apartments. Vitamin A level was significantly high in those acute respiratory infection children whose height-for-age was −2 SD and above (Z-score), and vitamin C levels were also significantly high in those acute respiratory infection children whose weight-for-height was −2 SD and below (Z-score).

Conclusion:

Deficiencies of antioxidant vitamins along with healthcare and lifestyle factors have a significant influence on the incidence of acute respiratory infection among under-5 children in Bangladesh.

Keywords

Immunonutrient healthcare factors lifestyle acute respiratory infection Bangladesh

Introduction

Acute respiratory infection (ARI) is a major public health problem affecting young children worldwide.¹ It is a leading cause of morbidity and mortality in children; particularly in developing countries, the mortality rate is 30–70 times higher than in developed countries.^2–5 In each year, ARI is responsible for nearly 4 million deaths and the leading cause of death for under-5 children in developing countries.⁶ Every year, 15 million under-5 children surrender to death in the developing countries and ARI accounts for one-third of these deaths.^7–10 It is frequently surpassing diarrheal diseases and every year more than 4 million children (>10,000 per day) die of ARI worldwide.¹¹ It has been reported that Bangladesh, India, Indonesia, and Nepal together account for 40% of the global ARI mortality.¹² Every day, 400 children die of ARI in Bangladesh and about 19% of all under-5 child deaths are linked to ARI.⁹

Nutrients from food source or supplementation are considered as key factors for oxidative stress and immunity in human.^13–15 Immunonutrients possess the ability to modulate the immune regulatory responses by interventions with specific nutrients. Vitamin A, C, and E are important antioxidant immunonutrients having potential immune-enhancing properties. Vitamin E is found to protect cells against lipid peroxidation, increase the production of total T-lymphocytes and T-helper marker, and enhance lymphocyte proliferation.¹⁶ Vitamin E has been further associated with reducing prostaglandin production and lipid peroxidation in the immune cells, as well as enhanced cell-mediated immunity.^16–18 Vitamin C is a quencher of free-radicals and singlet oxygen and it can also regenerate vitamin E.¹⁹ Vitamin C stimulates leukocyte functions including neutrophils motility, phagocytosis, delayed hypersensitivity, and antimicrobial activity.²⁰ Vitamin C deficiency has been noted to reduce T-lymphocyte-mediated activity and cell-mediated cytotoxicity. It is also associated with chemotactic function by reducing intra- and extracellular reactive oxygen species (ROS) and plays a unique role in protecting vitamin A and E.^17,21 The immunoenhancing property of antioxidant vitamins is attributable to their antioxidant activity.^22–25 Vitamin A supplementation enhances immune responses including antigen-specific T-lymphocyte proliferation, antibody production, and resistance to infection.^26–29

It is evident from numerous sources that multiple immunonutrient deficiencies are associated with ARI, diarrhea, and other infections.^30–32 Immunonutrients possess the ability to modulate and regulate immune responses by interventions with specific nutrients. Vitamin A, E, and C are important antioxidant immunonutrients having potential immune-enhancing properties. Supplementation of immunonutrient has been observed to significantly reduce ARI-specific morbidity and mortality,^33–35 but there has been some dubiety regarding this outcome.^36,37 However, deficiencies of the micronutrients contribute to the development of immunodeficiency and multiple disorders.^38–41 Although several types of research on ARI, particularly on its incidence, prevalence, and management, have been carried out worldwide, studies relating the role of immunonutritional status on the occurrence of ARI are too scarce to be found. Therefore, attempts have been made, in this study, to investigate the immunonutritional profile, healthcare, lifestyle, and socioeconomic factors of the ARI-affected children and the possible correlation of these factors with the incidence of ARI.

Materials and methods

Study population

This is a prospective case–control study conducted at the pediatrics department of Dhaka Medical College Hospital (DMCH), Dhaka, Bangladesh, from May 2017 to April 2018. We selected DMCH for our study place as it is the country’s leading tertiary care teaching hospital and patients are frequently admitted here from different parts of Bangladesh. The sample size was calculated based on the standard method as described by World Health Organization (WHO) and International Development Research Centre (IDRC) (1991). We expected that alpha risk and exposed controls will be 5% and 15%, respectively. To detect an odds ratio of 3, we designed a 1:2 matched case–control study with 95% power. The estimated total sample was 276 (184 cases and 92 controls) based on the above assumptions. Thus, this study recruited 200 children (aged 6–59 months) suffering from ARI and 100 non-ARI healthy children having similar age, sex, and socioeconomic backgrounds as cohort controls. The main clinical features considered for the diagnosis of ARI in the children were cough, fever, rapid respiration, chest indrawing, and culture test.

A questionnaire was prepared and subjected to a preliminary test among 50 hospitalized ARI children, who were excluded from the study population. The questionnaire was used only for this study as a pilot test (see the Supplemental Material). Immunization history (such as BCG, DPT, Polio, and Measles), as well as a history of colostrum and breastfeeding practices of the ARI children along with supplementation of high potency vitamin A capsule, was also investigated. Exclusion criteria included a history of diarrhea or other infectious diseases; known or suspected cases of renal, heart, and liver diseases; bone marrow hypoplasia; aplasia; autoimmune diseases such as systemic lupus erythematosus (SLE); and cancer. Children who were being treated with gold, antimalarial drugs, immunosuppressants, and phenylbutazone were also excluded. The socioeconomic status including information on education, occupation, income, and housing conditions was collected by a physician for both ARI and non-ARI children. The study was designed to analyze serum concentrations of antioxidant vitamins (A, C, and E) of ARI children.

Biochemical analysis

The venous blood sample was collected aseptically from each of the case and control subjects, and the blood specimen was subjected to centrifugation (3000 r/min, 10 min) to extract serum. A part of the serum was treated with trichloroacetic acid (TCA) for analysis of vitamin C. The remaining serum was aliquot into Eppendorf tubes and stored at −20°C for analysis of vitamin A and E as retinol and α-tocopherol. Reversed-phase high-performance liquid chromatography (HPLC, LC-10AD; Shimadzu, Japan) was used for the simultaneous determination of serum vitamin A and E.⁴² The analytes vitamin A and E were isolated from the serum by liquid–liquid extraction using n-hexane, concentrated by evaporation under a nitrogen stream and reconstituted with HPLC-grade ethanol. The reconstituted sample (50 µL) was then injected into the HPLC instrument. A reverse-phase shim-pack C₁₈ CLC-ODS (M) column of diameter 4.6 mm (LC Column, 4.6 mm × 250 mm, No. 1256168; Shimadzu) was used with methanol: water (95:5) as mobile phase flowing at 1 mL/min, detector set at one attenuation. The column was re-equilibrated with the mobile phase for 5 min before the next injection. Vitamin A and E were detected spectrophotometrically at 291 nm. Every sample was injected consequently twice to have replicate chromatographs. Standard analytes were injected for every 25–30 test samples. Vitamin A and E were detected spectrophotometrically at 291 nm. Standard vitamin E, A, and C were purchased from Sigma Chemical Co. (USA) and solvents (HPLC grade) were purchased from Merck (Germany).

The serum, after extraction, was treated immediately with TCA and centrifuged at 3000 r/min for 10 min for vitamin C analysis. The clear supernatant thus obtained was stored at −20°C until analysis. Serum vitamin C was estimated using spectrophotometry with phenylhydrazine as an indicator.⁴³ Absorbance was measured against a reagent blank at 520 nm using a spectrophotometer (UV-1201, UV-vis; Shimadzu). Every sample was analyzed twice to have duplicate readings. Chemicals used in the analysis of serum vitamin C were purchased from Merck and Sigma Chemical Co.

Statistical analysis

SPSS software package (version 23.0; SPSS Inc., USA) was used to analyze the data. Descriptive statistics (frequencies, descriptive, crosstabs) and compare means (independent-samples t-test) were used to calculate all variables. Values were expressed as percentage, mean, and standard deviation. One-way analysis of variance (ANOVA, descriptive) and correlation (Pearson’s and χ²) were used to evaluate the influence of socioeconomic factors and healthcare facilities on the different parameters investigated.

Results

Results showed that serum vitamin A, C, and E levels in the ARI children were significantly low than that of non-ARI children (Table 1 and Figure 1). Vitamin A levels were found to be significantly low in the ARI children (0.94 ± 0.77 μmol/L) compared to non-ARI controls (1.28 ± 0.43 μmol/L) (t = 4.15, p < 0.001). Vitamin C content was significantly low in the ARI children (25.36 ± 15.71 μmol/L) compared to non-ARI controls (29.36 ± 12.75 μmol/L) (t = 2.20, p = 0.02). Serum concentrations of vitamin E were found to be 4.45 ± 4.05 μmol/L in the ARI children, while it was 6.51 ± 5.12 μmol/L in the non-ARI controls (t = 3.86, p < 0.001).

Table 1.

Serum concentration of vitamin E, C, and A of ARI (N = 200) and non-ARI (N = 100) children.

Antioxidant vitamin (μmol/L)	ARI children		Non-ARI children		p-value*
	% (n)	Mean ± SD	% (n)	Mean ± SD
Vitamin E
0.00–4.9	64.5 (129)	4.45 ± 4.05	54.0 (54)	6.51 ± 5.12	t = 3.86 p < 0.001
5.0–9.9	27.0 (54)		33.0 (33)
10.0–14.9	5.0 (10)		6.0 (6)
15.0–19.9	1.5 (3)		3.0 (3)
20.0–30.0	2.0 (4)		4.0 (4)
Vitamin C
4.0–9.9	21.5 (43)	25.36 ± 15.71	4.0 (4)	29.36 ± 12.75	t = 2.20 p = 0.02
10.0–19.9	16.0 (32)		28.0 (28)
20.0–29.9	28.0 (56)		34.0 (34)
30.0–39.9	15.5 (31)		22.0 (22)
40.0–60.0	19.0 (38)		12.0 (12)
Vitamin A
0.00–0.49	21.0 (42)	0.94 ± 0.77	11.0 (11)	1.28 ± 0.43	t = 4.15 p < 0.001
0.50–0.99	24.5 (49)		19.0 (19)
1.00–1.49	31.5 (63)		41.0 (41)
1.50–1.99	10.5 (21)		25.0 (25)
2.00–3.00	12.5 (25)		4.0 (4)

ARI: acute respiratory infection; SD: standard deviation.

Every sample was analyzed twice to have replicate readings. Human antioxidant vitamin level in serum ranges—vitamin E: 22–29 μmol/L, vitamin A: 0.35–1.75 μmol/L, and vitamin C: 30–110 μmol/L.

p < 0.05.

Figure 1.

Mean (SEM) concentration of serum antioxidant vitamins (E, C, and A) in ARI (N = 200) and non-ARI (N = 100) children.

Effect of healthcare on the antioxidant vitamin status of children with ARI

DPT, Polio, colostrum, and vitamin A supplementation showed no influence on serum vitamin status (Table 2). BCG and measles vaccination had a positive correlation vitamin E. Period of breastfeeding had positive correlation with vitamin A. The serum concentration of vitamin E was found to be significantly high in the ARI children who were immunized with BCG vaccine (F(1, 198) = 3.73, p = 0.05) and measles vaccine (F(1, 198) = 5.63, p = 0.01). The serum concentration of vitamin A was found to be significantly high in the ARI children who were breastfed for more than 1 year (F(1, 198) = 5.53, p = 0.02).

Table 2.

Effect of healthcare factors on the antioxidant vitamin status of ARI children.

Parameters		% (n)	Vitamin E^a Mean ± SD	Vitamin A^b Mean ± SD	Vitamin C^c Mean ± SD
BCG¹
	Yes	90.0 (180)	4.60 ± 4.13*	0.95 ± 0.77	25.20 ± 15.87
	No	10.0 (20)	2.77 ± 2.50*	0.82 ± 0.78	26.81 ± 14.41
DPT²
	Yes	90.0 (180)	4.59 ± 4.13	0.95 ± 0.77	25.65 ± 15.72
	No	10.0 (20)	2.81 ± 2.48	0.78 ± 0.68	22.81 ± 15.71
Polio³
	Yes	97.0 (194)	4.44 ± 4.03	0.94 ± 0.77	25.20 ± 15.72
	No	3.0 (6)	3.55 ± 2.30	89 ± 0.83	30.49 ± 15.58
Measles⁴
	Yes	62.0 (124)	4.94 ± 4.52*	0.90 ± 0.71	24.79 ± 15.43
	No	38.0 (76)	3.56 ± 2.88*	0.99 ± 0.87	26.29 ± 16.20
Colostrum⁵
	Yes	91.0 (182)	4.39 ± 4.07	0.93 ± 0.77	25.07 ± 15.84
	No	9.0 (18)	4.66 ± 3.42	1.01 ± 0.79	28.27 ± 14.35
Breast feeding (m)⁶
	>12	53.0 (106)	4.45 ± 4.06	1.05 ± 0.77*	25.48 ± 15.85
	⩽12	47.0(94)	3.59 ± 3.15	0.79 ± 0.76*	22.43 ± 12.12
Vitamin A supplementation⁷
	Yes	68.5 (137)	4.47 ± 4.03	0.93 ± 0.78	24.81 ± 16.25
	No	31.5 (63)	4.29 ± 4.05	0.95 ± 0.76	26.57 ± 14.49

SD: standard deviation.

F(1, 198) = 3.73, p = 0.05; ^1bF(1, 198) = 0.47, p = 0 .49; ^1cF(1, 198) = 0.18, p = 0.66; ^2aF(1, 198) = 3.56, p = 0.06; ^2bF(1, 198) = 0.86, p = 0.35; ^2cF(1, 198) = 0.58, p = 0.44; ^3aF(1, 198) = 0.28, p = 0.59; ^3bF(1, 198) = 0.01, p = 0.89; ^3cF(1, 198) = 0.65, p = 0.41; ^4aF(1, 198) = 5.63, p = 0.01; ^4bF(1, 198) = 0.68, p = 0.41; ^4cF(1, 198) = 0.42, p = 0.51; ^5aF(1, 198) = 0.07, p = 0.78; ^5bF(1, 198) = 0.18, p = 0.66; ^5cF(1, 198) = 0.67, p = 0.41; ^6aF(1, 198) = 0.34, p = 0.55; ^6bF(1, 198) = 5.53, p = 0.02; ^6cF(1, 198) = 0.28, p = 0.59; ^7aF(1, 198) = 0.08, p = 0.76; ^7bF(1, 198) = 0.03, p = 0.86; ^7cF(1, 198) = 0.54, p = 0.46.

p < 0.05.

Effect of lifestyle on the antioxidant vitamin status of children with ARI

Educational qualification and type of occupation of the parents did not influence the serum levels of vitamins A, C, and E (Table 3), but income and housing status had a significant impact on the serum levels of vitamin A and E. It was found that the income of the parents had a significant influence on vitamin A content of ARI children (F(2, 197) = 2.80, p = 0.05). Moreover, vitamin E level was high in those ARI children who resided in the apartments (F(2, 197) = 3.35, p = 0.03). As the age of the children with ARI increased, serum vitamin E (F(3, 196) = 2.70, p = 0.04) and C (F(3, 196) = 2.89, p = 0.03) levels significantly decreased. Z-scores (height-for-age and weight-for-height) had a significant influence on serum vitamin A and C levels (Table 3). The concentration of vitamin A was found to be significantly high in those ARI children whose height-for-age was −2 SD and above (Z-score) (F(1, 197) = 3.52, p = 0.05). Serum vitamin C level was also shown to be significantly high in those ARI children whose weight-for-height was −2 SD and below (Z-score) (F(1, 198) = 3.45, p = 0.05).

Table 3.

Effect of socioeconomic factors and Z-scores on the vitamins of ARI children (N = 200).

Sociodemographic factors	% (n)	Vitamin E^a (µmol/L)	Vitamin A^b (µmol/L)	Vitamin C^c (µmol/L)
Education¹
Illiterate	24.0 (48)	3.36 ± 2.38	0.79 ± 0.75	26.09 ± 13.76
Primary	36.5 (73)	4.72 ± 4.27	0.91 ± 0.72	26.83 ± 17.69
Secondary	17.5 (35)	4.58 ± 4.44	1.03 ± 0.68	22.29 ± 15.05
>Secondary	22.0 (44)	4.92 ± 4.44	1.05 ± 0.83	22.59 ± 14.81
Occupation²
Business	22.0 (44)	5.25 ± 4.89	1.10 ± 0.71	24.29 ± 15.91
Labor	24.0 (48)	4.03 ± 3.71	0.86 ± 0.71	26.79 ± 18.46
Rickshaw puller	19.0 (38)	4.70 ± 4.59	0.75 ± 0.64	24.23 ± 15.37
Service	24.0 (48)	4.22 ± 3.61	0.93 ± 0.80	26.11 ± 14.17
Others	11.0 (22)	3.51 ± 2.17	1.10 ± 0.81	24.70 ± 13.39
Income³ (M) US$
40–60	48.5 (97)	4.10 ± 3.69	0.89 ± 0.74*	24.79 ± 16.87
61–80	41.5 (83)	4.48 ± 4.19	0.90 ± 0.79*	25.23 ± 14.88
>80	10.0 (20)	5.68 ± 4.80	1.32 ± 0.78*	28.69 ± 13.32
Age (month)⁴
6–24	38.0 (76)	4.04 ± 3.18*	0.93 ± 0.86	28.43 ± 16.68*
25–36	20.0 (40)	6.01 ± 5.54*	0.79 ± 0.74	27.25 ± 14.72*
37–48	18.5 (37)	4.17 ± 4.00*	1.02 ± 0.73	20.53 ± 16.61*
49–59	23.5 (47)	3.86 ± 2.52*	0.99 ± 0.67	22.59 ± 12.98*
Housing status⁵
Building	18.5 (37)	5.85 ± 5.19*	1.02 ± 0.77	21.49 ± 11.64
Tin shed	34.0 (68)	4.42 ± 3.71*	1.03 ± 0.72	25.74 ± 16.84
Kacha	47.5 (95)	3.85 ± 3.62*	0.83 ± 0.80	26.60 ± 16.15
Z-score⁶
Height for age⁽ⁱ⁾
−2.00 and below	37.0 (74)	4.33 ± 4.16	0.80 ± 0.73*	23.20 ± 15.58
above −2.00	63.0 (126)	4.46 ± 3.97	1.01 ± 0.79*	27.31 ± 15.64
Weight for age⁽ⁱⁱ⁾
−2.00 and below	69.0 (138)	4.47 ± 4.15	0.93 ± 0.76	25.72 ± 16.35
above −2.00	31.0 (62)	4.30 ± 3.78	0.95 ± 0.80	25.15 ± 15.38
Weight for height⁽ⁱⁱⁱ⁾
−2.00 and below	47.5 (95)	4.32 ± 4.22	0.95 ± 0.75	25.50 ± 16.32*
above −2.00	52.5 (105)	4.51 ± 3.86	0.92 ± 0.80	25.06 ± 14.37*

F(3, 196) = 1.48, p = 0.21; ^1bF(3, 196) = 1.09, p = 0.35; ^1cF(3, 196) = 0.72, p = 0.53; ^2aF(4, 195) = 0.93, p = 0.44; ^2bF(4, 195) = 1.42, p = 0.22; ^2cF(4, 195) = 0.23, p = 0.92; ^3aF(2, 197) = 1.28, p = 0.27; ^3bF(2, 197) = 2.80, p = 0.05; ^3cF(2, 197) = 0.51, p = 0.60; ^4aF(3, 196) = 2.70, p = 0.04; ^4bF(3, 196) = 0.70, p = 0.54; ^4cF(3, 196) = 2.89, p = 0.03; ^5aF(2, 197) = 3.35, p = 0.03; ^5bF(2, 197) = 1.54, p = 0.21; ^5cF(2, 197) = 1.44, p = 0.23; ^6a(i)F(1, 198) = 0.05, p = 0.82; ^6b(i)F(1, 197) = 3.52, p = 0.05;^6c(i)F(1, 197) = 0.06, p = 0.80; ^6a(ii)F(1, 198) = 0.07, p = 0.78; ^6b(ii)F(1, 198) = 0.04, p = 0.83;^6c(ii)F(1, 198) = 0.03, p = 0.85; ^6a(iii)F(1, 198) = 0.11, p = 0.73; ^6b(iii)F(1, 198) = 0.08, p = 0.77; ^6c(iii)F(1, 198) = 3.45, p = 0.05.

p < 0.05.

Discussion

ARI is one of the leading causes of morbidity and mortality among children in the developing world.⁴⁴ Prevention and reduction of this mortality rate is a worldwide public health priority, but its referral system to hospitals for case management is poor.⁴⁵ The prevalent malnutrition is an associated cause of death in about 30%–45% of ARI patients.⁴⁶ Many of these deaths could be prevented by early diagnosis and appropriate antimicrobial therapy. Unfortunately, the widespread, often unnecessary, use of antimicrobials has resulted in the emergence of drug-resistant organisms contributing to an already high ARI-related mortality. To combat this huge number of deaths from ARI, a thorough careful history, clinical examination, proper investigation, and case management are of utmost importance. Therefore, to address this public health issue given clinical management, this study has attempted to an extensive investigation into the immunonutritional profile of the ARI children encompassing their socioeconomic and healthcare facilities.

Analysis of serum vitamins A, C, and E indicated that there had been a significant decrease in the concentrations of these antioxidant vitamins in ARI children as compared to that of the non-ARI cohort controls. The results indicate that the ARI children had been suffering from deficiencies of multiple antioxidant vitamins. Deficiencies of immunoregulating antioxidant vitamins in infections are well evidenced.^29,38 This particular outcome might be associated with decreased food intake, impaired nutrient absorption causing direct nutrient loss, increased metabolic requirements or catabolic loss, and impaired utilization by infections.⁴⁷ Vaccination with DPT and Polio did not give significant correlation with vitamin E, but BCG and measles vaccination showed that the ARI children, who are immunized with BCG, measles, and are breastfed, have higher serum level of vitamin A and E, and may be less likely to come across ARI incidence. In addition, proper breastfeeding is one of the key factors in early life nutrition among children and adolescents. It shows several beneficial effects on physical and cardiorespiratory fitness.⁴⁸

In investigating the effect of socioeconomic and anthropometric factors on the vitamin level, income and housing status of the parents of ARI children had a significant correlation with vitamin A and E. The variables were positively correlated with age for vitamin A and C levels, stunting with vitamin A level and wasting with vitamin C level. Healthcare facilities, as well as socioeconomic factors of the ARI children, apparently influenced the level of these vitamins. Moreover, antioxidant vitamins and other nutrients may affect oxidative stress and immunity by interacting with each other when given combinedly. The combined supplementation of vitamin E and omega-3 fatty acids will increase the levels of total antioxidant capacity (TAC).⁴⁹ Vitamin D supplementation increases the serum levels of TAC, whereas decreases serum malondialdehyde levels.⁵⁰ In the present state of knowledge, no studies correlating the effect of immunonutritional profile together with socioeconomic and anthropometric factors on the antioxidant vitamin level of ARI-affected children in Bangladesh have been reported.

Limitations of the study

Although the research has attempted to be comprehensive, several limitations exist in this study. It would be better if we could evaluate the dietary intake and the quantity of antioxidants in the diet of participating children. This is considered a major limitation of this study. Besides, we did not measure the daily physical activities that effect the metabolism of vitamins in the body. Also, we did not detect the status of some other micro- and macronutrients, such as zinc, omega-3 fatty acids, vitamin D, copper, iron, and selenium, involved in the immunity. Only patients with microbiologically confirmed infections along with fast breathing and lower chest wall indrawing were included, while asymptomatic carriers were excluded in our analysis, which may have resulted in an underestimation of the true prevalence of the disease.

Conclusion

The study provides a wealth of information and allows exploring patterns related to ARI susceptibility among young children of Bangladesh in much greater detail than has been possible in preceding research. It has been found that poor socioeconomic conditions as well as housing patterns, proper vaccination, and multiple immunonutritional deficiencies are the significant factors of ARI in children and make them extremely prone to ARI. Immunonutritional deficiencies, in turn, induce increased susceptibility to ARI. These findings on the lifestyle and health variables and their relationships to ARI symptoms have thus been able to advance our knowledge. This will allow scholars and policymakers to evaluate the potential effectiveness of current undertakings aimed at refining public policy regarding ARI among young children. A significant reduction in the mortality rate can be achieved by implementing policies that embrace making available basic housing standards, enhancing the nutritional quality of diet, as well as improving immunization outreach program.

Supplemental Material

ARI_patient_Screening_Questionnaire – Supplemental material for Effect of immunonutritional status, healthcare factors, and lifestyle on acute respiratory infections among under-5 children in Bangladesh

Supplemental material, ARI_patient_Screening_Questionnaire for Effect of immunonutritional status, healthcare factors, and lifestyle on acute respiratory infections among under-5 children in Bangladesh by Md. Mustafa Kamal, Farina Aziz, Md. Rabiul Islam, Monira Ahsan and Sheikh Nazrul Islam in SAGE Open Medicine

Footnotes

Acknowledgements

The authors are thankful to the Department of Pediatrics, Dhaka Medical College and Hospital and Institute of Nutrition and Food Science, University of Dhaka for their technical and administrative support.

Author contributions

M.M.K., M.A., and S.N.I. conceived, designed, conducted, and analyzed the experiment. F.A. and M.R.I. collected the sample, analyzed the experiment, performed statistical analyses, wrote, and revised the manuscript. M.M.K. diagnosed and evaluated the study participants. M.A. and S.N.I. supervised the whole work and gave important intellectual content in the manuscript. All authors read and approved the final manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

The study was approved by the Ethical Review Committee of the Department of Pediatrics, Dhaka Medical College and Hospital, Dhaka, Bangladesh. All steps of these investigations were conducted as per the guideline declared by the Declaration of Helsinki.

Informed consent to participate

The aim of this study was briefly explained to each participant and written consent was taken from each of them who willingly participated in this study.

Informed consent to publish

All study participants or their primary caregivers acknowledged that anonymous data would be published in journal articles.

Informed consent

Legal protectors of all study participants were well briefed about the objective of the study and they signed informed consent. The written consent of the related was obtained from the primary care-giver if independent thinking capacity of any patient was suspected.

ORCID iD

Md. Rabiul Islam

Availability of data and materials

Data supporting our findings are available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

References

Benguigui

. Acute respiratory infections control in the context of the IMCI strategy in the Americas. Rev Bras Saúde Matern Infant 2003; 3(1): 25–36.

Broor

Pandey

Ghosh

, et al. Risk factors for severe acute lower respiratory tract infection in under-five children. Indian Pediatr 2001; 38(12): 1361–1369.

Dudley

Hussey

Huskissen

, et al. Vitamin A status, other risk factors and acute respiratory infection morbidity in children. S Afr Med J 1997; 87(1): 65–70.

Sikolia

Mwololo

Cherop

, et al. The prevalence of acute respiratory infections and the associated risk factors: a study of children under five years of age in Kibera Lindi Village, Nairobi, Kenya. J Natl Inst Public Heal 2002; 51(1): 67–72.

Zaman

Baqui

Yunus

, et al. Acute respiratory infections in children: a community-based longitudinal study in rural Bangladesh. J Trop Pediatr 1997; 43(3): 133–137.

Stewart

Parker

Chakraborty

, et al. Acute respiratory infections (ARI) in rural Bangladesh: perceptions and practices. Med Anthropol 1993; 15(4): 377–394.

Brüssow

Rytz

Freire

, et al. Risk factors associated with the recall of respiratory diseases in the Ecuadorian children. J Diarrhoeal Dis Res 1995; 13(4): 212–218.

Victora

Fuchs

Flores

JAC

, et al. Risk factors for pneumonia among children in a Brazilian metropolitan area. Pediatrics 1994; 93(6 Pt 1): 977–985.

Rashid

Hadi

Afsana

, et al. Acute respiratory infections in rural Bangladesh: cultural understandings, practices and the role of mothers and community health volunteers. Trop Med Int Health 2001; 6(4): 249–255.

10.

Sazawal

Black

. Meta-analysis of intervention trials on case-management of pneumonia in community settings. Lancet 1992; 340(8818): 528–533.

11.

Stanek

3rd Wafula

Onyango

, et al. Characteristics related to the incidence and prevalence of acute respiratory tract infection in young children in kenya. Clin Infect Dis 1994; 18(4): 639–647.

12.

Park

. Park’s textbook of preventive and social medicine. 23rd ed., India: Bhanot Publishers, 2015, p. 167.

13.

Heshmati

Morvaridzadeh

Maroufizadeh

, et al. Omega-3 fatty acids supplementation and oxidative stress parameters: a systematic review and meta-analysis of clinical trials. Pharmacol Res 2019; 149: 104462.

14.

Heshmati

Golab

Morvaridzadeh

, et al. The effects of curcumin supplementation on oxidative stress, Sirtuin-1 and peroxisome proliferator activated receptor γ coactivator 1α gene expression in polycystic ovarian syndrome (PCOS) patients: a randomized placebo-controlled clinical trial. Diabetes Metab Syndr 2020; 14(2): 77–82.

15.

Morvaridzadeh

Sepidarkish

Daneshzad

, et al. The effect of pomegranate on oxidative stress parameters: a systematic review and meta-analysis. Complement Ther Med 2020; 48: 102252.

16.

Penn

Purkins

Kelleher

, et al. The effect of dietary supplementation with vitamins A, C and E on cell-mediated immune function in elderly long-stay patients: a randomized controlled trial. Age Ageing 1991; 20(3): 169–174.

17.

Jeng

Yang

Siu

, et al. Supplementation with vitamins C and E enhances cytokine production by peripheral blood mononuclear cells in healthy adults. Am J Clin Nutr 1996; 64(6): 960–965.

18.

Meydani

Barklund

Liu

, et al. Vitamin E supplementation enhances cell-mediated immunity in healthy elderly subjects. Am J Clin Nutr 1990; 52(3): 557–563.

19.

Mayes

Botham

. Lipids of physiological significance. In: Murry

Granner

Mayes

, et al. (eds) Harper’s biochemistry. 25th ed. Stamford, CT: Appleton and Lange Stamford, 2000, pp. 160–171.

20.

Siegel

. Vitamin C and the immune response in health and disease. In: Klurfeld

(ed.) Nutrition and immunology. Boston, MA: Springer, 1993, pp. 167–196.

21.

Washko

Rotrose

Levine

. Ascorbic acid transport and accumulation in human neutrophils. Ann N Y Acad Sci 1989; 264(32): 18996–19002.

22.

Bendich

Antioxidant vitamins and immune responses. In: Chandra

(ed.) Nutrtion and immunology. New York: Alan R. Liss, 1988, pp. 125–147.

23.

Bendich

. Antioxidant micronutrients and immune responses. Ann N Y Acad Sci 1990; 587: 168–180.

24.

Bendich

. Vitamins and immunity. J Nutr 1992; 122(suppl_3): 601–603.

25.

Tengerdy

. The role of Vitamin E in immune response and disease resistance. Ann N Y Acad Sci 1990; 587: 24–33.

26.

Chandra

. 1990 McCollum Award Lecture. Am J Clin Nutr 1991; 53(5): 1087–1101.

27.

Duggan

Colin

Agil

, et al. Vitamin A status in acute exacerbations of cystic fibrosis. Am J Clin Nutr 1996; 64(4): 635–639.

28.

Friedman

Sklan

. Vitamin A and immunity. In: Klurfeld

(ed.) Nutrition and immunology. Boston, MA: Springer, 1993, pp. 197–216.

29.

Scrimshaw

SanGiovanni

. Synergism of nutrition, infection, and immunity: an overview. Am J Clin Nutr 1997; 66(2): 464S–477S.

30.

Martinez

. Clinical features and management. Ann Nestle 1999; 57: 88–95.

31.

Tupasi

Velmonte

Sanvictores

MEG

, et al. Determinants of morbidity and mortality due to acute respiratory infections: implications for intervention. J Infect Dis 1988; 157(4): 615–623.

32.

Victora

Kirkwood

Ashworth

, et al. Potential interventions for the prevention of childhood pneumonia in developing countries: improving nutrition. Am J Clin Nutr 1999; 70(3): 309–320.

33.

Hemilä

Douglas

. Vitamin C and acute respiratory infections. Int J Tuberc Lung Dis 1999; 3(9): 756–761.

34.

Grubesic

. The impact of vitamin a supplementation on children age 6-60 months in the mid-hills of Nepal. PhD Dissertation, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, 2001.

35.

Sazawal

Black

Jalla

, et al. Zinc supplementation reduces the incidence of acute lower respiratory infections in infants and preschool children: a double-blind, controlled trial. Pediatrics 1998; 102(1 Pt. 1): 1–5.

36.

Kjolhede

Chew

Gadomski

, et al. Clinical trial of vitamin A as adjuvant treatment for lower respiratory tract infections. J Pediatr 1995; 126(5 Pt. 1): 807–812.

37.

Stansfield

Pierre-Louis

Augustin

, et al. Vitamin A supplementation and increased prevalence of childhood diarrhoea and acute respiratory infections. Lancet 1993; 342(8871): 578–582.

38.

Chandra

. Nutrition and the immune system: an introduction. Am J Clin Nutr 1997; 66(2): 460S–463S.

39.

Marcos

Varela

Toro

, et al. Interactions between nutrition and immunity in anorexia nervosa: a 1-y follow-up study. Am J Clin Nutr 1997; 66(2): 485S–490S.

40.

Varela

Marcos

Santacruz

, et al. Human immunodeficiency virus infection and nutritional status in female drug addicts undergoing detoxification: anthropometric and immunologic assessments. Am J Clin Nutr 1997; 66(2): 504S–508S.

41.

Varela

Marcos

Ripoll

, et al. Effects of human immunodeficiency virus infection and detoxification time on anthropometric measurements and dietary intake of male drug addicts. Am J Clin Nutr 1997; 66(2): 509S–514S.

42.

Bieri

Tolliver

Catignani

. Simultaneous determination of α-tocopherol and retinol in plasma or red cells by high pressure liquid chromatography. Am J Clin Nutr 1979; 32(10): 2143–2149.

43.

Islam

Hossain

Kamal

, et al. Serum immunoglobulins and white blood cells status of drug addicts: influence of illicit drugs and sex habit. Addict Biol 2004; 9(1): 27–33.

44.

Ghazal

Al Howasi

Chowdhury

. Acute respiratory tract infections: epidemiological data, guided case management and outcome in a pediatric hospital in Riyadh. Ann Saudi Med 1998; 18(1): 75–78.

45.

Reyes

Perez-cuevas

Salmeron

, et al. Infant mortality due to acute respiratory infections: the influence of primary care processes. J Clin Epidemiol 1998; 51: S12.

46.

Fonseca

Kirkwood

Victora

, et al. Risk factors for childhood pneumonia among the urban poor in Fortaleza, Brazil: a case—control study. Bull World Health Organ 1996; 74(2): 199–208.

47.

Stephensen

. Vitamin A, infection, and immune Function. Annu Rev Nutr 2001; 21(1): 167–192.

48.

Heshmati

Sepidarkish

Shidfar

, et al. Effect of breastfeeding in early life on cardiorespiratory and physical fitness: a systematic review and meta-analysis. Breastfeed Med 2018; 13(4): 248–258.

49.

Sepidarkish

Akbari-Fakhrabadi

Daneshzad

, et al. Effect of omega-3 fatty acid plus vitamin E co-supplementation on oxidative stress parameters: a systematic review and meta-analysis. Clin Nutr 2020; 39(4): 1019–1025.

50.

Sepidarkish

Farsi

Akbari-Fakhrabadi

, et al. The effect of vitamin D supplementation on oxidative stress parameters: a systematic review and meta-analysis of clinical trials. Pharmacol Res 2019; 139: 141–152.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB