PREVALENCE OF ANEMIA AMONG CHILDREN DIAGNOSED WITH PNEUMONIA ATTENDING BIRAT MEDICAL COLLEGE TEACHING HOSPITAL, MORANG, NEPAL

1* 2 3 Chandra Bhushan Jha , Hem Sagar Rimal , Ram Bhakta Subedi Introduc on Childhood pneumonia is the leading cause of serious illness and death worldwide. In developing countries, pneumonia is the biggest single cause of childhood death under the age of 5 years. Globally, anemia is a major nutri onal problem of immense public health significance. Iron deficiency anemia in children occurs most frequently between the age of 6 months and 3 years, the same period of age when repeated infec ons occur. Objec ve The main objec ve of this study is to determine the prevalence of anemia among children diagnosed with pneumonia. Methodology This is a hospital based cross sec onal study carried out in the Department of Paediatrics, Birat Medical College th th Teaching Hospital from 15 February 2020 to 15 August 2020. The physical finding such as: fever, tachypnoea, breathing difficul es, rhonchi, crackles, and wheezing were used to diagnose pneumonia. According to World Health Organiza on, the tachypnea thresholds to diagnose pneumonia are: in children between two and twelve months, 50 breaths per minute (Normal 25-40 breaths per minute); 40 breaths per minute in children between one and five years (Normal 20-30 breaths per minute). This study was performed on 150 pneumonic children between 6 to 60 months of age. History regarding fever, cough and fast breathing was taken. All the data were recorded in the preformed proforma. Data was analyzed using SPSS version 16. Result This study was performed on 150 pneumonic children, in which male babies (n=93; 62%) outnumbered the female babies (n=57; 38%). The majority of children were in the age group of 6 to 24 month (n=85; 56.7%). The mean hemoglobin level was 9. 49±1.39 gm/dl. The hemoglobin level less than 11 gm/dl was seen in 102 (68%) cases. Microcy c hypochromic anemia was present in 73 (71.6%) children. Conclusion The prevalence of anemia among the pneumonic children of 6-60 months is 68% that is higher than the na onal data (52.6%) of prevalence of anemia in the same age group. While trea ng childhood pneumonia, checking hemoglobin on regular basis will be very useful to diagnose and manage concurrent anemia

Teaching Hospital from 15 February 2020 to 15 August 2020. The physical finding such as: fever, tachypnoea, breathing difficul es, rhonchi, crackles, and wheezing were used to diagnose pneumonia. According to World Health Organiza on, the tachypnea thresholds to diagnose pneumonia are: in children between two and twelve months, 50 breaths per minute (Normal 25-40 breaths per minute); 40 breaths per minute in children between one and five years (Normal 20-30 breaths per minute). This study was performed on 150 pneumonic children between 6 to 60 months of age. History regarding fever, cough and fast breathing was taken. All the data were recorded in the preformed proforma. Data was analyzed using SPSS version 16.

Conclusion
The prevalence of anemia among the pneumonic children of 6-60 months is 68% that is higher than the na onal data (52.6%) of prevalence of anemia in the same age group. While trea ng childhood pneumonia, checking hemoglobin on regular basis will be very useful to diagnose and manage concurrent anemia KEYWORDS Anemia, Hemoglobin, Pneumonia.

INTRODUCTION
Childhood pneumonia is the leading cause of serious illness and death worldwide and it can be generally defined as 1. inflamma on of the lung parenchyma. In developing countries, pneumonia is the biggest single cause of childhood death under the age of 5 years. Globally each year there are about three million deaths, less than 5 years of age are due to pneumonia. Out of total deaths, 90 to 95% are in the 2 developing countries. Globally, anemia is a major nutri onal problem of immense public health significance, affec ng persons of all ages, sex 3 and economic group. Various predisposing factors, including nutri onal, gene c, and infec ous disease factors are seen; however, iron deficiency causes 75% of anemia 4 cases. An iron deficiency is frequently iden fied during the 6 months to 3 years which can be due to the loss of the iron stock taken from the mother during the last trimester of pregnancy and due to the lack of iron intake due to the food 5 diversifica on and explora on period. The hemoglobin (Hb) level is the most reliable indicator in the diagnosis of anemia 6 among individuals. In the immune system, iron func ons are essen al, among which are: the maintenance of the ac vity of phagocyte oxidase; the increase of expression of the inducible nitric oxide synthase (iNOS). In the same way, intracellular iron promotes the ac va on of factor nuclear kappa B (NF-κB) 7 and toll-like receptor 4 (TLR4) signaling. Therefore, there is an associa on between iron deficiency and a reduced immune response to infec on. On the other hand, an iron excess can be used by bacteria to improve its growth. This associa on between iron and the immunological system could explain an increased risk of respiratory tract infec on 8 observed in children with iron deficiency anemia. Iron deficiency anemia in children occurs most frequently between the age of 6 months and 3years, the same period of age when repeated infec ons occur. Whatever may be the e ology of anemia is, the rela on between low hemoglobin level and pneumonia has not been fully evaluated, and only 2 few reports are available evalua ng this subject. Detailed clinical examina on and imaging may help in diagnosing pneumonia but clinical management is dependent on the predisposing factors associated with pneumonia. Thus, it holds a very important diagnos c significance. Significant morbidity or morbidity can be prevented if anemia as a risk factor associated with pneumonia is diagnosed early. The research findings may be useful for the pediatricians to make comprehensive management plan at an early stage while dealing with children with pneumonia. The main objec ve of this study is to determine the prevalence of anemia among children diagnosed with pneumonia. 30 breaths per minute). The study was conducted on 150 children between the age of 6 month to 60 month with the clinical diagnosis of pneumonia. The informed wri en consent was taken from their parents. Parents of children unwilling to give consent, children with other systemic illness, those already received an bio cs from outside and with the diagnosis of concomitant condi ons that could affect the anthropometric or hemoglobin parameters, or that could predispose to pneumonia were excluded. Hemoglobin level below 11 gm/dl was considered low in this study. The complete history and thorough physical examina on were carried out in all the children. Complete blood count, mainly considering hemoglobin level and red blood cell indices were es mated. In red blood cell indices, mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentra on (MCHC) and red cell distribu on width (RDW) were es mated to classify the type of anemia. Anemia was defined and classified according to WHO criteria and the severity of anemia according to pa ent's hemoglobin level (Severe anemia, Hb <7 gm/dl; moderate anemia, Hb 7-9.9 gm/dl; and mild anemia, Hb 10-10.9 gm/dl). The data was recorded in a predesigned proforma and data analysis was done using sta s cal package of social science (SPSS) version 16. Numerical variables were reported in terms of mean and standard devia on. Categorical variables were reported in terms of numbers and percentages.

RESULTS
The present study cons tuted a total of 150 cases, in which male babies (n=93; 62%) outnumbered the female babies (n=57; 38%). The majority of children were in the age group of 6 to 24 month (n=85; 56.7%), and the remaining 65 (43.3%) children between 25 to 60 month.
Cough, fever and fast breathing were the main symptoms  The hemoglobin level less than 11 gm/dl was seen in 102 (68%) cases and greater than 11 gm/dl was seen in 48(32%) cases. Therefore the prevalence of anemia in pneumonic children was 68% in our study. The mean hemoglobin level was 9. 49±1.39 gm/dl. (Table 3)   The majority of anemic children, 64 (62.7%) were in the age group of 6 to 24 month with 38(37.3%) being of 24 to 60 months. (Table 5) Out of 102 anemic cases, 4 (3.9%) belonged to <7 gm/dl, 25 (24.5%) belonged to 7 to 9.9 gm/dl and 73(71.6%) belonged to 10 to 10.9 gm/dl. (Figure 1)  male children with pneumonia respec vely. In this study, 85 (56.7%) children were of 6-to-24-month age group with 65 (43.3%) children of 25 to 60 month which is comparable with the study conducted by Km et al where 10 79% children were of 6 to 24 months. The increased incidence of Pneumonia in below 24-month age group can be due to loss of acquired immunity and the fragility of the defense system in the context of contouring and consolida on of the immune status but also of the contact with the environment. In this study, cough, fever and fast breathing were the main symptoms observed in 150 (100%), 121 (80.7%) and 102 The most common cause for microcy c and hypochromic anemia is iron deficiency and a er 6month of age, iron stores are depleted and it is the me at which iron demand increases. Microcy c and hypochromic anemia was diagnosed on the basis of high RDW, low MCV, low MCH and low MCHC which are the findings seen in iron deficiency anemia as well. Serum ferri n level was not done as ferri n level is not reliable in cases with infec on as it increases probably as acute phase protein.

CONCLUSION
Increased prevalence of anemia is noted in children below 24 months with pneumonia in our study. While trea ng childhood pneumonia, anemia is generally neglected so pediatricians must check hemoglobin levels on a rou ne basis among this targeted popula on.

RECOMMENDATION
In the view of high probability of anemia in pneumonic children, screening for anemia on a regular basis needs to be considered.

LIMITATIONS OF STUDY
An important limita on to our study is the small number of pa ents. Our study reflects data from one center only and may not represent that of other centers across the country. Hence, mul center trials would be necessary to determine the prevalence of anemia in pneumonic children.