Hemoglobin level as a risk factor for lower respiratory tract infections in Lebanese children

Childhood Anemia and Risk for Acute Respiratory Infection, Gastroenteritis, and Urinary Tract Infection: A Systematic Review

Objective Children younger than 5 years, particularly children below 2 years, are among the most vulnerable groups for developing anemia and infections. This review is intended to assess the association between anemia and childhood acute respiratory infections (ARTIs), acute gastroenteritis (AGE), and urinary tract infections (UTIs).

Methods PubMed was searched for published articles from January 2000 to August 2021 in English using the following terms: anemia and acute respiratory tract infections in children; anemia and UTIs in children; anemia and AGE in children. The data extraction were conducted by two investigators using the same methodology. Using descriptive statistics, the data from different sources were synthesized, including medians and ranges.

Results A total of 426 articles and 27 original articles and 1 systematic review were included. Iron deficiency anemia is common among children between 6 months and 3 years of age. This age group can be considered a highly susceptible age for contraction of ARTI and AGE. Children below 5 years suffer five to six episodes of acute ARTI per year on average, and pneumonia accounts for the highest number of deaths, which is around 1.1 million each year. When considered, the odds ratio of anemia to increase the susceptibility of contracting lower ARTI would range from 2 to 5.7. Also, anemic children were 10 times more susceptible to developing acute recurrent ARTI and 4 times more susceptible to contracting pneumonia. Respiratory syncytial virus is the commonest viral etiology. Anemia would increase the risk of diarrhea by 2.9-fold in toddlers, while mild anemia, moderate anemia, and severe anemia would increase the susceptibility to contract AGE by 1.6, 1.6, and 8.9 times, respectively. Rotavirus is the commonest etiology. Some studies observed a protective effect of mild to moderate iron-deficient anemia from respiratory infections.

Conclusion Infectious disease imposes a heavy burden on the health sector in a country. The highest susceptibility for infections and the development of anemia would be due to inadequate nutrition supplementation to meet the demand during rapid body growth. Therefore, based on the available evidence, one can take the necessary steps to reduce the infectious disease burden by correcting the anemia status in children.

Factors associated with severe childhood community-acquired pneumonia: a retrospective study from two hospitals

Background

Community-acquired pneumonia (CAP) is the leading cause of death in children globally. Indonesia is ranked 1st in South East Asia with the highest burden of pneumonia. Identification of risk factors is necessary for early intervention and better management. This study intended to describe CAP’s clinical signs and laboratory findings and explore the risk factors of severe CAP among children in Indonesia.

Methods

This was a retrospective study of childhood hospitalizations in Siloam General Hospitals and Siloam Hospitals Lippo Village from December 2015 to December 2019. Demographic data, clinical signs, and laboratory findings were collected and processed using IBM SPSS 26.0.

Results

This study included 217 participants with 66 (30.4%) severe pneumonia cases. Multivariate analysis shows that fever that lasts more than 7 days (ORadj = 4.95; 95%CI 1.61–15.21, Padj = 0.005) and increase in respiratory rate (ORadj = 1.05, 95%CI 1.01–1.08, Padj = 0.009) are two predictors of severe pneumonia. Meanwhile, a normal hematocrit level (ORadj = 0.9; 95%CI 0.83–0.98, Padj = 0.011) and children with normal BMI (ORadj = 0.7; 95%CI 0.57–0.84, Padj < 0.001) are significant independent predictors of severe pneumonia. The Hosmer-Lemeshow test shows that this model is a good fit with a P-value of 0.281. The AUC for this model is 0.819 (95%CI = 0.746–0.891, P-value < 0.001) which shows that this model has good discrimination.

Conclusion

Pediatric CAP hospitalizations with fever lasting > 7 days and tachypnea were at higher risk for progressing to severe pneumonia. A normal hematocrit level and a normal BMI are protective factors for severe pneumonia.

The association of anemia with the clinical outcomes of community-acquired pneumonia in children

OBJECTIVES

Anemia is associated with severe outcomes in adult community-acquired pneumonia (CAP), but few studies investigated its association with pediatric CAP. Hence, we tried to delineate the association of anemia with the clinical outcomes of CAP in children.

METHODS

This retrospective cohort study was conducted from 2010 to 2019 in a medical center. Inpatients aged 6 months to 17 years who were diagnosed with CAP and without major underlying diseases were included. The subjects' clinical data within 24 h of admission and clinical outcomes were collected. We accessed the rates of adverse outcomes and the adjusted odds ratios (ORs) of these outcomes between anemic and nonanemic patients, as well as among patients with different types of anemia.

RESULTS

In this study of 3601 patients, the prevalence of anemia was 11.6% (418/3601). Anemic patients had higher rates of intensive care (16.8% vs. 3.6%; p < 0.001), endotracheal intubation (11.0% vs. 1.3%; p < 0.001), and empyema (8.6% vs. 0.6%; p < 0.001) than nonanemic patients. In addition, anemia was independently associated with intensive care (adjusted OR, 3.00; 95% confidence interval [CI], 2.03-4.42), endotracheal intubation (adjusted OR, 3.79; 95% CI, 2.17-6.63), and empyema (adjusted OR, 4.72; 95% CI, 2.30-9.69). Iron-deficiency anemia (IDA) and normocytic anemia were associated with these adverse outcomes but not with anemia due to thalassemia trait.

CONCLUSION

Anemia is a biomarker associated with poor outcomes in pediatric CAP, and patients with IDA or normocytic anemia should be carefully monitored and managed since they may have higher disease severity.

On-admission anemia predicts mortality in COVID-19 patients: A single center, retrospective cohort study

Objectives

We investigated the impact of anemia based on admission hemoglobin (Hb) level as a prognostic risk factor for severe outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19).

Methods

A single-center, retrospective cohort study was conducted from a random sample of 733 adult patients (age ≥ 18 years) obtained from a total of 4356 laboratory confirmed SARS-CoV-2 cases who presented to the Emergency Department of Montefiore Medical Center between March–June 2020. The primary outcome was a composite endpoint of in-hospital severe outcomes of COVID-19. A secondary outcome was in-hospital all-cause mortality.

Results

Among the 733 patients included in our final analysis, 438 patients (59.8%) presented with anemia. 105 patients (14.3%) had mild, and 333 patients (45.5%) had moderate-severe anemia. Overall, 437 patients (59.6%) had a composite endpoint of severe outcomes. On-admission anemia was an independent risk factor for all-cause mortality, (Odds Ratio 1.52, 95% CI [1.01–2.30], p = 0.046) but not for composite severe outcomes. However, moderate-severe anemia (Hb < 11 g/dL) on admission was independently associated with both severe outcomes (OR1.53, 95% CI [1.05–2.23], p = 0.028) and mortality (OR 1.67, 95% CI [1.09–2.56], p = 0.019) during hospitalization.

Conclusion

Anemia on admission was independently associated with increased odds of all-cause mortality in patients hospitalized with COVID-19. Furthermore, moderate-severe anemia (Hb <11 g/dL) was an independent risk factor for severe COVID-19 outcomes. Moving forward, COVID-19 patient management and risk stratification may benefit from addressing anemia on admission.

Sudden Sensorineural Hearing Loss Associated with Nutritional Anemia: A Nested Case-Control Study Using a National Health Screening Cohort

Previous studies have suggested an association of anemia with hearing loss. The aim of this study was to investigate the association of nutritional anemia with sudden sensorineural hearing loss (SSNHL), as previous studies in this aspect are lacking. We analyzed data from the Korean National Health Insurance Service-Health Screening Cohort 2002-2015. Patients with SSNHL (n = 9393) were paired with 37,572 age-, sex-, income-, and region of residence-matched controls. Both groups were assessed for a history of nutritional anemia. Conditional logistic regression analyses were performed to calculate the odds ratios (ORs) (95% confidence interval, CI) for a previous diagnosis of nutritional anemia and for the hemoglobin level in patients with SSNHL. Subgroup analyses were conducted for age and sex. Age, sex, income, and region of residence were stratified. Obesity, smoking, drinking alcohol, systolic/diastolic blood pressure, fasting blood glucose, total cholesterol, and the Charlson Comorbidity Index were considered in the regression models. Nutritional anemia was present in 4.8% (449/9393) of patients with SSNHL and 4.0% (1494/37,572) of controls (p < 0.001). The SSNHL group demonstrated 1.20-fold higher odds for nutritional anemia (95% CI = 1.08-1.34, p = 0.001). Hemoglobin levels were not associated with SSNHL. In subgroups <60 years old, there was a consistent positive association of nutritional anemia with SSNHL (adjusted OR = 1.55, 95% CI = 1.11-2.15, p = 0.010 for men <60 years old, and adjusted OR = 1.22, 95% CI = 1.02-1.45, p = 0.028 for women <60 years old). Nutritional anemia, but not hemoglobin level, was associated with an increased risk of SSNHL.

The Association between Iron Deficiency and Otitis Media with Effusion

OBJECTIVES

The purpose of this trial is to examine the clinical role of iron metabolism on development of Otitis media with effusion.

MATERIALS AND METHODS

This prospective study was conducted in a tertiary referral center. The study group made up of children who had surgery for Otitis media with effusion (OME). Control group was comprised of children who had surgery by a pediatric surgeon for inguinal hernia repair or circumcision operations with normal ear nose throat examination. Each group was evaluated depending on the serum iron metabolism parameters.

RESULTS

One-hundred-thirteen children with OME and 117 control patients were included to the study. Iron deficiency anemia was detected in 18 out of 113 patients (15.9%) in study group while there were 4 out of the 117 patients (3.4%) in control group (p:0.001).The mean hemoglobin level was 12.16 ± 1.16 in OME group and 12.93 ± 1.08 in control group (p<0.001).

CONCLUSION

The current study shows the rate of iron deficiency anemia is higher in patients with OME than controls. Iron-deficiency anemia might be considered a potential risk factor for development of otitis media with effusion, and iron parameters should be evaluated in these children.

Childhood iron deficiency anemia leads to recurrent respiratory tract infections and gastroenteritis

Anemia affects approximately 30% of children all over the world. Acute respiratory tract infections (ARTI), urinary tract infections (UTI) and gastroenteritis (GE) are common infectious entities in children. Here, we assessed the association between anemia and development of recurrent ARTI, UTI, and GE in children. This was a case-control study in hospitalized 2–5 years old children in Professorial Pediatric Unit at Teaching Hospital Anuradhapura, Sri Lanka. An 18-month follow up was done to assess the risk factors for the development of recurrent ARTI, GE, UTI, and control presented without infections. Further, 6-month follow up done after 3-month iron supplementation to assess the occurrence of recurrences. Blood Hb concentration was measured using Drabking’s reagent. Logistic regression was used to find the risk factors for the development of recurrences. In ARTI, 121/165 (73.3%), GE, 88/124 (71%), UTI 46/96 (47.9%) and control 40/100 (40%) were having anemia. Initial ARTI group, recurrent ARTI was 24 (14.5%, p = 0.03); initial GE group: recurrent GE was 14 (11.3%, p = 0.03), recurrent ARTI was 11 (8.9%, p = 0.04); initial UTI group, development of; recurrent UTI was 8 (8.3%, p = 0.04); control, recurrent ARTI was 11 (11%, p = 0.03). Following 3-month iron supplementation reduction of recurrences was significant: initial ARTI recurrent ARTI in 90%, recurrent GE in 77.7%; initial GE recurrent GE in 83.3%, recurrent ARTI in 80%; initial UTI recurrent ARTI in 71.4% and control recurrent ARTI in 88.8%. Iron deficiency is a major type of anemia and anemic children are more prone to develop recurrent ARTI and GE. Once iron deficiency being corrected the rate of recurrent ARTI and GE was reduced. This would be a boost for policy developers to implement strategies at the community level to prevent iron deficiency in children to reduce ARTI and GE recurrences.

Implications of the Iron Deficiency in Lower Tract Respiratory Acute Infections in Toddlers

Iron deficiency anemia can result in an abnormal immune response and an increased incidence of the respiratory tract infections. In this study we analyzed statistically the association of acute lower respiratory tract infections with anemic status and associated risk factors for a number of 166 toddlers (1-3 years), using a control group of 26 cases without infectious status. The statistical analysis indicated the significant association of the infectious status with the anemic status of the patients as well as with the rural living areas, non-natural nutrition, prematurity and respiratory history. At the same time, we found a statistically significant association of anemic status with rural living areas and non-natural diet. The results obtained can be used to stratify patients for standardized treatment to regulate the iron metabolism and implicitly to combat the infectious disease.

Infant anemia is associated with reduced TLR-stimulated cytokine responses and increased nasopharyngeal colonization with Moxarella catarrhalis

Anemia is a major public health problem in young children. Reports on the role of anemia on infectious diseases remained controversial. We aim to investigate the effect of anemia on innate immunity, nasopharyngeal bacterial colonization, and subsequent infectious outcome. Blood tests were examined at the age of 12 months. TLR-induced cytokine production was assessed by ELISA. Bacteria from nasopharyngeal specimens were identified with traditional culture. Clinical infectious diseases were followed yearly until 3 years of age. Result showed that of the 423 infants, 72 had hemoglobin level ≤ 11 g/dL, among which 55% had normal iron level. There was significant association between hemoglobin level and TLR1-2, and 4 induced IL-6 (p = 0.04, 0.02) and that of TLR4 stimulated TNF-α response (p = 0.04). Children with anemia had higher nasopharyngeal colonization with Moxarella catarrhalis. Clinical analysis did not show anemia to be associated with infectious morbidity. However, children who developed LRTIs had mean lower ferritin levels. We speculated that iron might be the key factor related to infectious morbidity. Thus, to investigate the role of anemia in infectious diseases, it is important to first consider the prevalence of iron deficit, since the incidence of iron deficiency-induced anemia may vary among different regions.

[Anemia, a new severity factor in young infants with acute viral bronchiolitis?]

INTRODUCTION

The role of anemia is raised as a risk of low respiratory infection of the child, but there are no data on anemia as a severity factor in acute viral bronchiolitis (AVB) in infants.

METHODS

All infants less than 16 weeks old admitted to Montpellier University Hospital from 2015/10/01 to 2016/04/01 for AVB were included in a retrospective observational study. The primary objective was to determine whether the hemoglobin (Hb) concentration on admission was an independent factor of clinical severity, judged by the modified Wood's clinical asthma score (m-WCAS). The secondary objective was to assess the impact of Hb level on the characteristics of hospitalization, including the type and duration of respiratory support.

RESULTS

The m-WCAS was used at least once during hospitalization in 180 out of 220 patients (82%), making it possible to distinguish patients with mild AVB (maximum m-WCAS<2, n=81) from patients with severe AVB (maximum m-WCAS>2, n=99). A logistic regression model indicated that the Hb concentration, for every 1g/dL decrement, was an independent factor of AVB severity (OR 1.16 [1.03-1.29], P=0.026). A level under 10g/dL on admission was associated with a higher use of continuous positive airway pressure (P<0.001), as well as a longer duration of respiratory support (P=0.01).

CONCLUSION

This study suggested that anemia may influence the clinical expression of AVB in young infants.

Pneumonia risks in bedridden patients receiving oral care and their screening tool: Malnutrition and urinary tract infection-induced inflammation

AIM

Pneumonia develops in bedridden patients even when they are receiving oral care. However, the pneumonia risk in bedridden patients remains unclear, and no screening tool has been developed to assess this risk by using daily hospital data.

METHODS

We retrospectively examined pneumonia risk factors by analyzing the records of 102 bedridden patients receiving oral care.

RESULTS

Body mass index, peripheral blood hemoglobin, and serum concentrations of total protein, albumin, total cholesterol and uric acid in the pneumonia group (n = 51; mean age 73.4 years) were lower than those in the non-pneumonia group (n = 51; mean age 68.1 years). In the univariate analysis, body mass index; leukocytosis; high C-reactive protein; low levels of hemoglobin, total protein and albumin (<3.5 g/dL); and urine bacteria were associated with the development of pneumonia. Furthermore, in the multivariate analysis, low levels of albumin and urine bacteria were independently associated with pneumonia. We developed a bedridden patient pneumonia risk (BPPR) score using these two risk factors to assess pneumonia risk. We applied scores of zero (0) or one (1) according to the absence or presence of the two risk factors and summed the scores in each patient. The proportion of pneumonia patients increased with increasing BPPR score when the patients were divided into three groups - low, moderate and high risk - according to the BPPR score (0, 1 or 2, respectively).

CONCLUSIONS

Malnutrition, urinary tract infection-induced inflammation and anemia were associated with pneumonia in bedridden patients. BPPR scoring might be useful for assessing pneumonia risk and managing affected patients. Geriatr Gerontol Int 2018; 18: 714-722.

Deferral for low hemoglobin is not associated with increased risk of infection in Danish blood donors

BACKGROUND

Low hemoglobin (Hb) is associated with poor general health and adverse outcomes in a wide range of diseases. However, a link between Hb levels and the risk of infection among healthy individuals has yet to be investigated.

STUDY DESIGN AND METHODS

Using data from the Scandinavian Donations and Transfusions database, 497,390 donors were followed after 5,458,499 donations in health registers. With 1,339,362 person-years of follow-up, Andersen-Gill Cox regression was used to study the association of Hb levels below deferral thresholds, very low Hb levels (in the lowest 0.1 percentile), and declining Hb levels with the risk of infection as measured by hospital or outpatient contact for infection and filling of prescription for antimicrobials, respectively, within 3 months of donation. Analyses were stratified by sex, menopausal status, and frequency of donation.

RESULTS

Hb levels below deferral thresholds were not associated with a risk of hospital contact for infection among premenopausal women (hazard ratio [HR], 1.04; 95% confidence interval [CI], 0.95-1.14), postmenopausal women (HR, 0.77; 95% CI, 0.54-1.11), or men (HR, 0.97; 95% CI, 0.81-1.16), nor was there any association with hospital contact for very low Hb levels or patterns of declining Hb levels. However, subthreshold Hb levels were associated with a reduced risk of antimicrobial prescriptions among premenopausal women (HR, 0.92; 95% CI, 0.91-0.93), postmenopausal women (HR, 0.93; 95% CI, 0.89-0.97), and men (HR, 0.91; 95% CI, 0.88-0.94).

CONCLUSIONS

Neither Hb levels below deferral thresholds nor very low or declining Hb levels were associated with an increased risk of infection. This is reassuring, because blood donation can lead to lower Hb levels.

Incidence and risk factors associated with iron deficiency anaemia among hospitalised Lebanese infants

OBJECTIVES

The primary objective of this study was to determine the prevalence of iron deficiency anaemia (IDA) in hospitalised 6- to 24-month-old infants in rural versus urban settings. The secondary objective was to determine associated risk factors in rural versus urban settings.

METHODS

A 6-month prospective multicentre cross-sectional study was conducted in paediatrics departments of three Lebanese hospitals. Preterm to term infants aged 6-24 months were included. Infants with blood disorders, chronic infections, congenital immunodeficiency and mental or congenital growth retardation were excluded. Incidence of IDA was assessed using haematologic laboratory values, while risk factors were assessed using questionnaires addressed to infants' caregivers. For data analysis, P values, chi-squared and logistic regression were used.

KEY FINDINGS

Among 520 screened infants, a total of 100 patients were selected. Thirty-seven per cent of patients were anaemic with haemoglobin levels <11 g/dl. Significant risk factors included: exclusive breastfeeding for more than 6 months (95% CI, 1.03 to 8.9; P = 0.043), low family income (95% CI, 0.19 to 0.98; P = 0.045), residing in rural areas (95% CI, 0.064 to 0.0509; P < 0.001), inadequate maternal iron supply (95% CI, 1.01 to 8.26; P = 0.05), low maternal education level (95% CI, 0.07 to 0.88; P = 0.03) and lack of infant iron supply (95% CI, 1.39 to 8.41; P = 0.007).

CONCLUSION

Incidence of IDA among Lebanese infants is moderate and multifactorial. High maternal education level, urban residence, giving iron supplements to exclusively breastfed infants starting from 6 months of age, adequate family income and iron supplementation in both mother and infant are significant protective factors against anaemia in this population.

Low Hemoglobin Level a Risk Factor for Acute Lower Respiratory Tract Infections (ALRTI) in Children

BACKGROUND

Acute lower respiratory tract infection is a major cause of death in under five years of age, and anemia is the commonest co-factor in pediatric patients seeking medical advice especially in developing countries.

AIM

To analyze whether a low hemoglobin level is a risk factor for acute lower respiratory tract infections (ALRTI) in children.

MATERIALS AND METHODS

Prospective case control study on 220 children (110 cases and controls each) was carried out in our children's hospital (G.B. Pant Hospital), an associated hospital of Government Medical College Srinagar, of Kashmir Northern India. All patients between the age of 1 month to 5 years of age who fulfilled the inclusion criteria were included. We used WHO criteria to diagnose ALRTI among the cases, and age and sex matched patients who did not have respiratory complaints were kept as controls. Patients who had congenital heart diseases, tuberculosis, malignancies, or dysmorphic features were excluded from the study. All patients were subjected to detailed history and through clinical examination followed by investigations like complete blood count (CBC), peripheral blood film (PBF) smear, blood culture and sensitivity test, X-ray chest, serum iron and iron binding capacity were done in all cases.

RESULTS

Our study had slightly male preponderance 57.3% in study group and 59.1% in control group. Maximum number of children were between 3 months and 23 months both in the study (80.9%) as well as in the control (81.8%) group. In this study hemoglobin level <11 gm/dl was considered low. Mean Hb level was 8.8 gm/dl in the study group and 11.6 gm/dl in the control group. Anemia was found in 71 (64.5%) cases in the study group and in 31 (28.2%) cases in the control group. Anemic patients were found to be 4.6 times more susceptible to ALRTI in our study (Odds Ratio was 4.63), p-value <0.01. Iron deficiency was found in 78.9% of total anemic cases in the study group, p-value <0.01. In the study group, the mean serum iron level was 35.3 mcg/dl in the anemic cases and 57.1 mcg/dl in the non-anemic cases. while in the control group, these values were 52.4 mcg/dl and 62.6% mcg/dl respectively, (p-value ,<0.01).

CONCLUSION

Anemia, predominantly iron deficiency anemia, was significantly found in ALTRI patients, and these patients were found to be 4.6 times more susceptible to ALRTI. Early and accurate diagnosis of anemia in children suffering from various ailments in particular to ALRTI will serve the mankind in a better way.