Assessment of Acute Respiratory Infection and Common Medication Use in Children below Five Years in Sulaimani, Kurdistan, Iraq

1. INTRODUCTION

Acute respiratory infections (ARIs) represent a significant global health issue due to their high morbidity and mortality rates. Data from the World Health Organization indicate that in 2016, ARIs were the fourth leading cause of global mortality, accounting for approximately three million deaths, or 40 deaths/100,000 people. In particular, acute lower respiratory infections (ALRIs), such as pneumonia and bronchiolitis, are leading causes of hospital admissions and death among young children, especially in low- and middle-income countries [1].

The upper respiratory tract encompasses the airways from the nostrils to the vocal cords within the larynx, including the middle ear and paranasal sinuses. In contrast, the lower respiratory tract includes the airways extending from the trachea and bronchi to the bronchioles and alveoli. Mortality rates for infants, children, and the elderly are notably high, particularly in low- and middle-income countries [2].

Children under 5 years old are particularly vulnerable to respiratory tract infections (RTIs) due to a range of sociocultural, socioeconomic, and environmental risk factors. Even though many of these risk factors may be avoided, however, they have a major impact on the occurrence of these infections in this age group [3]. Ear infections frequently develop as a complication of upper RTIs, such as colds, caused by bacteria and viruses. These pathogens can enter the middle ear through the eustachian tube, leading to inflammation and potential blockage. This obstruction disrupts the function of the eustachian tube, resulting in the accumulation of infectious fluid in the middle ear [4].

Influenza viruses not only represent a significant global health threat but are also a leading cause of seasonal illness and mortality. Understanding the epidemiology and etiology of influenza is crucial for the effective identification, assessment, and treatment of affected individuals. Staying informed about the latest advancements in healthcare is vital for providing optimal patient care, particularly in an era of rapid technological progress. Recent developments include the introduction of new medications and software-driven tools for managing respiratory diseases. Maximizing the use of these advanced technologies, innovative drugs, and enhanced international surveillance is essential [5].

Studies indicated that various factors associated with ARIs vary across different countries. Evidence from developing countries suggests several significant risk factors for ARIs including low birth weight, exposure to indoor air pollution, non-exclusive breastfeeding, incomplete immunization, overcrowding in households, poor nutrition, formula feeding, weaning, young age of the mother, low parental educational status, premature birth, inadequate access to medical care, low family income, and parental cigarette smoking [6]. Interventions to control ARIs can be broadly categorized into four main areas: vaccination against specific infections, early diagnosis and treatment of diseases, improved nutrition, and the creation of safer environments [7]. It is recommended that preventative programs focusing on minimizing exposure to these risk factors be prioritized, particularly in less developed countries [8].

In 2009, the Global Action Plan for the Prevention and Control of Pneumonia was established to reduce pneumonia-related mortality [9]. Despite international efforts to combat pneumonia and diarrhea, fifteen countries account for more than two-thirds of the global mortality burden from these diseases. Notably, nearly half of the worldwide deaths from pneumonia and diarrhea occur in just two countries: Nigeria and India. Addressing the various risk factors identified in previous studies is crucial to reducing the mortality and morbidity associated with ARIs. These risk factors include aspects related to the home environment, the mother, and the child, such as age, gender, nutritional status, and household income [10]. Research has shown that children who are underweight and come from low-income families are at a higher risk of developing ARIs [11]. In addition, studies indicate that children who have recently experienced diarrhea are more susceptible to ARIs [12].

A cross-sectional study conducted in India has underscored the negative impact of other sources of indoor air pollution, such as the absence of a separate kitchen and exposure to second-hand smoke [13]. In addition, a quantitative systematic review of studies from developed countries has estimated that handwashing can reduce the prevalence of respiratory illnesses [14]. Previous research has also indicated that ambient humidity is a significant factor in respiratory illnesses, potentially explaining their increased incidence during winter months [15]. Moreover, a cross-sectional study in Brazil involving young children found that living in overcrowded households increases the risk of acute lower RTIs [16]. It is crucial for caregivers to promptly recognize symptoms of infection and provide the necessary care [17]. To prevent pneumonia-related deaths, it is essential to initiate a course of antibiotics immediately [18].

Health-seeking behaviors are influenced by a variety of factors, including financial, social, and demographic considerations. Previous studies have shown that maternal education positively affects healthcare-seeking behaviours [19]. In addition, research has demonstrated that family size, socioeconomic status, and accessibility to health-care facilities significantly impact individuals’ actions when seeking medical attention [20]. The aim of the current study was to assess ARI and common medication use in children below 5 years in Sulaimani, Kurdistan, Iraq’ because the respiratory infection is associated with significant health burden as it is an important cause of hospitalization and death in children under 5 years.

2. PATIENTS AND METHODS

3. RESULTS

3.1. Part 1: Socio-demographic and Clinical Characteristic of the Childrens

The current results indicated that 45.2% of the participants were neonates under 1 year old (6–11 months). Among the remaining respondents, 26.2% were aged 1–<2 years, 19% were 2–<3 years, and 9.6% were 3–<5 years. Of the total participants, 66.7% were male and 33.3% were female. Additionally, 52.3% of the participants resided in urban areas, while 47.7% lived in rural areas (Table 1).

TABLE 1: Distribution of children’s demographic data

From this study, it was demonstrated that 47.6% of the respondents were partially immunized, while 42.9% were fully immunized, and 9.5% were not immunized. In addition, 42.8% of the participants were bottle-fed, 33.3% were breast-fed, and 23.8% were fed a combination of food and milk (Table 2).

TABLE 2: Distribution of childrens according to vaccination and nutritional status

The current results showed that 66.7% of the participants experienced disease recurrence, while 33.3% did not. Among those with recurrence, 83.3% had episodes lasting 1–5 days, whereas 16.7% had episodes lasting more than 5 days (Table 3).

TABLE 3: Distribution of children according to disease recurrence and duration

Our observations demonstrated that 26.2% of the participants received amoxicillin, 19% were administered ceftriaxone, 11.9% received a combination of amoxicillin and ceftriaxone, 2.4% were given amikacin and ceftriaxone, and 2.4% received azithromycin. Additionally, 38.1% of the participants did not use antibiotics. Regarding steroid medications, 88.1% of participants were treated with dexamethasone, while 4.8% did not receive steroids. The remaining participants were treated with either dexamethasone and hydrocortisone (2.4%), hydrocortisone alone (2.4%), or prednisolone (2.4%). Concerning analgesic drugs, 54.8% of participants used acetaminophen, 40.4% did not use paracetamol, and 4.8% were given a combination of ibuprofen and paracetamol. For nebulizers, 52.4% of participants used Ventolin, while 47.6% did not use nebulizers. Regarding Montelukast, 95.2% of participants did not receive the drug, whereas 4.8% were treated with Montelukast (Table 4).

TABLE 4: Sample distribution according analgesic using

3.2. Part 2: Socio-demographic and Clinical Characteristic of the Children’s Parents of the Study

It was showed that 42.9% of the fathers of the children had achieved a primary level of literacy, 33.3% were illiterate, 16.7% had secondary education, and 7.1% had attended college or an institute. Among the mothers, 40.5% were illiterate, 35.7% had a primary level of education, 19% had secondary education, and 4.8% had attended college or an institute (Table 5).

TABLE 5: Distribution of sample according to parent’s socio-demographic data

Regarding employment, 76.1% of the mothers were not employed, while 23.9% were employed. Additionally, 73.9% of the families were in an economically insufficient state. Smoking habits showed that 71.4% of fathers and 26.1% of mothers were smokers, whereas 12% of fathers were former smokers and 28.5% of mothers were exposed to second-hand smoke. The majority of families (66.7%) consisted of 3–5 members, with 52.3% being nuclear families and 47.7% being extended families (Table 5).

4. DISCUSSION

The current study revealed that neonates aged 6–11 months constituted over half of the participants. Less than 25% were between the ages of 2–<3 years and 3–<5 years, while more than 25% were aged 1–<2 years. More than half of the respondents were male, and the majority were from urban areas, with the remainder from rural areas. These findings align with those of Basiouny and Hamad [21] in Egypt, who reported a predominance of male participants from urban areas.

This study also found that nearly half of the respondents were either partially or fully immunized, while less than a quarter were not immunized. In terms of nutritional status, less than a quarter consumed solid food, two-thirds drank milk, and nearly half were exclusively bottle-fed. More than half of the participants experienced disease recurrence, with the majority of illness episodes lasting 1–5 days, and less than a quarter having symptoms for more than 5 days.

Regarding medication use, more than a quarter of participants took amoxicillin, while less than a quarter used ceftriaxone, a combination of amoxicillin and ceftriaxone, amikacin and ceftriaxone, or azithromycin. Two-thirds of participants did not use antibiotics. Most participants received dexamethasone for steroid treatment, while less than a quarter used other steroids, including dexamethasone combined with hydrocortisone, hydrocortisone alone, or prednisolone.

In terms of analgesics, over half used acetaminophen, under half did not use paracetamol, and <25% used a combination of ibuprofen and paracetamol. For nebulizer use, over half utilized Ventolin, while nearly half did not use nebulizers. Only a small percentage of participants used Montelukast, with the majority not using it. These findings are consistent with the 2019 study by Basiouny and Hamad [21] in Egypt, which found that most participants used paracetamol. However, their study indicated higher usage rates for ibuprofen and antihistamines compared to this study.

In the current analysis, significant associations with ARI were found concerning the child’s age and gender, vaccination status, paternal education level, and parental smoking habits. The multivariable analysis revealed that children aged 24–35 months and 36–59 months had a lower likelihood of developing ARIs. This finding is consistent with studies conducted by Prajapati et al. in Ahmedabad City and similar research in other low- and middle-income countries in India [22]. Additionally, research from the People’s Republic of China and South India also indicated a high prevalence of ARIs among children aged 6–36 months. This is attributed to the strengthening of the immune system in older children, which enhances their ability to resist infections (Lu et al., 2013; Dhananjaya Sharma et al., 2013 in South India) [23], [24].

The current study revealed that a significant proportion of fathers had only a primary school education, while nearly half of the mothers were illiterate. Approximately three-quarters of the families experienced economic hardship. Additionally, around three-quarters of the fathers and over a quarter of the mothers were active smokers. Less than a quarter of the fathers were former smokers, and more than a quarter of the mothers were exposed to secondhand smoke. Moreover, more than half of the families consisted of three or more individuals. This finding is consistent with the family structure observed in an Egyptian study [21], where the majority of families were nuclear. However, our study’s parents predominantly had only primary education or were illiterate, in contrast to the Egyptian study, which included parents with higher education levels.

According to our study, nearly two-thirds of the mothers and almost half of the fathers had only an elementary education, and nearly three-quarters of families experienced financial difficulties. Higher parental education has been identified as a protective factor against ARI in children under five, which aligns with research by Ujunwa and Ezeonu in Southeast Nigeria [25]. However, studies conducted in Solapur, Ethiopia by Fekadu et al. and in southern Brazil by Cardoso et al. found no significant correlation between ARI and paternal education [26], [27]. Furthermore, <25% of mothers were employed, with more than 75% being unemployed. Working mothers, who often have secondary or higher education, tend to spend less time at home and cooking, thereby reducing their children’s exposure to indoor air pollution. Thus, higher education and better income are considered protective factors against ARI in children under five, consistent with studies from southern Brazil, India, Ahmedabad City, and Gondar City in Ethiopia [6], [27]–[29]. Consequently, the current study recommends providing educational information to mothers as a crucial measure for protecting children under five from ARIs.

5. CONCLUSION

This study identified several significant risk factors associated with ARI among children under 5 years old in Sulaimani City. The findings highlighted that male patients, incomplete immunization, inadequate nutritional status, and low socioeconomic status are major contributors to the prevalence of ARI. In addition, low levels of parental education, particularly among mothers, along with cigarette smoking and exposure to secondhand smoke, further exacerbate these risk factors. The results emphasize the need for targeted public health interventions aimed at improving immunization rates, providing dietary support, and implementing educational programs for parents. Efforts to reduce cigarette smoking and minimize exposure to second-hand smoke are also crucial in addressing the percentage of ARI in this population.