Predisposing risk factors of community acquired pneumonia in children and efficacy of homoeopathic remedies

Predisposing risk factors of community acquired pneumonia in children and efficacy of homoeopathic remedies

Dr. Nahida M. Mulla _{MD. (HOM), MACH}
Professor & PG Guide ,Department Of  Paediatrics
A M Shaikh Homoeopathic Medical College
Belgaum -590010
Dr. Kedar P. Samaji Pg _{PEDIATRICS (HOM)}

ABSTRACT

BACKGROUND AND OBJECTIVES
Pneumonia probably is one of the oldest diseases as old as antiquity known to human kind and has always remained a subject of challenge to medical science, despite extended research. Pneumonia is number one cause of less than five childhood mortality across the globe particularly in developing countries. So this study has been proposed to know the predisposing risk factors in children and to explore the scope of homoeopathic medicines in children suffering from community acquired pneumonia children. 

METHODS
The subjects for this study were taken from OPD/IPD/Village camps and satellite clinics of A. M. Shaikh Homoeopathic Medical College, Hospital, and PG Research center, Belgaum. A prospective non control study has been done on 30 subjects, selected as per the inclusion and exclusion criteria

RESULTS
Study shows positive treatment response with homoeopathic medicines and improvement was observed in 21 patients. Studies done according to homoeopathic principles and the Chi-Square test was observed to be significant based on the p-value (0.028<0.05) which is less than the standard 0.05 value as assumed for the test. The study concludes the effectiveness of homoeopathic remedies in the treatment of CAP in children. Various observations made to assess the susceptibility of children in acquiring community acquired pneumonia. Various factors responsible to acquire pneumonia like socioeconomic status, locality, family predispositions, vaccination, overcrowding, hygienic measures, nutrition, health awareness, mothers education, and seeking treatment were observed during this study.

CONCLUSION
The study concludes the positive role of homoeopathic medicines in early treatment and management of community acquired pneumonia in children. It has been also observed that the socioeconomic status, residing locality, associated illnesses, mother’s education, seasonal impact on health, vaccination, and children’s susceptibility plays important role in acquiring the disease.

Key Words – LRTI, CAP, Susceptibility, Homoeopathy.

INTRODUCTION
Pneumonia remains one of the major disease entities, practicing physician must manage. It is leading cause of infection related mortality in all age groups. More than 100 years ago William Osler noted “Pneumonia remains now, as then the most serious acute diseases with which physician have to deal”. It is medically humbling to note that the importance of pneumonia has not changed dramatically since Osler’s writings.

Childhood Acute Respiratory Infection (ARI) is the largest cause of morbidity among under-five children across the world. Pneumonia – the most serious presentation – is singly responsible for almost one fifth of total mortality in this vulnerable age group. Therefore the importance of ARI and pneumonia cannot be over-emphasized. Consequently, global health-care agencies such as the World Health Organization (WHO), United Nations Children’s Fund (UNICEF), national and state Governments, as well as international and local agencies involved with aid, academics, and research- have all focused on this area. In India, ARI has been given top priority in all Government programs including the current Reproductive and Child Health Program, Phase-II (RCH-II). The successful management of childhood pneumonia at a programmatic level revolves around four prongs viz. rapid and accurate detection of pneumonia in children, early treatment/management with specific therapy, management of co-morbid conditions, and efforts at primary prevention. These basic tenets are utilized to varying degrees in different programs to manage the burden of childhood pneumonia at the national and international levels. However, there are several challenges in implementing and managing a successful program to reduce the mortality and morbidity due to childhood pneumonia, necessitating periodic review and rethinking.

One of the multicentric hospital based study suggests that 3.6 million episodes of severe pneumonia, and 0.35million all pneumonia deaths occurred in children younger than 5 years in India. The states that merit special mention include Uttar Pradesh, Bihar, Madhya Pradesh and Rajasthan. Thus results highlight the need to improve access to care and increase coverage with high pneumonia burden.

Overall prevalence of acute respiratory infection was observed to be 59.1%, with prevalence in urban and rural areas being 63.7% and 53.7% respectively. Bivariate analysis indicated that overcrowding, place of residence, and mother’s educations were significantly associated with acute respiratory infection. Prematurity, low birth weight, failure to breast feed, malnutrition, an attack of measles, domestic smoke and overcrowding have been implicated as the main predisposing factors.

Respiratory illnesses are common in children. Repeated and persistent acute upper respiratory tract infections results in lower respiratory illnesses particularly pneumonia. Acute lower respiratory tract illnesses are the most frequent illnesses of children and are an important cause of disability and days lost from school. Acute lower respiratory infections particularly pneumonia are an important cause of hospitalization.  The repeated respiratory infection affects both physical and mental development in children. Pneumonia probably is one of the oldest diseases as old as antiquity known to human kind and has always remained a subject of challenge to medical science, despite extended research. Pneumonia is number one cause of less than five childhood mortality across the globe particularly in developing countries. Unfortunately over the years the mortality remained the same and hence it is also been called as “forgotten killer” or “silent killer”.

Thus it is the privilege of the homoeopath to preserve repair and restore the normal functioning of respiratory unit of lung in whatever condition it is found. This will avoid up unnecessary course of antibiotics and antimicrobial resistance.

There is various research studies conducted in Homoeopathy on acute upper respiratory infections, allergic conditions and lower respiratory infections. But very few studies has been conducted on pneumonia and homoeopathy. So I felt of necessary to conduct this research to add on the role of homeopathy in treatment of acute respiratory infections especially in children.

So this study has been proposed to explore the scope of Homoeopathic medicines in children suffering from community acquired pneumonia. And also to study the various social and demographic factors predisposing the pneumonia in community. 

OBJECTIVES

1. To study the common and uncommon clinical presentation and predisposing factors of community acquired pneumonia in children.
2. To study the role of Homoeopathic remedies in the treatment of community acquired pneumonia in children.

METHODOLOGY:

The subjects for this study were taken from OPD / IPD / Village camps and satellite clinics of A. M. Shaikh Homoeopathic Medical College, Hospital, and PG Research centre, Belgaum. In this sample study the following parameters were applied in collecting data.

1. Study design: Non control trial.
2. Type of research: Prospective case study.
3. Sample size: Minimum 30 in number.
4. Participant subjects: Subjects who fitted into the inclusion and exclusion criteria as mentioned. Subjects of both sex and age group between 0 to 14 years, irrespective of religion and socioeconomic status.
5. Duration of study: Cases registered between 1st of May 2017 to 30th of November 2018.
6. Follow up: Follow up of cases were done as per need of the case, for a minimum period of six months to assess the progress of the subject under study.

INCLUSION CRITERIA

1. Subject presenting with acute lower respiratory tract infection and diagnosed cases of pneumonia. 
2. Subjects of both sex and age group between 0-14 years.

EXCLUSION CRITERIA

1. Cases with advanced pathological conditions of pneumonia with organ damage.
2. Subjects with severe respiratory distress in pneumonia who needs intensive treatment and management.
3. Complicated cases of pneumonia, associated with pleural effusion and empyema thoracis.

STATISTICAL METHOD EMPLOYED

The result was analyzed through “Chi square test”. 

General Management

Parents instructed about the maintenance of proper healthy diet of child, avoidance of cold food and drinks, maintenance of hygiene, prevention of exposure to fumes, dust cold and humidity.

Allparticipants’ parents and guardians were informed prior to the study about its implications in their vernacular language.Subjects were selected on inclusion and exclusion criteria, history and finding. Remedies were indicated from assessing the totality got from the interview conducted on the basis of individualization process.The potency selection and repetition of the doses were done according to the demand of the case. Follow ups were done as per required depending on the case. Assessment of prognosis is improved and not improved.

OBSERVATIONS AND RESULTS
In this study total number of 30 patients of lower respiratory tract infection with clinical pneumonia and diagnosed cases of pneumonia were considered. The statistical study was conducted with respect to age, sex, socioeconomic status, past history, the susceptibility of children to acquire infections, medicines administered and the progress monitored with clinical improvement of symptoms in patients. These are presented in statistical tables under the following headings.

DISTRIBUTION OF CASES IN RELATION TO AGE INCIDENCE

Table no. 1

SL. NO.	AGE GROUP IN YEARS	NO. OF PATIENTS	PERCENTAGE
1.	02	11	36.66%
2.	35	10	33.33%
3.	>5	09	30%
	TOTAL	30	100%

The observation shows that there is maximum age incidence in the age group of 0-2 years, of about 11 cases (36.33%). This is followed by the age group of 3-5 years, of about 10 cases (33.33%), then by the age group >5 years, of about 9 cases (30%). From the above observations it is inferred that the age group of 0-2 years has the highest incidence of CAP in children. And in overall less than 5 years children has more incidence of CAP in comparison with children above the age of 5 years. 

DISTRIBUTION OF CASES IN RELATION TO SEX INCIDENCE

Table No. 2

SL. NO.	SEX	NO. OF CASES	PERCENTAGE
1.	Male	18	60%
2.	Female	12	40%
	Total	30	100%

The above observation shows that the incidence of patients who were males was about 18 cases (60%) and females were about 12 cases (40%), from above observation it can be inferred that incidence of CAP is more in males than females

DISTRIBUTION OF CASES IN RELATION TO SOCIOECONOMIC STATUS

Statistical data of 30 cases has shown following socioeconomic status of patients in CAP in children.

Table No. 3

SL. NO.	SOCIAL STATUS	NO. OF CASES	PERCENTAGE
1.	Lower Class	16	53.33%
2.	Middle Class	10	33.33%
3.	Upper Class	04	13.33%
	Total	30	100%

In the above study 16 cases (53.33%) were from lower socioeconomic class, 10 cases (33.33%) were from middle class, and 4 cases (13.33%) were from upper class. From the observation it can be inferred that patients belonging to the lower socioeconomic group were having the high incidence, followed by middle class, then upper class. 

STATISTICAL DATA OF CASES IN RELATION TO RESIDING LOCALITY 

Table No. 4

SL. NO.	LOCALITY	NO. OF CASES	PERCENTAGE
1.	Urban	08	26.66%
2.	Suburban	09	30.00%
3.	Rural	13	43.33%
	Total	30	100%

In the above study 13 cases (43.33%) were from rural locality, 9 cases (30%) were from suburban locality, and 8 cases (26.66%) were from urban locality. From the observation it can be inferred that patients belonging to rural and suburban locality were having the high incidence of CAP in children. 

STATISTICAL DATA OF CASES IN RELATION TO PAST HISTORY OF LRTI

Table No. 5

SL. NO.	PAST HISTORY	NO. OF CASES	PERCENTAGE
1.	Present	07	23.33%
2.	Absent	23	76.66%
	Total	30	100%

In the study of 30 cases of CAP in children, the observation shows that the past history of lower respiratory infection was noted in 07 cases (23.33%), and no association with previous infection or recurrent infection was noted in 23 cases (76.66%)

STATISTICAL DATA OF CASES IN RELATION TO FAMILY HISTORY OF RESPIRATORY AFFECTIONS

Table No.6

SL. NO.	FAMILY HISTORY	NO. OF CASES	PERCENTAGE
1.	Present	05	16.66%
2.	Absent	25	83.33%
	Total	30	100%

In the study of 30 cases of CAP in children, it has been observed that family history of respiratory affections like COPD, Bronchitis, Asthma, and allergy has some affinity towards CAP in children, the above observation shows 05 cases (16.66%) with family history of respiratory affections and 25 cases (83.33%) without family history of respiratory affections.

STATISTICAL DATA OF INDICATED HOMOEOPATHIC REMEDIES

Table No.7

SL. NO.	INDICATED  REMEDIES	NO. OF CASES	PERCENTAGE
1.	Ant. Tart	7	23.33%
2.	Arsenic alb.	3	10%
3.	Bryonia alba	3	10%
4.	Belladonna	3	10%
5.	Nat. Suph	2	6.66%
6.	Drosera	2	6.66%
7.	Kali. Carb	2	6.66%
8.	Iodum	1	3.33%
9.	Ars.iod	1	3.33%
10.	Ipecac	1	3.33%
11.	Heparsulph	1	3.33%
12.	Pulsatilla	1	3.33%
13.	Aconite	1	3.33%
14.	Calcarea carb	1	3.33%
15.	Baryta carb	1	3.33%
	Total	30	100%

In the study of 30 cases of CAP in children, the observation shows that the Antimonium tart was indicated in 7 cases (23.33%). Arsalb, Bryoniaalba and Belladona was indicated in 3 cases each (10% each). Nat sulph, Drosera, and Kali carb indicated in 2 cases each (6.66% each). Iodum, Ars.iod, Ipecac, Heparsulph, Pulsatilla, Aconite, Calcarea carb, Baryta carb was indicated in 1 case each (3.33% each).

STATISTICAL DATA OF ASSESSMENT OF EFFECTS OF TREATMENT

Table No. 8

SL. NO.	RESULT	NO. OF CASES	PERCENTAGE
1.	Improvement	21	70%
2.	No Improvement	09	30%
3.	Drop outs	00	00%
	Total	30	100%

In the study of 30 cases of CAP in children it has been observed that 21 cases (70%)  has shown improvement with homoeopathic medicines and 09 cases (30%) have not shown improvement with homoeopathic medicines.

CHI-SQUARE TEST OF INDEPENDENCE

Chi Square Test for Goodness of Fit

Treatment outcome	Frequency	Percent
IMPROVED	21	70%
NOT IMPROVED	9	30%
Total	30	100%

CONTINGENCY TABLE OF OBSERVED & EXPECTED FREQUENCY
Treatment outcome	Observed N	Expected N	Residual
Improved	21	15	6
Not Improved	9	15	– 6
Total	30	—	—

CHI-SQUARE TEST STATISTICS
	Treatment outcome
Chi-Square value	4.800
Df	1
p-value	0.028*

The above statistical analysis shows the significant outcome under the given conditions using the SPSS software version 23. The hypothesis was tested using the non-parametric test, Chi-Square and the results are show in the above tables. The Chi-Square test was observed to be significant based on the p-value (0.028<0.05) which is less than the standard 0.05 value as assumed for the above test. Further, it is also analyzed from the calculated chi-square value that, calculated value is greater than the standard chi-square table with df = 1 & α = 5%, i.e. 4.800 > 3.984. Therefore, the null hypothesis, “Homoeopathic medicines are not effective in management of community acquired pneumonia in children” was rejected and the alterative hypothesis, “Homoeopathic medicines are effective in management of community acquired pneumonia in children.” was accepted. 

DISCUSSION
In this study various observations were made to assess the susceptibility of children in acquiring community acquired pneumonia. Susceptibility is assessed considering age, sex, intensity of symptoms, seat of disease, habit and environment, temperament and constitution. Various factors responsible to acquire pneumonia like socioeconomic status, locality, family predispositions, vaccination, overcrowding, hygienic measures, nutrition, health awareness and seeking treatment were observed during this study. Study also shows positive treatment response with homoeopathic medicines in early treatment of CAP in children.

In homoeopathy the patient is treated rather than the disease. In acute illness, the patient changes from the normal are taken into account. Homoeopathic remedies are prescribed holistically rather than one part. The homoeopathic system of Medicine with its unique Similia principle and with its Individualistic approach helps to overcome the acute deviation from health, helps to decrease the duration of acute phenomenon and prevents the hospitalization.

• From the study it was found that after the use of homoeopathic medicines there was statistical improvement in cases of CAP in children. The results of treatment were clearly shown improvement in 21 cases and no improvement in 9 cases. The Chi-Square test was observed to be significant based on the p-value (0.028<0.05) which is less than the standard 0.05 value as assumed for the test.
• The study also showed common disease presentation of CAP in children i.e. Fever, cough, cold, tachypnea with marked chest signs. But from homoeopathic point of view the clinical presentation in patient has some uncommon peculiar individualizing symptoms which helped in framing the acute totality and selection of medicines.
• The study also showed the role of susceptibility in both acquiring the disease in children and its selection of homoeopathic medicines and potency. 
• The study shows that there is maximum age incidence of CAP in children in the age group of 0-2 years, and 2-5 years, then by the age group >5 years, it shows that that the age group of 0-2 years has the highest incidence of CAP in children. And in overall less than 5 years children has more incidence of CAP in comparison with children above the age of 5 years. 
• The study shows that the incidence of CAP is more in males than females.
• From the study it can be inferred that patients belonging to the lower socioeconomic group were having the high incidence, followed by middle class, then upper class. The differences might be due to cleanliness, overcrowding, nutrition, seeking treatment, cross ventilation, health awareness, mother’s education, parental smoking, use of domestic fuel and hygienic measures in respective socioeconomic class.
• Study also shows that the past history of upper and lower respiratory infections has some affinity in developing pneumonia. It might be because of the lowering of the defense mechanism of respiratory tract.
• Study also shows vaccinated children has more affinity that is increased morbid susceptibility in acquiring infection. And also showed some familial dispositions with family history of respiratory affections.
• The study also concludes children belonging to rural and suburban locality were having the high incidence of CAP. Again the differences might be due to cleanliness, overcrowding, cross ventilation, seasonal variations, humidity, dampness, nutrition, vaccination, seeking treatment, health awareness, education and hygienic measures in respective residing localities of patient.
• The study also shows that homoeopathic remedies Antimonium tart, arsalb, belladonna, bryoniaalba, natrumsulph, kali carb, drosera are helpful in treatment of pneumonia in children. It shows that remedies selected on the basis of acute totality comprising both short acting and long acting drugs are effective in treatment of pneumonia. 

Conclusive remarks:
The above study revealed the significant effect of individualized homoeopathic medicines in treatment and management of CAP in children.  The rapid and accurate detection of pneumonia in children, early treatment and management with specific homoeopathic therapy, management of co-morbid conditions, and efforts at primary prevention helps to overcome the morbidity and mortality of CAP, and also disability and days lost from school and hospitalization in children. 

The above study also showed the correlation between associated illnesses and factors like cleanliness, overcrowding, nutrition, seeking treatment, health awareness, education and hygienic measures in respective socioeconomic class. Few cases also shown impact of recurrent LRTI and family history of respiratory illnesses in predisposing CAP in children. The incidence of CAP was seen to be more prevalent in under 5 year’s age group.

Limitation
This study has a limitation in terms of time period and volume of the study. So Further studies with greater magnitude may be needed to explore the therapeutic usefulness of homoeopathic medicines in treatment of CAP in children.