Association of serum vitamin D with acute lower respiratory infection in Indian children under 5 years: a case control study


  • Deepandra Garg Department of Paediatrics, RUHS College of Medical Sciences, Jaipur, Rajasthan
  • Vikas K. Sharma Medical Officer, Govt. of Rajasthan, Rajasthan
  • B. S. Karnawat Department of Paediatrics, J.L.N. Medical College, Ajmer, Rajasthan



ALRI, Sunlight exposure, Vitamin D


Background:Acute lower respiratory infection (ALRI), primarily pneumonia and bronchiolitis, is a substantial cause of morbidity and mortality in children <5 years of age, particularly in developing countries. Vitamin D deficiency is a significant risk factor for severe ALRI in Indian infants and children <5 years of age. This study was done to determine the relationship, if any, between respiratory illnesses and serum vitamin D status.

Methods: This study included 40 (22 boys and 18 girls) hospitalized children of 6 months to 5 years of age with ALRI as cases and 40 (25 boys and 15 girls) age and sex matched children with no respiratory illness and no clinical manifestation of vitamin D deficiency as controls. Sociodemographic profile, feeding history, immunization history, sun exposure, drug history, causes of admission were taken by interviewing the child's mother or guardian. Serum vitamin D was estimated using commercially available kit by chemiluminiscence technique. General physical and systemic examination with emphasis on respiratory system was performed. ALRI diagnosis was made by clinical, radiographic and biochemical findings.

Results:Among vitamin D deficient and insufficient children, 71% and 74% were adequately exposed to sunlight respectively. 50% vitamin D deficient children were diagnosed of bronchial asthma and 33% of bronchopneumonia. Among vitamin D insufficient, 48% had acute bronchiolitis and 35% had bronchopneumonia. Among sufficient Vitamin D, bronchopneumonia and acute bronchiolitis were 36% each i.e. most of the cases of bronchial asthma (60%) had vitamin D deficiency whereas majority of acute bronchiolitis cases (73%) had vitamin D insufficiency. Statistically significant difference was seen between cases and control among vitamin D sufficient, insufficient and deficient groups with higher number of sufficient vitamin D controls. Low vitamin D levels were significantly correlated with ALRI.

Conclusions:Subclinical vitamin D deficiency is significant risk factors for severe ALRI in Indian children of less than 5 years of age.



Wardlaw TM, Johansson EW, Hodge MJ. UNICEF; 2006. World Health Organization. Pneumonia: The Forgotten killer of Children. Available at: /maternal_child_adolescent /documents / 9280640489/en. Accessed on 25 July, 2016.

UNICEF; 2008. The State of Asia Pacific's Children 2008: Child Survival. Available at: http: // Accessed on 25 July, 2016.

Jain N, Lodha R, Kabra SK. Upper respiratory tract infections. Indian J Pediatr. 2001;68:1135-8.

Vashishtha VM. Current status of tuberculosis and acute respiratory infections in India: Much more needs to be done! Indian Pediatr. 2010;47:88-9.

Causes of neonatal and child mortality in India: A nationally representative mortality survey Causes of neonatal and child mortality in India 2010. Available at: uploads/ Causes of neonatal and child mortality in India 2010. Pdf. Accessed on 25 July, 2016.

Rudan I, Boschi Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008;86:408-16.

Dongre AR, Deshmukh PR, Garg BS. Health expenditure and care seeking on acute child morbidities in periurban Wardha: A prospective study. Indian J Pediatr. 2010;77:503-7.

Rudan I, Boschi-Pinto C, Biloglav Z, Mulholland K, Campbell H. Epidemiology and etiology of childhood pneumonia. Bull World Health Organ. 2008;86:408-16.

Cannell JJ, Vieth R, Umhau JC. Epidemic influenza and vitamin D. Epidemiol Infect. 2006;134:1129-40.

Salimpour R. Rickets in Tehran. Arch Dis Child. 1975;50:63-5.

Lubani MM, Al-Sheb TS, Sharda DC, Quattawi SA. Vitamin-D deficiency rickets in Kuwait: the prevalence of preventable disease. Ann Trop Paediatr. 1989;3:134-9.

Lawson DEM, Cole TJ, Salem SI. Aetiology of rickets in Ethiopian children. Hum Nutr Clin Nutr. 1987;41:199-208.

Auss-Kettis A, Bjornesjo KB, Manneimer E, Cvibach T. The occurrence and clinical picture of disease in a clinic in Addis Ababa. Ethiopia Med J. 1965;3:109-21.

Muhe L, Lulseged S, Mason KE, Simoes EAF. Case control study of the role of nutritional rickets in the risk of developing pneumonia in Ethiopian children. Lancet. 1997;349:1801-4.

Wayse V, Yousafzai A, Mogale K, Filteau S. Association of subclinical vitamin D deficiency with severe acute lower respiratory infection in Indian children under 5 years. Eur J Clin Nutr. 2004;58:563-7.

Roth DE, Shah R, Black RE. Vitamin D status and acute respiratory infection in early childhood in sylhet, Bangladesh. Acta Paediatr. 2010;99:389-93.

Inamo Y, Hasegawa M, Saito K. Serum vitamin D concentrations and associated severity of acute respiratory infection in Japanese hospitalized children. Pediatr Int. 2011;53:199-201.

Belderbos ME, Houben ML, Wilbrink B. Cord blood vitamin D deficiency is associated with respiratory syncytial virus bronchiolitis. Pediatrics. 2011;127:1513-20.

Atiq M, Suria A,Nizami SQ, Ahmed I. Vitamin D status of breastfed Pakistani infants. Acta Pediatr. 1998;87:737-40.

Goswami R, Gupta N, Goswami D, Marwaha RK. Prevalence and significance of low 25-hydroxyvitamin D concentration in healthy subjects in Delhi. Am J Clin Nutr. 2000;72:472-5.

Andran N, Yordam N, Ozon A. Risk factor for vitamin D deficiency in breastfed new-borns and their mothers. Nutrition. 2002;18:47-50.

WHO child growth standards. Acta pediatr supplement. 2006;450:5-101.

Specker BL, Valanis B, Hertzberg V, Edwards N. Sunshine exposure and serum 25 hydroxyvitamin D concentrations in exclusively breastfed infants. J Pediatr. 1985;107(3):3726.

Gordon CM, Feldman HA, Sinclair L, Williams AL. Prevalence of vitamin D deficiency among healthy infants and toddlers. Arch Pediatr Adolesc Med. 2008;162(6):505-12.

Banajeh SM, Al-Sunbali NN, Al-Sanhani. Clinical characteristics and outcome of children aged under 5 years hospitalized with severe pneumonia in Yemen. Ann Trop Paediatr. 2007;17:321-6.

Census data 2011. Available at /data_files /india / Rural_ Urban _2011.pdf. Accessed on 25 July, 2016.

Human development report, Government of Rajasthan. 2008. Available at Accessed on 25 July, 2016.

Bener A, Al-Ali M, Hoffmann GF. Vitamin D deficiency in healthy children in a sunny country: associated factors. Int J Food Sci Nutr. 2009;60(5):6070.

Ahmed P, Babaniyi IB, Yusuf KK, Dodd C. Vitamin D status and hospitalisation for childhood acute lower respiratory tract infections in Nigeria. Paediatr Int Child Health. 2015;35(2):151-6.

McNally JD, Leis K, Matheson LA, Karuananyake C. Vitamin D deficiency in young children with severe acute lower respiratory infection. Pediatr Pulmonol. 2009;44(10):9818.

Chinellato I, Piazza M, Sandri M, Peroni D. Vitamin D serum levels and markers of asthma control in Italian children. J Pediatr. 2011;158:437-41.

Joseph N, Unnikrishnan B, Naik VA, Mahantshetti NS. Infant rearing practices in South India: a longitudinal study. J Family Med Prim Care. 2013;2(1):3743.

Darmstadt GL, Saha SK. Traditional practice of oil massage of neonates in Bangladesh. J Health Popul Nutr. 2002;20(2):1848.

Hansdottir S, Monick MM, Lovan N, Powers L. Vitamin D decreases respiratory syncytial virus induction of NF-kappa B-linked chemokines and cytokines in airway epithelium while maintaining the antiviral state. J Immunol. 2010;184:965-74.

Hawrylowicz CM, O’Garra A. Potential role of interleukin-10 secreting regulatory T cells in allergy and asthma. Nat Rev Immunol. 2005;5:271-83.

Sutherland ER, Goleva E, Jackson LP. Vitamin D levels, lung function, and steroid response in adult asthma. Am J Respir Crit Care Med. 2010;181:699-704.






Original Research Articles