Pneumonia is the term used to describe inflammation of the lung. The World Health Organization defines pneumonia as an acute disease episode with cough combined with fast breathing with age-specific cutoff-values for increased respiratory rate¹. Pneumonia is a common illness that affects millions of people each year globally². Community-acquired pneumonia (CAP) is a major public health issue and a principal cause of morbidity and mortality in children under 5 years of age³. According to UNICEF 2019 report pneumonia claimed 8 lakh lives in under 5 years of age and out of which 1.27 lakh were from India which is 2^nd highest in the world⁴. Pneumonia has been identified as the major “forgotten killer of children” by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO)⁵.

Pneumonia can affect anyone however, it has been observed that children are at a higher risk of developing the disease than others. There are many risk factors which have been associated with the increased chances of CAP in children⁶ namely indoor air pollution, malnutrition, lack of breastfeeding, low maternal education, low socioeconomic status (SES), poor access to health care, and concomitant illnesses etc. The purpose of our study is to determine the risk factors associated with childhood CAP in developing countries like India which has implemented many welfare and health programs in the last decade. The controlled and modified control of these risk factors can be used in the future to reduce the mortality and morbidity caused by pneumonia in India.

1. To assess the risk factors in children with pneumonia.
2. To compare the risk factors in children with pneumonia and those without pneumonia.
3. To determine the strength of association of the risk factors in children with pneumonia and those without pneumonia.
4. To assess the severity of pneumonia to various risk factors.

Failure to exclusively breastfeed the baby for 6 months, bottle feeding, malnutrition and incomplete immunization were significantly associated with CAP.

Pneumonia in children under five years of age is a leading cause of morbidity and mortality in India and other developing countries^4,7. Identifying risk factors for childhood pneumonia that are amenable to intervention is of public health importance. In our study, most of the cases were infants (57%), similar to Cunha et al 2000⁸ which concluded lower age as a risk factor for developing pneumonia. This might be because in young children immunity is not well established, and also because of narrow airways, relatively short bronchial trees, and incomplete development of lungs⁹. Males outnumber the females in our study, this might be due to early reporting and hospitalization of a male child. In our study, 73% of the cases belonged to the urban locality, our hospital is located in Bhopal, this might explain more number of cases belonging to the urban area in our study. The presence of many co-morbidities and disease history has been accepted as risk factors for CAP. Children who have a concomitant chronic illness may have their immunity lowered making them more susceptible to severe disease. In our study, 46% of the cases and only 11% of the control have a history of LRTI/ asthma/ allergy/ rhinitis/ CHD/ diarrhea in the last 3 months that was statistically significant. In our study, 16 % of cases have a family history of Asthma/Allergy/TB/Rhinitis in comparison to 4% in the controls that were significant which is in concordance to Mahalanabis et al 2002¹⁰ who concluded that history of asthma in siblings or family were 2.4 times more prone to develop pneumonia.

Studies from different parts of the world had reported indoor air pollution caused by indoor smoking and the use of biomass as a cooking fuel to increased respiratory morbidity in children. The present study also concludes indoor air pollution as a risk factor for CAP. In our study, 43% of pneumonia cases were exposed to indoor smoke in comparison to 14% in controls and this association was found to be significant. The severity of pneumonia was also analyzed in the present study for different risk factors, only previous treatment and delayed presentation were the two factors found to increase the severity of pneumonia. In the present study among those who were previously treated 78% landed up with severe pneumonia in comparison to 47% in those who presented directly. Those who were previously treated might be severely ill from the start of the illness itself which can explain higher severity among the previously treated children. However, we did not have the details of their previous treatment which might have been inadequate. Somaya Aftab 2017¹² In their study also concluded that delay in presentation is a risk factor for complicated pneumonia.

The present study is not devoid of the limitation. As the present study was hospital-based, hospitalized cases may not be representative of all pneumonia cases in the community, similarly, neighbourhood controls would have offered better comparisons and given the interviewers a chance to observe the housing conditions would have been better instead of hospital-based controls. This type of study design was particularly prone to bias compared with other analytical designs, in the particular selection and recall bias. Our study had a small sample size so there is a need for extensive population-based research.

Concentrated efforts are needed to strengthen the health facilities and immunization coverage in the population. Public awareness should also be increased to improve the better utilisation of available resources. Improving the socio-economical status of people are welcome, this can take a long time to bear fruit. We should promote and ensure the implementation of several preventive measures that will have a major impact on the prevalence and complications of malnutrition and infection.