Acute Lower Respiratory Tract Infection (ALRTI) is the most common cause of death in children under five. Acute respiratory infections (ARI) result in 1.9 million childhood deaths per year in developing countries and 20% of these deaths are from India [1]. Epidemiological factors and the disease burden differ in developing and industrialised countries [2-6]: in industrialised countries morbidity predominates, whereas in developing countries mortality due to acute lower respiratory tract infections (ALRTI) is a significant problem, along with considerable morbidity and hospitalisations, particularly in children aged <5 years.

Various demographic, socio-economic and environmental factors have been associated with ALRTI, with conflicting results [2-7]. Congenital heart disease is primarily a disease condition of infant’s neonates and children. Out of all congenital anomalies, congenital heart disease is the leading condition of mortality and morbidity in children under 5 years of age [8]. Often the circulatory derangement also places stress on the respiratory system itself [9]. Children with congenital heart diseases are more vulnerable to lower respiratory tract infections following the fact that they had an anatomical defect that causes hemodynamic disturbance of lung circulation such as pulmonary over circulation, increased capillary wedge pressure and left atrial pressure which results in luminal narrowing and mucosal oedema finally leads to decreased lung compliance and recurrent lower respiratory tract infections [10].

There is a conflict among study results regarding the vulnerability of children with CHD for LRTI [11-13]. also there is a paucity of such studies in the Indian setting. Hence this study is taken up to evaluate clinical, radiological & microbiological characteristics of lower respiratory tract infection in children with CHD.

Setting: This study was conducted at a tertiary care medical teaching hospital.

Duration and Type of Study: This study was done over two and half years. This was a Hospital-based Cross-sectional study.

Sampling Methods: A consecutive type of non-probability sampling was used during the study.

[Table .1]. Out of the total 114 cases, 67.5% were males and 32.5% were females [Fig.1]. VSD was seen in 64.9% of cases while 10.5% of cases had VSD and ASD. Isolated ASD and PDA were seen in 12.3% of cases [Table.2]. Most common presenting symptoms were: cough (98.2%), reduced feeding (97.4%), fever (89.5%), running nose (67.5%) and wheeze (49.1%) [Table.2]. Inter-costal indrawing and subcostal indrawing were seen in 36% and 40.4% cases while both inter-costal and sub-costal indrawing were seen in 23.7% of cases [Table.2]. In lab investigations, Leucocytosis and raised ESR were seen in 66.7% and 64.9% cases respectively. Positive CRP was seen in 8.8% of cases [Table.2]. In Throat swab Commensals were seen in 36% cases while gram-positive cocci were seen in 3.5% cases respectively [Table.2]. Blood culture was done in 25 cases with Streptococcus pneumoniae being the commonest organism isolated (n-16) [Table.2]. Bilateral and unilateral opacities on chest x-ray were seen in 16.7% and 12.3% cases respectively. Bronchopneumonia was diagnosed in 57.9% of cases while Bronchiolitis and Lobar pneumonia was diagnosed in 33.3% and 8.8% cases respectively. IV antibiotics were required in 92.1% of cases while oral antibiotics were given in 7.9% of cases [Table.2].

Table 1. Distribution of cases as per age group

Figure.1. Distribution of cases as per Gender

Table.2: Clinical and lab parameters

The commonest CHD was ventricular septal defect (50.00%) in the study by Sadoh et al. [22]. while in the study by Gabriela K et al. [24]. The most common types of CHD were Patent Ductus Arteriosus (47.6%), followed by Ventricular Septal Defect (47%). Singh PK et al. [25]. in their study observed VSD in 43.6% cases while 7.7% cases had VSD and ASD. Isolated ASD and PDA were seen in 28.2% and 17.9% cases respectively. Pongiglione G et al. [23]. a similar study observed the most frequent heart defects as a ventricular septal defect (23.1%) and coarctation of the aorta (14.3%).

Demography: Mean age of the study subjects was 2 years with 43.9% of the cases being 1 year or less and 53.5% cases were between 1-5 years of life. In the present study 67.5% were males and 32.5% were females. Sadoh et al. [22]. in their study evaluated the contribution of CHD to pneumonia in children seen in a tertiary hospital. There were 121 children with pneumonia of which 61(50.40%) were males and their mean age was 10.2 ± 10.93 months. Singh PK et al. [25]. studied a total of 43 patients with CHD and recurrent LRTI with 53.4% males and 46.5% females. Sahan OY et al. [26]. evaluated 50 children who had congenital heart disease and were hospitalized with lower respiratory tract infections. There were 26 boys and 24 girls. The average age of the cyanotic group was 23.88±28.81, and the acyanotic group was 12.25±15.45 months old. Gabriela K et al. [24]. their study also observed the majority of children (80%) being under 1 year of age.

Presenting Complaints: Symptoms and signs of pneumonia may be subtle, particularly in infants and young children. The combination of fever and cough is suggestive of pneumonia; other respiratory findings (eg, tachypnea, increased work of breathing) may precede the cough. Neonates and young infants may present with difficulty feeding, restlessness, or fussiness rather than with cough and/or abnormal breath sounds [27]. In the present study, the most common presenting symptoms were: cough (98.2%), reduced feeding (97.4%), fever (89.5%), running nose (67.5%) and wheeze (49.1%). Gabriela K et al. [24]. in their study clinical symptoms mostly found where the difficulty of breathing (98%), fever (85.2%), cough (75.2%), and runny nose (63.1%). Similarly in the study by Sadoh et al. [22]. and Singh PK et al. [25]. The most common presenting complaints were cough and fever. In a multicenter population-based study that included 2358 children <18 years hospitalized

Our study results were also comparable to Srinivasa S et al. [37]. bronchopneumonia was diagnosed in 42% of cases while Bronchiolitis and lobar pneumonia was diagnosed in 17% and 14% cases respectively. This is also comparable with the study done by Reddaiah et al. where they reported bronchopneumonia as a major LRTI [38]. Mungala VK et al. also reported bronchopneumonia as the commonest LRTI in their study [39].

Bronchopneumonia was the commonest LRTI in children with the predominance of VSD. We thus conclude that respiratory infections in children with congenital heart disease is common, however they have a good outcome. The majority of CHD lesions are Ventricular Septal defects while Bronchopneumonia was the most common diagnosis.

Dr. Afsal conceptualized and designed the study, interpreted data, revised the manuscript and approved the final version to be published. He will act as the guarantor of the study. Dr. Sandeep acquired the data, drafted the article and helped in the final approval of the manuscript. Dr.Manjunath Babu analyzed the data, revised contents and helped in final approval.

Earlier it was believed that respiratory infections especially lower Respiratory Tract infections in a child with CHDs worsens the prognosis and outcome of these children but now with this study and similar studies it can be seen that Lower Respiratory Tract infections especially ones like Pneumonia can coexist with CHDs and can be diagnosed and treated early and in an efficient way and the outcome of these children is also good.