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ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 3  |  Page : 886-890

Hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma


1 Department of Pediatric, Faculty of Medicine, Student's Hospital, Menoufia University, Menoufia, Egypt
2 Department of Pediatric, Student's Hospital, Menoufia University, Menoufia, Egypt

Date of Submission02-Feb-2019
Date of Decision06-Mar-2019
Date of Acceptance10-Mar-2019
Date of Web Publication30-Sep-2020

Correspondence Address:
Manal A Elsayed Yousef
Shebin Elkom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_46_19

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  Abstract 


Objective
The main objective is to study the frequency of hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma and its relation to severity of the disease.
Background
Hyponatremia is the most common electrolyte abnormality seen in hospitalized patients with lower respiratory tract infections such as bronchiolitis and bronchial asthma.
Patients and methods
This is a case–control study, involving 69 cases of bronchiolitis and 31 cases of severe bronchial asthma, conducted in Menoufia University Hospitals from November 2017 to April 2018. All cases were subjected to history taking, clinical assessment, and investigations, including complete blood count, C-reactive protein, serum urea, serum creatinine, serum glutamic oxaloacetic transaminase, serum glutamate pyruvate transaminase, serum sodium, and serum potassium.
Results
The age of bronchiolitis cases ranged from 1 to 24 months of life, with mean age of 7.39 ± 7.63 months, whereas the age of severe bronchial asthma cases ranged from 36–138 months of life, with mean age of 56.71 ± 25.0 months. Clinical presentation of bronchiolitis was cough (100%), fever (40.8%), and poor feeding (55%), whereas that of patients with severe asthma was cough (100%), wheezy chest (67.7%), dyspnea (38.7%), and tight chest (25.8%). Incidence of hyponatremia in patients with bronchiolitis was 5.8% whereas in patients with severe bronchial asthma was 25.8%.
Conclusion
Hyponatremia is a common electrolyte abnormality in hospitalized children with lower respiratory tract infections such as bronchiolitis and bronchial asthma. The incidence of hyponatremia increased with the severity of the disease.

Keywords: children, hyponatremia, infection, lower respiratory tract diseases, viral


How to cite this article:
Elella SS, Tawfiq MA, Mekawy M, Elsayed Yousef MA. Hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma. Menoufia Med J 2020;33:886-90

How to cite this URL:
Elella SS, Tawfiq MA, Mekawy M, Elsayed Yousef MA. Hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma. Menoufia Med J [serial online] 2020 [cited 2020 Nov 26];33:886-90. Available from: http://www.mmj.eg.net/text.asp?2020/33/3/886/296699




  Introduction Top


Lower respiratory tract infection (LRTI) is one of the most serious illnesses, especially in those less than 5 years of age, requiring hospitalization and attributes to 30% of deaths annually worldwide. LRTI is infection below the larynx and may be taken to include bronchitis, bronchiolitis, pneumonia, and empyema. It is an inflammation of the airways and pulmonary tissue owing to viral or bacterial infection. Bronchiolitis is a common childhood illness, and its most common etiologic agent is respiratory syncytial virus [1].

Hospitalization is required in approximately in 1% of affected children, primarily because of dehydration, inadequate oral intake, or respiratory insufficiency [2].

Bronchial asthma is one of the chronic inflammatory diseases that affect infants, young children, and even adult. It is a chronic inflammatory disorder of the airways that causes recurrent episodes of wheezing, chest tightness, and cough, particularly at night or early in the morning. Asthma is a common disease in children that forms a major comorbidity illness [3].

Asthma is a global health problem affecting approximately 300 million individuals of all ages, ethnic groups, and countries. It is estimated that approximately 250 000 people die prematurely each year as a result of asthma. Concepts of asthma severity and control are important in evaluation. Severe asthma is defined by the level of current clinical control and risks as uncontrolled asthma, which can result in risk of frequent severe exacerbation and/or adverse reaction to medication and/or chronic morbidity. Fluids and electrolytes are the main pillars in maintenance of body homeostasis. The most important among electrolyte is sodium, which is an abundant cation in extracellular fluid. Hyponatremia is considered a common laboratory finding in children with LRTI [4].

Hyponatremia is defined as a plasma sodium concentration of less than 135 mmol/l. The etiology of hyponatremia in critically ill child may reflect an endogenous state of sodium dysregulation, iatrogenic causes, or both. Children admitted to critical care unit for respiratory insufficiency owing to respiratory tract infection have increased risk for developing hyponatremia, possibly owing to dysregulation of arginine vasopressin, antidiuretic hormone, excessive water administration, or deficient sodium intake [5].

The purpose of the study was to identify the frequency of hyponatremia in hospitalized children with bronchiolitis and severe bronchial asthma.


  Patients and Methods Top


The study protocol was approved by the ethical committee of Faculty of Medicine, Menoufia University, from November 2017 to April 2018 in Pediatric Department of Menoufia University Hospital. An informed written consent was taken from patients' care givers before participation in the study.

Studied cases were divided into two groups: group 1 included infants with bronchiolitis, under 2 years of age, who developed cough, wheeze, shortening of breath which was preceded by low-grade fever and runny nose; some cases progressed to severe diseases, presented by poor feeding, decreased activity, respiratory rate more than 70, nasal flaring or grunting, cyanosis, and history of stopped of breath. Group 2 included children with severe asthma, under 14 years of age, with history of recurrent attacks of episodic wheeze, dyspnea, chest tightness, and cough triggered with allergen. Patient presented with increased respiratory rate, retraction of accessory muscles, dyspnea, and oxygen saturation in room air less than 92%.

Sodium concentration was measured in both groups. They were classified as normonatremic if serum sodium concentration was from 135 to 155 mmol/l, and hyponatremia when sodium concentration was below 135 mmol/l. We have excluded from our study cases of chronic diseases other than bronchial asthma.

All cases were subjected to full detailed history taking and meticulous clinical examination, including general and local examination. General examination included anthropometric measures such as weight, length, and head circumference. We did not forget to record vital signs for all cases including temperature, respiratory rate, pulse, blood pressure measurement, or any abnormal skin and mucus membrane colors like pallor, jaundice, or cyanosis.

Local examination was done for all cases by full systematic review, but special emphasis was laid on head examination to exclude the presence of cephalohematoma; chest examination, including symmetry, breath sounds, and signs of respiratory distress; heart examination, including heart rate and presence of audible murmurs; abdominal examination to exclude any abdominal mass or hepatosplenomegaly; genitalia to exclude erythema, structural abnormalities, phimosis, periurethral, or tenderness in the external urethra or presence of congenital anomalies like hypospadias in males causing urinary tract infection; and neurological examination, including muscle tone [hypotonia, hypertonia, and reflexes (hyporeflexia and hyperreflexia)].

Investigations were done for all cases, including laboratory investigations such as complete blood count using electronic counter system Kx-21 N USA, C-reactive protein using latex serology test, serum urea and creatinine using automatic chemistry analyzer, serum glutamic oxaloacetic transaminase and serum glutamate pyruvate transaminase using automatic chemistry analyzer, and serum sodium and serum potassium were analyzed by an automatic chemistry analyzer (AU 480 System; Backman Coulter Inc, Brea, California, US).

Radiologic investigation such as chest radiography was done for all cases.

Statistical analysis

Continuous variables with normal distribution were expressed as the mean and SD whereas quantitative variables with non-normal distribution were presented as range. The statistics analysis was done using SPSS program 'statistical package for the social sciences,' 20th version ('International Business Machines;' IBM Company, New York, USA). Moreover, we used Microsoft Office Excel 2007 (Microsoft Corporation Company, USA) to make charts of results.


  Results Top


A total of 69 patients with bronchiolitis and 31 patients with severe asthma were referred for the study. [Table 1] shows the demographic data of the studied cases. Most patients with bronchiolitis were males (69.6%) and 30.4% were females, with mean age of 7.39 ± 7.63 months. Most patients with severe bronchial asthma were males (61.3%) and 38.7% were females, with mean age of 56.7 ± 25.0 months. There was obvious male predominance among cases of bronchiolitis and severe asthma.
Table 1: The demographic data of patients with bronchiolitis and patients with bronchial asthma

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Patients with bronchiolitis with positive history of paternal smoking represented 65.2%. Patients with asthma with positive history of paternal smoking represented 67.2%. Our study showed that patients with bronchiolitis with positive history of asthma in their family represented 15.9%. Patients with asthmatic with positive family history of asthma represented 32.3%.

Analysis of social level among patients with bronchiolitis revealed 81.8% were of average social level, whereas 16.1% were of below average social level. Patients with severe asthma revealed 77.4% were of average social level, whereas 16.2% were of below average social level. [Table 2] shows the clinical presentation of studied cases of bronchiolitis, which was cough in 100%, fever in 60.8%, and poor feeding in 55%. [Table 3] shows the clinical presentation of patients with severe asthma, which was cough in 100%, dyspnea in 38.7%, wheezy chest in 67.7%, and chest tightness in 25.8%. [Table 4] shows that the incidence of hyponatremia in patients with bronchiolitis was 5.8% whereas in patients with severe asthma was 25.8%. [Table 5] shows the division of cases into two groups (A and B); group A 'hyponatremic group' includes cases with serum sodium level less than 135 mmol/l and group B 'normonatremic group' included cases with serum sodium 135–155 mmol/l. Group A had 50% males and 50% female, and their age ranged from 3 to 120 months, with mean age of 44.5 ± 34.6 months. Group B had 69.3% male and 30.7% female, and their age ranged from 2 to 38 months, with mean age of 19.6 ± 25.7. There was a significant difference between both groups regarding age, and no significant difference between both groups regarding sex.
Table 2: The clinical presentation of patients with bronchiolitis

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Table 3: The clinical presentation of patients with bronchial asthma

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Table 4: The sodium level of patients with bronchiolitis and those with bronchial asthma

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Table 5: The sex and age of the patients with hyponatremia and normal sodium level

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  Discussion Top


LRTI is one of the leading causes of death in children under 5 years of age. According to WHO estimates, nearly two million children younger than 5 years die owing to acute respiratory tract infection (ARTI) every year, corresponding to approximately 19% of all deaths in this age group. Bronchiolitis is a common childhood illness, and its most common etiologic agent is respiratory syncytial virus. Hospitalization is required primarily because of dehydration, inadequate oral intake, or respiratory insufficiency [1].

Asthma is a common chronic disease that causes considerable morbidity. In 2007, 9.6 million children (13.1%) had been diagnosed with asthma in their lifetimes (GINA) [2].

Identification of modifiable risk factors of LRTI may help in reducing the burden of disease and prevent deaths along with many risk factors like low birth weight, lack of breast feeding, severe malnutrition, and smoking [6].

Hyponatremia is defined as a plasma sodium concentration of less than 135 mmol/l. It is a very common electrolyte abnormality occurring in hospitalized patients with LRTI. The etiology of hyponatremia in these patients can range from syndrome of inappropriate antidiuretic hormone release observed frequently in pulmonary diseases to iatrogenic fluid overload, which occurs during resuscitation [4].

The present study was conducted on hospitalized patients of Pediatric Department, Menoufia University Hospitals, during the period from November 2017 to April 2017. Our studied cases were divided into two groups according to clinical diagnosis (bronchiolitis and severe bronchial asthma) and according to sodium level (normonatremic and hyponatremic group). The study showed that patients with bronchiolitis represented 69.6% male and 30.4% females, with mean age of 7.39 ± 7.63 months. Patients with severe asthma had 61.3% males and 38.7% females, with mean age of 56.7 ± 25.0 months.

Our study revealed that there is male sex predominance among cases of bronchiolitis, which is in agreement with Mohd et al. [7], who found that ∼57.5% of hospitalized children because of acute lower respiratory tract infection (ALRTIs) were males.

Juven et al. [8] found that 56% of children hospitalized because of LRTLs in Finland were males. The study showed male patients with asthma represented 61.3%, whereas females represented 38.7%. This is in agree with Hassan et al. [9], who reported that asthma is more common in male.

According to GINA [10], male sex is a risk factor for asthma in children before the age of 14 years. Some experts find that male's airway size is smaller when compared with the female's airway, which may contribute to increased risk of wheezing after a cold or other viral infection [11].

The study showed that of among patients with bronchiolitis, 16.1% were of below average social class whereas 81.1% were of average social class. Among patients with severe asthma, 16.2% were below average social class whereas 77.4% were of average social class. The relation between social class and occurrence of LRTI was studied by few investigators and epidemiological studies [12]. They studied the effect of socioeconomic status and LRTI in Egyptian children and found by multivariate analysis that low maternal education level, low family income, and parents smoking habits were significant independent predictive risk factors for occurrence and severity of LRTI in Egyptian children.

The study showed that patients with bronchiolitis with positive history of paternal smoking represented 65.2%. Patients with asthma with positive history of paternal smoking represented 67.7%.

These agrees with GINA [13] which stated that exposure to external tobacco smoke (passive smoking) increased the risk of LRTI in infancy and childhood.

Moreover, Sturm et al. [14] concluded that even at low levels of exposure, childhood cigarette smoking and external tobacco smoke are independently associated with asthmatic symptoms.

Our study showed that patients with bronchiolitis with positive history of asthma in their family represented 15.9%, whereas patients with asthmatic with positive family history of asthma represented 32.3%. This result is in agreement with Pavlo et al. [15], who showed that genetic background, environmental factor, and the presence of comorbidities such as rhinitis and atopic eczema are associated with the genesis of asthma.

Analysis of clinical manifestations revealed that the most presenting symptoms of bronchiolitis patients were cough (100%), fever (60%), and poor feeding (55%) of patients. These results are in agreement with Mohd et al. [7], who found that the most frequent symptoms of LRTIs in children under 5 years of age were cough (100%), fever (94.5%), and tachypnea (67.3%).

Malla et al. [16] found that the most frequent symptoms of LRTIs in children under 5 years of age were cough (100%), fever (96.42%), and dyspnea (57.8%). The WHO uses tachypnea in the presence of cough as diagnostic criteria of LRTI in developed countries.

In patients with severe bronchial asthma, the most frequent symptoms were cough (100%), wheezy chest (67.7%), dyspnea (38.7%), and chest tightness (25.8%). Similarly, El-Saify et al. [17] found that the commonest chest complaints in asthmatic children were cough, dyspnea, wheezy chest, nocturnal symptoms, and chest infection.

Regarding serum sodium level, the incidence of hyponatremia was 5.8% in infants with bronchiolitis, 25.8% in patients with severe asthma. Incidence of hyponatremia in children with severe asthma was more than in those with acute bronchiolitis.

The mechanism of hyponatremia in children with LRTI may have many explanations. The most important mechanism compromises the part of syndrome of inappropriate antidiuretic hormone secretion (SIADH); the secretion of antidiuretic hormone (ADH) typically results in water retention with minimal weight gain. Many studies demonstrated that SIADH occurs in more than one-third of children hospitalized for pneumonia [18].

Friedman [19] found that one of the mechanisms of hyponatremia in hospitalized children is iatrogenic use of hypotonic intravenous fluids to maintain fluid and electrolyte requirements.

On dividing the cases into two groups, normonatremic group included cases with serum sodium level between 135 and 155 mmol/l and hyponatremic group with serum sodium level below 135 mmol/l. The study showed that there was no statistical difference between hyponatremic and normonatremic groups regarding sex and socioeconomic status. This signifies that hyponatremia is not affected by sex of the affected children.


  Conclusion Top


Our study suggests that patients with severe asthma are at high risk of developing hyponatremia than hospitalized infants with bronchiolitis. Thus, serum electrolyte should be measured in children hospitalized for LRTI, and appropriate fluid therapy must be carefully arranged in children with LRTI. Our recommendation is to increase medical awareness about electrolyte abnormalities associated with LRTI. Hyponatremia is a common electrolyte disturbance that occurs in patients with LRTI, especially admitted to pediatric ICU, so serum sodium should be measured in admitted cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Sturm JJ, Yeatts K, Loomis D. Effects of tobacco smoke exposure on asthma prevalence and medical care use in North Carolina Middle school children. Am J Public Health 2004; 94:308–313.  Back to cited text no. 14
    
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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