Socio demographic and clinical characteristics of asthmatic children seen at Aminu Kano Teaching Hospital Kano Nigeria

Niger J Paed 2014; 41 (4): 360 - 364

ORIGINAL

Garba BI

Socio-demographic and clinical

Ibrahim M

Johnson A-WBR

characteristics of asthmatic

children seen at Aminu Kano

Teaching Hospital, Kano,

Nigeria

DOI:http://dx.doi.org/10.4314/njp.v41i4,14

Accepted: 25th July 2014

Abstract Introduction: Asthma is

examination were documented.

a chronic inflammatory disorder

Results: Seventy asthmatic

Garba BI (

)

associated with variable air flow

children were recruited of which

Department of Paediatrics,

50(71.4%) were males and

Yariman Bakura Specialist Hospital,

obstruction and bronchial hyper-

Gusau, Zamfara State. Nigeria.

responsiveness. It is characterised

20(28.6%) were females, giving a

Email: bgilah@yahoo.com

clinically by recurrent episodes of

male: female ratio of 2.5:1. Insec-

cough, difficulty in breathing and

ticide was the commonest asthma

Ibrahim M

wheezing which resolves sponta-

trigger (64.3%) and 26(37.1%)

Umaru Musa Yar’adua University,

neously or with treatment. The

patients belonged to socio eco-

Katsina, Katsina State. Nigeria.

socio-demographic and clinical

nomic class III. Mild persistent

characteristics of asthmatic chil-

asthma was the commonest form

Johnson A-WBR

dren in north western Nigeria

of asthma severity encountered.

Department of Paediatrics and Child

There was positive correlation

Health, University of Ilorin Teaching

have not been reported.

Hospital, Kwara State. Nigeria.

Methods: This was a descriptive

between PEFR and height

study in children with asthma

(r = 0.577, p< 0.0001).

aged 4-15 years carried out over a

Conclusion: Most of the asthmat-

3 month period Aminu Kano

ics children seen at AKTH, Kano

Teaching

Hospital

(AKTH),

were males with mild persistent

Kano. The aim was to determine

asthma, had positive family history

the socio-demographic and clini-

of atopy and belonged to the mid-

cal parameters of asthmatic chil-

dle socio economic class.

dren. Asthmatic children whose

parents or guardian consented to

Key words: Asthma, Children,

the study were recruited consecu-

Socioeconomic class, Asthma se-

tively.

Their

bio-data,

socio-

verity

demographic and physical

Introduction

than girls before puberty ^5,6 .

Mielcket al found prevalence of severe asthma to be

Asthma is a chronic inflammatory disorder associated

significantly higher in the low as compared with the

with variable airflow obstruction and bronchial hyper

high socioeconomic group. This association could not be

explained by established risk factors . As compared with

responsiveness. It presents with recurrent episodes of

wheeze, cough, shortness of breath, and chest tightness .

children from the most advantaged homes, children from

With regard to age at first presentation, approximately

the least advantaged homes were more likely to present

50% present with symptoms by three years of age

2,3

with exercise induced bronchial asthma and to report

Caucasians and indeed, 80% by the sixth year of life.

night cough . Georgy et al demonstrated a significant

However not all children who experience recurrent

association between socioeconomic status and symp-

wheezing will go on to have persistent asthma in later

toms, with both higher prevalence and severity found in

childhood . Aderele reported 63% of asthmatic children

the lower socioeconomic group.

seen in Ibadan had their first attack before the age of

three years and 97% of study population were under the

Earlier reports on asthmatic children in Northern Nigeria

were done in the 1970s, both were from Zaria

10,11

age of 5years.

. Asani

et al in 2005 reported on childhood asthma in Kano,

In general boys are thrice as affected as girls, but during

however their study did not report on socio-economic

adolescence, the prevalence becomes equal between the

class and peak expiratory flow rate (PEFR). There is no

genders. Beyond adolescence however, the prevalence is

reported study combining socio-demographic and clini-

higher in women than men . Most surveys of childhood

cal characteristics including PEFR of asthmatic children

asthma suggest that boys are more frequently affected

in North western Nigeria.

361

Materials and Methods

The occupations were scored thus

This was a descriptive study in 70 children with asthma

Class I: Professionals, managers, contractors, big traders

aged 4-15 years carried out between September and De-

and transporters.

cember 2010 at Aminu Kano Teaching Hospital, Kano

Class II: Semi professionals e.g technicians, printers,

(AKTH). The aim of which was to determine the socio-

senior school teachers and senior public

demographic and clinical parameters of asthmatic chil-

servants.

dren.

Class III: Medium grade traders, insurance agents,

The subjects were children with asthma attending emer-

policemen and medium grade public servants.

gency paediatric unit, paediatric outpatient department

Class IV: Drivers, artisans, junior public servants and

and cardio-pulmonary clinic of AKTH, Kano. Asthmatic

similar grades.

children that have inter current infections and those with

Class V: Petty traders, labourers and similar grades,

chronic respiratory or cardiac diseases were excluded.

subsistence farmers, unemployed.

Ethical approval was obtained from the Medical Ethics

While the second scale scores the educational level from

Committee of AKTH, Kano. Informed consent was

1-5 from university graduate to no formal education.

however obtained from the respective parent or guardian

and children > 7 years gave their assent.

The educational levels attained were scored thus

Data was collected using a pre-tested interviewer admin-

Class I: University and post graduate certificates.

istered questionnaire which was administered by the

Class II: School certificate (ordinary level GCE) plus

researcher and trained assistants to the parent/ guardian

teaching or other professional training

and the child. The children were recruited consecutively.

certificates.

The bio-data, socio-demographic and physical examina-

Class III: Ordinary level GCE, West African School

tion were documented. Physical examination included

Certificate, grade II teachers and equivalents.

weight and height measurement, general examination

Class IV: Modern three and equivalent certificates, pri

relating to allergy, respiratory examination and peak

mary six certificate.

expiratory flow rate measurement.

Class V: No formal education.

The social class allocated for the family was the mean of

Weight was measured using a well calibrated bathroom

the four scores (two for the father and two for the

weighing scale (Hanson®, model 89 C 1 Ireland) to the

mother) to the nearest whole number.

nearest 0.1kilogramme with the subject wearing light

clothing. While height was measured using the Harpen-

Statistical analysis

den® stadio metre which measures up to two metre. The

PEFR was determined using the mini-Wright Peak Flow

Data was entered into a Statistical Package for Social

Metre® (Aimed Clement Clarke, England). This was

Sciences version 16 for cleaning and analysis. Quantita-

calibrated in L/min (litre per minute) up to 900L/min.

tive variables were summarized using mean and stan-

The subjects were taught how to blow through the meter

dard deviation. Categorical variables were summarized

at the peak of deep inspiration with maximum effort and

using frequency and percentages. Relationship between

without air leak around the mouth piece.

continuous variables was described using Pearson corre-

lation co-efficient. A p value of <0.05 was considered

The subjects were stratified into age groups as follows:

statistically significant.

4 to 5 years, 6 to 10 years and 11 to 15years to ease

comparison with a 5year interval. However, PEFR is

difficult to obtain in under fives, hence only 4-5 year

olds were enrolled. Asthma severity was classified

Results

according to GINA guidelines using frequency of symp-

toms per week, exercise tolerance and nocturnal

Demographic characteristics of study population

symptoms.

The age ranged from 4 to 15 years with a mean ± SD of

8.97 ± 2.88 years. In table 1, the 6-10 years age-group

Assessment of socio-economic class

constituted the highest percentage of subjects, followed

by those aged 11-15 years. There were 50 males (71.4%)

The socio-economic classes of the patients were as-

and 20 (28.6%) females giving male to female ratio of

sessed according to the method suggested by Oyedeji .

2.5: 1.

The social class of each child was determined from the

occupational and educational level of both parents using

Socio-economic class of study subjects

standard scoring scales on both the occupational and

educational level for each parent. The first scale scores

Twenty six (37.1%) of the subjects belonged to socio-

the different occupational categories 1-5 from profes-

economic class III, followed by class IV with

sional to unemployed.

19(27.1%), then class II with 13(18.6%). Those in class

I were 9(12.9%) and only 3(4.3%) belonged to class V.

362

Age at diagnosis

(41.0%), ten (25.6%), nine (23.1%) and four (10.3%) of

the subjects respectively. Some of the first degree rela-

The youngest child diagnosed was at eight months and

tives had more than one atopic disease. The atopic dis-

oldest was at 15 years. The mean age at diagnosis was

eases included asthma in 21(48.8%), allergic rhinitis in

4.68 ± 2.91years. Twenty eight (40%) of the patients

nine (20.9%), allergic conjunctivitis in 13(30.2%). None

were diagnosed asthmatic before the age of three years

of the subjects had relatives with atopic dermatitis.

while 55(78.8%) were diagnosed by age six years.

Asthma symptoms

Table 1: Age and gender distribution of the study population

Males

Females

Majority of the subjects had multiple symptoms.

Age-group

n (%)

Total (%)

Subjects with history of chronic recurrent cough with

(years)

nocturnal or seasonal exacerbations constituted

4-5

6 (8.6)

6(2.9)

12(17.2)

55(78.6%), nocturnal wheezing were 39(55.7%), exer-

6-10

24(34.3)

11(18.6)

35(50.0)

cise intolerance 33(47.1%), recurrent colds and cough

11-15

20(28.5)

3(7.1)

23(32.8)

with a slow or protracted resolution of symptoms

Total

50(71.4)

20(28.6)

70(100.0)

30(42.9%), while history of diurnal wheezing was seen

n= number

%= percentage.

in 23(32.9%).

Trigger factors

Asthma severity using GINA guidelines

Table 2 shows insecticide spray to be the commonest

Table 4 shows that mild persistent asthmatics were the

trigger factor constituting 64.3%, followed by exercise

majority while severe persistent asthmatics were the

which constituted 47.1%.

least.

Table 2: Trigger factors of asthma attack

Table 4: Asthma severity of study population

Trigger factor

Frequency %

Asthma severity

Number (%)

Insecticide

(64.3)

Mild intermittent

26(37.1)

Exercise

(47.1)

Mild persistent

30(42.9)

Exposure to Cold

(34.3)

Moderate persistent

9(12.9)

Perfume

(32.9)

Severe persistent

5(7.1)

Dust

(31.4)

Total

70(100.0)

Some of the children had multiple trigger factors

Clinical features of atopy

Location of kitchen of the study subjects

Table 5 shows that allergic conjunctivitis was the com-

monest of the general clinical stigmata of atopy encoun-

Fifty four (77.1%) subjects live in houses with kitchen

tered, while only two subjects had eczema.

located within the house and 16(22.9%) outside the

PEFR values Mean PEFR was 177.6 ± 57.2 L/min, with

house. Types of kitchen fuel used in the various homes

a range of 60 to 300 L/min. There was positive correla-

included kerosene, firewood, charcoal and gas. Table 3

tion seen between PEFR and height in the subjects

shows the various types of kitchen fuel used; with kero-

(r = 0.577, p = 0.0001).

sene being the commonest fuel used in the homes of

asthmatic subjects.

Table 5: A topic features in study population

Atopic feature

Table 3: Types of kitchen fuel used in homes of study popula-

tion

Allergic conjunctivitis

23(32.9)

Type of fuel

Frequency %

Dennie Morgan’s lines

6(5.7)

Allergic shiners

4(5.7)

Kerosene

(20.0)

Allergic salute

3(4.3)

Firewood

(17.2)

Eczema

2(2.9)

Charcoal

(15.7)

Kerosene and firewood

(14.3)

Not all subjects had atopic features and some had multiple

Kerosene and gas

(8.6)

features

Charcoal and firewood

(8.6)

Gas

(7.1)

Kerosene and charcoal

(5.7)

Firewood and gas

(2.8)

Total

(100.0)

Discussion

Family history of atopy

The highest number of asthmatic subjects recorded in

our study was in the 6-10 year age-group which ac-

Thirty six (51.4%) subjects had first degree relatives

counted for 50.0% of the study group. This may be

with atopic disease. Having a mother, father, brother or

partly due to the fact that most children with asthma

tend to present with symptoms by six years of age

3,5

sister with atopic conditions were observed in sixteen

and

363

also children of this age group are of school age with

Family history of atopy was recorded in 51.4% of the

likelihood of exposure to trigger factors at school such

subjects which was higher than 40.0% obtained by Ad-

erele in Ibadan and 22% obtained by Warrellet al

as exercise, dust and contagious viral respiratory tract

infections. Many of these children may be walking to

Zaria. This may be due to increase in awareness of the

school which may serve as a form of exercise and hence

disease with more health facilities and also with indus-

trigger asthma attack. Previous study by Aderele in

trialization, since both studies were conducted decades

Ibadan showed 49% of the asthmatic children were

ago. Family history of asthma was common as also seen

and Onazi et al . On compar-

by Aderele Asani et al

under the age of five years. Reason for this difference is

because children less than four years were excluded.

ing the frequency of which relative is affected, having a

mother with asthma was highest and similar to that re-

ported by Godfrey . Majority of the subjects had history

There were more males than females in the present study

and male preponderance for asthma before adolescence

of nocturnal wheezing and recurrent cough with noctur-

appears to be a universal finding as similar observations

nal or seasonal exacerbation. This may be explained by

were made by Aderele , Abdurrahman and other work-

the fact that cough is a major symptom in asthmatic pa-

ers

12,14

. Factors responsible for male preponderance are

tients. Cough and wheezing were also major symptoms

not clear.

in 96% of children seen at Ibadan. Onazi etal

found

Majority of the subjects belonged to middle socio-

wheezing to be common amongst school children with

economic class which was not in accord with studies

exercise induced bronchospasm in Gusau.

reported by Mielcket al , Ernst et al and others

9,15

where

asthmatics were found to be more in lower socio-

Using the GINA classification of asthma severity on

economic class. Aderele however found majority of

follow up of the children, mild persistent asthmatics

their asthmatic children were in the upper socio-

were the majority, followed by mild intermittent, moder-

economic class. Reason for this disparity could be

ate persistent and then severe persistent asthmatics. Mild

explained by the difference in the socio-economic classi-

persistent asthma was also the commonest form of

fication used. The asthmatic subjects belonging in the

asthma severity in children at 1 year follow up in Beni-

nas reported by Oviawe et al . This pattern was not in

middle socio-economic class are most likely to present

conformity with the findings of Qianet al where severe

to the hospital for accurate diagnosis and management.

The lower socio-economic class may be patronizing

persistent asthmatic subjects constituted the largest

other hospitals, patent medicine stores or traditional

group with 37.0%, followed by mild intermittent with

medicine due to cost in our hospital, hence the lower

29.9%, moderate persistent were 22.4% and mild persis-

percentage in this study. The asthmatics in high socio-

tent 10.7%. Reason for this difference may be due to a

larger sample size used by Qianet al

economic class may prefer going to their doctors

where 281 asth-

directly or private hospitals when they have complaints

matic subjects were studied. Another explanation for the

without necessarily attending routine clinic.

difference may be probably because developed countries

have high level of industrialization with attendant dusty

Trigger factors identified in this study were similar to

air and air pollutants which may contribute to severe

those reported by Aderele in Ibadan and Asaniet al in

persistent asthma seen in such countries.

Kano. While 31.4% of patients had asthmatic attack

triggered by dust in the present study, Aderele reported

Various clinical stigmata of atopy were seen of which

2.5% and Asaniet al reported a higher value of 52.0%.

presence of allergic conjunctivitis was the commonest,

The geographical location of Kano and its neighboring

this was seen in 32.9% of subjects. This is in agreement

with earlier work reported by Aderele. Abdurrahman et

states in the dusty savannah region of northern Nigeria

and Onazi et al . However, the finding in both

in contrast to Ibadan which is situated in the rain forest

ISAAC studies done by Faladeet al

20,21

belt of southern Nigeria, may account for this remark-

which reported

able difference. Exposure to cold accounted for 34.3%

eczema as a common disorder (10.1% in 6-7year old and

in this study as compared to 9.0% and 48.0% obtained

26.1% in 13-14year old respectively) was not in agree-

by Aderele and Asaniet al respectively. However exer-

ment with this study as only 2.9% of asthmatic subjects

cise as a trigger factor which constituted 47.0% was

had atopic dermatitis. This may be due to the difference

similar to 44.0% obtained by Asaniet al

but higher

in sample size where 1,704 6-7year olds and 3,058 13-

14 year olds were studied by Faladeet al

20,21

than 30% obtained by Aderele and 39.7% obtained by

respec-

Onazi et al . Reason for this cannot be explained, as we

tively. Present finding is similar to 5% reported by Ad-

erele and no subject was seen by Warrelet al . The

cannot confirm if asthmatic children in Kano engage in

more exercise than those in Ibadan and Gusau.

reason for their findings may be probably because both

Presence of indoor cooking was higher than 32.5% ob-

studies were conducted when the rate of industrialization

tained by Onaziet al . The predominant method of

was low. Another reason for the small percentage in this

cooking in these homes was combination of kerosene,

study may be due to tendency of atopic dermatitis to

firewood, charcoal and gas. These emit gases which the

improve by two to three years of age and subside in

many children before seven years of age , however this

children are constantly exposed to at home which may

is not in conformity with Aderele’s findings.

precipitate asthma symptoms. This observation was

similar to that reported by Sudhiret al in India . How-

ever; exposure to smoke as a possible trigger factor was

The positive correlation between PEFR and height is

not assessed in this study.

expected as similar observation of correlation between

364

PEFR and height was observed by Jaja et al and other

Author’s contributions

workers

24,25

. This is because with increasing height,

Garba BI: Data collection, analysis, introduction,

PEFR values increase as a result of increase in lung vol-

literature review, and discussion

ume, hence the force and amount of air expired during

Johnson A-WBR, Ibrahim M: Revised the

PEFR measurement.

manuscript

Conflict of Interest: None

Funding: None

Conclusion

In conclusion, most of the asthmatics found in Kano

Acknowledgements

were males, with mild persistent asthma, had positive

family history of atopy and belonged to the middle socio

We wish to acknowledge the contributions of Professor

economic class.

O Oyelami, and Dr Ibrahim Aliyu. We are also grateful

to the resident doctors of Paediatric department, Aminu

Kano Teaching Hospital, Kano for their assistance.

References

International consensus on (ICON)

Georgy V, Fahim HI, El Gaafary

18. Oviawe O, Osarogiagbon WO.

pediatric asthma. Papadopoulos

M, Walters S. Prevalence and

Trend in asthma severity in steroid

NG, Arakawa H, Carlsen KH,

socioeconomic association of

naive asthmatic children in Benin

Custovic A, Gern J, Lemanske R

asthma and allergic rhinitis in

city, Nigeria. Niger J Clin Pract

et al. Allergy 2012; 67: 976–997.

Northern Africa. Eur Respir

2013;16(3):371-374.

Expert Panel Report 3: Guidelines

2006;28:756-762.

19. Qian FH, Zhang Q, Zhou LF, Liu

for the diagnosis and management

10. Abdurrahman MB, TaqiAM.

H, Huang M, Zhang XL, et al.

of asthma. NIH publication no. 07-

Childhood asthma in northern

High sensitivity C- reactive pro-

4051. Bethesda, MD: US. Depart-

Nigeria. Clin Allergy 1982;12

tein:a predicative marker in severe

ment of Health and Human Ser-

(4):379-384.

asthma. Respirology 2008;13

vices; National institutes of

11. Warrel DA, Fawcett IW, Harrison

(5):664-9.

Health; National Heart, Lung, and

BDW, Agamah AJ, Ibu JO, Pope

20. Falade AG, Olawuyi F, Osinusi K,

Blood Institute; National Asthma

HM et al. Bronchial asthma in the

Onadeko BO. Prevalence and

Education and Prevention Pro-

Nigerian savannah region. A clini-

severity of symptoms of asthma,

gram. 2007. cited 2008 Nov 4.

cal and laboratory study of 106

allergic rhinoconjuctivitis and

Available from http://

patients with a review of literature

atopic eczema in 6-to-7yr old Ni-

www.nhlbi.nih.gov/ guidelines/

on asthma in the tropics . Qtly J

gerian primary school children: the

asthma/asthgdln.pdf

Med 1975;174:325-347.

international study of asthma and

Wilmott R. In: Polin RA, Ditmar

12. Asani MO, Adeleke SI, Ibrahim

allergies in childhood. Med Princ

MF.Pediatric Secrets.4 ed. Phila-

M. Childhood asthma in Kano,

Pract 2004;13(1):20-25.

delphia: Elsevier Mosby; 2005.

Nigeria. Niger J Basic Clin Sci

21. Falade AG, Olawuyi F, Osinusi K ,

p .576-581.

2005;2:6-9.

Onadeko BO. Prevalence and

Liu AH, Covar RA, Spahn JD,

13. Oyedeji GA. Socio-economic and

severity of symptoms of asthma,

Leung DYM. Childhood asthma.

cultural background of hospital-

allergic rhinoconjuctivitis and

In; Kliegman RM, Behrman RE,

ized children in Ilesha. Niger J

atopic eczema in secondary school

Jenson HB, Stanton BF. Nelson

Paediatr 1985;12:111-7.

children in Ibadan Nigeria. East

textbook of Paediatrics. 18 ed.

14. Onazi SO, OrogadeAA,Yakubu

Afr Med J 1998;75(12):695-698.

Philadelphia: Saunders Elsevier;

AM. Exercise-induced broncho-

22. Leung DYM. Atopic dermatitis

2007. p.953-970

spasm among school children in

(atopic eczema). In; Kliegman

Aderele WI. Bronchial asthma in

Gusau, Nigeria. West Afr J Med

RM, Behrman RE, Jenson HB,

Nigerian children. Arch Dis Child

2012;31(2):76-80

Stanton BF. Nelson textbook of

paediatrics. 18 ed. Philadelphia:

1979;54:448-453.

15. Almqvist C, Pershagen G, Wick-

Nicolai T, Bliznakova P, Illi S,

man M. Low socioeconomic status

Saunders Elsevier; 2007. p. 971-

Reinhardt D, Mutius

as a risk factor for asthma, rhinitis

75.

E.Longitudinal follow-up of the

and sensitisation at 4 years in a

23. Jaja SI, Fagbenro AO. Peak expi-

changing gender ratio in asthma

birth cohort. Clin Exp Allergy

ratory flow rate in Nigerian school

from childhood to adulthood: role

2005;35(5):612-618.

children. Afr J Med Sci

of delayed manifestation in

16. Sudhir P, Prasad CE. Prevalence

1995;24:379-384.

girls. Ped All Immunol 2003;14

of exercise induced bronchospasm

24. Onadeko BO, Iyun AO, Sofowora

(4):280-283.

in school children: an urban-rural

EO, Adamu SO. Peak expiratory

Mielck A, Reitmeir P, Wjst M.

comparison. J Trop Pediatr

flow rate in normal Nigerian chil-

Severity of childhood asthma by

2003;49:104-108.

dren. Afr J Med Sci 1984;13:25-

socioeconomic status. Int J Epid

17. Godfrey S. Exercise and hyper-

32.

1996;25 ( 2)388-93.

ventilation induced asthma. In:

25. Agaba PA, Thacher TD, Angyo

Ernst P, Demisse K, Joseph L,

Clark TJH, Godfrey S, Lee TH

IA, Agaba EI. Peak expiratory

(eds). Asthma. 3 ed. London:

Locher U, Becklake MR. Socio-

flow rates in healthy Nigerian

economic status and indicators of

Chapman and Hall; 1992. p. 73-

children. J Trop pediatr

asthma in children . Am J Respir-

101.

2003;49:157-9.

Crit Care Med 1995;152(2)570-5.