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Original Article

DOI: 103126/JNPS.V4113

Original Article

DOI: 103126/JNPS.V4113

Original Article

DOI: 103126/JNPS.V4113

Study of vitamin D level in Paediatric Asthma at a Tertiary Care 
Center

Introduction: There are few studies that suggest low Vitamin D levels are 
associated with asthma. Present study was conducted to evaluate the 
association between vitamin D levels with asthma and its severity in children. 

Methods: This cross-sectional study included 70 children (35 asthmatic 
and 35 controls) aged between three to 12 yrs. CBC, AEC, IgE, spirometry, 
chest X-ray, and serum vitamin D levels were measured. Vitamin D levels 
were categorized according to guidelines of the American Academy of 
Paediatrics (2008) and compared between the two groups. The association 
between vitamin-D levels with asthma and its severity was studied. 

Result: The mean age of study group cases was 9.23 ± 2.62 yr. The 
male:female ratio in the study group was 2.5: 1. Cough and wheezing was 
the commonest manifestation (100%). Most of the patients had mild asthma 
(45.71%). Asthma was more common in the urban population (68.57%) 
and children belonging to lower socioeconomic status (51.43%). The 
markers of allergic disorders {Eosinophils, AEC and IgE} were elevated (all 
p-values ≤ 0.0001) in study group. Mean serum vitamin D levels in the study 
group and control group patients were 45.21 ± 28.52 nmol/L and 57.03 
± 40.01 nmol / L respectively. The mean levels of vitamin D in the study 
group were insufficient as per AAP criteria. Vitamin D levels were more 
deficient in severe asthma (26.19 ± 14.46 nmol/L). 

Conclusions: In the present study Vitamin D insufficiency was seen in 
patients with asthma.

Abstract

1 Professor, Department of Paediatrics, S.N. Medical College, Agra, UP, India.
2 Junior Resident, Department of Paediatrics, S.N. Medical College, Agra, UP, India.

Pankaj Kumar,1 Rajesh Kumar1, Pratap Bhanu Singh2

*Corresponding Author

Pankaj Kumar,
Professor, 
Department of Paediatrics,
S.N. Medical College, 
Agra, UP, India.
Email: drpankaj_peds@hotmail.com

Article History 
Received On: 08 Aug, 2022
Accepted On: 26 Apr, 2023

Funding sources: None

Conflict of Interest: None

Keywords: 
Allergy; Asthma; Vitamin D deficiency

Online Access

DOI:
https://doi.org/10.3126/jnps.v42i3.47355

Copyrights & Licensing © 2022 by author(s). This is an Open Access article dis-
tributed under Creative Commons Attribution License (CC BY NC )

Introduction
Asthma is a heterogeneous disease, usually characterized by chronic 
airway inflammation affecting one to 18% of the population in different 
countries.1 It is defined by the history of respiratory symptoms such as 
wheeze, shortness of breath, chest tightness, and cough that vary over 
time and in intensity, together with variable expiratory airflow limitation. 
Symptoms are often triggered by factors such as exercise, allergen or 
irritant exposure, change in weather, or viral respiratory infections. 
Recently, many studies have shown that the prevalence of asthma and 
allergic conditions have increased in various regions of the world.2 
According to WHO, in 2005 around 300 million people suffered from 
asthma and 2,55,000 died of asthma.3 It is expected to increase to 
400 million by 2025.4 Numerous studies conducted in different countries 
have reported an increase in asthma prevalence of approximately 50% 
per decade.5



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  2022 57

Original ArticleVitamin D level in paediatric asthma Original Article

DOI: 103126/JNPS.V4113

Asthma may have significant relation with serum Vitamin 
D level. There has been extensive studies regarding this 
matter. However, Indian studies are relatively lacking and 
inconclusive on this matter. For eg, Somashekar et al in their 
study conducted in Bangalore found that serum vitamin-D 
level was significantly lower in asthmatic children.6 On 
the other hand Dogru M et al found that no significant 
difference was found between mean serum vitamin D levels 
in asthmatic children and control.7 

Keeping this background in mind, the present study was 
conducted to evaluate the vitamin D levels in asthmatic 
children and their association with the severity of asthma 
in North India.

Methods
This cross-sectional study was conducted at a tertiary care 
center in Agra, India between March 2015 and August 
2016. Children between three to 12 years of age attending 
paediatric OPD and IPD, having clinical features suggestive 
of asthma, were enrolled as study subjects after taking 
informed consent from the parents or guardian. Patients with 
bronchial asthma were diagnosed using GINA guidelines 
(2015). Only newly diagnosed cases of asthma were taken 
as study subjects. Healthy children aged between three to 
12 years, without a history or family history of asthma, 
coming to the paediatric outpatient department or ward, 
were enrolled as controls. Children with other systemic 
illnesses or receiving Vitamin D therapy or drugs that might 
affect vitamin D levels for the past one year were excluded 
from the study. Data were collected on demographic 
variables (age, sex, height, weight, place of residence, 
socioeconomic status, and family history) and compared 
between the study and control group. The patients included 
in the study group underwent a detailed history, thorough 
clinical examination, and relevant investigations.

Complete blood count, absolute eosinophil count, serum 
IgE levels, and vitamin D levels were done for both the 
study and the control groups. The serum IgE levels were 
measured by Chemiluminescence Immunoassay (CLIA) 
by using a CLIA kit. Vitamin D levels were determined 
by measuring 25-hydroxyvitamin D levels. Estimation of 
serum vitamin D was done by electrochemiluminescence 
binding assay. An X-ray chest (Plain radiograph) was done. 
Spirometry was done in children above six years of age. 
For the bronchodilator reversibility test, salbutamol was 
given by MDI / nebulization. An increase in FEV1 of > 
12% predicted was considered positive for a diagnosis of 
asthma.

Study subjects were categorized based on their vitamin D 
levels as classified by the American Academy of Paediatrics 
(2008).8-10

Severely deficient: ≤ 12.5 nmol / L (≤ 5 ng / mL)

Deficient: ≤ 37.5 nmol/L (≤ 15 ng / ml)

Insufficient: > 37.5 nmol/L to < 50 nmol / L (> 15 ng / ml 
to < 20 ng / ml)

Sufficient: ≥ 50 nmol / L to 250 nmol / L (≥ 20 ng / ml to 
100 ng / ml)

Study was approved by ethical committee of the institute. 
The results of this study were analyzed and presented as 
numbers, percentages, or mean ± SD. Statistical analysis 
was performed by applying the Student “t” test, Fisher’s 
exact test, and the Analysis of variance (ANOVA) technique. 
A p-value less than 0.05 was considered to be significant 
for the statistical hypothesis.

Results
Thirty-five children suffering from asthma and 35 healthy 
children were included in our study. The mean age of study 
and control group cases was 9.23 ± 2.62 yr and 7.94 
± 3.05 yr respectively. The male:female ratio was 2.5:1 
and 1.7:1 in the study and control groups respectively. The 
socio-demographic profile of the study and control group is 
shown in table no.1.

Table 1: Demographic and Laboratory profile of study and 
control group

Demographic 
profile

Study 
(N=35)

Control 
(N=35)

p-value

Age group
3-6 yr
6-9 yr
9-12 yr

3 (8.57%)
11 (31.43%)
21(60%)

6 (17.14%)
12 (34.29%)
17 (48.57%)

0.5018

Gender
Male
Female

25 (71.43%)
10 (28.75%)

22 (62.86%)
13 (37.14%)

0.460

Rural
Urban

11 (31.43%)
24 (68.57%)

12 (34.29%)
23 (65.71%)

1.000

SES
Lower
Middle
Upper

18 (51.43%)
15 (42.86%)
2 (5.71%)

17 (48.57%)
10 (28.57%)
8 (22.86%)

0.1192

Laboratory parameters

Eosinophilscount (%) 6.97 ± 3.58 0.85 ± 2.40 < 0.0001

AEC(cells/mm3)
690.23 ± 
418.67

278.14 ±  
96.07

< 0.0001

IgE (IU/ml)
1035.69 ± 
937.64

174.29 ± 
217.31

< 0.0001

Vit. D (nmol/L)
45.21 ± 
28.52

57.03 ± 
40.01

0.1597

Cough and wheezing was the commonest presentation [35 
/ 35 (100%)] in the study group. Dyspnea was present in 
28 / 35 (80%) and night symptoms in 17 / 35 (48.57%) 



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  202258

Original Article Vitamin D level in paediatric asthma

of patients. Twenty-one (60%) of asthmatic children had 
co-existing allergic rhinitis and four (11.4%) had atopic 
dermatitis. Of the study group cases, 13 / 35 (37.14%) 
cases had a positive family history of allergy. Of the total 
35 children suffering from bronchial asthma, 16 (45.71%) 
had mild asthma, 15 (42.86%) had moderate asthma; only 
four (11.4%) children were suffering from severe asthma.

Mean FEV1 values in mild, moderate, and severe asthma 
cases were 85.13 ± 3.72, 74.85 ± 7.50, and 51.33 ± 
6.43 of the percentage predicted respectively. The value of 
FEV1 / FVC in mild asthma was 94.67 ± 6.66, in moderate 
was 81.54 ± 4.91 and in severe asthma was 65.33 ± 6.43 
of the percentage predicted value. Comparisons of mean 
serum Eosinophils count (%), AEC, IgE, and Vitamin D levels 
in the study and control group had been described in table 
1. Mean eosinophils counts (6.96 ± 3.58%), AEC (690.23 
± 418.67 cells / mm3) and IgE (1035.69 ± 937.64 IU / 
ml) levels were higher in the study group than in the control 
group and the difference was statistically significant. Mean 
vitamin D levels in the study group was 45.21 ± 28.52 
nmol / L which was insufficient as per AAP guidelines. 
Mean serum vitamin D levels in mild, moderate and severe 
asthma cases were 52.56 ± 26.28, 42.44 ± 31.88 and 
26.19 ± 14.46 nmol / L respectively. The level of vitamin D 
showed declining trend with increasing severity of asthma. 
Patients with severe asthma have very low levels of vitamin 
D as compared to patients suffering from mild asthma (p = 
0.0249).

Discussion
The prevalence and severity of asthma and allergic diseases 
in children continue to increase worldwide. Based on the 
results of various studies conducted in India as well as in 
other countries, the association of vitamin D deficiency with 
asthma is still controversial and confusing. Several studies 
suggest a positive correlation between serum vitamin D 
levels and asthma but some studies are contradicting the 
same.6,7,11,12

The mean age group and male-female ratio in our study and 
control group were comparable to several other studies.6,13 
In the study as well as in the control group most of the cases 
belonged to urban areas. This is comparable with several 
other studies where the prevalence of asthma was higher in 
children belonging to urban areas.14,15 Increased number 
of cases from urban areas can be explained by the easy 
accessibility of health care facilities in urban areas. Most of 
the cases in our study belonged to lower SES followed by 
middle and upper SES. Asthma and allergic disorders are 
more related to tobacco smoking, air pollution (Wood or 
coal-burning smoke, dust, etc.), poor housing conditions, 
and indoor allergens (animal dander, dust mites, 
cockroaches, molds), and diet which were related to lower 
SES.5 It may also be explained by the fact that most of the 

patients visiting Government hospitals belonged to lower 
SES because of relatively cheaper healthcare facilities. In 
the study group, 37.14% of cases had a positive family 
history of asthma. Other studies also showed similar trends 
of prevalence of family history.16,17 Several studies show 
the co-existence of allergic disorders with asthma which is 
similar to our study.18,19

In our study subjects, most of the children were suffering 
from mild asthma followed by moderate and severe asthma 
which is consistent with a study done by Lal et al.15 The 
mean value of eosinophil count (%), serum AEC levels, and 
IgE levels were significantly elevated in the study group 
than in control group (all p-value = < 0.0001). Eosinophil 
count ≥ 4% in peripheral blood is a risk factor for early 
childhood asthma.5 The presence of > 500 eosinophils / 
ml in peripheral blood is the most common hematologic 
abnormality of allergic patients.20 Average total IgE levels 
are higher in the population of allergic patients than in 
comparable populations without allergic disease.20 Ehlayel 
et al also observed the mean IgE levels were significantly 
higher (p- value = < 0.001) in asthmatic children.13

Mean serum vitamin D levels in the study group and control 
group patients were 45.21 ± 28.52 nmol / L and 57.03 
± 40.01 nmol / L respectively. Though the levels of vitamin 
D in the study group was insufficient as per AAP criteria, 
the difference in the levels of vitamin D between the two 
group was not statistically significant (p-value = 0.1597).8-
10 These findings were comparable with several studies 
done in various parts of the world.7,12,21 In the study subject 
vitamin D deficiency was present only in 48.57% of subjects 
which was consistent with a study done by Yao TC et al in 
which vitamin D deficiency was present in 51.0% of study 
subjects.12

In our study cases from rural areas had sufficient vitamin D 
levels while cases belonging to urban areas had deficient 
levels of vitamin D and the difference was statistically 
significant (p-value = 0.0462). There was also an increased 
prevalence of asthma in the urban population. This is the 
only point that suggests some association between vitamin 
D levels and asthma. A similar result was seen in a study 
done in central Ethiopia where vitamin D deficiency was 
significantly higher among students in an urban setting.22 
The present study found that children from the upper and 
middle socioeconomic groups had insufficient vitamin D 
levels. While children belonging to low SES had sufficient 
vitamin D levels. Prevalence of asthma was more in patients 
who belonged to lower SES as compared to upper SES.

The maximum no. of patients in our study belonged to mild 
asthma followed by moderate and severe asthma. Vitamin 
D levels in patients suffering from mild and moderate asthma 
were sufficient and insufficient respectively. Only patients 
with severe asthma had vitamin D deficiency. Increased 
severity of asthma was associated with decreased levels of 



J Nepal Paediatr Soc | VOL 42 | ISSUE 03 |SEP-DEC,  2022 59

Original ArticleVitamin D level in paediatric asthma

vitamin D in several other studies.23 As the sample size of 
the present study is relatively small, more studies are needed 
to look for any consistent correlation between vitamin D 
deficiency and asthma. The small sample size in our study 
can be considered one of the limitations in our study.

Conclusions
In the present study, Vitamin D levels were insufficient (as 
per AAP classification) in study group and deficiency was 
more pronounced in patients with severe asthma.

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