Respiratory tract infections remain a major cause of morbidity and mortality among children under five years of age, especially in developing countries. According to the World Health Organization, acute respiratory infections (ARIs) contribute to nearly 20% of global under-five deaths annually, with recurrent episodes significantly amplifying the healthcare burden and associated morbidity [1]. Recurrent respiratory infections (RRIs), typically defined as three or more distinct episodes within a six-month period, are increasingly recognized as a clinical condition with both immediate and long-term health implications in early childhood [2].

In low- and middle-income countries such as India, the high incidence of RRIs in early childhood is influenced by a combination of socioeconomic, environmental, and nutritional factors. These include poverty, inadequate sanitation, overcrowding, exposure to indoor air pollution, undernutrition, incomplete immunization, and lack of exclusive breastfeeding [1,3]. Furthermore, the immature immune systems of young children heighten their susceptibility to frequent infections, and delayed access to healthcare—common in rural areas—may result in mismanagement or recurrence [4,5].

While programs like the Integrated Management of Neonatal and Childhood Illness (IMNCI) have improved the management of ARIs, there remains a paucity of community-based studies specifically examining the incidence and determinants of RRIs [1,5]. Recent data from both national and international studies highlight variations in RRI incidence due to regional disparities, COVID-19 impacts, and evolving risk patterns [2,6]. Hence, identifying the prevalence and modifiable risk factors of RRIs in specific populations is essential to inform targeted interventions and policy decisions.

This study was therefore conducted to determine the incidence of recurrent respiratory infections and to assess the demographic, environmental, and nutritional factors associated with RRIs among under-five children in a rural community setting.

Study Design and Setting:

This was a community-based, cross-sectional observational study conducted in the rural field practice area of Government Medical College (GMC), Kamareddy, Telangana, India.

Study Period:

The study was carried out over a period of six months, from July 2024 to December 2024.

Study Population:

The study included children aged 0 to 59 months (under-five children) residing in the catchment area of the GMC Kamareddy urban and rural health training centers. Children with known congenital respiratory anomalies, immunodeficiency disorders, or chronic illnesses were excluded.

Sample Size and Sampling Technique:

A total of 100 children were included in the study. Participants were selected using systematic random sampling from family registers maintained by the community health workers in the selected villages.

Data Collection:

Data were collected through face-to-face interviews with the caregivers using a pretested, structured questionnaire. The questionnaire captured information on:

Demographic details (age, sex, birth history)

Socioeconomic status (as per modified BG Prasad classification)

Maternal education and occupation

Environmental factors (overcrowding, indoor air pollution, housing conditions)

Nutritional status (weight-for-age using WHO growth charts)

Immunization status (verified using immunization cards)

Breastfeeding and weaning practices

Definition of Recurrent Respiratory Infections (RRIs):
RRIs were defined as the occurrence of three or more distinct episodes of respiratory infections (upper or lower respiratory tract) within the preceding six months, each separated by at least 7 days of symptom-free interval.

Ethical Considerations:

The study was approved by the Institutional Ethics Committee of GMC Kamareddy. Written informed consent was obtained from the caregivers of all participating children. Confidentiality and anonymity of the data were ensured throughout the study.

Statistical Analysis:

Data were entered in Microsoft Excel and analyzed using SPSS version 25.0. Descriptive statistics such as means, frequencies, and percentages were calculated. Associations between categorical variables and RRIs were analyzed using the Chi-square test, and a p-value < 0.05 was considered statistically significant.

A total of 100 under-five children were included in the study. The mean age of the participants was 30.6 ± 14.2 months. Of the enrolled children, 58 (58%) were male and 42 (42%) were female (Table 1).

Table 1: Demographic Characteristics of Study Participants (N = 100)

The incidence of recurrent respiratory infections (RRIs), defined as three or more episodes of respiratory tract infections within a 6-month period, was found to be 39% (n = 39), while 61% (n = 61) of children did not meet the criteria for RRIs (Table 2).

Table 2: Incidence of Recurrent Respiratory Infections (RRIs)

Sociodemographic analysis revealed that children from low socioeconomic backgrounds had a significantly higher prevalence of RRIs (66.7%) compared to those without RRIs (24.6%) (p = 0.01). Similarly, maternal illiteracy was associated with a higher burden of RRIs (74.4% vs. 21.3%, p = 0.005). Other significant factors included overcrowded living conditions (61.5% vs. 31.1%, p = 0.003), exposure to indoor air pollution (69.2% vs. 40.9%, p = 0.01), and incomplete immunization (23.1% vs. 6.6%, p = 0.02) (Table 3).

Table 3: Sociodemographic and Environmental Determinants of RRIs

Nutritional assessment showed that undernutrition, defined as weight-for-age below -2 standard deviations, was significantly more prevalent in children with RRIs (53.8%) compared to those without (21.3%) (p < 0.001). Additionally, a history of non-exclusive breastfeeding during the first six months was significantly associated with RRIs (48.7% vs. 24.6%, p = 0.01). Although prematurity or low birth weight was more common in RRI cases (20.5% vs. 8.2%), the association did not reach statistical significance (p = 0.06) (Table 4).

Table 4: Nutritional and Clinical Observations Related to RRIs

This community-based cross-sectional study conducted in the rural field practice area of GMC Kamareddy found that 39% of under-five children experienced recurrent respiratory infections (RRIs), a finding that aligns with global estimates from similar low-resource settings such as rural Malawi and Bangladesh, where respiratory infection prevalence and recurrence are significantly high among young children [7,8]. These findings emphasize the continuing burden of RRIs in early childhood and the necessity of community-based preventive interventions.

Sociodemographic factors were strongly associated with RRIs. Children from low socioeconomic backgrounds and those with mothers lacking formal education experienced significantly higher infection rates. These results support the existing literature highlighting the role of social determinants like poverty and maternal illiteracy in limiting access to adequate nutrition, clean environments, and health education, thereby increasing RRI susceptibility [9].

Environmental risk factors, including overcrowded households and exposure to indoor air pollution from biomass fuel, were significantly linked to RRI occurrence. Similar associations have been reported in studies from Greenland and Cabo Verde, where household smoke exposure and suboptimal ventilation conditions were major contributors to respiratory illness in children [10,12].

Nutritional deficiencies were another critical determinant. Over half of the children with RRIs were undernourished, underscoring the link between malnutrition and compromised immunity. The lack of exclusive breastfeeding also emerged as a statistically significant contributor. These results are supported by inter-society consensus guidelines and surveillance data, which emphasize the protective effects of optimal infant feeding and nutrition in preventing recurrent infections [9,11].

Although a greater proportion of RRI cases had a history of prematurity or low birth weight, the difference was not statistically significant, possibly due to the limited sample size. Nevertheless, other studies suggest that such children remain at higher risk for repeated respiratory episodes and warrant close monitoring [8,11].

Overall, this study supports the growing body of evidence that recurrent respiratory infections in early childhood are driven by preventable and modifiable risk factors. Strengthening maternal education, improving nutrition, reducing indoor air pollution, and promoting exclusive breastfeeding should be prioritized in public health programs targeting under-five populations in resource-limited settings.

This study highlights a significant incidence (39%) of recurrent respiratory infections among under-five children in a rural community of Kamareddy. The findings underscore the multifactorial etiology of RRIs, with strong associations observed with low socioeconomic status, maternal illiteracy, overcrowding, indoor air pollution, undernutrition, incomplete immunization, and suboptimal breastfeeding practices. Most of these determinants are preventable or modifiable through community-level interventions and improved maternal and child healthcare services. Strengthening awareness, promoting exclusive breastfeeding, ensuring complete immunization, and addressing indoor air quality could substantially reduce the RRI burden. Targeted interventions addressing these risk factors are essential to improving respiratory health and overall well-being in this vulnerable population.

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