Serum zinc level in children with acute lower respiratory tract infection: A hospital-based case-control study
Keywords:
acute lower respiratory tract infection, serum zinc, zinc deficiencyAbstract
Background: A few studies of Bangladeshi children have reported an independent association between severe zinc deficiency and acute lower respiratory tract infection (ALRTI) after adjusting for important confounders, although evidence to the contrary also exists. The current study was conducted to examine the relationship between low zinc levels in children with ALRTI and in those without respiratory disease who attended a tertiary hospital in Bangladesh.
Methods: This hospital-based case-control study was conducted among 36 children aged 2–60 months with ALRTI and 36 controls without respiratory illness. Clinical data were recorded, and serum zinc levels were measured within 24 hours of enrollment. Multivariate logistic regression was used to adjust for age, sex, family size, maternal education, breastfeeding, immunisation status, passive smoking exposure and anthropometric indices.
Results: The median (inter-quartile range) serum zinc level was significantly lower among cases than controls [82.5 (51.5–102.3) µg/dL vs. 133.0 (100.8–171.0) µg/dL; P < 0.001]. Zinc deficiency (serum zinc ≤60 µg/dL) was more frequent among cases (41.7%) than controls (2.8%). After adjustment for age, sex, family size, breastfeeding, anthropometric indices, immunisation, maternal education, and passive smoking exposure, low serum zinc levels were independently associated with ALRTI (adjusted OR = 26.2; 95% CI: 2.8–248.6). Passive smoking exposure was also independently associated with ALRTI (adjusted OR = 5.6; 95% CI: 1.5–21.0).
Conclusion: Low serum zinc levels (≤60 µg/dL) were strongly associated with ALRTI among children, with affected children having approximately 26-fold higher odds of ALRTI than those with higher zinc levels. These findings suggest that zinc deficiency may be an important modifiable risk factor for ALRTI in this population.
1
References
Kortz TB, Mediratta RP, Smith AM, Nielsen KR, Agulnik A, Gordon Rivera S, Reeves H, O'Brien NF, Lee JH, Abbas Q, Attebery JE, Bacha T, Bhutta EG, Biewen CJ, Camacho-Cruz J, Coronado Muñoz A, deAlmeida ML, Domeryo Owusu L, Fonseca Y, Hooli S, Wynkoop H, Leimanis-Laurens M, Nicholaus Mally D, McCarthy AM, Mutekanga A, Pineda C, Remy KE, Sanders SC, Tabor E, Teixeira Rodrigues A, Yuee Wang JQ, Kissoon N, Takwoingi Y, Wiens MO, Bhutta A. Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis. Front Pediatr. 2024 Jun 7;12:1397232. doi: https//doi.org/10.3389/fped.2024.1397232
UNICEF. Fighting for breath in Bangladesh . 2020 [cited 2025 Nov 11]. Available at: https://stoppneumonia.org/wp-content/uploads/2020/06/BANGLADESH-2020.pdf [Accessed on 17 June 2026].
Kirolos A, Blacow RM, Parajuli A, Welton NJ, Khanna A, Allen SJ, McAllister DA, Campbell H, Nair H. The impact of childhood malnutrition on mortality from pneumonia: a systematic review and network meta-analysis. BMJ Glob Health. 2021 Nov;6(11):e007411. doi: https//doi.org/10.1136/bmjgh-2021-007411
Ginsburg AS, Izadnegahdar R, Berkley JA, Walson JL, Rollins N, Klugman KP. Undernutrition and pneumonia mortality. Lancet Glob Health. 2015 Dec;3(12):e735-6. doi: https//doi.org/10.1016/S2214-109X(15)00222-3
Jackson S, Mathews KH, Pulanic D, Falconer R, Rudan I, Campbell H, Nair H. Risk factors for severe acute lower respiratory infections in children: a systematic review and meta-analysis. Croat Med J. 2013 Apr;54(2):110-21. doi: https//doi.org/10.3325/cmj.2013.54.110
Stiles LI, Ferrao K, Mehta KJ. Role of zinc in health and disease. Clin Exp Med. 2024 Feb 17;24(1):38. doi: https//doi.org/10.1007/s10238-024-01302-6
Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. Am J Clin Nutr. 1998 Aug;68(2 Suppl):447S-463S. doi: https//doi.org/10.1093/ajcn/68.2.447S
Tie HT, Tan Q, Luo MZ, Li Q, Yu JL, Wu QC. Zinc as an adjunct to antibiotics for the treatment of severe pneumonia in children <5 years: a meta-analysis of randomised-controlled trials. Br J Nutr. 2016 Mar 14;115(5):807-16. doi: https//doi.org/10.1017/S0007114515005449
Haider BA, Lassi ZS, Ahmed A, Bhutta ZA. Zinc supplementation as an adjunct to antibiotics in the treatment of pneumonia in children 2 to 59 months of age. Cochrane Database Syst Rev. 2011 Oct 5;2011(10):CD007368. doi: https//doi.org/10.1002/14651858.CD007368.pub2
Shakur MS, Malek MA, Bano N, Islam K. Zinc status in well nourished Bangladeshi children suffering from acute lower respiratory infection. Indian Pediatr. 2004 May;41(5):478-81. PMID: 15181298
Rahman MM, Vermund SH, Wahed MA, Fuchs GJ, Baqui AH, Alvarez JO. Simultaneous zinc and vitamin A supplementation in Bangladeshi children: randomised double blind controlled trial. BMJ. 2001 Aug 11;323(7308):314-8. doi: https//doi.org/10.1136/bmj.323.7308.314
Yokokawa H, Fukuda H, Saita M, Miyagami T, Takahashi Y, Hisaoka T, Naito T. Serum zinc concentrations and characteristics of zinc deficiency/marginal deficiency among Japanese subjects. J Gen Fam Med. 2020 Sep 18;21(6):248-255. doi: https//doi.org/10.1002/jgf2.377
GBD 2023 Lower Respiratory Infections and Antimicrobial Resistance Collaborators. Global burden of lower respiratory infections and aetiologies, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet Infect Dis. 2026 Apr;26(4):343-361. doi: 10.1016/S1473-3099(25)00689-9. Epub 2025 Dec 15. Erratum in: Lancet Infect Dis. 2026 Apr;26(4):e214. doi: https//doi.org/10.1016/S1473-3099(26)00124-6
World Health Organization. Pneumonia in children. Geneva: World Health Organization; 2022. Available at: https://www.who.int/en/news-room/fact-sheets/detail/pneumonia. [Accessed on 17 June 2026].
Natroshvili M, Chkhaidze M. Impact of Zinc Deficiency on the Severity of Pneumonia in Pediatric Patients: A Cross-Sectional Study. Cureus. 2025 Dec 3;17(12):e98383. doi: https//doi.org/10.7759/cureus.98383
Howie S, Bottomley C, Chimah O, Ideh R, Ebruke B, Okomo U, Onyeama C, Donkor S, Rodrigues O, Tapgun M, Janneh M, Oluwalana C, Kuti B, Enwere G, Esangbedo P, Doherty C, Mackenzie G, Greenwood B, Corrah T, Prentice A, Adegbola R, Zaman S. Zinc as an adjunct therapy in the management of severe pneumonia among Gambian children: randomized controlled trial. J Glob Health. 2018 Jun;8(1):010418. doi: https//doi.org/10.7189/jogh.08.010418
Brown N, Kukka AJ, Mårtensson A. Efficacy of zinc as adjunctive pneumonia treatment in children aged 2 to 60 months in low-income and middle-income countries: a systematic review and meta-analysis. BMJ Paediatr Open. 2020 Jul 12;4(1):e000662. doi: https//doi.org/10.1136/bmjpo-2020-000662
Wessells KR, Brown KH. Estimating the global prevalence of zinc deficiency: results based on zinc availability in national food supplies and the prevalence of stunting. PLoS One. 2012;7(11):e50568. doi: https//doi.org/10.1371/journal.pone.0050568
Saaoud F, Shao Y, Cornwell W, Wang H, Rogers TJ, Yang X. Cigarette Smoke Modulates Inflammation and Immunity via Reactive Oxygen Species-Regulated Trained Immunity and Trained Tolerance Mechanisms. Antioxid Redox Signal. 2023 May;38(13-15):1041-1069. doi: https//doi.org/10.1089/ars.2022.0087
Jones LL, Hashim A, McKeever T, Cook DG, Britton J, Leonardi-Bee J. Parental and household smoking and the increased risk of bronchitis, bronchiolitis and other lower respiratory infections in infancy: systematic review and meta-analysis. Respir Res. 2011 Jan 10;12(1):5. doi: https//doi.org/10.1186/1465-9921-12-5
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2026 Taskina Mosleh, Nitin Das, Nilanjon Ghose
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
