|Year : 2020 | Volume
| Issue : 1 | Page : 179-185
Assessment of blood level of vitamin C in children with bronchial asthma
Fahima M Hassan1, Ahmed A Khatab1, Rania S El-Zayat1, Sally M El-Hefnawy2, Heba G. A El-Hameed3
1 Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt
2 Department of Biochemistry, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia, Egypt
3 Department of Pediatrics, Agouza Police Hospital, Giza, Egypt
|Date of Submission||16-Sep-2018|
|Date of Decision||27-Oct-2018|
|Date of Acceptance||11-Nov-2018|
|Date of Web Publication||25-Mar-2020|
Heba G. A El-Hameed
Diploma, 34 El-Thalatheni El-Gedid Street, Haram, Giza
Rania S El-Zayat
Department of Pediatrics, Faculty of Medicine, Menoufia University, Shebin El-Kom, Menoufia
Source of Support: None, Conflict of Interest: None
The aim was to assess the serum level of vitamin C in children with bronchial asthma.
Vitamin C is abundant in the extracellular and intracellular lining fluid of the lungs, so it can participate in the primary lung defense against the reduction of oxidative mechanisms and therefore it has protective effects against bronchial asthma.
Patients and methods
This study was a case–control study that involved 60 pediatric patients with bronchial asthma as the cases group and 25 apparently normal children as the control group. All patients and controls were subjected to the same history taking, clinical examination, and investigations which involved: (a) laboratory investigations such as (i) complete blood count (red blood cells–white blood cells–platelets) by coulter, (ii) Differential leukocytic count especially (eosinophils), (iii) estimation of plasma level of vit C; (b) plain radiography for chest and heart (posteroanterior view): to exclude other chest diseases such as atelectasis or pneumonia and heart failure or cardiomegaly; and (c) pulmonary function tests such as spirometry: the apparatus used was ZAN 100 Spirometry. This was a portable spirometer capable of measuring both expiratory and inspiratory parameters. It was done to children above 6 years of age only. The pulmonary function tests used were forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC%).
Bronchial asthma was predominant in men (about 31 men, 51.66%) than women (about 29 women 48.33%) in the cases group. Thirty-two asthmatic children (about 53.3%) had a positive history of consanguinity and 32 asthmatic children (about 53.33%) had a positive history of atopy. There were highly statistically significant differences between cases and control groups as regards FVC% and FEV1(P < 0.001) as mean + SD of FVC% of the cases group were 80.25 ± 7.0123 while in the control group it were 92.36 ± 3.463 and mean + SD of FEV1of cases group were 69.68 ± 8.977 while in the control group it were 84.36 ± 6.987. There were highly statistically significant differences between cases and control groups as regards serum vitamin C level (P < 0.001) as mean + SD of vitamin C level in the cases group was 175.85 ± 101.607 and in the control group was 884.40 ± 439.878.
We found that children with bronchial asthma had significant lower levels of serum vitamin C than the control children. There were statistically significant differences between cases and control groups as regards severity of asthma and serum vitamin C levels. We concluded that a low level of vitamin C may influence the development of bronchial asthma and serum vitamin C deficiency may be caused or aggravated in asthmatic children.
Keywords: bronchial asthma, children, eosinophils, spirometry, vitamin C
|How to cite this article:|
Hassan FM, Khatab AA, El-Zayat RS, El-Hefnawy SM, El-Hameed HG. Assessment of blood level of vitamin C in children with bronchial asthma. Menoufia Med J 2020;33:179-85
|How to cite this URL:|
Hassan FM, Khatab AA, El-Zayat RS, El-Hefnawy SM, El-Hameed HG. Assessment of blood level of vitamin C in children with bronchial asthma. Menoufia Med J [serial online] 2020 [cited 2020 Mar 30];33:179-85. Available from: http://www.mmj.eg.net/text.asp?2020/33/1/179/281295
| Introduction|| |
Bronchial asthma is a chronic inflammatory disease of the airways that causes periodic 'attacks' of coughing, wheezing, shortness of breath, and chest tightness.
The effect of vitamin C on asthmatic Egyptian children is heterogeneous. It is important to carry out further researches to confirm the findings.
Atopy is strongly linked to asthma and to other respiratory diseases such as chronic sinusitis, middle ear infections, and nasal polyps. Most of the recent analysis of people with asthma showed that those who had both atopy and asthma were much more likely to have nighttime awakening due to asthma, miss work because of asthma, and require more powerful medications to control their symptoms.
Asthma is associated with mast cells, eosinophils, and T lymphocytes. Mast cells are the allergy-causing cells that release chemicals like histamine. Histamine is the substance that causes nasal stuffiness and dripping in a cold or hay fever, constriction of airways in asthma and itchy areas in skin allergy. Eosinophils are a type of white blood cells associated with allergic diseases. T lymphocytes are also white blood cells which are associated with allergy and inflammation.
The ultimate goal is to prevent symptoms, minimize morbidity from acute episodes, and to prevent functional and psychological morbidity to provide a healthy or near-healthy lifestyle appropriate to the children.
Both the prevalence and mortality of asthma increased during the last four decades. Asthma is the most frequent chronic disease in childhood and is characterized by recurrent cough and wheezes. Vitamin C as ascorbic acid is a water-soluble antioxidant present in physiologic concentrations in the airway and alveolar lining fluid. Vitamin C can modify oxidative insults from inhaled agents, infectious agents, or cellular inflammations as it acts as an antioxidant agent. Vitamin C deficiency acts as a predisposing factor of oxidative lung or airway injury from inflammatory cells. It influences the development, maintenance, differentiation, and regeneration of lung epithelial cells and plays a central role in the development of airway diseases, so asthma pathogenesis is synthesized due to the imbalance between oxidant and antioxidant processes that is called oxidant stress.
The aim of this study was to assess the serum level of vitamin C in children with bronchial asthma.
| Patients and Methods|| |
The study protocol was approved by the local ethics Committee of the Menoufia University. Informed consents were taken from the parents of both patients and control groups before the beginning of the study. This study was case–control study which was carried out over the period from August 2013 to October 2015. It involved children whose ages were between 6 and 14 years and were attending the pediatric chest clinic and the Inpatient Pediatric Department in Menoufia University. They were divided into two groups, children with bronchial asthma (cases group) who were 60 children and apparently normal children (control group) who were 25 children with comparable age, sex, and socioeconomic status.
Children who had any other acute or chronic disorders or were taking multivitamins for at least 6 months before the study were excluded. The two groups were subjected to the same history, examinations, and investigations.
Full history taking
- Personal history: name, age, sex, residence, and socioeconomic factors as regards the Fahmy and El-Sherbini Socioeconomic Score, which consisted of the score of occupation, education, and social class that included the income, crowding index, and sanitation score
- Compliant: cough, wheezing, breathlessness, sneezing, skin itching, or rash
- History of present illness: age of onset and duration of illness, frequency of attacks, duration of attack, diurnal and seasonal variation, precipitating factors (infection, emotion, odors, exercise, and foods), and medication used for treatment
- Past history: history of hospitalization, any drug sensitivity such as penicillin or sulfa and history of allergic conditions like allergic rhinitis or atopic dermatitis
- Family history: consanguinity and family history of allergic conditions
- Medical history including asthma treatment and vitamin intake.
- Vital signs (respiratory rate, temperature, heart rate, and blood pressure)
- Anthropometric measurements [weight in kg, height in cm, BMI (weight in kg/height in meter2)]
- Skin color: pallor or cyanosis
- Neck: lymph nodes or veins
- Upper and lower limbs: clubbing or edema
- Abdomen, cardiac, and central nervous system (CNS) examination.
Local chest examination
- Inspection: shape of the chest, respiratory rate, chest movement, retraction (suprasternal–intercostal–subcostal) and pulsations
- Percussion: degree of resonance
- Auscultation: as regards the type of breathing, air entry, and adventitious sound (e.g. rhonchi, crepitations).
Laboratory investigations involved
- Complete blood count (red blood cells–white blood cells–platelets) by coulter
- Differential leukocytic count especially (eosinophils)
- Estimation of plasma level of vitamin C.
Methodology of the test: blood samples were collected from every child about 4 ml and then 1 ml of them was transferred into the EDTA tube for complete blood count (CBC); 3 ml was transferred into a plain tube, centrifuged for 10 min at 4000 rpm. Human vitamin C concentrations in serum were measured using an enzyme-linked immunosorbent assay kit (WKEA MED SUPPLIES CORP, Jilin, China) according to the manufacturer's recommendation.
Plain radiography for chest and heart (posteroanterior view)
To exclude other chest diseases such as atelectasis or pneumonia and heart failure or cardiomegaly.
Pulmonary function tests
Spirometry: the apparatus used was ZAN 100 spirometry. This was a portable spirometer which is capable of measuring both expiratory and inspiratory parameters. It was done to the children above 6 years of age only in the respiratory function unit of the Pediatric Department of Menoufia University Hospital.
Methodology of the test
Spirometry was performed in the standing position. The lung function parameters measured were forced vital capacity (FVC%) and forced expiratory volume in 1 s (FEV1%).
- Qualitative data were expressed in number (frequency) and percentage
- Quantitative data were expressed in mean, SD, and SE
- Data entry of this study, coding, and analysis was done using SPSS (20), released 2011, IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, New York, USA)
- Tests of significance used were Student's t-test, analysis of variance (F-test), post-hoc test, Pearson's correlation coefficient and χ2-test
- The level of significance used was 95%. So, a P value greater than 0.05 was considered a nonstatistically significant; a P value less than or equal to 0.05 was considered statistically significant and a P value less than or equal to 0.001 was considered highly statistically significant.
| Results|| |
Our study was carried out on 85 children (60 cases and 25 controls) whose ages were between 6 and 14 years. Bronchial asthma was more predominant in males about 31 (51.66%) males than females about 29 (48.33%) females in cases group. Statistically, there were no significant differences between cases and control groups as regards age, sex, and consanguinity. As regards anthropometric measurements there were statistically significant differences between the two groups as regards the weight (P < 0.001). There are no statistically significant differences between cases and control groups as regards BMI (P = 0.08) and height (P = 0.06) [Table 1] and [Table 2].
|Table 2: Demographic data, anthropometric measures, pulmonary function tests, and laboratory data in the studied groups|
Click here to view
Thirty-two asthmatic children about 53.3% had a positive history of consanguinity and 32 patient children (about 53.33%) had a positive history of atopy. There were highly statistically significant differences between cases and control groups as regards weight (P < 0.001) with mean ± SD of cases which were 28.10 ± 5.489 and in the control group were 32.52 ± 8.661 and also as regards FVC% and FEV1(P < 0.001) as mean + SD of FVC% of cases group were 80.25 ± 7.0123 while in control group were 92.36 ± 3.463 and mean + SD of FEV1 of cases group were 69.68 ± 8.977 while in control group were 84.36 ± 6.987. There were statistically significant differences between cases and control groups as regards the FEV1/FVC ratio (P = 0.03) as mean + SD of FEV1/FVC% ratio of the cases group was 0.873 ± 0.127, while in the control group it was 0.913 ± 0.07. Also, there were highly statistically significant differences between cases and control groups as regards white blood cells and eosinophils (P < 0.001) as mean ± SD of white blood cells of the cases group were 6966.67 ± 2126.720 and in the control group were 5552.00 ± 799.020 while the mean ± SD of eosinophils of the cases group was 346.02 ± 106.968 and in the control group was 142.04 ± 37.904 [Table 2].
There were highly statistical differences between cases and control groups as regards serum vitamin C levels (P < 0.001) as mean ± SD of serum vitamin C. Levels in cases group were 175.85 ± 101.607 and in the control group were 884.40 ± 439.878 [Table 2].
There were statistically significant differences between cases and control groups as regards severity of asthma with serum vitamin C levels (P = 0.006) and FEV1(P = 0.039) but the severity of asthma had no statistically significant differences with FVC%, FEV1/FVC ratio, HB%, WBCs, and eosinophils (P > 0.05) [Table 3].
|Table 3: Comparison between severity of asthma regarding serum vitamin C level, spirometric measures and laboratory results|
Click here to view
There were positive correlations and statistically significant differences between serum vitamin C levels and FVC% and FEV1 between cases and control groups, but there were no statistically significant differences between serum vitamin C levels and FEV1/FVC ratios between cases and control groups. However, there were positive correlations and highly statistically significant differences between serum vitamin C levels and eosinophils [Table 4].
|Table 4: Correlations between serum vitamin C levels with spirometric findings and eosinophils|
Click here to view
| Discussion|| |
Our study involved 85 children (about 60 cases and 25 controls). All cases and controls were subjected to detailed history taking, clinical examinations with special emphasis on chest examination, chest radiography, laboratory findings (CBC, serum vitamin C level), and spirometeric measures (FVC%, FEV1, FEV1/FVC% ratio).
Regarding demographic data of the studied groups, no significant differences were found between cases and controls as regards age, sex residence, socioeconomic status, and history of paternal smoking.
Although we found no significant differences regarding sex in our cases, Akshay and Sood found that boys were consistently reported to have more prevalent wheezes and asthma than girls. Before the age of puberty, more boys than girls have asthma.
As regards consanguinity, we found that 53.3% of cases had a positive history of consanguinity and there were no statistically significant differences between cases and controls (P = 0.254).
Our study was in disagreement with Abdulrazzaq et al. who found in a study from the United Arab Emirates (a country with a high rate of consanguinity) that the occurrence of asthma was more in the offspring of consanguineous marriages (7.9%) than nonconsanguineous marriages (6.9%). Also, another study by Mahdi et al. demonstrated that family history of consanguinity is an important risk factor for developing asthma in the offspring of asthmatic parents.
Another study from Kuwait by Hijazi et al. was in agreement with our findings as it stated that there was no increased risk of asthma in children of consanguineous marriages. Also Hussain et al. found that parental consanguinity does not influence the risk of bronchial asthma in children.
The reasons for the discrepancy in the results of these studies are not clear. A possible explanation may be related to the sample size which is smaller in the studies from the Emirates, Kuwait, and ours. Another possible explanation may be related to the epidemiological variation of bronchial asthma with age suggesting an increasing role of genetic factors with increasing age.
As regards anthropometric measurements, we found that the cases had a lower weight than controls and the differences between the two groups were statistically significant (P < 0.001). Although no statistically significant differences were found between cases and control groups as regards height and BMI.
In contrast Ginda et al. found positive association between obesity and asthma and confirmed that overweight status was extremely high in children with bronchial asthma, so it had a role to increase the risk of bronchial asthma.
As regards spirometric measures, our study showed that cases had lower FEV1 and FVC% than controls (68.62 ± 12.708 vs. 84.36 ± 6.987 and 79.10 ± 12.443 vs. 92.36 ± 3.463, respectively) and the differences between the two groups were highly statistically significant (P < 0.001). Also, there were statistically significant differences between cases and controls as regards FEV1/FVC%.
As regards laboratory data, our study showed that there were no statistically significant differences between cases and control groups as regards Hb%. On the other hand, there were highly statistically significant differences between cases and control groups as regards white blood cells and eosinophils (P < 0.001). We found 26 cases with eosinophilia (eosinophil count >350 cell/mm3 HPF) out of 60 and their mean count was 440.53 ± 89.85, while all control group had normal eosinophilic count.
This was in agreement with Radinger et al. who found that allergic inflammation was associated with marked infiltration of eosinophils in affected tissues. The eosinophils was believed to be a key effector cells in allergen-induced asthma pathogenesis.
As regards serum vitamin C levels in the studied groups, our study showed that serum vitamin C levels were significantly lower in cases than in controls (175.85 ± 101.607 vs. 884.40 ± 439.878, respectively) (P < 0.01).
This was in agreement with Aderele et al. who also found that asthmatic patients had lower serum vit.C levels than healthy controls. Similarly, Kalayci et al. found that serum vitamin C levels were significantly lower in asthmatics compared with controls. He determined that serum levels of ascorbic acid in 14 asthmatic children and 12 healthy children as controls.
As regards severity of asthma, serum vitamin C levels were lowest in severe asthmatic children and the differences between its levels in mild, moderate, and in severe cases were statistically significant. This was in agreement with Farkhutdinov who found that vitamin C had great effect to decrease the production of the active oxygen forms which had great importance in the pathogenesis of bronchial asthma.
In our study, there were significant positive correlations between serum vitamin C levels and spirometric findings (FVC% and FEV1), but it showed no correlations and no statistically significant differences between serum vit.C levels and FEV1/FVC% ratios between the two groups.
Also, our study demonstrated that there were positive correlations and statistically significant differences between serum vit. C levels and eosinophils. Also, Chang et al. found that serum vitamin C level was associated with a decrease in eosinophilic count. In contrast Kodama et al. did not find any corresponding change of the eosinophilic count with increase in serum vitamin C level.
| Conclusion|| |
Asthmatic children had significant lower levels of serum vitamin C than control children. There were statistically significant differences between cases and control groups as regards severity of asthma and serum vitamin C levels. We concluded that a low level of serum vitamin C may influence the development of asthma and serum vitamin C deficiency may be caused or aggravated in asthmatic children.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Denis C, Robert A, Raida I, Harik-Khan K. Serum vitamin levels and the risk of asthma in children. Epidemiology J 2003; 159
Biltagi M, Baset A, Bassiouny M, Kasrawi M, Attia M. Omega-3 fatty acids, vitamin C and Zn supplementation in asthmatic children: a randomized self-controlled study. Acta Paediatr J 2012; 101
Robert K, Andrew D, Bonita S, Joseph W. Childhood asthma. Nelson textbook of pediatrics
ed. Elsiever, Amsterdam, The Netherlands; 2011.
Karen M, Robert K, Hal J, Richard B. Childhood asthma. Nelson textbook of pediatrics
Courtney AU, McCarter DF, Pollart SM. Childhood asthma: treatment update. Am Fam Physician J 2005; 71:1959–1968.
Schock BC, Young IS, Brown V. Antioxidants and protein carbonyls in bronchoalveolar lavage fluid of children: normal data. Pediatr Res J 2001; 49
Sheila M, Mike S, Boreen N. Respiratory disorders. In: AGM Campbell, Mclntoch N, editors. Forfar and Arneils textbook of pediatric
ed. New York: Churchill Livingstone; 2013. 536–550.
Fahmy S, El-Sherbini B. Socioeconomic scoring. Eastern Mediterranean Health Journal La Revue de Santé de la Méditerranée orientale. EMHJ
Sood A. Sex differences: implications for the Obesity-Asthma Association. Exerc Sport Sci Rev 2011; 39
Joseph M, Zoubeidi T, Al-Dhaheri SM, Al-Muhairi SJ, Al-Dhaheri AA, et al
. Paternal asthma is a predictor for childhood asthma in the consanguineous families from the United Arab Emirates. J Asthma 2012; 46
Mahdi B, Mahesh PA, Savitha Mysore R, Kumar P, Jayaraj BS, Ramachandra NB. Inheritance patterns, consanguinity and risk for asthma. Indian J Med Res 2010; 132
Hijazi Z, Jacques PF, Haider MZ, Sulsky SI, Sadowski JA, P. Influence of consanguinity and IgE receptor genotypes on clinical manifestations of asthma in Kuwaiti children. J Trop Pediatr 2013; 47
Hussain M, El Mouzan MI, Al Salloum AA, Al Herbish AS, Al Omar AA, et al.
Does consanguinity increase the risk of bronchial asthma in children? Department of Pediatrics, King Saud University, Riyadh, Saudi Arabia. Ann Thorac Med 2012; 3
Ginda AA, Santillan AA, Clark S, Camargo Jr CA. Body mass index and acute asthma severity among children. Pediatr Allergy Immunol 2009; 22
Arnold DH, Jones BP, Fleming GM, Otillio JK, Asokan I. Pediatric acute asthma exacerbations: evaluation and management from emergency department to intensive care unit. J Asthma 2016; 53
Zimmerman N, Hershy G, Foster P, Rothenberg ME. Chemokines in asthma: Cooperative interaction between chemokines and IL-13. J Allergy Clin Immunol 2009; 111
Aderele WI, Ette SI, Oduwole O, Ikpeme SJ. Plasma vitamin C (ascorbic acid) levels in asthmatic children. Afr J Med Med Sci 2005; 14
Kalayci O, Besler T, Kilinic K, Sekerel BE, Saraclar Y. Serum levels of antioxidants vitamins (alpha tocopherol, beta carotene, and ascorbic acid) in children with bronchial asthma. Turk J Pediatr 2000; 42
Farkhutdinov U. Shamil Farkhutdinov Study of antioxidant use in patients with asthma exacerbations. Eur Respir J 2013; 42
Chang HH, Chen CS, Lin JY. effect of vitamin C on eosinophilic infiltration and TH cells. Agric Food Chem 2009; 57
Kodama M, Kodama T, Murakami M, Kodama M. Autoimmune disease and allergy are controlled by vitamin C treatment. In Vivo
[Table 1], [Table 2], [Table 3], [Table 4]