recurrent respiratory infections

Download Recurrent respiratory infections

Post on 06-Mar-2016




0 download

Embed Size (px)




  • Recurrent RespiratoryInfectionsAndrew Bush, MBBS (Hons), MA, MD, FRCP, FRCPCHa,b,*

    underlying condition.The key decision, whether or not to investigate, is always made on the basis of clin-

    ical judgment and experience. Factors to be considered vary with the different specificconditions and are discussed later. General pointers are listed in Boxes 13.

    , UKDepartment of Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street,

    London SW3 6NP, UKHospital, Sydney Street,

    KEYWORDSPediatr Clin N Am 56 (2009) 67100* Department of Paediatric Respiratory Medicine, Royal BromptonLondon SW3 6NP, UK.E-mail address: a.bush@rbh.nthames.nhs.uka Imperial School of Medicine at National Heart and Lung Institute, LondonbThis article begins with a symptom-based approach to the diagnosis of the child whohas recurrent infections of the upper or lower respiratory tract, or of both. Becausethe differential diagnosis is huge, it is summarized in tables, but no attempt is madetodescribe in detail every conceivable condition that canpresent (eg,multifocal consol-idation). The second section discusses the presentation of a few specific respiratoryconditions that may present as recurrent upper and/or lower respiratory tract infection(eg, cystic fibrosis [CF]). For reasons of space, this article does not discuss the details ofspecific therapies for these conditions. The problem in trying to provide an evidence-based review of this topic is that there is very little, if any, evidence to review. Themeth-odology requiredwould be to recruit prospectively a large cohort of children presentingwith a particular condition (eg, multifocal consolidation), to investigate them in detail, togenerate predictive indices for particular conditions or indices that would exclude theneed for certain tests, and to validate these indices in at least one other population.Although a systematic approach has been described for cough,1 it has not been vali-dated in a second population, and in most cases there is not even a discoverypopulation.Most children experience one or more acute respiratory infections. The challenge is

    first to decide when the time has come to move from symptomatic therapy to perform-ing diagnostic testing, then to determine which tests need to be done and when test-ing should be discontinued, and finally to institute specific therapies for the childs

    Pneumonia Croup Otitis media Immunodeficiency Cystic fibrosis Primary ciliary dyskinesia Human immunodeficiency virus Gastro-esophageal refluxdoi:10.1016/j.pcl.2008.10.004 pediatric.theclinics.com0031-3955/08/$ see front matter 2009 Elsevier Inc. All rights reserved.

  • Unless otherwise stated in this article, the level of evidence should be assumed to

    Box1Pointers that suggest early investigation of a child with recurrent infection may be indicatedThe acronym SPUR (Severe, Persistent,Unusual, Recurrent) may be a useful mnemonic.Respiratory infection plus extrapulmonary infections or other disease (eg, arthropathy)

    Positive family history: unexplained death, infections or multisystem disease

    Severe infectionPersistent infection and failure of expected recoveryUnusual organisms (eg, Pneumocystis jiroveci)Recurrent infection

    Bush68be low, based on informal consensus and case reports or series.

    CLINICAL SCENARIOS: UPPER AIRWAYMost children presenting with recurrent upper airway infection are normal. Immunode-ficiency, however, can present with upper airway problems.2,3 Particular triggers forfurther investigation include:4

    Eight or more new ear infections within a yearTwo or more serious sinus infections (eg, requiring intravenous antibiotic treatment)

    within a yearPersistent oral or cutaneous candidiasisTwo or more months of continuous antibiotics with no effectThe need for intravenous antibiotics to clear infectionsAssociated systemic features including recurrent deep-seated or skin abscesses

    or infections, recurrent pneumonia, failure to thrive, positive family history ofimmunodeficiency

    Recurrent Viral Colds

    A large, community-based study documented that in childhood the median number ofviral colds is five per year, but more than 10% of children have 10 or more colds perBox 2Pointers in the history of a child presenting with respiratory symptoms that should leadto further investigationIs the child/family in fact describing true wheeze?

    Marked chronic upper airway symptoms: snoring, rhinitis, sinusitis

    Symptoms from the first day of life

    Very sudden onset of symptoms

    Chronic moist cough/sputum production (differentiate from recurrent acute symptoms)

    More severe symptoms (or irritability) after feeds and when the child is lying down (vomitingand choking on feeds suggests gastroesophageal reflux or aspiration syndrome)

    Any feature of a systemic immunodeficiency

    Continuous, unremitting, or worsening symptoms

  • Recurrent Respiratory Infections 69year.5,6 A viral cold usually is a trivial illness. The mean duration of symptoms is around8 days, but the normal range extends beyond 2 weeks.6 Symptoms are nasal conges-tion, rhinorrhea, cough, sore throat, and fever. Thus a normal child may have symp-toms of the common cold for nearly 6 months in the year. The misinterpretation ofcommon symptoms as wheeze710 may lead to an incorrect diagnosis of asthma.Not unexpectedly, attendance in child day care facilities early in life increases therisk of viral colds.11 The frequency and duration of colds may come as a surprise, par-ticularly to first-time parents, and misconceptions about the need for treatment arecommon.12 The issue of virally induced wheezing is discussed under in the sectiondevoted to the lower airway.

    RecommendationsIn theabsenceofanyotherworrying featuresonhistoryandexamination (Boxes2and3),isolated recurrent viral colds do not require further investigation unless the frequency ismore than15per year, and thedurationhabitually ismore than15daysperepisode.Levelof evidence: low.


    Intermittent acute rhinitis must be distinguished from chronic rhinitis, which has awiderdifferential diagnosis. The definitions of acute and persistent rhinitis are variably de-fined; one group defined persistent rhinitis as occurring at least 4 days a week for

    Box 3Pointers in the physical examination of a child presenting with respiratory symptoms that shouldlead to further investigationDigital clubbing, signs of weight loss, failure to thrive

    Upper airway disease: enlarged tonsils and adenoids, prominent rhinitis, nasal polyps

    Unusually severe chest deformity (Harrisons sulcus, barrel chest)

    Fixed monophonic wheeze

    Stridor (monophasic or biphasic)

    Asymmetric wheeze

    Signs of cardiac or systemic diseaseat least 4 weeks;13 another group holds that acute rhinitis may last as long as12 weeks.14 The evidence base on the timing and nature of appropriate investigationsin persistent rhinitis is scanty; however, recent combined adult and pediatric guide-lines have listed potential investigations that may be useful.14 The two commoncauses are infective and allergic rhinitis, and skin prick testing may be indicated.Unilateral rhinitis should lead to consideration of anatomic abnormalities such asunilateral choanal stenosis or the presence of a foreign body. The combination of per-sistent rhinitis and lower respiratory tract symptoms should prompt diagnostic consid-eration of allergic rhinitis and asthma (the most common cause); primary ciliarydyskinesia (PCD), especially with neonatal onset of rhinitis; CF (especially if thereare nasal polyps); and Wegeners granulomatosis (seen in 21 of 25 patients in oneseries).15

    RecommendationsPersistent rhinitis usually does not require detailed investigations. Evidence of allergicsensitization may be sought, and empiric therapeutic trials are reasonable, unless

  • Bush70there is evidence that rhinitis is part of a more generalized disease. Level of evidence:low.

    Recurrent Tonsillitis and Pharyngitis

    In childhood, significant tonsillar disease manifests commonly as either obstructivesleep apnea (not discussed here) or recurrent acute tonsillitis. Children are consideredto have an episode of significant tonsillitis if they satisfy at least one of the followingcriteria: (1) an oral temperature of at least 38.3C; (2) cervical lymphadenopathy (en-larged by > 2 cm or tender cervical nodes); (3) tonsillar or pharyngeal exudate; and(4) a positive culture for group A b-hemolytic streptococcus. Conventionally, tonsillec-tomy is indicated if there have been seven or more documented episodes in the pre-ceding year, five or more in each of the 2 preceding years, or three or more in each ofthe preceding 3 years.16 The other indication for tonsillectomy is obstructive sleep ap-nea. One study has suggested tonsillectomy is a cost-effective strategy for treatingobstructive sleep apnea,17 but in a randomized, controlled trial the risks of surgerywere thought to outweigh any benefits.18 Furthermore, about two thirds of operationsare performed for less stringent and thus even less evidence-based criteria.19 Usuallyno other investigations are performed for isolated recurrent tonsillitis in the absence offeatures listed in Boxes 2 and 3, but there is no good-quality evidence to inform thedecision making about the need for further investigation.

    RecommendationsIsolated recurrent tonsillitis and pharyngitis do not require further investigation in theabsence of any other worrying features (see Boxes 2 and 3). Level of evidence: low.


    Acute sinusitis in children is common and usually a self-limiting disease that requiresno investigation. Further investigation, usually in collaboration with an ear, nose, andthroat surgeon, should be considered in children who have recurrent acute or severechr