Indian J. Pediat. 34 : 283, 1967

RECURRENT RESPIRATORY INFECTIONS* VIJAY KUMAR*

New De~i

Patients with recurrent respiratory infections comprise a very sizable portion of any pediatric out-patients' department or children's ward. Seemingly trivial, the problem of repeated chest infections is quite annoying. It significantly disturbs the child, his parents, the physician and the community at large. The maximum brunt of the illness falls on. the patient in whom the disease produces general debility, irritability, frequent absenteeism from school, sleep and behaviour disturbances. The parents are naturally worried about the welfare of the child and the recurrent medical expenses are a burden on their financial resources. The other siblings may suffer through neglect. The physician has an intractable problem, since specific cure israre and management is mostly symptomatic. Success in therapy is infrequent and therefore, it is frustrating. He has also to debate about the use of antibiotics, advisaability of tonsillectomy and adenoidectomy, and may have to deal with some or many complications of recurrent respiratory infections, namely nephritis, rheumatic heart disease, pulmonary abscess, bronchiectasis, *Presented to the Journal Club, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi-16. **Present Address : Children's Hospital, Denver, Colorado, U.S.A,

empyema, pneumothorax, etc. The affected children may transmit infections to friends and thus the community at large, especially class mates and neighbours, are at risk. The society incurs a considerable amount of expenditure on treatment of such infections, operations on tonsils and adenoids and hospital beds occupied by the sick children. Such patients may grow up to be chronic respiratory invalids and have several other disabling complications, which add further to the problem. It is most pertinent to examine the issue thoroughly and plan out a rational way of management.

Anatomical and Physiological Features During infancy and childhood, certain peculiarities of structure and function make the subject more prone to respiratory infections. Further, there are several normal features of breathing in an infant which may look 'different' enough to be called abnormal. Noisy breathing is often seen in infants 4-6 weeks' old. This increases with feeding in the supine posture and disappears when the infant is propped up. It is not an indication of disease. Rapid respiration may be due to a benign a cause as a blocked nose.

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Patency of the nasal passages must be ensured before attaching undue significance to merely an increase in respiratory rate. Tonsillar enlargement is a part of physiological lymphoid hyperplasia in childhood. It reaches its peak between 8-10 years. This is true for the cervical lymph-nodes also. The tonsils may be so large physiologically that during gag they are seen to almost touch each other in the centre. Constrictors of the pharynx tend to displace the tonsils medially. One must look for other signs of infection, and not size alone, for diagnosing tonsillitis. The paranasal sinuses are not likely to get infected till the time they are pneumatised. This process may not occur in the frontal and sphenoidal sinuses till the a.ge of 6 years. Translucency seen radiologically must not be misinterpreted as an evidence of sinusitis. The eustachian tubes in infants are wide, short and horizontal, thereby permitting access to infected nasopharyngeal secretions and predisposing the child to recurrent otitis media. The larynx is soft and narrow with easily compressible walls. Thus spasm and secretions produce obstructive symptoms rapidly. Bronchioles are small and even partial obstruction by spasm or secretions may produce devastating results on effective alveolar ventilation. A seemingly minor upper respiratory catarrh may rapidly progress to fulminant life-threatening bronchiolitis. The alveolar surface is inadequate due to a relatively greater encroachment on space by the heart, mediastinum, larger-sized bronchi and thick-

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walled alveoli. The alveolar exchange of gases is also hampered by congestion of the puhnonary vascular bed and the presence of mucus due to nonevacuation by the infant's poor cough reflex. The thoracic cage is soft and pliable. Permanent chest deformity is a likely consequence of repeated respiratory infections. Physical signs are more difficult to elicit and interpret. Respiration is rapid and frequently irregular normally. Due to a thin chest wall and relatively large bronchi, the percussion note is almost tympanitic, breathing is harsh and exact localization of disease is difficult and sometimes impossible. A skiagram of the chesi must be interpreted with care as rapid changes occur in the mediastinal size during the phases of breathing and by an abnormal posture.

Predisposing Factors Infections in children are often recurrent since there is a large number of pathogens with an equally large number of strains capable of infecting the respiratory tract. The child has little passive immunity and thus exposure to such bacteria and viruses almost always results in infection. Immunity is species and strain-specific in the majority of pathogens. T h i s predisposition to disease is increased by a limited capacity of the young host for gamma-globulin synthesis. Nutritional deficit increases susceptibility by an impairment of antibody production, reduction in lysozyme and phagocytic activity, interference with the integrity of the mucosa and loss of ciliary action. Surprisingly,

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malnourished children can tolerate viral infections much bctter than bacterial ones. Nasobronchial allergy is almost always associated with recurrent infections. Antimicrobial therapy if prolonged, encourages the emergence of resistant strains by altering the bacterial ecology. Staphylococcal, pseudomonas and monilial superinfections are typical examples of this phenomenon, Viral infections by denudation of the mucosal cells make bacterial invasion more likely. It is also known that in some viral exanthems, there is an elevated endogenous corticosteroid production which would diminish the host resistance. Agammaglobulinemia and dysgammaglobulinemia, which are often congenital, increase, predisposition to infections due to poor antibody formarion. Agranuloeytosis and neutropenia of any etiology lowers the host cellular resistance and thereby infections once acquired are difficult to get rid of and there is an enhanced risk of their becoming chronic. Anatomical defects of the chest wall or lungs should be suspected if there are recurrent infections in a localised area. Sequestration of a lobe is one such example. In some infants, the trachea and the bronchi have soft collapsible walls and predispose to early and complete bronchial obstruction. There is increased susceptibility to develop bronchiectasis. Foreign body, cbronic lung abscess, bronchiectasis and cystic fibrosis of the pancreas may give rise to recurrent infections which persist so long as the primary cause is present.

Congenital cardiovascular defects like left-right shunls, vascular rings, should be suspected and ruled out in children with recurrent chest infections. The latter condition may have associated features of croup, stridor and inspiratory obstruction. Splenectomy, radiation therapy and cytotoxic drugs lower the body's resistance and suppress antibody response.

Clinical Features Recurrent respiratory infections are frequent till the age of 2 years, the peak incidence is between the 4th and 8th year and later there is a decline in the rate with a tendency for the child to outgrow the attacks, especially if there is an elder school-going sibling. The disease is more severe in children from poor socioeconomic strata, occurs more frequently in w i n t e r ; and modern management has not changed morbidity though mortality is certainly reducd. Peculiarly, infants resist viral infections well and bacterial infections poorly. It would be well to remember that the respiratory tract has one continuous mucosal surface and there is bound to be a considerable overlap in the involvement of different anatomical regions in various infections. Exact localization is therefore, more of an academic exercise rather than of practical value. Etiological diagnosis on a clinical basis is impossible and even after elaborate laboratory tests, the reports of which may be available after several days, the pathogen cannot often be recovered. The diagnostic riddle is further complicated by the fact that the same pathogen may produce a variety of lesions in diffe-

286 n,,rOIANJOURNALOF PEDIATRICS rcnt anatomic sites in the same host at different times. Thc diagnosis of otitis media should be bascd on dcfinite signs of a bulging drum, hazy anatomic outlincs, discharge, perforation and toxemia. A child with any respiratory infection may have congestion of the ear drums without actual invasion of the middle ear. Tonsillar enlargement has already been commented upon. It may occur alone or as part of a generalised infection of the respiratory tract. Tonsillitis is a serious disease which may be followed by such chronic disabling complications as rheumatic heart disease, cervical adenitis, nephritis, quinsy, otitis and sinusitis. In a child with. wheezing, bronchial allergy must be considered. Prolonged rhinitis lasting for more than 2 weeks, a positive family history, paroxysmal episodes, recurrent bronchiolitis and infantile eczema are some ancillary aids in the diagnosis of allergy. Bronchitis and bronchiolitis are commoner in infants and young children. Pneumonia is more frequent in older children. The affection is generalised in infants but segmental or lobar in older individuals.

Management Specific. The various basic etiological tactors in recurrent respiratory infections (allergy, congenital heart disease, aspiration of foreign body, immunological or cellular defects, anatomical defects, etc. ) should be sought out and dealt with in order to cure the child. Without that one can at best alleviate symptoms with symptomatic therapy. General. Certain general measures are helpful in prevention and treat-

VOL. 34 NO. 235 ment of respiratory infections. In a household, infants and young children should, as far as possible, be kept away from intimate contact with persons suffering from respiratory and other infections. Simple remedies like steam and regular use of decongestive nasal drops bring considerable relief. Antihistaminics have a role to play in patients with an allergic background. It would be desirable to condemn inappropriate and prologned use of 'cough syrups' especially those containing codein. Potassium iodide is a useful agent which liquifies tenacious mucous secretion. Postural drainage following steam inhalation helps to keep the lungs dry in children with, chronic suppurative disease. In the acute stage, there may be respiratory difficulty and oxygen is then indicated. Vaccines. Non-specific anticatarrhal vaccines are o f little use. However, if a vaccine is prepared from bacteria isolated out of bronchial or sinus secretions, it is likely to benefit the child at/east for some time, till other bacteria take over and produce fresh symptoms. It is also useful to protect such children with prophylactic agents like D. P . T . , influenza and measles vaccines since the course of the natural disease may be severe and adversely affect the pulmonary parenchyma. Antibiotics. There is a general tendency to their over-use. One must be aware that the etiology of a particular episode of respiratory infection cannot easily be determined, few organisms cause a fatal disease and antibiotics are useful against organisms sensitive to them. Most of the respiratory illnesses are viral and self-limiting and antibiotics do

KUMAR--RECURRENT RESPIRATORY INFECTIONS

not always significantly alter the duration or the course. They are expensive drugs and have their own side effects. It is wouid not be untrue to say that many a physician is prompted to use them due to pressure from parents, o r f r o m medical representatives of pharmaceutical firms, in disgust or out of habit. On the contrary, antibiotics can be very usefully employed in certain situations, for example, in very small infants, patients with severe disease, malnourished children, non-response to general measures, those with a past history of severe prolonged illness and children suffering from leukemia, agammaglobulinemia or on steroid therapy.

Tonsillectomy and adenoidectomy. In the past, failure to thrive, persistent enlargement of the tonsils, frequent upper respiratory infections, otitis media, rheumatic heart disease were considered indications for this operation. However, the absolute indications are quinsy, the diphtheria carrier state and more than 4-6 attacks of acute purulent tonsillitis. On the other hand, the procedure is not entirely safe and unnecessary deaths may be caused if the operation is done on flimsy indications. In many an instance, the removal of the tonsils and the adenoids is not followed by any sizable improvement except for serving as psychotherapy. Conclusion To sum up, recurrent respiratory infections have indefinite difficult-to-

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determine etiology, vague nomenclature and uncertain epidemiology. Management to date is not gratifying. Research in this field has not made much headway. No study has been done in the community in India. Moreover, detailed investigations take a long time and are often preceded by a remission, and postmortem material is scanty and not representative of the problem. Future work should concentrate on developing easy and rapid methods tbr isolation of respiratory viruses and study of the disease at the community level with special emphasis Oll study of its natural history, epidemiology, and prognosis. In such a projcct, the family physician or the gencral practitioner should be actively involved with participation by the pediatrician, allergist, E.N.T. specialist, microbiologist, psychiatrist and social scientist.

References Eichenwald, H.. F. and Shincfield, H. R. (1960). Nonspecifie mechanisms of resistance to infection. Pediat. Clinics N. Amer. 7, 813. Fry, John.(1961). The catarrhal child. Butter. worth, London. Garrow, B. (1965). Acute respiratory infections in childhood. Brit. med. d. 2, 297. Gitlin, D. and Janeway, C. A. (1962). Undue susceptibility to infections. Pediat. Clinics N. Amer. 9, 405. Jancway, C. A. (1960). Infectious disease and immunity in early life. lbid. 7, 799. Kaufmann, M. (1961). Respiratory allergy. Ibid. 8, 280. Pipkin, F. (1961). Acute respiratory tract in. fections. Ibid, 8, 111.

INDIAN J O U R N A L OF PEDIATRICS

Fig. 1. Skiagram skull showing characteristic oxycephalic features.

GARG.--OXYCEFHALY.

PLATE 11