”Recurrent infections in a child” usually refers to frequent infections of the respiratory tract.
A child will normally have 6-10 respiratory tract infections in one year.
An overwhelming majority of children suffering from recurrent infections have a normal immune system. The following features are suggestive of a normally functioning immune system:
the onset of recurring infections coincides with the child starting to attend a child care facility
the infections only affect the respiratory tract
the infections are caused by viruses
the recovery from individual infections is normal
the child's growth and development are normal
normal physical status (and chest x-ray, see below)
no family history of diagnosed immunodeficiencies.
Aetiology
Related to the child
Due to genetic factors, there are differences between children regarding their susceptibility to infections. Boys are more likely to have infections than girls.
Some children have dysfunctional problems of the middle ear or the Eustachian tube.
Children who have problems with gastro-oesophageal reflux tend to have more frequent infections of both upper and lower respiratory tract.
Periodic fever syndrome may be the aetiology behind recurrent fever in a child; some cases are hereditary.
Congenital immunodeficiencies are rare, but remember to consider these.
Environmental factors
Frequent contact with infections
Small children attending a child care facility have 1.5-3 times more infections than children cared for at home.
Passive smoking
Smoking at home may double the number of infections.
Investigations in recurring cycle of infections
In order to obtain a proper overall picture and provide support for the family, the care of a child with recurrent infections should be dedicated to one physician.
History
The age of the child at the onset of recurrent infections (compare with the age when started to attend a child care facility)
The number and duration of infections (6-10 infections a year with symptoms for 2-4 months may often be considered normal in children aged less than 3 years)
The type of infections (deep/severe), the number of antimicrobial courses and/or hospital admissions
Recovery from infections (complications?) and health between infections
Gastrointestinal and skin symptoms (diarrhoea, eczema, abscesses)
Atopic symptoms, signs of respiratory tract obstruction, signs of gastro-oesophageal reflux
The child's other illnesses, medication (immunosuppressive)
Family history: atopy, asthma, abnormalities in growth, susceptibility to infections, failure to thrive in infancy, deaths through infection
Type of day care (size of the group)
Passive smoking
Vaccinations
Status
The consistency of growth and development should be checked (growth charts!).
Ear examination with a pneumatic otoscope or a tympanometer (focus of infection)
Heart and lung auscultation (focus of infection, also to rule out a heart defect)
Abdominal palpation (to rule out organomegaly)
The condition of skin, nails, hair, teeth and mucous membranes (hypoplasia, rash, abscesses, onychomycosis, chronic thrush)
Size or possible absence of palatine tonsils
Palpation of the lymph node areas
Primary investigations
A child with recurrent infections should have his/her basic blood count with differential white cell count and ESR (during an infection free period) checked once in primary care. If considered necessary, plasma IgG, IgA and IgM (note age-related variation) and HIV antigen and antibodies are examined.
In an acute infection, an x-ray is warranted if recurring pneumonia is suspected.
Treatment
Own doctor (repeated contact, record of infections)
Advice (symptomatic treatment of infections, stopping smoking at home)
The type of day care should be considered (smaller groups, care at home)
Tympanostomy should be considered after more than 3 documented episodes of acute otitis media in 6 months, or more than 4 episodes in one year, or if the child has glue ear.
Indications for special investigations in suspected immunodeficiency
Primary immunodeficiencies
Primary immunodeficiency (PID) refers to a congenital disorder of the immune system caused by a genetic alteration. It leads to impaired infection defence and an increased risk of immunological diseases.
Isolated immunodeficiencies are rare, but more common than thought due to underdiagnosis.
Congenital immunodeficiencies are classified as deficiencies of B cells or T cells, combined T and B cell defects, phagocytic cell defects, and defects in innate immunity.
The majority (> 50-80%) are B-cell deficiencies, i.e. deficiencies in the humoral immunity, manifested mainly as hypogammaglobulinaemia (plasma IgG, IgA, IgM < -2 SD).
Deficiency or a functional defect of B-cells may predispose the child to recurrent infections caused by extracellular bacteria, particularly to infections by polysaccharide-encapsulated bacteria
The aetiologies of hypogammaglobulinaemia include:
transient hypogammaglobulinaemia of childhood (1/16 000)
IgG subclass deficiencies, specific inability to form polysaccharide antibodies and certain complement deficiencies also increase the risk of infections caused by polysaccharide encapsulated bacteria.
Patients with cell-mediated immunodeficiency, i.e. decreased number or deficient functioning of T-cells, are at an increased risk of infections caused by intracellular pathogens (viruses, Pneumocystis jirovecii, mycobacteria, fungi).
If the immunodeficiency is caused by a disturbed co-operation between B-cells and T-cells (CVI and CSR deficiency), the patient will be prone to infections caused by both extracellular and intracellular pathogens.
Severe combined immunodeficiency (SCID) http://www.orpha.net/en/disease/detail/183660 is a very rare condition. It is an immunological emergency leading to death, unless a stem cell transplantation is performed in time. T cells are absent leading to a low absolute lymphocyte count (< 2.0 × 109 /l) in the infant. Additionally, also B cells and/or NK cells may be absent. Nowadays the disease is screened in newborn babies with TREC (T cell receptor excision circles) test in many countries.
Other biochemical abnormalities predisposing to infections
In primary health care, the susceptibility to infections is documented (infection diary), and complete blood count (note particularly neutropenia, lymphopenia) and immunoglobulins (plasma IgA, IgG, IgM, serum IgE; note concentrations < -2 SD of the age-adjusted reference values) are examined. HIV antigen and antibody assay as considered necessary.
If immunodeficiency is suspected on the basis of the symptoms and signs listed above (history and/or laboratory findings), the child should be referred to a paediatric unit for further investigations.
Specialist intervention is needed to decide on individual treatment management which should be based on the child's age at symptom onset, character of the symptoms, the health of body systems, the type of infections and the causative agents.
Disability benefit
A child with recurrent respiratory infections or ear infections may be entitled to disability benefit or other types of social support. Find out about local policies and practices and make the necessary medical certificates.
References
Bousfiha A, Moundir A, Tangye SG, et al. The 2022 Update of IUIS Phenotypical Classification for Human Inborn Errors of Immunity. J Clin Immunol 2022;42(7)1508-1520. [PubMed]
Schuez-Havupalo L, Toivonen L, Karppinen S, et al. Daycare attendance and respiratory tract infections: a prospective birth cohort study. BMJ Open 2017;7(9)e014635. [PubMed]
Selenius JS, Martelius T, Pikkarainen S ym. Unexpectedly High Prevalence of Common Variable Immunodeficiency in Finland. Front Immunol 2017;8():1190. [PubMed]
Trotta L, Hautala T, Hämäläinen S ym. Enrichment of rare variants in population isolates: single AICDA mutation responsible for hyper-IgM syndrome type 2 in Finland. Eur J Hum Genet 2016;24(10):1473-8. [PubMed]
Davis SD, Ferkol TW, Rosenfeld M, et al. Clinical features of childhood primary ciliary dyskinesia by genotype and ultrastructural phenotype. Am J Respir Crit Care Med 2015;191(3)316-24. [PubMed]
Marciano BE, Spalding C, Fitzgerald A, et al. Common severe infections in chronic granulomatous disease. Clin Infect Dis 2015;60(8)1176-83. [PubMed]
Picard C, Al-Herz W, Bousfiha A et al. Primary Immunodeficiency Diseases: an Update on the Classification from the International Union of Immunological Societies Expert Committee for Primary Immunodeficiency 2015. J Clin Immunol 2015;35(8):696-726. [PubMed]
Science M, Maguire JL, Russell ML, et al. Low serum 25-hydroxyvitamin D level and risk of upper respiratory tract infection in children and adolescents. Clin Infect Dis 2013;57(3)392-7. [PubMed]
Tregoning JS, Schwarze J. Respiratory viral infections in infants: causes, clinical symptoms, virology, and immunology. Clin Microbiol Rev 2010;23(1):74-98. [PubMed]
Hammarén-Malmi S, Saxen H, Tarkkanen J et al. Adenoidectomy does not significantly reduce the incidence of otitis media in conjunction with the insertion of tympanostomy tubes in children who are younger than 4 years: a randomized trial. Pediatrics 2005;116(1):185-9. [PubMed]
Lucero MG, Dulalia VE, Parreno RN, Lim-Quianzon DM, Nohynek H, Mäkelä H, Williams G. Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and pneumonia with consolidation on x-ray in children under two years of age. Cochrane Database Syst Rev 2004 Oct 18;(4):CD004977. [PubMed]
American Academy of Pediatrics Committee on Infectious Diseases. Recommendations for influenza immunization of children. Pediatrics 2004 May;113(5):1441-7. [PubMed]
Mattila PS, Joki-Erkkilä VP, Kilpi T, Jokinen J, Herva E, Puhakka H. Prevention of otitis media by adenoidectomy in children younger than 2 years. Arch Otolaryngol Head Neck Surg 2003 Feb;129(2):163-8. [PubMed]
Nafstad P, Hagen JA, Oie L, Magnus P, Jaakkola JJ. Day care centers and respiratory health. Pediatrics 1999 Apr;103(4 Pt 1):753-8. [PubMed]
Paradise JL, Bluestone CD, Colborn DK, Bernard BS, Smith CG, Rockette HE, Kurs-Lasky M. Adenoidectomy and adenotonsillectomy for recurrent acute otitis media: parallel randomized clinical trials in children not previously treated with tympanostomy tubes. JAMA 1999 Sep 8;282(10):945-53. [PubMed]
Uhari M, Kontiokari T, Koskela M, Niemelä M. Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. BMJ 1996 Nov 9;313(7066):1180-4. [PubMed]
Wald ER, Guerra N, Byers C. Frequency and severity of infections in day care: three-year follow-up. J Pediatr 1991 Apr;118(4 ( Pt 1)):509-14. [PubMed]