Acute Respiratory Infections in

. Children: Etiology and Epidemiology

Floyd W. Denny, MD*

Acute respiratory infections are the Likewise, emphasis will be placed on

most common affliction of humans, respiratory illnesses as they are en-
EDUCATiONAL OBJECTIVES
and their tendency to occur with countered in the practice of pediat-
much greater frequency in children rics, only a small proportion of which 98. Appropriate recognition of the
makes them especially important to require hospitalization. risks of indoor air pollution (Recent
the pediatrician. A host of microbial Advances, 87/88).
agents can cause acute respiratory CLASSIFICATION OF ACUTE 99. Appropriate knowledge of the
infections but only a few are respon- RESPIRATORY INFECTIONS multiple factors involving suscep-
sive to antimicrobial agents. Because tibility to respiratory diseases in
of the paucity of definitive laboratory Acute respiratory infections can be
children (Recent Advances, 87/
tools that allow the easy recognition classified conveniently by separating
88).
of the cause of acute respiratory in- the upper from the lower tracts at the
fections, it is important for the prac- epiglottis, although it is recognized
ticing pediatrician to have other meth- that infection involves both areas in
ods that aid in the clinical manage- some children (Fig 1).
ment of children with these infections.
It is the purpose of this review to Upper Respiratory Tract Infections Lower Respiratory Tract Infections
discuss the etiology and epidemiol- The majority of upper respiratory The majority of lower respiratory
ogy of acute respiratory infections tract infections are not complicated tract infections are not complicated
with emphasis on how this knowl- by any of the entities listed in Fig 1 . and can be classified by the anatomic
edge can guide the clinician in their The most common complication is area of the respiratory tract that is
management. The groundwork for otitis media. The proportion of pi primarily affected. The findings that
the major emphasis of the paper will
be laid by suggesting a classification
tients with upper respiratory tract in- /
characterize the clinical lower respi-
fection in whom otitis media develops ratory tract infection syndromes are
S of upper and lower respiratory
infections. Causative
tract
agents will be
depends on several factors, including
age of the child and the agent causing
given in Table 1 Infection may involve
.

>more than one site of the lower tract,

enumerated and put into perspective.
The major factors associated with the
the upper respiratory tract infection, (
but most infected children have a sin-
and vanes from 15% to 25% in chil- gle site of major involvement. This
occurrence of acute respiratory infec- dren younger than 1 year of age and \ciassification of lower respiratory
tions will be discussed in some detail 2% to 5% in those of early school)tract infections has been especially
and several risk factors will be eval- age.1 Our present knowledge of the useful because there is close associ-
uated. etiology of upper respiratory tract in- ation between syndrome and other
It is important for the reader to fections suggests that among un- associated factors, including causa-
understand that the field of acute res- complicated cases it is important only tive agent.
piratory tract infections is so exten- to identify those children infected with
sive and complex that a complete the group A streptococcus. Although
discussion of the entire field is not ETIOLOGY OF ACUTE
the upper respiratory tract infection
possible in this review. Emphasis will RESPIRATORY TRACT
clinical syndromes of herpetic gin- INFECTIONS
be placed primarily on uncomplicated givostomatitis, pharyngoconjunctival
acute respiratory infections with only fever, herpangina, lymphonodular The causative agents associated
mention of the role of complications. pharyngitis, and hand, foot, and with acute respiratory infections are
mouth disease may suggest specific relatively well understood and are
causative agents, the specific orga- similar everywhere in the world where
* Dr Denny received his medical and pediatric nism is usually not clear. Many terms studies have been done. All classes
housestaff training at Vanderbilt University.
have been used to classify infections of microorganisms, including viruses,
After holding faculty positions at the University of the upper respiratory tract includ- bacteria, fungi, parasites, and proto-
of Minnesota, Vanderbilt University, and Case ing common cold; upper respiratory zoa are capable of infecting the res-
Western Reserve University, he was Chairman tract infection, either afebnle or fe- piratory tract. Only certain viruses
of Pediatrics at the University of North Carolina
from 1960 to 1981. He is now director of the
brile; pharyngitis; tonsillitis; and phar- and bacteria are common causes, es-
University of North Carolina School of Medicine yngotonsillitis. Because of the vague- pecially in nonhospitalized children,
Program on Health Promotion and Disease Pre- ness of most of these terms, it is and this review will be restricted to
vention. He has had an interest for many years probably best to concentrate primar- these agents. The isolations of vi-
ily on differentiating group A strepto- ruses and bacteria in children in day-
S aspects
in
dress:
the laboratory,
Medicine,
Department
of childhood clinical,
University
of
respiratory
Pediatrics,
and infections.
epidemiologic
of North Carolina,
School Ad-of
Chapel
coccal upper respiratory tract infec-
tions from all others that do not re-
care and a pediatric
Chapel Hill, NC are shown in Tables
practice in

Hill, NC 27514. quire antimicrobial therapy. 2 and 3, respectively, and are repre-

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Respiratory Infections

Upper Respiratory Infections TABLE 1. Clinical Syndromes in

Childhood Infections of Lower
Respiratory Tract
Uncomplicated Complicated Infection Signs of Illness

Adenitis
Croup Hoarseness,
cough, inspira-
Epiglottitis
tory stridor with
1 Lower respiratory infection
Mastoiditis
laryngeal 01>
StreptococcalNonstreptococcal struction
Otitis medle
Peritonsillar abscess
Tracheo- Cough and rhonchi;
Retropharyngeal abscess
bronchitis no laryngeal 01>
Sinusitis
struction or
wheezing
Bronchiolitis Expiratory wheez-
ing with or with-
Lower Respiratory Infections out tachypnea,
air trapping, and
substemal re-
tractions
Uncomplicated
Pneumonia Rales or evidence
Complicated
or pulmonary
Croup Atelectasis
consolidation on
Tracheobronchitis physical exami-
Bacterial tracheltis
Bronchiolitis Empyema
nation or radi-
Pneumonia Lung abscess
ograph
Mediastinitis
Pencarditis
Pneumothorax

Fig 1. Classification of acute upper and lower respiratory tract infections.

discussed in further detail. Chiamydia
trachomatis has been described re-
cently as a cause of pneumonia in
hospitalized children, but its role in
sentative of other similar studies.2’3 acute respiratory infections are nonhospltalized thildren is unknown4;
In the day-care center fewer than shown in Table 4. Corynebacterium it has also been described in one
1 0% of infections involved the lower diphtheriae, Bordetella pertussis, study as a cause of pharyngitis in
respiratory tract; therefore figures in and Mycobacterium tuberculosis are adults,5 but results of other studies
Table 2 represent the causes primar- listed as unusual causes because have not confirmed this.6 Data are
ily of upper respiratory tract infec- they are not common causes of acute beginning to accumulate that suggest
tions, whereas figures in Table 3 are respiratory infections in the United that non-group A streptococci, es-
exclusively from children with lower States today, although there is some pecially group C and G, may cause
respiratory tract infections. A com- fear (supported by some data) that pharyngitis, but their precise role is
parison of the tables shows that the pertussis may be increasing in fre- unclear.7 C trachomatis and non-
same agents are involved generally in quency. Legionella pneumophlla group A streptococci will not be con-
infertions in both sites but vary in does not cause frequent disease sidered further.
their relative roles. The group A strep- in children. Staphylococcus aureus, The roles of S pneumoniae and
tococcus is a common cause of up- group B streptococcus, Enterobac- Haemophllus influenzae cannot be
per respiratory tract infections but teriaceae, and nckettsiae cause dispatched so easily. Both are rec-
rarely of lower respiratory tract infec- acute respiratory infections but only ognized causes of lower respiratory
tions. Other examples are the ade- in certain special circumstances, an tract infections but pose special prob-
noviruses, enteroviruses, and rhino- example being in the newborn. The lems in diagnosis. Although type b H
viruses which are more commonly agents that cause infections unusu- influenzae is associated commonly
found in infections of the upper res- ally or only in special circumstances with acute epiglottitis, and S pneu-
piratory tract and MyCoplasma pneu- are of less concern in the daily prac- moniae with lobar pneumonia in the
moniae in infections of the lower res- tice of pediatrics and will not be con- older child, these two bacteria have
piratory tract. With the exceptions of sidered further. not been associated closely with any
the group A streptococcus and M Group A streptococcus is the prime of the syndromes listed in Table 1,
pneumoniae, bacterial causes of bacterial cause of upper respiratory and they are not recognized causes
acute respiratory infections are less tract infections and M pneumoniae is of uncomplicated upper respiratory
well-defined. The author’s perception a common cause of lower respiratory tract infections. This makes the clini-
of the role of bacteria as causes of tract infections; these agents will be cal diagnosis of lower respiratory

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 INFECTIOUS DISEASE

S tract infections caused by these

agents difficult. This problem is com- TABLE 2. Viral and Bacterial TABLE 3. Viral and
pounded by the carnage of H influ- Causes of Acute Respiratory Mycoplasmal Causes of Acute
enzae and S pneumoniae in the upper Infections of Children in Day Care, Lower Respiratory Tract Infections
respiratory tract in a high percentage Chapel Hill, North Carolina in Children, Chapel Hill, North
(up to 20% and 50%, respectively) of Relative Carolina*
normal children at certain ages and Cause Role Relative
during seasons.8 The failure
certain (%) Cause Role
of anticapsular polysaccharide anti- Viruses (%)
bodies to develop in young children Adenoviruses 22.0 Viruses
has also hampered etiologic studies. Type 1 3.7 Adenoviruses, 7
At the present, in the absence of Type 2 7.5 all types
epiglottitis or lobar pneumonia in the Types 9.8 Influenza 12
older child, the only way to associate Not typed 10 TypeA 4
H influenzae or S pneumoniae with Enteroviruses 13.6 TypeB 6
lower respiratory tract infection is to Influenza 4.7 Not typed 2
Type A 2.0 Parainfluenza 35
isolate the bacterium from the blood Type B 2.7 Typel 19
or pleural space or directly from the Parainfluenza 24.1 Type2 3
lung by percutaneous aspiration. Be- Type 1 4.1 Type3 13
cause of these problems, the roles of Type 2 8.5 Respiratory syn- 22
these two bacteria as causes of lower Type 3 11.5 cytial virus
respiratory tract infections in children Respiratory syn- 9.5 Miscellaneous 9
are largely unknown. Although stud- cytial virus
9.5 Enteroviruses 3
ies suggest that the organisms are Rhinoviruses Rhinoviruses 3
infrequent causes in the United Other 6.1 Other viruses 3
States, especially when compared Bacteria Mycoplasma pneumo- 15
Group A strepto- 8.8 niae
with viruses and M pneumoniae,
cocci
there is widespread belief, and some Mycoplasma pneu- 1.7 * Roles of other agents, especially
evidence, that they play a major role
S in the increased morbidity and mor-
moniae
Streptococcus pneumoniae and
Haemophllus influenzae, not listed
tality associated with lower respira-
tory tract infections in developing because they are unknown.
countnes.9
The occurrence of acute respira-
tory infections is associated with 5ev-
ROLE OF GROUP A eral important factors: the age of the important and, at least in part, may
STREPTOCOCCUS, M patient, season of the year, clinical explain the decrease in incidence as
PNEUMONIAE, AND syndrome, infecting agent, and the the child gets older.
RESPIRATORY VIRUSES AS extent of contact (crowding). The relative roles by age of viruses,
CAUSES OF ACUTE group A streptococci, and M pneu-
RESPIRATORY TRACT moniae as causes of pharyngitis in
INFECTIONS Upper Respiratory Tract children are shown in Fig 3#{149}11Children

The incidences of total acute re\ younger

infected than
with 2 group
years ofAage are rarely
Much is known of the roles of
group A streptococci,
piratory in two different re
infections which infect primarily-) streptococci
school-aged
M pneumoniae, ports, the Cleveland Family Study1#{176} j children, as does M pneumoniae, but
and viruses as causes of childhood and Chapel Hill day-care studies, are ,/ at a slightly older age. There are also
acute respiratory infections. In most compared in Fig 2.8 It is recognized ( seasonal variations in upper respira-
instances, the isolation of these that there is risk in comparing data tory tract infections caused by var-
agents from the upper respiratory collected under such diverse circum agents. Group A streptococci
tract can be correlated with active stances, but carefully controlled com cause infections in all seasons but
infections; with few exceptions, the parative data are not available. R are generally most common in the
most notable being the group A suIts of both studies show that a#{235}utewinter and spring. The seasonal oc-
streptococcus, they are not isolated respiratory infections are common in currence of viral and M pneumoniae
from the throats of well children. Fur- children, occurring at a rate of four to( acute respiratory infections will be
thermore, specific clinical syndromes nine per year, depending on age anq discussed in more detail.
are associated frequently with spe- contact. Results of both studies indi(.
S cific agents. These associations
been confirmed
have
by accurate serologic
cate that increased contact, either Lower Respiratory Tract
from siblings or in day care, increase
tests that demonstrate specific anti- the incidence. Findings from the day-k The various factors that have been
body responses. care study suggest that seasoning i) associated most commonly with the

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Respiratory Infections

occurrence of childhood lower respi-

TABLE 4. Bacterial Causes of Acute Respiratory Infections in Children ratory tract infections will be dis-
cussed in more detail. The data and
Agent
illustrations are taken from the
Unusual causes in United States Corynebacterium diphtheriae Chapel Hill studies and are consid-
Bordetella pertussis
ered representative of similar studies
Mycobacterium tuberculosis
reported by others.1214
Legionella pneumophlla
Found only in special circumstances Staphylococcus aureus Age and Gender Incidence. The
Group B Streptococcus age -and gender-specific attack rates
Enterobactenaceae for total lower respiratory tract infec-
Rickettsiae tions and four respiratory syndromes
Common causes are shown in Fig 4 and several im-
Defined role Hemolytic streptococci, group A and portant aspects of lower respiratory
possibly groups C and G tract infections are demonstrated.
Mycoplasma pneumoniae Lower respiratory tract infections are
Undefined role Chiamydia trachomatis common and in this study one of
Haemophllus influenzae
every four or five children younger
Streptococcus pneumoniae
than 1 year of age, on the average,
was taken to the pediatrician be-
cause of a lower respiratory tract in-
fection each year. This rate declined
with age until the late elementary
school ages. Lower respiratory tract
infections occur in more young boys
10 than girls, and this persists through
the lower elementary school ages
both for total lower respiratory tract
4 HOME CARE* infections and the specific syn-
LU Sibs in School dromes. Of the syndromes, croup is
>-
the most likely to occur in boys with 5
a male to female ratio of 1 .73 in 6- to
-I 1 2-month-old infants. As shown in
I the four lower frames of Fig 4, with
07-
the exception of bronchiolitis, the
age-specific attack rates for the din-
LU ical syndromes were different from
Q_ 6- those of total lower respiratory tract
(I) infections and also different from
LU
U)
CARE each other. All syndromes occurred
(I.) 5- less frequently during the first 6
LU months of life. The incidence of bron-
z
chiolitis most nearly resembled the
_J 4- overall incidence of lower respiratory
tract infections, peaking in 6- to 12-
>-.
a: month-old infants and declining
sharply thereafter. Croup peaked in
the second year and pneumonia in
a: the third year. Of all the syndromes,
0. 2- tracheobronchitis was most likely to
U) be found in children after the first few
LU years of life.
a: Association of Respiratory Agents
and Syndromes. The association be-
0 tween respiratory syndromes and in-
fecting agents is well established and
0 I 2 3 4 5 is demonstrated in Fig 5. These data
show associations across all age
AGE (YEARS) groups; with corrections for age,
these associations become more dra-
Fig 2. Comparative incidences of respiratory illnesses in different child care settings. Asterisks matic. Croup was caused most fre-
refer to data from Dingle et al.1#{176}
From Denny et a!.8 quently by the parainfluenza viruses,

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 INFECTIOUS DISEASE

S especially
was associated
type 1 Tracheobronchitis
.

with respiratory syn- 50- VIRUSES

cytial virus, M pneumoniae, and the
influenzae viruses. The cause of
bronchiolitis was most frequently res- 40-
piratory syncytial virus. Respiratory
syncytial virus and M pneumoniae 30
were common causes of pneumonia. L&i
In our studies, the influenza viruses >
20
were not prominent causes of pneu-
monia, as reported by Glezen.15 Influ-
(1) I0-
enza A virus was not isolated as fre-
0
quently by us, probably because of
the relatively insensitive isolation sys- U U U U

tem used. U)
Age Distribution of Lower Respira- I-,
tory Tract Infections Caused by Spe- z GROUP A PTOCOCCI
cific Infecting Agents. As has been ‘Ii 50-
shown, the respiratory infecting
agents are associated to some de-
gree with all respiratory syndromes.
The age-specific incidence of lower
IL 30-
respiratory tract infections caused by
specific agents differs, at times to a
0
marked degree, and is shown in Fig I- 20-
6. In all instances, with the exception z
of the adenoviruses, rates during the Iii I0-
first 3 months of life were lower than 0
in later months. The patterns of the
5 curves for respiratory syncytial virus
Iii
and parainfluenza type 3 were similar
except that respiratory syncytial virus 20’ MYCOPL ASAVA PNEUMONIA (
rates were higher in the first few
years. By comparison, parainfluenza
virus type 1 occurred in slightly older
children, and adenovirus infections U I U U I j
occurred almost exclusively in the <2 25 6-8 9lI 12-141519 20
first 5 years of life. The influenza vi-
ruses occurred commonly in all age
groups. The rates for M pneumoniae
AGE IN YEARS
infections show an entirely different
age distribution; no isolates were Fig 3. Frequency by age of recovery of microbial agents from children with pharyngitis in
made in children younger than 3 Chapel Hill, NC. From Glezen et al.11
months of age and the peak rates
occurred in school-aged children.
Seasonal Occurrence of Syn- background of infections by other winter. As observed earlier, the most
dromes and Agents. The respiratory agents. The tendency of viral agents common causes of pneumonia are
agents, and consequently the asso- not to cause simultaneous epidemics respiratory syncytial virus and M
ciated syndromes, frequently have in a community, as demonstrated pneumoniae but, because these
characteristic seasonal patterns. An here, has been shown by others as agents occur usually in different sea-
example of this (Fig 7) shows the well.15 The general aspects of sea- sons and in different age groups, the
monthly occurrence of various agents sonal occurrence are as follows. seasonal occurrence of pneumonia
in relationship to occurrence of total There is a close association between can differ markedly. Tracheobronchi-
lower respiratory tract infections. the seasonal incidence of bronchioli- tis also occurs in seasonal patterns
Parainfluenza virus type 1 caused a tis and the isolation of respiratory according to the causative agent but
large outbreak in the fall, primarily of syncytial virus, both occurring in the is most closely associated with the
croup. This was followed by a winter winter to early spring. The occur- influenzae viruses which occur in win-
S epidemic of respiratory syncytial virus
disease and a spring outbreak
rence of croup, which is closely as- ter and spring.
sociated with the isolation of the par- Combined Roles of Agents, Age,
caused by influenza virus type b. All ainfluenza viruses, especially type 1, and Season on Attack Rates of Total
of this occurred against a low level is predominantly in the fall and early Lower Respiratory Tract Infections

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Respiratory Infections

ruses, however, were isolated rarely

in school-aged children, whereas par-
ainfluenza virus type 3 continued to
S
cause some illness in this group. The
fall/winter occurrence of M pneumo-
niae in school-aged children is also
shown, as is the impact in all age
groups of the winter/spring occur-
rence of the influenza viruses.
MALES
FEMALES
ROLE OF VARIOUS RISK
FACTORS ON THE
OCCURRENCE OF ACUTE
RESPIRATORY INFECTIONS
‘U
Risk factors that cause increased
z
incidences and/or severity of respi-
cRo
ratory infections have been identified.

5.
- 16-121-2
0-6
Fig 4. Age- and gender-specific
respiratory syndromes, 1964 to 1975. Rate for boys is represented
girls is represented by stippled portion. From Denny and Clyde.
and Four Respiratory Syndromes.
The separate effects of the infecting
agent, age and gender of the host,
relationship of agents and syn-
dromes, and season on the ex-
pression of lower respiratory tract
infections in children have been dis-
cussed. The interactions of these var-
ious factors are shown in Figs 8 to
10; data from all 11 years of the
Chapel Hill study are presented
month. The impact of yearly and sea-
sonal variations in occurrence
agents is blunted by presenting the
data in this manner. The scales of the
vertical axis of the three figures are
2-3 3-5 5-9
YEARS
AGE
attack rates for total lower respiratory illnesses and four
by entire column; that for
the same to allow comparison of the
rates of illness and agent isolation
among age groups. Total lower res-
piratory tract infections and the syn-
dromes are more common in younger
children, and the rates of all decline
with age. The association of the win-
ter/spring occurrence of respiratory
syncytial virus with bronchiolitis
younger children is shown clearly, as
by is the association of croup and para-
influenza virus type 1 in early fall.
of Parainfluenza virus type 3 and the
adenoviruses are the most ubiquitous
of the agents, occurring in most
months of the year. The adenovi-
Crowding
Respiratory infections, for the most
part, are spread by direct contact or
large droplets from the respiratory
tract and are thus more likely to occur
during conditions that foster close
contact. This has been demonstrated
for all forms of crowding-number of
siblings, room occupancy, population
density, and probably day-care at-
tendance. The role of day care has
S
not been defined as clearly as is de-
sirable but presently available data
suggest higher incidence figures for
day-care attendees.8 Most crowding
would be expected to increase mci-
dence primarily but might play a role
in increasing severity as well in situ-
ations in which crowding is so intense
that the infecting dose of microorga-
nisms is large. It is speculated that
this might play a role in the increase
in severity of acute respiratory infec-
tions in developing countries.
Gender
The role of gender as a risk factor
has received little attention. Data sug-
gest only slight and probably mnsignif-
icant differences in incidences be-
tween boys and girls for upper res-
in piratory tract infections.16 There are
clear-cut gender differences for acute
lower respiratory tract infections,
with a preponderance of disease oc-
curnng in boys, suggesting that the
risk is to increased seventy.2 These
differences may have pathogenetic
5
significance but are of little help to

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 INFECTIOUS DISEASE

the pediatrician in managing children

with acute respiratory infections. 50 Croup
40
Inhaled Pollutants

Inhaled pollutants have received

much attention in the past few years.
Although studies vary somewhat in
l-

Oz
30
20
10

0
________ Th
‘
_______

Tracheobronchitis
the degree of risk caused by passive
tobacco smoking, both for increased
incidence and for increased severity, Ow
there is increasingly strong evidence z>- 40
that passive smoking is an important O W30 Bronchiolitis
risk factor.17’18 The impact of passive 20
smoking appears to be greatest in 0(1) 10
the child younger than 1 year of age
0< 0
and is related most closely with ma- cr0 Pneumonia
a-
ternal smoking. There is also evi-
dence that wood-burning stoves19
and possibly the use of gas for
cooking2#{176}
are responsible for increas-
ing the risk of acute respiratory infec- RS Para 1 Para 3 M. neu- Adeno- Influenza Other
Virus Virus virus moniae viruses Viruses Viruses
tions.

Fig 5. Associations between principal agents and four respiratory syndromes. Note that almost
Anatomic Abnormalities, Metabolic 50% of croup is caused by parainfluenza type 1 but that all agents share fairly equally in
and Genetic Disease, and tracheobronchitis. RS virus, respiratory syncytial virus; para 1 virus, parainfluenza virus type 1,
Immunologic Deficiencies21 para 3 virus, parainfluenza virus type 3. From Denny and Clyde.2

It is clear that abnormalities such

as tracheoesophageal fistulas, cystic
fibrosis, congenital heart disease,
and immunodeficiency syndromes ing and inhaled pollutants, it has not Social and Economic Factors
are associated to varying degrees been possible to define clearly its
It is difficult, if not impossible, to
with increased risk for respiratory in- role. The recent report of the role of
vitamin A deficiency in increasing risk separate the various social and eco-
fections, both in incidence and sever- nomic factors that may have an im-
ity. It is beyond the scope of this for acute respiratory infections is of
pact on the occurrence of acute res-
review to consider these further. The interest but needs further study to
assess its importance.22 Breast-feed- piratory infections, but low social
role of atopy and/or reactive airways class is linked clearly with increased
in increasing the risk for respiratory ing appears to be important in devel-
nsk.25 Crowding, malnutrition, and in-
infection is controversial. There oping countries in reducing the risk
haled pollutants, all found in low so-
seems to be a relationship between for acute respiratory infections,9 but
cioeconomic classes, especially in
respiratory infections and asthma, the data relating to a protective effect
but the “chicken and egg” relation- of breast-feeding in developed coun-
ship is unclear. The same is true for tries is contradictory. Results of stud-
the relationship between atopy and ies show only small or no reductions To manage uncomplicated
bronchiolitis. It is commonly believed in the incidence of all respiratory in- upper respiratory tract
that the atopic child has more fre- fections but do suggest that the se- infections it is necessary
quent bouts of otitis media and sinu- verity of infections might be de- only to differentiate
sitis, but prospective studies to prove creased in young breast-fed infants.23 streptococcal from
this point have not been reported. The role of “prop feeding” is contro- nonstreptococcal infections.
versial. Early reports indicated that
this was important as a contributing
Nutrition, Including Breast-Feeding factor in otitis media and more severe
lower respiratory tract infections, but developing countries, are contribut-
It seems probable that malnutrition recent data are more conflicting.24 It ing factors. The role of stress, re-
is important in increasing the risk for is clear that the effect of nutrition on ported by Meyer and Haggerty,26 and
the risk for acute respiratory infec- now receiving greater attention,
S acute respiratory
cially in developing
infections,
countnes.9
espe-
Be- tions, including breast and other could be a contributing factor, partic-
cause malnutrition is often associated forms of feeding, needs increased at- ularly with the stress that is associ-
with other risk factors such as crowd- tention. ated with being poor.27

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Respiratory Infections

If the clinical syndrome, the age and

gender of the patient, and the season
of the year are considered, a good S
estimation of cause can be made; this
Rsspatory Syncytlal virus.. could lead to more precise and effec-
tive use of antibiotics. Suggested
guidelines for the practitioner follow.
These guidelines are designed for the
practice of pediatrics in the United
States and for the “average” patient
seen by most pediatricians. Patients
4
“I . suffering from one or more of the risk
‘U factors described, especially those in
z developing countries, should be man-
‘U
aged accordingly.
0
-J
I
U
0 I!I
0 Croup
0 Par#{252}Wluenza Virus Typ 3
IC
‘I) Most croup is caused by viruses,
5 especially the parainfluenza viruses.
U . Mpneumoniae is an infrequent cause;
‘U 0
Mycopls.ms pnsumonlae other bacteria such as C diphtheriae
I
5 are involved rarely. Because parain-
fluenza virus type 1 the most com-
,

mon cause of croup, is isolated most

I0
frequently in the fall, this is the croup
season. Croup occurs rarely in the

01 1.. Vfruss
. first few months of life and reaches
its peak occurrence in the second
S
lnflusnza
year; it occurs preponderantly in
boys. Most cases of croup are mild
6I2 1-2 2-3 3-5 5-9 9-IS and require only supportive treat-
0-3
3-6 Ys.rs ment, but an occasional child has
AGE findings, although consistent with Ia-
ryngeal obstruction, that require dif-
ferent management. The child with
Fig 6. Age-specific attack rates of lower respiratory tract infections caused by certain agents.
From Denny and Clyde.2
epiglottitis probably is infected with II
influenzae type b and should be
treated accordingly. A rare patient
with laryngeal obstruction suggestive
IMPLICATIONS2 cision when the illness involves the of croup or epiglottitis may have bad-
lower respiratory tract is more com- tenal laryngotracheobronchitis. This
A large proportion of ill children
plex. Because of the lack of quick, clinical syndrome, caused by S au-
seen by the primary care physician
have acute respiratory ailments. reus, S pneumoniae, H influenzae, or
Many of these involve only the upper group A streptococci, was apparently
respiratory tract, and a throat swab common before the advent of anti-
If the clinical syndrome, the microbial agents; our attention was
processed by a rapid technique to age and gender of the
detect group A streptococcal antigen called to it again in 1979, but it has
patient, and the season of been recognized infrequently since
and/or cultured on sheep blood agar the year are considered, a
for the isolation and identification of then. Thus, with few exceptions, the
good estimation of the cause clinician can diagnose croup with din-
group A streptococci is the most im- of acute lower respiratory
portant guide for antibiotic therapy.28 ical and epidemiologic tools and be
tract infections can be made.
reasonably confident that the deci-
At the present time, we recommend
that a rapid diagnostic test be per- sion to withhold antibiotics is correct.
formed first. If the result of this test
is positive, a culture is not done; if easy, and inexpensive methods for Tracheobronchitis
the results are negative, a culture is identifying causative agents in these
done. The decision to treat is made patients, the clinician has only clinical Physicians have long recognized
that a productive cough and rhonchi
5
on clinical grounds with help from and epidemiological tools to aid in the
these laboratory aids. Making this de- decision of whether to use antibiotics. can be present without other findings

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 INFECTIOUS DISEASE

of lower respiratory tract involve-

S ment,
has beenbut clarified
the entityonlytracheobronchitis
recentIy.#{176}The
30

agents involved are viruses and M

pneumoniae. All of the agents we dis-
cuss can cause tracheobronchitis, I0J
20 RESPIRATORY
but respiratory syncytial virus, M
pneumoniae, and the influenza vi-
ruses are most commonly isolated. 40
These agents have definite age and
seasonal patterns, thus dictating the
age of patients with tracheobronchitis
and the seasons when these infec-
tions occur. Respiratory syncytial in-
fection occurs in young children in
winter and spring, the influenza vi-
ruses in all age groups in the winter
and spring, and M pneumoniae in
school-aged
though erythromycin
children in the fall. Al-
and the tetra-
30
20
TJ__
ZNFLUENZAVIRUSTjrn
PARAINFLUENZA
VIRUS
TYPE I
__
So
40
30
20
I0-I&.
0Iii

cydlines are effective against M pneu- INFLUENZA VIRUS TYPE z

moniae infections, supportive treat-
ment is all that is required for most 0 10
children with tracheobronchitis. I OTHER PICORNAVIRUSES ,ADENOVIRUSES
I - - - -
01
. M Diltumorno M horn/n/s
L -

In office practice, of the

common causes of croup,
tracheobronchftis, and
bronchiolitis-
viruses and M pneumonlae-
the only ones requiring
antimicrobial treatment are
those due to
M pneumoniae.

JUL AUG S OCT NOV DEC JAN FEB MAR APR MAY JUN
1970 1971
Bronchiolitis
Bronchiolitis is the most common
Fig 7. Number of agents isolated by month from children with lower respiratory tract illnesses
lower respiratory tract infection syn- seen in office practice, 1970 to 1971. Note propensity of some agents to cause rather discreet
drome in small children. It is caused outbreaks at time when other agents were present in only small numbers. From Denny and
usually by respiratory syncytial virus, Clyde.2
although all other respiratory agents
can cause wheezing. Bronchiolitis oc-
curs in the winter and spring during vitro and has been reported to ame- with an uncomplicated infection, the
respiratory syncytial virus epidemics liorate illnesses caused by this clinician is justified in withholding an-
in young children. Lower respiratory agent.31 It is not recommended for tibiotics. The role of bacteria in pneu-
tract infections with wheezing in general use at this time. monia, other than M pneumoniae, is
school-aged children in the fall are much less clear, presenting the clini-
frequently related to M pneumoniae. cian with a somewhat different chal-
Pneumonia
This syndrome does not appear to be lenge. Several circumstances that
caused by other bacteria. Manage- Bacteria other than M pneumoniae may suggest methods of manage-
ment of bronchiolitis is supportive in are unusual causes of croup, tra- ment follow. Respiratory syncytial vi-
S most cases; data to support the use
of bronchodilators are lacking. Riba-
cheobronchitis,
children
and bronchiolitis.
with one of these syn-
In rus and the influenza viruses are the
most common causes of pneumonia
virin, a new antiviral agent, is effective dromes, when all other clinical and in young children. The older child with
against respiratory syncytial virus in epidemiologic data are compatible lobar pneumonia probably is infected

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 Respiratory Infections

crobial treatment until recovery or un-

til studies
necessary.
indicate that this
The child with mild pneu-
is not
S
monia, at a time when a respiratory
Virus 5 causing disease common in
other children in the community, can
be safely observed without antibiotic
therapy.

Pneumonia is more difficult

to manage. S pneumoniae
and H influenzae are not
thought to be common
Respiratory Syncytial Viruses
causes in the United States.
Because no diagnostic tests
are available for recognizing
those that do occur unless
the organisms are isolated
from the blood or directly
from the lung or pleural
space, patients with severe
4- pneumonia should receive
antibiotics.
3

o
2 Parainfluenza Virus Type 3
In determining the general applica-
c1 bility of the guidelines, the physician
should keep in mind that most of the
S
2 j Mycoplasma pneumorae
observations discussed were made
in a small city in North Carolina. Cer-
tam correlations, however, have been
constant regardless of where studies
have been performed. Respiratory
2 Influenza Viruses syncytial virus, parainfluenza virus

)1
%J July Aug. Sept. Oct. Nov. Dec. Jon. Feb. Mar. Apr. May June
types 1 and 3, M pneumoniae,
adenoviruses, and the influenza
the
vi-
ruses have consistently been the
MONTH most common infecting agents. The

Fig 8. Monthly attack rates of total lower respiratory tract illnesses, four syndromes, and
infections caused by certain agents in children 0 to 2 years of age. From Denny and 32

S pneumoniae and
H influenzae appear to be
common and important
with S pneumoniae. The presence of suggests the diagnosis. The simulta-
causes of pneumonia in the
significant amounts of pleural fluid neous presence of several children
developing world.
suggests a causative agent other with similar findings in a community
than M pneumoniae or a virus. M usually indicates the community oc-
pneumoniae infections occur in currence of M pneumoniae disease
school-aged children and are usually and simplifies management in similar
characterized by the gradual onset of patients for the duration of the epi- age-related attack rate of agents and
symptoms, notably cough. Pulmo- demic. In the absence of clinical and age-related syndromes and the as-
nary infiltrates are usually of intersti- epidemiologic data suggesting viral sociation of certain agents and partic-
tial or bronchopneumonic character, or M pneumoniae pneumonia, the se- ular syndromes also have been con-
involving
demonstration
one of the lower lobes. The
of high (>1 :1 28) or in-
verity of illness is probably
guide to management;
the best
the child who
sistent, as has the preponderance
lower respiratory tract infections
of
in
5
creasing titers of cold hemagglutinins is severely ill should receive antimi- boys. The epidemiologic aspect most

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 INFECTIOUS DISEASE

variable and most likely to differ

Total Lowsr Ristory ssis
among geographic locations is the
seasonal occurrence of infections
with specific agents. In general,
trends reported here are similar to
those reported by other investigators
in the United States but may differ in
other parts of the world. In the trop-
ics, for example, lower respiratory

I tract infections tend to be more fre-

quent during the rainy season. The
presence of regional laboratories ca-

I pable of identifying the agents caus-

ing current respiratory
in various geographic areas might be
tract

of help to the practicing pediatrician.

infections

I u
1
I Pvslnflusnz.
-
Virus Typ. 3
The Centers for Disease Control has
performed this task for many years
for the United States and reports the
isolation of influenza viruses in Mor-
bidity and Mortality Weekly Report.
. Several laboratories in various parts
of the country report the isolation of
I I Adsnovlru...
: respiratory disease agents in local
01 -

2 klfkmnza Virus.s
communities.
In seems likely that S pneumoniae
1 -

and H influenzae are not major

July A44 SSpt Oct. No Dec. Jan. Fe Apr. May kits
MONTH causes of lower respiratory tract in-
fections in developed countries. This
Fig 9. Monthly attack rates of total lower respiratory tract illnesses, four syndromes, and may not be true in developing coun-
infections caused by certain agents in children 2 to 5 years of age. From Denny and 2 tries, and clinicians caring for children
in these areas should be aware of the
role these two bacteria may play in
the excessive morbidity and mortality
among children with lower respiratory
11
tract infections, especially pneu-
monia.

I
2 Rss*ty Syncyti& Virus
1
0
REFERENCES
V
...%
I 2 P&alnfkjsnzs VIrus Type 1
‘U 1 . Henderson FW, Collier AM, Sanyal MA, et
al: A longitudinal study of respiratory vi-
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I 2 P&ainfkisnz* Virus Type 3
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1 982;306:1 377
80 0 - - -

Cl)
‘U
2L
3, Mycoplssins pnwnonla
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ized children. J Pediatr 1986;1O8:635
U) 3. Loda FW, Glezen WP, Clyde WA Jr: Res-
4
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1 4. Brasfield DM, Stagno S, Whitley RJ, et al:

I Infant pneumonitis associated with cyto-
megalovirus, chlamydia, Pneumocystis,
i and Ureaplasma: Follow-up. Pediatrics
!iy __. I 1987;79:76
Au Sept. Oct. Nov. Dec. Jait Feb Mar. Apr. May June .: . Komaroff AL, Aronsen MD, Pass TM, et
MONTH al: SerOlOgiC evidence of chlamydial and
i mycoplasmal pharyngitis in adults. Sci-
ence 1983;222:927
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infections caused by certain agents in children 5 to 9 years of age. From Denny and Clyde.2 Role of Chlamydia trachomatis in acute

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pharyngitis in young adults. J Clln Micro- 1981144:433 risk of respiratory disease and diarrhea in
biol 1984;20:993
7. Schwartz RH, Shulman ST: Group C and
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S
Advances in Pediatrics

A number of advances in behavioral and development pediatrics have occurred

during the last 20 years that have changed pediatric practice. They should be added
to the list of major advances by Dr Rapkin published last year(Pediatr Rev 1987;8:248).

Infant Temperament
The concept of infant temperament was formalized by Chess, Birch, and Thomas
and popularized for pediatrics by Dr Carey. There are nine categories of temperament
(activity level, rhythmicity or regularity of bodily functions, approach or withdrawal,
adaptability, intensity of reaction, threshold of responsiveness, quality of mood,
distractibility, and attention span and persistence). From this there has been a
characterization of the difficult child: one who shows irregularity of bodily functions,
intensity of reaction (of the negative kind), tendency to withdraw from new stimuli,
and nonadaptability. The recognition that these characteristics were not the mother’s
fault but were the result of an innate temperament has led to an understanding among
parents that they are not to blame for the difficult child and has led to better
understanding of how to adapt child-rearing practices to such children. (A. Zisman,
MD, Spring Valley, NY)

PIR 146 pediatrics in review #{149} vol. 9 no. 5 november 1987

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 Acute Respiratory Infections in Children: Etiology and Epidemiology
Floyd W. Denny
Pediatrics in Review 1987;9;135
DOI: 10.1542/pir.9-5-135

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 Acute Respiratory Infections in Children: Etiology and Epidemiology
Floyd W. Denny
Pediatrics in Review 1987;9;135
DOI: 10.1542/pir.9-5-135

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pedsinreview.aappublications.org/content/9/5/135

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and
trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143.
Copyright © 1987 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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