CHILD WHO GETS SICK OFTEN

What is

And 'one of the' problems' more common in the daily practice of the pediatrician and often a source of great anxiety for parents. Affects many children age asylum which, for this reason, they are often subjected to repeated antibiotic therapy, a tedious, asphyxiating, repeated aerosol treatments, including radiological investigations, treatments with "vaccines", and sometimes even , to treatments with penicillin injections every 2-3 weeks. Very often, in a deeply rooted tradition especially among grandparents but also, unfortunately, to the ignorance of some pediatrician, ends up being held responsible for all the "throat" and invariably the little child is brought to the ear. However, as many otolaryngologists are objectively well prepared and have a non-sectoral vision of these problems, most unfortunately ends to focus on the tonsils, from time to time labeled as "large", "sick", " cryptic "," flaming "," ruined "and very often, in a sad but established custom, this journey that often also unlikely unlikely assessments and therapies ends with the sacrifice of the poor and innocent tonsils. That, in fact, as we shall have nothing to do practically never.
then begin to clarify.

The child age of asylum which often gets sick, that is "always wrong" as the parents, a child who usually suffer from repeated episodes of fever, not present in all the episodes, cold and cough. Sometimes also has a low voice, sometimes the barking cough, "by Seal." Are infections of the upper respiratory tract, upper respiratory tract. In technical terms are called undifferentiated infections of the upper respiratory tract. Sometimes there is also the interest of the ears or sinuses or bronchi. Tonsillitis "true", tonsillitis also are not very common, although often the focus is on them. It 'not uncommon, that is, that the baby has only fever and pain on swallowing, with the exclusive presence of the pharynx and tonsils reddened or "exudate", the so-called "plaques" on the tonsils. Usually when the pediatrician speak broadly of red throat the child does not have a true tonsillitis "pure." If there is too cold or cough or low voice, it is not a true tonsillitis but simply faringotonsillare region, one that sees the pediatrician with the spatula and the bulb is red because it is part of a process of inflammation that also affects nose, the retronaso, the larynx; that is part of a more extensive inflammation of the upper airway. Speak generically of "red throat" is wrong. Sends the message that the pediatrician is ambiguous and results in the mind of an equation parent: the child becomes ill always have her tonsils throat = sick.
Instead, it is, as mentioned, in the vast majority of cases of viral infections of the respiratory upper airway, mostly without any complication, sometimes complicated by ear infections, sinusitis, bronchitis. Sometimes, in some children, with constitutionally small size of the bronchi, may appear in the course of viral infection, outside of any allergic component, wheezing, ie what is usually called "bronchospasm" or "bronchitis asthmatiform".
Only very rarely these children may have major complications in the lungs (this is bronchopneumonia). It is usually of episodes that are unique after a series of infections much less important as those described.

To what extent is normal

However these recurrent episodes of fever, cold and cough (so-called recurrent respiratory infections) are in most cases a quite normal. It 's normal that a child in kindergarten can get sick even once a month: in the period of greatest frequency, ie from October to April-May these children socialized in this way can get sick, but it represents an index of particular disease, up to eight times for children under age three and up to six children over three years. Taking into account that each episode of respiratory infection can give high as 5-6 days of fever and cough as 10-15 days, is easily explained as apparently these children move from an infection to another seamlessly. Sometimes children who have been kept at home for a week or two immediately fall ill again when they come to kindergarten giving parents and grandparents feel their particular fragility. However, as mentioned, this apparently continuous recurrence of respiratory infections affects children completely normal.
are very rare cases where the problem has characters worrying worry and look for a pathological motivation in re-infection if the number of them is significantly higher than the limits of normality, although in the time interval between an incident and the other the general condition of the child, his vitality, his mood not entirely recovered, if, finally, recurrent infections not only affect the high respiratory tract but also affects the lower respiratory, in other words, if your child has frequent bronchopneumonia.

What are the causes

Any parent who usually accompany their child to kindergarten can be seen that a good half of the children is normally absent, sick children are left at home, and that a good proportion of these are children, "cool", with cough, nasal runny ecc.Il reason for this particular susceptibility to respiratory infections of preschoolers are in their own age and in their togetherness. These are small children with defense capability against infections ("immune") not yet fully developed, inserted in a community where the circulation of the agents responsible for diseases, virus in the head, is remarkable and in which, therefore, are continually exposed all'aggressioni by these "pathogens". Of course many times this aggression will prevail and the virus or microbe, not winning the strong resistance of the child, be able to give the disease. The key factors responsible for recurrent respiratory infections of the small child are therefore the age of the child, with the immune system is still in the process of evolution, and its socialization, that is, exposure to multiple and repeated attacks, especially viral. Being together with many other children makes our little will be achieved in an almost continuous virus, transmitted by their peers, with whom he has not yet had contact and to which, therefore, has not yet been able to develop appropriate "weapons of defense. " But there's more: each viral infection that causes a child contracts the further impoverishment of its defense capabilities, a transient immune suppression. For this reason, any infection facilitates the next, in a kind of vortex. The child is left at home because ill has not yet had time to regain, after infection, an adequate level of defense, to overcome the immune suppression that the virus caused when material is returned asylum and restated in this state of weakness, a new further aggression. Invariably riammala, has a new further reduction of defenses and, therefore, to return to kindergarten a new infection ...... and so on in a vicious circle often increasingly tight until, with the maximum despair of the parents, it sometimes seems that it is enough to endanger the nose, even for a single day in kindergarten for riammalarsi!
In these children, it is practically useless to look for a cause beyond their age and attending kindergarten. Are hardly ever "immunocarenti" in the medical sense of the term, almost never a lack of "antibodies": their defense capabilities are simply those age-appropriate and are evolving. It often happens instead subjected to laboratory tests will be labeled as "poor of antibodies." Often it is not considered that the small child levels of these antibodies are naturally and physiologically lower than those of adults and that, often, are the values ??of those adults that are placed as a reference in the reports of the analyzes. Still sometimes not you consider that even when a genuine deficiency of antibodies is detected, as in the case of so-called IgA, it may not be due to infection but simple consequence of viral infection itself.
Another motivation that often is alleged, in addition to the deficit the immune system, is that of "tonsils sick." We have already seen that tonsils actually have nothing to do at all: they are not responsible for this frequent sick of preschoolers though, often, as we shall see, are charged and convicted of anything grubbing.

How important is allergy?

These children are "sick often" often are led by pediatrician allergist. The nose always closed and leaking, the cough that apparently never goes out, episodes of bronchitis, asthma-inducing parents and pediatricians to assume a role of allergy in this their sick. In some cases, but certainly less frequently than you might think, these children are truly allergic to house dust are mainly, or rather to mites in house dust. Being allergic to dust (or cats or mold) can in fact be the basis of recurrent episodes of bronchospasm even when quite clearly they are associated with infection by viruses. In fact, even in children allergic frankly most of the episodes of asthma, bronchitis or bronchospasm or asthma-like if you prefer, are triggered by viral infections that are persistently inflamed bronchi for exposure to mite allergens an essential condition for triggering the crisis. The allergic children, therefore, if they attend the nursery have easier acute episodes of coughing, wheezing and whistling breath than other children, just as allergic, not exposed to viral infections. Not only be allergic and be continuously exposed to the allergenic substance, for example precisely to dust mites, causes the wall of the respiratory tract produces substances ("adhesion molecules") that facilitate the attachment to the wall itself of the virus and then the infection. In other words, the allergic child more easily than non-allergic children tend to get sick of these viral infections and viral infections are the same allergic child, the trigger of asthma attacks. Another vicious cycle to stop which is appropriate for the child with asthma infrequent asylum.
course, not all children who become ill often are allergic, allergy sufferers are in fact only a minority interest. Are not allergic those children, most of which have repeatedly fever, cold, cough, without other symptoms. They can be allergic to those who have repeated episodes of bronchitis, asthma-like, but not all!. The two-thirds of children with bronchitis asthmatiform (or "bronchospasm") applicant, in fact, are not allergic but are only constitutionally children who have a reduced diameter of the bronchi whereby when the wall of them swells to the viral infection this diameter is reduced further to determine the wheezing, namely that whistle that you can sometimes feel directly with the ear. These children with asthma, non-allergic, are intended to heal with time, as increasing the diameter of the bronchi increases. At a certain age, while cooling will no longer have asthma-bronchitis. It 'what once dared to say that asthma often goes with age.
's not what happens, on the contrary, that one-third of children with recurrent bronchospasm really asthmatics. These children can be identified by a number of factors often have allergic parents or siblings, sometimes have atopic dermatitis or hay fever, sometimes have a history of problems with growth or chronic diarrhea, sometimes have a special design with dry skin, pallor, dark circles. In these children the right look with allergy skin tests.

What to do?

In most cases nothing but reassure genitori.La vast majority of children who become ill often has nothing but his own age and being ass nursery or kindergarten. Viral infections are a kind of recurring fee to be paid to the socialization of the child and the needs of working parents. On the other hand it is, as repeatedly said, in the overwhelming majority of cases of trivial infections, benign, without complications which, being exquisitely viral, do not require any treatment with antibiotics.
In special cases, but only in them, it may be appropriate perform allergy tests, when the family and personal history of the child, or the combination of skin diseases of the digestive system, distinguishing marks such as those described above, suggest an allergic component.
Investigations of more extensive laboratory should be reserved solely to those cases, very rare in daily office practice, infections extremely frequent or recurrent infections (not for unique or almost) by the low tract (bronchial pneumonia, bronchopneumonia recurring in the same area of the lungs, etc..).

What not to do?

- Always give antibiotics: recurrent infections of children are socialized especially viral infections that do not require antibiotics unless symptoms are not such as to suggest a complication supported by microbes or unless there is an ear infection in children under two years or one acute rhinosinusitis.
- Investigation of X-ray and laboratory burst tests on exams: recurrent infections in the respiratory tract, that is, almost always, are completely useless. They can even be misleading and counterproductive. It 'totally unnecessary and extremely dangerous, in fact, take some exams such as TAS and the throat swab. Almost always useless dosage of anticorpi.Perché can be "dangerous" to have these tests? Because in addition to not having any relation to the problem at hand, if not properly interpreted can create false problems and lead to unnecessary treatment and repeated and further investigations as unnecessary and repetitive.
The throat swab is useless because the microbe that you go to search with it, streptococcus _ hemolytic group A (SBEA) has nothing to do with recurrent respiratory infections. Even less to do with they other microbes (Staphylococcus aureus, Pseudomonas etc..) May be identified by the buffer: the latter fact when retrieved from the buffer should not be considered as a cause or potentially cause disease but only as normal inhabitants ("saprophytic" ) in the region faringotonsillare. In other words the SBEA is the only microbe capable of giving acute tonsillitis or pharyngitis (but not infection involving also the nose, larynx, trachea ie with cough runny or blocked nose, low voice, etc..: Namely respiratory infections of which 're talking about). All other microbes possibly found are not able to give disease but can be found simply because in that case, ie the region of the tonsils and the pharynx, may normally live there. How many times happen to see antibiotic treatments however long and protracted hunt for ......... home these microbes, in this context, are completely innocent!
Returning to SBEA and reaffirming that it is never responsible for infections of the upper respiratory tract but only faingotonsilliti a part of the "pure", the risk you run improperly performing in these children the throat swab is that it is positive. That is to say that this microbe, although not absolutely undifferentiated responsible for infections of the upper respiratory tract, which are, as said, exquisitely viral, could be randomly found from the swab. This is possible because approximately 30% of the children generally in the throat ("carriers or chronic") the SBEA give anything without this. These children should not be treated with antibiotics, first of all because these streptococci are not pathogenic, ie they are not able to give the infection and disease, and secondly because when they are not absolutely pathogens are not sensitive to antibiotics administered, and then can not disappear! The only reason to run the throat swab for strep throat a child is 'true' acute in place: that is, the buffer needs to be done to the child with fever, pain upon swallowing, throat and tonsils red to see if this disease is due to SBEA, as occurs in one third of cases, in which case it is right that the child take antibiotics indicated, or, if the buffer is negative, whether it is a virus, as occurs in two-thirds of the cases. In this case no antibiotic treatment has to be done. Never, ever, the swab should be performed on the child just because you get sick often and out of the acute episode of true stress and true, sore throat.
How many times, on the contrary, children with recurrent infections of the upper respiratory are treated with antibiotics for positive swabs, and how often to check the buffer rightly remains positive despite treatment, leading to further more aggressive therapies and more traumatizing. How many times, finally, these infants after various treatments and numerous checks are sent, another error, dall'otorino not considering the death of the microbe expression of severe chronic infection of the tonsils. How many times at the end of these poor innocent, after other treatments, other controls are eradicated!
SBEA I wanted the buffer has therefore nothing to do with the child who is always sick with fever, cough and cold, and less than ever to deal with it the TAS. If the swab is positive for strep can express, but not always!, An acute infection of the SLT is back in action almost always an expression of a streptococcal infection in the old time, past. So not only expresses an infection of a microbe that is never responsible for the problem of the child who goes to kindergarten and get sick often, but even expresses only the memory that the infection of this microbe has left the body. The CAS, in fact, the extent of infection in place, but the antibodies that the body has produced in the past against this infection and who have remained and will remain for a long time in the blood. The TAS itself then does not mean either acute or chronic infection of the tonsils does not mean rheumatism or whatever. It 'an examination in daily practice should never be executed because of no use from an operational perspective and foreboding, if misinterpreted, as often happens, practices bad medicine.
goes without saying, then, that among the things to do in the face of a child who gets sick often refer to the otolaryngologist. The problem is not, in fact, the otolaryngologist since there is no underlying "defect" or "disease" particular industry ear nose and throat, but since this is an almost physiological linked to their immune situation of the child of that age. Second, unfortunately, often consulted ENT specialists do not see the "pediatric" of the problem and being substantially surgeons almost always end responsibility for the tonsils and remove them. The everything, even worse, after repeated unnecessary analysis and analysis of control (buffer, TAS etc..) And after, often, absurd treatments with three weekly injections bi-penicillin. Recurrent respiratory infections in the young child are mostly viral and not prevented by penicillin, penicillin can not "cure" the TAS because it is not an infection but the memory of a past and entirely overcome infection; injections of penicillin the only indication in pediatric patients have relapse prevention of acute articular rheumatism in children who had a true acute articular rheumatism and not something "given" to a high TAS, some vague muscle pain or bone, some vague mention of heart murmurs more or less innocent.

Are useful "vaccines"?

There is much debate about the usefulness of the so-called "antibacterial vaccines" and immunostimulants, however, often, even to the pressing demands of parents indoctrinated by relatives and friends, are prescribed to these children. However, no study carried out shows the effectiveness of these treatments, the most favorable of them appears to show that administering continuously for several months one of these products to children you could get a reduction in infections in a proportion not exceeding 16%. A very modest reduction compared with a treatment very protracted and interesting all the critical period and not just a few months before the winter season usually runs as a daily practice. However this study, the more favorable as mentioned, in addition to the limit does not give evidence for a truly significant improvement and determining the situation suffers from a serious defect basic: has been done within the same manufacturer! Most scholars do not recognize these treatments a real significance and on the other hand, it should not be surprising: the child with recurrent respiratory infections is, from the point of view of the immunological capacity quite adequate. There is no need for the immune system to be "stimulated".

Nothing to do with the tonsils?

We have repeatedly said that the tonsils are not responsible for recurrent respiratory infections and are simply involved, such as the nose, pharynx, larynx, trachea, and sometimes the ears, sinuses sometimes, in a wider process of infection and generalized. Probably if it was just as easy by otolaryngologists remove the nose or pharynx would arise not popular tradition that removing the tonsils the child does not get sick anymore but that removing the nose every infection of the small child disappears!
There is certainly a type of disease that concerns the tonsils but it is not the events more frequent and more classic child of the nursery school and kindergarten. 's tonsillitis
tonsillitis are "real" tonsillitis also characterized by fever and pain on swallowing. Tonsillitis are not well faringotonsillare hyperemia in the region, the "red gorges", associated with signs of viral infection of the upper respiratory such as cold and cough. If there is cold and cough is not true tonsillitis.
Even in case of tonsillitis true, in any case, the indications for surgery are coded and are as follows:
_ 7 or more episodes of tonsillitis true in a year or 5 a year for two years or three a year for three years;
peritonsillar abscess _,
_ Grave adenotonsillar hypertrophy with respiratory failure;
_ tonsillar cancer.
Outside of these situations there is no indication for surgery.
This situations concerning its rarity that contrast with the frequent abuse intervention tonsillectomy.
A corollary of this must be stressed that there are no objective criteria which would justify a condition of chronic tonsillitis (among other things denied by most of the authors): tonsils "bad" tonsils "big" tonsils "cryptic" variants are still within the normal range and do not express a disease condition, as well as the infamous maneuver squeezing tonsillar does not express the presence of purulent material but only of caseous material (cell debris, cell exfoliation, food debris). Nor is there any laboratory tests that express a condition of chronic tonsillitis; has a completely different meaning, in fact, the TAS which expression is, simply, a production of antibodies as a result of a previous, also very far away in time, streptococcal infection _ hemolytic group A (SBEA). Many authors believe that the TAS is actually an examination by never ask.
All this suggests that the extraordinary majority of tonsillectomy is unjustified.
The only indications for tonsillectomy are therefore those mentioned above.
should be noted that for other Very often, tonsillitis "real" authentically applicants (statistically very rare occurrence) recognize a virus called adenovirus as a cause which would not be readily removed at the level of the tonsils, but it would remain within the organization and would, from time to time, new infections.
This If, in the case of tonsillitis "true" recurring according to the criteria described above, there would be an actual, legitimate indication for tonsillectomy. However these recurrent tonsillitis by adenovirus, which in practice are simply those who do not respond to one, maximum two days, antibiotic, may also be treated with a single evening administration of cortisone by mouth. This treatment is very effective and usually the child wakes up in the morning without fever and pain.
Did we mention the problem of the throat swab. The buffer, as mentioned, has a single indication: the acute pharyngotonsillitis "true" in place. In fact, in this case it is important to distinguish the forms viral (especially adenovirus and EB virus), which are the majority (about 2/3), by bacterial forms (supported substantially exclusively by streptococcus _ hemolytic group A) to decide on the need for antibiotic treatment or not.
Outside of this information is not there are others with the exception of the research of the carrier state in children in the community in which an epidemic of scarlet fever or other infections by SBEA.
therefore, are not indications execution of the buffer, we repeat, the Recurrent Respiratory Infections that respond to quite different reasons and are substantially supported by viral infections, is no indication of the size of the tonsils, not to be found either "cured" the carrier state of Streptococcus _ hemolytic group A. In fact, a large percentage of children is usually a carrier of the germ in the oropharynx, or because chronic carriers (about 20%) after an acute episode, or because carriers (about 15%), and that this fact be associated with any disease. The carrier also disseminates the SBEA not: it's just the sick person who disseminates the germ.
Neither should be backed pad "control" after antibiotic treatment: eradication failure cases should not be persecuted with other antibiotic treatments and other controls, but considered simply carriers.
should also be noted that the SBEA is the only potentially pathogenic bacterial agent for the district faringotonsillare, all other germs may be identified by the buffer (eg, Staphylococcus aureus) are only saprophytic, normal inhabitants, that do not require any treatment.

Common Mistakes

1. Treating the SLT. The high titre does not express the existence of an infection but only an antibody level, the "remember" in the blood of an ancient infezione.2. Request TAS. The determination of antistreptolysin title dl (TAS) is the only indication the demonstration of a streptococcal origin in acute articular rheumatism. In this case, two samples are needed to demonstrate the increase of the level in time.

3. Giving antibiotics to people with allergies to dust mites with hyperemic pharynx ("red throat"). Hyperemia is due to inflammation induced by inhalation of mites. In the case of true infection there is fever. The Boy in the throat always red could then be a allergic child for which there may be an indication of the performance of prick test.

4. Treat the healthy carrier of SBEA. 15% of children are healthy carrier and does not require treatment. The only exception carriers in communities where there is an ongoing epidemic of scarlet fever or other infections SBEA.

5. Search the SBEA in recurrent respiratory infections. The only indication for the buffer faringotonsillare is pure tonsillitis, acute, actually, to distinguish bacterial forms (basically only SBEA) requiring antibiotic treatment shaped viruses (adenovirus, EBV).

6. Run the buffer "control" after antibiotic treatment. The cases of non-eradication should not be "persecuted" but considered healthy carriers.

7. Treating Tonsillitis by SBEA with the macrolide. The resistance to macrolides are now very high. The antibiotic of choice should be the semisynthetic penicillin or cephalosporins. The only indication to the use of macrolide nell'infezione from SBEA is the intracellular infection.

8. Make the prophylaxis of IRR with benzathine penicillin (Wycillina, Diaminocillina). The IRR are basically viruses.