Often ill children : what they are sick , really?

infections ear, nose and throat, as well as bronchopulmonary infections constitute the main list of diseases in childhood.Acute respiratory tract illness (ARI) can cause more than 300 different microorganisms, specific protection from which a person acquires throughout life.

In domestic medicine children with recurrent upper respiratory tract infections in the group decided to combine clinical supervision "often ill children" (FIC).The criterion for setting this "diagnosis", by the way, is not in the International Classification of Diseases, is the number of postponed child in the year of infectious diseases.

According to some publications, the incidence of acute respiratory infections in children of preschool and school age should not exceed 4-6 times a year.Unfortunately, we could not find published data confirming the validity of such criteria "pathology", as well as statistically significant studies showing the presence of certain abnormalities in children carrying the SARS more than 4 per year.On

the contrary, the WHO data indicate that SARS rate 8 times per year is a normal rate for children of preschool and primary school age attending children's institutions.

The reasons more frequent than with older diseases of young children can be both anatomical and physiological characteristics of the respiratory tract (mucociliary and surfactant system, especially the structure of the bronchi) and transient age characteristics of the immune system of the patients.A major role is also played by the increase in contacts between a child and an adult.However, of course, that in addition to the physiological characteristics of anatomical defects of organs and systems, as well as congenital or acquired pathology in Vol. H. And the immune system, can also affect the incidence of infectious diseases of children.

Thus, the "diagnosis" FIC, were so widespread in the medical pediatric population, especially among pediatricians, is dangerous because this group can get a little healthy children and children with serious chronic diseases.In the first case, a child is exposed to unreasonable diagnostic interventions and receives empirical "immunomodulatory" therapy, in the second - does not receive the necessary pathogenetic therapy due to lack of adequate diagnosis.


pediatricians What follow when choosing tactics of the so-called FIC?

research group "often ill children" were held in an attempt to answer this question we have.

not heavy leaking, but recurrent viral and bacterial infections of the respiratory tract characterized by the subgroup of primary immunodeficiency states [7].This is the so-called small-cell defects in the immune system.This group includes selective IgA deficiency, deficiency of IgG subclasses, defect-specific antibody, the diagnosis of which is placed on the basis of criteria established by the European Society of immunodeficient states. [8]

Materials and Methods

The study included 90 people aged from one to 15 years, sent from district clinics with the diagnosis "frequently ill child."Parents complained of frequent acute respiratory viral infections (ARI), recurrent bacterial infections such as purulent sinusitis, otitis, tonsillitis, pneumonia and other

for clinical and laboratory analysis we arbitrarily assigned the children into groups according to the clinical manifestations:.

  • I group - children with isolated recurrent viral upper respiratory tract infections - 56 people.The group included children with recurrent viral infections of the respiratory tract and upper respiratory tract and a disease duration of more than one year;
  • II group - children with a combination of recurrent viral upper respiratory tract infections and recurrent bacterial (two or more per year) infection with disease duration of more than one year - 26 people .;
  • II group - children with prevalence of recurrent bacterial infections (two or more per year), or transferred to a heavy or prolonged bacterial infection - 8 people.

The study did not include children with isolated recurrent furunculosis, patients with recurrent infections one location associated with anatomic defects of an organ, in Vol. H. Children with recurrent infections of the genitourinary system.

diagnosis of "primary immunodeficiency" is set according to the criteria of the European Society of immunodeficient states.The diagnosis of "asthma" was established according to the criteria proposed by the scientific-practical program for asthma Union of pediatricians of Russia.

The study was conducted according to a single plan that includes medical history analysis (the debut of clinical manifestations, frequency, nature of the disease);analysis of clinical symptoms at the time of the survey and in the dynamics of received therapy;standard (complex), instrumental and laboratory examination of patients.

All patients underwent a comprehensive immunological examination.The content of immunoglobulin A, G, M, E in the serum was determined by nephelometric turbidity meter at 100 BN (Dade Bering, FRG) using the Dade Behring kit according to the manufacturer's instructions.IgG subclasses in serum was determined by nephelometry at 100 BN nephelometer (Dade Bering, Germany) using the kits and according to the manufacturer's instructions.Lymphocyte phenotyping was performed by flow cytometry on FacsScan instrument (Becton Dickenson, USA) using fluorescently-labeled monoclonal antibodies.Studies

specific IgG antibodies to measles virus was carried out using solid-phase immunoassay using company reagents (HUMAN GmbH, Germany).Mitogenic response was evaluated by determining early lymphocyte activation marker (CD69) by flow cytometry on FacsScan instrument (Becton Dickenson, USA) after stimulation of whole blood lymphocyte PHA.

results

In group I, children with recurrent viral infections of the respiratory tract (56 pers.) In the course of the study a higher rate of previously diagnosed asthma was identified (BA).Children with newly diagnosed asthma amounted to 22 people (40%).In 15 children (68%) diagnosed with asthma immunological parameters were within normal limits.The remaining 7 patients (32%) had the so-called small forms of immunodeficiencies (transient hypogammaglobulinemia of childhood, selective IgA deficiency, a deficiency of a specific antibody).

other children (. 34 persons) I group was as follows: 13 persons.We had recurrent infections of more than 8 times a year, 21 people.- At least 8 times a year.This division was based on WHO's position, that healthy, younger children tend to carry up to 8 SARS year.

Most children (71%) with a frequency of SARS at least 8 times a year is not determined by breaches in the immune status.The other children in this subgroup as follows: 19% (. 4 persons) cases, there was a "transient hypogammaglobulinemia of childhood", 5% of children (1 pers.) Has been identified "selective deficiency of IgA" and 5% (1 person) -. deficit IgG2 subclass (Table 1)..
Among children suffering from isolated viral infections of the respiratory tract often expected, that is. E. More than 8 times a year, and in most (62%) cases not detected or determined immunological defects transient compromised immune systems (Table. 2).

Group II consisted of patients with a history of frequent combination of viral (8 or more) and bacterial (two or more per year) infections - 27 people.Indicators of immune status in these patients were different and in most cases had abnormalities.However, even in this group, 23% of the patients has been identified previously undiagnosed asthma.

Among children with a combination of recurrent viral and bacterial infections of the frequency of occurrence of various defects of the immune system was 74%, with the predominant IgG subclass deficiency (IgG1 and IgG3).Normal indicators of immune system have been identified only in 26% of cases (Table. 3).

Children with recurrent (two or more per year), severe, protracted bacterial infections accounted for Group III patients (8 pers.).Like the group II, in patients of this group in most cases immunologic parameters did not meet the age norm.In 6 children defects of the immune status were found (agammaglobulinemia, deficit IgG3, IgG1, IgG4 subclasses) (tab. 4).

We have compared the clinical symptoms of patients with immunological survey data.According to the history of life of patients included in our study, all infectious diseases which have occurred (Table. 5) were summarized.
From the conducted analysis shows that such infectious manifestations as recurrent purulent otitis, stomatitis, skin infections, as well as repeated (more than two), pneumonia, correlate with defects of the immune system.

these patients need a complete immunoassay for the detection of the defect and the appointment of adequate therapy.Recurrent catarrhal otitis, acute bronchitis, pneumonia Moved once in the absence of other severe infectious diseases are rarely signs of immune disorders, and are not a sufficient basis for the full-scale immunoassay child (tab. 6).

Discussion and conclusions

This study showed that in children, observed the so-called diagnosis "often ill children" much more often than in the general population, there is underdiagnosis of asthma.Among the children who came to the reception to the immunologist guide diagnosis of FIC district clinics, 40% of patients with isolated recurrent viral infections and 23% of patients treated with the combination of recurrent viral and bacterial infections were diagnosed with asthma.

of asthma especially in this age group is the prevalence of inflammation, edema of the bronchial mucosa, mucus hypersecretion of bronchial obstruction, which leads to a kind of clinical picture of "wet asthma" in this age of less severity and longer duration attacks.Thus, according to the author of scientific-practical program for asthma, asthma in young children can occur under the guise of recurrent bronchitis, which often is the cause of the incorrect diagnosis.

of the study also showed that not only the frequency, as the nature of recurrent infections VAR suggests the presence of immune system defects dolaboratornom stage.

Thus, according to the immunoassay, in children with isolated recurrent viral infections (8 or more per year), in most cases the immunological changes observed were not identified or transient disorders of the immune system.
Among children with a combination of recurrent viral and bacterial infections have been identified in patients with primary immunodeficiency.

In most cases, these were the so-called small-cell defective immune system (selective IgA deficiency, deficit of subclasses IgG, specific antibodies selective deficiency, transient hypogammaglobulinemia of childhood).However, there were among them, and patients with severe immunodeficiency states, such as agammaglobulinemia, giperIgM syndrome.Babies also with recurrent purulent otitis, stomatitis, infections of the skin, and for patients who have had multiple (more than two) of pneumonia, shows immunological examination to eliminate serious immunological diseases.

Thus, the above can be summarized in the following conclusions:

1. The use of the term "often ill children" as the diagnosis is unfounded.
2. children with recurrent respiratory tract infections must first rule out a diagnosis of asthma.
3. Isolated viral infections VDP is not a sufficient indication for immunological examination of children.
4. Indications for referral to the immunologist is the combination of recurrent viral and bacterial infections or the presence of severe, protracted bacterial infections.
5. To verify the diagnosis "primary immunodeficiency" necessary clinical and laboratory examination in a specialized immunological units.


Recommended reading
1. Tatochenko VKPractical pediatric pulmonology (reference).Moscow, 2000. 89 pp.
2. Albitsky VY, Baranov AAOften ill children.Clinical and social aspects, improvement of the way.Saratov 1986.89.
3. Report of a WHO scientific group.Primary Immunodeficiency Diseases.Blackwell Science Ltd, Clinical and Experimental Immunology.1997, 109, Suppl.1: 1-28.
4. Armstrong D., Cohen J. Infection diseases // Mosby.1999, 4: 2.11-2.12
5. Markova, TP, Chuvirov DGLong and often ill children // BC.2002. T. 10. S. 3 number 125.
6. Union of pediatricians of Russia.Asthma in children: diagnosis, treatment and prevention.Scientific-practical program.M., 2004, pp 21-22.
7. Stiehm E. R. Immunologic disorders in infants and children.4th edition.W. B. Saunders company.1996, 321-324.
8. Conley M. E., Notarangelo L. D., Etzioni A. Diagnostic criteria for primary immunodeficiencies // Clinical Immunology 1999, 93, 3: 190-197.
9. Haryanova NEInfluence polyoxidonium mielopida and the formation of post-vaccination immunity in frequently and chronically ill children / Author.diss.M., 2000.

Magazine "Difficult patient» / №2-2007 /

article is provided by a charitable foundation to help children with impaired immunity "Sunflower".

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