Approach to Recurrent Lower Respiratory Tract Infections in Childhood

Definition and Evaluation

Recurrent lower respiratory tract infections (LRTIs) can be defined as more than three respiratory tract infections requiring antibiotics per winter season or a severe/atypical response to a single infection, according to the European Respiratory Society 1
Initial evaluation should include comprehensive documentation of frequency, severity, and pattern of infections, as well as assessment for specific risk factors including immunodeficiency, anatomical abnormalities, and neuromuscular disorders, as recommended by the European Respiratory Society 1
Basic immunological investigations including total immunoglobulin levels, specific antibody responses to vaccines, and immunophenotyping of peripheral blood should be performed, as suggested by the European Respiratory Society 1

For infants with persistent wheezing despite treatment, airway survey via flexible fiberoptic bronchoscopy is recommended, and bronchoalveolar lavage (BAL) should be performed to identify potential bacterial infections, as recommended by the American Thoracic Society 2
Approximately 20-30% of children with persistent wheezing who undergo bronchoscopy with BAL will have symptoms improve with targeted antibiotic therapy, according to the American Thoracic Society 2
Regular surveillance microbiology on respiratory samples should be performed to guide antimicrobial therapy, as recommended by the European Respiratory Society 1
Consider evaluation for underlying allergies, particularly allergic rhinitis, immunodeficiencies (IgA and IgG deficiency), cystic fibrosis, gastroesophageal reflux disease, and anatomical abnormalities (including vascular rings, malacia), as suggested by the American Academy of Pediatrics 3 and the American Thoracic Society 2

Early aggressive antibiotic treatment for documented infections is essential, and consider prophylactic antibiotics when the burden of respiratory infections is high, as recommended by the European Respiratory Society 1
Macrolide antibiotics may be beneficial for chronic respiratory symptoms, according to the European Respiratory Society 4
All available immunizations to respiratory pathogens should be administered, including pneumococcal vaccines (conjugate followed by polysaccharide) and annual inactivated influenza vaccine, as recommended by the European Respiratory Society 1 and the Centers for Disease Control and Prevention 5
Consider immune replacement therapy when hypogammaglobulinemia and/or specific antibody deficiency is present with recurrent respiratory infections, as suggested by the European Respiratory Society 1

Regular assessment of lung function at least twice yearly, even in the absence of symptoms, to detect subtle progression of lung disease, as recommended by the European Respiratory Society 1
Spirometry should be attempted in children old enough to perform tests, and early intervention for respiratory illnesses and perioperative assessment should be considered, as suggested by the European Respiratory Society 1

For recurrent throat infections, watchful waiting is recommended if there have been fewer than 7 episodes in the past year, fewer than 5 episodes per year in the past 2 years, or fewer than 3 episodes per year in the past 3 years, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6 and 7
Consider tonsillectomy for children meeting the Paradise criteria (specific frequency and clinical features of infections), as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 7
For sinusitis, evaluate for recurrent acute bacterial sinusitis if a child has ≥4 episodes of respiratory symptoms lasting >10 days per year, and consider prophylactic antimicrobial agents only in carefully selected children whose infections have been thoroughly documented, as recommended by the American Academy of Pediatrics 3

Avoid exposure to tobacco smoke and other environmental irritants, as recommended by the European Respiratory Society 1
Annual influenza vaccination for all children with recurrent LRTIs, as recommended by the European Respiratory Society 1 and the Centers for Disease Control and Prevention 5
For children with allergic rhinitis, consider intranasal steroids and non-sedating antihistamines, as suggested by the American Academy of Pediatrics 3
For those with gastroesophageal reflux disease, antireflux medications may be helpful, as recommended by the American Academy of Pediatrics 3