54
Journal of the Royal Society of Medicine Volume 72 January 1979
totally eliminated. It is most important that common-sense prevails in matching the efforts at allergen elimination with the clinical benefits achieved. Hyposensitization has, in my clinical practice, very little place. I only regularly prescribe such injections for insect sting anaphylaxis where the results are excellent. Occasionally, pollen hyposensitization can benefit summer seasonal wheezing, but it can scarcely be looked upon as an ideal therapy. After a detailed study of mite hyposensitization (D'Souza et al. 1973), I am convinced that such treatment is clinically effective. However, the degree to which improvement occurs only rarely justifies the time, discomfort and risks of the treatment. More recently J 0 Warner (1977, personal communication) has confirmed that such injections are clinically effective, but he has emphasized that selection of patients should be by bronchial-challenge testing, which at present rules this therapy out of most routine clinical practice.
Summary Allergy must be seen as playing an important role in both predisposing children to wheeze and actually precipitating many attacks of asthma. The current specifically allergic treatments are, however, somewhat disappointing.
References Davis J B (1976) Clinical Allergy 6, 329-338 D'Souza M F & Davies R J (1977) American Review of Respiratory Diseases 115, 211 D'Souza M F, Pepys J, Wells I D, Tai E, Palmer F, Overell B G, McGrath I T & Megson M (1973) Clinical Allergy 3, 177-193 Forgacs P (1967) Lancet i, 203-205 Gell P G H & Coombs R R A (1968) Clinical Aspects of Immunology. 2nd edn. Blackwell, Oxford Goldberg N D, Haddox M K, Nicol S E, Sanford C H & Glass D B (1975) In: New Directions in Asthma. Ed. M Stein. American College of Chest Physicians, Illinois; p 103-124 Hendricks D J, Davies R J, D'Souza M F & Pepys J (1975) Thorax 30, 2-8 Ishizaka K, Ishizaka T & Hornbrook M M (1966) Journal ofImmunology 97, 840 Kimura I, Tanizaki Y, Takahashi K, Saito K, Ueda N & Sato S (1974) Clinical Allergy 4, 281-290
Parish W E (1970) Lancet ii, 591 Pepys J (1972) Proceedings of the Royal Society of Medicine 65, 271 Pepys J, Hargreaves F E, Chan M & McCarthy D S (1968) Lancet 2, 134 Porter R R (1959) Biochemical Journal 73, 119 Safirstein B H, D'Souza M F, Simon G, Tai E H & Pepys J (I1973) American Review of Respiratory Diseases 108, 450459
Szentivanyi A (1971) In: Immunological Diseaes. 2nd edn. Ed. M Samter et al. Little Brown, Boston; p 356-374 von Pirquet C (1906) Munchen Medizinische Wochenschrift 54, 1457 Warrell D A, Fawcett I W, Harrison B D W, Agamah A J, Ibu J O, Pope H M & Maberly D J (1975) Quarterly Journal of Medicine 174, 325-347
Infections in the wheezy child D G Sims MB MRCP1
Booth Hall Children's Hospital, Manchester M9 2AA
Viruses are the pathogens most commonly associated with wheezing in childhood. Table 1 shows viruses demonstrated by immunofluorescence or culture techniques in the respiratory tracts of 2225 infants and 2132 older children over a 5-year period to April 1974 in Newcastle upon Tyne. Respiratory syncytial (RS) virus was found in 83.5% of virus-positive infants who wheezed but in only 42% of older children. Of the infants with RS virus 75.8% wheezed, but only 46.8% of older children did so. Parainfluenza viruses were the next most common viruses found in wheezy infants and children. Influenza, like RS virus a winter pathogen, accounted for only 1.500 of those wheezy infants in whom a virus was demonstrated, and only 1 7.6% infected with influenza wheezed. The cause of the greatly increased relationship of wheezing with RS virus in infancy is unknown but McIntosh (1976) has recently reviewed current theories. 1
Present address: Oldham & District General Hospital, Oldham OLI 2JH
0 141-0768/79/010054-03/$01.00/0
,lr-"I 1979 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 72 January 1979
55
Table 1. Viruses demonstrated in respiratory illnesses in infants and children over 12 months old in a consecutive 5-year period Wheezy illness i.e. bronchitis, bronchiolitis, asthma
Virus
Parainfluenza Influenza Adenovirus Rhinovirus Enterovirus Herpes virus hominis Other viruses RS virus Total virus isolates
Infants (total 1036)0 56 12 22 23 9 4
2 648 776 (74.9%)
Children (total 524)E 31 20 24 21 7 15 2 87 207 (39.5%)
Upper respiratory infection, croup, pneumonia, febrile convulsions
Total
Infants (total 1189)
Infants (total 2225)
96 56 75 46 32 10 5 207 527 (44.3%)
Children (total 1608) 149 183 111 40 63 77
5 99 727 (45.2%)
152 68 97 69 41 14 7 855 1303 (58.6%)
Children (total 2132) 180 203 135 61 70 92 7 186 934 (43.8%)
* 46.6% of all infants * 24.6% of all children
Rooney & Williams (1971) reported that 56% of 62 infants who had suffered RS virus bronchiolitis wheezed recurrently, when followed up at the ages 2-7 years. Those from families with a positive history of asthma were most likely to wheeze again. A recent study of 35 children aged 8 years who had had RS virus bronchiolitis in infancy showed that the majority had wheezed again but that in many cases further wheezing was mild and had frequently stopped completely by 8 years. Only 2 patients still required regular antispasmodic therapy. A relationship between recurrent wheezing and an allergic history in the family was not apparent in this study (Sims et al. 1978). Studies on children with a past history of wheezing have shown that viral infections are associated with episodes of recurrent wheezing. Thus McIntosh et al. (1973) found that 42% of wheezing episodes in 32 hospitalized, asthmatic, mostly atopic children were associated with virus infections in winter. RS virus caused 25 infections (96% with wheezing), parainfluenza 39 infections (51% wheezing), coronaviruses 19 infections (68% wheezing), and influenza A 10 infections with no wheezing. Common respiratory bacteria were often found in the respiratory tract during and without symptoms and did not correlate with wheezing illness (McIntosh et al. 1973). Horn et al. (1975) found that rhinoviruses were often associated with episodes of wheezing in children in general practice. Minor and his colleagues (Minor, Baker et al. 1974, Minor, Dick et al. 1974) found that asthmatic children acquired more rhinovirus infections than their nonasthmatic siblings and that these viruses were more likely to precipitate asthma in this group of children. Mitchell et al. (1976), investigating 267 episodes of wheezing in children admitted to hospital throughout the year, found virus infection in 17.2%. Rhinoviruses, RS virus and adenoviruses were most commonly identified by these authors. After infancy paediatricians recognize that allergy, exercise and emotion play an increasing part in producing bronchospasm. However, viral infection occurs in a proportion of wheezy children. McIntosh (1976) has hypothesized that after the age of 1 year less and less wheezy episodes are due to infection; that RS virus becomes less important as a cause of wheezing beyond the age of 1 year, whereas rhinoviruses become increasingly important; and that the older the children are at the time of a virus infection triggering an attack of bronchospasm, the greater the percentage who will wheeze recurrently.
56
Journal of the Royal Society of Medicine Volume 72 January 1979
Treatment
Cough swabs and, if possible, sputum should be examined bacteriologically in all cases, but most attacks of acute wheezing in infancy and childhood do not require antibiotic treatment (Phelan & Stocks 1974). Sputum appearing purulent may be due, not to infection, but to large numbers of eosinophils (Altounyan 1970). Fever and a leukocytosis do not necessarily indicate infection in acute wheezing (Simpson 1973). Sinusitis, otitis media or bacterial tonsillitis occurring in a wheezy child merits treatment with antibiotics in its own right. Other indications for antibiotics include a chest X-ray with segmental areas of consolidation suggesting pneumonia, or lobar collapse. Subsegmental areas of collapse/consolidation on a chest X-ray are not necessarily indications for antibiotics (Simpson et al. 1974). For severe bronchospasm managed in hospital, many would use antibiotics as secondary bacterial infection usually cannot be excluded. However, pneumonitis has occurred in 12 of 24 childhood asthma deaths in spite of antibiotic therapy in 10 of them (Richards & Patrick 1965). Excessive sedation, inadequate rehydration and overdosage with aminophylline probably played a part in many of the deaths. These authors advised against the routine use of antibiotics in children with asthma and status asthmaticus. If antibiotics are to be used, a combination of methicillin and gentamicin below 1 year and ampicillin above that age seem suitable (Phelan & Stocks 1974). Prevention
Breast-feeding protects against RS virus infection in infancy (Downham et al. 1976). Measures to remedy overcrowding and high unemployment might reduce the risk of wheezing, at least in infancy (Sims et al. 1976), as might a reduction in the number of parents who smoke (Harlap & Davies 1974). Virus cross-infection in hospital exposes infants and young children to attacks of wheezing, and measures to try to reduce this risk have been suggested (Sims et al. 1975). References Altounyan R E C (1970) In: Disodium Cromoglycate in Allergic Airways Disease. Ed. J Pepys and A W Frankland. Butterworths, London; p 51 Downham M A P S, Scott R, Sims D G, Webb J K G & Gardner P S (1976) British Medical Journal ii, 274 Harlap S & Davies A M (1974) Lancet i, 529 Horn M E C, Brain E, Gregg l, Yealland S J & Inglis J M (1975) Journal of Hygiene 74, 157 McIntosh K (1976) Journal ofAllergy and Clinical Immunology 57, 595 McIntosh K, Ellis E F, Hoffman L S & Lybass T G (1973) Journal of Paediatrics 82, 578 Minor T E, Baker J W, Dick E C, DeMeo A N, Oueliette J J, Cohen M & Reed C E (1974) Journal of Paediatrics 85, 472 Minor T E, Dick E C, DeMeo A N, Ouellette J J, Cohen M & Reed C E (1974) Journal of the American Medical Association 227, 292 Mitchell I, Inglis H & Simpson H (1976) Archives of Disease in Childhood 51, 707 Phelan P D & Stocks J G (1974) Archives of Disease in Childhood 49, 143 Richards W & Patrick J R (1965) American Journal of Diseases in Children 110, 4 Rooney J C & Williams H E (1971) Journal of Paediatrics 79, 744 Simpson H (1973) In: Textbook of Paediatrics. Ed. J 0 Forfar and G C Arneil. Churchill Livingstone, Edinburgh & London; p 554 Simpson W, Hacking P M, Court S D M & Gardner P S (1974) Paediatric Radiology 2, 155 Sims D G, Downham M A P S, McQuillan J & Gardner P S (1976) British Medical Journal ii, 1095 Sims D G, Downham M A P S, Webb J K G, Gardner P S & Weightman D (1975) Acta paediatrica Scandinavica 64, 541 Sims D G, Downham M A P S, Gardner P S, Webb J K G & Weightman D (1978) British Medical Journal i, 11
Emotional considerations in wheezy children
Bryan Lask MPhil MRCPsych The Hospitalfor Sick Children, Great Ormond Street, London WCIN 3JH
Wheezy children suffer from a primary organic problem. Their wheezing is not caused psychologically, they are not necessarily psychologically disturbed, nor can psychiatrists cure 0 1 41-0768/79/010056-04/$O 1.00/0
,'.
1979 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 72 January 1979
totally eliminated. It is most important that common-sense prevails in matching the efforts at allergen elimination with the clinical benefits achieved. Hyposensitization has, in my clinical practice, very little place. I only regularly prescribe such injections for insect sting anaphylaxis where the results are excellent. Occasionally, pollen hyposensitization can benefit summer seasonal wheezing, but it can scarcely be looked upon as an ideal therapy. After a detailed study of mite hyposensitization (D'Souza et al. 1973), I am convinced that such treatment is clinically effective. However, the degree to which improvement occurs only rarely justifies the time, discomfort and risks of the treatment. More recently J 0 Warner (1977, personal communication) has confirmed that such injections are clinically effective, but he has emphasized that selection of patients should be by bronchial-challenge testing, which at present rules this therapy out of most routine clinical practice.
Summary Allergy must be seen as playing an important role in both predisposing children to wheeze and actually precipitating many attacks of asthma. The current specifically allergic treatments are, however, somewhat disappointing.
References Davis J B (1976) Clinical Allergy 6, 329-338 D'Souza M F & Davies R J (1977) American Review of Respiratory Diseases 115, 211 D'Souza M F, Pepys J, Wells I D, Tai E, Palmer F, Overell B G, McGrath I T & Megson M (1973) Clinical Allergy 3, 177-193 Forgacs P (1967) Lancet i, 203-205 Gell P G H & Coombs R R A (1968) Clinical Aspects of Immunology. 2nd edn. Blackwell, Oxford Goldberg N D, Haddox M K, Nicol S E, Sanford C H & Glass D B (1975) In: New Directions in Asthma. Ed. M Stein. American College of Chest Physicians, Illinois; p 103-124 Hendricks D J, Davies R J, D'Souza M F & Pepys J (1975) Thorax 30, 2-8 Ishizaka K, Ishizaka T & Hornbrook M M (1966) Journal ofImmunology 97, 840 Kimura I, Tanizaki Y, Takahashi K, Saito K, Ueda N & Sato S (1974) Clinical Allergy 4, 281-290
Parish W E (1970) Lancet ii, 591 Pepys J (1972) Proceedings of the Royal Society of Medicine 65, 271 Pepys J, Hargreaves F E, Chan M & McCarthy D S (1968) Lancet 2, 134 Porter R R (1959) Biochemical Journal 73, 119 Safirstein B H, D'Souza M F, Simon G, Tai E H & Pepys J (I1973) American Review of Respiratory Diseases 108, 450459
Szentivanyi A (1971) In: Immunological Diseaes. 2nd edn. Ed. M Samter et al. Little Brown, Boston; p 356-374 von Pirquet C (1906) Munchen Medizinische Wochenschrift 54, 1457 Warrell D A, Fawcett I W, Harrison B D W, Agamah A J, Ibu J O, Pope H M & Maberly D J (1975) Quarterly Journal of Medicine 174, 325-347
Infections in the wheezy child D G Sims MB MRCP1
Booth Hall Children's Hospital, Manchester M9 2AA
Viruses are the pathogens most commonly associated with wheezing in childhood. Table 1 shows viruses demonstrated by immunofluorescence or culture techniques in the respiratory tracts of 2225 infants and 2132 older children over a 5-year period to April 1974 in Newcastle upon Tyne. Respiratory syncytial (RS) virus was found in 83.5% of virus-positive infants who wheezed but in only 42% of older children. Of the infants with RS virus 75.8% wheezed, but only 46.8% of older children did so. Parainfluenza viruses were the next most common viruses found in wheezy infants and children. Influenza, like RS virus a winter pathogen, accounted for only 1.500 of those wheezy infants in whom a virus was demonstrated, and only 1 7.6% infected with influenza wheezed. The cause of the greatly increased relationship of wheezing with RS virus in infancy is unknown but McIntosh (1976) has recently reviewed current theories. 1
Present address: Oldham & District General Hospital, Oldham OLI 2JH
0 141-0768/79/010054-03/$01.00/0
,lr-"I 1979 The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 72 January 1979
55
Table 1. Viruses demonstrated in respiratory illnesses in infants and children over 12 months old in a consecutive 5-year period Wheezy illness i.e. bronchitis, bronchiolitis, asthma
Virus
Parainfluenza Influenza Adenovirus Rhinovirus Enterovirus Herpes virus hominis Other viruses RS virus Total virus isolates
Infants (total 1036)0 56 12 22 23 9 4
2 648 776 (74.9%)
Children (total 524)E 31 20 24 21 7 15 2 87 207 (39.5%)
Upper respiratory infection, croup, pneumonia, febrile convulsions
Total
Infants (total 1189)
Infants (total 2225)
96 56 75 46 32 10 5 207 527 (44.3%)
Children (total 1608) 149 183 111 40 63 77
5 99 727 (45.2%)
152 68 97 69 41 14 7 855 1303 (58.6%)
Children (total 2132) 180 203 135 61 70 92 7 186 934 (43.8%)
* 46.6% of all infants * 24.6% of all children
Rooney & Williams (1971) reported that 56% of 62 infants who had suffered RS virus bronchiolitis wheezed recurrently, when followed up at the ages 2-7 years. Those from families with a positive history of asthma were most likely to wheeze again. A recent study of 35 children aged 8 years who had had RS virus bronchiolitis in infancy showed that the majority had wheezed again but that in many cases further wheezing was mild and had frequently stopped completely by 8 years. Only 2 patients still required regular antispasmodic therapy. A relationship between recurrent wheezing and an allergic history in the family was not apparent in this study (Sims et al. 1978). Studies on children with a past history of wheezing have shown that viral infections are associated with episodes of recurrent wheezing. Thus McIntosh et al. (1973) found that 42% of wheezing episodes in 32 hospitalized, asthmatic, mostly atopic children were associated with virus infections in winter. RS virus caused 25 infections (96% with wheezing), parainfluenza 39 infections (51% wheezing), coronaviruses 19 infections (68% wheezing), and influenza A 10 infections with no wheezing. Common respiratory bacteria were often found in the respiratory tract during and without symptoms and did not correlate with wheezing illness (McIntosh et al. 1973). Horn et al. (1975) found that rhinoviruses were often associated with episodes of wheezing in children in general practice. Minor and his colleagues (Minor, Baker et al. 1974, Minor, Dick et al. 1974) found that asthmatic children acquired more rhinovirus infections than their nonasthmatic siblings and that these viruses were more likely to precipitate asthma in this group of children. Mitchell et al. (1976), investigating 267 episodes of wheezing in children admitted to hospital throughout the year, found virus infection in 17.2%. Rhinoviruses, RS virus and adenoviruses were most commonly identified by these authors. After infancy paediatricians recognize that allergy, exercise and emotion play an increasing part in producing bronchospasm. However, viral infection occurs in a proportion of wheezy children. McIntosh (1976) has hypothesized that after the age of 1 year less and less wheezy episodes are due to infection; that RS virus becomes less important as a cause of wheezing beyond the age of 1 year, whereas rhinoviruses become increasingly important; and that the older the children are at the time of a virus infection triggering an attack of bronchospasm, the greater the percentage who will wheeze recurrently.
56
Journal of the Royal Society of Medicine Volume 72 January 1979
Treatment
Cough swabs and, if possible, sputum should be examined bacteriologically in all cases, but most attacks of acute wheezing in infancy and childhood do not require antibiotic treatment (Phelan & Stocks 1974). Sputum appearing purulent may be due, not to infection, but to large numbers of eosinophils (Altounyan 1970). Fever and a leukocytosis do not necessarily indicate infection in acute wheezing (Simpson 1973). Sinusitis, otitis media or bacterial tonsillitis occurring in a wheezy child merits treatment with antibiotics in its own right. Other indications for antibiotics include a chest X-ray with segmental areas of consolidation suggesting pneumonia, or lobar collapse. Subsegmental areas of collapse/consolidation on a chest X-ray are not necessarily indications for antibiotics (Simpson et al. 1974). For severe bronchospasm managed in hospital, many would use antibiotics as secondary bacterial infection usually cannot be excluded. However, pneumonitis has occurred in 12 of 24 childhood asthma deaths in spite of antibiotic therapy in 10 of them (Richards & Patrick 1965). Excessive sedation, inadequate rehydration and overdosage with aminophylline probably played a part in many of the deaths. These authors advised against the routine use of antibiotics in children with asthma and status asthmaticus. If antibiotics are to be used, a combination of methicillin and gentamicin below 1 year and ampicillin above that age seem suitable (Phelan & Stocks 1974). Prevention
Breast-feeding protects against RS virus infection in infancy (Downham et al. 1976). Measures to remedy overcrowding and high unemployment might reduce the risk of wheezing, at least in infancy (Sims et al. 1976), as might a reduction in the number of parents who smoke (Harlap & Davies 1974). Virus cross-infection in hospital exposes infants and young children to attacks of wheezing, and measures to try to reduce this risk have been suggested (Sims et al. 1975). References Altounyan R E C (1970) In: Disodium Cromoglycate in Allergic Airways Disease. Ed. J Pepys and A W Frankland. Butterworths, London; p 51 Downham M A P S, Scott R, Sims D G, Webb J K G & Gardner P S (1976) British Medical Journal ii, 274 Harlap S & Davies A M (1974) Lancet i, 529 Horn M E C, Brain E, Gregg l, Yealland S J & Inglis J M (1975) Journal of Hygiene 74, 157 McIntosh K (1976) Journal ofAllergy and Clinical Immunology 57, 595 McIntosh K, Ellis E F, Hoffman L S & Lybass T G (1973) Journal of Paediatrics 82, 578 Minor T E, Baker J W, Dick E C, DeMeo A N, Oueliette J J, Cohen M & Reed C E (1974) Journal of Paediatrics 85, 472 Minor T E, Dick E C, DeMeo A N, Ouellette J J, Cohen M & Reed C E (1974) Journal of the American Medical Association 227, 292 Mitchell I, Inglis H & Simpson H (1976) Archives of Disease in Childhood 51, 707 Phelan P D & Stocks J G (1974) Archives of Disease in Childhood 49, 143 Richards W & Patrick J R (1965) American Journal of Diseases in Children 110, 4 Rooney J C & Williams H E (1971) Journal of Paediatrics 79, 744 Simpson H (1973) In: Textbook of Paediatrics. Ed. J 0 Forfar and G C Arneil. Churchill Livingstone, Edinburgh & London; p 554 Simpson W, Hacking P M, Court S D M & Gardner P S (1974) Paediatric Radiology 2, 155 Sims D G, Downham M A P S, McQuillan J & Gardner P S (1976) British Medical Journal ii, 1095 Sims D G, Downham M A P S, Webb J K G, Gardner P S & Weightman D (1975) Acta paediatrica Scandinavica 64, 541 Sims D G, Downham M A P S, Gardner P S, Webb J K G & Weightman D (1978) British Medical Journal i, 11
Emotional considerations in wheezy children
Bryan Lask MPhil MRCPsych The Hospitalfor Sick Children, Great Ormond Street, London WCIN 3JH
Wheezy children suffer from a primary organic problem. Their wheezing is not caused psychologically, they are not necessarily psychologically disturbed, nor can psychiatrists cure 0 1 41-0768/79/010056-04/$O 1.00/0
,'.
1979 The Royal Society of Medicine
