VOLUME 87 FEBRUARY

#{149} 1991 e NUMBER 2

Pediatrics
Upper Respiratory Tract Infections in Young
Children: Duration of and Frequency of
Complications

Ellen R. Wald, MD; Nancy Guerra, CRNP; and Carol Byers, CRNP

From the Department of Pediatrics, University of Pittsburgh School of Medicine and

Children s Hospital of Pittsburgh, Pennsylvania

ABSTRACT. This study was performed to determine the The major events predisposing to the develop-
usual duration of community-acquired viral upper respi-
ment of acute bacterial sinusitis are viral upper
ratory tract infections and the incidence of complications
(otitis media/sinusitis) of these respiratory tract infec-
respiratory tract infection (URI) and allergic in-
tions in infancy and early childhood. Children in various flammation. The frequency with which viral URI
forms of child-care arrangements (home care, group care, in childhood is complicated by secondary bacterial
and day care) were enrolled at birth and observed for 3 infections, either otitis media or sinusitis, has not
years. Families were telephoned every 2 weeks to record
been documented. Estimation of the frequency of
on a standardized form the type and severity of illnesses
experienced during the previous interval. Only children
bacterial sinusitis as a complication of URI (be-
remaining in their original child-care group for the entire tween 0.5% and 5%) has been hampered by the lack
study period were compared. The mean duration of an of a direct, noninvasive, and precise measure of
upper respiratory tract infection varied between 6.6 days infection of the paranasal sinuses.12 One suggested
(for 1- to 2-year-old children in home care) and 8.9 days
clinical marker of acute sinusitis in children 2 to
(for children younger than 1 year in day care). The
percentage of apparently simple upper respiratory tract
16 years of age is a history of respiratory symptoms
infections that lasted more than 15 days ranged from that have lasted more than 10 days and have not
6.5% (for 1- to 3-year-old children in home care) to 13.1% begun to improve.2 This marker has proved to be
(for 2- to 3-year-old children in day care). Children in clinically useful and is associated with significantly
day care were more likely than children in home care to
abnormal maxillary sinus radiographs in 88% of 2-
have protracted respiratory symptoms. Of 2741 respira-
tory tract infections recorded for the 3-year period, 801 to 6-year-old children.3 The combination of this
(29.2%) were complicated by otitis media. During the clinical marker and abnormal maxillary sinus ra-
first 2 years of life, children in any type of day care were diographs predicts the recovery of fluid from the
more likely than children in home care to have otitis maxillary sinus aspirate of all children and bacteria
media as a complication of upper respiratory tract infec-
in high density from 75%#{149}4This study was under-
tion. In year 3, the risk of otitis media was similar in all
taken to determine the usual duration of viral URIs
types of child care. Pediatrics 1991;87:129-133; upper
respiratory tract infection, sinusitis, otitis media, day care, acquired in the community and the incidence of
respiratory symptoms. complications of such respiratory tract infections
in infancy and early childhood.

METHODS
Received for publication Jan 8, 1990; accepted Feb 28, 1990.
In the context of a study designed to compare the
Reprint requests to (E.R.W.) Childrens Hospital of Pittsburgh,
3705 Fifth Aye, Pittsburgh, PA 15213.
frequency and severity of infections experienced by
PEDIATRICS (ISSN 0031 4005). Copyright : 1991 by the youngsters in different kinds of child care, we pro-
American Academy of Pediatrics. spectively observed a large cohort of children for a

PEDIATRICS Vol. 87 No. 2 February 1 991 129

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3-year period.5 Full-term infants born at the Magee the child no longer had symptoms and the activity
Womens Hospital from July 1, 1985, through April level was normal. An illness episode was counted
30, 1986, who resided in Allegheny County were as a new one when symptoms occurred at least 3
eligible for entry into the study. Subjects were days after the stated time of resolution of a previous
enrolled after informed consent was obtained, pro- episode. When an illness lasted more than 30 days
vided that their mothers had decided on a type of and extended into the next month it was counted
child care and were willing to maintain a daily as a new illness.
health calendar. Three types of care were described.
Home care was defined as care of one or more Statistical Methods
children from a single family in a residential setting.
Group care was defined as care of a child and at Only children who remained in their original
least one other nonfamily member in a group of child-care group for an entire year were evaluated
two to six children for at least 20 hours per week in each years analysis. The youngsters within each
in a residential setting. Day care was defined as child-care arrangement were compared with respect
care of a child in a group of at least seven children, to the duration of simple URIs and the frequency
for at least 20 hours per week, in a nonresidential of complication of URI by otitis media and pro-
setting. longed respiratory symptoms. These comparisons
Children were excluded if they had a congenital were assessed by the x2 statistic.
condition known to predispose to increased sucep-
tibility to infectious illnesses, such as sickle cell RESULTS
anemia, congenital heart disease, or cystic fibrosis.
Families without a telephone or access to a tele- Children were followed up for 30 to 36 months.
phone were not recruited for the study. The source of medical care and assessment was a
private pediatrician for 99% ofthe enrolled children
Study Design (100% of children in group and day care, 97% of
children in home care). The groups were compa-
Each participating family was telephoned every
rable for sex, race, number of siblings, and family
2 weeks by a nurse practitioner. A standardized
history of allergy at entry and at the 1-year follow-
questionnaire was used to collect systematically
up. There was a slightly higher socioeconomic sta-
information about illnesses experienced during the
tus among the mothers of children in group and
previous 2 weeks. Each illness was characterized as
day care (Table i). At entry, there were 159 chil-
to type and severity.
dren in home care, 40 in group care, and 45 in day
care. The overall attrition rate in the first year was
Definitions
12.3% and was almost entirely a result of relocation
An illness was defined as the reported occurrence to other geographic areas. Ninety-one children
of one or more symptoms lasting for more than 1 crossed over from one child-care setting to another
day. Symptoms lasting 1 day or less were not during the first year. One hundred fifty-three re-
counted. mained in the same child-care arrangement
A simple URI was defined as the presence of throughout the first year: 97 were in home care, 23
nasal discharge or nasal congestion with or without in group care, and 33 in day care. In year 2, there
cough. A complicated URI was defined as a simple were 86 children in home care, 18 in group care,
URI accompanied by otitis media or sinusitis re- and 26 in day care. In year 3, there were 77 children
portedly confirmed by a physician. in home care, 11 in group care, and 21 in day care.
An illness was considered to have resolved when The duration and complications of URIs were as-

TABLE 1. De mographic Characteristics at Entry and at 1-Year Followup*

Characteristic Home Care Group Care Da y Care

Entry (n = 159) Follow-up (n = 97) Entry (n = 40) Follow-up (n = 23) Entry (n = 45) Follow-up (n = 33)

Sex (female) 55 55 50 53 56 58
Race (white) 87 92 88 83 89 94
0 Siblings 66 66 73 78 60 58
1+ Siblings 27 28 25 22 29 30
Allergy (yes) 38 43 47 44 36 38
SES (3/4/5) 27/31/42 26/31/43 20/25/55 21/17/61 13/39/58 9/30/61
* Results are given as percentages. SES, socioeconomic status; 3 = completed high school, 4 = some college, and 5 =

baccalaureate degree or higher.

130 UPPER RESPIRATORY TRACT INFECTIONS

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TABLE 2. Prolonged Upper Respirato ry Tract Infec- shows that the likelihood that a respiratory tract
tions (URIs ) According to Age and Type of Child Care*
infection was complicated by otitis media varied
Age, y Home Care Group Care Day Care according to the age of the child and type of child
<1 16.8/8.4 20.5/9.8 29.2/11.2 care. For children younger than 1 year of age, those
1-2 13.4/6.5 21.5/10.8 17.9/10.6 in day care were significantly more likely than those
2-3 14.9/6.5 18.3/11.3 19.0/13.1
in home care to have otitis media as a complication
*_ Results are given as percentage of uncomplicated URIs of URI (P < .001). In the second year of life,
lasting at least 10 days/percentage of uncomplicated children in group care were more likely than chil-
URIs lasting at least 15 days.
dren in home care (P = .001) or in day care (P =
.013) to experience otitis media as a complication
of their URI. In year 3, the risk of otitis media as
an event complicating URI was similar in all types
sessed for children who stayed within a particular
of child care.
day-care arrangement for the duration of the study.
Overall there were 1940 respiratory infections for
which medical care was not sought or for which
antimicrobials were not prescribed when the child
visited the physician (simple URIs). Table 2 shows 2O

the percentages of apparently simple URIs that

lasted at least 10 days and those that lasted at least
15
15 days. In each age group, children in home care
with simple URI recovered more quickly than chil-
dren in day care. Nearly twice as many children in % Children HC
1o
day care compared with those in home care expe-
rienced upper respiratory symptoms for more than
15 days in the second and third years of life (P < 5

.01). By day 15, between 6.5% (1- to 3-year-old

children in home care) and 13.1% (3-year-old chil-
dren in day care) of children still had symptoms of
20
URI. Assuming that most children with a URI who
were still symptomatic but improving at 10 days
had completely recovered by day 15, the number of 15
children with symptoms beyond 15 days may be
used as an approximation of the number of children
experiencing acute sinusitis.
The Figure shows the distribution of the duration
of a simple URI for children younger than age 1
year in home care, group care, and day care. Most
children in home care in this age group had simple
URIs that lasted less than 8 days. The mean dura- . It
tion of a simple URI in year 1 for children in home
care was 7.3 days; adding two standard deviations
to the mean (placing an upper bound) and consid-
15
ering this duration of prolonged respiratory symp-
toms
sinusitis.
tion,
as

and
defining
Table
percentage
3 shows
sinusitis,
the
of subjects
5.2%
mean,
of children
standard
with duration
had
devia-
of
% Children DC
10
hhhi1bh1u1!1_1t
URI longer than the mean plus two standard devia-
tions. The percentage of children with prolonged 5
respiratory symptoms ranged from 4.6% to 5.0%
for children in home care and 4.0% to 7.3% for
children in other day-care arrangements.
There were 2741 respiratory tract infections re- Days
corded for the 3-year period for the children who
Figure. Bar graph showing the duration of simple upper
remained in a particular child-care arrangement. respiratory tract infections in children younger than 1
Overall, 801 (29.2%) of these infections were re- year of age, according to the type of child care. HC, home
ported to be complicated by otitis media. Table 4 care; GC, group care; DC, day-care center.

ARTICLES 131
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 TABLE 3. Mean and Standard Deviation of Duration of an Upper Respiratory Tract
Infection for Children of Various Ages in Different Types of Child Care*
Type of Age, y Mean, d SD, d Mean + 2 SD, d % Duration>
Care Mean + 2 SD

HC <1 7.33 5.54 18.4 5.2

HC 1-2 6.63 5.13 16.9 4.6
HC 2-3 6.79 4.96 16.7 5.0
GC <1 8.32 6.19 20.7 6.4
GC 1-2 7.98 6.67 21.3 6.0
GC 2-3 7.20 5.84 18.9 5.6
DC <1 8.87 6.72 22.3 7.3
DC 1-2 7.29 6.54 20.4 5.5
DC 2-3 7.82 6.40 20.6 4.0
* BC, home care; GC, group care; DC, day care.

TABLE 4. Percentage of Respiratory Tract Infections to note the day on which symptoms began to im-
Complicated by Otitis Media According to Age and Type prove. To estimate the number of children with
of Child Care
sinusitis, we assumed that most children with a
Age, y Home Care Group Care Day Care
URI who were still symptomatic but improving at
<1 27.4 34.6 43.1* 10 days had completely recovered by day 15. There-
1-2 23.6 39.6t 27.2
fore, the number of children with respiratory symp-
2-3 23.2 29.0 30.6
toms beyond 15 days is an approximation of the
* For year 1, P < .001 for children in day care compared
number of children who may be experiencing acute
with children in home care.
sinusitis. Six percent to 13% of infants and pre-
t For year 2, P < .001 for children in group care compared
with children in home care; P .013 for children =
in group schoolers in various child-care settings had symp-
care compared with children in day care. toms lasting more than 15 days. Nearly twice as
many children in day care compared with those in
home care experienced protracted respiratory
symptoms in the second and third years of life.
DISCUSSION
Children in day care are subject to more frequent
The frequency of respiratory illnesses in the first and more severe respiratory illnesses in the first
few years of life has received ample study. However, year of life than children in home care.5 This same
less attention has been paid to the duration of trend probably continues in the second and third
symptoms and rate of complications experienced years of life. An inflamed respiratory mucosa may
by the URI sufferer. recover incompletely between episodes of infection,
There are several potential strategies for deter- thereby leading to recurrent and persistent symp-
mining the duration of a URI in previously well toms.
children. Cases of URI can be identified in the An alternate way to estimate the frequency of
course of acute care visits to private offices or sinusitis as a complication of URI is to calculate
clinics. History of duration of symptoms plus pro- the percentage of children experiencing symptoms
spective follow-up will provide the necessary infor- beyond two standard deviations from the mean
mation; however, sick care visits involve a selection duration of respiratory symptoms. This figure var-
process in which parents deem the illness to be ied between 4.0% and 7.3% for all children and was
sufficiently severe or complicated to require medical highest for day-care children in their first year of
assessment. Accordingly, this strategy may not life. The two methods used to estimate the fre-
identify milder illnesses for which medical atten- quency of sinusitis as a complication of URI provide
tion is not sought. An alternative method involves similar ranges.
closely spaced, longitudinal evaluations of a previ- Otitis media is recognized as a frequent compli-
ously selected cohort of children, to ascertain (by cation of simple URI. In this study, 20% to 40% of
parental report) the frequency, duration, and sever- URIs were complicated by otitis media, depending
ity of illness. Unfortunately, this latter method does on the age and source of child care. These data
not always permit verification of illness by a phy- confirm the observations of others that children in
sician or standardization of diagnostic criteria used day care experience otitis more often than children
by physicians. in home care.69 Viral URI is the major risk factor
In this study, parental reports concerning the for Eustachian tube dysfunction leading to otitis
duration of respiratory illnesses were obtained media.1#{176}Inflammatory changes of the respiratory
every 2 weeks. Unfortunately, no attempt was made mucosa experienced early during the first year may

132 UPPER RESPIRATORY TRACT INFECTIONS

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predispose to recurrent and persistent middle ear tassium in acute paranasal sinus infections in children: a
double-blind, placebo-controlled trial. Pediatrics.
effusions.2
1986;77:795-800
Numerous studies have shown that prophylactic 4. Wald ER, Milmoe GJ, Bowen AD, Ledesma-Medina J,
antibiotics are ineffective in altering the natural Salomon N, Bluestone CD. Acute maxillary sinusitis in
children. N EngI J Med. 1981;304:749-754
history of viral URIs in children without a past
5. Wald ER, Dashefsky Guerra
B, Byers C,
N, Taylor F.
history of recurrent respiratory illness.13 Nonethe- Frequency and severity of infections in day care. J Pediatr.
less, this study highlights the observation that otitis 1988;112:540-546
media and sinusitis often complicate viral URIs in 6. Strangert K. Otitis media in young children in different
types of day care. Scand J Infect Dis. 1977;9:119-123
infants and young children. The frequency of these 7. Pukander J, Sipila M, Karma P. Occurrence of and risk
complications may require the practitioner to re- factors in acute otitis media. In: Lim DJ, Bluestone DC,
evaluate children examined early in the course of Klein JO, Nelson JD, eds. Recent Advances in Otitis Media
With Effusion. Philadelphia, PA: BC Decker; 1984:9-13
their URI or call for examination those whose res- 8. Visscher W, Mandel JS, Batalden PB, Russ JN, Giebink
piratory symptoms become protracted. GS. A case-control study exploring possible risk factors for
childhood otitis media. In: Lim DJ, Bluestone DC, Klein
JO, Nelson JD, eds. Recent Advances in Otitis Media With
Effusion. Philadelphia, PA: BC Decker; 1984:13-15
9. Ingvarsson L, Lundgren K, Olofsson B. Epidemiology of
ACKNOWLEDGMENTS
acute otitis media in children: a cohort study in an urban
We gratefully acknowledge Diane Cline for secretarial population. In: Lim DJ, Bluestone DC, Klein JO, Nelson
assistance and Dr Barry Dashefsky for review of the JD, eds. Recent Advances in Otitis Media With Effusion.
Philadelphia, PA: BC Decker; 1984:19-22
manuscript.
10. Henderson FW, Giebink GS. Otitis media among children
in day care: epidemiology and pathogenesis. Rev Infect Dis.
1986;8:533-538
11. Howie VM, Ploussard JH, Sloyer J. The otitis-prone con-
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SETTING FEES BY GETTING INSIDE DOCTORS HEADS

As increases in doctors fees outpace increases in hospital charges, insurers

and employers are focusing more of their cost-cutting efforts on physician
reimbursement.
A fee schedule developed by Medirisk, a health-care consulting firm in
Norcross, Ga., indicates companies may be able to save as much as 7% on
physician charges by using information on what doctors are willing to accept to
negotiate lower fees.
The Medirisk fee schedule stems from the companys survey of 100 health-
maintenance organizations and preferred-provider organizations in 32 states
with about 120,000 physicians under contract. The managed-care plans were
asked what fees they were willing to accept for 100 procedures, from an office
visit to a coronary bypass. The data show, for instance, that in a single market,
some physicians were willing to accept $3,600 for a particular knee operation,
while others were willing to take only $1,200.

Ruffenach G. Setting fees by getting inside doctors heads. The Wall Street Journal. January 2,
1990. Health Costs.

ARTICLES 133
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Upper Respiratory Tract Infections in Young Children: Duration of and Frequency of
Complications
Ellen R. Wald, Nancy Guerra and Carol Byers
Pediatrics 1991;87;129

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since . Pediatrics is owned, published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright
1991 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .

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Upper Respiratory Tract Infections in Young Children: Duration of and Frequency of
Complications
Ellen R. Wald, Nancy Guerra and Carol Byers
Pediatrics 1991;87;129

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pediatrics.aappublications.org/content/87/2/129

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has
been published continuously since . Pediatrics is owned, published, and trademarked by the American
Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright
1991 by the American Academy of Pediatrics. All rights reserved. Print ISSN: .

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