Chronic Bronchitis in Childhood: What Is It?

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VOLUME 67 . JANUARY 1981 #{149}NUMBER 1

Pediatrics

Chronic

Bronchitis

in Childhood:

What

Is It?

Lynn M. Taussig, MD, Sandra M. Smith, MD,

and Ronald Blumenfeld, MD

From the Pediatric Pulmonary Section, Department of Pediatrics, Division of Respiratory Sciences, Arizona Health Sciences Center and Group Health Medical Associates, Tucson

ABSTRACT. According to national statistics, over 2.5 million children have chronic bronchitis (CB). The char-acteristics of childhood CB and the similarities to the adult form are unknown. To determine the conditions under which childhood CB is diagnosed and to evaluate how it is treated, questionnaires were sent to 103 pedia-tricians and family physicians in Tucson. Forty-five

per-cent responded. A chronic productive cough lasting at

least three months a year was important for the diagnosis of CB for only 55% of pediatricians and 74% of family physicians. Recurrent episodes of cough lasting more than two weeks were important for the diagnosis of CB for 86% pediatricians. Sputum production was important for the diagnosis for about 50% of physicians, whereas wheezing was considered an important diagnostic crite-non for nearly 60% of physicians. Most physicians felt that allergies were a common cause of childhood CB and bronchodilators were commonly used to treat CB. The results of this survey suggest that: (1) the diagnosis of CB in childhood is not often based on the usual epidemiologic criteria used for diagnosing CB in adults; and (2) CB in childhood may have considerable overlap with asthma with respect to etiology, pathophysiology, and treatment. In fact, for many children, there appear to be few ways to

distinguish asthma from CB. Pediatrics 67:1-5, 1981;

bronchitis, chronic bronchitis, cough, wheeze, asthma.

consecutive years in patients with no other obvious underlying disease. According to national statistics,2

more than 2.5 million children in the United States

supposedly have CB. Considering the high

preva-lence rate for this disease, it is astonishing that there are almost no publications on clinical char-acteristics, etiologic factors, treatment, or prognosis

of CB in childhood. In fact, major pediatric

text-books3’4 and pediatric pulmonary references5’6 make

little or no mention of CB. The characteristics of childhood chronic bronchitis and the similarities to

the adult form are unknown. A recent epidemiologic

study7 suggests that childhood CB is considerably

different from CB observed or diagnosed in adults, in that the pediatric form may not be associated with a chronic productive cough lasting at least

three months a year. One clinical study8 indicated that CB with prolonged chronic productive cough is actually rare in children. The present study was done to determine the criteria by which

pediatri-cians and family physicians in Tucson diagnose CB

in children, and to examine their concepts of

etiol-ogy and treatment of this disorder.

Chronic bronchitis (CB) has been defined,’ for

epidemiologic purposes, as chronic productive

cough occurring for three months a year for two

Received for publication April 14, 1980; accepted July 6, 1980.

Reprint requests to (L.M.T.) Department of Pediatrics, Arizona

Health Sciences Center, Tucson, AZ 85724.

American Academy of Pediatrics.

MATERIALS AND METHODS

A questionnaire, devised by the investigators, was divided into three components: diagnosis, etiology, and treatment. The questionnaire was sent to all

pediatricians (PED), family physicians, and general practice physicians in the Tucson telephone

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2 CHRONIC BRONCHITIS IN CHILDHOOD

grouped into the category of “Family Physician” (FP). Physicians were asked to answer the ques-tions as they applied to the children for whom they cared. Only questionnaires from physicians in-volved in some form of primary care of children were analyzed; for example, questionnaires from

neonatologists were not examined. Questionnaires

were returned anonymously, and the respondents were identified only by specialty and other demo-graphic information.

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analyses were used to compare the answers of the PED and FP.

RESULTS

Questionnaires

were sent to 52 PED and were returned by 27 (52%). Fifty-one questionnaires were

sent to FP and 19 (37%) were returned. The total

response was 45%. Every question was not

neces-sarily answered by each physician. For purposes of data analysis, the denominator used for each ques-tion evaluated was the total number of respondents (for PED and FP separately) for the particular questions. This denominator ranged from 21 to 24 for PED and 17 to 19 for FP.

Diagnosis

The survey indicated that a diagnosis of chronic

bronchitis is rarely made by PED in children in

Tucson (Table 1). Over one quarter of PED never

made this diagnosis, and the remaining 72% do so infrequently. Among FP, 73% make the diagnosis

less than one time per week. The frequency with

which the diagnosis of CB was made differed

sig-nificantly in the two groups of physicians (P = .01).

FP and PED demonstrated considerable discord-ance with respect to diagnostic criteria for chronic

bronchitis. The majority of PED (86%) considered

recurrent episodes of cough (lasting longer than two weeks) as essential for the diagnosis of CB, while only 53% of FP considered this finding important for diagnosis (P = .02). Conversely, 73.7% of FP

considered cough occurring for longer than three months per year as an essential diagnostic criterion,

whereas only 54.5% of PED used this criterion for diagnosis; however, this difference was not signifi-cantly different. Sputum production was essential for the diagnosis for only 46% of PED and 58% of

FP.

Nearly half of PED occasionally made the

diag-nosis of CB on purely historical grounds while 48%

would never do so. For FP, 39% indicated that they usually make the diagnosis on historical grounds alone, with 50% doing so occasionally, and 11%

never doing so. These results were significantly

different for the two groups of physicians. Wheez-ing, diffuse rales, and tachypnea were important for

the diagnosis of CB for both groups of physicians. As shown in Table 1, both PED and FP frequently diagnosed CB in patients who were known to have asthma or allergies.

Eighty-three percent of the PED and 74% of FP indicated that they have not changed their criteria for diagnosing CB since beginning practice; 63% of the PED and 74% of FP had been in practice in excess of eight years.

Etiology

The majority of PED (91%) and FP (83%) felt that allergies were a common cause of CB in chil-then (Table 2). Only one third of PED thought bacteria were important in causing CB whereas 89% of the FP felt that bacteria were important (P =

.001). Viruses were considered common etiologic

agents by nearly two thirds of both groups of phy-sicians. Most physicians made a clinical distinction between “asthmatic bronchitis” and “infectious bronchitis.”

Treatment

Antibiotics, bronchodilators, and expectorants were the most commonly used drugs in the treat-ment of CB by both groups of physicians (Table 3). Antihistamines were less commonly used.

Expec-torants and antihistamines were more commonly used by FP in the treatment of CB. Two thirds of the PED and 63% of FP indicated that they have not changed their treatment of CB since they began practicing medicine.

DISCUSSION

The results from this small survey indicate that the diagnosis of CB is rarely made in children, either by PED or FP. This raises questions as to the significance and meaning of the national

statis-tics2 which indicate that over 2.5 million children

have CB. (A more recent unpublished survey in

1978 indicated that the prevalence figures for child-hood CB had not changed appreciably [National Health Interview Survey, National Center for Health Statistics, Department of Health and Hu-man Services], personal communication.) These

statistics were derived from family interviews and,

thus, may indicate that parents call any cough CB, no matter what the duration or whether associated with sputum. The present study also indicates that the accepted epidemiologic criteria’ for the diag-nosis of CB are frequently not adhered to by the majority of PED and FP in diagnosing CB in child-hood. Recurrent episodes of cough lasting less than three months are often considered important crite-na for the diagnosis of chronic bronchitis. Most

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TABLE 1. Physicians’ Considerations in Diagnosing Chronic Bronchitis in Childhood*

PED (%) FP (%) P Valuet

.01

NS

* Abbreviations used are: PED, pediatricians; FP, family physicians and general practitioners (including osteopaths);

CB, chronic bronchitis; URI, upper respiratory infection.

t x2

analysis

:1:For questions 1 and 2, percentages reflect positive responses.

§Physical findings were rated not important/important/very important; thus, three values are given.

physicians surveyed did not think that sputum pro- groups of physicians, especially with respect to cri-duction was essential for the diagnosis. Wheezing teria for diagnosis, and the role of bacteria in caus-and diffuse rales were common criteria for diagnosis ing the symptoms of CB. These findings suggest and both groups of physicians indicated that they that FP may apply criteria to children similar to would not hesitate in making the diagnosis in those used for diagnosing CB in their adult patients.

known asthmatic or allergic subjects. There were The results from this survey also suggest that the

some interesting differences between the two approach to treatment is at times inconsistent with

1. How often do you make the diagnosis

of CB? a. Never b. <Once/wk

C. 1-5/wk d. >5/wk

2. Which of the following need to be

present for you to make a diagnosis of

CB?

a. Cough on most days for >2 wk b. Cough on most days for >1 mo

C. Cough present on most days >3

mo/yr

d. Recurrent epidoses of prolonged (>2 wks) cough

e. Cough occurring without an URI f. Sputum production

3. Would you make a diagnosis of CB purely on history if the physical and laboratory fmdings were normal? a. Always

b. Usually c. Occasionally d. Never

4. How important are the following

phys-ical findings in making the diagnosis of

CB?

a. Diffuse rales b. Low-grade fever c. Tachypnea

d. Wheezing

5. Do you make the diagnosis of CB if wheezing is present with the coughing?

a. Always b. Usually c. Occasionally d. Never

6. Do you make the diagnosis of CB in a

known asthmatic? a. Always b. Usually

c. Occasionally d. Never

7. Do you make the diagnosis of CB in a

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4 CHRONIC BRONCHITIS IN CHILDHOOD

TABLE 2. Physicians’ Perceptions of Etiologic Factors in Chronic Bronchitis in

Childhood*

PED FP

Rare Common Rare Common

(%) (%) (%) (%)

P Valuet

1. How would you rate the following in terms of their frequency as etiologic

factors of CB?

a. Allergy 9.5 90.5 16.7 83.3 NS

b. Bacterial infections 65.2 34.8 11.1 88.9 .001

c. Viral infections 38.1 61.9 33.3 66.7 NS

d. Mycoplasma infections 71.4 28.6 66.7 33.3 NS

2. Do you make a clinical distinction between asthmatic bronchitis and

in-fectious bronchitis?

a. Always 8.3 26.3

b. Usually 70.8 52.6

c. Occasionally 12.5 21.1 NS

d. Never 8.3 0

* Abbreviations as in Table 1.

t x2

analysis.

TABLE 3. Physicians’ Treatment of Chronic Bronchitis in Childhood*

PED (%) FP (%) P Valuet

1. How often do you treat CB with antibiotics?

a. Always 4.2 16.7

d. Never 8.3 5.6

2. How often do you use bronchodilators to treat CB?

a. Always 9.1 26.3

c. Occasionally 50.0 36.8

NS

d. Never 0 0

3. How often do you use expectorants to treat CB?

a. Always 9.1 26.3

d. Never 0 0

4. How often do you use antihistamines to treat CB?

a. Always 0 11.1

b. Usually 4.8 5.6

d. Never 38.1 33.3

* Abbreviations as in Table 1.

t x2

analysis.

the expected etiologies. Although 89% of FP felt bacterial infections were common etiologic agents for CB, only 44.5% reported that they always or

usually treated with antibiotics.

This survey admittedly samples the opinions of a relatively small group of physicians in a limited

geographic area. However, since the medical school

in Tucson is only 11 years old, most Tucson physi-cians trained elsewhere, and it is thus unlikely that their approach to chronic bronchitis is unique to this area. As noted above, pediatric literature offers little or no information regarding childhood CB, and there is no clear picture of the clinical manifes-tations, etiologic factors, diagnostic criteria, or

ap-propriate treatment. Given this dearth of facts, it is not surprising that the survey reflects inconsisten-cies among practicing physicians regarding their understanding of this disease entity.

In 1975, Burrows and Lebowitz7 reported the results of their epidemiologic survey of CB in a large population of children residing in Tucson. They found that, in children with a physician

di-agnosis of CB, only one third had chronic cough, and only 15% had chronic sputum production. Also, wheezing was frequently found (74%) in children with a diagnosis of CB. A diagnosis of asthma was present in one third of their subjects and was most prevalent in those children who also had the

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nosis of CB. The children and/or parents were the sources of information in this study, and this may account for some of the discrepancies between their

results and ours (eg, data from our survey would lead one to expect a higher frequency of chronic cough and sputum production than was found in the study by Burrows and Lebowitz). However, their data support ours in two important ways: (1) both studies indicate that children with a diagnosis of chronic bronchitis often do not meet epidemio-logic criteria for this diagnosis; and (2) both studies

suggest that many children simultaneously carry

the diagnoses of CB and asthma. Hamman et al

also found that young children commonly devel-oped bronchitis and asthma during the same year, that the two entities commonly coexisted, and that the risk of developing bronchitis following asthma was considerably higher than the risk of asthma developing after bronchitis. They suggested, in fact,

that “the clinical presentation of either [could be]

merely a different manifestation ofthe same process rather than an entirely separate disease.”

Recent studies by McFadden’#{176} and Corrao et al” in adults and by Cloutier and Loughlin’2 in children have shown that chronic cough may be the primary

or sole manifestation of bronchial asthma. These

studies suggest that cough alone may not be

corn-patible with the diagnosis of chronic bronchitis in a certain group ofpatients. In children, where smok-ing is less common, a chronic cough may be more indicative of reactive airway disease than of a chronic inflammatory process of the tracheobron-chial tree. Therefore, chronic bronchitis in child-hood may have considerable overlap with asthma in etiology and treatment. Certainly, many of the

symptoms which influence the diagnosis of CB have been shown to be related to allergy skin test reac-tivity.’3

The results of this study, as well as those of

Burrows and Lebowitz7 and Hamman et al,9 suggest

that the definition of CB in childhood may need to

be redefined. According to the results ofthis survey, chronic bronchitis (as usually defined) is not a diagnosis commonly made by physicians caring for children. Using the epidemiologic definition for

CB,’ it would appear that during childhood, this is indeed an unusual disease. Considering the

magni-tude of the problem of chronic obstructive lung

disease in adults and the apparent relationships between pediatric respiratory ifinesses and chronic

lung disease in adults,’4’6 it is unfortunate that no indepth studies exist of the clinical, allergic, im-munologic, and physiologic characteristics of chil-dren with chronic cough.

The validity of separating diagnoses such as asthma and chronic bronchitis in childhood is open to question and the overlap between these two entities appears to be extensive. The different fac-tors underlying the development of childhood

chronic bronchitis and asthma and the different prognosis for each need to be carefully compared to

determine the unique characteristics of each

dis-ease.

ACKNOWLEDGMENTS

This work was supported in part by National Heart,

Lung, and Blood Institute Grant (Specialized Center of

Research) No. 14136.

The authors thank Adele Goodberry for secretarial

assistance and Maryann Matuska for editorial assistance.

REFERENCES

1. Committee on Diagnostic Standards for Non-Tuberculous Respiratory Diseases, American Thoracic Society: Defmi-tions and classification of chronic bronchitis, asthma, and pulmonary emphysema. Am Rev Respir Dis 85:762, 1962 2. Wilder CS: Prevalence of Selected Chronic Respiratory

Conditions, Vital and Health Statistics Series 10, No. 84. Rockville, MD, US Department of Health, Education and Welfare, 1970

3. Stern RC: Chronic bronchitis, in Vaughan VC III, McKay RI Jr, Behrman RE (eds): Nelson Textbook of Pediatrics,

ed 11. Philadelphia, WB Saunders Co, 1979, pp 1202-1203 4. Rudolph AM (ed): Pediatrics, ed 16. New York,

Appleton-Century-Crofts, 1977

5. Turner JAP: Bronchitis, in Kendig EL Jr (ed): Disorders of the Respiratory Tract in Children, ed 3. Philadelphia, WB Saunders Co, 1977

6. Williams HE, Phelan PD: Respiratory Illness in Children.

London, Blackwell Scientific Publications, 1975, pp 69-79 7. Burrows B, Lebowitz MD: Characteristics of chronic

bron-chitis in a warm, dry region. Am Rev Respir Dis 112:365, 1975

8. Kubo S, Funabashi S, Uehara S, et al: Clinical aspects of “asthmatic bronchitis” and chronic bronchitis in infants and children. J Asthma Res 15:99, 1978

9. Hamman RF, Haul T, Holland WW: Asthma in schoolchil-dren. Br J Prey Soc Med 29:228, 1975

10. McFadden ER Jr: Exertional dyspnea and cough as preludes

to acute attacks ofbronchial asthma. N Engi JMed 292:555, 1975

11. Corrao WM, Braman SS, Irwin RS: Chronic cough as the

sole presenting manifestation of bronchial asthma. N Engi

JMed300:633, 1979

12. Cloutier MM, Loughlin GM: Chronic cough in children: A manifestation of airway hyperreactivity. Pediatrics 67:6, 1981

13. Burrows B, LebOWitZ MD, Barbee HA: Respiratory disorders and allergy skin-test reactions. Ann Intern Med 84:134, 1976 14. Taussig LM: Clinical and physiologic evidence for the

per-sistence of pulmonary abnormalities after respiratory illness

in infancy and childhood. Pediatr Res 11:216, 1977

15. Colley JRT, Douglas JWB, Reid DD: Respiratory disease in young adults: Influence of early childhood lower respiratory tract illness, social class, air pollution, and smoking. Br Med

J3:195, 1973

16. Burrows B, Knudson RJ, LebOWitZ MD: The relationship of

childhood respiratory illness to adult obstructive airway

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1981;67;1

Pediatrics

Lynn M. Taussig, Sandra M. Smith and Ronald Blumenfeld