Open Journal of Pediatrics, 2012, 2, 244-249 OJPed Published Online September 2012 (
Upper respiratory tract infections in children: A normal
stage or high parental concern?
Ellen J. Van Der Gaag, Nicole Van Droffelaar
Department of Pediatrics, Hospital Group Twente, Hengelo, The Netherlands
Received 8 March 2012; revised 19 April 2012; accepted 18 June 2012
Background: Families function less efficiently when
one of the children suffers from illness. Upper respi-
ratory tract infections (URTI) are common among
children. Though the child may have no critical or
serious health problem, the parents may frequently
get worried and visit the general practitioner or pe-
diatrician. Do children with URTI who visit the doc-
tor frequently pass through a normal stage in child-
hood or are their parents more concerned than usual?
Methods: A questionnaire was filled out for 76 chil-
dren between 1 and 4 years of age. Two groups were
created: a URTI group and a control group. Results:
The URTI group suffered from these infections for
19.4 days a month, compared with 5.9 days in the
control group. In addition, they also suffered from
feve r for a longe r durat ion and u sed more antibio tics.
The parents of these children were found to be more
concerned, caused by a fear of a serious disease. They
often keep their child at home and make their child
consume more medicines. Conclusions: Parents of
children with recurrent infections are found to be
more concerned and a hypothesis of high parental
concern and child’s illness is discussed. Minimizing
parental concern can therefore be a possible preven-
tive treatment.
Keywords: R ecurrent Infecti ons; Children; Concern;
Family Functioning
Children with recurren t illnesses are of great concern for
parents and influence their family interactions. When
children are ill, da ily routines are changed and the parent
usually adjusts to the need of the child. When the child
suffers from recurrent infections, daily routines and
family functioning can be disturbed for long periods of
time. What can be done when there is no cure for these
recurrent infections?
General pediatricians often come across parents who
mention that their child has upper respiratory tract
infections. The children may have no critical or serious
health problem, but may not be doing well. During the
in-between days they may be relatively normal but the
subsequent infectious episode may already be emerging.
Sometimes, the parents are reassured that everything is
fine or some laboratory examinations are conducted to
exclude immunologic disorders. Further evaluation is
may be carried out by the pediatrician. Most of the time
the condition can be addressed as being a normal stage in
childhood [1]. Occasionally, older siblings may contami-
nate the younger children or they could be infected from
daycare centers [2 -4]. However, when the infections per-
sist and no abnormalities are detected, it is very difficult
for the pediatrician to treat the child.
In this study, we examined this group of child ren with
upper respiratory tract infections without a somatic or
immunologic disorder, who are frequent visitors to the
doctor. We observed that the incidence of parents visit-
ing the doctor with children suffering from upper respi-
ratory tract infections has been growing in the last years.
We conducted this study to elucidate this phenomenon.
Can the infections be addressed as being a normal stage
in childhood or does it exceed the normal incidence?
Looking at the function ing of families; is there a relation
between infections and high parental concern or should it
be addressed as coincidence?
2.1. Study Population
Children aged 1 - 4 years who visited the pediatric out-
patient clinic because of recurrent upper respiratory tract
infections were selected as the upper respiratory tract
infections (URTI) group. These children were frequent
visitors to the doctor according to their general practitioner.
They were referred to the pediatrician by their general
practitioner for further evaluation of their infections.
They were not randomly selected and all parents were
asked to fill out the questionnaire.
E. J. Van Der Gaag, N. Van Droffelaar / Open Journal of Pediatrics 2 (2012) 244-249 245
The control group had no medical history and was
recruited at the outpatient clinic of the ophthalmologist.
When children in the control group had a case of
physical problems or illness, they were excluded from
the control group. Both groups were recruited in a 3
month period between December 2007 and February
2008 at the Ziekenhuis Groep Twente a general hospital
in Hengelo, The Netherlands.
All patients were measured for weight, height, and
body mass index. To calculate the standard deviation of
growth from each patient for comparison with the normal
Dutch population, Growth Analyzer (version 3.5, Dutch
Growth Stichting, The Netherlands) was used. Patients
who visited the outpatient clinic for recurrent upper
respiratory tract infections were blood tested for im-
munologic disorders according to our protocol [5].
2.2. Questionnaire
The questionnaire was newly developed and was com-
prised of the following questions: 1) How many days a
month did your child suffer from upper respiratory tract
infections (take the mean of the entire year)? 2) How
many days a month is your child ill from an infection
(take the mean over the entire year) and do you think
your child is tired when compared with toddlers of the
same age group? 3) How many antibiotic treatments a
year is your child receiving from a doctor? 4) Is your
child going to school, a daycare center, or does your
child stay s at home? 5) Can you explain your family
structure (two parents, divorced parents, single-parent
family, or foster parents)? 6) How many children are
there in your family? 7) Do you give your child over-
the-counter medication or vitamins? 8) Are you worried
when your child is not feeling well? 9) If you are worried,
who can reduce your worries (choose from nobody,
husband/wife, family, general practitioner, pediatrician,
Internet)? 10) If your child is not feeling well, what do
you do (choose from keep my child inside the house,
keep my child in bed, buy medication, go the general
practitioner, dress my child warm, do nothing)?
All the patients received an oral and written explana-
tion about the goal of the study. All the patients gave
their informed consent prior to their inclusion in the
study. The ethical committee gave exemption to the re-
viewing of the questionnaire, because they considered
that a questionnaire need not be reviewed.
2.3. Statistical Analysis
Statistical analysis was carried out using SPSS 11.5 for
Windows (SPSS Inc, United States of America), and
Student’s t-tests, Mann—Whitney U analysis, and re-
gression analysis were used.
3.1. Participants
In the URTI group, all parents participated in the study
and 42 questionnaires were filled out. Five patients were
excluded because of an incomplete questionnaire (1 pa-
tient), chromosomal abnormality with eating disorder (2
patients), and a combinatio n of two children in one ques-
tionnaire (2 patients). In the control group, 45 parents
filled out the questionnaire. Six children were excluded
because of a systemic disease (3 children suffered from
eczema, 2 from constipation, and 1 from recurrent uri-
nary tract infections).
The group characteristics are described in Table 1.
Gender , weight, and h eight were co mparable in th e three
groups as was the family structure. Children in the URTI
group were younger when compared with the control
group. They were usually the eldest instead of the
youngest in their family. In the following results there
was a correction for age.
3.2. Incidence of Infections
The characteristics of the upper respiratory tract infec-
tions are described in Table 1. The URTI group suffered
more from upper respiratory tract infections (19 days a
month) when compared with the control group (6 days).
Furthermore, these children suffered from (unexplained)
fever for 7.4 days a month, thus significantly more than
the control group. As a result, these children took more
antibiotics. All the children in the URTI group had no
immunologic abnormalities in their blood results which
could explain the recurrent infections.
Table 1. Clinical characteristics of children with upper respi-
ratory tract infection (URTI), an d control group.
URTI group
N = 37 Control group
N = 39
Sex (M/F), n 18/19 18/21
Age (months) 30 (14) 40 (1)**
Family with two parents, n (%)37 (100) 38 (97.3)
Divorced parents, n (%) 0 1 (2.7)
Foster parents, n (%) 0 0
Children in fam i ly 1.8 (0.6) 2. 2 (0.7)*
Day care (days a week) 2.1 2.3
Allergic co nstitution (%) 22.2 10.2
URTIs (days a month) 19.4 (11) 5.9 (9)**
Fever (days a month) 7.8 (9) 1.4 (5) **
Antibiotic use (courses a year) 2.1 (1.7) 0.2 (0.4)**
Vitamins/over the counter, n 27 (73%) 23 (59%)
Hospitalisation 10 (27%) 4 (10.3%)
Parents fear serious disease 18 (66.7%) 7 (30.4%)*
*p < 0.05, **p < 0.01. Data are mean (SD) except when otherwise indicated.
Copyright © 2012 SciRes. OPEN ACCESS
E. J. Van Der Gaag, N. Van Droffelaar / Open Journal of Pediatrics 2 (2012) 244-249
3.3 Parental Concern
Parents of the children in the URTI group were more
afraid of a serious disease (66.7%) compared with the
control group (30.4%; p < 0.05). With experience, the
fear disappeared. We observed that when parents had
another child in the family (in both groups), the child had
a chance reduction of 0.4 that his/her parents were afraid
when the child was not feeling well. The children in the
URTI group had a 4.6 times greater chance than those in
the control group as having a parent who fears a serious
disease when the child is not feeling well. When the
parents of the children in the URTI group were worried,
they more often had an urge to visit the pediatric clinic
than those in the con trol group (Table 2). The parents of
the children in the URTI group were less easily soothed
by family or their partners when compared with those of
the children in the control group, though this data was
not significant. According to the parents, 24% of the
children in the URTI group were more tired when com-
pared with children of the same age group. The con-
trol-group children were not (0%).
Table 2 also show s the actions that parents take when
their child is not feeling well. Paren ts of the URTI-group
children tend to keep their child at home more rather
than sending them to school, a daycare center, or a baby-
sitter when compared with those of the children in the
control group. When the significant items were com-
bined, a child with an upper respiratory tract infection
Table 2. Percentage of parents who are worried, who reduces
their worries, and their actions when their child is not feeling
URTI group
N = 37 Control group
N = 39
Parents are worried 36 (97.3%) 22 (56.5%)**
Who takes worries away?
Nobody 3 (8.3%) 0 (0%)
Spouse 23 (63.9%) 28 (75.7%)
Family 13 (36.1%) 18 (48.6%)
GP 20 (55.6%) 22 (59.5%)
Pediatrician 22 (61.1%) 0 (0%)**
Internet 1 (2.8%) 1 (2.7%)
Keep child in house 29 (80.6%) 18 (47.4%)**
Keep child in bed 22 (62.9%) 30 (76.9%)*
Buy medication 17 (47.3%) 7 (18%)*
Go to GP 9 (25%) 1 (2.6%)**
Dress child warm 4 (11%) 5 (12.8%)
Nothing 7 (20%) 15 (38.5%)
*p < 0.05, **p < 0.01.
who stays at home, lies more often in bed, and gets more
over-the-counter medication, is considered as needing
treatment. The parents become worried and visit the
general practitioner who in turn could not detect any-
thing but decides to prescribe s antibiotics (Table 1).
The normal variation of upper respiratory tract infections
(including common cold) in toddlers consists of 6 - 8
periods a year [6,7]. When a mean is taken of 7 - 10 days
for every infectious period, up to 6 days a month seems a
reasonable period to have an infection [8-10]. According
to the data, this number could be observed in the control
group. A more recent study in Germany showed a lower
frequency of common colds [11]. This study with diaries
revealed a mean duration of a common cold episode
between 9 and 15 days in children aged 0 - 4 years.
These children had a mean cumulative time of common
cold of about 4 weeks a year concentrated in the winter
period. The URTI group in our study exceeded this
number with a mean of 19 days a month. The days when
a child had an unexplained fever were also increased
when compared with the control group. The study of
Gruber also described children with recurrent common
cold episodes (>8 episodes a year), their cumulative time
of common cold episodes exceeds the 4 weeks. The
cumulative time of co mmon cold in this sp ecific group is
not mentioned in their study. In the literature, the
incidence of parents visiting the pediatrician with in-
nocent recurrent infections is frequent [12], although the
exact numbers are lacking.
What possible factors can contribute to the mechanism
of upper respiratory tract infections? The group of
toddlers suffering from upper respiratory tract infections
was younger compared with the control group. The data
was therefore statistically corrected for this age factor.
Daycare attendance was observed to be a possible risk
factor, along with factors such as having school-aged
siblings and suffering from allergies [11,13,14]. In our
study population, daycare attendance among children
with upper respiratory tract infections was found to be
lesser. In addition to this, there were a less number of
children in the family and no significant increase in
allergic disease. The children in both groups had similar
growth parameters and social home environments. Do
the parents perceive to have a problem and seek medical
attention or is there really a problem with the children?
We did observe that the incidence of upper respiratory
tract infections is increased in the URTI group and
exceeds the normal variation. The parents therefore do
have a reason to visit the general practitioner. When we
investigated parental fears, parents of the children in the
URTI group were found to have a fear of serious disease.
The worries and concern of the parents of the children in
Copyright © 2012 SciRes. OPEN ACCESS
E. J. Van Der Gaag, N. Van Droffelaar / Open Journal of Pediatrics 2 (2012) 244-249 247
the URTI group was expressed by adopting more
concerning behavior, such as buying more vitamins and
over-the-counter medication for everyday use. When
their child was not feeling well, they tended to k eep their
child more in the house or in bed. They bought more
medication and visited the general practitioner more
often. Adopting a patient attitude was more difficult for
them. When they were worried, they hoped that the
pediatrician could take their worries away. This is a bit
surprising because most of these children with upper
respiratory tract infections visited th e pediatric outpatien t
clinic for the first time. Our results of parental concern
are almost similar to those obtained by Spurrier et al. [15]
They in v es tiga te d th e r el atio n be tween as th ma man age men t
by parents and the perception of parents regarding their
children’s vulnerability to illn ess. Parents who perceived
that their children were more vulnerable to medical
illness were more likely to keep their children home from
school, visit the general practitioner for acute asthma
care, and give their children regular preventive medication
[15]. In contrast, the use of hospital services by parents
was more associated with asthmatic symptoms than the
parents’ perception of vulnerability. In our study, we
found that the parents wished to visit a pediatrician, but
did not actually visit the hospital for the complaint until
the general practitioner asked them to.
Could upper respiratory tract infections be the result of
high parental concern? This is a question that is hypo-
thetical and not easy to answer. There are numerous
known and probably unknown variables involved in the
pathogenesis of recurrent upper respiratory tract infec-
tions. In the recent literature, some associations between
parenting and the development of disease in children
could be found .
Sepa et al. proposed a mechanism of psychoneuroim-
munology. High parental stress and lack of social support
could influence the immune system by altering the
hormonal and nervous signals [16-18]. They related a
number of disparate variables of social, environmental,
and medical character to the presence of high parenting
stress and a lack of social support for the mothers. They
stated that with this correlation, previously found risk
factors for the disease could be mediated by psycho-
logical mechanisms. Boyce et al. showed that children
with high environmental stress had altered immune
reactivity, and therefore elevated rates of respiratory
disease [19]. They showed two types of children: child-
ren with high or low immune reactivity to the stress of
starting school. Combined with family circumstances,
children with high immune reactivity and whose parents
reported large numbers of stressful life events had the
highest rates of respiratory disease. In contrast, children
with low immune reactivity showed low numbers of
illness in both high- and low-stress families. This was
similar to the high immune reactivity children coming
from low-stress families. Andre et al. found that child ren
from families with high parental concern suffered from
more respiratory tract infections in a month when
compared with those from families with medium or low
concern [20]. These families also believed that their
children were ill, though their children did not suffer
from fever. These studies support our findings and
suggest a correlation between respiratory disease and
high parental stress, although direct evidence is lacking.
These findings could also mean a possible target for
prevention. Could a therapy of reducing parental anxiety
bring down the visits to the doctor? Or could the actual
rate of infections be influenced? These questions should
be investigated clinically before definite conclusions can
be made.
A possible limitation s of our study could be the time
period used, as toddlers typically suffer from a common
cold more frequently in winter season [11]. The effect of
the cold season could contribute to the disease, although
similar numbers were also found in studies conducted in
the summer (manuscript in preparation). The parents an d
the children could also be referred because the parents
are more concerned. This can introduce a selection bias
into our study. We think this is a reasonable assumption
but choose to accept this selection bias. This population
of parents is especially difficult for doctors to deal with.
The parents are usually very persistent and the symptoms
of their children are usually difficult to interpret. We
tried to objectify and separate parental fears from health
parameters but found they cannot be separated com-
Secondly, our study sample was relatively small and
the children in the URTI group were younger when
compared with those in the control group. The incidence
of the infections could be explained by the younger age
of our URTI group. Other studies showed a mean in-
cidence of 2.7 episodes of common cold in children aged
30 months compared to 2.2 episodes in children aged 40
months [11]. Based on these numbers, one would expect
less episodes of common cold in the control group. We
did find less episodes, but the difference between the
control children and the children with URTI was bigger
than could be explained by the age factor alone. Hence,
we performed a statistical correction for the age factor to
minimize this variable. The influence of the age factor
should be investigated in future studies.
In this study we worked with parental recalls, but they
are less reliable compared to collection of data on a
day-to-day base. Both groups used the same recall method,
but with concerned parents, one can expect higher recall
numbers of sickness days compared with the control
Copyright © 2012 SciRes. OPEN ACCESS
E. J. Van Der Gaag, N. Van Droffelaar / Open Journal of Pediatrics 2 (2012) 244-249
According to the data obtained, it can be observed that
both the assumptions were confirmed. Children with
upper respiratory tract infections who visit the doctor
frequently, were found to exceed the normal variation of
incidence of respiratory disease according to their parental
recalls. This being a normal stage in childhood is there-
fore unlikely. This incidence was found to be high and
resulted in an emerging phenomenon. High parental
concern was however also observed. A relation between
high parental co ncern and children ’s respiratory illnesses
could be possible but further data is needed to elucidate
the exact mechanism.
EvdG thanks her co-researchers/friends who helped to translate daily
practice into scientific research. We thank Professor J. van der Palen
(Medical School Twente, University Twente, Enschede, The Netherlands)
for assisting us with the statistical analysis.
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