How Many Infections is Too Many?

“It feels like my child is sick all the time, is this normal?” A comment and question we pediatricians here much of the year, but especially in the fall and winter months. What’s normal? When should I be worried about my child’s immune system? When should I consider seeing ENT for ear tubes, or tonsil removal for recurrent strep? Let’s take a deeper dive into these recurrent infection FAQs.

What’s “normal?”

While cold and flu season varies somewhat by geographic region, our season in Richmond is typically October through March, with the peak being mid-December through late February. It has long been observed that children under the age of 5 years old who are around other children (e.g. daycare, preschool, older siblings in daycare/preschool) average 1 cold virus per month in the late spring, summer, and early fall months (i.e. outside of cold and flu season). October through March, however, these same children average 2 cold viruses per month. Because of a combination of factors such as maturing immune system, inability to effectively blow their noses, and less productive coughs than older children and adults, young child cold symptoms will typically last 10-14 days. Another common refrain we hear is, “it seems like my child is sick all the time.” Unfortunately, when we factor that children may have two cold viruses per month at 10-14 days each, it “seems like” they are sick all the time because they ARE sick [almost] all the time during cold and flu season. The silver lining is the immunity built fighting all these germs at younger ages makes them less likely to be as sick during the elementary school years and beyond.

When should I be worried about my child’s immune system?

There are many factors pediatricians monitor that may indicate a weakened immune system (aka immunodeficiency). Recurrent infections may be related to immunodeficiency if one or more of the following are also present:

  • Inadequate weight gain and growth
  • Need for IV antibiotics or hospitalization to clear infections
  • Two or more serious/life-threatening infections (e.g. bloodstream infection, joint/bone infection, or meningitis)
  • Two or more months of antibiotics with little effect
  • Complications from live vaccines (e.g. rotavirus, MMR, and chicken pox vaccines)
  • Chronic diarrhea
  • Nonhealing wounds
  • Family history of immunodeficiency, or early (< 30 years old) unexplained death

If you are concerned about the strength of your child’s immune system, or if they have had recurrent infections in addition to any of the above findings, schedule an appointment to discuss whether screening bloodwork would be helpful to rule out immunodeficiency.

When should I consider talking with an ENT (Ear, Nose and Throat; also known as otolaryngologist) about ear tubes?

As it relates to recurrent ear infections, there are two primary criteria we use to determine which patients should consult with an ENT to discuss the benefits and risks of ear tubes:

  • 4 unique infections in 6 months or less (NOTE: sometimes a single infection requires multiple courses of antibiotics. We do not count the number of different antibiotics, just the number of unique infections)
  • Persistent fluid – whether infected or not – behind the ear drum(s) for 3 consecutive months

We are fortunate to have such a great network of community ENT physicians in the greater Richmond area. If your child meets or is close to the above criteria, we will make recommendations on who to call for an appointment. If your child has had ear infections diagnosed at urgent care centers, please be sure to ask if we’ve received documentation of those visits.

When should I consider talking with an ENT about tonsil removal for my child?

Tonsil removal for recurrent strep infections also has specific criteria.  We recommend an ENT consultation if your child has the following number of strep throat infections:

  • 7 infections in 12 months
  • 5 infections per year for 2 consecutive years
  • 3 infections per year for 3 consecutive years

A couple notes about these two ENT surgeries:

Just because your child meets the criteria for a particular ENT surgery does not mean they necessarily should/must have surgery. The consultation with the ENT will provide more information about the benefits and risks of surgery. Armed with that knowledge, you will be better equipped to make the decision you think best for your child.  

Timing may play a role.

  • If your child gets a 4th ear infection in 6 months, for example, but it occurs in April or May, we may recommend holding off on ear tubes knowing we’re exiting cold and flu season, and the risk for further ear infection recurrence over the late spring and summer months should go down significantly.

  • Tonsil removal requires a longer recovery period so these procedures may want to be deferred until long school breaks such as winter or summer break.