Green mucus anxiety and managing childhood respiratory events. Part 1: Expectations
|Professor Richard Harvey MD PhD.
Rhinologist, surgeon and educator.
About the author: Professor Harvey leads innovative research into the causes of chronic sinus disease and novel therapies to manage the condition. As program head, Rhinology and Skull Base Surgery, at UNSW and Macquarie University, he is asked to speak nationally and internationally on changing the traditional paradigms in upper airway and sinus care. His research has provided fundamental shifts in the way sinus disease is managed.
As nose and sinus specialist, I’m often asked for advice, by parents, on managing recurrent respiratory symptoms during childhood. The symptoms of nasal discharge, congestion and cough, are common during childhood and may even appear persistent as the break between events is short. While there are some significant medical problems that can produce true ‘persistent’ nasal symptoms, with no return to normal function in between, most respiratory events during childhood are ‘episodic’ and represent part of the normal exposure and immune development that occurs during these years.
Unfortunately, the medical marvel of antibiotic development, which changed the mortality associated with severe bacterial infections such as pneumonia, sepsis and meningitis, is now over applied in our community. There is a growing concern that modern health therapies applied inappropriately and unnecessarily to our population, and especially children, is not only wasteful but harmful to health. A great example of this is the overuse of antibiotics to manage recurrent respiratory exacerbation in childhood.
These events are viral and don’t represent bacterial infections. I intentionally avoid the use of the term ‘majority of events’ as this is misleading and an unnecessary ‘disclaimer’ as the number of viral respiratory events that become bacterial and need treatment is much less than 1%. Unfortunately, 50% of children still leave an consultation from a local family doctor with a course of antibiotics1 and while this is an improvement from the 1990’s, when sadly, up to 75% of all antibiotic prescriptions were used on children2, it still remains unacceptably too high.
Mucus production observed by parents drives much of this anxiety3. And, in particular, green or discoloured mucus. As a parent myself, its normal behaviour to want to help our children when they are ill, however, understanding the nature, duration and frequency for these mucus producing events is critical to ensuring that care or interventions we offer our children are both safe, effective and appropriate.
The green color of mucus is produced from myeloperoxidase or MPO. This enzyme arises from white blood cells (neutrophils) and presents 5% of the dry weight neutrophils4. The green pigment iron-containing heme groups within MPO. Neutrophils and MPO are normally expressed (100 fold) during viral respiratory events. Green mucus is not a sign of ‘bacterial’ infection but simply an immune response from our children.
Viral events are common in childhood. Communal day-care, centralised schooling and urban living all provide much closer human contact at an earlier stage in life compared to our ancestors. One of the resulting effects is frequent viral respiratory events, as multiple serotypes are quickly transmitted. The frequency of these events is 4 episodes a year5(Table) and duration of viral events commonly 10 days6. Thus the average ‘healthy’ child should expect to have 40 days or more with respiratory symptoms (and green mucus) as part of their normal immune growth and development.
Over a series of postings we will discuss the expectations, symptom management and prevention strategies for childhood respiratory events.
1. Jansen AG, Sanders EA, Schilder AG, et al. Primary care management of respiratory tract infections in Dutch preschool children. Scand J Prim Health Care 2006;24:231-236.
2. Acute respiratory infections: the forgotten pandemic. Communique from the International Conference on Acute Respiratory Infections, held in Canberra, Australia, 7-10 July 1997. Int J Tuberc Lung Dis 1998;2:2-4.
3. Taylor JA, Kwan-Gett TS, McMahon EM, Jr. Effectiveness of a parental educational intervention in reducing antibiotic use in children: a randomized controlled trial. Pediatric Infectious Disease Journal 2005;24:489-493.
4. Schultz J, Kaminker K. Myeloperoxidase of the leucocyte of normal human blood. I. Content and localization. Archives of Biochemistry & Biophysics 1962;96:465-467.
5. Leder K, Sinclair MI, Mitakakis TZ, et al. A community-based study of respiratory episodes in Melbourne, Australia. Aust N Z J Public Health 2003;27:399-404.
6. Lambert SB, O’Grady KF, Gabriel SH, et al. Respiratory illness during winter: a cohort study of urban children from temperate Australia. J Paediatr Child Health 2005;41:125-129.
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