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A child presenting with recurrent respiratory infections or radiographic abnormalities poses a common diagnostic problem for general pediatricians and pulmonary specialists alike. Pneumonia can be described both in clinical and radiographic terms. The World Health Organization defines pneumonia clinically as cough or dyspnea in association with labored breathing or tachypnea, and radiographically as an opacity occupying at least part of a single lobe and up to the entire lung.1,2 The incidence of pneumonia in developed countries is approximately 3–3.6 children per 100, whereas in developing countries, it can reach as high as 40 per 100 children.3 Recurrent pneumonia has been defined as two episodes in 1 year or 3 in a lifetime, with radiographic clearing between episodes.4 The incidence of recurrent pneumonia among large populations of children is unknown.

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Several series have described both the frequency of recurrent pneumonia, as well as the leading causes for such, in various smaller populations of children. These studies demonstrate that the majority of children with recurrent pneumonia have an identifiable cause for their recurrent symptoms. The most common cause, however, varies depending on the characteristics of the population of children studied, whether inpatient or outpatient, referred to a subspecialty or general pediatric service, or from developed or developing countries. In a 10-year review of hospital records at a tertiary care children's hospital, 8% of 2952 children with pneumonia had a recurrent episode.5 Of those 238 children, 92% had an “underlying illness.” The leading diagnosis was oropharyngeal incoordination with aspiration, occurring in 48%, followed by immune disorders. Lodha et al.6 reviewed all children presenting to a pediatric pulmonary clinic in New Delhi in a 4-year period. Children were included in the analysis, if they met clinical criteria and had radiographic confirmation of pneumonia. Additionally, children with cystic fibrosis and congenital heart disease were excluded. Seventy children of 2264 (3.1%) in a 5-year period met these standards. An underlying illness was diagnosed in 84% of children; the most common diagnosis was recurrent aspiration, in 24.2% of children, followed by immune deficiency and asthma. In contrast, Ciftci et al.7 reviewed all children admitted to the pediatric infectious disease service of a tertiary care hospital in Turkey. Children without radiographic diagnostic confirmation were excluded from analysis. Nine percent of 288 patients met the criteria. Underlying disease was identified in 85% of patients, with asthma occurring in 32%, and therefore the most common diagnosis. Swallowing dysfunction was present in only 3%. Children with cystic fibrosis and congenital heart disease were included in this analysis.

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Eigen et al.8 found similar results in a population of children referred to a tertiary care pediatric hospital for evaluation of persistent or recurrent pneumonia. Children were divided into two groups—those with apparent causes for persistent or recurrent radiographic densities, and those without. Approximately 50% of those in the group with predisposing causes had either gastroesophageal reflux or oropharyngeal incoordination. Of the group with no apparent ...

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