Updates to the Pediatrics Asthma Management Guidelines

Intestinal microbiota and probiotic intervention in children with bronchial asthma

Objective

This study aims to understand the differences in intestinal flora, expression of helper T cells, allergy-related indicators, and cytokine levels between children with bronchial asthma and healthy children. The study seeks to clarify the effectiveness and safety of probiotic preparations in the treatment of bronchial asthma in children, and to provide new methods for the treatment of bronchial asthma.

Methods

A total of 66 pediatric patients aged 3-6 years with bronchial asthma and 35 healthy children undergoing physical examination during the same period were enrolled, designated as the asthma group and the healthy group, respectively. The asthma group was further divided into the probiotic group and the non-probiotic group based on whether probiotics were used. The gut microbiota, serum IgE antibody levels, cytokines (IL-4, IL-5, IL-9, IL-13 levels), proportions of helper T cells (Th1, Th2), and hypersensitive C-reactive protein were measured and compared among the groups.

Results

Children with bronchial asthma had decreased abundance and reduced diversity of intestinal flora compared to the healthy group. At the genus level, the asthma group showed increased abundance of Bacteroides and decreased abundance of Faecalibacterium and Veillonella; The probiotic group demonstrated a significantly higher improvement in the abundance of these genera before and after treatment compared to the non-probiotic group (P < 0.05). Compared to the healthy group, children with asthma had elevated levels of serum IgE, IL-4, IL-5, IL-9, and IL-13, as well as a decreased Th1/Th2 ratio, all of which showed statistical differences (P < 0.05). After treatment, all immune indicators improved. Specifically, the probiotic group exhibited a more significant decrease in serum IgE, IL-4, and IL-13 levels compared to the non-probiotic group (P < 0.05).

Conclusion

Children with bronchial asthma exhibit dysbiosis of intestinal flora, characterized by an increased abundance of the Bacteroides and decreased abundance of the Faecalibacterium and Veillonella. This imbalance in intestinal flora increases the risk of allergic diseases. Probiotics can effectively improve dysbiosis of intestinal flora, contributing to the balance of immune function in children, and can be used as an adjunct therapy for the treatment of bronchial asthma.

Pediatric asthma inhaler technique: quality and content analysis of YouTube videos

BACKGROUND

Proper technique for using inhalers is crucial in treating pediatric asthma. YouTube offers a wide range of videos on pediatric inhaler technique, but there is a need to analyze the quality, reliability, and content of these resources.

AIMS

This study aims to analyze the quality, reliability, and content of YouTube videos on pediatric asthma inhaler techniques.

METHODS

The study has a descriptive, retrospective, and cross-sectional design. The research was conducted by searching YouTube using the "Pediatric Metered Dose Inhaler," "Pediatric Accuhaler," and "Pediatric Diskus." The video's popularity was measured using the Video Power Index. The quality and reliability of the videos were evaluated using the modified DISCERN and Global Quality Scale (GQS).

RESULTS

This study analyzed 55 YouTube videos on the pediatric inhaler technique. 19 of the videos were related to the pMDI inhaler with a spacer for tidal breathing, 14 pMDI inhaler with a spacer for single breath, and 22 diskus device. Findings show that videos demonstrating the use of pMDI devices for single breath have more reliable modified DISCERN scores. However, videos related to tidal breathing are more popular than those showing the use of diskus devices and single breath. Based on the checklist for videos on diskus devices, the steps with the highest error rates are 'Check dose counter' at 72.7% and 'Breathe out gently, away from the inhaler' at 63.6%. A moderate correlation was observed between the modified DISCERN score and the GQS.

CONCLUSIONS

While YouTube videos on the pMDI single-breath technique may be useful for pediatric patients and caregivers, it is crucial for them to receive inhaler technique education from their healthcare provider. This study's findings hold great significance for pediatric patients and caregivers, particularly those who rely on YouTube for health-related information.

Identification of severe acute pediatric asthma phenotypes using unsupervised machine learning

RATIONALE

More targeted management of severe acute pediatric asthma could improve clinical outcomes.

OBJECTIVES

To identify distinct clinical phenotypes of severe acute pediatric asthma using variables obtained in the first 12 h of hospitalization.

METHODS

We conducted a retrospective cohort study in a quaternary care children's hospital from 2014 to 2022. Encounters for children ages 2-18 years admitted to the hospital for asthma were included. We used consensus k means clustering with patient demographics, vital signs, diagnostics, and laboratory data obtained in the first 12 h of hospitalization.

MEASUREMENTS AND MAIN RESULTS

The study population included 683 encounters divided into derivation (80%) and validation (20%) sets, and two distinct clusters were identified. Compared to Cluster 1 in the derivation set, Cluster 2 encounters (177 [32%]) were older (11 years [8; 14] vs. 5 years [3; 8]; p < .01) and more commonly males (63% vs. 53%; p = .03) of Black race (51% vs. 40%; p = .03) with non-Hispanic ethnicity (96% vs. 84%; p < .01). Cluster 2 encounters had smaller improvements in vital signs at 12-h including percent change in heart rate (-1.7 [-11.7; 12.7] vs. -7.8 [-18.5; 1.7]; p < .01), and respiratory rate (0.0 [-20.0; 22.2] vs. -11.4 [-27.3; 9.0]; p < .01). Encounters in Cluster 2 had lower percentages of neutrophils (70.0 [55.0; 83.0] vs. 85.0 [77.0; 90.0]; p < .01) and higher percentages of lymphocytes (17.0 [8.0; 32.0] vs. 9.0 [5.3; 14.0]; p < .01). Cluster 2 encounters had higher rates of invasive mechanical ventilation (23% vs. 5%; p < .01), longer hospital length of stay (4.5 [2.6; 8.8] vs. 2.9 [2.0; 4.3]; p < .01), and a higher mortality rate (7.3% vs. 0.0%; p < .01). The predicted cluster assignments in the validation set shared the same ratio (~2:1), and many of the same characteristics.

CONCLUSIONS

We identified two clinical phenotypes of severe acute pediatric asthma which exhibited distinct clinical features and outcomes.

Online-merge-offline (OMO)-based music therapy for asthmatic children during the COVID-19 pandemic in China

The purpose of this study is to evaluate online-merge-offline (OMO)-based music therapy (MT) as a complementary option for asthma management in pediatric patients. A total of 86 children diagnosed with mild asthma were enrolled and treated with the same drug therapy. They were assigned into three groups: Music I group (standard medical care plus a single individualized MT session along with singing training and breathing exercise), Music II group (similar as Music I as well as further wind instrument playing), and Control group (standard medical care). Primary endpoints included pulmonary function tests FEV1, FVC, FEV1/FVC, MMEF 75/25, and PEF, c-ACT, PAQLQ, and PACQLQ. After 6 months of continuous intervention of MT, significant differences in FEV1, FVC, MMEF75/25, PEF, c-ACT score, PAQLQ, PACQLQ (p < 0.001), and FEV1/FVC (p < 0.05) were observed among Music I, Music II, and Control groups. Besides, FEV1, FVC, FEV1/FVC, MMEF75/25, and PEF showed positive trends in Music I and Music II groups compared to those in Control group (p < 0.05). The c-ACT score of children was significantly increased in Music I (p < 0.001) and II (p < 0.001) groups in contrast with Control group. Children in Music I and II groups had better quality of life than those in Control group (PAQLQ, p < 0.001), and the parents in Music I and II groups also showed better quality of life than those in Control group (PACQLQ, p < 0.001).     Conclusion: As a child-friendly, low-risk, and convenient intervention, the OMO-based MT has a positive impact on pediatric asthma management during the COVID-19 pandemic. What is Known: • A few findings proved the positive effect of MT on pediatric asthma. What is New: • Our study further proving the validation and effectiveness of MT with OMO-based model on pediatric asthma, wind instrument playing has a greater impact on pediatric asthma control via small airways and might be recommended to mix to singing and breathing to improve effectiveness of MT for asthmatic children.

Effectiveness of a Vendor Predictive Model for the Risk of Pediatric Asthma Exacerbation: A Difference-in-Differences Analysis

BACKGROUND

Asthma is a common cause of morbidity and mortality in children. Predictive models may help providers tailor asthma therapies to an individual's exacerbation risk. The effectiveness of asthma risk scores on provider behavior and pediatric asthma outcomes remains unknown.

OBJECTIVE

Determine the impact of an electronic health record (EHR) vendor-released model on outcomes for children with asthma.

METHODS

The Epic Systems Risk of Pediatric Asthma Exacerbation model was implemented on February 24, 2021, for volunteer pediatric allergy and pulmonology providers as a noninterruptive risk score visible in the patient schedule view. Asthma hospitalizations, emergency department (ED) visits, or oral steroid courses within 90 days of the index visit were compared from February 24, 2019, to February 23, 2022, using a difference-in-differences design with a control group of visits to providers in the same departments. Volunteer providers were interviewed to identify barriers and facilitators to model use.

RESULTS

In the intervention group, asthma hospitalizations within 90 days decreased from 1.4% (54/3,842) to 0.7% (14/2,165) after implementation with no significant change in the control group (0.9% [171/19,865] preimplementation to 1.0% [105/10,743] post). ED visits in the intervention group decreased from 5.8% (222/3,842) to 5.5% (118/2,164) but increased from 5.5% (1,099/19,865) to 6.8% (727/10,743) in the control group. The adjusted difference-in-differences estimators for hospitalization, ED visit, and oral steroid outcomes were -0.9% (95% confidence interval [CI]: -1.6 to -0.3), -2.4% (-3.9 to -0.8), and -1.9% (-4.3 to 0.5). In qualitative analysis, providers understood the purpose of the model and felt it was useful to flag high exacerbation risk. Trust in the model was calibrated against providers' own clinical judgement.

CONCLUSION

This EHR vendor model implementation was associated with a significant decrease in asthma hospitalization and ED visits within 90 days of pediatric allergy and pulmonology clinic visits, but not oral steroid courses.

Overview of the Updates for the Management of Asthma Guidelines

Asthma is a common diagnosis for pediatric patients, and something frequently managed in the primary care setting. Due to the multitude of factors that affect asthma, obtaining good control of the disease can be difficult. Managing triggers, medications, and adherence are key to maintaining good asthma control and quality of life. The National Heart, Lung, and Blood Advisory Council has released new guidelines and recommendations to help assist in the management of asthma. The expert panel addressed several key areas and made recommendations based on the available data. Areas addressed were the use of intermittent inhaled corticosteroids, the use of long-acting muscarinic antagonist, allergen mitigation, fractional exhaled nitric oxide testing for asthma diagnosis and management, and immune modulation for asthma control. This article summarizes the key recommendations and changes to the guideline. [Pediatr Ann. 2022;51(4):e132-e135.].

CLCA1 mediates the regulatory effect of IL-13 on pediatric asthma

OBJECTIVE

CLCA1 is a secreted protein with protease activity, and its expression is associated with inflammatory airway diseases. This study aimed to investigate the role of CLCA1 and IL-13 in pediatric asthma.

METHODS

In asthmatic and healthy children, the correlation between CLCA1 expression and blood IL-4, and IL-13 levels were investigated by serological analyses such as RT-qPCR and ELISA. The effects on the activity and apoptosis of bronchial epithelial cells following IL-13 stimulation were explored in vitro by the CCK-8 assay and flow cytometry, respectively. CLCA1 siRNA was used to knock down the expression level of bronchial epithelial cells and the effect of IL-13 stimulation on these cells was assessed by the CCK-8 assay and flow cytometry.

RESULTS

CLCA1, IL-4, and IL-13 were highly expressed in the serum of children with asthma. CLCA1 expression was highly correlated to serum IL-13. IL-13 stimulation reduced the activity of bronchial epithelial cells in vitro and promoted apoptosis. Lastly, knockdown of CLCA1 rescued the IL-13-induced decrease in activity and apoptosis.

CONCLUSION

CLCA1 is highly expressed in children with asthma and mediates the contributory effect of IL-13 on the occurrence and development of pediatric asthma.

Keeping Pace with Adolescent Asthma: A Practical Approach to Optimizing Care

Known for their pre-occupation with body image, self-identity creation, peer acceptance, and risk-taking behaviors, adolescents with asthma face unique challenges. Asthma is a heterogeneous disease and accurate diagnosis requires assessment through detailed clinical history, examination, and objective tests. Diagnostic challenges exist as many adolescents can present with asthma-like symptoms but do not respond to asthma treatment and risk being mis-diagnosed. Under-recognition of asthma symptoms and denial of disease severity must also be addressed. The over-reliance on short-acting beta-agonists in the absence of anti-inflammatory therapy for asthma is now deemed unsafe. Adolescents with mild asthma benefit from symptom-driven treatment with combination inhaled corticosteroids (ICS) and long-acting beta-agonist (LABA) on an as-required basis. For those with moderate-to-persistent asthma requiring daily controller therapy, maintenance and reliever therapy using the same ICS-LABA controller simplifies treatment regimes, while serving to reduce exacerbation risk. A developmentally staged approach based on factors affecting asthma control in early, middle, and late adolescence enables better understanding of the individual's therapeutic needs. Biological, psychological, and social factors help formulate a risk assessment profile in adolescents with difficult-to-treat and severe asthma. Smoking increases risks of developing asthma symptoms, lung function deterioration, and asthma exacerbations. Morbidity associated with e-cigarettes or vaping calls for robust efforts towards smoking and vaping cessation and abstinence. As adolescents progress from child-centered to adult-oriented care, coordination and planning are required to improve their self-efficacy to ready them for transition. Frequent flare-ups of asthma can delay academic attainment and adversely affect social and physical development. In tandem with healthcare providers, community and schools can link up to help shoulder this burden, optimizing care for adolescents with asthma.