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Tennis P, Toback SL, Andrews EB, McQuay LJ, Ambrose CS. A US postmarketing evaluation of the frequency and safety of live attenuated influenza vaccine use in nonrecommended children younger than 5 years: 2009-2010 season. Vaccine 2012; 30:6099-102. [PMID: 22841479 DOI: 10.1016/j.vaccine.2012.07.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 07/12/2012] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
The 2007 US approval for use of Ann Arbor strain live attenuated influenza vaccine (LAIV) in children aged 24 through 59 months included precautions against use in (1) children <24 months and children aged 24 through 59 months with (2) asthma, (3) recurrent wheezing, and (4) altered immunocompetence. Results from the third season (2009-2010) of a 3-year study postmarketing commitment to monitor LAIV vaccination rates and frequency of hospitalizations or emergency department visits within 42 days after LAIV are reported here. As in the first 2 seasons, LAIV usage in cohorts 1, 2, and 4 were low relative to those in LAIV-recommended populations. The only numerically increased risk observed was for respiratory events in children aged <24 months administered LAIV, compared to those administered trivalent inactivated influenza vaccine (TIV). The number of children vaccinated with LAIV was small and precluded precise quantification of rare event.
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Affiliation(s)
- Patricia Tennis
- RTI Health Solutions, 3040 Cornwallis Road, Post Office Box 12194, Research Triangle Park, NC 27709, USA.
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Tennis P, Toback SL, Andrews E, McQuay LJ, Ambrose CS. A postmarketing evaluation of the frequency of use and safety of live attenuated influenza vaccine use in nonrecommended children younger than 5 years. Vaccine 2011; 29:4947-52. [PMID: 21596087 DOI: 10.1016/j.vaccine.2011.04.113] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 03/14/2011] [Accepted: 04/29/2011] [Indexed: 11/24/2022]
Abstract
The 2007 US approval for use of live attenuated influenza vaccine (LAIV) in children aged 24-59 months included precautions against use in (1) children <24 months and children aged 24-59 months with (2) asthma, (3) recurrent wheezing, and (4) altered immunocompetence. A postmarketing commitment was initiated to monitor LAIV use and the frequency of select safety outcomes in these cohorts. Vaccination rates and the frequency of hospitalizations or emergency department visits within 42 days after LAIV and trivalent inactivated influenza vaccine (TIV) administration were estimated from 2007 to 2009 claims data from a health insurance database. Rates of LAIV use per 10,000 child-days among cohorts 1, 2, and 4 were low relative to rates among the LAIV-recommended population (2007-2008; 0.03-0.78 vs. 1.32, 2008-2009; 0.08-3.26 vs. 5.94). However, rates of LAIV use per 10,000 child-days in cohort 3 were similar to rates among the LAIV-recommended population (2007-2008; 1.55 vs. 1.32, 2008-2009; 5.01 vs. 5.94). The rate of emergency department visits/hospitalizations within 42 days of vaccination with LAIV was the same as or less than the rate within 42 days of vaccination with TIV. Less restricted LAIV use in children with past wheezing may be related to the broad definition of recurrent wheezing used in national guidelines and the current study. In the small number of nonrecommended children receiving LAIV, no safety signals were identified.
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Affiliation(s)
- Patricia Tennis
- RTI Health Solutions, 200 Park Office Drive, Research Triangle Park, NC 27709, USA.
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Papi A, Nicolini G, Baraldi E, Boner AL, Cutrera R, Rossi GA, Fabbri LM. Regular vs prn nebulized treatment in wheeze preschool children. Allergy 2009; 64:1463-1471. [PMID: 19772514 DOI: 10.1111/j.1398-9995.2009.02134.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND International guidelines recommend regular treatment with inhaled glucocorticoids for children with frequent wheezing; however, prn inhaled bronchodilator alone or in combination with glucocorticoid is also often used in practice. We aimed to evaluate whether regular nebulized glucocorticoid plus a prn bronchodilator or a prn nebulized bronchodilator/glucocorticoid combination is more effective than prn bronchodilator alone in preschool children with frequent wheeze. METHODS Double-blind, double-dummy, randomized, parallel-group trial. After a 2-week run-in period, 276 symptomatic children with frequent wheeze, aged 1-4 years, were randomly assigned to three groups for a 3-month nebulized treatment: (1) 400 microg beclomethasone bid plus 2500 microg salbutamol prn; (2) placebo bid plus 800 microg beclomethasone/1600 microg salbutamol combination prn; (3) placebo bid plus 2500 microg salbutamol prn. The percentage of symptom-free days was the primary outcome measure. Secondary outcomes included symptom scores, use of relief medication and exacerbation frequency. RESULTS As compared with prn salbutamol (61.0 +/- 24.83 [SD]), the percentage of symptom-free days was higher with regular beclomethasone (69.6%, SD 20.89; P = 0.034) but not with prn combination (64.9%, SD 24.74). Results were no different in children with or without risk factors for developing persistent asthma. The effect of prn combination was no different from that of regular beclomethasone on the primary and on several important secondary outcomes. CONCLUSIONS Regular inhaled glucocorticoid is the most effective treatment for frequent wheezing in preschool children. However, prn bronchodilator/glucocorticoid combination might be an alternative option, but it requires further study.
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Affiliation(s)
- A. Papi
- Department of Respiratory Diseases, Research Center on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | - G. Nicolini
- Medical Department, Chiesi Farmaceutici, Parma, Italy
| | - E. Baraldi
- Department of Pediatrics, Unit of Allergy and Respiratory Medicine, University of Padova, Padova, Italy
| | - A. L. Boner
- Department of Pediatrics, University of Verona, Verona, Italy
| | - R. Cutrera
- Respiratory Unit, Department of Pediatrics, Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - G. A. Rossi
- Department of Pediatrics, Ospedale Gaslini, Genova, Italy
| | - L. M. Fabbri
- Department of Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
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Mallol J, Aguirre V, Barrueto L, Wandalsen G, Tepper R. Effect of inhaled fluticasone on lung function in infants with recurrent wheezing: a randomised controlled trial. Allergol Immunopathol (Madr) 2009; 37:57-62. [PMID: 19445860 DOI: 10.1016/s0301-0546(09)71105-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Inhaled corticosteroids are used to treat infants with troublesome asthma-like symptoms but their effect on the lung function of these young patients is controversial. MATERIAL AND METHODS Forty-four infants with recurrent wheezing (more than 3 episodes) and family history of asthma completed this randomised, parallel, double-blind, controlled trial to compare the effect on lung function (main endpoint) of once-daily inhaled fluticasone (375 microg) versus placebo for 3 months. Pulmonary function was measured while infants were asymptomatic, using the raised volume rapid thoracic compression technique (spirometry-like), and values were converted to z-scores. RESULTS The fluticasone group showed a significant increase in forced flows, (p < 0.001), a lower number of physician diagnosed wheezing episodes (p < 0.002), and a significant decrease in the parent-reported number of wheezing episodes per month (p < 0.03), as compared to placebo. One third of parents in the placebo group reported a clinical improvement in their infants. There was no significant difference in morning plasma cortisol between groups at entry or discharge. CONCLUSIONS We conclude that once-daily treatment with 375 microg fluticasone increased forced flows and controlled symptoms in infants with recurrent wheezing without altering plasma cortisol levels. The spirometry-like technique is a useful tool to objectively assess the efficacy of anti-asthma medications in infants with repeated troublesome asthma-like symptoms.
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Affiliation(s)
- Javier Mallol
- Department of Pediatric Respiratory Medicine, Hospital El Pino, University of Santiago de Chile (USACH), Santiago, Chile.
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Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing and asthma: a systematic review with meta-analysis. Pediatrics 2009; 123:e519-25. [PMID: 19254986 DOI: 10.1542/peds.2008-2867] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To compare the efficacy of inhaled corticosteroids in infants and preschoolers with recurrent wheezing or asthma. METHODS Randomized, prospective, controlled trials published January 1996 to March 2008 with a minimum of 4 weeks of inhaled corticosteroids versus placebo were retrieved through Medline, Embase, and Central databases. The primary outcome was wheezing/asthma exacerbations; secondary outcomes were withdrawal caused by wheezing/asthma exacerbations, changes in symptoms score, pulmonary function (peak expiratory flow and forced expiratory volume in 1 second), or albuterol use. RESULTS Of eighty-nine studies identified, 29 (N = 3592 subjects) met the criteria for inclusion. Patients who received inhaled corticosteroids had significantly less wheezing/asthma exacerbations than those on placebo (18.0% vs 32.1%); posthoc subgroup analysis suggests that this effect was higher in those with a diagnosis of asthma than wheeze but was independent of age (infants versus preschoolers), atopic condition, type of inhaled corticosteroid (budesonide metered-dose inhaler versus fluticasone metered-dose inhaler), mode of delivery (metered-dose inhaler versus nebulizer), and study quality (Jadad score: <4 vs >/=4) and duration (<12 vs >/=12 weeks). In addition, children treated with inhaled corticosteroids had significantly fewer withdrawals caused by wheezing/asthma exacerbations, less albuterol use, and more clinical and functional improvement than those on placebo. CONCLUSIONS Infants and preschoolers with recurrent wheezing or asthma had less wheezing/asthma exacerbations and improve their symptoms and lung function during treatment with inhaled corticosteroids.
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Affiliation(s)
- Jose A Castro-Rodriguez
- Department of Pediatrics and Family Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
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Abstract
PURPOSE OF REVIEW The evidence for effectiveness of currently used asthma medication for wheeze in young children is reviewed. RECENT FINDINGS The management of the infant and preschool child with wheezing is complicated by the uncertainty with respect to the aetiology. Difficulties in defining phenotypes and objective outcome parameters combined with the transient nature of symptoms which often resolve spontaneously have confounded many therapeutic studies. Recent studies on the effect of pharmacotherapy in wheezing infants have tried to define a more homogeneous phenotype as well as make a selection of patients that are likely to respond to the studied drug. In addition, these studies have used lung function parameters and nitric oxide as one of the outcome measurements. Studies on the nature of inflammation and the development of airway remodelling in infants and young children are done to further define phenotypes. SUMMARY Currently, there are no evidence-based guidelines and not even consensus statements on the right approach in pharmacological treatment of wheezing in infants and preschool children. The main issue still is the difficulty in coming to a correct diagnosis. Further studies are needed on the nature and the diagnostics of phenotypes and on the effect of early intervention.
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Affiliation(s)
- Annemie L M Boehmer
- Division of Respiratory Medicine, Department of Paediatrics, Sophia Children's Hospital, Erasmus University and University Hospital, Rotterdam, The Netherlands
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Kugelman A, Shaoul R, Goldsher M, Srugo I. Persistent cough and failure to thrive: a presentation of foreign body aspiration in a child with asthma. Pediatrics 2006; 117:e1057-60. [PMID: 16651284 DOI: 10.1542/peds.2005-2196] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Severe failure to thrive (FTT) in a child with asthma and a persistent cough should not be explained solely by asthma and warrants a thorough and prompt evaluation. The finding of a foreign body in our case was surprising, because it does not usually present as or lead to FTT. Good clinical judgment and habits could prevent the course of events that we described in this case. Following are the key lessons to be learned from this presentation: (1) maintain a high index of suspicion for foreign body aspiration, even in toddlers with asthma, (2) pay special attention to a child with FTT, (3) be aware of localizing findings on physical examination and chest radiographs, and (4) perform a chest radiograph no later than after 1 month of chronic cough.
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Affiliation(s)
- Amir Kugelman
- Department of Pediatrics, Bnai Zion Medical Center, The B. Rappaport Faculty of Medicine, Haifa, Israel.
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Merkus PJFM, de Jongste JC. Inhaled corticosteroids in wheezy infants. Am J Respir Crit Care Med 2006; 172:1058-9; author reply 1059. [PMID: 16216841 DOI: 10.1164/ajrccm.172.8.956] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hofhuis W, van der Wiel EC, Nieuwhof EM, Hop WCJ, Affourtit MJ, Smit FJ, Vaessen-Verberne AAPH, Versteegh FGA, de Jongste JC, Merkus PJFM. Efficacy of fluticasone propionate on lung function and symptoms in wheezy infants. Am J Respir Crit Care Med 2004; 171:328-33. [PMID: 15531753 DOI: 10.1164/rccm.200402-227oc] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The role of inhaled corticosteroids in the treatment of recurrent or persistent wheeze in infancy remains unclear. We evaluated the effect of 3 months of treatment with inhaled fluticasone propionate, 200 microg daily (FP200), on lung function and symptom scores in wheezy infants. Moreover, we evaluated whether infants with atopy and/or eczema respond better to FP200 as compared with non-atopic infants. Forced expiratory flow (Vmax(FRC)) was measured at baseline and after treatment. Sixty-five infants were randomized to receive FP200 or placebo, and 62 infants (mean age, 11.3 months) completed the study. Mean Vmax(FRC), expressed as a Z score, was significantly below normal at baseline and after treatment in both groups. The change from baseline of Vmax(FRC) was not different between the two treatment arms. After 6 weeks of treatment, and not after 13 weeks, the FP200 group had a significantly higher percentage of symptom-free days and a significant reduction in mean daily cough score compared with placebo. Separate analysis of treatment effect in infants with atopy or eczema showed no effect modification. We conclude that in wheezy infants, after 3 months of treatment with fluticasone, there was no improvement in lung function and no reduction in respiratory symptoms compared with placebo.
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Affiliation(s)
- Ward Hofhuis
- Division of Respiratory Medicine, Department of Pediatrics, Erasmus University MC/Sophia Children's Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
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Moeller A, Franklin P, Hall GL, Turner S, Straub D, Wildhaber JH, Stick SM. Inhaled fluticasone dipropionate decreases levels of nitric oxide in recurrenty wheezy infants. Pediatr Pulmonol 2004; 38:250-5. [PMID: 15274106 DOI: 10.1002/ppul.20055] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We examined the effect of inhaled fluticasone diproprionate (FDP) on symptoms, lung function (FEV(0.5)), and exhaled nitric oxide (Fe(NO)) in infants with recurrent wheeze and raised Fe(NO). Thirty-one infants aged 6-19 months (mean, 12.7 months; 12 girls) completed the study. All infants had a history of recurrent wheeze and a parental history of atopy. All children had raised Fe(NO), as determined by an offline tidal breathing technique prior to randomization. Lung function and Fe(NO) were assessed before and after 4 weeks of treatment with FDP or placebo. The parents recorded daily symptoms during the treatment period. Sixteen infants received FDP and 15 the placebo for 4 weeks. At completion of the study, infants treated with FDP had a significant reduction in Fe(NO) (35.0 ppb to 16.5 ppb) compared to those that received placebo (35.2 ppb to 30.2 ppb) (P = 0.05). Small increases in FEV(0.5) were observed in both groups, but these changes were not different between groups (P = 0.8). Symptom scores were not significantly different in either group following the intervention. We showed that a moderate dose of inhaled FDP reduces levels of Fe(NO), a potential marker of airway inflammation, even in the absence of significant changes in lung function and symptoms.
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Affiliation(s)
- Alexander Moeller
- Department of Respiratory Medicine, University Children's Hospital, Zürich, Switzerland. mailto:
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Abstract
Delivering aerosolised drugs to infants poses a number of challenges. It is clear that drug delivery is possible via the inhaled route but to date it has been difficult to demonstrate clearly therapeutic benefit from the use of any conventional therapy in the vast majority of infants. This is probably related to the nature of pulmonary disease in this age group. While most aerosol scientists focus on factors such as aerosol size and airways geometry drug delivery, as in all age groups, is most dependent upon patient behaviour. A small amount of drug reaches the lungs of distressed infants. Consideration of patient device interactions is vital if successful drug delivery is to be achieved and this includes consideration of mask design. Doses reaching the lungs are generally very low when considered in terms of the nominal dose but when considered in terms of dose delivered per kilogram body weight drug delivery to the lungs is generally similar to or greater than in adults. Upper airways deposition is relatively greater than in older subjects, in large part because of nasal breathing, and this will affect the 'therapeutic index' of some drugs.
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Affiliation(s)
- Mark L Everard
- Department of Respiratory Medicine, Sheffield Children's Hospital, Western Bank, Sheffield S10 2TH, UK.
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