Daycare attendance and risk for respiratory morbidity among young very low birth weight children

Number of children in the household influences respiratory morbidities in children with bronchopulmonary dysplasia in the outpatient setting

BACKGROUND

Bronchopulmonary dysplasia (BPD), a common complication of prematurity, is associated with outpatient morbidities, including respiratory exacerbations. Daycare attendance is associated with increased rates of acute and chronic morbidities in children with BPD. We sought to determine if additional children in the household conferred similar risks for children with BPD.

METHODS

The number of children in the household and clinical outcomes were obtained via validated instruments for 933 subjects recruited from 13 BPD specialty clinics in the United States. Clustered logistic regression models were used to test for associations.

RESULTS

The mean gestational age of the study population was 26.5 ± 2.2 weeks and most subjects (69.1%) had severe BPD. The mean number of children in households (including the subject) was 2.1 ± 1.3 children. Each additional child in the household was associated with a 13% increased risk for hospital admission, 13% increased risk for antibiotic use for respiratory illnesses, 10% increased risk for coughing/wheezing/shortness of breath, 14% increased risk for nighttime symptoms, and 18% increased risk for rescue medication use. Additional analyses found that the increased risks were most prominent when there were three or more other children in the household.

CONCLUSIONS

We observed that additional children in the household were a risk factor for adverse respiratory outcomes. We speculate that secondary person-to-person transmission of respiratory viral infections drives this finding. While this risk factor is not easily modified, measures do exist to mitigate this disease burden. Further studies are needed to define best practices for mitigating this risk associated with household viral transmission.

Health-Related Quality of Life for Parents of Infants with Bronchopulmonary Dysplasia

OBJECTIVE

To determine how bronchopulmonary dysplasia (BPD) affects health-related quality of life (HRQL) among infants from NICU hospitalization through 1-year postdischarge.

STUDY DESIGN

This was a prospective cohort study of infants with BPD and their parents. Parent HRQL was measured with the PedsQL Family Impact Module before NICU discharge and 3- and 12-months post-discharge. At 12 months, parent-reported child health outcomes included questions from the Test of Respiratory and Asthma Control in Kids, Warner Initial Developmental Evaluation of Adaptive and Functional Skills, and National Survey of Children with Special Health Care Needs. HRQL change over time was assessed by multivariable linear regression.

RESULTS

Of 145 dyads, 129 (89%) completed 3-month follow-up, and 113 (78%) completed 12-month follow-up. In the NICU, lower HRQL was associated with earlier gestational age, postnatal corticosteroids, outborn status, and gastrostomy tubes. At 3 months, lower HRQL was associated with readmissions and home oxygen use. At 12 months, lower HRQL was associated with parent-reported difficulty breathing, lower developmental scores, and not playing with other children. At 3 and 12 months, 81% of parents reported similar or improved HRQL compared with the NICU period. Parents reporting infant respiratory symptoms experienced less improvement.

CONCLUSIONS

BPD affects parent HRQL over the first year. Most parents report similar or better HRQL after discharge compared with the NICU stay. Less improvement is reported by parents of infants experiencing respiratory symptoms at 12 months. Efforts to improve parent HRQL should target respiratory symptoms and social isolation.

Daycare Attendance is Linked to Increased Risk of Respiratory Morbidities in Children Born Preterm with Bronchopulmonary Dysplasia

OBJECTIVES

To test the hypothesis that daycare attendance among children with bronchopulmonary dysplasia (BPD) is associated with increased chronic respiratory symptoms and/or greater health care use for respiratory illnesses during the first 3 years of life.

STUDY DESIGN

Daycare attendance and clinical outcomes were obtained via standardized instruments for 341 subjects recruited from 9 BPD specialty clinics in the US. All subjects were former infants born preterm (<34 weeks) with BPD (71% severe) requiring outpatient follow-up between 0 and 3 years of age. Mixed logistic regression models were used to test for associations.

RESULTS

Children with BPD attending daycare were more likely to have emergency department visits and systemic steroid usage. Children in daycare up to 3 years of age also were more likely to report trouble breathing, having activity limitations, and using rescue medications when compared with children not in daycare. More severe manifestations were found in children attending daycare between 6 and 12 months of chronological age.

CONCLUSIONS

In this study, children born preterm with BPD who attend daycare were more likely to visit the emergency department, use systemic steroids, and have chronic respiratory symptoms compared with children not in daycare, indicating that daycare may be a potential modifiable risk factor to minimize respiratory morbidities in children with BPD during the preschool years.

Influences of environmental exposures on preterm lung disease

Introduction: Environmental factors play a critical role in the progression or resolution of chronic respiratory diseases. However, studies are limited on the impact of environmental risk factors on individuals born prematurely with lung disease after they leave the neonatal intensive care unit and are discharged into the home environment.Areas covered: In this review, we cover current knowledge of environmental exposures that impact outcomes of preterm respiratory disease, including air pollution, infections, and disparities. The limited data do suggest that certain exposures should be avoided and there are potential preventative strategies for other exposures. There is a need for additional research outside the neonatal intensive care unit that focuses on individual and community-level factors that affect long-term outcomes.Expert opinion: Preterm respiratory disease can impose a significant burden on infants, children, and young adults born prematurely, but may improve for many individuals over time. In this review, we outline the exposures that may potentially hasten, delay, or prevent resolution of lung injury in preterm children.

Decreased ventricular size and mass mediate the reduced exercise capacity in adolescents and adults born premature

BACKGROUND

Premature birth is associated with lower levels of cardiorespiratory fitness (CRF) but the underlying mechanisms responsible remain unclear. This study assessed whether differences in cardiac morphology or function mediate differences in CRF among adolescents and young adults born preterm.

METHODS

Adolescents and young adults born moderately to extremely premature (gestational age ≤ 32 weeks or birth weight < 1500 g) and age-matched term born participants underwent resting cardiac MRI and maximal exercise testing. Mediation analysis assessed whether individual cardiovascular variables accounted for a significant proportion of the difference in maximal aerobic capacity between groups.

RESULTS

Individuals born preterm had lower VO2max than those born term (41.7 ± 8.6 v 47.5 ± 8.7, p < 0.01). Several variables differed between term and preterm born subjects, including systolic and diastolic blood pressure, mean pulmonary artery pressure, indexed left ventricular end-diastolic volume (LVEDVi), right ventricular end-diastolic volume (RVEDVi), LV mass (LVMi), LV stroke volume index (LVSVi), and LV strain (p < 0.05 for all). Of these variables, LVEDVi, RVEDVi, LVSVi, LVMi, and LV longitudinal strain were significantly related to VO2max (p < 0.05 for all). Significant portions of the difference in VO2max between term and preterm born subjects were mediated by LVEDVi (74.3%, p = 0.010), RVEDVi (50.6%, p = 0.016), and LVMi (43.0%, p = 0.036).

CONCLUSIONS

Lower levels of CRF in adolescents and young adults born preterm are mediated by differences in LVEDVi, RVEDVi, and LVMi. This may represent greater risk for long-term cardiac morbidity and mortality in preterm born individuals.

Risk Factors for Chronic Cough in Young Children: A Cohort Study

Background and Objective: Data on the predictors of chronic cough development in young children are scarce. Our primary objective was to examine the factors associated with young children developing a chronic cough, with a focus on childcare attendance. Methods: A secondary analysis of data collected in a prospective cohort study of children presenting to three emergency departments and three primary healthcare centers in southeast Queensland, Australia. Eligible children where those aged <6-years presenting with cough and without known underlying chronic lung disease other than asthma. Children were followed for 4 weeks to ascertain cough duration. The primary outcome was persistent cough at day-28. Logistic regression models were undertaken to identify independent predictors of chronic cough including sensitivity analyses that accounted for children with unknown cough status at day-28. Results: In 362 children, 95 (26.2%) were classified as having chronic cough. In models that included only children for whom cough status was known at day-28, symptom duration at enrolment, age <12 months [adjusted odds ratio (aOR) 4.5, 95% confidence interval (CI) 1.1, 18.7], gestational age (aOR 3.2, 95%CI 1.4, 7.9), underlying medical conditions (aOR 2.6, 95% CI 1.3, 5.5), a history of wheeze (aOR 2.6, 95% CI 1.4, 4.8) and childcare attendance (aOR 2.3, 95% CI 1.2, 4.4) were independent predictors of chronic cough. Amongst childcare attendees only, 64 (29.8%) had chronic cough at day-28. The strongest predictor of chronic cough amongst childcare attendees was continued attendance at childcare during their illness (aOR = 12.9, 95% CI 3.9, 43.3). Conclusion: Gestational age, underlying medical conditions, prior wheeze and childcare attendance are risk factors for chronic cough in young children. Parents/careers need to be aware of the risks associated with their child continuing to attend childcare whilst unwell and childcare centers should reinforce prevention measures in their facilities.

Association Between Preterm Birth and Arrested Cardiac Growth in Adolescents and Young Adults

Importance

Premature birth is associated with substantially higher lifetime risk for cardiovascular disease, including arrhythmia, ischemic disease, and heart failure, although the underlying mechanisms are poorly understood.

Objective

To characterize cardiac structure and function in adolescents and young adults born preterm using cardiac magnetic resonance imaging (MRI).

Design, Setting, and Participants

This cross-sectional cohort study at an academic medical center included adolescents and young adults born moderately to extremely premature (20 in the adolescent cohort born from 2003 to 2004 and 38 in the young adult cohort born in the 1980s and 1990s) and 52 age-matched participants who were born at term and underwent cardiac MRI. The dates of analysis were February 2016 to October 2019.

Exposures

Premature birth (gestational age ≤32 weeks) or birth weight less than 1500 g.

Main Outcomes and Measures

Main study outcomes included MRI measures of biventricular volume, mass, and strain.

Results

Of 40 adolescents (24 [60%] girls), the mean (SD) age of participants in the term and preterm groups was 13.3 (0.7) years and 13.0 (0.7) years, respectively. Of 70 adults (43 [61%] women), the mean (SD) age of participants in the term and preterm groups was 25.4 (2.9) years and 26.5 (3.5) years, respectively. Participants from both age cohorts who were born prematurely had statistically significantly smaller biventricular cardiac chamber size compared with participants in the term group: the mean (SD) left ventricular end-diastolic volume index was 72 (7) vs 80 (9) and 80 (10) vs 92 (15) mL/m2 for adolescents and adults in the preterm group compared with age-matched participants in the term group, respectively (P < .001), and the mean (SD) left ventricular end-systolic volume index was 30 (4) vs 34 (6) and 32 (7) vs 38 (8) mL/m2, respectively (P < .001). Stroke volume index was also reduced in adolescent vs adult participants in the preterm group vs age-matched participants in the term group, with a mean (SD) of 42 (7) vs 46 (7) and 48 (7) vs 54 (9) mL/m2, respectively (P < .001), although biventricular ejection fractions were preserved. Biventricular mass was statistically significantly lower in adolescents and adults born preterm: the mean (SD) left ventricular mass index was 39.6 (5.9) vs 44.4 (7.5) and 40.7 (7.3) vs 49.8 (14.0), respectively (P < .001). Cardiac strain analyses demonstrated a hypercontractile heart, primarily in the right ventricle, in adults born prematurely.

Conclusions and Relevance

In this cross-sectional study, adolescents and young adults born prematurely had statistically significantly smaller biventricular cardiac chamber size and decreased cardiac mass. Although function was preserved in both age groups, these morphologic differences may be associated with elevated lifetime cardiovascular disease risk after premature birth.

Recurrent wheezing during the first 3 years of life in a birth cohort of moderate-to-late preterm infants

BACKGROUND

Data addressing short- and long-term respiratory morbidity in moderate-late preterm infants are limited. We aim to determine the incidence of recurrent wheezing and associated risk and protective factors in these infants during the first 3 years of life.

METHODS

Prospective, multicenter birth cohort study of infants born at 32⁺⁰ to 35⁺⁰  weeks' gestation and followed for 3 years to assess the incidence of physician-diagnosed recurrent wheezing. Allergen sensitization and pulmonary function were also studied. We used multivariate mixed-effects models to identify risk factors associated with recurrent wheezing.

RESULTS

A total of 977 preterm infants were enrolled. Rates of recurrent wheezing during year (Y)1 and Y2 were similar (19%) but decreased to 13.3% in Y3. Related hospitalizations significantly declined from 6.3% in Y1 to 0.75% in Y3. Independent risk factors for recurrent wheezing during Y2 and Y3 included the following: day care attendance, acetaminophen use during pregnancy, and need for mechanical ventilation. Atopic dermatitis on Y2 and male sex on Y3 were also independently associated with recurrent wheezing. Palivizumab prophylaxis for RSV during the first year of life decreased the risk or recurrent wheezing on Y3. While there were no differences in rates of allergen sensitization, pulmonary function tests (FEV_0.5 ) were significantly lower in children who developed recurrent wheezing.

CONCLUSIONS

In moderate-to-late premature infants, respiratory symptoms were associated with lung morbidity persisted during the first 3 years of life and were associated with abnormal pulmonary function tests. Only anti-RSV prophylaxis exerted a protective effect in the development of recurrent wheezing.

Bronchopulmonary dysplasia: what are its links to COPD?

Emerging evidence suggests that adverse early life events can affect long-term health trajectories throughout life. Preterm birth, in particular, is a significant early life event that affects approximately 10% of live births. Worldwide, prematurity is the number one cause of death in children less than 5 years of age and has been shown to disrupt normal lung development with lasting effects into adult life. Along with impaired lung development, interventions used to support gas exchange and other sequelae of prematurity can lead to the development of bronchopulmonary dysplasia (BPD). BPD is a chronic respiratory disease of infancy characterized by alveolar simplification, small airways disease, and pulmonary vascular changes. Although many survivors of BPD improve with age, survivors of BPD often have chronic lung disease characterized by airflow obstruction and intermittent pulmonary exacerbations. Long-term lung function trajectories as measured by FEV1 can be lower in children and adults with a history BPD. In this review, we discuss the epidemiology and manifestations of BPD and its long-term consequences throughout childhood and into adulthood. Available evidence suggests that disrupted lung development, genetic susceptibility and subsequent environment and infectious events that occur in prenatal and postnatal life likely increase the predisposition of children with BPD to develop early onset chronic obstructive pulmonary disease (COPD). The reviews of this paper are available via the supplemental material section.

Day-care center attendance and risk of Asthma-A systematic review

INTRODUCTION AND OBJECTIVES

Asthma and other wheezing disorders are common chronic health problems in childhood. We aim to evaluate whether the attendance by children under three years of age to day-care centers is a protector or risk factor in the development of recurrent wheezing or asthma in the following years of their lives.

METHODS

Systematic review of published cohort or cross-sectional studies, without any time limitation. We searched in PubMed, Cinhal, Cuiden and Scopus (EMBASE included). The quality of the studies was evaluated using the Newcastle-Ottawa Scale. Disagreements were solved by mutual consensus. Weighted odds ratio (ORs) were estimated using RevMan 5.3, following random effects models.

RESULTS

We selected 18 studies for qualitative analysis, nine cohort studies and nine cross-sectional studies. Day-care center attendance is associated with an increased risk of early recurrent wheezing (four studies; 50,619 subjects; adjusted OR 1.87 [1.21 to 2.88]; I² 91%) and asthma before the age of six (five studies; 5412 subjects; adjusted OR 1.59 [1.26 to 2.01]; I² 0%), but not later (five studies; 5538 subjects; adjusted OR 0.86 [0.55 to 1.32]; I² 76%).

CONCLUSIONS

Children attending day-care center during the first years of life have a higher risk of recurrent wheezing during the first three years and asthma before the age of six, but not later. This risk must be taken into account to inform parents in order to choose what kind of care children should have throughout infancy and to implement preventive measures to reduce its impact.

Bronchopulmonary Dysplasia Within and Beyond the Neonatal Unit

BACKGROUND

Bronchopulmonary dysplasia (BPD), also known as chronic lung disease of prematurity or chronic neonatal lung disease, is a major cause of respiratory illness in premature babies. Newborn babies survive at gestational ages of 23 to 26 weeks, earlier than when BPD was first described. New mechanisms of lung injury have therefore emerged and the clinical and pathological characteristics of pulmonary involvement have changed.

PURPOSE

Improved neonatal intensive care unit modalities have increased survival rates; the overall prevalence of the condition, however, has not changed. Management of evolving BPD aims at minimizing lung injury. Management of established, especially severe BPD, still poses significant clinical challenge as these babies need long-term oxygen therapy (LTOT) for variable length of time. We aim to give an overview of management of established BPD with particular focus on weaning home oxygen therapy at our local center in the United Kingdom.

SEARCH AND RESULTS

On the basis of most recent evidence, we concluded that an integrated pathway for managing babies on LTOT is very important after discharge from neonatal unit.

IMPLICATIONS FOR PRACTICE

A structured weaning pathway for premature babies on home oxygen improves outcome.

IMPLICATIONS FOR RESEARCH

The management of severe BPD and related complications, particularly during the first 2 years of life, remains a continuing challenge for parents and healthcare providers. The most beneficial respiratory support strategy to minimize lung injury and/or promote lung healing remains unclear and requires further investigation.

Risk factors for bronchiolitis, recurrent wheezing, and related hospitalization in preterm infants during the first year of life

BACKGROUND

Airway diseases are highly prevalent in infants and cause significant morbidity. We aimed to determine the incidence and risk factors for respiratory morbidity in a Spanish cohort of moderate-to-late preterm (MLP) infants prospectively followed during their first year of life.

METHODS

SAREPREM is a multicenter, prospective, longitudinal study. Preterm infants born at 32-35 weeks of gestation with no comorbidities were enrolled within 2 weeks of life and followed at 2-4 weeks, 6, and 12 months of age. Multivariate mixed-models were performed to identify independent risk factors associated with (i) development of bronchiolitis, (ii) recurrent wheezing, or (iii) related hospital admissions.

RESULTS

Overall, 977 preterm infants were included, and 766 (78.4%) completed follow-up. Of those, 365 (47.7%) developed bronchiolitis during the first year, 144 (18.8%) recurrent wheezing, and 48 (6.3%) were hospitalized. While low birthweight, day care attendance (DCA) and school-age siblings were significantly and independently associated with both the development of bronchiolitis and recurrent wheezing, lower maternal age increased the risk for bronchiolitis and respiratory-related hospitalizations. Lastly, mechanical ventilation was associated with a higher risk of bronchiolitis and history of asthma in any parent increased the likelihood of developing recurrent wheezing.

CONCLUSIONS

In this study, several non-modifiable parameters (family history of asthma, low birthweight, need for mechanical ventilation) and modifiable parameters (young maternal age, DCA, or exposure to school-age siblings) were identified as significant risk factors for the development of bronchiolitis and recurrent wheezing during the first year of life in MLP infants.

Child, household, and caregiver characteristics associated with hospitalization for influenza among children 6-59 months of age: an emerging infections program study

BACKGROUND

Young children are at increased risk of severe outcomes from influenza illness, including hospitalization. We conducted a case-control study to identify risk factors for influenza-associated hospitalizations among children in US Emerging Infections Program sites.

METHODS

Cases were children 6-59 months of age hospitalized for laboratory-confirmed influenza infections during 2005-2008. Age- and zip-code-matched controls were enrolled. Data on child, caregiver and household characteristics were collected from parents and medical records. Conditional logistic regression was used to identify independent risk factors for hospitalization.

RESULTS

We enrolled 290 (64%) of 454 eligible cases and 1089 (49%) of 2204 eligible controls. Risk for influenza hospitalization increased with maternal age <26 years [odds ratio (OR): 1.8, 95% confidence interval (CI): 1.1-2.9]; household income below the poverty threshold (OR: 2.2, 95% CI: 1.4-3.6); smoking by >50% of household members (OR: 2.9, 95% CI: 1.4-6.6); lack of household influenza vaccination (OR: 1.8, 95% CI: 1.2-2.5) and presence of chronic illnesses, including hematologic/oncologic (OR: 11.8, 95% CI: 4.5-31.0), pulmonary (OR: 2.9, 95% CI: 1.9-4.4) and neurologic (OR: 3.8, 95% CI: 1.6-9.2) conditions. Full influenza immunization decreased the risk among children 6-23 months of age (OR: 0.5, 95% CI: 0.3-0.9) but not among those 24-59 months of age (OR: 1.5, 95% CI: 0.8-3.0; P value for difference = 0.01).

CONCLUSIONS

Chronic illnesses, young maternal age, poverty, household smoking and lack of household influenza vaccination increased the risk of influenza hospitalization. These characteristics may help providers to identify young children who are at greatest risk for severe outcomes from influenza illness.

Secondhand smoke exposure in preterm infants with bronchopulmonary dysplasia

OBJECTIVES

Preterm infants and children with bronchopulmonary dysplasia (BPD) often experience significant respiratory morbidities during the first two years of life. Second hand smoke (SHS) has been demonstrated to lead to respiratory morbidities in the general population. The objectives of this study were to assess the prevalence/impact of SHS on preterm infants and children with BPD.

METHODS

Subjects (n = 352) were recruited from the Johns Hopkins BPD outpatient clinic between January 2008 and August 2012. Second hand smoke exposure and respiratory morbidities were assessed through questionnaires and chart review.

RESULTS

Twenty-eight percent of preterm infants with BPD were exposed to SHS in the home setting, despite having significant lung disease. SHS was associated with multiple measures of socio-economic status, including lower household income (P < 0.001), lower caregiver education level (P = 0.013), and having public versus private insurance (P = 0.002). We found no difference in acute care use or chronic symptoms with SHS exposure. We observed trends that preterm infants who were exposed to SHS were more likely to be prescribed inhaled corticosteroids (P = 0.054) and were weaned off of supplemental oxygen over 2 months later (P = 0.13) than infants not exposed to SHS.

CONCLUSION

SHS exposure in preterm infants with BPD is common, even in those receiving supplemental oxygen and respiratory medications. Although there were no associations between respiratory outcomes and self-reported SHS exposure, trends toward increased use of inhaled steroids and a longer duration of supplemental oxygen use were noted. Further work is needed to determine more accurate means of assessing SHS risk in this vulnerable population.

Very low birth weight infants after discharge: What do parents describe?

BACKGROUND

Morbidity and mortality in Very Low Birth Weight (VLBW) infants during their hospital stay have been well described. However, there are insufficient data regarding health problems after discharge.

STUDY DESIGN

In a multicenter study performed between January 2009 and December 2010 including 2493 VLBW infants, questionnaires were sent out to all participating parents in the first year of life. We compared the parental reported health of VLBW infants with a national cohort (KIGGS).

RESULTS

The reported health of VLBW infants born after 29 weeks of gestation was identical to term infants. Even in the group of infants born before 24 weeks of gestation health was regarded as very good or good in >70% of cases. However, parents described a delayed development in >50% increasing to >70% with lower gestational age. In the first year of life VLBW infants have an increased risk of visual and hearing problems. Bronchitis was more frequent in VLBW infants but there were no differences in other infections typical for that age group. VLBW infants had less sleeping problems. No gender differences were described.

CONCLUSION

VLBW infants in our study require slightly more medical care compared to their peers. However, medical problems are relatively small compared to the developmental needs as perceived by their parents. Therefore, close follow-up and advice by specialists in infant development are needed.

Environmental Modifiers of Chronic Lung Disease of Prematurity During Infancy

Chronic lung disease is a common complication of prematurity with substantial mortality and morbidity. Although the variation seen in bronchopulmonary dysplasia has a strong genetic component, the limited environmental variation in neonatal intensive care units may lead to underestimates of the contribution of environmental factors to lung disease variation. Once discharged from the hospital, preterm infants are exposed to a variety of environmental factors that likely worsen their disease. Recognition of these factors may lead to improved outcomes in this vulnerable population through more effective guidelines and counseling. This review examines the role of selected outpatient environmental factors on respiratory outcomes during infancy in preterm infants with lung disease.