The global burden of respiratory disease-impact on child health

Exploring Machine Learning Applications in Pediatric Asthma Management: Scoping Review

BACKGROUND

The integration of machine learning (ML) in predicting asthma-related outcomes in children presents a novel approach in pediatric health care.

OBJECTIVE

This scoping review aims to analyze studies published since 2019, focusing on ML algorithms, their applications, and predictive performances.

METHODS

We searched Ovid MEDLINE ALL and Embase on Ovid, the Cochrane Library (Wiley), CINAHL (EBSCO), and Web of Science (core collection). The search covered the period from January 1, 2019, to July 18, 2023. Studies applying ML models in predicting asthma-related outcomes in children aged <18 years were included. Covidence was used for citation management, and the risk of bias was assessed using the Prediction Model Risk of Bias Assessment Tool.

RESULTS

From 1231 initial articles, 15 met our inclusion criteria. The sample size ranged from 74 to 87,413 patients. Most studies used multiple ML techniques, with logistic regression (n=7, 47%) and random forests (n=6, 40%) being the most common. Key outcomes included predicting asthma exacerbations, classifying asthma phenotypes, predicting asthma diagnoses, and identifying potential risk factors. For predicting exacerbations, recurrent neural networks and XGBoost showed high performance, with XGBoost achieving an area under the receiver operating characteristic curve (AUROC) of 0.76. In classifying asthma phenotypes, support vector machines were highly effective, achieving an AUROC of 0.79. For diagnosis prediction, artificial neural networks outperformed logistic regression, with an AUROC of 0.63. To identify risk factors focused on symptom severity and lung function, random forests achieved an AUROC of 0.88. Sound-based studies distinguished wheezing from nonwheezing and asthmatic from normal coughs. The risk of bias assessment revealed that most studies (n=8, 53%) exhibited low to moderate risk, ensuring a reasonable level of confidence in the findings. Common limitations across studies included data quality issues, sample size constraints, and interpretability concerns.

CONCLUSIONS

This review highlights the diverse application of ML in predicting pediatric asthma outcomes, with each model offering unique strengths and challenges. Future research should address data quality, increase sample sizes, and enhance model interpretability to optimize ML utility in clinical settings for pediatric asthma management.

Environmental exposures associated with early childhood recurrent wheezing in the mother and child in the environment birth cohort: a time-to-event study

BACKGROUND

Antenatal factors and environmental exposures contribute to recurrent wheezing in early childhood.

AIM

To identify antenatal and environmental factors associated with recurrent wheezing in children from birth to 48 months in the mother and child in the environment cohort, using time-to-event analysis.

METHOD

Maternal interviews were administered during pregnancy and postnatally and children were followed up from birth to 48 months (May 2013-October 2019). Hybrid land-use regression and dispersion modelling described residential antenatal exposure to nitrogen dioxide (NO2) and particulate matter of 2.5 µm diameter (PM2.5). Wheezing status was assessed by a clinician. The Kaplan-Meier hazard function and Cox-proportional hazard models provided estimates of risk, adjusting for exposure to environmental tobacco smoke (ETS), maternal smoking, biomass fuel use and indoor environmental factors.

RESULTS

Among 520 mother-child pairs, 85 (16%) children, had a single wheeze episode and 57 (11%) had recurrent wheeze. Time to recurrent wheeze (42.9 months) and single wheeze (37.8 months) among children exposed to biomass cooking fuels was significantly shorter compared with children with mothers using electricity (45.9 and 38.9 months, respectively (p=0.03)). Children with mothers exposed to antenatal ETS were 3.8 times more likely to have had recurrent wheeze compared with those not exposed (adjusted HR 3.8, 95% CI 1.3 to 10.7). Mean birth month NO2 was significantly higher among the recurrent wheeze category compared with those without wheeze. NO2 and PM2.5 were associated with a 2%-4% adjusted increased wheezing risk.

CONCLUSION

Control of exposure to ETS and biomass fuels in the antenatal period is likely to delay the onset of recurrent wheeze in children from birth to 48 months.

A real-world evaluation of the effectiveness and Sufficiency of Current Emergency Department Preventative Strategies for Reducing Emergency Department revisits in a Canadian children's hospital: a retrospective cohort study

BACKGROUND

Despite asthma guidelines' recommended emergency department preventative strategies (EDPS), repeat asthma-related emergency department (ED) visits remain frequent.

METHODS

We performed a retrospective cohort study of children aged 1-17 years presenting with asthma to the Children's Hospital of Eastern Ontario (CHEO) ED between September 1, 2014 - August 31, 2015. EDPS was defined as provision of education on trigger avoidance and medication technique plus documentation of an asthma action plan, a prescription for an inhaled controller medication or referral to a specialist. Logistic regression was used to identify factors associated with receipt of EDPS. We further compared the odds of repeat presentation to the ED within the following year among children who had received EDPS versus those who had not.

RESULTS

1301 patients were included, and the mean age of those who received EDPS was 5.0 years (SD = 3.7). Those with a moderate (OR = 3.67, 95% CI: 2.49, 5.52) to severe (OR = 3.69, 95% CI: 2.50, 5.45) asthma presentation were most likely to receive EDPS. Receiving EDPS did not significantly reduce the adjusted odds of repeat ED visits, (OR = 0.82, 95% CI: 0.56, 1.18, p = 0.28).

CONCLUSIONS

Patients with higher severity asthma presentations to the ED were more likely to receive EDPS, but this did not appear to significantly decrease the proportion with a repeat asthma ED visit. These findings suggest that receipt of EDPS in the ED may not be sufficient to prevent repeat asthma ED visits in all children.

Once-daily fluticasone furoate/vilanterol vs once-daily fluticasone furoate in patients with asthma aged 5 to 17 years

BACKGROUND

Limited data exist comparing inhaled corticosteroid (ICS) plus adjunctive therapy vs ICS alone in pediatric asthma patients.

OBJECTIVE

To evaluate the efficacy and safety of fluticasone furoate/vilanterol (FF/VI) vs FF in children and adolescents with asthma.

METHODS

This phase 3, randomized, double-blind, multicenter study (NCT03248128) included participants aged 5 to 17 years with six months or more asthma history uncontrolled on ICS monotherapy. Participants received 4-week open-label fluticasone propionate (100 µg) twice daily before 1:1 randomization to 24-week double-blind FF (50 µg:100 µg) or FF/VI (50/25 µg:100/25 µg) once daily. Two populations with different primary endpoints were analyzed to meet United States (week 12 weighted mean forced expiratory volume in 1 second [FEV1; 0-4 hours]; participants aged 5-17 years) and European (change from baseline predose morning peak expiratory flow [ΔAM PEF] averaged over weeks 1-12; participants aged 5-11 years) regulatory requirements.

RESULTS

Overall, 902 participants, including 673 children aged 5 to 11 years, were randomized and treated. In participants aged 5 to 17, week 12 weighted mean FEV1 (0-4 hours) was greater with FF/VI vs FF (difference: 0.083 L; P < .001). In participants aged 5 to 11, ΔAM PEF over weeks 1 to 12 showed numerical improvement with FF/VI vs FF but was not statistically significant (difference: 3.2 L/min; P = .228). No drug-related serious adverse events or deaths were reported.

CONCLUSION

FF/VI significantly improved weighted mean FEV1 (0-4 hours; participants aged 5-17 years), but not ΔAM PEF (participants aged 5-11 years) vs FF. No new safety concerns were apparent.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03248128.

Lipid-Laden Macrophages in Pulmonary Diseases

Pulmonary surfactants play a crucial role in managing lung lipid metabolism, and dysregulation of this process is evident in various lung diseases. Alternations in lipid metabolism lead to pulmonary surfactant damage, resulting in hyperlipidemia in response to lung injury. Lung macrophages are responsible for recycling damaged lipid droplets to maintain lipid homeostasis. The inflammatory response triggered by external stimuli such as cigarette smoke, bleomycin, and bacteria can interfere with this process, resulting in the formation of lipid-laden macrophages (LLMs), also known as foamy macrophages. Recent studies have highlighted the potential significance of LLM formation in a range of pulmonary diseases. Furthermore, growing evidence suggests that LLMs are present in patients suffering from various pulmonary conditions. In this review, we summarize the essential metabolic and signaling pathways driving the LLM formation in chronic obstructive pulmonary disease, pulmonary fibrosis, tuberculosis, and acute lung injury.

Mutual Associations of Exposure to Ambient Air Pollutants in the First 1000 Days of Life With Asthma/Wheezing in Children: Prospective Cohort Study in Guangzhou, China

BACKGROUND

The first 1000 days of life, encompassing pregnancy and the first 2 years after birth, represent a critical period for human health development. Despite this significance, there has been limited research into the associations between mixed exposure to air pollutants during this period and the development of asthma/wheezing in children. Furthermore, the finer sensitivity window of exposure during this crucial developmental phase remains unclear.

OBJECTIVE

This study aims to assess the relationships between prenatal and postnatal exposures to various ambient air pollutants (particulate matter 2.5 [PM2.5], carbon monoxide [CO], sulfur dioxide [SO2], nitrogen dioxide [NO2], and ozone [O3]) and the incidence of childhood asthma/wheezing. In addition, we aimed to pinpoint the potential sensitivity window during which air pollution exerts its effects.

METHODS

We conducted a prospective birth cohort study wherein pregnant women were recruited during early pregnancy and followed up along with their children. Information regarding maternal and child characteristics was collected through questionnaires during each round of investigation. Diagnosis of asthma/wheezing was obtained from children's medical records. In addition, maternal and child exposures to air pollutants (PM2.5 CO, SO2, NO2, and O3) were evaluated using a spatiotemporal land use regression model. To estimate the mutual associations of exposure to mixed air pollutants with the risk of asthma/wheezing in children, we used the quantile g-computation model.

RESULTS

In our study cohort of 3725 children, 392 (10.52%) were diagnosed with asthma/wheezing. After the follow-up period, the mean age of the children was 3.2 (SD 0.8) years, and a total of 14,982 person-years were successfully followed up for all study participants. We found that each quartile increase in exposure to mixed air pollutants (PM2.5, CO, SO2, NO2, and O3) during the second trimester of pregnancy was associated with an adjusted hazard ratio (HR) of 1.24 (95% CI 1.04-1.47). Notably, CO made the largest positive contribution (64.28%) to the mutual effect. After categorizing the exposure according to the embryonic respiratory development stages, we observed that each additional quartile of mixed exposure to air pollutants during the pseudoglandular and canalicular stages was associated with HRs of 1.24 (95% CI 1.03-1.51) and 1.23 (95% CI 1.01-1.51), respectively. Moreover, for the first year and first 2 years after birth, each quartile increment of exposure to mixed air pollutants was associated with HRs of 1.65 (95% CI 1.30-2.10) and 2.53 (95% CI 2.16-2.97), respectively. Notably, SO2 made the largest positive contribution in both phases, accounting for 50.30% and 74.70% of the association, respectively.

CONCLUSIONS

Exposure to elevated levels of mixed air pollutants during the first 1000 days of life appears to elevate the risk of childhood asthma/wheezing. Specifically, the second trimester, especially during the pseudoglandular and canalicular stages, and the initial 2 years after birth emerge as crucial susceptibility windows.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-ROC-17013496; https://tinyurl.com/2ctufw8n.

Evaluation of the Early Effects of Childhood Asthma and Its Treatment on Cardiac Function as Revealed by Two-Dimensional Speckle-Tracking Echocardiography

There is minimal information available regarding the early effects of bronchial asthma (BA) and its treatment on cardiac function in children. We used two-dimensional speckle-tracking echocardiography (2D-STE) to evaluate cardiac function before and after the treatment of childhood BA. We enrolled 44 children with moderate and severe BA who had not been treated over the preceding 3 months or who were newly diagnosed. All children received the same treatment (that recommended by the Global Initiative for Asthma [GINA] in 2017). All children also underwent transthoracic 2D-STE before treatment and 6 months later. Clinical data were compared before and after treatment. After treatment, significant increases were evident in right ventricular (RV) systolic and diastolic strain, as well as the systolic strain rate. Before and after treatment, the RV global longitudinal systolic strains were - 22.8 ± 3.6 and - 25.1 ± 4.5, respectively (p = 0.036); the RV global longitudinal diastolic strains were - 18.5 ± 6.0 and - 21.5 ± 5.2, respectively (p = 0.038); and the RV systolic strain rates were - 1.26 ± 0.4 and - 1.12 ± 0.3, respectively (p = 0.025). After treatment, significant increases were observed in the right atrial (RA) peak longitudinal strain and strain rate. Before and after treatment, the RA peak atrial longitudinal strains were 32.5 ± 10.8 and 44.7 ± 11.2, respectively (p = 0.042) and the RA longitudinal strain rates were - 1.6 ± 0.3 and - 2.0 ± 0.5, respectively (p = 0.041). RV and RA subclinical dysfunction may develop in children with early-stage BA. However, asthma treatment appears to improve such dysfunction. In children with BA, clinical and subclinical changes in cardiac functions can be easily detected via 2D-STE.

Indoor air pollution is associated with respiratory symptoms in children in urban Vietnam

Exposure to indoor air pollution (IAP) is a leading environmental risk for respiratory diseases. We investigated the relationship between respiratory symptoms and polluting indoor activities such as smoking, cooking and contact with pets among children in Ho Chi Minh City (HCMC), Vietnam. A cross-sectional survey applied a multistage sampling method in 24 randomly selected secondary schools across the city. Approximately 15,000 students completed self-administrated questionnaires on risk factors and respiratory health outcomes within the preceding 12 months. Data were analyzed using a multivariable logistic regression model with robust standard errors. Wheeze was the most common respiratory symptom (39.5 %) reported, followed by sneezing and runny nose (28.3 %). A small percentage of students self-reported asthma (8.6 %). Approximately 56 % of participants lived with family members who smoked. A positive association between exposure to indoor secondhand smoke and respiratory symptoms was observed, with adjusted odds ratios (aOR) of 1.41 (95 % CI: 1.25-1.60, p < 0.001) for wheezing and 1.64 (95 % CI: 1.43-1.87, p < 0.001) for sneezing and runny nose, respectively. Using an open stove fuelled by coal, wood, or kerosene for cooking was associated with wheeze (aOR: 1.36, CI 95 %: 1.10-1.68, p = 0.01) and sneezing and runny nose (aOR: 1.36, CI 95 %: 1.09-1.69, p = 0.01). In the present study, IAP was associated with adverse health outcomes, as evidenced by an increase in respiratory symptoms reported within the previous 12 months.

Overcoming the Low-Stability Bottleneck in the Clinical Translation of Liposomal Pressurized Metered-Dose Inhalers: A Shell Stabilization Strategy Inspired by Biomineralization

Currently, several types of inhalable liposomes have been developed. Among them, liposomal pressurized metered-dose inhalers (pMDIs) have gained much attention due to their cost-effectiveness, patient compliance, and accurate dosages. However, the clinical application of liposomal pMDIs has been hindered by the low stability, i.e., the tendency of the aggregation of the liposome lipid bilayer in hydrophobic propellant medium and brittleness under high mechanical forces. Biomineralization is an evolutionary mechanism that organisms use to resist harsh external environments in nature, providing mechanical support and protection effects. Inspired by such a concept, this paper proposes a shell stabilization strategy (SSS) to solve the problem of the low stability of liposomal pMDIs. Depending on the shell material used, the SSS can be classified into biomineralization (biomineralized using calcium, silicon, manganese, titanium, gadolinium, etc.) biomineralization-like (composite with protein), and layer-by-layer (LbL) assembly (multiple shells structured with diverse materials). This work evaluated the potential of this strategy by reviewing studies on the formation of shells deposited on liposomes or similar structures. It also covered useful synthesis strategies and active molecules/functional groups for modification. We aimed to put forward new insights to promote the stability of liposomal pMDIs and shed some light on the clinical translation of relevant products.

Clinical determinants for State-Trait Anxiety Inventory of the parents of children with respiratory problems

BACKGROUNDS

Understanding factors associated with anxiety of parents/carers of children with respiratory problems is clinically important yet there is relative paucity of data. In 106 children seen in the respiratory clinic of a pediatric hospital, we evaluated (a) the determinants for parental anxiety and (b) whether the anxiety scores correlate with quality-of-life (QoL) scores in the subset with chronic cough.

METHODS

We opportunistically re-analyzed data of our main study that examined the benefits of using spirometry for pediatric respiratory consultation where parents completed an anxiety questionnaire (State-Trait Anxiety Inventory, STAI) pre- and postconsultation. A subset (children with chronic cough) also completed the parent-proxy quality-of-life (PC-QoL) tool. We computed the association between clinical characteristics and anxiety scores using multivariable regression and between the two patient-reported outcome measures using Spearman's correlation.

RESULTS

The majority of parents/carers were women (n = 89, 84%). Most children (mean age = 10.9 years, SD = 3.7 years) were previously seen at the clinic (n = 67, 63.2%). In multivariate regression, parental anxiety score was significantly associated with reported presence of cough [coefficient β = 17.31 (95% confidence interval 9.62, 25.1)] and lower forced expiratory volume in first second (FEV1 )/forced vital capacity (FVC) [-3.88 (-7.05, -0.71)] at preconsultation, but associated with cough only [coefficient β = 12.04 (5.24, 18.84)] at postconsultation, all p < .05. STAI strongly correlated with PC-QoL scores at pre- but only modestly at postconsultation (rs  = -.63 and -.39, respectively, p < .05).

CONCLUSION

Parental anxiety levels of children attending respiratory clinics are influenced by the presence of cough and low FEV1 /FVC of their child and are associated with poorer QoL. These highlight the need for on-going research to reduce parental anxiety focusing on cough and lung function indices.

Anti-inflammatory effects of reticuline on the JAK2/STAT3/SOCS3 and p38 MAPK/NF-κB signaling pathway in a mouse model of obesity-associated asthma

BACKGROUND

Asthma associated with obesity is a chronic disease characterized by earlier airway remodeling, severe wheezing, and increased insensitivity to hormone therapy. Reticuline, a bioactive compound of Magnoliae Flos, exerts anti-inflammatory activity and can inhibit neutrophil recruitment. Thus, this study investigated the role of reticuline in obesity-related asthma.

METHODS

The BALB/c mice fed a low-fat diet (LFD) and high-fat diet (HFD) were intranasally challenged with house dust mites (HDMs) or ovalbumin (OVA). Reticuline (0.25 mg/kg) was administrated into mice by intragastrical gavage. Airway hyper-responsiveness was examined after the final challenge. Body weight was measured, and bronchoalveolar lavage fluid (BALF) and lung tissues were collected. The number of inflammatory cells in BALF was estimated. Histological changes were assessed by performing hematoxylin-eosin staining, and production of proinflammatory cytokines and IgE was examined by ELISA kits. Related pathways were studied with western blotting.

RESULTS

Reticuline suppressed airway resistance and inflammatory infiltration in lung tissue and reduced inflammatory cell recruitment in BALF in obesity mice with asthma. Additionally, the levels of IL-17A, IL-1β, IL-5, macrophage inflammatory protein 2, and regulated on activation, normal T cell expressed and secreted in the lung were reduced by reticuline. Mechanistically, reticuline inactivated the JAK2/STAT3/SOCS3 and p38 MAPK/NF-κB signaling pathways in obesity-related asthma.

CONCLUSION

Reticuline alleviates airway inflammation in obesity-related asthma by inactivating the JAK2/STAT3/SOCS3 and p38 MAPK/NF-κB signaling pathways.

A low power respiratory sound diagnosis processing unit based on LSTM for wearable health monitoring

Early prevention and detection of respiratory disease have attracted extensive attention due to the significant increase in people with respiratory issues. Restraining the spread and relieving the symptom of this disease is essential. However, the traditional auscultation technique demands a high-level medical skill, and computational respiratory sound analysis approaches have limits in constrained locations. A wearable auscultation device is required to real-time monitor respiratory system health and provides consumers with ease. In this work, we developed a Respiratory Sound Diagnosis Processor Unit (RSDPU) based on Long Short-Term Memory (LSTM). The experiments and analyses were conducted on feature extraction and abnormality diagnosis algorithm of respiratory sound, and Dynamic Normalization Mapping (DNM) was proposed to better utilize quantization bits and lessen overfitting. Furthermore, we developed the hardware implementation of RSDPU including a corrector to filter diagnosis noise. We presented the FPGA prototyping verification and layout of the RSDPU for power and area evaluation. Experimental results demonstrated that RSDPU achieved an abnormality diagnosis accuracy of 81.4 %, an area of 1.57 × 1.76 mm under the SMIC 130 nm process, and power consumption of 381.8 μW, which met the requirements of high accuracy, low power consumption, and small area.

Technical Factors That May Influence mHealth Adherence in Children With Chronic Pulmonary Diseases: Scoping Review

PURPOSE

To synthesize the technical factors influencing adherence to nonpharmacological treatment (NPhT) in children with chronic pulmonary diseases (CPDs), using mobile health (mHealth) technology.

METHODS

Five electronic databases were searched from inception to October 12, 2022, with terms related to pediatrics, CPDs, adherence, NPhT, and mHealth. The methodological quality was assessed using the Critical Appraisal Skills Programme and the Mixed Methods Appraisal Tool checklist.

RESULTS

Eleven articles were included. Six major technical themes were supported by the evidence that may influence adherence to NPhT: design and context, technical support/business model, connectivity, free availability, privacy and security, and cultural readiness.

CONCLUSIONS

The design of mHealth applications (apps) should be done according to the needs of pediatric patients. This may mitigate any barriers and potentially foster adherence to the use of the apps.

WHAT THIS ADDS TO THE EVIDENCE

Six major technical themes may influence adherence to NPhT in children with chronic respiratory diseases.Video Abstract: Supplemental digital content available at http://links.lww.com/PPT/A487 .

Association of Air Pollution with the Number of Common Respiratory Visits in Children in a Heavily Polluted Central City, China

Children's respiratory health is vulnerable to air pollution. Based on data collected from June 2019 to June 2022 at a children's hospital in Zhengzhou, China, this study utilized Spearman correlation analysis and a generalized additive model (GAM) to examine the relationship between daily visits for common respiratory issues in children and air pollutant concentrations. Results show that the number of upper respiratory tract infection (URTI), pneumonia (PNMN), bronchitis (BCT), and bronchiolitis (BCLT) visits in children showed a positive correlation with PM2.5, PM10, NO2, SO2, and CO while exhibiting a negative correlation with temperature and relative humidity. The highest increases in PNMN visits in children were observed at lag 07 for NO2, SO2, and CO. A rise of 10 μg/m3 in NO2, 1 μg/m3 in SO2, and 0.1 mg/m3 in CO corresponded to an increase of 9.7%, 2.91%, and 5.16% in PNMN visits, respectively. The effects of air pollutants on the number of BCT and BCLT visits were more pronounced in boys compared to girls, whereas no significant differences were observed in the number of URTI and PNMN visits based on sex. Overall, air pollutants significantly affect the prevalence of respiratory diseases in children, and it is crucial to improve air quality to protect the children's respiratory health.

High and low-fidelity simulation for respiratory diseases pediatric training: a prospective and randomized study

OBJECTIVE

To compare high and low-fidelity simulations for the recognition of respiratory distress and failure in urgency and emergency pediatric scenarios.

METHODS

70 fourth-year medical students were randomly distributed in high and low-fidelity groups and simulated different types of respiratory problems. Theory tests, performance checklists, and satisfaction and self-confidence questionnaires were used in the assessment. Face-to-face simulation and memory retention was applied. The statistics were evaluated by averages and quartiles, Kappa, and generalized estimating equations. The p-value was considered 0.05.

RESULTS

In the theory test there was an increase in scores in both methodologies (p < 0.001); in memory retention (p = 0.043) and at the end of the process the high-fidelity group had better results. The performance in the practical checklists was better after the second simulation (p > 0,05). The high-fidelity group felt more challenged in both phases (p = 0.042; p = 0.018) and showed greater self-confidence to recognize changes in clinical conditions and in memory retention (p = 0.050). The same group, in relation to the hypothetical real patient to be treated in the future, felt better confident to recognize respiratory distress and failure (p = 0.008; p = 0.004), and better prepared to make a systematic clinical evaluation of the patient in memory retention (p = 0.016).

CONCLUSION

The two levels of simulations enhance diagnostic skills. High fidelity improves knowledge, leads the student to feel more challenged and more self-confident in recognizing the severity of the clinical case, including memory retention, and showed benefits regarding self-confidence in recognizing respiratory distress and failure in pediatric cases.

Periodontopathogens Porphyromonas gingivalis and Fusobacterium nucleatum and Their Roles in the Progression of Respiratory Diseases

The intricate interplay between oral microbiota and the human host extends beyond the confines of the oral cavity, profoundly impacting the general health status. Both periodontal diseases and respiratory diseases show high prevalence worldwide and have a marked influence on the quality of life for the patients. Accumulating studies are establishing a compelling association between periodontal diseases and respiratory diseases. Here, in this review, we specifically focus on the key periodontal pathogenic bacteria Porphyromonas gingivalis and Fusobacterium nucleatum and dissect their roles in the onset and course of respiratory diseases, mainly pneumonia, chronic obstructive pulmonary disease, lung cancer, and asthma. The mechanistic underpinnings and molecular processes on how P. gingivalis and F. nucleatum contribute to the progression of related respiratory diseases are further summarized and analyzed, including: induction of mucus hypersecretion and chronic airway inflammation; cytotoxic effects to disrupt the morphology and function of respiratory epithelial cells; synergistic pathogenic effects with respiratory pathogens like Streptococcus pneumoniae and Pseudomonas aeruginosa. By delving into the complex relationship to periodontal diseases and periodontopathogens, this review helps unearth novel insights into the etiopathogenesis of respiratory diseases and inspires the development of potential therapeutic avenues and preventive strategies.

The relationship between the use of GLP-1 receptor agonists and the incidence of respiratory illness: a meta-analysis of randomized controlled trials

AIM

We aimed to assess the association between the use of Glucagon-like peptide-1 receptor agonists and the risk of 12 respiratory diseases in patients with type 2 diabetes, obesity, or overweight.

METHOD

The PubMed (MEDLINE), EMBASE, Cochrane Library, and ClinicalTrials.gov databases were searched from the establishment of the database to December 24, 2022. Dichotomous outcomes were analyzed using RR and 95% CI calculated from fixed-effects models.

RESULTS

Twenty-eight RCTs were ultimately included for analysis, involving a total of 77,485 participants. Compared to controls, patients with GLP-1RAs have a 14% lower risk of respiratory disease (RR 0.86, 95% CI 0.81-0.93 p < 0.0001), with Semaglutid (RR 0.82, 95% CI 0.68-0.97, p = 0.02), Liraglutide (RR 0.86. 95% CI 0.75-0.98, p = 0.03), Dulaglutide (RR 0.82, 95% CI 0.70-0.96, p = 0.02), Albiglutide (RR 0.93,95% CI 0.79-1.10, p = 0.40), Exenatide (RR 0.93, 95% CI 0.74-1.18, p = 0.55), Lixisenatide (RR 0.83, 95% CI 0.62-1.12, p = 0.22), and Efpeglenatide (RR 0.76, 95% CI 0.46-1.24, p = 0.27). Semaglutide, Liraglutide and Dulaglutide reduce the risk of respiratory diseases by 18%, 14% and 18%, respectively.Trial duration, control type, and indication were not associated with the impact of GLP-1 receptor agonists on overall respiratory disease. Among secondary outcomes, the risk of Pulmonary edema (RR 0.66, 95% CI 0.44-0.98, p = 0.04), and Bronchitis (RR 0.86, 95% CI 0.74-1.00, p = 0.04) was reduced.

CONCLUSION

In conclusion, GLP-1RAs were linked to a lower risk of overall respiratory diseases, especially Pulmonary edema and Bronchitis. In the future, physicians should pay attention to the relationship between GLP-1 RA and the risk of respiratory diseases and evaluate the efficacy of GLP-1RAs in the primary and secondary prevention of respiratory diseases. Trial registration CRD42023396138.

At-Home Saliva Sampling in Healthy Adults Using CandyCollect, a Lollipop-Inspired Device

Respiratory infections are common in children, and there is a need for user-friendly collection methods. Here, we performed the first human subjects study using the CandyCollect device, a lollipop-inspired saliva collection device .We showed that the CandyCollect device can be used to collect salivary bacteria from healthy adults using Streptococcus mutans and Staphylococcus aureus as proof-of-concept commensal bacteria. We enrolled healthy adults in a nationwide (USA) remote study in which participants were sent study packages containing CandyCollect devices and traditional commercially available oral swabs and spit tubes. Participants sampled themselves at home, completed usability and user preference surveys, and mailed the samples back to our laboratory for analysis by qPCR. Our results showed that for participants in which a given bacterium (S. mutans or S. aureus) was detected in one or both of the commercially available methods (oral swab and/or spit tubes), CandyCollect devices had a 100% concordance with the positive result (n = 14 participants). Furthermore, the CandyCollect device was ranked the highest preference sampling method among the three sampling methods by 26 participants surveyed (combining survey results across two enrollment groups). We also showed that the CandyCollect device has a shelf life of up to 1 year at room temperature, a storage period that is convenient for clinics or patients to keep the CandyCollect device and use it any time. Taken together, we have demonstrated that the CandyCollect is a user-friendly saliva collection tool that has the potential to be incorporated into diagnostic assays in clinic visits and telemedicine.

Insights into the mechanism of histamine synthesis and recycling disruption induced by exposure to CdO NPs in the fruit fly (Drosophila melanogaster)

Exposure to a sublethal concentration of CdO nanoparticles impairs the vision of the fruit fly (Drosophila melanogaster) by disrupting histamine (HA) synthesis and recycling mechanisms. To gain more insights, we measured HA titer using HPLC in CdO NP-treated vs. non-treated adults in the current study and found that CdO NPs caused an increase in the level of HA in the head and the decapitated body. We asked whether HA accumulation (increase) is a response of photoreceptors or CNS histaminergic neurons, and whether there is any difference in the expression levels of HA recycling and transport encoding genes (Lovit, CarT, Ebony, Tan, BalaT) between the adult fly head and decapitated body that could explain this HA accumulation. We used GAL4/UAS system tool with three GAL4 drivers: ubiquitous tubP-GAL4, nervous system driver (elav Gal4), and compound eye drivers (sev Gal4 and GMR Gal4) to silence HA synthesis in site specific manner followed by detecting the expression level of genes involved in HA recycling and transport in both the heads and the decapitated bodies of CdO treated and non-treated flies. We found an increase in Lovit expression in the heads of treated adults, which is responsible for HA loading into synaptic vesicles and release from photoreceptors, as well as a decrease in catalytic enzymes involved in HA recycling, which leads to HA accumulation without increasing the real signal. To conclude, both photoreceptors and CNS histaminergic neurons are responsible for the increase in HA in CdO NP-treated flies, but through different mechanisms. Our results provide more insights on the underlying molecular mechanism of vision impairment because of nano-sized cadmium particles exposure.

Effect of radon exposure on asthma morbidity in the School Inner-City Asthma study

BACKGROUND

Radon may have a role in obstructive lung disease outside its known carcinogenicity. Little is known about radon's effects on asthma morbidity.

OBJECTIVE

To determine the effect of radon on fractional exhaled nitric oxide (FE NO), asthma symptom-days, and lung function in inner-city asthmatic school children.

METHODS

Two hundred ninety-nine school-aged asthmatic children enrolled in the School Inner-City Asthma Study (SICAS-1) were followed. One and two-month averaged radon was assessed using a spatiotemporal model predicting zip code-specific monthly exposures. FE NO and spirometry were measured twice during the academic year. Asthma symptoms were assessed four times during the academic year. The interaction between indoor radon exposure (Bq/m3 ) and seasonality predicting log-transformed FE NO, forced expiratory volume in 1 s (FEV1 ) % predicted, forced vital capacity (FVC) % predicted, FEV1 /FVC, and asthma symptom-days was evaluated.

RESULTS

Participants with high radon exposure had greater change in FE NO from warm to cold periods compared to low radon exposure (interaction p = 0.0013). Participants with >50th percentile radon exposure experience significant FE NO increase from warm to cold weather (β $\beta $  = 0.29 [95% confidence interval [CI]: 0.04-0.54], p = 0.0240). We report a positive association between radon 1-month moving average (incidence rate ratio [IRR] = 1.01, p = 0.0273) and 2-month moving average (IRR = 1.01, p = 0.0286) with maximum asthma symptom-days (n = 299, obs = 1167).

CONCLUSIONS

In asthmatic children, radon may be associated with increased asthma morbidity, suggesting radon may be a modifiable environmental risk factor for airway inflammation.

Elevated third trimester corticosteroid levels are associated with fewer offspring infections

Respiratory infections are a leading cause of morbidity and mortality in early life, and recurrent infections increase the risk of developing chronic diseases. The maternal environment during pregnancy can impact offspring health, but the factors leading to increased infection proneness have not been well characterized during this period. Steroids have been implicated in respiratory health outcomes and may similarly influence infection susceptibility. Our objective was to describe relationships between maternal steroid levels and offspring infection proneness. Using adjusted Poisson regression models, we evaluated associations between sixteen androgenic and corticosteroid metabolites during pregnancy and offspring respiratory infection incidence across two pre-birth cohorts (N = 774 in VDAART and N = 729 in COPSAC). Steroid metabolites were measured in plasma samples from pregnant mothers across all trimesters of pregnancy by ultrahigh-performance-liquid-chromatography/mass-spectrometry. We conducted further inquiry into associations of steroids with related respiratory outcomes: asthma and lung function spirometry. Higher plasma corticosteroid levels in the third trimester of pregnancy were associated with lower incidence of offspring respiratory infections (P = 4.45 × 10-7 to 0.002) and improved lung function metrics (P = 0.020-0.036). Elevated maternal androgens were generally associated with increased offspring respiratory infections and worse lung function, with some associations demonstrating nominal significance at P < 0.05, but these trends were inconsistent across individual androgens. Increased maternal plasma corticosteroid levels in the late second and third trimesters were associated with lower infections and better lung function in offspring, which may represent a potential avenue for intervention through corticosteroid supplementation in late pregnancy to reduce offspring respiratory infection susceptibility in early life.Clinical Trial Registry information: VDAART and COPSAC were originally conducted as clinical trials; VDAART: ClinicalTrials.gov identifier NCT00920621; COPSAC: ClinicalTrials.gov identifier NCT00798226.

Disparities in prevalence and outcomes of respiratory disease in low- and middle-income countries

OBJECTIVES

To provide a comprehensive overview of disparities in prevalence and outcomes of respiratory diseases and notable challenges for providing optimal treatment to pediatric patients with respiratory diseases living in low- and middle-income countries (LMICs), as an input to help better understand the roots of respiratory health disparities.

METHODS

We conducted a narrative review of relevant literature published in electronic databases from inception to February 2023 that present data on disparities in prevalence and outcomes of respiratory disease in LMICs. Additionally, we included studies that describe and discuss challenges for providing optimal treatment to pediatric patients with respiratory diseases living in LMICs.

RESULTS

A number of early life exposures have been associated with adverse respiratory outcomes in later life. Several studies have shown marked geographical variations in the prevalence and burden of pediatric asthma, with consistently lower prevalence rates but significantly higher burdens and worse outcomes in LMICs. There is a wide range of challenges that adversely affect the efficient care of children with respiratory diseases that can be classified into three categories: patient-related factors, social/environmental factors, and factors related to healthcare providers or the healthcare system.

CONCLUSIONS

Respiratory health disparities in children living in LMICs represent a global public health issue mainly explained by an unequal distribution of preventable and modifiable risk factors for respiratory diseases across different demographic groups.

Resurgence of influenza and respiratory syncytial virus in Egypt following two years of decline during the COVID-19 pandemic: outpatient clinic survey of infants and children, October 2022

INTRODUCTION

Two years after unprecedented low rates of circulation of most common respiratory viruses (SARS-CoV-2), the Egyptian ARI surveillance system detected an increase in acute respiratory infections (ARIs) with a reduced circulation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), especially among school children. A national survey was conducted to estimate the burden and identify the viral causes of ARIs among children < 16 years of age.

METHODS

A one-day survey was carried out in 98 governmental outpatient clinics distributed all over Egypt 26 governorates. The four largest referral hospitals in each governorate where most influenza-like illness (ILI) patients seek care were selected. Using the WHO case definition, the first five patients < 16 years of age with ILI symptoms visiting the selected outpatient clinics on the survey day were enrolled. Basic demographic and clinical data of patients were collected using a linelist. Patients were swabbed and tested for SARS-CoV-2, influenza, and Respiratory Syncytial virus (RSV) by RT-PCR at the Central Laboratory in Cairo.

RESULTS

Overall, 530 patients enrolled, their mean age was 5.8 ± 4.2, 57.1% were males, and 70.2% reside in rural or semi-rural areas. Of all patients, 134 (25.3%) had influenza, 111 (20.9%) RSV, and 14 (2.8%) coinfections. Influenza-positive children were older compared to RSV, (7.2 ± 4.1, 4.3 ± 4.1, p < 0.001), with more than half of them (53.0%) being school students. Dyspnea was reported in RSV more than in influenza (62.2% vs. 49.3%, p < 0.05). Among RSV patients, children < 2 years had a higher rate of dyspnea than others (86.7% vs. 53.1%, < 0.001).

CONCLUSIONS

A resurgence of influenza and RSV was detected in Egypt in the 2022-2023 winter season. Influenza caused a higher rate of infection than RSV, while RSV caused more severe symptoms than influenza. Monitoring a broader range of respiratory pathogens is recommended to estimate the ARI burden and risky groups for severe disease in Egypt.

A life course approach to asthma and wheezing among young children caused by ozone: A prospective birth cohort in northern China

BACKGROUND

Given differences in vulnerability of children in early life, a life course approach to asthma and wheezing (AW) in young children caused by ozone (O₃) is not fully understood.

METHODS

We conducted a birth cohort in Jinan, China from 2018 to 2021 to elucidate the onset model of childhood AW due to O₃ exposure. An inverse distance weighted model was used for individual exposure assessment. The time-dependent Cox proportional-hazard model and logistic model were used to investigate the effects of O₃ exposure on AW. Principal component analysis, interaction analysis, and distributed lag model were used to analyze the life course approach.

RESULTS

The cumulative incidence rate for AW among 6501 children aged 2 was 1.4%. A high level of O₃ was related to AW (HR: 2.10, 95% CI: 1.31, 3.37). Only O₃ exposure after birth was associated with AW, with an OR of 1.82 (1.08, 3.12), after adjusting for the effect before birth. Furthermore, adjusting for other air pollutants, the HR for the individual effect of high O₃ exposure on AW was 2.44 (1.53, 3.89). Interestingly, P values for interactions for O₃ and the principal components of other pollutants, as well as the characteristic variable of open windows were less than 0.1. Moreover, an increase in the IQR of O₃ exposure at the 31st to 37th weeks before birth and the 1st to 105th weeks after birth was associated with an increase in the HRs for AW.

CONCLUSIONS

High-level of O₃ exposure after birth could lead to AW among young children. Importantly, the AW onset model may include the risk factors accumulation and the sensitive period model. Specifically, there are two sensitive windows in early life, and the correlated insults between the high level of O₃ and other pollutants as well as open windows in the asthma-inducing effect.

At-home saliva sampling in healthy adults using CandyCollect, a lollipop-inspired device

Respiratory infections are common in children, and there is a need for user-friendly collection methods. Here, we performed the first human subjects study using the CandyCollect device, a lollipop inspired saliva collection device. 1 We showed the CandyCollect device can be used to collect salivary bacteria from healthy adults using Streptococcus mutans and Staphylococcus aureus as proof-of-concept commensal bacteria. We enrolled healthy adults in a nationwide (USA) remote study in which participants were sent study packages containing CandyCollect devices and traditional commercially available oral swabs and spit tubes. Participants sampled themselves at home, completed usability and user preference surveys, and mailed the samples back to our laboratory for analysis by qPCR. Our results showed that for participants in which a given bacterium ( S. mutans or S. aureus ) was detected in one or both of the commercially available methods (oral swab and/or spit tubes), CandyCollect devices had a 100% concordance with the positive result (n=14 participants). Furthermore, the CandyCollect device was ranked the highest preference sampling method among the three sampling methods by 26 participants surveyed (combining survey results across two enrollment groups). We also showed that the CandyCollect device has a shelf life of up to 1 year at room temperature, a storage period that is convenient for clinics or patients to keep the CandyCollect device and use it any time. Taken together, we have demonstrated that the CandyCollect is a user-friendly saliva collection tool that has the potential to be incorporated into diagnostic assays in clinic visits and telemedicine.

For Table of Contents Only

Pediatric Pulmonology Training in India: Current Status and Future Directions

Respiratory illnesses are common causes of morbidity and mortality in children. Postgraduates in Pediatrics spent significant time in learning to manage respiratory disorders. Improved survival of preterm neonates, improved diagnosis and survival of chronic respiratory problems, and advances in diagnosis and therapeutics have increased the need for specialists trained in managing these patients. Training programs in Pediatric Pulmonology are evolving over the past few decades. In India, super-specialty training in Pediatric Pulmonology has grown over the past few years. There is a need to modify the training structure used in industrialized countries due to differences in patient population, priorities, and limited available resources and expertise. Formal training courses have been started in a limited number of institutions. There is a large gap between the need for a trained workforce and the available specialists in the limited number of institutions. The Indian Academy of Pediatrics National Respiratory Chapter (IAPNRC) has initiated a fellowship program to bridge the gap. Comprehensive training involving academic and hands-on training may go a long way to improve the care of children with acute and chronic respiratory problems. For sustainable development of the super specialty, there is a need to work towards creating Pediatric Pulmonology service departments in various institutions that may be responsible for comprehensive training and research activities to answer common research questions.

Prevalence and Etiology of Community- and Hospital-Acquired Pneumonia in Saudi Arabia and Their Antimicrobial Susceptibility Patterns: A Systematic Review

(1) Background and Objectives: Pneumonia is a major cause of morbidity and mortality worldwide, including in Saudi Arabia, and the prevalence and etiology of the disease varies depending on the setting. The development of effective strategies can help reduce the adverse impact of this disease. Therefore, this systematic review was conducted to explore the prevalence and etiology of community-acquired and hospital-acquired pneumonia in Saudi Arabia, as well as their antimicrobial susceptibility. (2) Materials and Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 recommendations were followed for this systematic review. Several databases were used to perform a thorough literature search, and papers were then assessed for eligibility by two independent reviewers. The Newcastle-Ottawa Scale (NOS) was used to extract the data from the relevant research and evaluate its quality. (3) Results: This systematic review included 28 studies that highlighted the fact that gram-negative bacteria, particularly Acinetobacter spp. and Pseudomonas aeruginosa, were the common cause of hospital-acquired pneumonia, while Staphylococcus aureus and Streptococcus spp. were responsible for community-acquired pneumonia in children. The study also found that bacterial isolates responsible for pneumonia showed high resistance rates against several antibiotics, including cephalosporins and carbapenems. (4) Conclusions: In conclusion, the study found that different bacteria are responsible for community- and hospital-acquired pneumonia in Saudi Arabia. Antibiotic resistance rates were high for several commonly used antibiotics, highlighting the need for rational antibiotic use to prevent further resistance. Moreover, there is a need to conduct more regular multicenter studies to assess etiology, resistance, and susceptibility patterns of pneumonia-causing pathogens in Saudi Arabia.

C reactive protein-guided prescription of antibiotics for children under 12 years with respiratory symptoms in Kyrgyzstan: protocol for a randomised controlled clinical trial with 14 days follow-up

INTRODUCTION

While lower respiratory tract infections are the main cause of death for children under 5 globally, only a small proportion of children with respiratory tract infections need antibiotics. Overuse of antibiotics globally is leading to increasing rates of antibiotic resistance. In Kyrgyzstan, healthcare workers regularly prescribe antibiotics when clinical uncertainty is present to err on the side of caution. Targeting antibiotic use with biomarkers of inflammation such as C reactive protein (CRP) testing at the point-of-care test (POCT) has been shown to reduce antibiotic use in general, but only few studies have been done in children and no studies exist from Central Asia. This study aims to assess whether the use of a CRP POCT can safely decrease prescription of antibiotics for children with acute respiratory symptoms in primary level healthcare centres in Kyrgyzstan.

METHODS AND ANALYSIS

Multicentre, open-label, individually randomised, controlled clinical trial with 14 days follow-up (follow-up by phone on days 3, 7 and 14) in rural lowland Chui and highland Naryn regions of Kyrgyzstan. The population are children aged 6 months to 12 years attending the primary level healthcare centres during normal business hours with acute respiratory symptoms. CRP POCT equipment will be supplied to healthcare centres, along with a short training session in CRP use, including the interpretation of results to support the clinical evaluation of the child with acute respiratory infection. The primary outcomes are the proportion of patients prescribed an antibiotic within 14 days of index consultation (superiority analysis) and days to recovery (non-inferiority analysis). Secondary outcomes are antibiotics prescribed at index consultation, reconsultations, hospital admission and vital status within 14 days. Analysis of the first primary outcome, antibiotic use, will be intention to treat using a logistic regression model. Analysis of the second primary outcome, days to recovery, will be per protocol using a linear regression model and a non-inferiority margin of 1 day.

ETHICS AND DISSEMINATION

The study was approved on 18 June 2021 by the Ethics Committee (ref: no. 1) of the National Centre of Maternity and Childhood Care, Bishkek, Kyrgyzstan. The results of the study regardless of the conclusion will be presented at international conferences and published in peer-reviewed scientific medical journals along with policy briefs and technical reports.

TRIAL REGISTRATION NUMBER

NCT05195866.

Environmental toxicants and health adversities: A review on interventions of phytochemicals

Toxicity arising from environmental contaminants has attracted global interest in the last few decades, due to the high morbidity and mortality associated with them. Efforts have been made to combat the consequential outcomes of environmental toxicity in humans through traditional remediation techniques and therapeutic measures which have been hampered by one or more limitations. Consequently, this scenario has triggered interest in the medicinal properties of phytochemicals. Thus, this review gives a succinct and in-depth elucidation of the various environmental contaminants and their toxicity effects on humans. It delves into the various classes of phytochemicals and their intervention roles. The study adopted a desk review of existing literatures from scientific reports and peer reviewed articles through triangulation of data sources. "Phytochemicals" are group of secondary metabolites obtained from plants with medicinal properties. These groups of compounds are included but not limited to flavonoids, tannins, saponins, alkaloids, cardenoloids, terpenoids, and phytosteroids. This review corroborates the prophylactic and therapeutics efficacy of these phytochemicals as anti-metastatic, anti-inflammatory, anti-aging, anti-oxidant, anti-microbial and live saving substances with empirical findings from several laboratory, clinical trials and epidemiologic studies. It conclude that given the wide range of medicinal properties of phytochemicals, there is an urgent need for its full optimization in the pharmaceutical industry and future studies should focus on identifying the bioactive molecules in these compounds and its effectiveness against mixer toxicity.

A path forward in the development of new aerosol drug delivery devices for pediatrics

Inhaled medications are widely accepted as being the optimal route for treating pediatric respiratory diseases, a leading cause of hospitalization and death. Despite jet nebulizers being the preferred inhalation device for neonates and infants, current devices face performance issues with most of the drug never reaching the target lung location. Previous work has aimed to improve pulmonary drug deposition, yet nebulizer efficiency remains low. The development of an inhalant therapy that is efficacious and safe for pediatrics depends on a well-designed delivery system and formulation. To accomplish this, the field needs to rethink the current practice of basing pediatric treatments on adult studies. The rapidly evolving pediatric patient (i.e. neonates to eighteen) needs to be considered because they are different from adults with respect to airway anatomy, breathing patterns, and adherence. Previous research approaches to improve deposition efficiency have been limited due to the complexity of combining physics, which drives aerosol transport and deposition, and biology, especially within the area of pediatrics. To address these critical knowledge gaps, we need a better understanding of how patient age and disease state affect deposition of aerosolized drugs. The complexity of the multiscale respiratory system makes scientific investigation very challenging. The authors have simplified the complex problem into five components with these three areas as ones to address first: how the aerosol is (i) generated in a medical device, (ii) delivered to the patient, and (iii) deposited inside the lung. In this review, we discuss the technological advances and innovations made from experiments, simulations, and predictive models in each of these areas. In addition, we discuss the impact on patient treatment efficacy and recommend a clinical direction, with a focus on pediatrics. In each area, a series of research questions are posed and steps for future research to improve efficacy in aerosol drug delivery are outlined.

Point-of-care lung ultrasound score for predicting escalated care in children with respiratory distress

PURPOSE

Respiratory distress due to lower respiratory illnesses is a leading cause of death in children. Early recognition of high-risk populations is critical for the allocation of adequate resources. Our goal was to assess whether the lung ultrasound (US) score obtained at admission in children with respiratory distress predicts the need for escalated care.

METHODS

This prospective study included 0-18-year-old patients with respiratory distress admitted to three emergency departments in the state of Sao Paulo, Brazil, between July 2019 and September 2021. The enrolled patients underwent lung US performed by a pediatric emergency physician within two hours of arrival. Lung ultrasound scores ranging from 0 to 36 were computed. The primary outcome was the need for high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), or mechanical ventilation within 24 h.

RESULTS

A total of 103 patients were included. The diagnoses included wheezing (33%), bronchiolitis (27%), pneumonia (16%), asthma (9%), and miscellaneous (16%). Thirty-five patients (34%) required escalated care and had a higher lung ultrasound score: median 13 (0-34) vs 2 (0-21), p < 0.0001; area under the curve (AUC): 0.81 (95% confidence interval [CI]: 0.71-0.90). The best cut-off score derived from Youden's index was seven (sensitivity: 71.4%; specificity: 79.4%; odds ratio (OR): 9.6 [95% CI: 3.8-24.7]). A lung US score above 12 was highly specific and had a positive likelihood ratio of 8.74 (95% CI:3.21-23.86).

CONCLUSION

An elevated lung US score measured in the first assessment of children with any type of respiratory distress was predictive of severity as defined by the need for escalated care with HFNC, NIV, or mechanical ventilation.

Association of low physical activity with higher respiratory tract infections frequency among pre-school children

BACKGROUND

There is no consensus on the benefits of physical activity (PA) regarding upper respiratory tract infections (URTIs) among children. This study aimed to determine an association between the PA level and URTIs in preschoolers.

METHODS

In 4-7-year-old participants, URTI symptoms were monitored using the Polish version of the Wisconsin Upper Respiratory System Survey for Kids. The daily number of steps, PA intensity, and sleep duration were measured with a Garmin-vivofit pedometer. The lag effect between the initial level of daily PA and the frequency of infections was evaluated.

RESULTS

The average daily step count from healthy days was a significant determinant of the total number of days with the URTI symptoms, and it accounted for 44% (p < 0.001) of this variable variance. A low level of baseline PA (initial 14-day "run-in" observation period) was associated with an increased risk of URTI. In the non-sport group, the severity of the URTI symptoms depended on the number of daily steps. No significant correlation was found between sleep duration and the number of URTI days.

CONCLUSION

Low levels of PA in preschoolers result in increased susceptibility to respiratory infections. Parents should encourage children to engage in PA to prevent URTIs.

IMPACT

In pre-school children, higher physical activity (PA) is associated with fewer days of upper respiratory tract infection symptoms (URTIS). Children with a higher average daily step count have fewer days with URTIS over a long-term observation period. A change in the average number of steps per day by 1000 changed the number of days with symptoms of URTI by 4 days. The severity of URTIS was inversely related to the degree of PA. Children who participate in sports 3 or more hours per week have fewer URTIS than those who do not engage in sports regularly.

A machine learning approach to the development and prospective evaluation of a pediatric lung sound classification model

Auscultation, a cost-effective and non-invasive part of physical examination, is essential to diagnose pediatric respiratory disorders. Electronic stethoscopes allow transmission, storage, and analysis of lung sounds. We aimed to develop a machine learning model to classify pediatric respiratory sounds. Lung sounds were digitally recorded during routine physical examinations at a pediatric pulmonology outpatient clinic from July to November 2019 and labeled as normal, crackles, or wheezing. Ensemble support vector machine models were trained and evaluated for four classification tasks (normal vs. abnormal, crackles vs. wheezing, normal vs. crackles, and normal vs. wheezing) using K-fold cross-validation (K = 10). Model performance on a prospective validation set (June to July 2021) was compared with those of pediatricians and non-pediatricians. Total 680 clips were used for training and internal validation. The model accuracies during internal validation for normal vs. abnormal, crackles vs. wheezing, normal vs. crackles, and normal vs. wheezing were 83.68%, 83.67%, 80.94%, and 90.42%, respectively. The prospective validation (n = 90) accuracies were 82.22%, 67.74%, 67.80%, and 81.36%, respectively, which were comparable to pediatrician and non-pediatrician performance. An automated classification model of pediatric lung sounds is feasible and maybe utilized as a screening tool for respiratory disorders in this pandemic era.

Clinical benefits of β-glucan supplementation in children: a review

Malnutrition is a global concern since it affects 130 million children under the age of 5 worldwide. The child’s immunity is brutally compromised, making them susceptible to various diseases and infections, leading to a high mortality rate. Multiple strategies have been implemented to strengthen immunity in children with compromised immunity, such as rendering a balanced diet, fortifying food, dietary supplements, and introducing potential natural dietary fibers to maintain good nutrition status, such as β-glucan. A class of biologically active polysaccharides, sourced from yeast, mushroom, bacteria, and cereals with versatile immunomodulatory benefits that potentially primes the host immune system, drives several metabolic health effects, increases infection resistance, shields against the damaging effects of stress, and maintains healthy energy levels. This review focuses on the capabilities, underlying mechanisms, immune-stimulating potency, and clinically meaningful shreds of evidence to substantiate the multiple health benefits of β-glucan in children. Although, more clinical studies are required, current findings confirms the various biological response modifying abilities of β-glucan that may notably aid in the development of a strong immune system in children for their overall health and wellbeing.

Economic impact of acute respiratory disease pandemics: A scoping review

Background

The economic impact of acute respiratory disease pandemics has yet to be specifically systematically reviewed. The aim of this scoping review is to identify and classify the economic impacts and its values and ranges.

Materials and Methods

We conducted a literature search across three key databases using an extensive list of keywords. Then, we included studies which explored direct and indirect costs as well as broader economic impact associated with different nine acute respiratory diseases, i.e., pandemic and seasonal influenza, avian influenza, equine influenza, swine influenza, severe acute respiratory syndrome, coronavirus disease 2019, Middle East respiratory syndrome, H1N1, and H7N9.

Results

We included 62 studies in English language between 1987 and 2020, mostly from the countries of East Asia and Pacific pertinent. We classified the economic impact into 5 main categories and 18 subcategories. The main categories were macroeconomic impacts, impacts on health cost, industry, businesses and trade, and education.

Conclusion

Respiratory disease pandemics have widely impacted different sectors of economy such as the direct cost on macroeconomic, providing and receiving health services, disease management, industries, business and trade, education, and indirect costs due to productivity losses. However, lots of the reviewed studies were unable to quantify the actual economic cost of these impacts. This made it challenging to conduct any kind of quantitative comparison of the results. A key priority for future research is to develop standard methods to quantify the broader economic costs of respiratory disease pandemics. Understanding the total economic impact of respiratory disease pandemics is a key step to inform national and international priority setting for disease prevention and pandemic control interventions.

Wingless/integrase-1 signaling in allergic asthma and pediatric lung diseases

PURPOSE OF REVIEW

To provide an update on the current understanding of the role of wingless/integrase-1 (Wnt) signaling in pediatric allergic asthma and other pediatric lung diseases.

RECENT FINDINGS

The Wnt signaling pathway is critical for normal lung development. Genetic and epigenetic human studies indicate a link between Wnt signaling and the development and severity of asthma in children. Mechanistic studies using animal models of allergic asthma demonstrate a key role for Wnt signaling in allergic airway inflammation and remodeling. More recently, data on bronchopulmonary dysplasia (BPD) pathogenesis points to the Wnt signaling pathway as an important regulator.

SUMMARY

Current data indicates that the Wnt signaling pathway is an important mediator in allergic asthma and BPD pathogenesis. Further studies are needed to characterize the roles of individual Wnt signals in childhood disease, and to identify potential novel therapeutic targets to slow or prevent disease processes.

Association of household fuel with acute respiratory infection (ARI) under-five years children in Bangladesh

In developing countries, acute respiratory infections (ARIs) cause a significant number of deaths among children. According to Bangladesh Demographic and Health Survey (BDHS), about 25% of the deaths in children under-five years are caused by ARI in Bangladesh every year. Low-income families frequently rely on wood, coal, and animal excrement for cooking. However, it is unclear whether using alternative fuels offers a health benefit over solid fuels. To clear this doubt, we conducted a study to investigate the effects of fuel usage on ARI in children. In this study, we used the latest BDHS 2017-18 survey data collected by the Government of Bangladesh (GoB) and estimated the effects of fuel use on ARI by constructing multivariable logistic regression models. From the analysis, we found that the crude (the only type of fuel in the model) odds ratio (OR) for ARI is 1.69 [95% confidence interval (CI): 1.06-2.71]. This suggests that children in families using contaminated fuels are 69.3% more likely to experience an ARI episode than children in households using clean fuels. After adjusting for cooking fuel, type of roof material, child's age (months), and sex of the child-the effect of solid fuels is similar to the adjusted odds ratio (AOR) for ARI (OR: 1.69, 95% CI: 1.05-2.72). This implies that an ARI occurrence is 69.2% more likely when compared to the effect of clean fuel. This study found a statistically significant association between solid fuel consumption and the occurrence of ARI in children in households. The correlation between indoor air pollution and clinical parameters of ARI requires further investigation. Our findings will also help other researchers and policymakers to take comprehensive actions by considering fuel type as a risk factor as well as taking proper steps to solve this issue.

Prevalence and associated factors of common childhood illnesses in sub-Saharan Africa from 2010 to 2020: a cross-sectional study

OBJECTIVE

This study aimed to assess the prevalence and determinants of common childhood illnesses in sub-Saharan Africa.

DESIGN

Cross-sectional study.

SETTING

Sub-Saharan Africa.

PARTICIPANTS

Under-5 children.

PRIMARY OUTCOME

Common childhood illnesses.

METHODS

Secondary data analysis was conducted using data from recent Demographic and Health Survey datasets from 33 sub-Saharan African countries. We used the Kids Record dataset file and we included only children under the age of 5 years. A total weighted sample size of 208 415 from the pooled (appended) data was analysed. STATA V.14.2 software was used to clean, recode and analyse the data. A multilevel binary logistic regression model was fitted, and adjusted OR with a 95% CI and p value of ≤0.05 were used to declare significantly associated factors. To check model fitness and model comparison, intracluster correlation coefficient, median OR, proportional change in variance and deviance (-2 log-likelihood ratio) were used.

RESULT

In this study, the prevalence of common childhood illnesses among under-5 children was 50.71% (95% CI: 44.18% to 57.24%) with a large variation between countries which ranged from Sierra Leone (23.26%) to Chad (87.24%). In the multilevel analysis, rural residents, mothers who are currently breast feeding, educated mothers, substandard floor material, high community women education and high community poverty were positively associated with common childhood illnesses in the sub-Saharan African countries. On the other hand, children from older age mothers, children from the richest household and children from large family sizes, and having media access, electricity, a refrigerator and improved toilets were negatively associated.

CONCLUSIONS

The prevalence of common illnesses among under-5 children was relatively high in sub-Saharan African countries. Individual-level and community-level factors were associated with the problem. Improving housing conditions, interventions to improve toilets and strengthening the economic status of the family and the communities are recommended to reduce common childhood diseases.

Reduced Steroid Metabolites Identify Infection-Prone Children in Two Independent Pre-Birth Cohorts

Recurrent respiratory infections are a leading cause of morbidity and mortality in early life, but there is no broadly accepted means to identify infection-prone children during this highly vulnerable period. In this study, we investigated associations between steroid metabolites and incident respiratory infections in two pre-birth cohorts to identify novel metabolomic signatures of early infection proneness. Children from the Vitamin D Antenatal Asthma Reduction Trial and the Copenhagen Prospective Studies on Asthma in Childhood were included, and profiling was performed on plasma samples collected at ages 1 and 6 years. Both cohorts recorded incidence of lower respiratory infections, upper respiratory infections, ear infections, and colds. Poisson regression analysis assessed the associations between 18 steroid metabolites and the total number of respiratory infections that occurred in offspring during follow-up. We found that steroid metabolites across androgenic, corticosteroid, pregnenolone, and progestin classes were reduced in children that suffered more infections, and these patterns persisted at age 6 years, generally reflecting consistency in direction of effect and significance. Our analysis suggested steroid metabolite measurement may be useful in screening for infection proneness during this critical developmental period. Future studies should clinically evaluate their potential utility as a clinical screening tool.

Quantification of lung function on CT images based on pulmonary radiomic filtering

PURPOSE

To develop a radiomics filtering technique for characterizing spatial-encoded regional pulmonary ventilation information on lung computed tomography (CT).

METHODS

The lung volume was segmented on 46 CT images, and a 3D sliding window kernel was implemented across the lung volume to capture the spatial-encoded image information. Fifty-three radiomic features were extracted within the kernel, resulting in a fourth-order tensor object. As such, each voxel coordinate of the original lung was represented as a 53-dimensional feature vector, such that radiomic features could be viewed as feature maps within the lungs. To test the technique as a potential pulmonary ventilation biomarker, the radiomic feature maps were compared to paired functional images (Galligas PET or DTPA-SPECT) based on the Spearman correlation (ρ) analysis.

RESULTS

The radiomic feature maps GLRLM-based Run-Length Non-Uniformity and GLCOM-based Sum Average are found to be highly correlated with the functional imaging. The achieved ρ (median [range]) for the two features are 0.46 [0.05, 0.67] and 0.45 [0.21, 0.65] across 46 patients and 2 functional imaging modalities, respectively.

CONCLUSIONS

The results provide evidence that local regions of sparsely encoded heterogeneous lung parenchyma on CT are associated with diminished radiotracer uptake and measured lung ventilation defects on PET/SPECT imaging. These findings demonstrate the potential of radiomics to serve as a complementary tool to the current lung quantification techniques and provide hypothesis-generating data for future studies.

Dancing for Health and Wellbeing: A Feasibility Study of Examining Health Impacts of Online Dancing among Pulmonary Fibrosis Patients

BACKGROUND

Physical activity (PA) is recommended in the management of patients with pulmonary fibrosis (PF) to improve health outcomes. Dance is one such form of PA which is meaningful, valuable, enjoyable and has demonstrated positive physical and mental health effects.

METHODS

With pre-post design, 16 patients, members of the Irish Lung Fibrosis Association, were enrolled in this study. Once weekly, 75-min dance sessions were delivered for eight weeks via Zoom by an experienced choreographer. Participants completed Chronic Respiratory Questionnaire Self-Administered Standardised Format (CRQ-SAS) and European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) to assess self-rated quality of life. A paired-sample t-test was employed to assess the mean differences between the pre-and post-intervention scores.

RESULTS

Most patients (78.57%) were aged over 60 years; with 71.43% diagnosed with pulmonary fibrosis more than 3 years ago. We performed an analysis of 10/16 participants who completed the intervention (5 males, 5 females). On CRQ-SAS scale we found, (a) dyspnoea-small to moderate magnitude improvement of 0.5-1.0 among 50%, (b) fatigue-small to moderate magnitude improvement of 0.5-1.0 among 40%, (c) emotional function-small to high magnitude improvement of 0.5-2.0 among 50%, (d) mastery-small magnitude improvement of 0.5 among 20%. Participants reported their health moderate to best on Visual Analogue Scale of EQ-5D-3L which improved by 1-3 scale among 40%. Mental health improved as percentage of not feeling anxious or depressed rose post event from 42.86% to 72.73%.

CONCLUSION

Our findings demonstrate that a virtual dance intervention is acceptable, enjoyable and feasible for improving health outcomes among PF patients. More organised and continuous events in future may reveal cost-benefit ratio and impact on health outcomes.

Relationship between Early Childhood Caries and Prolonged Coughing Episodes in a Cohort of Cambodian Children

Studies have shown an association between Early Childhood Caries (ECC) and respiratory infections; however, most have been cross-sectional, and all have been in high-income countries. Inverse probability treatment weighting (IPTW) was applied to longitudinal data from the Cambodia Health and Nutrition Monitoring Study. An analytical sample of 1703 Cambodian children between 1- and 4-years old was used to examine the effect of caries incidence (ECC Activity) on the odds of a child subsequently experiencing an episode of prolonged coughing (>14 days) over the subsequent 18 m. ECC activity occurred among 523 children (30.7%) while prolonged coughing was observed among 235 children (13.8%). ECC activity increased the risk of prolonged coughing (RR 1.23; 95% CI 0.95, 1.58; Average treatment effect = 3%). Follow-up investigations are justified in order to examine whether ECC may be a modifiable risk factor for prevention of respiratory illness among young children.

Associations of Early-Life Exposure to Submicron Particulate Matter With Childhood Asthma and Wheeze in China

IMPORTANCE

Exposure to particulate matter (PM) has been associated with childhood asthma and wheeze. However, the specific associations between asthma and PM with an aerodynamic equivalent diameter of 1 μm or less (ie, PM1), which is a contributor to PM2.5 and potentially more toxic than PM2.5, remain unclear.

OBJECTIVE

To investigate the association of early-life (prenatal and first year) exposure to size-segregated PM, including PM1, PM1-2.5, PM2.5, PM2.5-10, and PM10, with childhood asthma and wheeze.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was based on a questionnaire administered between June 2019 and June 2020 to caregivers of children aged 3 to 6 years in 7 Chinese cities (Wuhan, Changsha, Taiyuan, Nanjing, Shanghai, Chongqing, and Urumqi) as the second phase of the China, Children, Homes, Health study.

EXPOSURES

Exposure to PM1, PM1-2.5, PM2.5, PM2.5-10, and PM10 during the prenatal period and first year of life.

MAIN OUTCOMES AND MEASURES

The main outcomes were caregiver-reported childhood asthma and wheeze. A machine learning-based space-time model was applied to estimate early-life PM1, PM2.5, and PM10 exposure at 1 × 1-km resolution. Concentrations of PM1-2.5 and PM2.5-10 were calculated by subtracting PM1 from PM2.5 and PM2.5 from PM10, respectively. Multilevel (city and child) logistic regression models were applied to assess associations.

RESULTS

Of 29 418 children whose caregivers completed the survey (15 320 boys [52.1%]; mean [SD] age, 4.9 [0.9] years), 2524 (8.6%) ever had wheeze and 1161 (3.9%) were diagnosed with asthma. Among all children, 18 514 (62.9%) were breastfed for more than 6 months and 787 (2.7%) had parental history of atopy. A total of 22 250 children (75.6%) had a mother with an educational level of university or above. Of the 25 422 children for whom information about cigarette smoking exposure was collected, 576 (2.3%) had a mother who was a current or former smoker during pregnancy and 7525 (29.7%) had passive household cigarette smoke exposure in early life. Early-life PM1, PM2.5, and PM10 exposure were significantly associated with increased risk of childhood asthma, with higher estimates per 10-μg/m3 increase in PM1 (OR, 1.55; 95% CI, 1.27-1.89) than in PM2.5 (OR, 1.14; 95% CI, 1.03-1.26) and PM10 (OR, 1.11; 95% CI, 1.02-1.20). No association was observed between asthma and PM1-2.5 exposure, suggesting that PM1 rather than PM1-2.5 contributed to the association between PM2.5 and childhood asthma. There were significant associations between childhood wheeze and early-life PM1 exposure (OR, 1.23; 95% CI, 1.07-1.41) and PM2.5 exposure (OR, 1.08; 95% CI, 1.01-1.16) per 10-μg/m3 increase in PM1 and PM2.5, respectively.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, higher estimates were observed for the association between PM with smaller particles, such as PM1, vs PM with larger particles and childhood asthma. The results suggest that the association between PM2.5 and childhood asthma was mainly attributable to PM1.

The burden of chronic respiratory disease and attributable risk factors in North Africa and Middle East: findings from global burden of disease study (GBD) 2019

BACKGROUND

North Africa and Middle East (NAME) has an increasing burden of chronic respiratory diseases (CRDs); however, a systematic understanding of the distribution and trends is not available. We aimed to report the trends of CRDs and attributable risk factors in this region between 1990 and 2019.

METHODS

Using data from the Global Burden of Diseases Study (GBD) 2019, cause specific mortality served as the basis for estimating incidence and disability-adjusted life years (DALYs). The burden attributable to risk factors was calculated by a comparative risk assessment and contribution of population ageing and growth was determined by decomposition analysis.

RESULTS

The number of deaths due to CRD in 2019 were 128,513 (110,781 to 114,351). In 2019, the age-standardized incidence rate (ASIR) of CRDs was 1052.8 (924.3 to 1209.4) per 100,000 population and had a 10.3% increase and the age-standardized death rate (ASDR) was 36.1 (30.9 to 40.3) with a 32.9% decrease compared to 1990. In 2019, United Arab Emirates had the highest ASIR (1412.7 [1237.3 to 1622.2]) and Afghanistan had the highest ASDR (67.8 [52.0 to 81.3]). CRDs were responsible for 2.91% of total DALYs in 2019 (1.69% due to chronic obstructive pulmonary disease [COPD] and 1.02% due to asthma). With regard to the components of DALYs, the age-standardized rate of years of life lost (YLL) had a - 39.0% (- 47.1 to - 30.3) decrease; while the age-standardized rate of years lived with disability (YLD) had a 13.4% (9.5 to 17.7) increase. Of total ASDRs of CRDs, 31.6% were attributable to smoking and 14.4% to ambient particulate matter pollution.

CONCLUSION

CRDs remain a leading cause of death and disability in NAME, with growth in absolute numbers. COPD and asthma were the most common CRDs and smoking was the leading risk factor especially in men. More attention is needed in order to reduce CRDs' burden through appropriate interventions and policies.

CandyCollect: at-home saliva sampling for capture of respiratory pathogens

Streptococcus pyogenes is a major human-specific bacterial pathogen and a common cause of a wide range of symptoms from mild infection such as pharyngitis (commonly called strep throat) to life-threatening invasive infection and post-infectious sequelae. Traditional methods for diagnosis include collecting a sample using a pharyngeal swab, which can cause discomfort and even discourage adults and children from seeking proper testing and treatment in the clinic. Saliva samples are an alternative to pharyngeal swabs. To improve the testing experience for strep throat, we developed a novel lollipop-inspired sampling platform (called CandyCollect) to capture bacteria in saliva. The device can be used in clinics or in the home and shipped back to a lab for analysis, integrating with telemedicine. CandyCollect is designed to capture bacteria on an oxygen plasma treated polystyrene surface embedded with flavoring substances to enhance the experience for children and inform the required time to complete the sampling process. In addition, the open channel structure prevents the tongue from scraping and removing the captured bacteria. The flavoring substances did not affect bacterial capture and the device has a shelf life of at least 2 months (with experiments ongoing to extend the shelf life). We performed a usability study with 17 participants who provided feedback on the device design and the dissolving time of the candy. This technology and advanced processing techniques, including polymerase chain reaction (PCR), will enable user-friendly and effective diagnosis of streptococcal pharyngitis.

Alarming Levels of Multidrug Resistance in Aerobic Gram-Negative Bacilli Isolated from the Nasopharynx of Healthy Under-Five Children in Accra, Ghana

Nasopharyngeal carriage of aerobic Gram-negative bacilli (GNB) may precede the development of invasive respiratory infections. We assessed the prevalence of nasopharyngeal carriage of aerobic GNB and their antimicrobial resistance patterns among healthy under-five children attending seven selected day-care centres in the Accra metropolis of the Greater Accra region of Ghana from September to December 2016. This cross-sectional study analysed a total of 410 frozen nasopharyngeal samples for GNB and antimicrobial drug resistance. The GNB prevalence was 13.9% (95% CI: 10.8-17.6%). The most common GNB were Escherichia coli (26.3%), Klebsiella pneumoniae (24.6%), and Enterobacter cloacae (17.5%). Resistance was most frequent for cefuroxime (73.7%), ampicillin (64.9%), and amoxicillin/clavulanic acid (59.6%). The organisms were least resistant to gentamicin (7.0%), amikacin (8.8%), and meropenem (8.8%). Multidrug resistance (MDR, being resistant to ≥3 classes of antibiotics) was observed in 66.7% (95% CI: 53.3-77.8%). Extended-spectrum beta-lactamase (ESBL)-producing bacteria constituted 17.5% (95% CI: 9.5-29.9%), AmpC-producing bacteria constituted 42.1% (95% CI: 29.8-55.5%), and carbapenemase-producing bacteria constituted 10.5% (95% CI: 4.7-21.8%) of isolates. The high levels of MDR are of great concern. These findings are useful in informing the choice of antibiotics in empiric treatment of GNB infections and call for improved infection control in day-care centres to prevent further transmission.

Short-term exposure to gaseous air pollutants and daily hospitalizations for acute upper and lower respiratory infections among children from 25 cities in China

To examine the short-term association between gaseous air pollutants (CO, NO₂, SO₂, and O₃) and all-cause respiratory disease, acute upper respiratory infections (AURIs) as well as acute lower respiratory infections (ALRIs) among children, we conducted the study from 25 major cities in China. Hospitalization records of children aged 0-18 years due to all-cause respiratory diseases (889,926), AURIs (97,858), and ALRIs (642,154) from 2016 to 2019 were extracted. Concentrations of CO, NO₂, SO₂, and O₃ were averaged across monitoring stations. Generalized additive models were used to estimate the associations between gaseous air pollutants and daily hospitalizations for all-cause respiratory disease, AURIs, and ALRIs. The meta-analysis was used to combine the city-specific estimates. A 10 mg/m³ increase in CO at lag01, and a 10 μg/m³ increase in NO₂, SO₂, and O₃ at lag01 were associated with 1.65% (95%CI, 0.41-2.91), 0.54% (95%CI, 0.30-0.79), 0.60% (95%CI, 0.22-0.99), and 0.23% (95%CI, 0.06-0.39) increase of hospitalizations due to all-cause respiratory disease, respectively. For the disease subtype, O₃ only had adverse effects on AURIs, CO and SO₂ mainly on ALRIs, and NO₂ on both AURIs and ALRIs. Children aged 4-6years were more vulnerable to the effects of CO and NO₂, but those aged <1year were more susceptible to SO₂ and O₃. Besides, the O₃ effect was stronger in the warm season than in the cold season. The study indicated that short-term exposure to CO, NO₂, SO_2, and O₃ was associated with increased hospitalization for pediatric respiratory disease, and the association may vary by position of the respiratory tract, age, and season.

Mediating Role of Fine Particles Abatement on Pediatric Respiratory Health During COVID-19 Stay-at-Home Order in San Diego County, California

Lower respiratory tract infections disproportionately affect children and are one of the main causes of hospital referral and admission. COVID-19 stay-at-home orders in early 2020 led to substantial reductions in hospital admissions, but the specific contribution of changes in air quality through this natural experiment has not been examined. Capitalizing on the timing of the stay-at-home order, we quantified the specific contribution of fine-scale changes in PM_2.5 concentrations to reduced respiratory emergency department (ED) visits in the pediatric population of San Diego County, California. We analyzed data on pediatric ED visits (n = 72,333) at the ZIP-code level for respiratory complaints obtained from the ED at Rady Children's Hospital in San Diego County (2015-2020) and ZIP-code level PM_2.5 from an ensemble model integrating multiple machine learning algorithms. We examined the decrease in respiratory visits in the pediatric population attributable to the stay-at-home order and quantified the contribution of changes in PM_2.5 exposure using mediation analysis (inverse of odds ratio weighting). Pediatric respiratory ED visits dropped during the stay-at-home order (starting on 19 March 2020). Immediately after this period, PM_2.5 concentrations, relative to the counterfactual values based in the 4-year baseline period, also decreased with important spatial variability across ZIP codes in San Diego County. Overall, we found that decreases in PM_2.5 attributed to the stay-at-home order contributed to explain 4% of the decrease in pediatric respiratory ED visits. We identified important spatial inequalities in the decreased incidence of pediatric respiratory illness and found that brief decline in air pollution levels contributed to a decrease in respiratory ED visits.