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Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, Jartti T, Oommen A, Twynam-Perkins J, Lewis S, Cunningham S. Efficacy of oral corticosteroids for acute preschool wheeze: a systematic review and individual participant data meta-analysis of randomised clinical trials. THE LANCET. RESPIRATORY MEDICINE 2024; 12:444-456. [PMID: 38527486 DOI: 10.1016/s2213-2600(24)00041-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Oral corticosteroids are commonly used for acute preschool wheeze, although there is conflicting evidence of their benefit. We assessed the clinical efficacy of oral corticosteroids by means of a systematic review and individual participant data (IPD) meta-analysis. METHODS In this systematic review with IPD meta-analysis, we systematically searched eight databases (PubMed, Ovid Embase, CINAHLplus, CENTRAL, ClinicalTrials.gov, EudraCT, EU Clinical Trials Register, WHO Clinical Trials Registry) for randomised clinical trials published from Jan 1, 1994, to June 30, 2020, comparing oral corticosteroids with placebo in children aged 12 to 71 months with acute preschool wheeze in any setting based on the Population, Intervention, Comparison, Outcomes framework. We contacted principal investigators of eligible studies to obtain deidentified individual patient data. The primary outcome was change in wheezing severity score (WSS). A key secondary outcome length of hospital stay. We also calculated a pooled estimate of six commonly reported adverse events in the follow-up period of IPD datasets. One-stage and two-stage meta-analyses employing a random-effects model were used. This study is registered with PROSPERO, CRD42020193958. FINDINGS We identified 16 102 studies published between Jan 1, 1994, and June 30, 2020, from which there were 12 eligible trials after deduplication and screening. We obtained individual data from seven trials comprising 2172 children, with 1728 children in the eligible IPD age range; 853 (49·4%) received oral corticosteroids (544 [63·8%] male and 309 [36·2%] female) and 875 (50·6%) received placebo (583 [66·6%] male and 292 [33·4%] female). Compared with placebo, a greater change in WSS at 4 h was seen in the oral corticosteroids group (mean difference -0·31 [95% CI -0·38 to -0·24]; p=0·011) but not 12 h (-0·02 [-0·17 to 0·14]; p=0·68), with low heterogeneity between studies (I2=0%; τ2<0·001). Length of hospital stay was significantly reduced in the oral corticosteroids group (-3·18 h [-4·43 to -1·93]; p=0·0021; I2=0%; τ2<0·001). Subgroup analyses showed that this reduction was greatest in those with a history of wheezing or asthma (-4·54 h [-5·57 to -3·52]; pinteraction=0·0007). Adverse events were infrequently reported (four of seven datasets), but oral corticosteroids were associated with an increased risk of vomiting (odds ratio 2·27 [95% CI 0·87 to 5·88]; τ2<0·001). Most datasets (six of seven) had a low risk of bias. INTERPRETATION Oral corticosteroids reduce WSS at 4 h and length of hospital stay in children with acute preschool wheeze. In those with a history of previous wheeze or asthma, oral corticosteroids provide a potentially clinically relevant effect on length of hospital stay. FUNDING Asthma UK Centre for Applied Research.
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Affiliation(s)
- Bohee Lee
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
| | - Steve Turner
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, UK
| | - Meredith Borland
- Perth Children's Hospital Emergency Department and Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, WA, Australia
| | - Péter Csonka
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Terveystalo Healthcare, Tampere, Finland
| | - Jonathan Grigg
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | - Theresa W Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland; PEDEGO Research Unit, University of Oulu, Oulu, Finland; Department of Pediatrics, Oulu University Hospital, Oulu, Finland
| | - Abraham Oommen
- Department of Paediatrics, Milton Keynes University Hospital NHS Trust, Milton Keynes, UK
| | - Jonathan Twynam-Perkins
- Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK; Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Steff Lewis
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steve Cunningham
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Bonner K, Scotney E, Saglani S. Factors and mechanisms contributing to the development of preschool wheezing disorders. Expert Rev Respir Med 2021; 15:745-760. [PMID: 33881953 DOI: 10.1080/17476348.2021.1913057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Half of all children will experience an episode of wheezing by their sixth birthday and acute episodes of wheezing in preschool children account for the majority of all childhood hospital admissions for wheeze. Recurrent preschool wheezing associates with early loss of lung function and a life-long impact on lung health. AREAS COVERED We reviewed the literature on PubMed from August 2010-2020 focussing on factors associated with wheeze inception and persistence, paying specific attention to mechanistic studies that have investigated the impact of early life exposures in shaping immune responses in children with underlying susceptibility to wheezing. In particular, the role of early allergen sensitization, respiratory infections, and the impact of the environment on shaping the airway microbiome and resulting immune responses are discussed. EXPERT OPINION There is an abundance of associative data showing the role of in utero and postnatal factors influencing wheeze onset and persistence. However, mechanistic and stratified, biomarker-based interventional studies that confirm these associations are now needed if we are to impact the significant healthcare burden resulting from preschool wheezing disorders.
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Affiliation(s)
- Katie Bonner
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Elizabeth Scotney
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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Kitazawa H, Yamaide A, Wada T, Arakawa H. CQ8 Are systemic corticosteroids for prevention of relapse following acute exacerbations of bronchial asthma in children effective? ACTA ACUST UNITED AC 2017. [DOI: 10.3388/jspaci.31.343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hiroshi Kitazawa
- Department of general Pediatrics, Division of Allergy, Miyagi Children’s Hospital
| | - Akiko Yamaide
- Department of Allergy and Rheumatology, Chiba Children’s Hospital
| | - Takuya Wada
- Department of Pediatrics, University of Toyama
| | - Hirokazu Arakawa
- Department of Pediatrics, Gunma University Graduate School of Medicine
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Deshpande DR, Martinez FD. The dilemma of systemic steroids in preschool children with recurrent wheezing exacerbations. Pediatr Pulmonol 2016; 51:775-7. [PMID: 27158816 DOI: 10.1002/ppul.23465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 01/19/2023]
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Castro-Rodriguez JA, Beckhaus AA, Forno E. Efficacy of oral corticosteroids in the treatment of acute wheezing episodes in asthmatic preschoolers: Systematic review with meta-analysis. Pediatr Pulmonol 2016; 51:868-76. [PMID: 27074244 PMCID: PMC5007060 DOI: 10.1002/ppul.23429] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Revised: 02/01/2016] [Accepted: 03/05/2016] [Indexed: 12/22/2022]
Abstract
RATIONALE Systemic corticosteroids (SCS) are used for treat preschoolers with acute asthma or wheezing exacerbations, with conflicting results. OBJECTIVE To evaluate the effectiveness of oral corticosteroids (OCS) compared to placebo in preschoolers presenting with acute asthma/wheezing exacerbations. METHODS Five electronic databases were searched for all placebo-controlled, randomized clinical trials of OCS in children <6 years of age presenting with recurrent wheezing/asthma exacerbations of any severity. Primary outcomes were hospitalizations, unscheduled emergency department (ED) visits in following month, need of additional OCS courses, and length of stay (ED or hospital). RESULTS Eleven studies met inclusion criteria (n = 1,733); four were conducted on an outpatient basis, five in inpatients, and two in the ED. Significant heterogeneity was found when pooling all studies, and thus analysis was stratified by trial setting. Among the outpatient studies, children who received OCS had a higher hospitalization rate (RR: 2.15 [95%CI = 1.08-4.29], I(2) = 0%) compared to those to received placebo. Among the ED studies, children who received OCS had a lower risk of hospitalization (RR: 0.58 [0.37-0.92], I(2) = 0%). Among the inpatient studies, children who received OCS needed fewer additional OCS courses than those on placebo (RR: 0.57 [0.40-0.81], I(2) = 0%). CONCLUSIONS Treatment with OCS in the ED or hospital may be beneficial in toddlers and preschoolers with frequent asthma/wheezing exacerbations. However, more studies are needed before OCS can be broadly recommended for this age group. Future trials should be carefully designed to avoid bias and according to our findings regarding administration setting. Pediatr Pulmonol. 2016;51:868-876. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Jose A Castro-Rodriguez
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrea A Beckhaus
- Division of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Erick Forno
- Division of Pediatric Pulmonary Medicine, Allergy, and Immunology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania
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Fitzgerald DA, Mellis CM. Leukotriene receptor antagonists in virus-induced wheezing : evidence to date. ACTA ACUST UNITED AC 2016; 5:407-17. [PMID: 17154670 DOI: 10.2165/00151829-200605060-00006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Virus-induced wheezing is a relatively benign entity that is usually transient in early childhood but is responsible for much health care utilization. The condition, seen traditionally as a subset of those children diagnosed as having frequent episodic asthma, is often treated with inhaled corticosteroids, despite their lack of efficacy. However, there remains some confusion differentiating atopic asthma from virus-induced wheezing in young children and their respective treatment strategies.The demonstration of cysteinyl leukotrienes in the nasopharyngeal secretions of infants and young children who wheeze prompted investigation of the role of leukotriene receptor antagonists in the treatment of virus-induced wheezing for young children with bronchiolitis and virus-induced wheezing.Montelukast, the only leukotriene receptor antagonist studied in young children, has been proven useful in increasing the number of symptom-free days and delaying the recurrence of wheeze in the month following a diagnosis of respiratory syncytial virus-induced wheezing in children aged 3-36 months. Subsequently, in children aged 2-5 years with frequent episodic asthma, primarily involving viral induced attacks in this age group, regular therapy with daily montelukast for 12 months reduced the rate of asthma exacerbations by 31% over placebo, delayed the time to the first exacerbation by 2 months, and lowered the need to prescribe inhaled corticosteroids as preventative therapy. Additionally, montelukast has been demonstrated to be efficacious as an acute episode modifier in children aged 2-14 years (85% children <6 years) with virus-induced wheezing where it was prescribed at the onset of a viral infection in children with an established pattern of viral induced episodes of wheeze in the preceding year. In this study, emergency department visits were reduced by 45%, visits to all health care practitioners were reduced by 23%, and time of preschool/school and parental time off work was reduced by 33% for children who took montelukast for a median of 10 days.At present, there is good evidence to support the use of bronchodilators in the acute treatment of virus- induced wheezing, and increasing evidence to support the use of leukotriene receptor antagonists, in particular montelukast, in the management of children with virus-induced wheezing.
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Affiliation(s)
- Dominic A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, AustraliaDiscipline of Paediatrics and Child Health, Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
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Collins AD, Beigelman A. An update on the efficacy of oral corticosteroids in the treatment of wheezing episodes in preschool children. Ther Adv Respir Dis 2014; 8:182-90. [PMID: 25294845 DOI: 10.1177/1753465814552283] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Traditionally, oral corticosteroids (OCSs) have been the mainstay of treatment for acute wheezing episodes among preschool children with a history of recurrent wheezing. Although there is substantial evidence for the efficacy of OCSs as a treatment for asthma exacerbations in school-aged children and adolescents, recent clinical studies questioned the benefits of OCSs as a treatment for acute wheezing in preschool children. This review summarizes the current evidence on the efficacy of OCSs as a treatment for acute wheezing episodes among preschool age children with episodic wheezing, focusing on studies performed in three different settings: OCS treatment initiated by parents in the outpatient setting, OCS treatment initiated in the emergency department (ED), and OCS treatment among hospitalized preschool children. The results of most studies reviewed in this paper do not support the efficacy of OCS treatment among preschool children with recurrent wheezing. The heterogeneity of early childhood wheezing and asthma might be part of the explanation for lack of efficacy of this intervention noted in multiple studies.
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Affiliation(s)
| | - Avraham Beigelman
- Division of Allergy, Immunology and Pulmonary Medicine. Department of Pediatrics. Washington University School of Medicine. 660 S. Euclid Ave. Campus Box 8116 St. Louis, MO 63110
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Klein MO, Hilpert F, Ankermann T. [Use in special patient groups: beta-sympathomimetics in children and pregnant women]. ACTA ACUST UNITED AC 2012; 40:417-21. [PMID: 22299160 DOI: 10.1002/pauz.201100437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marcus O Klein
- UKSH-Campus Kiel, Klinik für Allgemeine Pädiatrie, Arnold-Heller-Straße 3, 24105 Kiel
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Abstract
Wheeze, a common symptom in pre-school children, is a continuous high-pitched sound, with a musical quality, emitting from the chest during expiration. A pragmatic clinical classification is episodic (viral) wheeze and multiple-trigger wheeze. Diagnostic difficulties include other conditions that give rise to noisy breathing which could be misinterpreted as wheeze. Most preschool children with wheeze do not need rigorous investigations. Primary prevention is not possible but avoidance of environmental tobacco smoke exposure should be strongly encouraged. Bronchodilators provide symptomatic relief in acute wheezy episodes but the evidence for using oral steroids is conflicting for children presenting to the Emergency Department [ED]. Parent initiated oral steroid courses cannot be recommended. High dose inhaled corticosteroids [ICS] used intermittently are effective in children with frequent episodes of moderately severe episodic (viral) wheeze or multiple-trigger wheeze, but this associated with short term effects on growth and cannot be recommended as a routine. Maintenance treatment with low to moderate continuous ICS in pure episodic (viral) wheeze is ineffective. Whilst low to moderate dose regular ICS work in multi-trigger wheeze, the medication does not modify the natural history of the condition. Even if there is a successful trial of treatment with ICS, a break in treatment should be given to see if the symptoms have resolved or continuous therapy is still required. Maintenance as well as intermittent Montelukast has a role in both episodic and multi trigger wheeze. Good multidisciplinary support and education is essential in managing this common condition.
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Affiliation(s)
- Jayesh M Bhatt
- Consultant in Respiratory Paediatrics, Nottingham University Hospitals NHS Trust (QMC campus), Nottingham, NG7 2UH.
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Affiliation(s)
| | - Shawn Ralston
- Department of Pediatrics University of Texas Health Science Center San Antonio, TX 78229
| | - Matthew Garber
- Department of Pediatrics University of South Carolina School of Medicine Columbia, SC 29203-6878
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Pedersen SE, Hurd SS, Lemanske RF, Becker A, Zar HJ, Sly PD, Soto-Quiroz M, Wong G, Bateman ED. Global strategy for the diagnosis and management of asthma in children 5 years and younger. Pediatr Pulmonol 2011; 46:1-17. [PMID: 20963782 DOI: 10.1002/ppul.21321] [Citation(s) in RCA: 186] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 05/31/2010] [Accepted: 05/31/2010] [Indexed: 12/28/2022]
Abstract
Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity from chronic disease as measured by school absences, emergency department visits, and hospitalisation. During the past two decades, many scientific advances have improved our understanding of asthma and our ability to manage and control it effectively. However, in children 5 years and younger, the clinical symptoms of asthma are variable and non-specific. Furthermore, neither airflow limitation nor airway inflammation, the main pathologic hallmarks of the condition, can be assessed routinely in this age group. For this reason, to aid in the diagnosis of asthma in young children, a symptoms-only descriptive approach that includes the definition of various wheezing phenotypes has been recommended. In 1993, the Global Initiative for Asthma (GINA) was implemented to develop a network of individuals, organizations, and public health officials to disseminate information about the care of patients with asthma while at the same time assuring a mechanism to incorporate the results of scientific investigations into asthma care. Since then, GINA has developed and regularly revised a Global Strategy for Asthma Management and Prevention. Publications based on the Global Strategy for Asthma Management and Prevention have been translated into many different languages to promote international collaboration and dissemination of information. In this report, Global Strategy for Asthma Management and Prevention in Children 5 Years and Younger, an effort has been made to present the special challenges that must be taken into account in managing asthma in children during the first 5 years of life, including difficulties with diagnosis, the efficacy and safety of drugs and drug delivery systems, and the lack of data on new therapies. Approaches to these issues will vary among populations in the world based on socioeconomic conditions, genetic diversity, cultural beliefs, and differences in healthcare access and delivery. Patients in this age group are often managed by pediatricians and general practitioners routinely faced with a wide variety of issues related to childhood diseases.
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Abstract
Children from Indigenous populations experience more frequent, severe, and recurrent lower respiratory infections as infants and toddlers. The consequences of these infections are chronic lung disorders manifested by recurrent wheezing and chronic productive cough. These symptoms are aggravated more frequently by active and passive tobacco smoke exposure among Indigenous groups. Therapies for these symptoms, although not specific to children of Indigenous origins, are described as is the evidence for their use.
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Affiliation(s)
- Gregory J Redding
- Department of Pediatrics, University of Washington School of Medicine, WA, USA.
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Pérez-Yarza EG, Sardón Prado O, Korta Murua J. [Recurrent wheezing in three year-olds: facts and opportunities]. An Pediatr (Barc) 2009; 69:369-82. [PMID: 18928707 DOI: 10.1157/13126564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The 3 year-old group of children has an increased incidence and prevalence of recurrent wheezing episodes. There are different subgroups, who give different inflammatory responses to different triggering agents, and subgroups that differ in aetiopathology and immunopathology. Current diagnostic methods (exhaled nitric oxide in multiple breaths, nitric oxide in exhaled air condensate, induced sputum, broncho-alveolar lavage and endo-bronchial biopsy), enable the inflammatory pattern to be identified and to give the most effective and safe treatment. The various therapeutic options for treatment are reviewed, such as inhaled glucocorticoids when the inflammatory phenotype is eosinophilic, and leukotriene receptor antagonists, when the inflammatory phenotype is predominantly neutrophilic. In accordance with the current recommendations, for the diagnosis as well as for the therapy initiated in children of this age, they must be regularly reviewed, so that if the benefit is not clear, the treatment must be stopped and an alternative diagnosis and treatment considered. The start of treatment should be determined depending on the intensity and frequency of the symptoms, with the aim of decreasing morbidity and increasing the quality of life of the patient.
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Affiliation(s)
- E G Pérez-Yarza
- Unidad de Neumología, Servicio de Pediatría, Hospital Donostia, San Sebastián, España.
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Bacharier LB, Phillips BR, Zeiger RS, Szefler SJ, Martinez FD, Lemanske RF, Sorkness CA, Bloomberg GR, Morgan WJ, Paul IM, Guilbert T, Krawiec M, Covar R, Larsen G, Mellon M, Moss MH, Chinchilli VM, Taussig LM, Strunk RC. Episodic use of an inhaled corticosteroid or leukotriene receptor antagonist in preschool children with moderate-to-severe intermittent wheezing. J Allergy Clin Immunol 2008; 122:1127-1135.e8. [PMID: 18973936 DOI: 10.1016/j.jaci.2008.09.029] [Citation(s) in RCA: 196] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 09/15/2008] [Accepted: 09/18/2008] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute wheezing illnesses in preschoolers require better management strategies to reduce morbidity. OBJECTIVES We sought to examine the effectiveness of episodic use of an inhaled corticosteroid and a leukotriene receptor antagonist in preschoolers with intermittent wheezing. METHODS In a randomized, double-blind, placebo-controlled 12-month trial, 238 children aged 12 to 59 months with moderate-to-severe intermittent wheezing received 7 days of either budesonide inhalation suspension (1 mg twice daily), montelukast (4 mg daily), or placebo in addition to albuterol with each identified respiratory tract illness (RTI). Proportion of episode-free days (EFDs) during the 12-month trial was the primary outcome. RESULTS The 3 treatment groups did not differ in proportions of EFDs, with adjusted mean EFDs of 76% (95% CI, 70% to 81%) for budesonide, 73% (95% CI, 66% to 79%) for montelukast, and 74% (95% CI, 65% to 81%) for conventional therapy (P = .66). The 3 groups did not differ in oral corticosteroid use, health care use, quality of life, or linear growth. However, during RTIs, budesonide and montelukast therapy led to modest reductions in trouble breathing (38% [P = .003] and 37% [P = .003], respectively) and interference with activity scores (32% [P = .01] and 40% [P = .001], respectively) that were most evident in those with positive asthma predictive indices. CONCLUSIONS In preschool children with moderate-to-severe intermittent wheezing, episodic use of either budesonide or montelukast early in RTIs, when added to albuterol, did not increase the proportion of EFDs or decrease oral corticosteroid use over a 12-month period. However, indicators of severity of acute illnesses were reduced, particularly in children with positive asthma predictive indices.
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Affiliation(s)
- Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, MO 63110, USA.
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Busquets Monge RM, Escribano Montaner A, Fernández Benítez M, García-Marcos L, Garde Garde J, Ibero Iborra M, Pardos Rocamora L, Sánchez Jiménez J, Sánchez Sánchez E, Sanz Ortega J, Villa Asensi JR. [Consensus on the treatment of asthma in pediatrics]. An Pediatr (Barc) 2006; 64:365-78. [PMID: 16606575 DOI: 10.1157/13086527] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Monge RMB, Montaner AE, Benítez MF, García-Marcos L, Garde JG, Iborra MI, Rocamora LP, Jiménez JS, Sánchez ES, Ortega JS, Asensi JRV. Consensus statement on the management of paediatric asthma. Allergol Immunopathol (Madr) 2006; 34:88-101. [PMID: 16750118 DOI: 10.1157/13088174] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Fontes MJF, Fonseca MTM, Camargos PAM, Affonso AGA, Calazans GMC. Asma em menores de cinco anos: dificuldades no diagnóstico e na prescrição da corticoterapia inalatória. J Bras Pneumol 2005. [DOI: 10.1590/s1806-37132005000300011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O objetivo deste trabalho foi fazer um levantamento bibliográfico focalizando as dificuldades para se diagnosticar a asma e se estabelecer o início da corticoterapia inalatória em menores de cinco anos. As fontes pesquisadas foram as bases de dados LILACS e MEDLINE, no período de 1991 a 2002, em português, espanhol e inglês. A asma, doença crônica mais comum na infância, apresenta o início dos sintomas nos primeiros anos de vida em grande percentagem dos casos. Na atualidade, não existem meios propedêuticos disponíveis rotineiramente que permitam estabelecer com certeza o diagnóstico em menores de cinco anos. De acordo com as manifestações clínicas, lactentes e pré-escolares podem demandar tratamento semelhante ao da asma desde que precedido por avaliação clínica criteriosa. Conclui-se que o diagnóstico da asma nos primeiros anos de vida é complexo e eminentemente clínico. A corticoterapia inalatória constitui recurso eficaz, mas exige ponderação dos riscos e benefícios.
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Sethi GR, Nagar G. Evidence based treatment of bronchiolitis. Indian J Pediatr 2004; 71:733-7. [PMID: 15345876 DOI: 10.1007/bf02730665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- G R Sethi
- Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
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Busquets Monge RM, Sánchez Sánchez E, Pardos Rocamora L, Villa Asensi JR, Sánchez Jiménez J, Ibero Iborra M, Fernández Benítez M, Sanz Ortega J. [SENP-SEICAP (Spanish Society of Pediatric Pneunomology. Spanish Society of Pediatric Clinical Immunology and Allergology) consensus on asthma, pneumonology, and pediatric allergy (Draft)]. Allergol Immunopathol (Madr) 2004; 32:104-18. [PMID: 15120025 DOI: 10.1016/s0301-0546(04)79295-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Oommen A, Lambert PC, Grigg J. Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial. Lancet 2003; 362:1433-8. [PMID: 14602435 DOI: 10.1016/s0140-6736(03)14685-5] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Episodic wheeze triggered by viral colds is common in children aged between 1 and 5 years (preschool viral wheeze). Most affected children are asymptomatic by age 6 years. Persistence of wheeze is associated with above-average systemic eosinophil priming. Use of parental-initiated oral prednisolone is recommended at the first sign of preschool viral wheeze. However, evidence for this treatment strategy is conflicting. We therefore aimed to assess the efficacy of a short course of oral prednisolone for preschool viral wheeze, with stratification for systemic eosinophil priming. METHODS Children aged 1-5 years admitted to hospital with viral wheeze were allocated to either a high-primed or low-primed stratum according to amounts of serum eosinophil cationic protein and eosinophil protein X, and randomised to parent-initiated prednisolone (20 mg one daily for 5 days) or placebo for the next episode. The primary outcomes were the 7-day mean daytime and night-time respiratory symptom scores, which were analysed by mean differences between treatment groups. FINDINGS 108 children were randomised to placebo and 109 to prednisolone. Outcome data were available for 120 (78%) of 153 children who had a further episode of viral wheeze, of whom 51 received prednisolone and 69 placebo. Mean daytime (difference in means -0.01 [-0.22 to 0.20]) and night-time (0.10 [-0.12 to 0.32]) respiratory symptom scores and need for hospital admission did not differ between treatment groups. Within the high-primed (n=59) and low-primed (n=61) strata there was no difference in primary outcome between treatment groups. INTERPRETATION There is no clear benefit of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years even in those with above-average eosinophil priming.
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Affiliation(s)
- Abraham Oommen
- Leicester Children's Asthma Centre, Institute for Lung Health, University of Leicester, Leicester, UK
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Abstract
Asthma represents the most common chronic disease in preschool children. Hospital admission for wheezy disorders is the most common paediatric chronic disease causing hospital admission and more common in young children than later in life.
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Affiliation(s)
- H Bisgaard
- Department of Paediatrics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Abstract
Consultant paediatricians were questioned about their management of wheezing disorders in infants. Salbutamol was the preferred bronchodilator for recurrent wheeze, whereas ipratropium was preferred in viral bronchiolitis. Doses of both medications varied widely. Both inhaled and oral corticosteroids were considered by most respondents. Practice does not clearly follow guidelines or evidence and presumably continues to be based on anecdote.
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Affiliation(s)
- R J Chavasse
- The Royal Alexandra Hospital for Sick Children, Brighton BN1 3JN, UK.
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Jartti T, Vanto T, Heikkinen T, Ruuskanen O. Systemic glucocorticoids in childhood expiratory wheezing: relation between age and viral etiology with efficacy. Pediatr Infect Dis J 2002; 21:873-8. [PMID: 12352814 DOI: 10.1097/00006454-200209000-00019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Tuomas Jartti
- Department of Pediatrics, Turku University Hospital, Turku, Finland
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Chavasse R, Seddon P, Bara A, McKean M. Short acting beta agonists for recurrent wheeze in children under 2 years of age. Cochrane Database Syst Rev 2002; 2010:CD002873. [PMID: 12137663 PMCID: PMC8456461 DOI: 10.1002/14651858.cd002873] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Wheeze is a common symptom in infancy and is a common cause for both primary care consultations and hospital admission. Beta2-adrenoceptor agonists (b2-agonists) are the most frequently used as bronchodilator but their efficacy is questionable. OBJECTIVES To determine the effectiveness of b2-agonist for the treatment of infants with recurrent and persistent wheeze. SEARCH STRATEGY Relevant trials were identified using the Cochrane Airways Group database (CENTRAL), Medline and Pubmed. The database search used the following terms: Wheeze or asthma and Infant or Child and Short acting beta-agonist or Salbutamol (variants), Albuterol, Terbutaline (variants), Orciprenaline, Fenoterol SELECTION CRITERIA Randomised controlled trials comparing the effect of b2-agonist against placebo in children under 2 years of age who had had two or more previous episodes of wheeze, not related to another form of chronic lung disease. DATA COLLECTION AND ANALYSIS Eight studies met the criteria for inclusion in this meta-analysis. The studies investigated patients in three settings: at home (3 studies), in hospital (2 studies) and in the pulmonary function laboratory (3 studies). The main outcome measure was change in respiratory rate except for community based studies where symptom scores were used. MAIN RESULTS The studies were markedly heterogeneous and between study comparisons were limited. Improvement in respiratory rate, symptom score and oxygen saturation were noted in one study in the emergency department following two salbutamol nebulisers but this had no impact on hospital admission. There was a reduction in bronchial reactivity following salbutamol. There was no significant benefit from taking regular inhaled salbutamol on symptom scores recorded at home. REVIEWER'S CONCLUSIONS There is no clear benefit of using b2-agonists in the management of recurrent wheeze in the first two years of life although there is conflicting evidence. At present, further studies should only be performed if the patient group can be clearly defined and there is a suitable outcome parameter capable of measuring a response.
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Affiliation(s)
- R Chavasse
- Kings Healthcare NHS Trust, Kings College Hospital, Bessemer Road, Denmark Hill, London, UK, SE5 9RS.
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Chavasse RJ, Bastian-Lee Y, Richter H, Hilliard T, Seddon P. Inhaled salbutamol for wheezy infants: a randomised controlled trial. Arch Dis Child 2000; 82:370-5. [PMID: 10799426 PMCID: PMC1718341 DOI: 10.1136/adc.82.5.370] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Salbutamol is frequently used as a bronchodilator for infants who wheeze. Many single dose studies have questioned its effectiveness. AIMS To investigate the response of wheezy infants to salbutamol over an extended time period in order to elucidate either symptomatic relief or a protective effect. METHODS Eighty infants under 1 year, with persistent or recurrent wheeze and a personal or family history of atopy, were recruited to a randomised, double blind, cross over, placebo controlled trial. Salbutamol (200 microg three times daily) or placebo were administered regularly over two consecutive treatment periods of four weeks via a spacer and mask. Symptoms of wheeze and cough were recorded in a diary. At the end of the study pulmonary function tests were performed before and after salbutamol (400 microg). RESULTS Forty eight infants completed the diary study; 40 infants underwent pulmonary function testing. No difference in mean daily symptom score was observed between the salbutamol and placebo periods. There was no difference in the number of symptom free days. Compliance and forced expiratory flows remained unchanged and resistance increased following salbutamol. There was no relation between the response measured by symptom score or pulmonary function in individual patients. CONCLUSION In wheezy infants with an atopic background, there was no significant beneficial effect of salbutamol on either clinical symptoms or pulmonary function. Clinical effects could not be predicted from pulmonary function tests. Salbutamol cannot be recommended as the bronchodilator of choice in this age group.
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Affiliation(s)
- R J Chavasse
- The Royal Alexandra Hospital for Sick Children, Dyke Road, Brighton BN1 3JN, UK.
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