Wheezing in preschool children

Managing children with frequent respiratory infections and associated wheezing: a preliminary randomized study with a new multicomponent nasal spray

BACKGROUND

Preschoolers frequently have respiratory infections (RIs), which may cause wheezing in some subjects. Type 2 polarization may favor increased susceptibility to RIs and associated wheezing. Non-pharmacological remedies are garnering increasing interest as possible add-on therapies. The present preliminary study investigated the efficacy and safety of a new multi-component nasal spray in preschoolers with frequent RIs and associated wheezing.

METHODS

Some preschoolers with these characteristics randomly took this product, containing lactoferrin, dipotassium glycyrrhizinate, carboxymethyl-beta-glucan, and vitamins C and D3 (Saflovir), two sprays per nostril twice daily for 3 months. Other children were randomly treated only with standard therapy. Outcomes included the number of RIs and wheezing episodes, use of medications, and severity of clinical manifestations.

RESULTS

Preschoolers treated add-on with this multicomponent product experienced fewer RIs and used fewer beta-2 agonists than untreated children (P = 0.01 and 0.029, respectively).

CONCLUSIONS

This preliminary study demonstrated that a multicomponent product, administered add-on as a nasal spray, could reduce the incidence of RIs and use of symptomatic drugs for relieving wheezing in children.

Referrals and Determinant Factors of a National School Health Campaign in Lebanon on Children Aged between 3 and 12 Years Old

In this extensive study examining the health of 7184 school children aged 3 to 12 in 27 Lebanese schools, screenings involved medical evaluation and interviews, complemented by phone interviews with 3880 parents. Notably, one in two students received a medical referral, revealing prevalent issues such as dental cavities (33%), under-vaccination (25%), undetected vision problems (13%), abnormal growth (6%), underweight (27%), and overweight (33%). Additional concerns encompassed abnormal vital signs (3%), abuse signs (0.6%), infectious skin lesions (1.6%), scoliosis (1.7%), abnormal auscultation (heart 1.1%, lungs 1.2%), ear problems (3.3%), precocious puberty (0.7%), and neurologic signs (0.6%). Mental health challenges affected 20-25% of students. Public schools and Beirut exhibited higher referral rates, with girls, older children, overweight students, those lacking regular pediatrician visits, and children of self-employed or less educated parents facing elevated referral rates. In contrast, children of healthcare workers experienced fewer referrals. Against this backdrop, the study emphasizes the imperative for targeted health initiatives, particularly in marginalized areas and for socioeconomically disadvantaged students. Priority areas include dental care, weight issues, mental health, vaccination compliance, and addressing vision problems to enhance learning outcomes.

Clinical efficacy and satisfaction of a digital wheeze detector in a multicentre randomised controlled trial: the WheezeScan study

Introduction

Wheezing is common in preschool children and its clinical assessment often challenging for caretakers. This study aims to evaluate the impact of a novel digital wheeze detector (WheezeScan™) on disease control in a home care setting.

Methods

A multicentre randomised open-label controlled trial was conducted in Berlin, Istanbul and London. Participants aged 4-84 months with a doctor's diagnosis of recurrent wheezing in the past 12 months were included. While the control group followed usual care, the intervention group received the WheezeScan™ for at-home use for 120 days. Parents completed questionnaires regarding their child's respiratory symptoms, disease-related and parental quality of life, and caretaker self-efficacy at baseline (T0), 90 days (T1) and 4 months (T2).

Results

A total of 167 children, with a mean±sd age of 3.2±1.6 years, were enrolled in the study (intervention group n=87; control group n=80). There was no statistically significant difference in wheeze control assessed by TRACK (mean difference 3.8, 95% CI -2.3-9.9; p=0.2) at T1 between treatment groups (primary outcome). Children's and parental quality of life and parental self-efficacy were comparable between both groups at T1. The evaluation of device usability and perception showed that parents found it useful.

Conclusion

In the current study population, the wheeze detector did not show significant impact on the home management of preschool wheezing. Hence, further research is needed to better understand how the perception and usage behaviour may influence the clinical impact of a digital support.

Outdoor air pollution exposure and the risk of asthma and wheezing in the offspring

According to the "fetal origin of disease" hypothesis, air pollution exposure in pregnancy may play an important role in stimulating the early programming of asthma and allergies. However, previous studies reported inconsistent findings. The aim of this meta-analysis was to provide higher grade evidence and quantitatively analyze the link between prenatal exposure to outdoor air pollutants and childhood asthma and wheezing. Databases (Web of Science and PubMed) were extensively searched for articles published from the start of the database to September 15, 2021. Either random-effect model or fixed-effect model was used to estimate the disease-specific relative risks (RR) with the corresponding 95% confidence intervals (CIs) to estimate the association. Newcastle-Ottawa Quality Score (NOS) was used to assess the quality of studies. This study finally included 13 cohort studies, and the findings showed that NO₂ and SO₂ exposure during entire pregnancy was significantly associated with wheezing (RR = 1.032, 95% CI: 1.000, 1.066) and asthma (RR = 1.114, 95% CI: 1.066, 1.164), respectively. Further analyses showed that PM_2.5 were positively associated with asthma in the second (RR = 1.194, 95% CI: 1.143, 1.247) and third trimester (RR = 1.050, 95% CI: 1.007, 1.094), while NO₂ (RR = 1.060, 95% CI: 1.021, 1.101) and SO₂ (RR = 1.067, 95% CI: 1.013, 1.123) were shown positively associated with asthma only in the second trimester. The relationship between wheezing and outdoor air pollutants was not significant in any of the pregnancy subgroups. This study suggests that prenatal exposure of outdoor air pollution may increase the asthma and wheezing risk in the offspring and that the second trimester may be a sensitive period for air pollution exposure. But the interpretation of the causal association is hampered by limited number of studies on dose response.

Probiotics in Children with Asthma

A type-2 immune response usually sustains wheezing and asthma in children. In addition, dysbiosis of digestive and respiratory tracts is detectable in patients with wheezing and asthma. Probiotics may rebalance immune response, repair dysbiosis, and mitigate airway inflammation. As a result, probiotics may prevent asthma and wheezing relapse. There is evidence that some probiotic strains may improve asthma outcomes in children. In this context, the PROPAM study provided evidence that two specific strains significantly prevented asthma exacerbations and wheezing episodes. Therefore, oral probiotics could be used as add-on asthma therapy in managing children with asthma, but the choice should be based on documented evidence.

Association of children wheezing diseases with meteorological and environmental factors in Suzhou, China

Wheezing diseases are one of the major chronic respiratory diseases in children. To explore the effects of meteorological and environmental factors on the prevalence of children wheezing diseases, clinical data of children hospitalized with wheezing diseases in Suzhou, China from 2013 to 2017 were collected. Meteorological and environmental factors from 2013 to 2017 were obtained from the local Meteorological Bureau and Environmental Protection Bureau. Relationships between wheezing diseases and meteorological and environmental factors were evaluated using Pearson's correlation and multivariate regression analysis. An autoregressive integrated moving average (ARIMA) model was used to estimate the effects of meteorological and environmental variables on children wheezing diseases. Children wheezing diseases were frequently presented in infants less than 12 months old (1897/2655, 58.28%), and the hospitalization rate was highest in winter (1024/3255, 31.46%). In pathogen-positive specimens, the top three pathogens were respiratory syncytial virus (21.35%), human rhinovirus (16.28%) and mycoplasma pneumoniae (10.47%). The seasonality of wheezing children number showed a distinctive winter peak. Children wheezing diseases were negatively correlated with average temperature (P < 0.001, r =  - 0.598). The ARIMA (1,0,0)(0,0,0)₁₂ model could be used to predict temperature changes associated wheezing diseases. Meteorological and environmental factors were associated with the number of hospitalized children with wheezing diseases and can be used as early warning indicators for the occurrence of wheezing diseases and prevalence of virus.

Impulse Oscillometry System for the Diagnosis of Wheezing Episode in Children in Office Practice

Background and Objective

Objectively differentiating between wheezing episodes and other respiratory disorders will be helpful in treatment in office practice. The impulse oscillometry system has been useful in assessing airway resistance in children 3–6 years old. As the reference values are different in geographical regions the use of the impulse oscillometry is still limited. Comparison between the percent change in IOS parameters as compared to reference standards and changes in actual IOS parameters was done to diagnose wheezing episodes.

Methodology

Three to six years old children with a history of fever, cough, cold, and/or breathlessness with noisy breathing and who were not on any regular medications, whose parents gave consent were recruited in the study. The children underwent an impulse oscillometry system examination as per the guidelines. The test was repeated after they were given nebulization by salbutamol (2.5 mg) (before COVID 19 pandemic). Final diagnosis was done by following patients for 7 days.

Results

About 106 children were recruited in the study. Five children could not perform the IOS test. Eighteen children did not complete the follow-up. Hence, 83 children were analyzed. There were 47 males and 36 female patients. The change in actual values of AX, R5, and X20 showed statistically significant difference in wheezing episode group (p-value<0.001). The percentage change as compared to predicted values of R5 and X20 also showed a statistically significant difference in the wheezing episode group and the others group (p-value<0.001).

Conclusion

The change in actual values of AX, R5, X20, and resonant frequency may help to differentiate wheezing episode from other respiratory diseases.

Role of montelukast in multitrigger wheezers attending chest clinic in Punjab, India

BACKGROUND

Wheeze is seen in 40% of preschool children, one-third of these may develop recurrent wheeze. Montelukast is an oral, once a day, easy to give therapy but there is no definite evidence to support its use in a recent meta-analysis. Present study was done to evaluate role of daily montelukast and various factors affecting the outcome after therapy in multitrigger wheeze (MTW).

METHODS

A prospective study conducted in Pediatric chest clinic over 18 months at DMCH, Ludhiana. Children from 6 months to 5 years, diagnosed cases of MTW were started on montelukast. Diagnosis based on symptoms of recurrent wheeze triggered by various allergens/precipitants was made by pediatrician in charge of chest clinic. Children were followed up at 1 and 3 months. They were labeled as controlled, partially controlled, or uncontrolled as per global initiative for asthma guidelines. Data were used to compare the outcome related to various factors.

RESULTS

Total 139 out of 150 children came for regular follow-up. At the end of 3 months, 94 (67.7%) were controlled, 8 (5.7%) partially controlled, and 37 (26.6%) children remained uncontrolled on montelukast. Factors associated with poor control were onset of symptoms at younger age (<6 months of age), family history of allergies, prior multiple visits or hospitalizations due to MTW, use of MDI in the past. No significant side effects were reported by parents.

CONCLUSION

Symptomatically two-third of children became better after starting montelukast. There were few factors which resulted in poorer control in subset of patients.

A wheeze recognition algorithm for practical implementation in children

BACKGROUND

The detection of wheezes as an exacerbation sign is important in certain respiratory diseases. However, few highly accurate clinical methods are available for automatic detection of wheezes in children. This study aimed to develop a wheeze detection algorithm for practical implementation in children.

METHODS

A wheeze recognition algorithm was developed based on wheezes features following the Computerized Respiratory Sound Analysis guidelines. Wheezes can be detected by auscultation with a stethoscope and using an automatic computerized lung sound analysis. Lung sounds were recorded for 30 s in 214 children aged 2 months to 12 years and 11 months in a pediatric consultation room. Files containing recorded lung sounds were assessed by two specialist physicians and divided into two groups: 65 were designated as "wheeze" files, and 149 were designated as "no-wheeze" files. All lung sound judgments were agreed between two specialist physicians. We compared wheeze recognition between the specialist physicians and using the wheeze recognition algorithm and calculated the sensitivity, specificity, positive predictive value, and negative predictive value for all recorded sound files to evaluate the influence of age on the wheeze detection sensitivity.

RESULTS

The detection of wheezes was not influenced by age. In all files, wheezes were differentiated from noise using the wheeze recognition algorithm. The sensitivity, specificity, positive predictive value, and negative predictive value of the wheeze recognition algorithm were 100%, 95.7%, 90.3%, and 100%, respectively.

CONCLUSIONS

The wheeze recognition algorithm could identify wheezes in sound files and therefore may be useful in the practical implementation of respiratory illness management at home using properly developed devices.

Common causes of congenital stridor in infants

Stridor is a high-pitched respiratory sound that signals upper airway obstruction. It can be encountered by clinicians in a variety of clinical settings and requires a team-based, interdisciplinary approach. Early recognition is crucial, as the differential diagnosis can be broad, and causes range from benign to life-threatening. This article reviews the most commonly encountered causes of chronic congenital stridor in infants, focusing on the diagnostic approach, pathophysiology, clinical presentation, and management strategies.

Prenatal and early-life antibiotic use and risk of childhood asthma: A retrospective cohort study

BACKGROUND

Although associations between antibiotic exposure in infants and asthma development are reported, few studies have examined the effects of prenatal exposure to antibiotics. We evaluated this association considering the antibiotic types using a large-scale claim database in Japan.

METHODS

This retrospective study using health insurance administrative claim data in Japan included children born between January 2005 and September 2014. We constructed 2 cohorts: initial cohort, with information on children's mothers, and sibling cohort, with at least one sibling. Cox proportional hazard regression and sibling-matched cohort analyses were performed to determine the association between exposure to antibiotics in utero or the first year of life and asthma development until age 6.

RESULTS

In the initial cohort, antibiotic exposure during the foetal period was associated with early asthma development (until age 3; HR: 1.18, 95% CI: 1.08-1.30). However, this association disappeared after 3 years. The association between antibiotic exposure in the first year of life and asthma was stronger in early (HR: 2.43, 95% CI: 2.20-2.69) than later (HR: 1.23, 95% CI: 1.11-1.36) life. In the sibling cohort, we observed positive associations between foetal exposure and asthma by adjusting for familial factors (HR: 1.34, 95% CI: 1.05-1.72), which remained during the first year of life (HR: 1.62, 95% CI: 1.27-2.07).

CONCLUSIONS

Exposure to antibiotics during the first year of life was associated with childhood asthma even after adjusting for familial factors. However, a weak association was observed between prenatal antibiotic exposure and asthma development.

Validation of computerized wheeze detection in young infants during the first months of life

BACKGROUND

Several respiratory diseases are associated with specific respiratory sounds. In contrast to auscultation, computerized lung sound analysis is objective and can be performed continuously over an extended period. Moreover, audio recordings can be stored. Computerized lung sounds have rarely been assessed in neonates during the first year of life. This study was designed to determine and validate optimal cut-off values for computerized wheeze detection, based on the assessment by trained clinicians of stored records of lung sounds, in infants aged <1 year.

METHODS

Lung sounds in 120 sleeping infants, of median (interquartile range) postmenstrual age of 51 (44.5-67.5) weeks, were recorded on 144 test occasions by an automatic wheeze detection device (PulmoTrack®). The records were retrospectively evaluated by three trained clinicians blinded to the results. Optimal cut-off values for the automatically determined relative durations of inspiratory and expiratory wheezing were determined by receiver operating curve analysis, and sensitivity and specificity were calculated.

RESULTS

The optimal cut-off values for the automatically detected durations of inspiratory and expiratory wheezing were 2% and 3%, respectively. These cutoffs had a sensitivity and specificity of 85.7% and 80.7%, respectively, for inspiratory wheezing and 84.6% and 82.5%, respectively, for expiratory wheezing. Inter-observer reliability among the experts was moderate, with a Fleiss' Kappa (95% confidence interval) of 0.59 (0.57-0.62) for inspiratory and 0.54 (0.52 - 0.57) for expiratory wheezing.

CONCLUSION

Computerized wheeze detection is feasible during the first year of life. This method is more objective and can be more readily standardized than subjective auscultation, providing quantitative and noninvasive information about the extent of wheezing.

Pharmacological approach to wheezing in preschool children

INTRODUCTION

Wheezing disorders are very common during childhood (particularly among preschool children), and represent a significant burden for patients, their families, the healthcare system, and society as a whole. Identifying wheezing phenotypes, and recognizing the risk factors associated with each, may help to predict long-term outcomes, distinguish high-risk children who may benefit from secondary prevention measures, and ensure that the most effective therapy is prescribed for each case.

AREAS COVERED

The main aim of this review is to analyze the characteristics of the drugs currently used to treat wheezing in preschool children, and discuss the results obtained in children with different wheezing phenotypes.

EXPERT OPINION

The continuous or intermittent administration of various oral or inhaled drugs could theoretically be effective in preventing or controlling wheezing in preschool children. However, the optimal management of acute preschool wheezing episodes has not yet been determined mainly because of their phenotypical heterogeneity.

A Review of the CD4+ T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

Childhood asthma and wheezing are very common, especially in those born preterm. Genetic and environmental factors are associated with developing asthma and wheezing. Respiratory syncytial virus and rhinovirus infections have been implicated in playing a causal role in the development of childhood asthma and wheezing, perhaps by altering the development of the immune system. Several subtypes of asthma and wheezing have been described which involve different mechanisms of pathophysiology. Much of the recent work in the field of asthma research has focused on describing unique aspects of these disease subtypes, which could lead to new drug targets. Alterations in CD4+ T cells have been described with alterations in the T helper 1, 2, 17 and regulatory cell balance could provide valuable targets for the development of new treatment strategies for the various subtypes of disease. This review article focuses on factors involved in childhood asthma and wheeze and potential drug targets.