Pediatric Respiratory Infections

Consensus Document on Community-Acquired Pneumonia in Children. SENP-SEPAR-SEIP

Community-acquired pneumonia (CAP) is a prevalent disease among children and is frequently associated with both diagnostic and therapeutic uncertainties. Consensus has been reached between SEPAR, SENP and SEIP, and their conclusions are as follows.

Cardiac involvement in children with community-acquired pneumonia and respiratory failure

Background

Pneumonia causes significant incidence in children younger than 5 years. Most fatalities are resulted from complications. High rates of cardiac events were detected in adult studies but usually related to underlying diseases.

Objective

To study the cardiac effects of community-acquired pneumonia (CAP) with respiratory failure (RF) in healthy children.

Methods

The prospective cohort study was conducted in children aged 2–59 months with CAP and RF. Cardiac enzyme assessments, chest radiography, electrocardiography, and echocardiography were performed at the admission date and 2 weeks after admission. t-test and chi-square test were used for comparison between first and second investigations, and the statistically significance level was a P <0.05.

Results

Of the 135 patients, pericardial effusion occurred in 80 (59%), valvular regurgitation in 30 (22%), ST/T changes in 66 (49%), cardiac arrhythmia in 7 (5%), and myocardial injury in 83 (62%). Significant improvement of cardiothoracic-ratio, heart rate, ST/T changes, cardiac arrhythmia, troponin T, myocardial performance, and left-ventricular ejection fraction was demonstrated at second investigations. Three mortality cases exhibited evidence of congestive heart failure (CHF).

Conclusion

Children with CAP and RF had several cardiac effects even in healthy children. Most cardiac effects were mild and transient. Mortality cases were revealed evidence of congestive heart failure (CHF). Future research should be designed to find out the characteristics and predictors of CHF for early recognition and therapeutic strategy.

Lung ultrasound features of children with complicated and noncomplicated community acquired pneumonia: A prospective study

OBJECTIVE

The purpose of this study was to describe lung ultrasound (LUS) findings at baseline and 48 hours after the beginning of treatment and evaluate how they correlate with outcome DESIGN: We prospectively analyzed patients from 1 month to 17 years of age with community acquired pneumonia (CAP) evaluated at a tertiary level pediatric hospital. At baseline and 48 hours after the beginning of treatment, history, clinical examination, laboratory testing, chest X-ray, and LUS were performed.

RESULTS

One hundred one children were enrolled in the study (13 with complicated CAP). At baseline those who developed complications presented a larger size of the subpleural pulmonary parenchymal lesions (P = .001) often associated with a complex pleural effusion (63.6%, P = .013). Those with an uncomplicated CAP presented an air, arboriform, superficial and dynamic bronchogram, as opposed to complicated CAP which had an air and liquid bronchogram, deep, fixed (P = .001). At the 48-hour control in the noncomplicated CAP group, bronchogram was more frequently superficial and dynamic (P = .050). Pleural effusion disappeared in half cases (P = .050). In all patients, neutrophilic leucocytosis with increased C-reactive protein was detected and decreased at control (P = .001). The linear regression analyses showed the switch from a deep to a superficial bronchogram as the only explanatory variable (r = 0.97, R²  = 0.94, P = .001, t = 10.73).

CONCLUSIONS

Our study describe early LUS features of CAP that might be able to predict the development of complicated CAP.

Infants Are More Likely Than Older Children to Have Surgery for Cervical Infections

Objectives

To identify differences in cervical infection management in infants versus older children.

Methods

Charts of patients 0–18 years, diagnosed with a cervical infection at our institution between 2004 and 2015, were included. Age, gender, presenting symptoms, comorbidities, CT scan findings and management including admission, procedures, antibiotics, cultures, length of stay, readmission rates, and complications were included.

Results

239 patients were included: mean age was 4.6 years, with 55.6% boys and 44.4% girls. Mean length of stay was 3.2 days, with no significant difference between age categories. 12.55% were readmitted within 30 days with no significant difference when stratified for age (p = 0.268). The most common presenting symptoms were fever (74.3%), swelling (71.4%), and neck pain (48.2%). Infants had fewer symptoms documented than older children. 51% has lateral neck infections, and these were more common in younger children (p < 0.001). The most common antibiotic used was amoxicillin-clavulanic acid in 53.96% of inpatients and 48.05% of outpatients. Infants were most likely to have MRSA isolates (29.2% versus 11.7% of older children, p = 0.011). 70.0% went to the operating room for incision and drainage procedures. Younger children were more likely to undergo surgery, with an odds ratio of 2.38 for children under 1 year. (p = 0.029). 90.9% of infants underwent surgery with radiolucencies of at least 1 cm diameter in contrast to 50% of children over 8 years old.

Conclusions

This study emphasizes the importance of considering early operative treatment of cervical abscesses in infants despite fewer symptoms and smaller radiolucencies on CT.

Comparison of Prevalence and Outcomes of Pediatric Acute Respiratory Distress Syndrome Using Pediatric Acute Lung Injury Consensus Conference Criteria and Berlin Definition

OBJECTIVES

Our objective was to compare the prevalence and outcomes of pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference (PALICC) criteria and Berlin definitions.

METHODS

We screened case records of all children aged 1 month to 17 years of age admitted to the Pediatric Intensive Care Unit (PICU) over a 3-year period (2015-2017) for presence of any respiratory difficulty at admission or during PICU stay. We applied both PALICC and Berlin criteria to these patients. Data collection included definition and outcome related variables. Data were compared between the "PALICC only group" and the "Berlin with or without PALICC" group using Stata 11.

RESULTS

Of a total of 615 admissions, 246 were identified as having respiratory difficulty at admission or during PICU stay. A total of 61 children (prevalence 9.9%; 95% CI: 7.8-12.4) fulfilled the definition of acute respiratory distress syndrome (ARDS) with either of the two criteria. While 60 children (98%) fulfilled PALICC criteria, only 26 children (43%) fulfilled Berlin definition. There was moderate agreement between the two definitions (Kappa: 0.51; 95% CI: 0.40-0.62; observed agreement 85%). Greater proportion of patients had severe ARDS in the "Berlin with or without PALICC group" as compared to the "PALICC only" group (50 vs. 19%). There was no difference between the groups with regard to key clinical outcomes such as duration of ventilation (7 vs. 8 days) or mortality [51.4 vs. 57.7%: RR (95% CI): 0.99 (0.64-1.5)].

CONCLUSION

In comparison to Berlin definition, the PALICC criteria identified more number of patients with ARDS. Proportion with severe ARDS and complications was greater in the "Berlin with or without PALICC" group as compared to the "PALICC only" group. There were no differences in clinical outcomes between the groups.

Congestive heart failure in children with pneumonia and respiratory failure

BACKGROUND

Congestive heart failure (CHF) is one of the most common cardiac complications of pneumonia in adulthood leading to increased risk of morbidity and mortality. Little is known, however, of CHF and pneumonia in children. The aim of this study was therefore to investigate the characteristics and factors associated with CHF in under-5 children with pneumonia and respiratory failure.

METHODS

A retrospective cohort was conducted in hospitalized patients aged 2-59 months with community-acquired pneumonia and respiratory failure from June 2011 to June 2014 at Suratthani Hospital, Thailand. The characteristics, therapeutic strategy, and clinical outcomes of CHF were reviewed. Baseline characteristics and basic laboratory investigations on admission were compared between the CHF and non-CHF groups.

RESULTS

Of 135 patients, 14 (10%) had CHF. Compared with patients without CHF, the CHF group had prolonged intubation and hospital stay and high rates of associated complications such as ventilator-associated pneumonia, sepsis, shock, and 30 day mortality. CHF was significantly associated with certain characteristics, including male sex and bacterial pneumonia.

CONCLUSIONS

Pneumonia with respiratory failure is associated with CHF even in healthy children without cardiac risks. The awareness and early recognition of CHF, particularly in male, and bacterial pneumonia, is important in order to provide immediate treatment to reduce complications.

Pediatric Respiratory Emergencies

Respiratory emergencies are 1 of the most common reasons parents seek evaluation for the their children in the emergency department (ED) each year, and respiratory failure is the most common cause of cardiopulmonary arrest in pediatric patients. Whereas many respiratory illnesses are mild and self-limiting, others are life threatening and require prompt diagnosis and management. Therefore, it is imperative that emergency clinicians be able to promptly recognize and manage these illnesses. This article reviews ED diagnosis and management of foreign body aspiration, asthma exacerbation, epiglottitis, bronchiolitis, community-acquired pneumonia, and pertussis.

Antibiotics for preventing lower respiratory tract infections in high-risk children aged 12 years and under

BACKGROUND

Lower respiratory tract infections (LRTIs) in young children account for 1.4 million deaths annually worldwide. Antibiotics could be beneficial in preventing LRTIs in high-risk children, and may also help prevent school absenteeism and work days missed by children and/or carers. While it is well documented that the efficacy of antibiotic prophylaxis for RTIs decreases over time, there are no reviews that describe the use of antibiotic prophylaxis to prevent LRTIs in high-risk children aged 12 years and under.

OBJECTIVES

To assess the effectiveness and safety of antibiotic prophylaxis in the prevention of bacterial LRTIs in high-risk children aged 12 years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1) and the Database of Abstracts of Reviews of Effects (DARE), MEDLINE and MEDLINE In-Process (OvidSP) (1946 to 13 February 2015), EMBASE (OvidSP) (1974 to 12 February 2015), Science Citation Index Expanded (1945 to 13 February 2015) and Conference Proceedings Citation Index-Science (Web of Science Core Collection) (1990 to 13 February 2015). We searched for ongoing studies on ClinicalTrials.gov and the World Health Organization ICTRP. We handsearched the bibliographies of retrieved full texts of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing oral or intravenous antibiotics versus placebo or no treatment to prevent infections in high-risk children aged 12 years and under. We used a combination of the Centers for Disease Control and Prevention (CDC), National Health Service (NHS), American Academy of Paediatrics (AAP) and National Institute for Health and Care Excellence (NICE) guidelines to define conditions at higher risk of complications. Our primary outcome was the incidence of bacterial lower respiratory infections. Secondary outcomes included clinical function, hospital admission, mortality, growth, use of secondary antibiotics, time off school or parental work, quality of life and adverse events.

DATA COLLECTION AND ANALYSIS

We extracted data using a customised data extraction sheet, assessed the risk of bias of included studies using the Cochrane 'Risk of bias' criteria, and used the GRADE criteria to rate the quality of the evidence. We used a random-effects model for meta-analysis. We presented the results narratively where we could not statistically combine data.

MAIN RESULTS

We included 10 RCTs of high-risk children using antibiotics (azithromycin, ciprofloxacin, co-trimoxazole, isoniazid, oral penicillin V or vancomycin) to prevent LRTIs. Three studies included HIV-infected children (n = 1345), four cystic fibrosis (n = 429) and one each sickle cell disease (n = 219), cancer (n = 160) and low birth weight neonates with underlying respiratory disorders (n = 40). The study duration ranged from seven days to three years. The quality of the evidence from studies including children with HIV infection, cystic fibrosis or cancer was moderate. Due to inadequate data, we were unable to rate the quality of the evidence for two studies: one in children with sickle cell disease (low risk of bias), and another in low birth weight neonates with underlying respiratory disorders (high risk of bias).In HIV-infected children receiving continuous isoniazid prophylaxis, there was no significant difference in the incidence of pulmonary tuberculosis (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.32 to 1.29, I(2) statistic = 47%, P value = 0.21). There was no significant effect on mortality with co-trimoxazole or isoniazid prophylaxis (RR 0.82, 0.46 to 1.46, I(2) statistic = 76%, P value = 0.58); however, analysis of one study that used co-trimoxazole showed a significant reduction in mortality (RR 0.67, 95% CI 0.53 to 0.85, P value = 0.001). There was a significant decrease in the rates of hospital admission per child-year of follow-up with co-trimoxazole prophylaxis in one study (P value = 0.01). There was no evidence of increased adverse events due to antibiotic prophylaxis (RR 1.10, 95% CI 0.75 to 1.64, I(2) statistic = 22%, P value = 0.28); however, there was scant reporting of antibiotic resistance - the one study that did assess this found no increase.In two studies of children with cystic fibrosis receiving ciprofloxacin prophylaxis, there was no significant difference in Pseudomonas infections (RR 0.76, 0.44 to 1.31, I(2) statistic = 0%, P value = 0.33). In two studies assessing the benefit of azithromycin prophylaxis, there was a significant reduction in the frequency of pulmonary exacerbations (RR 0.60, 95% CI 0.48 to 0.76, I(2) statistic = 0%, P value < 0.0001). The effect of antibiotic prophylaxis on growth in children with cystic fibrosis was inconsistent across the studies. There was an increased risk of emergence of pathogenic strains with either azithromycin or ciprofloxacin prophylaxis in two studies reporting this outcome. There was no significant difference in the quality of life (one study). In three studies, there was no significant increase in the frequency of adverse events with prophylaxis with azithromycin (two studies) or ciprofloxacin (one study). There was no evidence of increased antibiotic resistance in two studies.In the one study of children with sickle cell disease, a significantly lesser proportion of children with pneumococcal septicaemia was reported with penicillin V prophylaxis (P value = 0.0025).In the one study of children with cancer there was a significant decrease in Pneumocystis carinii pneumonia with trimethoprim-sulfamethoxazole prophylaxis (RR 0.03, 95% CI 0.00 to 0.47, P value < 0.01). There was no significant increase in the frequency of adverse events with antibiotic prophylaxis.In low birth weight children with underlying respiratory disorders, there was no significant difference in the proportion of children with pulmonary infection with vancomycin prophylaxis (P value = 0.18).No included studies reported time off school or carer time off work.

AUTHORS' CONCLUSIONS

There is inconclusive evidence that antibiotic prophylaxis in certain groups of high-risk children can reduce pneumonia, exacerbations, hospital admission and mortality in certain conditions. However, limitations in the evidence base mean more clinical trials assessing the effectiveness of antibiotics for preventing LRTIs in children at high risk should be conducted. Specifically, clinical trials assessing the effectiveness of antibiotics for preventing LRTIs in congenital heart disease, metabolic disease, endocrine and renal disorders, neurological disease or prematurity should be a priority.

Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis

BACKGROUND AND OBJECTIVE

Pneumonia is the leading cause of death of children. Diagnostic tools include chest radiography, but guidelines do not currently recommend the use of lung ultrasound (LUS) as a diagnostic method. We conducted a meta-analysis to summarize evidence on the diagnostic accuracy of LUS for childhood pneumonia.

METHODS

We performed a systematic search in PubMed, Embase, the Cochrane Library, Scopus, Global Health, World Health Organization-Libraries, and Latin American and Caribbean Health Sciences Literature of studies comparing LUS diagnostic accuracy against a reference standard. We used a combination of controlled key words for age <18 years, pneumonia, and ultrasound. We identified 1475 studies and selected 15 (1%) for further review. Eight studies (765 children) were retrieved for analysis, of which 6 (75%) were conducted in the general pediatric population and 2 (25%) in neonates. Eligible studies provided information to calculate sensitivity, specificity, and positive and negative likelihood ratios. Heterogeneity was assessed by using Q and I(2) statistics.

RESULTS

Five studies (63%) reported using highly skilled sonographers. Overall methodologic quality was high, but heterogeneity was observed across studies. LUS had a sensitivity of 96% (95% confidence interval [CI]: 94%-97%) and specificity of 93% (95% CI: 90%-96%), and positive and negative likelihood ratios were 15.3 (95% CI: 6.6-35.3) and 0.06 (95% CI: 0.03-0.11), respectively. The area under the receiver operating characteristic curve was 0.98. Limitations included the following: most studies included in our analysis had a low number of patients, and the number of eligible studies was also small.

CONCLUSIONS

Current evidence supports LUS as an imaging alternative for the diagnosis of childhood pneumonia. Recommendations to train pediatricians on LUS for diagnosis of pneumonia may have important implications in different clinical settings.

Pre- and postnatal exposure to tobacco smoke and respiratory outcomes during the first year

The different role of prenatal and postnatal exposure to tobacco smoke in respiratory outcomes in infants has not yet been clearly established. Our objective is to assess the effects of these exposures on the risk of respiratory outcomes during the first year of life of infants from a Spanish multicenter cohort study. A total of 2506 women were monitored until delivery. About 2039 infants made up the final population. The outcomes were caused by the occurrence of the following: otitis, cough persisting for more than 3 weeks, lower respiratory tract symptoms (wheezing or chestiness), and lower respiratory tract infections (bronchitis, bronchiolitis, or pneumonia). The relationship between prenatal and postnatal exposure and health outcomes was explored using logistic regression analysis. Maternal smoking during pregnancy increased the odds for wheezing (OR: 1.41, 95% CI: 0.99-2.01) and chestiness (OR: 1.46, 95% CI: 1.03-2.01). Postnatal exposure from fathers was associated with otitis (OR: 1.25, 95% CI: 1.01-1.54). Passive exposure at work of non-smoking mothers during pregnancy was related to cough (OR: 1.62, 95% CI: 1.05-2.51). Exposure to tobacco smoke was related to a higher risk of experiencing respiratory outcomes in young infants. Prenatal exposure was that most clearly associated with the respiratory outcomes analyzed.

Question of an infectious etiology or contribution to the pathogenesis of infantile hypertrophic pyloric stenosis

Infantile hypertrophic pyloric stenosis is a concerning cause of nonbilious vomiting in the neonatal population. Although a number of etiological theories exist, its exact cause remains nebulous. The question of an infectious etiology (or contribution) has been previously examined in case reports and case series, with recent support through suggestions of seasonality and familial aggregation with unclear inheritance patterns. The present review discusses the published literature regarding infectious etiologies of infantile hypertrophic pyloric stenosis. Furthermore, it attempts to demonstrate that newer research regarding an NOS1 genetic etiology does not exclude, but rather can be consistent with, an infectious etiology.

Management of acute severe upper airway obstruction in children

There are many causes of acute severe upper airway obstruction (UAO) in children. The timing of symptom onset and the presence of fever will help to distinguish infectious from non-infectious conditions. Signs and symptoms from congenital malformations often present at birth but may also develop over time. The most common cause of UAO in children is croup. Choking on a foreign body also occurs relatively frequently. Evaluation of the child with UAO starts with a detailed history followed by a thorough physical examination, including an assessment of severity. Severe airway obstruction will result in respiratory failure. This situation requires an immediate response. A child with partial airway obstruction may initially have an adequate airway. However, this situation can deteriorate rapidly. Therefore, providing supportive care and mobilizing resources for definitive airway management may be the most appropriate interventions.

Bronchiolite del lattante

La bronchiolite è un’infezione virale stagionale delle vie respiratorie basse del lattante. Il suo agente causale principale è il virus respiratorio sinciziale. La comparsa di un distress respiratorio è legata all’intensità della risposta infiammatoria delle vie aeree. Benché si tratti di una malattia frequente, le cause della suscettibilità dei lattanti a questa infezione non sono conosciute. La diagnosi è clinica. Il trattamento è sintomatico in assenza di misure specifiche. I rapporti a medio e a lungo termine di un primo episodio di bronchiolite con le recidive e con l’asma non sono spiegati. Essi potrebbero dipendere dalla natura del virus in causa al momento del primo episodio e da fattori genetici individuali.

Membranous laryngitis in a child

The most common etiologies for acute infectious airway obstruction include epiglottitis, croup, and bacterial tracheitis. We present a unique cause of upper airway obstruction in a child not previously described. To our knowledge this is the first case in the literature of membranous laryngitis in a child due to Methicillin-resistant Staphylococcus Aureus (MRSA). The diagnosis was made by endoscopy and culture and treated with culture directed antibiotics and debridement of membranes from the larynx. The patient did not present with clinical symptoms consistent with epiglottitis as the disease course was not abrupt, and the patient did not present with classic posturing and drooling. Croup-like symptoms were described, but there was no evidence of subglottic involvement radiographically or on endoscopy. Additionally, there was no evidence of membranous plaques within the trachea or subglottis which would be suggestive of bacterial tracheitis. This unique finding is likely the result of MRSA superinfection in a child with Influenza type B.