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An analysis of risk factors associated with recurrent wheezing in the pediatric population. Ital J Pediatr 2023; 49:31. [PMID: 36927514 PMCID: PMC10022094 DOI: 10.1186/s13052-023-01437-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/05/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Recurrent wheezing is a common clinical problem in early childhood, which is associated with significant morbidity. There is no international consensus on the management and prevention of recurrent wheezing; therefore, identifying the risk factors associated with recurrent wheezing is crucial to prevent episodes of wheezing in young children. METHODS In this retrospective study, we collected the data of 24,737 patients who were admitted to our hospital between 27th April 2012 and 11th September 2019. After screening for patients with wheezing, we identified 8572 patients with a primary diagnosis of pneumonia with wheezing. Patients' clinical data were collected from the hospital medical records. Patients were stratified for age in the groups of < 6 months, 6-12 months, and > 12 months. RESULTS Among the 8569 pediatric pneumonia patients with wheezing, there were 343 patients with recurrent wheezing. Most enrolled patients were under 6 months of age (45.17%) and had a normal birth weight (86.95%). Winter was the most common onset season for the first episode of wheezing, while spring was the most common season for the second episode of wheezing for those with recurrent wheezing. The univariate and multivariate logistic regression analysis for the risk factor associated with recurrent wheezing showed that male gender, past history of respiratory and cardiovascular diseases, low birth weight, development of severe pneumonia, and PICU admission were significantly associated with recurrent wheezing. CONCLUSION Male gender, past history of respiratory and cardiovascular diseases, low birth weight, severe pneumonia, and PICU admission are independent risk factors of recurrent wheezing in the pediatric population.
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Prematurity-associated wheeze: current knowledge and opportunities for further investigation. Pediatr Res 2022:10.1038/s41390-022-02404-1. [PMID: 36463364 PMCID: PMC10238677 DOI: 10.1038/s41390-022-02404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
Prematurity-associated wheeze is a common complication of preterm birth, with significant impact on the health and healthcare utilization of former preterm infants. This wheezing phenotype remains poorly understood and difficult to predict. This review will discuss the current state of the literature on prematurity-associated wheeze. We will discuss etiology and pathophysiology, and offer two conceptual models for the pathogenesis of this complex condition. This review will also identify current methods of ascertainment, and discuss the strengths and limitations of each. We will explore research-backed approaches to prevention and management, and finally suggest both pre-clinical and clinical avenues for investigation. An in-depth understanding of prematurity-associated wheeze will aid clinicians in its diagnosis and management, and inspire scientists to pursue much-needed further study into causes and prevention of this common and impactful condition. IMPACT: There is no recent, concise review on the current state of research on prematurity-associated wheeze, which is a rapidly evolving area of study. This article highlights causal models of wheeze, methods of ascertainment, management strategies for the clinician, and opportunities for further research for the physician scientist.
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Grandinetti R, Fainardi V, Caffarelli C, Capoferri G, Lazzara A, Tornesello M, Meoli A, Bergamini BM, Bertelli L, Biserna L, Bottau P, Corinaldesi E, De Paulis N, Dondi A, Guidi B, Lombardi F, Magistrali MS, Marastoni E, Pastorelli S, Piccorossi A, Poloni M, Tagliati S, Vaienti F, Gregori G, Sacchetti R, Mari S, Musetti M, Antodaro F, Bergomi A, Reggiani L, Caramelli F, De Fanti A, Marchetti F, Ricci G, Esposito S. Risk Factors Affecting Development and Persistence of Preschool Wheezing: Consensus Document of the Emilia-Romagna Asthma (ERA) Study Group. J Clin Med 2022; 11:6558. [PMID: 36362786 PMCID: PMC9655250 DOI: 10.3390/jcm11216558] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 07/30/2023] Open
Abstract
Wheezing at preschool age (i.e., before the age of six) is common, occurring in about 30% of children before the age of three. In terms of health care burden, preschool children with wheeze show double the rate of access to the emergency department and five times the rate of hospital admissions compared with school-age asthmatics. The consensus document aims to analyse the underlying mechanisms involved in the pathogenesis of preschool wheezing and define the risk factors (i.e., allergy, atopy, infection, bronchiolitis, genetics, indoor and outdoor pollution, tobacco smoke exposure, obesity, prematurity) and the protective factors (i.e., probiotics, breastfeeding, vitamin D, influenza vaccination, non-specific immunomodulators) associated with the development of the disease in the young child. A multidisciplinary panel of experts from the Emilia-Romagna Region, Italy, addressed twelve key questions regarding managing preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes). Systematic reviews have been conducted on PubMed to answer these specific questions and formulate recommendations. The GRADE approach has been used for each selected paper to assess the quality of the evidence and the degree of recommendations. Based on a panel of experts and extensive updated literature, this consensus document provides insight into the pathogenesis, risk and protective factors associated with the development and persistence of preschool wheezing. Undoubtedly, more research is needed to improve our understanding of the disease and confirm the associations between certain factors and the risk of wheezing in early life. In addition, preventive strategies must be promoted to avoid children's exposure to risk factors that may permanently affect respiratory health.
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Affiliation(s)
- Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Gaia Capoferri
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Angela Lazzara
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Marco Tornesello
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Aniello Meoli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Barbara Maria Bergamini
- Paediatric Unit, Department of Medical and Surgical Sciences of Mothers, Children and Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Luca Bertelli
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Loretta Biserna
- Paediatrics and Neonatology Unit, Ravenna Hospital, AUSL Romagna, 48121 Ravenna, Italy
| | - Paolo Bottau
- Paediatrics Unit, Imola Hospital, 40026 Imola, Italy
| | | | - Nicoletta De Paulis
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Arianna Dondi
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Battista Guidi
- Hospital and Territorial Paediatrics Unit, Pavullo, 41026 Pavullo Nel Frignano, Italy
| | | | - Maria Sole Magistrali
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Elisabetta Marastoni
- Paediatrics Unit, Santa Maria Nuova Hospital, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | | | - Alessandra Piccorossi
- Paediatrics and Paediatric Intensive Care Unit, Cesena Hospital, AUSL Romagna, 47521 Cesena, Italy
| | - Maurizio Poloni
- Paediatrics Unit, Rimini Hospital, AUSL Romagna, 47921 Rimini, Italy
| | | | - Francesca Vaienti
- Paediatrics Unit, G.B. Morgagni—L. Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy
| | - Giuseppe Gregori
- Primary Care Pediatricians, AUSL Piacenza, 29121 Piacenza, Italy
| | | | - Sandra Mari
- Primary Care Pediatricians, AUSL Parma, 43126 Parma, Italy
| | | | | | - Andrea Bergomi
- Primary Care Pediatricians, AUSL Modena, 41125 Modena, Italy
| | | | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Alessandro De Fanti
- Paediatrics Unit, Santa Maria Nuova Hospital, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Federico Marchetti
- Paediatrics and Neonatology Unit, Ravenna Hospital, AUSL Romagna, 48121 Ravenna, Italy
| | - Giampaolo Ricci
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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Mocelin HT, da Silva Filho LVRF, Castro-Rodriguez JA, Sarria EE, Fischer GB. The wheezy infant: A viewpoint from low-middle income countries. Paediatr Respir Rev 2022:S1526-0542(22)00045-8. [PMID: 35906146 DOI: 10.1016/j.prrv.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To review the recent evidence in the literature of various aspects of recurrent/severe wheezing in children under 3 in low-middle income countries [LMICS]. SOURCES A non-systematic review including articles in English. We mainly selected publications from the last 5 years. Studies on epidemiology, aetiology, diagnosis, treatment, and prevention were included in the search. We reviewed differential diagnoses of wheezing that focused on LMICS. We also reviewed aspects of prevention. SUMMARY OF THE FINDINGS Many epidemiological studies have shown a variable but significant number of wheezy infants [WI] cases in LMICS when compared to other countries. The differential diagnosis of causes of wheezing in this age group is mandatory, taking into account local facilities. Few treatment options have been well studied for this age group. In LMICS, a pragmatic approach could be considered, as described in the article. It is difficult to study primary prevention for WI and secondary prevention (mainly environmental) may have some impact. A schematic approach for recurrent wheezers is presented, which takes into account settings with limited resources. CONCLUSION Severely or recurrently wheezy children under 3 is a common clinical issue in LMICS. Studies on this age group are needed to reduce the significant morbidity. It may be possible to lower the high burden of wheezing in this age group by selecting the phenotype which may respond to inhaled steroids.
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Affiliation(s)
- Helena Teresinha Mocelin
- Department of Paediatrics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil; Paediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.
| | - Luiz Vicente Ribeiro Ferreira da Silva Filho
- Instituto da Criança e do Adolescente, Hospital das Clínicas, University of São Paulo Medical School (USP), São Paulo, SP; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Jose A Castro-Rodriguez
- Department of Paediatric Pulmonology, School of Medicine, Pontificia Universidad Católica de Chile (PUC), Santiago, Chile
| | - Edgar E Sarria
- Department of Paediatrics, School of Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
| | - Gilberto Bueno Fischer
- Department of Paediatrics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil; Paediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.
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Manini MB, Matsunaga NY, Gianfrancesco L, Oliveira MS, Carvalho MRVD, Ribeiro GLMT, Morais EDO, Ribeiro MAGO, Morcillo AM, Ribeiro JD, Toro AADC. Risk factors for recurrent wheezing in preterm infants who received prophylaxis with palivizumab. J Bras Pneumol 2021; 47:e20210157. [PMID: 34669834 PMCID: PMC9013528 DOI: 10.36416/1806-3756/e20210157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine the prevalence of recurrent wheezing (RW) in preterm infants who received prophylaxis against severe infection with respiratory syncytial virus (RSV) and to identify genetic susceptibility (atopy or asthma) and risk factors for RW. METHODS This was a cross-sectional study involving preterm infants who received prophylaxis with palivizumab at a referral center in Brazil during the first two years of age. A structured questionnaire was administered in a face-to-face interview with parents or legal guardians. RESULTS The study included 410 preterm infants (median age = 9 months [0-24 months]). In the sample as a whole, 111 children (27.1%; [95% CI, 22.9-31.5]) had RW. The univariate analysis between the groups with and without RW showed no differences regarding the following variables: sex, ethnicity, maternal level of education, gestational age, birth weight, breastfeeding, number of children in the household, day care center attendance, pets in the household, and smoking caregiver. The prevalence of RW was twice as high among children with bronchopulmonary dysplasia (adjusted OR = 2.08; 95% CI, 1.11-3.89; p = 0.022) and almost five times as high among those with a personal/family history of atopy (adjusted OR = 4.96; 95% CI, 2.62-9.39; p < 0.001) as among those without these conditions. CONCLUSIONS Preterm infants who received prophylaxis with palivizumab but have a personal/family history of atopy or bronchopulmonary dysplasia are more likely to have RW than do those without these conditions.
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Affiliation(s)
- Mariana Bueno Manini
- . Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Natasha Yumi Matsunaga
- . Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
- . Laboratório de Fisiologia Pulmonar, Centro de Investigação em Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Lívea Gianfrancesco
- . Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
- . Laboratório de Fisiologia Pulmonar, Centro de Investigação em Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Marina Simões Oliveira
- . Programa de Pós-Graduação em Saúde da Criança e do Adolescente, Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
- . Laboratório de Fisiologia Pulmonar, Centro de Investigação em Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | | | | | | | - Maria Angela Gonçalves O Ribeiro
- . Centro de Investigação em Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - André Moreno Morcillo
- . Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - José Dirceu Ribeiro
- . Laboratório de Fisiologia Pulmonar, Centro de Investigação em Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
- . Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
| | - Adyléia Aparecida Dalbo Contrera Toro
- . Laboratório de Fisiologia Pulmonar, Centro de Investigação em Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
- . Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas - UNICAMP - Campinas (SP) Brasil
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Early Life Factors Associated with Preschool Wheezing in Preterm Infants. CHILDREN-BASEL 2021; 8:children8090732. [PMID: 34572164 PMCID: PMC8468763 DOI: 10.3390/children8090732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022]
Abstract
Advanced neonatal care has increased the survival of neonates born prematurely, and prematurity is a well-known risk factor for asthma/wheezing disorders. Thus, this prospective study aimed to determine the early life factors associated with preschool wheezing in premature neonates. Preterm neonates born between 2012 and 2017 were recruited, excluding those with bacterial infection within 7 days of life, maternal sepsis, and maternal chorioamnionitis. Birth and admission history, comorbidities, and maternal history were documented. Respiratory problems were followed-up at the neonatal outpatient department. Patients were divided into wheezing and non-wheezing groups. Data were analyzed using the Mann-Whitney test and Fisher's exact test, and multivariable logistic regression was used to define the risk factors of preschool wheezing/asthma. A total of 125 preterm infants were enrolled, including 19 in the wheezing group and 106 in the non-wheezing group. Patients in the wheezing group had longer duration of intubation (p = 0.025), higher rates for exclusive breast milk feeding (p = 0.012), and higher re-hospitalization rates for respiratory tract infections (p < 0.001), especially for respiratory syncytial virus (RSV) bronchiolitis (p = 0.045). The incidence of allergic rhinitis was also higher in the wheezing group (p = 0.005). After multivariable logistic regression, allergic rhinitis and re-hospitalization for respiratory tract infections were two significant risk factors for preschool wheezing/asthma in premature neonates. Close follow-up of premature infants at high risk for asthma susceptibility is recommended.
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Ramos ACR, Castro PS, Souza RG, Carneiro JA, Pinho LD, Caldeira AP. Factors associated with recurrent wheezing in the first year of life among premature newborns from Neonatal Intensive Care Units. REVISTA BRASILEIRA DE SAÚDE MATERNO INFANTIL 2021. [DOI: 10.1590/1806-93042021000300010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract Objectives: to determine the prevalence and factors associated with recurrent wheezing in the first year of life among premature newborns from Neonatal Intensive Care Units, in the city of Montes Claros, northern Minas Gerais. Methods: cross-sectional study, with data collection from medical records of a follow-up clinic, interviews with mothers and, eventually, search in hospital records. Bivariate analyzes were carried out between sociodemographic and clinical characteristics and recurrent wheezing. Variables associated up to the level of 20% were analyzed by binary logistic regression, and associations defined by the Odds Ratio and respective 95% confidence intervals. Only variables associated with a 5% significance level were maintained in the final model of logistic regression. Results: among 277 infants studied, about one fifth (21.3%) were extremely low birth weight preterm and more than half (60.7%) had birth weight below 1500 grams. The prevalence of recurrent wheezing was 14.4% (CI95% = 10.3-18.4). Mechanical ventilation (OR = 2.12; CI95% = 1.09-4.76; p = 0.030) and oxygen therapy time ≥ 15 days (OR = 2.49; CI95%= 1.12-5.00; p = 0.010) were the risk factors for the event. Conclusions: there is a high prevalence of recurrent wheezing in the evaluated group and the associated variables reiterate the risk of prolonged oxygen therapy and mechanical ventilation for premature newborns.
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Identification and seasonality of rhinovirus and respiratory syncytial virus in asthmatic children in tropical climate. Biosci Rep 2021; 40:226399. [PMID: 32914848 PMCID: PMC7517263 DOI: 10.1042/bsr20200634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION Asthma is a disease that has been associated with the presence of different genetic and socio-environmental factors. OBJECTIVE To identify and evaluate the seasonality of respiratory syncytial virus (RSV) and human rhinovirus (RV) in asthmatic children and adolescents in tropical climate, as well as to assess the socioeconomic and environmental factors involved. METHODS The study was conducted in a referral hospital, where a total of 151 children were recruited with a respiratory infection. The International Study of Asthma and Allergies in Childhood (ISAAC) protocol and a questionnaire were applied, and a skin prick test was performed. The nasal swab was collected to detect RV and RSV through molecular assay. National Meteorological Institute (INMET) database was the source of climatic information. RESULTS The socio-environmental characterization of asthmatic children showed the family history of allergy, disturbed sleep at night, dry cough, allergic rhinitis, individuals sensitized to at least one mite. We identified RV in 75% of children with asthma and 66.7% of RSV in children with asthma. There was an association between the presence of RV and the dry season whereas the presence of the RSV was associated with the rainy season. Contributing to these results, a negative correlation was observed between the RSV and the wind speed and the maximum temperature (T. Max) and a positive correlation with precipitation. CONCLUSIONS The results suggest a high prevalence of RV and RSV in asthmatic children and the seasonality of these viruses were present in different climatic periods. This has significant implications for understanding short- and long-term clinical complications in asthmatic patients.
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Quinn LA, Shields MD, Sinha I, Groves HE. Respiratory syncytial virus prophylaxis for prevention of recurrent childhood wheeze and asthma: a systematic review. Syst Rev 2020; 9:269. [PMID: 33239107 PMCID: PMC7690183 DOI: 10.1186/s13643-020-01527-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/09/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Acute bronchiolitis caused by respiratory syncytial virus (RSV) has been associated with greater risk of recurrent wheezing and asthma. However, it is unclear whether this association is causal. RSV-specific monoclonal antibodies have been shown to reduce RSV-related hospitalisations in high-risk infants, but the longer-term follow-up has given conflicting evidence for prevention of recurrent wheeze or asthma. OBJECTIVE We performed a systematic review and meta-analysis to determine whether monoclonal antibody prophylaxis against RSV bronchiolitis reduces the risk of subsequent recurrent wheeze or asthma. If so, this may support the hypothesis of causality. METHODS Studies were identified via an online database search using Embase, MEDLINE, PubMed, Web of Science and the Cochrane Library. Manufacturers of monoclonal antibodies were contacted directly for unpublished data. The intervention of interest was RSV monoclonal antibody prophylaxis, and the primary outcome measure was recurrent wheeze and/or asthma. Studies were screened according to inclusion/exclusion criteria. Included studies were evaluated for quality and assessed for bias independently by 3 reviewers using the 'Grading of Recommendations Assessment, Development and Evaluation' (GRADE) approach. Results were extracted into 2 × 2 outcome tables and a meta-analysis carried out producing forest plots based on relative risk. Heterogeneity was assessed using the I2 statistic. RESULTS The search identified 141 articles, which, after screening, resulted in eight studies (2 randomised controlled trials), thus including 11,195 infants in the meta-analysis. The overall result demonstrated a non-statistically significant reduction in relative risk of developing recurrent wheeze or asthma (RR 0.60; 95% CI 0.31 to 1.16). Study quality was generally low with evidence of publication bias and statistical heterogeneity. However, sub-group analysis excluding studies deemed to be 'very low' quality showed a relative risk of 0.42 (95% CI 0.22 to 0.80, p = 0.008). A further sub-group analysis for infants aged 32 to < 36 weeks showed a statistically significant relative risk of 0.35 (95% CI 0.14 to 0.86, p = 0.02). DISCUSSION We did not identify an overall statistically significant benefit. However, our two sub-group analyses did find statistically significant benefits of monoclonal antibody therapy on the risk of recurrent wheeze and asthma. The main limitation of this study is the lack of high-quality randomised controlled trials, highlighting the need for more research in this field.
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Affiliation(s)
| | - Michael D. Shields
- Centre for Experimental Medicine, Welcome Wolfson Institute for Experimental Medicine, Queen’s University Belfast, 17 Lisburn Road, Belfast, BT97BL Northern Ireland
| | - Ian Sinha
- University of Liverpool, Liverpool, England
| | - Helen E. Groves
- Queen’s University Belfast, University Road, BT71NN Belfast, Northern Ireland
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Brunwasser SM, Snyder BM, Driscoll AJ, Fell DB, Savitz DA, Feikin DR, Skidmore B, Bhat N, Bont LJ, Dupont WD, Wu P, Gebretsadik T, Holt PG, Zar HJ, Ortiz JR, Hartert TV. Assessing the strength of evidence for a causal effect of respiratory syncytial virus lower respiratory tract infections on subsequent wheezing illness: a systematic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2020; 8:795-806. [PMID: 32763206 PMCID: PMC7464591 DOI: 10.1016/s2213-2600(20)30109-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/26/2020] [Accepted: 02/27/2020] [Indexed: 12/26/2022]
Abstract
Background Although a positive association has been established, it is unclear whether lower respiratory tract infections (LRTIs) with respiratory syncytial virus (RSV) cause chronic wheezing illnesses. If RSV-LRTI were causal, we would expect RSV-LRTI prevention to reduce the incidence of chronic wheezing illnesses in addition to reducing acute disease. We aimed to evaluate the strength of evidence for a causal effect of RSV-LRTI on subsequent chronic wheezing illness to inform public health expectations for RSV vaccines. Methods We did a systematic review and meta-analysis of observational studies evaluating the association between RSV-LRTI and subsequent wheezing illness (exposure studies) and studies evaluating the association between RSV immunoprophylaxis and subsequent wheezing illness (immunoprophylaxis studies). Exposure studies were included if the exposure group members had an LRTI with laboratory-confirmed RSV and if the exposure ascertainment period began before 2 years of age and ended before 5 years of age. We required a wash-out period of more than 30 days between the index RSV-LRTI and the outcome measurement to allow for resolution of the acute illness. Comparisons between RSV-LRTI and non-RSV-LRTI were not included. Immunoprophylaxis studies were included if they measured the association with subsequent wheezing illness relative to a control group, either in a randomised controlled trial (RCT) or an observational design. For the immunoprophylaxis drugs in question, we required evidence of efficacy in targeting RSV-LRTI from at least one RCT to ensure biological plausibility. All variations of wheezing illness were combined into a single outcome that refers broadly to asthma or any other respiratory illness with wheezing symptoms. Ovid MEDLINE and Embase databases were searched from inception up to Aug 28, 2018. We evaluated whether data from exposure studies could provide evidence against the most viable non-causal theory that RSV-LRTI is a marker of respiratory illness susceptibility rather than a causal factor. Additionally, we tested whether RSV immunoprophylaxis reduces the odds of subsequent wheezing illnesses. We used a random-effects modelling framework and, to accommodate studies providing multiple correlated estimates, robust variance estimation meta-regressions. Meta-regression coefficients (b) quantify differences between exposure and comparator groups on the loge odds ratio (loge OR) scale. Findings From 14 235 records we identified 57 eligible articles that described 42 studies and provided 153 effect estimates. 35 studies estimated the direct effect of RSV-LRTI on wheezing illnesses (exposure studies) and eight evaluated the effect of RSV immunoprophylaxis (immunoprophylaxis studies). Exposure studies that adjusted for genetic influences yielded a smaller mean adjusted OR estimate (aOR+ 2·45, 95% CI 1·23–4·88) compared with those that did not (4·17, 2·36–7·37), a significant difference (b 0·53, 95% CI 0·04–1·02). Infants who were not protected with RSV immunoprophylaxis tended to have higher odds of subsequent wheezing illness, as we would expect if RSV-LRTI were causal, but the effect was not significant (OR+ 1·21, 95% CI 0·73–1·99). There was generally a high threat of confounding bias in the observational studies. Additionally, in both the observational studies and immunoprophylaxis RCTs, there was high risk of bias due to missing outcome data. Interpretation Our findings, limited to exposure and immunoprophylaxis studies, do not support basing policy decisions on an assumption that prevention of RSV-LRTI will reduce recurrent chronic wheezing illnesses. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Steven M Brunwasser
- Department of Psychology, Rowan University, Glassboro, NJ, USA; Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Amanda J Driscoll
- Centre for Vaccine Development and Global Health, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Deshayne B Fell
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David A Savitz
- School of Public Health, Brown University, Providence, RI, USA
| | - Daniel R Feikin
- Department of Immunizations, Vaccines and Biologicals, WHO, Geneva, Switzerland
| | | | - Niranjan Bhat
- Center for Vaccine Innovation and Access, PATH, Washington, DC, USA
| | - Louis J Bont
- Wilhelmina Children's Hospital and University Medical Centre Utrecht, Utrecht University, Utrecht, Netherlands
| | | | - Pingsheng Wu
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Patrick G Holt
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Heather J Zar
- Red Cross War Memorial Children's Hospital and South African Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Justin R Ortiz
- Centre for Vaccine Development and Global Health, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Tina V Hartert
- Department of Psychology, Rowan University, Glassboro, NJ, USA.
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