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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 2024; 51:32-37. [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] [MESH Headings] [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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Fang Z, Ma C, Xu W, Shi X, Liu S. Epidemiological Characteristics and Trends of Scarlet Fever in Zhejiang Province of China: Population-Based Surveillance during 2004-2022. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:6257499. [PMID: 39036471 PMCID: PMC11260510 DOI: 10.1155/2024/6257499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/29/2024] [Accepted: 06/21/2024] [Indexed: 07/23/2024]
Abstract
Background Over the past two decades, scarlet fever has resurged in some countries or areas. Nationwide nonpharmaceutical interventions changed the patterns of other infectious diseases, but its effects on the spread of scarlet fever were rarely studied. This study aimed to evaluate the changes in scarlet fever incidence in Zhejiang Province, China, before and during the COVID-19 pandemic periods and to provide references for scarlet fever prevention and control. Methods Scarlet fever surveillance data in Zhejiang, China (2004-2022), were analyzed in three stages. Two-sample z test, ANOVA, and Tukey's test were used to compare and analyze the characteristics of disease spread at different stages. The ARIMA model was used to predict the overall trend. The data were obtained from the National Infectious Disease Reporting Information System. Results A total of 28,652 cases of scarlet fever were reported across Zhejiang Province during the study period, with the lowest average monthly incidences in 2020 (0.111/100,000). The predominant areas affected were the northern and central regions of Zhejiang, and all regions of Zhejiang experienced a decrease in incidence in 2020. The steepest decline in incidence in 2020 was found in children aged 0-4 years (67.3% decrease from 23.8/100,000 to 7.8/100,000). The seasonal pattern changed, with peak occurrences in April to June and November to January during 2004-2019 and 2021 and a peak in January in 2020. The median duration from diagnosis to confirmation was highest before COVID-19 (4 days); however, it decreased to 1 day in 2020-2022, matching the other two medians. Conclusions In 2020, Zhejiang experienced an unprecedented decrease in scarlet fever, with the lowest incidence in nearly 18 years, but it rebounded in 2021 and 2022. The seasonal epidemiologic characteristics of scarlet fever also changed with the COVID-19 outbreaks. This suggested that nationwide nonpharmaceutical interventions greatly depressed the spread of scarlet fever. With the relaxation of non-pharmaceutical intervention restrictions, scarlet fever may reappear. Government policymakers should prioritize the control of future scarlet fever outbreaks for public health.
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Affiliation(s)
- Zhen Fang
- Center for Applied StatisticsSchool of StatisticsRenmin University of China, Beijing 100872, China
| | - Chenjin Ma
- College of Statistics and Data ScienceFaculty of ScienceBeijing University of Technology, Beijing 100124, China
| | - Wangli Xu
- Center for Applied StatisticsSchool of StatisticsRenmin University of China, Beijing 100872, China
| | - Xiuxiu Shi
- The Fourth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Shelan Liu
- Department of Infectious DiseasesZhejiang Provincial Center for Disease Control and Prevention, Hangzhou, Zhejiang 310051, China
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Krüger EL, Nedel AS, Dos Santos Gomes AC, Lúcio PS. Analyzing the relationship between air temperature and respiratory morbidity in children and the elderly in Porto Alegre, Brazil, before and during the COVID-19 pandemic. INTERNATIONAL JOURNAL OF BIOMETEOROLOGY 2023; 67:1461-1475. [PMID: 37438577 DOI: 10.1007/s00484-023-02516-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/07/2023] [Accepted: 06/29/2023] [Indexed: 07/14/2023]
Abstract
The aim of the study was to analyze the relationship between air temperature data against hospital admissions due to respiratory diseases of children (under five years of age) and the elderly (over 65) in subtropical Porto Alegre, Brazil, comparing outcomes for 3 sequential years, 2018-2020, pre- and post-COVID 19 pandemic. Meteorological and hospital admission (HA) data for Porto Alegre, marked by a Koeppen-Geiger's Cfa climate type with well-defined seasons, were used in the analyses. HA was obtained for respiratory diseases (J00-99, according to the International Classification of Diseases, ICD-10) from the Brazilian DATASUS (Unified Health System database). We performed correlation analysis between variables (HA versus air temperature and heat stress) in order to identify existing relationships and lag effects (between meteorological condition and morbidity). Relative risk (RR) was also obtained for the two age groups during the three years. Results showed that the pandemic year disrupted observed patterns of association between analyzed variables, with either very low or non-existent correlations.
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Affiliation(s)
- Eduardo L Krüger
- Departamento de Construção Civil, Universidade Tecnológica Federal do Paraná - UTFPR/Campus Curitiba - Sede Ecoville, Rua Deputado Heitor Alencar Furtado, 4900, Curitiba, 81280-340, Brazil.
| | - Anderson Spohr Nedel
- Faculdade de Agronomia, Universidade Federal da Fronteira Sul (UFFS), Cerro Largo, Rio Grande do Sul, Brazil
| | | | - Paulo S Lúcio
- Departamento de Ciências Atmosféricas e Climáticas, Universidade Federal do Rio Grande do Norte (UFRN), Natal, Brazil
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Pediatric hospital admissions, case severity, and length of hospital stay during the first 18 months of the COVID-19 pandemic in a tertiary children's hospital in Switzerland. Infection 2022; 51:439-446. [PMID: 36065045 PMCID: PMC9444086 DOI: 10.1007/s15010-022-01911-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022]
Abstract
Background SARS-CoV-2 directly contributes to the burden of respiratory disease in children, but indirect effects of protective measures also need to be considered to assess the overall impact of the pandemic on children's health. Methods We retrospectively compared pre-pandemic and pandemic data of main admission diagnoses, sorted by ICD-10 diagnosis groups, in a tertiary children's hospital in Switzerland from 2017 until August 2021. Hospital admission rates, severity, and length of stay (LOS) of the individual ICD-10 groups during the pandemic were compared with three previous years accounting for seasonal differences. Results Among 20,168 hospital admissions (n = 13′950 in pre-pandemic years; n = 3′120 in 2020 and n = 3′098 in 2021), there were significant decreases in numbers of admissions for respiratory diseases during the early pandemic with a rebound in summer 2021. During the pandemic, admissions for non-respiratory infections, neoplasms, and skin diseases decreased but increased for trauma. Particularly, a drop in admissions for different respiratory infections [e.g. respiratory syncytial virus (RSV) and bronchiolitis] was pronounced after introduction of strict measures, but admissions increased again after restrictions were loosened. While disease severity was lower for respiratory and neurologic diseases and bronchiolitis throughout the pandemic, gastrointestinal disease admissions had longer LOS and in the first pandemic year greater severity. For RSV and pneumonia, disease severity and LOS were higher in the first pandemic year and lower in the second pandemic year. Conclusion The pandemic and associated protective measures had a significant effect on respiratory and non-respiratory admissions, particularly with decreases in hospital admissions for respiratory infections followed by a rebound after loosening of measures. Supplementary Information The online version contains supplementary material available at 10.1007/s15010-022-01911-x.
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Oh KB, Doherty TM, Vetter V, Bonanni P. Lifting non-pharmaceutical interventions following the COVID-19 pandemic - the quiet before the storm? Expert Rev Vaccines 2022; 21:1541-1553. [PMID: 36039786 DOI: 10.1080/14760584.2022.2117693] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION In the first months of the novel coronavirus (COVID-19) pandemic that begun in 2020, non-pharmaceutical interventions (NPIs) have been adopted worldwide. However, the effects of NPI implementation go beyond slowing the spread of COVID-19. Here, we review the non-intended effects that may have arisen from prolonged application of NPIs. AREAS COVERED NPIs also affected the epidemiology of other infectious diseases, with unprecedentedly low circulation of several respiratory and gastrointestinal viruses being observed worldwide in 2020. While this was a welcome effect for already strained healthcare systems, prolonged low exposure to pathogens may result in an increased pool of individuals susceptible to certain diseases. Out-of-season or unusually intense outbreaks of non-vaccine preventable diseases have already been documented as NPIs were gradually eased. In the context of widespread and important disruptions in national vaccination programs during the early phase of the pandemic, the risk of vaccine-preventable disease resurgence after NPIs are lifted cannot be excluded either. EXPERT OPINION Awareness must be raised of the risk of vaccine-preventable disease resurgence, and efforts need to be made to mitigate this risk, where possible, by increasing vaccination coverage. Research and regulatory opportunities brought on by the COVID-19 pandemic should be seized.
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Affiliation(s)
| | | | | | - Paolo Bonanni
- Department of Health Sciences, University of Florence, Italy
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Tao Y, Zhang X, Qiu G, Spillmann M, Ji Z, Wang J. SARS-CoV-2 and other airborne respiratory viruses in outdoor aerosols in three Swiss cities before and during the first wave of the COVID-19 pandemic. ENVIRONMENT INTERNATIONAL 2022; 164:107266. [PMID: 35512527 PMCID: PMC9060371 DOI: 10.1016/j.envint.2022.107266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 05/02/2023]
Abstract
Caused by the SARS-CoV-2 virus, Coronavirus disease 2019 (COVID-19) has been affecting the world since the end of 2019. While virus-laden particles have been commonly detected and studied in the aerosol samples from indoor healthcare settings, studies are scarce on air surveillance of the virus in outdoor non-healthcare environments, including the correlations between SARS-CoV-2 and other respiratory viruses, between viruses and environmental factors, and between viruses and human behavior changes due to the public health measures against COVID-19. Therefore, in this study, we collected airborne particulate matter (PM) samples from November 2019 to April 2020 in Bern, Lugano, and Zurich. Among 14 detected viruses, influenza A, HCoV-NL63, HCoV-HKU1, and HCoV-229E were abundant in air. SARS-CoV-2 and enterovirus were moderately common, while the remaining viruses occurred only in low concentrations. SARS-CoV-2 was detected in PM10 (PM below 10 µm) samples of Bern and Zurich, and PM2.5 (PM below 2.5 µm) samples of Bern which exhibited a concentration positively correlated with the local COVID-19 case number. The concentration was also correlated with the concentration of enterovirus which raised the concern of coinfection. The estimated COVID-19 infection risks of an hour exposure at these two sites were generally low but still cannot be neglected. Our study demonstrated the potential functionality of outdoor air surveillance of airborne respiratory viruses, especially at transportation hubs and traffic arteries.
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Affiliation(s)
- Yile Tao
- Institute of Environmental Engineering, ETH Zurich, Zurich 8093, Switzerland; Laboratory for Advanced Analytical Technologies, Empa, Swiss Federal Laboratories for Materials Science and Technology, Dübendorf 8600, Switzerland
| | - Xiaole Zhang
- Institute of Environmental Engineering, ETH Zurich, Zurich 8093, Switzerland; Laboratory for Advanced Analytical Technologies, Empa, Swiss Federal Laboratories for Materials Science and Technology, Dübendorf 8600, Switzerland
| | - Guangyu Qiu
- Institute of Environmental Engineering, ETH Zurich, Zurich 8093, Switzerland; Laboratory for Advanced Analytical Technologies, Empa, Swiss Federal Laboratories for Materials Science and Technology, Dübendorf 8600, Switzerland
| | - Martin Spillmann
- Institute of Environmental Engineering, ETH Zurich, Zurich 8093, Switzerland; Laboratory for Advanced Analytical Technologies, Empa, Swiss Federal Laboratories for Materials Science and Technology, Dübendorf 8600, Switzerland
| | - Zheng Ji
- School of Geography and Tourism, Shaanxi Normal University, Xi'an 710119, China
| | - Jing Wang
- Institute of Environmental Engineering, ETH Zurich, Zurich 8093, Switzerland; Laboratory for Advanced Analytical Technologies, Empa, Swiss Federal Laboratories for Materials Science and Technology, Dübendorf 8600, Switzerland.
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Del Fiol FDS, Bergamaschi CDC, De Andrade IP, Lopes LC, Silva MT, Barberato-Filho S. Consumption Trends of Antibiotics in Brazil During the COVID-19 Pandemic. Front Pharmacol 2022; 13:844818. [PMID: 35387351 PMCID: PMC8978992 DOI: 10.3389/fphar.2022.844818] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/03/2022] [Indexed: 12/21/2022] Open
Abstract
Background: In 2019, a new type of coronavirus emerged and spread to the rest of the world. Numerous drugs were identified as possible treatments. Among the candidates for possible treatment was azithromycin alone or in combination with other drugs. As a result, many clinicians in Brazil have prescribed azithromycin in an attempt to combat or minimize the effects of COVID19. Aim: This study analyzed the sales data of the main antibiotics prescribed in Brazil to verify the change in consumption trends of these drugs during the COVID-19 pandemic. Methods: This is an interrupted time series that analyzed antimicrobial sales data between January 2014 and July 2021, publicly accessible information obtained from the Brazilian government's website. Monthly means of "defined daily doses of DDDs" (DDDs per 1,000 inhabitants per day) of antibiotics were compared by analysis of variance, followed by the Dunnett Multiple Comparisons Test. Monthly trend changes in antibiotic use were verified using Joinpoint regression. Results: Amoxicillin (31.97%), azithromycin (18.33%), and cefalexin (16.61%) were the most sold antibiotics in Brazil during the evaluation period. Azithromycin consumption rose from 1.40 DDDs in February 2020 to 3.53 DDDs in July 2020. Azithromycin sales showed a significant increase in the pandemic period [Monthly Percent Change (MPC) 5.83%, 95% 1.80; 10.00], whereas there was a fall in amoxicillin sales (MPC -9.00%, 95% CI -14.70; -2.90) and cefalexin [MPC-2.70%, 95% (CI -6.30; -1.10)] in this same period. Conclusion: The COVID-19 pandemic changed the pattern of antibiotic consumption in Brazil, with a decrease in the use of amoxicillin and cefalexin and an increase in the consumption of azithromycin.
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Change in Pediatric Health Care Spending and Drug Utilization during the COVID-19 Pandemic. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121183. [PMID: 34943379 PMCID: PMC8699860 DOI: 10.3390/children8121183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 11/26/2021] [Accepted: 12/09/2021] [Indexed: 12/23/2022]
Abstract
Objective: To evaluate how the restrictive measures implemented during the SARS-CoV-2 pandemic have influenced the incidence of the most common children’s diseases and the consumption of medications in 2020 compared to 2019. Methods: We involved all family pediatricians of the local health authority of Latina, from which we requested data of monthly visits in 2019 and 2020 for six common diseases disseminated through droplets and contact, and the territorial and integrative pharmaceutical unit of the area, from which we requested data of the net expenditure regarding the most commonly used drugs at pediatric age. Results: There was significant reduction in the incidence of the evaluated diseases and in the consumption of investigated drugs between 2019 and 2020 in the months when the restrictive measures were in place, with an attenuation of this effect during the months of the gradual loosening of those measures. Conclusion: Nonpharmaceutical intervention measures have caused changes in the diffusion of common pediatric diseases. We believe that the implementation of a reasonable containment strategy, even outside of the pandemic, could positively influence the epidemiology of infectious and allergic diseases in children, and healthcare system spending.
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Gastaldi A, Donà D, Barbieri E, Giaquinto C, Bont LJ, Baraldi E. COVID-19 Lesson for Respiratory Syncytial Virus (RSV): Hygiene Works. CHILDREN (BASEL, SWITZERLAND) 2021; 8:children8121144. [PMID: 34943339 PMCID: PMC8700687 DOI: 10.3390/children8121144] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 02/05/2023]
Abstract
Respiratory syncytial virus (RSV) is a leading cause of acute lower respiratory tract infections (LRTIs) in infants worldwide. The global direct medical cost associated with RSV LRTIs reaches billions of dollars, with the highest burden in low–middle-income countries. Many efforts have been devoted to improving its prevention and management, including both non-pharmaceutical and pharmaceutical strategies, often with limited routine use in high-income countries due to high costs. During the ongoing COVID-19 pandemic, a dramatic decrease in RSV infections (up to 70–90%) has been reported around the globe, directly related to the implementation of containment measures (face masks, hand hygiene, and social distancing). Primary prevention has demonstrated the highest cost effectiveness ratio in reducing the burden of a respiratory infection such as RSV, never reached before. Thus, we emphasize the importance of non-pharmaceutical preventive hygiene measures that should be implemented and maintained even after the COVID-19 outbreak.
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Affiliation(s)
- Andrea Gastaldi
- Division of Pediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (A.G.); (E.B.); (C.G.)
- Department of Pediatrics, Woman and Child Hospital, University of Verona, 37126 Verona, Italy
| | - Daniele Donà
- Division of Pediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (A.G.); (E.B.); (C.G.)
- Correspondence:
| | - Elisa Barbieri
- Division of Pediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (A.G.); (E.B.); (C.G.)
| | - Carlo Giaquinto
- Division of Pediatric Infectious Diseases, Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy; (A.G.); (E.B.); (C.G.)
| | - Louis J. Bont
- Department of Pediatrics, Wilhelmina Children’s Hospital, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
- Respiratory Syncytial Virus Network (ReSViNET) Foundation, 3703 CD Zeist, The Netherlands
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women’s and Children’s Health, University of Padua, 35128 Padua, Italy;
- Fondazione Istituto di Ricerca Pediatrica, 35127 Padua, Italy
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Dias CF, Sarria EE, Scheffel C, Delatorre LB, Sapiro A, Baldissera M, Chiapinotto S, Mocelin HT, Fischer GB, Mattiello R. COVID-19 Prevention Policies Reduce Pediatric Hospital Mortality Due to Community-acquired Pneumonia. Arch Bronconeumol 2021; 58:197-199. [PMID: 34629613 PMCID: PMC8485709 DOI: 10.1016/j.arbres.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Carolina F Dias
- Pediatric Department, Universidade Federal do Espírito Santo, Vitória, Brazil.,Pediatric Infectious Diseases Section, Hospital Infantil e Maternidade Dr. Alzir Bernardino Alves, Vila Velha, Brazil
| | - Edgar E Sarria
- Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil
| | - Camila Scheffel
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura B Delatorre
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alexander Sapiro
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Sabrina Chiapinotto
- Postgraduate Program in Pulmonology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Helena T Mocelin
- Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.,Pediatrics Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Gilberto B Fischer
- Pediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.,Pediatrics Department, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil.,Postgraduate Program in Pediatrics, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Rita Mattiello
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
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