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Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, Jartti T, Oommen A, Twynam-Perkins J, Lewis S, Cunningham S. Efficacy of oral corticosteroids for acute preschool wheeze: a systematic review and individual participant data meta-analysis of randomised clinical trials. THE LANCET. RESPIRATORY MEDICINE 2024; 12:444-456. [PMID: 38527486 DOI: 10.1016/s2213-2600(24)00041-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Oral corticosteroids are commonly used for acute preschool wheeze, although there is conflicting evidence of their benefit. We assessed the clinical efficacy of oral corticosteroids by means of a systematic review and individual participant data (IPD) meta-analysis. METHODS In this systematic review with IPD meta-analysis, we systematically searched eight databases (PubMed, Ovid Embase, CINAHLplus, CENTRAL, ClinicalTrials.gov, EudraCT, EU Clinical Trials Register, WHO Clinical Trials Registry) for randomised clinical trials published from Jan 1, 1994, to June 30, 2020, comparing oral corticosteroids with placebo in children aged 12 to 71 months with acute preschool wheeze in any setting based on the Population, Intervention, Comparison, Outcomes framework. We contacted principal investigators of eligible studies to obtain deidentified individual patient data. The primary outcome was change in wheezing severity score (WSS). A key secondary outcome length of hospital stay. We also calculated a pooled estimate of six commonly reported adverse events in the follow-up period of IPD datasets. One-stage and two-stage meta-analyses employing a random-effects model were used. This study is registered with PROSPERO, CRD42020193958. FINDINGS We identified 16 102 studies published between Jan 1, 1994, and June 30, 2020, from which there were 12 eligible trials after deduplication and screening. We obtained individual data from seven trials comprising 2172 children, with 1728 children in the eligible IPD age range; 853 (49·4%) received oral corticosteroids (544 [63·8%] male and 309 [36·2%] female) and 875 (50·6%) received placebo (583 [66·6%] male and 292 [33·4%] female). Compared with placebo, a greater change in WSS at 4 h was seen in the oral corticosteroids group (mean difference -0·31 [95% CI -0·38 to -0·24]; p=0·011) but not 12 h (-0·02 [-0·17 to 0·14]; p=0·68), with low heterogeneity between studies (I2=0%; τ2<0·001). Length of hospital stay was significantly reduced in the oral corticosteroids group (-3·18 h [-4·43 to -1·93]; p=0·0021; I2=0%; τ2<0·001). Subgroup analyses showed that this reduction was greatest in those with a history of wheezing or asthma (-4·54 h [-5·57 to -3·52]; pinteraction=0·0007). Adverse events were infrequently reported (four of seven datasets), but oral corticosteroids were associated with an increased risk of vomiting (odds ratio 2·27 [95% CI 0·87 to 5·88]; τ2<0·001). Most datasets (six of seven) had a low risk of bias. INTERPRETATION Oral corticosteroids reduce WSS at 4 h and length of hospital stay in children with acute preschool wheeze. In those with a history of previous wheeze or asthma, oral corticosteroids provide a potentially clinically relevant effect on length of hospital stay. FUNDING Asthma UK Centre for Applied Research.
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Affiliation(s)
- Bohee Lee
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
| | - Steve Turner
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, UK
| | - Meredith Borland
- Perth Children's Hospital Emergency Department and Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, WA, Australia
| | - Péter Csonka
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Terveystalo Healthcare, Tampere, Finland
| | - Jonathan Grigg
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | - Theresa W Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland; PEDEGO Research Unit, University of Oulu, Oulu, Finland; Department of Pediatrics, Oulu University Hospital, Oulu, Finland
| | - Abraham Oommen
- Department of Paediatrics, Milton Keynes University Hospital NHS Trust, Milton Keynes, UK
| | - Jonathan Twynam-Perkins
- Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK; Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Steff Lewis
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steve Cunningham
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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2
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O' Hagan S, Norman-Bruce H, Shields M, Groves HE. Role of oral corticosteroids in the treatment of acute preschool wheeze. Arch Dis Child 2024:archdischild-2023-326786. [PMID: 38649255 DOI: 10.1136/archdischild-2023-326786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Shaun O' Hagan
- Paediatric Infectious Diseases, Royal Belfast Hospital for Sick Children, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
| | - Hannah Norman-Bruce
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
| | - Michael Shields
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
- Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, Belfast, UK
| | - Helen Elizabeth Groves
- Paediatric Infectious Diseases, Royal Belfast Hospital for Sick Children, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
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Walsh E, Gangakhedkar A, Jelleyman T, Grant CC. Pre-school wheeze hospital presentations: A demographic profile and review of clinical management. J Paediatr Child Health 2023; 59:871-878. [PMID: 37036117 DOI: 10.1111/jpc.16404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/30/2022] [Accepted: 03/21/2023] [Indexed: 04/11/2023]
Abstract
AIM Pre-school wheeze is a common hospital presentation in Australasia. The aim of this study was to describe the regional hospital presentation and cost of pre-school wheeze. METHODS Audit of children diagnosed with pre-school wheeze at two hospitals in Auckland, New Zealand from October 2017 to September 2019. Guideline adherence was determined. RESULTS One hundred and ninety-two children made 247 pre-school wheeze hospital presentations. Pre-school wheeze accounted for a larger proportion of acute hospital presentations for Māori versus non-Māori children (rate ratio 1.76, 95% confidence intervals 1.32-2.31). Hospital representations with pre-school wheeze occurred in 38/192 (20%) children. The proportion with a pre-school wheeze representation was larger for Māori than non-Māori (30% vs. 16%, P = 0.02). Pre-school wheeze event median length of stay increased as household deprivation increased (P = 0.01). Clinical severity of 247 pre-school wheeze episodes was mild (n = 64, 26%), moderate (n = 153, 62%) and severe (n = 30, 12%). Of 244 episodes, inhaled bronchodilators only were given for 149 (61%), oxygen for 54 (22%) and intravenous treatment for 41 (17%). Hospital guideline use was evident in 164/247 (66%) episodes. Neither clinical severity nor treatment intensity varied with child sex, age or ethnicity or household deprivation. The estimated median (interquartile range) direct medical costs of each pre-school wheeze episode were NZ$1279 (NZ$774-2158). CONCLUSIONS In Auckland, pre-school wheeze accounts for a larger proportion of acute hospital presentations for Māori compared with non-Māori and Māori children have increased odds of pre-school wheeze readmissions. Length of hospital stay for pre-school wheeze episodes increased with household deprivation. In this audit pre-school wheeze guideline adherence was poor.
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Affiliation(s)
- Eamon Walsh
- University of Auckland, Auckland, New Zealand
| | - Arun Gangakhedkar
- Paediatrics and Newborn Services, Waitakere Hospital, Waitematā District Health Board, Auckland, New Zealand
| | - Timothy Jelleyman
- Paediatrics and Newborn Services, Waitakere Hospital, Waitematā District Health Board, Auckland, New Zealand
| | - Cameron C Grant
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
- General Paediatrics, Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
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4
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Bush A. Basic clinical management of preschool wheeze. Pediatr Allergy Immunol 2023; 34:e13988. [PMID: 37492909 DOI: 10.1111/pai.13988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
Preschool wheeze is very common and often difficult to treat. Most children do not require any investigations; only a detailed history and physical examination to ensure an alternative diagnosis is not being missed; and the differential diagnosis, and hence investigation protocols for the child in whom a major illness is suspected, shows geographical variation. The pattern of symptoms may be divided into episodic viral and multiple trigger to guide treatment, but the pattern of symptoms must be re-assessed regularly. However, symptom patterns are a poor guide to underlying pathology. Attention to the proper use of spacers, and adverse environmental exposures such as tobacco smoke exposure, is essential. There are no disease-modifying therapies, so therapy is symptomatic. This paper reviews recent advances in treatment, including new data on the place of leukotriene receptor antagonists, prednisolone for acute attacks of wheeze, and antibiotics, based on new attempts to understand the underlying pathology in a way that is clinically practical.
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Affiliation(s)
- Andrew Bush
- Imperial College, London, UK
- National Heart and Lung Institute, London, UK
- Royal Brompton Harefield NHS Foundation Trust, London, UK
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5
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Smith FM, Saglani S. Demystifying controversies in preschool wheeze. Expert Rev Respir Med 2023; 17:1023-1031. [PMID: 37979137 DOI: 10.1080/17476348.2023.2283128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Wheezing disorders in preschool children are common. Current treatment approaches assume all preschool wheezers are the same and will respond to a short course of oral corticosteroids (OCS) during acute attacks and subsequent maintenance inhaled corticosteroids (ICS) to prevent future attacks. But we have increasing evidence showing preschool wheezing disorders are markedly heterogeneous and the response to corticosteroids either during acute attacks or as maintenance therapy can be variable between patients and is determined by disease severity and underlying pathological phenotype. AREAS COVERED The aim of this review is to discuss recent evidence which will help to explain a few critical pathophysiological concepts that are often misunderstood, thus helping to demystify the controversies that often surround preschool wheezing disorders and can contribute to ineffective management. EXPERT OPINION Preschool wheezing disorders are distinct from school-age allergic asthma. There is little evidence to support the use of oral corticosteroids for acute attacks. A staged approach to confirm the diagnosis, and objective tests to determine the pathological phenotype of preschool wheeze is essential prior to initiating maintenance therapy to control symptoms and prevent attacks in children with recurrent preschool wheeze.
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Affiliation(s)
- Frank M Smith
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
- Imperial Centre for Paediatrics and Child Health, Imperial College London, London, UK
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Weinberger M. Short courses of oral corticosteroids are effective, important, and safe for virus-triggered wheeze. Ann Allergy Asthma Immunol 2023; 130:525. [PMID: 37005052 DOI: 10.1016/j.anai.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 01/04/2023] [Indexed: 04/03/2023]
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Ambrożej D, Makrinioti H, Whitehouse A, Papadopoulos N, Ruszczyński M, Adamiec A, Castro-Rodriguez JA, Alansari K, Jartti T, Feleszko W. Respiratory virus type to guide predictive enrichment approaches in the management of the first episode of bronchiolitis: A systematic review. Front Immunol 2022; 13:1017325. [PMID: 36389820 PMCID: PMC9647543 DOI: 10.3389/fimmu.2022.1017325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/17/2022] [Indexed: 11/23/2022] Open
Abstract
It has become clear that severe bronchiolitis is a heterogeneous disease; even so, current bronchiolitis management guidelines rely on the one-size-fits-all approach regarding achieving both short-term and chronic outcomes. It has been speculated that the use of molecular markers could guide more effective pharmacological management and achieve the prevention of chronic respiratory sequelae. Existing data suggest that asthma-like treatment (systemic corticosteroids and beta2-agonists) in infants with rhinovirus-induced bronchiolitis is associated with improved short-term and chronic outcomes, but robust data is still lacking. We performed a systematic search of PubMed, Embase, Web of Science, and the Cochrane’s Library to identify eligible randomized controlled trials to determine the efficacy of a personalized, virus-dependent application of systemic corticosteroids in children with severe bronchiolitis. Twelve studies with heterogeneous methodology were included. The analysis of the available results comparing the respiratory syncytial virus (RSV)-positive and RSV-negative children did not reveal significant differences in the associatons between systemic corticosteroid use in acute episode and duration of hospitalization (short-term outcome). However, this systematic review identified a trend of the positive association between the use of systematic corticosteroids and duration of hospitalization in RSV-negative infants hospitalized with the first episode of bronchiolitis (two studies). This evidence is not conclusive. Taken together, we suggest the design for future studies to assess the respiratory virus type in guiding predictive enrichment approaches in infants presenting with the first episode of bronchiolitis.
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Affiliation(s)
- Dominika Ambrożej
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Heidi Makrinioti
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Abigail Whitehouse
- Centre for Genomics and Child Health, Queen Mary University of London, London, United Kingdom
| | - Nikolas Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - Marek Ruszczyński
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Aleksander Adamiec
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Jose A. Castro-Rodriguez
- Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Khalid Alansari
- Department of Pediatric Emergency Medicine, Sidra Medicine, Doha, Qatar
- Clinical Pediatrics, Qatar University College of Medicine, Doha, Qatar
- Clinical Pediatrics, Weill Cornell Medical College- Qatar, Doha, Qatar
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland
- PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
- Department of Pediatrics and Adolescent Medicine, Oulu University Hospital, Oulu, Finland
| | - Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Wojciech Feleszko,
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8
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Viral Infections and Wheezing in Preschool Children. Immunol Allergy Clin North Am 2022; 42:727-741. [DOI: 10.1016/j.iac.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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9
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Management of Preschool Wheezing: Guideline from the Emilia-Romagna Asthma (ERA) Study Group. J Clin Med 2022; 11:jcm11164763. [PMID: 36013002 PMCID: PMC9409690 DOI: 10.3390/jcm11164763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/20/2022] Open
Abstract
Preschool wheezing should be considered an umbrella term for distinctive diseases with different observable and measurable phenotypes. Despite many efforts, there is a large gap in knowledge regarding management of preschool wheezing. In order to fill this lack of knowledge, the aim of these guidelines was to define management of wheezing disorders in preschool children (aged up to 5 years). A multidisciplinary panel of experts of the Emilia-Romagna Region, Italy, addressed twelve different key questions regarding the management of preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes) and systematic reviews have been conducted on PubMed to answer these specific questions, with the aim of formulating recommendations. The GRADE approach has been used for each selected paper, to assess the quality of the evidence and the degree of recommendations. These guidelines represent, in our opinion, the most complete and up-to-date collection of recommendations on preschool wheezing to guide pediatricians in the management of their patients, standardizing approaches. Undoubtedly, more research is needed to find objective biomarkers and understand underlying mechanisms to assess phenotype and endotype and to personalize targeted treatment.
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10
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Yang X, Jin H. Safety of corticosteroids in the treatment of acute respiratory disease in children: a systematic review and meta-analysis. Transl Pediatr 2022; 11:194-203. [PMID: 35282016 PMCID: PMC8905102 DOI: 10.21037/tp-21-577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 12/30/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Oral corticosteroids are often used to treat acute asthma or asthma caused by respiratory tract infection in adult patients, but the effect of oral corticosteroids in young children is still controversial. We conducted a meta-analysis of controlled clinical studies to examine the effect of oral corticosteroids in children with respiratory diseases. METHODS Embase, PubMed, Web of Science, Ovid, ClinicalTrials.org from January 2000 to August 2021 were searched for randomized control trials related to the treatment of pediatric respiratory diseases with corticosteroid drugs using the keywords "corticosteroids" and "acute respiratory diseases". After screening the articles, Revman 5.4 software was used for the analysis. RESULTS A total of 8 articles (comprising 2,327 patients, 4 kinds of corticosteroids, and 3 types of pediatric respiratory disease) were included in the meta-analysis. The results showed that the length of hospital stay of patients in the experimental group treated with corticosteroids was shorter than that of patients in the control group [mean difference =-2.03, 95% confidence interval (CI): -2.91, -1.14; P<0.00001]. Further, the number and proportion of uncured patients after 3 days of treatment were lower in the experimental group than the control group [odds ratio (OR) =0.55, 95% CI: 0.42, 0.72; P<0.00001]. There were no differences in relation to adverse reactions (OR =0.57, 95% CI: 0.31, 1.07; P=0.08), and the readmission rate between the experimental and control groups (OR =0.94, 95% CI: 0.66, 1.34; P=0.75). DISCUSSION Corticosteroid use in the treatment of respiratory diseases in children can significantly shorten hospitalization time and increase the cure rate without increasing adverse reactions.
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Affiliation(s)
- Xiaoyun Yang
- Department of Pediatrics, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Hui Jin
- Department of Pediatrics, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Gileles-Hillel A, Guttman S, Breuer O, Reiter J, Leshem R, Shoseyov D, Kerem E, Cohen-Cymberknoh M. Betamethasone versus dexamethasone for inpatient preschool wheezing-A case-control study. Pediatr Pulmonol 2021; 56:875-882. [PMID: 33524229 DOI: 10.1002/ppul.25274] [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: 09/14/2020] [Revised: 12/20/2020] [Accepted: 01/11/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVES Wheezing is one of the most common reasons for the presentation of children to primary care or the emergency ward, before 7 years of age. Current guidelines recommend a short course of oral corticosteroids (OCS) for those children with a wheezing attack severe enough to require hospitalization. However, the optimal choice of therapy is controversial. We aimed to compare the efficacy of betamethasone to that of dexamethasone in achieving clinical response in preschool children requiring hospitalization for an acute wheezing attack. METHODS This was a retrospective study. Medical records of healthy children without significant comorbidities between 1 and 7 years of age (n = 234) admitted with a moderate-severity acute wheezing attack to two pediatric wards between 2014 and 2018 were included. All children were treated with either betamethasone or dexamethasone exclusively during the hospitalization. The primary outcome of interest was the length of hospital stay (LOS). RESULTS The demographic parameters and the clinical severity of wheezing episodes were similar in the two study groups, as was the LOS. However, the dexamethasone cumulative dose used during hospitalization was significantly larger than the betamethasone cumulative dose (3.76 (1.88-5.64) vs. 1.86 (1.24-3.1) mg/kg of prednisone-equivalent dose, p < .001). CONCLUSION In preschool children with acute wheezing requiring hospitalization, betamethasone achieved a similar clinical response when compared to dexamethasone, with a lower cumulative steroid dose. Further studies are needed to understand the additional benefits of betamethasone over other steroids or placebo.
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Affiliation(s)
- Alex Gileles-Hillel
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sharon Guttman
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Oded Breuer
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joel Reiter
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Regina Leshem
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Shoseyov
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eitan Kerem
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Malena Cohen-Cymberknoh
- Pediatric Pulmonology, Sleep and CF Unit, Department of Pediatrics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Bonner K, Scotney E, Saglani S. Factors and mechanisms contributing to the development of preschool wheezing disorders. Expert Rev Respir Med 2021; 15:745-760. [PMID: 33881953 DOI: 10.1080/17476348.2021.1913057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Half of all children will experience an episode of wheezing by their sixth birthday and acute episodes of wheezing in preschool children account for the majority of all childhood hospital admissions for wheeze. Recurrent preschool wheezing associates with early loss of lung function and a life-long impact on lung health. AREAS COVERED We reviewed the literature on PubMed from August 2010-2020 focussing on factors associated with wheeze inception and persistence, paying specific attention to mechanistic studies that have investigated the impact of early life exposures in shaping immune responses in children with underlying susceptibility to wheezing. In particular, the role of early allergen sensitization, respiratory infections, and the impact of the environment on shaping the airway microbiome and resulting immune responses are discussed. EXPERT OPINION There is an abundance of associative data showing the role of in utero and postnatal factors influencing wheeze onset and persistence. However, mechanistic and stratified, biomarker-based interventional studies that confirm these associations are now needed if we are to impact the significant healthcare burden resulting from preschool wheezing disorders.
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Affiliation(s)
- Katie Bonner
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Elizabeth Scotney
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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Wallace A, Sinclair O, Shepherd M, Neutze J, Trenholme A, Tan E, Brabyn C, Bonisch M, Grey N, Johnson DW, McNamara D, Thompson JMD, Asher I, Dalziel SR. Impact of oral corticosteroids on respiratory outcomes in acute preschool wheeze: a randomised clinical trial. Arch Dis Child 2021; 106:339-344. [PMID: 33067310 DOI: 10.1136/archdischild-2020-318971] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine if administration of oral prednisolone to preschool children with acute wheeze alters respiratory outcomes. DESIGN Double-blind, randomised, placebo-controlled equivalence trial. SETTING Three hospitals in New Zealand. PATIENTS 477 children aged 24-59 months with acute wheeze associated with respiratory illness. INTERVENTIONS 2 mg/kg (maximum 40 mg) oral prednisolone or similar placebo, once daily for 3 days. MAIN OUTCOME MEASURES Primary outcome was change in Preschool Respiratory Assessment Measure (PRAM) score 24 hours after intervention. Secondary outcomes included PRAM score at 4 hours, length of emergency department and inpatient stays, admission and representation rates, time to return to normal activities and use of additional oral prednisolone or intravenous medications. Analysis was by intention-to-treat. RESULTS There was no difference between groups for change in PRAM score at 24 hours (difference between means -0.39, 95% CI -0.84 to 0.06, p=0.09). Absolute PRAM score was lower in the prednisolone group at 4 hours (median (IQR) 1 (0-2) vs 2 (0-3), p=0.01) and 24 hours (0 (0-1) vs 0 (0-1), p=0.01), when symptoms had resolved for most children regardless of initial treatment. Admission rate, requirement for additional oral prednisolone and use of intravenous medication were lower in the prednisolone group, although there were no differences between groups for time taken to return to normal activities or rates of representation within 7 days. CONCLUSION Oral prednisolone does not alter respiratory outcomes at 24 hours or beyond in preschool children presenting with acute wheeze.
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Affiliation(s)
- Alexandra Wallace
- Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand.,Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Owen Sinclair
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Paediatric Department, Waitakere Hospital, Auckland, New Zealand
| | - Michael Shepherd
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
| | - Jocelyn Neutze
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Kidz First, Middlemore Hospital, Auckland, New Zealand
| | - Adrian Trenholme
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Kidz First, Middlemore Hospital, Auckland, New Zealand
| | - Eunicia Tan
- Emergency Department, Middlemore Hospital, Auckland, New Zealand.,Department of Surgery, The University of Auckland, Auckland, New Zealand
| | | | - Megan Bonisch
- Children's Emergency Department, Starship Children's Health, Auckland, New Zealand
| | - Naomi Grey
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - David W Johnson
- Departments of Paediatrics, Emergency Medicine, and Pharmacology and Physiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - David McNamara
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Respiratory Medicine, Starship Children's Health, Auckland, New Zealand
| | - John M D Thompson
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Innes Asher
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Respiratory Medicine, Starship Children's Health, Auckland, New Zealand
| | - Stuart R Dalziel
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand .,Children's Emergency Department, Starship Children's Health, Auckland, New Zealand.,Department of Surgery, The University of Auckland, Auckland, New Zealand
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14
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Management of Asthma Exacerbations in the Emergency Department. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:2599-2610. [PMID: 33387672 DOI: 10.1016/j.jaip.2020.12.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Asthma exacerbations occur across a wide spectrum of chronic severity; they contribute to millions of emergency department (ED) visits in both children and adults every year. Management of asthma exacerbations is an important part of the continuum of asthma care. The best strategy for ED management of an asthma exacerbation is early recognition and intervention, continuous monitoring, appropriate disposition, and, once improved, multifaceted transitional care that optimizes subacute and chronic asthma management after ED discharge. This article concisely reviews ED evaluation, treatment, disposition, and postdischarge care for patients with asthma exacerbations, based on high-quality evidence (eg, systematic reviews from the Cochrane Collaboration) and current international guidelines (eg, the National Asthma Education and Prevention Program Expert Panel Report 3, Global Initiative for Asthma, and Australian guidelines). Special populations (young children, pregnant women, and the elderly) also are addressed. Despite advances in asthma science, there remain many important evidence gaps in managing ED patients with asthma exacerbation. This article summarizes several of these controversial areas and challenges that merit further investigation.
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15
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Makrinioti H, Bush A, Griffiths C. What are patient-reported outcomes and why they are important: improving studies of preschool wheeze. Arch Dis Child Educ Pract Ed 2020; 105:185-188. [PMID: 31473628 DOI: 10.1136/archdischild-2018-316476] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 08/16/2019] [Accepted: 08/23/2019] [Indexed: 11/04/2022]
Abstract
There are no outcomes-based commissioning structures in child health. This needs to change. Preschool wheeze is a very common condition. Many families present at emergency departments with their wheezy children and stay briefly. This highlights that this group of children may be lacking a more personalised approach. There are no user-friendly patient-reported outcome measures in preschool wheeze. This needs to change. Research in this area is therefore highly anticipated.
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Affiliation(s)
- Heidi Makrinioti
- Department of Paediatrics, Imperial College Healthcare NHS Trust, London, UK
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK.,Division of Medicine, Imperial College, London, United Kingdom
| | - Chris Griffiths
- Centre for Paediatrics, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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16
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Stokes JR, Bacharier LB. Prevention and treatment of recurrent viral-induced wheezing in the preschool child. Ann Allergy Asthma Immunol 2020; 125:156-162. [PMID: 32454096 DOI: 10.1016/j.anai.2020.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To summarize the recent evidence in the treatment of viral-induced wheezing in the infant and preschool aged child. DATA SOURCES Published literature obtained through PubMed database searches. STUDY SELECTIONS Studies relevant to phenotypes and treatment of wheezing illnesses in infants and preschool children were included. RESULTS Recurrent wheezing in preschool children is common and is frequently triggered by viral respiratory tract infections. Certain phenotypes may respond to treatments differently, depending on the risk factors identified. Inhaled corticosteroids, administered continuously or intermittently, reduce the risk of virus-induced wheezing episodes. The use of leukotriene modifying agents may have a role in wheezing episodes in a select group of preschool children. Early administration of azithromycin reduces the risk of severe lower respiratory tract illnesses in children. The effect of oral corticosteroids on wheezing episodes in young children varies by degree of episode severity. CONCLUSION Recurrent viral-induced wheezing illnesses has been the focus of many clinical trials, which now provide an increasingly robust evidence base for management. Additional research is needed to define optimal strategies, to best match therapies to specific phenotypes and endotypes, and will eventually begin to include therapies directed specifically at the viral triggers.
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Affiliation(s)
- Jeffrey R Stokes
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, St. Louis Children's Hospital, St. Louis, Missouri
| | - Leonard Benjamin Bacharier
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, St. Louis Children's Hospital, St. Louis, Missouri.
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17
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Douros K, Everard ML. Time to Say Goodbye to Bronchiolitis, Viral Wheeze, Reactive Airways Disease, Wheeze Bronchitis and All That. Front Pediatr 2020; 8:218. [PMID: 32432064 PMCID: PMC7214804 DOI: 10.3389/fped.2020.00218] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 04/14/2020] [Indexed: 12/11/2022] Open
Abstract
The diagnosis and management of infants and children with a significant viral lower respiratory tract illness remains the subject of much debate and little progress. Over the decades various terms for such illnesses have been in and fallen out of fashion or have evolved to mean different things to different clinicians. Terms such as "bronchiolitis," "reactive airways disease," "viral wheeze," and many more are used to describe the same condition and the same term is frequently used to describe illnesses caused by completely different dominant pathologies. This lack of clarity is due, in large part, to a failure to understand the basic underlying inflammatory and associated processes and, in part, due to the lack of a simple test to identify a condition such as asthma. Moreover, there is a lack of insight into the fact that the same pathology can produce different clinical signs at different ages. The consequence is that terminology and fashions in treatment have tended to go around in circles. As was noted almost 60 years ago, amongst pre-school children with a viral LRTI and airways obstruction there are those with a "viral bronchitis" and those with asthma. In the former group, a neutrophil dominated inflammation response is responsible for the airways' obstruction whilst amongst asthmatics much of the obstruction is attributable to bronchoconstriction. The airways obstruction in the former group is predominantly caused by airways secretions and to some extent mucosal oedema (a "snotty lung"). These patients benefit from good supportive care including supplemental oxygen if required (though those with a pre-existing bacterial bronchitis will also benefit from antibiotics). For those with a viral exacerbation of asthma, characterized by bronchoconstriction combined with impaired b-agonist responsiveness, standard management of an exacerbation of asthma (including the use of steroids to re-establish bronchodilator responsiveness) represents optimal treatment. The difficulty is identifying which group a particular patient falls into. A proposed simplified approach to the nomenclature used to categorize virus associated LRTIs is presented based on an understanding of the underlying pathological processes and how these contribute to the physical signs.
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Affiliation(s)
- Konstantinos Douros
- Third Department of Paediatrics, Attikon Hospital, University of Athens School of Medicine, Athens, Greece
| | - Mark L. Everard
- Division of Paediatrics and Child Health, Perth Children's Hospital, University of Western Australia, Nedlands, WA, Australia
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18
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De Filippo M, Clark E, Fillard A, Diaferio L, Caimmi D. Oral corticosteroids and asthma in children: Practical considerations. Pediatr Allergy Immunol 2020; 31 Suppl 24:43-45. [PMID: 32017205 DOI: 10.1111/pai.13151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2019] [Indexed: 12/01/2022]
Abstract
Corticosteroids (CS) are among the most prescribed drugs in pediatrics. In allergy, CS are prescribed for several different conditions. If CS show clear benefits when adequately prescribed, CS are also associated with several side effects, well known by pediatricians. As for asthma exacerbations, the oral route is always the preferred one in pediatrics. Several authors debated if the use of a single dose of dexamethasone is better in terms of efficacy, compared with a 3- to 5-day course of prednisone or prednisolone. Another interesting issue that has not been fully clarified concerns whether oral corticosteroids should be prescribed in preschoolers presenting with acute wheezing. The present review aims to review the most recent publications on this topic and to try to clarify which may be the best option in children suffering from asthma exacerbations.
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Affiliation(s)
- Maria De Filippo
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, CHU de Montpellier, Univ Montpellier, Montpellier, France.,Pediatric Unit of the University Hospital of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Evangéline Clark
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, CHU de Montpellier, Univ Montpellier, Montpellier, France
| | - Anouchka Fillard
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, CHU de Montpellier, Univ Montpellier, Montpellier, France
| | - Lucia Diaferio
- Department of Pediatrics, Aldo Moro University of Bari, Giovanni XXIII Hospital, Bari, Italy
| | - Davide Caimmi
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, CHU de Montpellier, Univ Montpellier, Montpellier, France.,Equipe EPAR - IPLESP, UMR 1136, INSERM - Sorbonne Université, Paris, France
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19
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Kwong CG, Bacharier LB. Management of Asthma in the Preschool Child. Immunol Allergy Clin North Am 2019; 39:177-190. [PMID: 30954169 DOI: 10.1016/j.iac.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The management of asthma in the preschool population is challenging because disease phenotypes are heterogeneous and evolving. Available therapies aimed at preventing persistent symptoms and recurrent exacerbations include inhaled corticosteroids and leukotriene receptor antagonists; episodic use of inhaled corticosteroids and azithromycin may result in a decrease in exacerbations among children with intermittent disease. This article reviews an approach using patient characteristics for selecting initial treatment approaches based on disease phenotype, such as symptom patterns or evidence of atopic markers. Evidence for and against the use of oral corticosteroids during acute episodes and barriers to adherence and effective treatment are discussed.
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Affiliation(s)
- Christina G Kwong
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine in St. Louis, Campus Box 8116, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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20
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May S, Brown SP, Schmicker RH, Emerson SS, Nkwopara E, Ginsburg AS. Non-inferiority designs comparing placebo to a proven therapy for childhood pneumonia in low-resource settings. Clin Trials 2019; 17:129-137. [PMID: 31814441 DOI: 10.1177/1740774519888460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/AIMS After a new treatment is recommended to be first-line treatment for a specific indication, outcome and population, it may be unethical to use placebo as a comparator in trials for that setting. Nevertheless, in specific circumstances, use of a placebo group might be warranted, for example, when it is believed that an active treatment may not be efficacious or cost-effective for a specific subpopulation. An example is antibiotic treatment for pneumonia, which may not be effective for many patients taking it due to the emergence of antibiotic-resistant strains or the high prevalence of viral and low prevalence of bacterial pneumonia. METHODS We explore the applicability of different design options in cases where the benefit of an established treatment is questioned, with particular emphasis on issues that arise in a low-resource setting. Using the example of a clinical trial comparing the effectiveness of placebo versus amoxicillin in treating children 2-59 months of age with fast breathing pneumonia in Lilongwe, Malawi, we discuss the pros and cons of superiority versus non-inferiority designs, an intent-to-treat versus as-treated analysis and the use and interpretation of one- versus two-sided confidence intervals. RESULTS We find that a non-inferiority design using an intent-to-treat analysis is the most appropriate design and analysis option. In addition, the presentation of one- versus two-sided confidence intervals can depend on the results but can maintain type I error. CONCLUSION In the setting where the benefit of a previously established beneficial treatment is questioned, a non-inferiority design that includes placebo as the tested treatment option can be the most appropriate design option.
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Affiliation(s)
- Susanne May
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Siobhan P Brown
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Robert H Schmicker
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Scott S Emerson
- UW Clinical Trials Center, Department of Biostatistics, University of Washington, Seattle, WA, USA
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21
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Jones YO, Hubbell BB, Thomson J, O’Toole JK. Things We Do for No Reason: Systemic Corticosteroids for Wheezing in Preschool-Aged Children. J Hosp Med 2019; 14:774-776. [PMID: 31339838 PMCID: PMC6897538 DOI: 10.12788/jhm.3255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Wheezing is common in preschool-aged children (ages 2-5
years), with up to half in this age group having experienced a
wheezing episode and up to one-third, recurrent wheezing.1,2
Young children with wheezing require ED visits and hospitalizations
at much higher rates than older children and adults.3 Several
studies have also demonstrated that children in this age
group have higher rates of SCS prescriptions compared with
older children.4,5 Despite the high prevalence of wheezing in
this age group, there is great heterogeneity in the etiology and
clinical progression of early childhood wheezing, with up to six
described phenotypes each with varying levels of association
with the development of asthma.6 Given the high frequency of
asthma, preschool-aged children admitted with wheezing are
often treated with SCS, as this is the standard of care for an
acute asthma exacerbation.7
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Affiliation(s)
- Yemisi O Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Corresponding Author: Yemisi O Jones, MD; E-mail: ; Telephone: 412-965-9630
| | - Brittany B Hubbell
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joanna Thomson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer K O’Toole
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
- University of Cincinnati Medical Center, Cincinnati, Ohio
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22
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Affiliation(s)
- Shilpa J Patel
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC
| | - Stephen J Teach
- Division of Emergency Medicine, Children's National Medical Center, Washington, DC
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23
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Heidi M, Emily K, Benjamin H, Michael C, Robert K, Mitch B, Chris G, Mando W, Andrew B. Patient reported outcomes for preschool children with recurrent wheeze. NPJ Prim Care Respir Med 2019; 29:7. [PMID: 30914646 PMCID: PMC6435695 DOI: 10.1038/s41533-019-0120-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 02/26/2019] [Indexed: 01/21/2023] Open
Abstract
Children with preschool wheeze regularly attend UK emergency departments. There is no international consensus on any specific personalised management approach. This paper describes the first attempt to co-design patient-centred outcomes with families. Preschool wheezers' parents participated in semi-structured interviews and focus-group discussions to air their concerns and identify potential additional support. Fifty-seven families participated in these interviews. From these, themes were defined through qualitative content analysis. Parental experience was mapped to the patient pathway and seven important personalised outcomes were described. These can be used to inform a tool which following further validation could potentially support management of children with preschool wheeze and provide an additional patient focused clinical outcome measure in audit and research.
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Affiliation(s)
- Makrinioti Heidi
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - Keating Emily
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Holden Benjamin
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Coren Michael
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Klaber Robert
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Blair Mitch
- Department of Paediatrics, Northwick Park Hospital, North West London Hospitals NHS Trust, London, UK.,Division of Medicine, Imperial College, London, UK
| | - Griffiths Chris
- Asthma UK Centre for Applied Research, Centre for Primary Care and Public Health, Blizard Institute, Barts and the London, School of Medicine and Dentistry, London, E1 2AT, UK
| | - Watson Mando
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Bush Andrew
- Division of Medicine, Imperial College, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
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24
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Saglani S, Fleming L, Sonnappa S, Bush A. Advances in the aetiology, management, and prevention of acute asthma attacks in children. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:354-364. [PMID: 30902628 DOI: 10.1016/s2352-4642(19)30025-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 12/17/2022]
Abstract
Acute attacks of wheeze or asthma are among the most common reasons for paediatric hospital attendance, and the incidence of severe attacks in the UK is among the highest in Europe. Although most attacks are driven by infection, there are important differences in the underlying pathophysiology of asthma and wheeze between preschool and school-aged children. Allergen sensitisation, airway eosinophilia, and type 2 inflammation predominate in older children, whereas phenotypes in preschool children are variable, often including non-atopic episodes driven by neutrophilic infection. Currently, a universal approach is adopted towards management, but there is a need to make objective assessments of airway function, inflammation, and infection, both during the attack and during stable periods, to identify treatable traits and to target therapy if outcomes are to be improved. An assessment of the risk factors that led to the attack and early, focused follow-up are essential to ensure attacks never occur again.
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Affiliation(s)
- Sejal Saglani
- National Heart & Lung Institute, Imperial College London, London, UK; Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK.
| | - Louise Fleming
- National Heart & Lung Institute, Imperial College London, London, UK; Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Samatha Sonnappa
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Andrew Bush
- National Heart & Lung Institute, Imperial College London, London, UK; Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
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25
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Abstract
Pediatric asthma is a common chronic condition with wide-ranging implications for children's health, their families, and the health care system. The diagnosis may be relatively straightforward for the child with characteristic symptoms, triggers, and response to therapy, but there are other less common presentations that can make the diagnosis challenging. Diagnosing asthma in a toddler with recurrent wheezing can be particularly difficult. Treating asthma in a step-wise fashion usually reduces symptom frequency and improves asthma control. Asthma exacerbations and poor outcomes from acute exacerbations remain an area in which we have room for improvement. This article provides an overview of the diagnosis and management of childhood asthma for the primary care provider. [Pediatr Ann. 2019;48(3):e103-e109.].
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26
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Question 3: Can we diagnose asthma in children under the age of 5 years? Paediatr Respir Rev 2019; 29:25-30. [PMID: 30528365 PMCID: PMC6444340 DOI: 10.1016/j.prrv.2018.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/18/2018] [Indexed: 12/27/2022]
Abstract
The diagnosis of asthma in children under five years has been controversial due to changing concepts of what true asthma is in this age group. Previous diagnostic algorithms that used clinical indices to predict the persistence of asthma symptoms or phenotypes based on asthma triggers do not predict which children will benefit from asthma medication. A pragmatic approach to asthma diagnosis in this age group is based on identifying signs and symptoms of reversible airflow obstruction and documenting their response to asthma medication. Hopefully, this approach will provide clearer guidance to clinicians and improve asthma morbidity in these young children.
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27
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Ferrara G, Petrillo MG, Giani T, Marrani E, Filippeschi C, Oranges T, Simonini G, Cimaz R. Clinical Use and Molecular Action of Corticosteroids in the Pediatric Age. Int J Mol Sci 2019; 20:ijms20020444. [PMID: 30669566 PMCID: PMC6359239 DOI: 10.3390/ijms20020444] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 12/19/2022] Open
Abstract
Corticosteroids are the mainstay of therapy for many pediatric disorders and sometimes are life-saving. Both endogenous and synthetic derivatives diffuse across the cell membrane and, by binding to their cognate glucocorticoid receptor, modulate a variety of physiological functions, such as glucose metabolism, immune homeostasis, organ development, and the endocrine system. However, despite their proved and known efficacy, corticosteroids show a lot of side effects, among which growth retardation is of particular concern and specific for pediatric age. The aim of this review is to discuss the mechanism of action of corticosteroids, and how their genomic effects have both beneficial and adverse consequences. We will focus on the use of corticosteroids in different pediatric subspecialties and most common diseases, analyzing the most recent evidence.
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Affiliation(s)
| | - Maria Grazia Petrillo
- Signal Transduction laboratory, NIEHS, NIH, Department of Health and Human Services, Research Triangle Park, Durham, NC 27709, USA.
| | - Teresa Giani
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy.
| | | | - Cesare Filippeschi
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Teresa Oranges
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Gabriele Simonini
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
| | - Rolando Cimaz
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
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28
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Should oral corticosteroids be prescribed for preschool viral wheeze? THE LANCET RESPIRATORY MEDICINE 2018; 6:e21. [PMID: 29856323 DOI: 10.1016/s2213-2600(18)30146-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/29/2018] [Indexed: 11/24/2022]
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29
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Borland ML, Foster SJ, Cooper MN, Oosterhof S. Should oral corticosteroids be prescribed for preschool viral wheeze? - Authors' reply. THE LANCET RESPIRATORY MEDICINE 2018; 6:e22. [PMID: 29856324 DOI: 10.1016/s2213-2600(18)30145-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 03/29/2018] [Indexed: 11/17/2022]
Affiliation(s)
- M L Borland
- Emergency Department, Princess Margaret Hospital for Children, Perth, WA 6840, Australia; Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia.
| | - S J Foster
- Emergency Department, Princess Margaret Hospital for Children, Perth, WA 6840, Australia
| | - M N Cooper
- Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - S Oosterhof
- Emergency Department, Princess Margaret Hospital for Children, Perth, WA 6840, Australia
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30
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Abrams EM, Becker AB, Szefler SJ. Use of Oral Corticosteroids in the Wheezy Toddler. J Pediatr 2018; 201:16-20. [PMID: 30251636 DOI: 10.1016/j.jpeds.2018.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/10/2018] [Accepted: 06/04/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Elissa M Abrams
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Allan B Becker
- Department of Pediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Stanley J Szefler
- Department of Pediatrics, Section of Pulmonary Medicine, Breathing Institute, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
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31
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Oral corticosteroids in preschool children with severe episodes of virus-associated wheeze: To treat or not to treat? J Allergy Clin Immunol 2018; 142:405-406. [DOI: 10.1016/j.jaci.2018.06.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 06/27/2018] [Indexed: 11/18/2022]
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32
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Abstract
This manuscript takes a challenging look at the management of asthma in childhood, in particular in the light of the recent Lancet commission. One of the central pillars of the Commission is the need to deliver personalized medicine for airway disease by deconstructing the airway into components of fixed and variable airflow obstruction, inflammation and infection. Before any treatment for asthma, a diagnostic workup is essential to exclude other conditions. A diagnosis of asthma needs to be based on objective evidence of bronchodilator sensitive variable airflow obstruction, eosinophilic airway inflammation and atopy. Most children with atopic asthma respond to low dose inhaled corticosteroids, sometimes requiring a long acting β-agonist. If the response is unsatisfactory, then, rather than escalate treatment, an approach for which there is little evidence, a full review of the child should be undertaken, including extrapulmonary comorbidities, adherence and adverse environmental influences. If these cannot or will not be addressed by the family, then further treatment including biologicals may be indicated. Asthma attacks are an important warning sign and should always be taken seriously, including a focused reassessment of all aspects of the management of the child. Finally, preschool children with wheeze can also be evaluated for eosinophilic airway inflammation using peripheral blood eosinophil count as a surrogate. It is essential that we start to deliver personalized medicine to children with airway disease.
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Affiliation(s)
- Andrew Bush
- Section of Pediatrics, Imperial College, London, UK - .,National Heart and Lung Institute, London, UK - .,Royal Brompton Harefield NHS Foundation Trust, London, UK -
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33
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Weinberger M, Hendeles L, Abu-Hasan M. Oral corticosteroids should be available on-hand at home for the next asthma exacerbation! Ann Allergy Asthma Immunol 2018; 121:18-21. [PMID: 29653237 DOI: 10.1016/j.anai.2018.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 03/30/2018] [Accepted: 04/02/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Miles Weinberger
- Pediatric Department, University of California-San Diego, Rady Children's Hospital, San Diego, California.
| | - Leslie Hendeles
- Pediatric Department, University of Florida, Gainesville, Florida
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34
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Zorc JJ. Oral corticosteroids reduce length of hospital stay for preschool children with virus-associated wheeze. THE LANCET RESPIRATORY MEDICINE 2018; 6:76-77. [PMID: 29352664 DOI: 10.1016/s2213-2600(18)30009-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/02/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Joseph J Zorc
- Perelman School of Medicine, University of Pennsylvania and The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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