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Prematurity-associated wheeze: current knowledge and opportunities for further investigation. Pediatr Res 2022:10.1038/s41390-022-02404-1. [PMID: 36463364 PMCID: PMC10238677 DOI: 10.1038/s41390-022-02404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 12/04/2022]
Abstract
Prematurity-associated wheeze is a common complication of preterm birth, with significant impact on the health and healthcare utilization of former preterm infants. This wheezing phenotype remains poorly understood and difficult to predict. This review will discuss the current state of the literature on prematurity-associated wheeze. We will discuss etiology and pathophysiology, and offer two conceptual models for the pathogenesis of this complex condition. This review will also identify current methods of ascertainment, and discuss the strengths and limitations of each. We will explore research-backed approaches to prevention and management, and finally suggest both pre-clinical and clinical avenues for investigation. An in-depth understanding of prematurity-associated wheeze will aid clinicians in its diagnosis and management, and inspire scientists to pursue much-needed further study into causes and prevention of this common and impactful condition. IMPACT: There is no recent, concise review on the current state of research on prematurity-associated wheeze, which is a rapidly evolving area of study. This article highlights causal models of wheeze, methods of ascertainment, management strategies for the clinician, and opportunities for further research for the physician scientist.
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2
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Goulden N, Cousins M, Hart K, Jenkins A, Willetts G, Yendle L, Doull I, Williams EM, Hoare Z, Kotecha S. Inhaled Corticosteroids Alone and in Combination With Long-Acting β2 Receptor Agonists to Treat Reduced Lung Function in Preterm-Born Children: A Randomized Clinical Trial. JAMA Pediatr 2022; 176:133-141. [PMID: 34902004 PMCID: PMC8669602 DOI: 10.1001/jamapediatrics.2021.5111] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 10/03/2021] [Indexed: 12/05/2022]
Abstract
Importance Decreases in future lung function are a hallmark of preterm birth, but studies for management of decreased lung function are limited. Objective To determine whether 12 weeks of treatment with inhaled corticosteroids (ICS) alone or in combination with long-acting β2 agonists (LABA) improves spirometry and exercise capacity in school-aged preterm-born children who had percent predicted forced expiratory volume in 1 second (%FEV1) less than or equal to 85% compared with inhaled placebo treatment. Design, Setting, and Participants A double-blind, randomized, placebo-controlled trial was conducted to evaluate ICS and ICS/LABA against placebo. Preterm-born children (age, 7-12 years; gestation ≤34 weeks at birth) who did not have clinically significant congenital, cardiopulmonary, or neurodevelopmental abnormalities underwent spirometry, exercise testing, and measurement of fractional exhaled nitric oxide before and after treatment. A total of 144 preterm-born children at the Children's Hospital for Wales in Cardiff, UK, were identified and enrolled between July 1, 2017, and August 31, 2019. Interventions Each child was randomized to 1 of 3 cohorts: fluticasone propionate, 50 μg, with placebo; fluticasone propionate, 50 μg, with salmeterol, 25 μg; or placebo inhalers, all given as 2 puffs twice daily for 12 weeks. Children receiving preexisting ICS treatment underwent washout prior to randomization to ICS or ICS/LABA. Main Outcomes and Measures The primary outcome was between-group differences assessed by adjusted pretreatment and posttreatment differences of %FEV1 using analysis of covariance. Intention-to-treat analysis was conducted. Results Of 144 preterm-born children who were identified with %FEV1 less than or equal to 85%, 53 were randomized. Treatment allocation was 20 children receiving ICS (including 5 with prerandomization ICS), 19 children receiving ICS/LABA (including 4 with prerandomization ICS), and 14 children receiving placebo. The mean (SD) age of children was 10.8 (1.2) years, and 29 of the randomized children (55%) were female. The posttreatment %FEV1 was adjusted for sex, gestation, bronchopulmonary dysplasia, intrauterine growth restriction, pretreatment corticosteroid status, treatment group, and pretreatment values. Posttreatment adjusted means for %FEV1, using analysis of covariance, were 7.7% (95% CI, -0.27% to 15.72%; P = .16) higher in the ICS group and 14.1% (95% CI, 7.3% to 21.0%; P = .002) higher in the ICS/LABA group compared with the placebo group. Active treatment decreased the fractional exhaled nitric oxide and improved postexercise bronchodilator response but did not improve exercise capacity. One child developed cough when starting inhaler treatment; no other adverse events reported during the trial could be attributed to the inhaler treatment. Conclusions and Relevance The results of this randomized clinical trial suggest that combined ICS/LABA treatment is beneficial for prematurity-associated lung disease in children. Trial Registration EudraCT number: 2015-003712-20.
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Affiliation(s)
- Nia Goulden
- NWORTH, Bangor University, Bangor, United Kingdom
| | - Michael Cousins
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Kylie Hart
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | | | - Gill Willetts
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Louise Yendle
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - Iolo Doull
- Department of Paediatrics, Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | - E. Mark Williams
- Faculty of Life Sciences and Education, University of South Wales, Pontypridd, United Kingdom
| | - Zoe Hoare
- NWORTH, Bangor University, Bangor, United Kingdom
| | - Sailesh Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
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3
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Cristea AI, Ren CL, Amin R, Eldredge LC, Levin JC, Majmudar PP, May AE, Rose RS, Tracy MC, Watters KF, Allen J, Austin ED, Cataletto ME, Collaco JM, Fleck RJ, Gelfand A, Hayes D, Jones MH, Kun SS, Mandell EW, McGrath-Morrow SA, Panitch HB, Popatia R, Rhein LM, Teper A, Woods JC, Iyer N, Baker CD. Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2021; 204:e115-e133. [PMID: 34908518 PMCID: PMC8865713 DOI: 10.1164/rccm.202110-2269st] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Premature birth affects millions of neonates each year, placing them at risk for respiratory disease due to prematurity. Bronchopulmonary dysplasia is the most common chronic lung disease of infancy, but recent data suggest that even premature infants who do not meet the strict definition of bronchopulmonary dysplasia can develop adverse pulmonary outcomes later in life. This post-prematurity respiratory disease (PPRD) manifests as chronic respiratory symptoms, including cough, recurrent wheezing, exercise limitation, and reduced pulmonary function. This document provides an evidence-based clinical practice guideline on the outpatient management of infants, children, and adolescents with PPRD. Methods: A multidisciplinary panel of experts posed questions regarding the outpatient management of PPRD. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. Results: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations were developed for or against three common medical therapies and four diagnostic evaluations in the context of the outpatient management of PPRD. Conclusions: The panel developed recommendations for the outpatient management of patients with PPRD on the basis of limited evidence and expert opinion. Important areas for future research were identified.
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Rhoads E, Montgomery GS, Ren CL. Wheezing in preterm infants and children. Pediatr Pulmonol 2021; 56:3472-3477. [PMID: 33580622 DOI: 10.1002/ppul.25314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/23/2021] [Accepted: 02/08/2021] [Indexed: 11/10/2022]
Abstract
Wheezing is a common outcome of preterm birth. This article will review the mechanisms, epidemiology, and treatment of wheezing in preterm children with and without a history of bronchopulmonary dysplasia.
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Affiliation(s)
- Eli Rhoads
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gregory S Montgomery
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Division of Pediatric Pulmonology, Allergy, and Sleep Medicine, Riley Hospital for Children, Indianapolis, Indiana, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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5
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Koo JK, Steinhorn R, C Katheria A. Optimizing respiratory management in preterm infants: a review of adjuvant pharmacotherapies. J Perinatol 2021; 41:2395-2407. [PMID: 34244615 DOI: 10.1038/s41372-021-01139-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/25/2021] [Accepted: 06/23/2021] [Indexed: 02/06/2023]
Abstract
Adjuvant respiratory therapies in preterm neonates aim to reduce long-term morbidities and mortality. Commonly utilized therapies include caffeine, systemic glucocorticosteroids, inhaled steroids, inhaled bronchodilators, and diuretics. This review discusses the available literature that supports some of these practices and points out where clinical practices are not corroborated by evidence. Therapies with no proven clinical benefit must be weighed against potential adverse effects.
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Affiliation(s)
- Jenny K Koo
- Sharp Mary Birch, Hospital for Women & Newborns, San Diego, CA, USA.,Sharp Neonatal Research Institute, San Diego, CA, USA
| | - Robin Steinhorn
- University of California San Diego, San Diego, CA, USA.,Rady Children's Hospital, San Diego, CA, USA
| | - Anup C Katheria
- Sharp Mary Birch, Hospital for Women & Newborns, San Diego, CA, USA. .,Sharp Neonatal Research Institute, San Diego, CA, USA.
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6
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Duijts L, van Meel ER, Moschino L, Baraldi E, Barnhoorn M, Bramer WM, Bolton CE, Boyd J, Buchvald F, Del Cerro MJ, Colin AA, Ersu R, Greenough A, Gremmen C, Halvorsen T, Kamphuis J, Kotecha S, Rooney-Otero K, Schulzke S, Wilson A, Rigau D, Morgan RL, Tonia T, Roehr CC, Pijnenburg MW. European Respiratory Society guideline on long-term management of children with bronchopulmonary dysplasia. Eur Respir J 2020; 55:13993003.00788-2019. [PMID: 31558663 DOI: 10.1183/13993003.00788-2019] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/30/2019] [Indexed: 12/22/2022]
Abstract
This document provides recommendations for monitoring and treatment of children in whom bronchopulmonary dysplasia (BPD) has been established and who have been discharged from the hospital, or who were >36 weeks of postmenstrual age. The guideline was based on predefined Population, Intervention, Comparison and Outcomes (PICO) questions relevant for clinical care, a systematic review of the literature and assessment of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. After considering the balance of desirable (benefits) and undesirable (burden, adverse effects) consequences of the intervention, the certainty of the evidence, and values, the task force made conditional recommendations for monitoring and treatment of BPD based on very low to low quality of evidence. We suggest monitoring with lung imaging using ionising radiation in a subgroup only, for example severe BPD or recurrent hospitalisations, and monitoring with lung function in all children. We suggest to give individual advice to parents regarding daycare attendance. With regards to treatment, we suggest the use of bronchodilators in a subgroup only, for example asthma-like symptoms, or reversibility in lung function; no treatment with inhaled or systemic corticosteroids; natural weaning of diuretics by the relative decrease in dose with increasing weight gain if diuretics are started in the neonatal period; and treatment with supplemental oxygen with a saturation target range of 90-95%. A multidisciplinary approach for children with established severe BPD after the neonatal period into adulthood is preferable. These recommendations should be considered until new and urgently needed evidence becomes available.
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Affiliation(s)
- Liesbeth Duijts
- Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands .,Dept of Pediatrics, Division of Neonatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Evelien R van Meel
- Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Laura Moschino
- Dept of Women's and Children's Health, University of Padua, Padua, Italy
| | - Eugenio Baraldi
- Dept of Women's and Children's Health, University of Padua, Padua, Italy
| | | | - Wichor M Bramer
- Medical Library, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Charlotte E Bolton
- NIHR Nottingham BRC Respiratory Theme and Division of Respiratory Medicine, University of Nottingham, Nottingham, UK
| | | | - Frederik Buchvald
- Pediatric Pulmonary Service, DBLC, Rigshospitalet, Copenhagen, Denmark
| | | | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Refika Ersu
- Division of Respirology, Marmara University Istanbul, Istanbul, Turkey.,Division of Respirology, University of Ottowa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anne Greenough
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Thomas Halvorsen
- Dept of Pediatrics, Haukeland University Hospital, Bergen, Norway.,Dept of Clinical Science, University of Bergen, Bergen, Norway
| | | | - Sailesh Kotecha
- Dept of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Sven Schulzke
- Dept of Neonatology, University Children's Hospital Basel UKBB, Basel, Switzerland
| | - Andrew Wilson
- Dept of Respiratory and Sleep Medicine, Princess Margaret Hospital for Children, Perth, Australia
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Rebecca L Morgan
- Dept of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Thomy Tonia
- Insitute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Charles C Roehr
- Dept of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK.,Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Marielle W Pijnenburg
- Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Gibbons JTD, Wilson AC, Simpson SJ. Predicting Lung Health Trajectories for Survivors of Preterm Birth. Front Pediatr 2020; 8:318. [PMID: 32637389 PMCID: PMC7316963 DOI: 10.3389/fped.2020.00318] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/18/2020] [Indexed: 11/13/2022] Open
Abstract
Rates of preterm birth (<37 weeks of gestation) are increasing worldwide. Improved perinatal care has markedly increased survival of very (<32 weeks gestation) and extremely (<28 weeks gestation) preterm infants, however, long term respiratory sequalae are common among survivors. Importantly, individual's lung function trajectories are determined early in life and tend to track over the life course. Preterm infants are impacted by antenatal, postnatal and early life perturbations to normal lung growth and development, potentially resulting in significant shifts from the "normal" lung function trajectory. This review summarizes what is currently known about the long-term lung function trajectories in survivors of preterm birth. Further, this review highlights how antenatal, perinatal and early life factors are likely to contribute to individual lung health trajectories across the life course.
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Affiliation(s)
- James T D Gibbons
- Telethon Kids Institute, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia.,Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia
| | - Andrew C Wilson
- Telethon Kids Institute, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia.,Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia
| | - Shannon J Simpson
- Telethon Kids Institute, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
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Urs R, Kotecha S, Hall GL, Simpson SJ. Persistent and progressive long-term lung disease in survivors of preterm birth. Paediatr Respir Rev 2018; 28:87-94. [PMID: 29752125 DOI: 10.1016/j.prrv.2018.04.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 02/05/2023]
Abstract
Preterm birth accounts for approximately 11% of births globally, with rates increasing across many countries. Concurrent advances in neonatal care have led to increased survival of infants of lower gestational age (GA). However, infants born <32 weeks of GA experience adverse respiratory outcomes, manifesting with increased respiratory symptoms, hospitalisation and health care utilisation into early childhood. The development of bronchopulmonary dysplasia (BPD) - the chronic lung disease of prematurity - further increases the risk of poor respiratory outcomes throughout childhood, into adolescence and adulthood. Indeed, survivors of preterm birth have shown increased respiratory symptoms, altered lung structure, persistent and even declining lung function throughout childhood. The mechanisms behind this persistent and sometimes progressive lung disease are unclear, and the implications place those born preterm at increased risk of respiratory morbidity into adulthood. This review aims to summarise what is known about the long-term pulmonary outcomes of contemporary preterm birth, examine the possible mechanisms of long-term respiratory morbidity in those born preterm and discuss addressing the unknowns and potentials for targeted treatments.
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Affiliation(s)
- Rhea Urs
- Telethon Kids Institute, Perth, Australia; School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Graham L Hall
- Telethon Kids Institute, Perth, Australia; School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
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9
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Onland W, Offringa M, van Kaam A. Late (≥ 7 days) inhalation corticosteroids to reduce bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2017; 8:CD002311. [PMID: 28836266 PMCID: PMC6483527 DOI: 10.1002/14651858.cd002311.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), defined as oxygen dependence at 36 weeks postmenstrual age (PMA), remains an important complication of prematurity. Pulmonary inflammation plays a central role in the pathogenesis of BPD. Attenuating pulmonary inflammation with postnatal systemic corticosteroids reduces the incidence of BPD in preterm infants but may be associated with an increased risk of adverse neurodevelopmental outcomes. Local administration of corticosteroids via inhalation might be an effective and safe alternative. OBJECTIVES To determine if administration of inhalation corticosteroids after the first week of life until 36 weeks PMA to preterm infants at high risk of developing BPD is effective and safe in reducing the incidence of death and BPD as separate or combined outcomes. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 4), MEDLINE via PubMed (1966 to 19 May 2017), Embase (1980 to 19 May 2017), and CINAHL (1982 to 19 May 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included randomised controlled trials comparing inhalation corticosteroids, started ≥ 7 days postnatal age (PNA) but before 36 weeks PMA, to placebo in ventilated and non-ventilated infants at risk of BPD. We excluded trials investigating systemic corticosteroids versus inhalation corticosteroids. DATA COLLECTION AND ANALYSIS We collected data on participant characteristics, trial methodology, and inhalation regimens. The primary outcome was death or BPD at 36 weeks PMA. Secondary outcomes were the combined outcome death or BPD at 28 days PNA, the seperate outcomes of death and BPD at both 28 days PNA, and at 36 weeks PMA, and short-term respiratory outcomes, such as failure to extubate; total days of mechanical ventilation and oxygen use; and the need for systemic corticosteroids. We contacted the original trialists to verify the validity of extracted data and to provide missing data. We analysed all data using Review Manager 5. When possible, we performed meta-analysis using typical risk ratio (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes along with their 95% confidence intervals (CI). We analysed ventilated and non-ventilated participants separately.We used the GRADE approach to assess the quality of the evidence. MAIN RESULTS We included eight trials randomising 232 preterm infants in this review. Inhalation corticosteroids did not reduce the separate or combined outcomes of death or BPD. The meta-analyses of the studies showed a reduced risk in favor of inhalation steroids regarding failure to extubate at seven days (typical RR (TRR) 0.80, 95% CI 0.66 to 0.98; 5 studies, 79 infants) and at the latest reported time point after treatment onset (TRR 0.60, 95% CI 0.45 to 0.80; 6 studies, 90 infants). However, both analyses showed increased statistical heterogeneity (I2 statistic 73% and 86%, respectively). Furthermore, inhalation steroids did not impact total duration of mechanical ventilation or oxygen dependency. There was a trend toward a reduction in the use of systemic corticosteroids in infants receiving inhalation corticosteroids (TRR 0.51, 95% CI 0.26 to 1.00; 4 studies, 74 infants; very low-quality evidence). There was a paucity of data on short- and long-term adverse effects. Our results should be interpreted with caution because the total number of randomised participants is relatively small, and most trials differed considerably in participant characteristics, inhalation therapy, and outcome definitions. AUTHORS' CONCLUSIONS Based on the results of the currently available evidence, inhalation corticosteroids initiated at ≥ 7 days of life for preterm infants at high risk of developing BPD cannot be recommended at this point in time. More and larger randomised, placebo-controlled trials are needed to establish the efficacy and safety of inhalation corticosteroids.
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Affiliation(s)
- Wes Onland
- Emma Children's Hospital AMC, University of AmsterdamDepartment of NeonatologyMeibergdreef 9AmsterdamNetherlands1105 AZ
| | - Martin Offringa
- Hospital for Sick ChildrenChild Health Evaluative Sciences555 University AvenueTorontoONCanadaM5G 1X8
| | - Anton van Kaam
- Emma Children's Hospital AMC, University of AmsterdamDepartment of NeonatologyMeibergdreef 9AmsterdamNetherlands1105 AZ
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Raffay TM, Dylag AM, Di Fiore JM, Smith LA, Einisman HJ, Li Y, Lakner MM, Khalil AM, MacFarlane PM, Martin RJ, Gaston B. S-Nitrosoglutathione Attenuates Airway Hyperresponsiveness in Murine Bronchopulmonary Dysplasia. Mol Pharmacol 2016; 90:418-26. [PMID: 27484068 PMCID: PMC5034690 DOI: 10.1124/mol.116.104125] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 07/28/2016] [Indexed: 12/20/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is characterized by lifelong obstructive lung disease and profound, refractory bronchospasm. It is observed among survivors of premature birth who have been treated with prolonged supplemental oxygen. Therapeutic options are limited. Using a neonatal mouse model of BPD, we show that hyperoxia increases activity and expression of a mediator of endogenous bronchoconstriction, S-nitrosoglutathione (GSNO) reductase. MicroRNA-342-3p, predicted in silico and shown in this study in vitro to suppress expression of GSNO reductase, was decreased in hyperoxia-exposed pups. Both pretreatment with aerosolized GSNO and inhibition of GSNO reductase attenuated airway hyperresponsiveness in vivo among juvenile and adult mice exposed to neonatal hyperoxia. Our data suggest that neonatal hyperoxia exposure causes detrimental effects on airway hyperreactivity through microRNA-342-3p–mediated upregulation of GSNO reductase expression. Furthermore, our data demonstrate that this adverse effect can be overcome by supplementing its substrate, GSNO, or by inhibiting the enzyme itself. Rates of BPD have not improved over the past two decades; nor have new therapies been developed. GSNO-based therapies are a novel treatment of the respiratory problems that patients with BPD experience.
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Affiliation(s)
- Thomas M Raffay
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Andrew M Dylag
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Juliann M Di Fiore
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura A Smith
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Helly J Einisman
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Yuejin Li
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mitchell M Lakner
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ahmad M Khalil
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Peter M MacFarlane
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Richard J Martin
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Benjamin Gaston
- Division of Neonatology (T.M.R., A.M.D., J.M.D.F., P.M.M., R.J.M.) and Division of Pediatric Pulmonology (L.A.S., H.J.E., Y.L., B.G.), Department of Pediatrics, Rainbow Babies and Children's Hospital, and Department of Pharmacology (M.M.L.) and Department of Genetics and Genome Sciences (A.M.K.), Case Western Reserve University School of Medicine, Cleveland, Ohio
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11
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Edwards MO, Kotecha SJ, Lowe J, Richards L, Watkins WJ, Kotecha S. Management of Prematurity-Associated Wheeze and Its Association with Atopy. PLoS One 2016; 11:e0155695. [PMID: 27203564 PMCID: PMC4874578 DOI: 10.1371/journal.pone.0155695] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 05/03/2016] [Indexed: 11/30/2022] Open
Abstract
Introduction Although preterm birth is associated with respiratory morbidity in childhood, the role of family history of atopy and whether appropriate treatment has been instituted is unclear. Thus we assessed (i) the prevalence of respiratory symptoms, particularly wheezing, in childhood; (ii) evaluated the role of family history of atopy and mode of delivery, and (iii) documented the drug usage, all in preterm-born children compared to term-born control children. Methods We conducted a cross-sectional population-based questionnaire study of 1–10 year-old preterm-born children (n = 13,361) and matched term-born controls (13,361). Data (n = 7,149) was analysed by gestational groups (24–32 weeks, 33–34 weeks, 35–36 weeks and 37–43 weeks) and by age, <5 years old or ≥ 5 years. Main Results Preterm born children aged <5 years (n = 2,111, term n = 1,402) had higher rates of wheeze-ever [odds ratio: 2.7 (95% confidence intervals 2.2, 3.3); 1.8 (1.5, 2.2); 1.5 (1.3, 1.8) respectively for the 24–32 weeks, 33–34 weeks, 35–36 weeks groups compared to term]. Similarly for the ≥5 year age group (n = 2,083, term n = 1,456) wheezing increased with increasing prematurity [odds ratios 3.3 (2.7, 4.1), 1.8 (1.5, 2.3) and 1.6 (1.3, 1.9) for the three preterm groups compared to term]. At both age groups, inhaler usage was greater in the lowest preterm group but prematurity-associated wheeze was independent of a family history of atopy. Conclusions Increasing prematurity was associated with increased respiratory symptoms, which were independent of a family history of atopy. Use of bronchodilators was also increased in the preterm groups but its efficacy needs careful evaluation.
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Affiliation(s)
- Martin O. Edwards
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Sarah J. Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - John Lowe
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Louise Richards
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - W. John Watkins
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Sailesh Kotecha
- Department of Child Health, Cardiff University School of Medicine, Cardiff, United Kingdom
- * E-mail:
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12
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Korhonen PH, Suursalmi PH, Kopeli T, Nieminen R, Lehtimäki L, Luukkaala T, Korppi M, Saari A, Moilanen E, Tammela OKT. Inflammatory activity at school age in very low birth weight bronchopulmonary dysplasia survivors. Pediatr Pulmonol 2015; 50:683-90. [PMID: 24668942 DOI: 10.1002/ppul.23038] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 02/28/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Airway inflammation is involved in the pathogenesis of bronchopulmonary dysplasia (BPD). The aim of the study was to evaluate the inflammatory activity in plasma and exhaled air in very low birth weight (VLBW) BPD survivors at school age. METHODS Twenty-one 6-14-year-old former VLBW (birth weight ≤1,500 g) children with severe radiographic BPD (radBPD), 19 without radBPD (nonBPD group) and 19 non-asthmatic term controls underwent measurement of eosinophil cationic protein, IL-6, IL-8, adiponectin, adipsin, leptin, and resistin in plasma, leukotriene B4 and 8-isoprostane in exhaled breath condensate, and NO in exhaled breath. Background data were obtained from patient records, clinical examination and parental questionnaire. Both univariate and multivariate models were applied in the statistical analysis. RESULTS There were no significant differences between the groups in any of the inflammatory markers measured. Five (25%) radBPD and 2 (11%) nonBPD children reported asthma (P = 0.058). In logistic regression analysis, exposure to chorioamnionitis was associated with low IL-8 (OR 29.0, 95% CI 3.27-258) and postnatal corticosteroid therapy with high adiponectin (OR 32.0, 95% CI 1.29-793). High body mass index standard deviation score (BMI-SDS) was associated with high plasma adipsin (OR 2.47, 95% CI 1.07-5.75) and leptin (OR 5.76, 95%CI 1.83-18.2) levels. CONCLUSIONS The inflammatory activity seems to decrease by school age in VLBW BPD survivors. Chorioamnionitis and postnatal corticosteroid treatment may modulate the inflammatory responsiveness in VLBW subjects even up to school age. The respiratory outcome in VLBW infants might be improved by preventing excessive weight gain.
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Affiliation(s)
- Päivi H Korhonen
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Piia H Suursalmi
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Tarja Kopeli
- Department of Pediatrics, Päijät-Häme Central Hospital, Lahti, Finland
| | - Riina Nieminen
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Tiina Luukkaala
- Science Center, Pirkanmaa Hospital District and School of Health Sciences, University of Tampere, Tampere, Finland
| | - Matti Korppi
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Antti Saari
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Eeva Moilanen
- The Immunopharmacology Research Group, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Outi K T Tammela
- Tampere Center for Child Health Research, Tampere University Hospital and University of Tampere, Tampere, Finland
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13
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Malmberg LP, Pelkonen AS, Malmström K, Saarinen KM, Kajosaari M, Hakulinen A, Mäkelä MJ. Very low birth weight and respiratory outcome: association between airway inflammation and hyperresponsiveness. Ann Allergy Asthma Immunol 2013; 111:96-101. [PMID: 23886226 DOI: 10.1016/j.anai.2013.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 04/29/2013] [Accepted: 06/01/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND The respiratory outcomes after preterm birth have changed, and it is unclear whether increased airway hyperresponsiveness (AHR) later in childhood is associated with airway inflammation. OBJECTIVE To investigate the association between AHR and fractional exhaled nitric oxide (FeNO), including the alveolar concentration of nitric oxide, in school-age children with very low birth weight (VLBW). METHODS Twenty-nine children with VLBW, 33 children with a history of early wheeze, and 60 healthy controls underwent a FeNO measurement and bronchial challenge test with histamine. Atopy was assessed with skin prick tests. RESULTS Children with VLBW had well-preserved baseline lung function but significantly increased AHR, expressed as the dose response slope (P < .001). Geometric mean FeNO levels were similar between VLBW children and healthy controls, and a history of bronchopulmonary dysplasia had no effect. In the VLBW and early wheeze groups, AHR was associated with FeNO (r = 0.47, P = .01, and r = 0.43, P = .013, respectively), but in a stratified analysis, this association was significant only in atopic individuals. By using the multiple flow FeNO technique, the bronchial nitric oxide flux rather than alveolar nitric oxide concentrations were associated with AHR in both children with early wheeze and VLBW. CONCLUSION We conclude that in VLBW children AHR is related to FeNO but only in atopic individuals. Similar to children with early wheeze, this association is dependent on bronchial flux rather than alveolar nitric oxide concentration. It is likely that AHR is modified by atopic inflammation rather than by inflammatory process due to prematurity.
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Affiliation(s)
- L Pekka Malmberg
- Skin and Allergy Hospital, Helsinki University Central Hospital, Helsinki, Finland.
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14
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Teig N, Allali M, Rieger C, Hamelmann E. Inflammatory markers in induced sputum of school children born before 32 completed weeks of gestation. J Pediatr 2012; 161:1085-90. [PMID: 22863260 DOI: 10.1016/j.jpeds.2012.06.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 05/09/2012] [Accepted: 06/05/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To test whether chronic bronchial inflammation may be a contributing risk factor for persistent airflow limitation in children born before 32 weeks of gestation in later life. STUDY DESIGN Thirty-six of 160 children born before 32 completed weeks of gestation who were born between 1988 and 1992 were recruited at a median age of 11 years. Eighteen age-matched children born at term were controls; 47% of the premature infants and 61% of the term born children produced sputum of sufficient quality for interleukin (IL)-8, cell numbers, and differential counts. RESULTS Compared with term born children, sputum from the premature group had a higher proportion of neutrophils (62% vs 3.8%; P < .001) and higher IL-8/protein values (1.93 μg/g vs 0.64 μg/g; P = .008). Forced expiratory flow 25%-75% and forced expiratory volume in 1 second/vital capacity were significantly lower (73.4 % vs 116% predicted, P = .002 and 97% vs 101%, P = .012, respectively). Lung function values and sputum indices did not correlate. IL-8/protein and neutrophil percentages correlated significantly with decreasing gestational age (Spearman rank coefficient = -0.58, P = .020 and -.70, P =.03 respectively). CONCLUSION A significant proportion of school children born very preterm demonstrate persistent peripheral airway obstruction that is accompanied by neutrophilic lower airway inflammation.
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Affiliation(s)
- Norbert Teig
- University Children's Hospital, St-Josef-Hospital, Ruhr-University Bochum, Bochum, Germany.
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15
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Onland W, Offringa M, van Kaam A. Late (≥ 7 days) inhalation corticosteroids to reduce bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2012:CD002311. [PMID: 22513906 DOI: 10.1002/14651858.cd002311.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD), defined as oxygen dependence at 36 weeks postmenstrual age (PMA), remains an important complication of prematurity. Pulmonary inflammation plays a central role in the pathogenesis of BPD. Attenuating pulmonary inflammation with postnatal systemic corticosteroids reduces the incidence of BPD in preterm infants but may be associated with an increased risk of adverse neurodevelopmental outcomes. Local administration of corticosteroids via inhalation might be an effective and safe alternative. OBJECTIVES To determine if administration of inhalation corticosteroids after the first week of life to preterm infants at high risk of developing BPD is effective and safe in reducing the incidence of death and BPD as separate or combined outcomes. SEARCH METHODS We identified randomised, controlled trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), PubMed (from 1966), EMBASE (from 1974), CINAHL (from 1982), references from retrieved trials and handsearches of journals, all assessed to February 2012. SELECTION CRITERIA Randomised controlled trials comparing inhalation corticosteroids, started ≥ 7 days postnatal age (PNA) but before 36 weeks PMA, to placebo in ventilated and non-ventilated infants at risk of BPD were included. Trials investigating systemic corticosteroids versus inhalation corticosteroids were excluded. DATA COLLECTION AND ANALYSIS Data on patient characteristics, trial methodology, and inhalation regimens were collected. The primary outcomes were death or BPD, or both, at 28 days PNA or 36 weeks PMA. Secondary outcomes were short-term respiratory outcomes, such as failure to extubate, total days of mechanical ventilation and oxygen use, and the need for systemic corticosteroids. The original trialists were contacted to verify the validity of extracted data and to provide missing data. All data were analysed using RevMan 5.0.24. When possible, meta-analysis was performed using typical risk ratio (TRR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes along with their 95% confidence intervals (CI). Ventilated and non-ventilated participants were analysed separately. MAIN RESULTS Eight trials randomising 232 preterm infants were included in this review. Inhalation corticosteroids did not reduce the separate or combined outcomes of death or BPD. Furthermore, inhalation steroids did not impact short-term respiratory outcomes such as failure to extubate and total duration of mechanical ventilation or oxygen dependency. There was a trend to a reduced use of systemic corticosteroids in favour of inhalation corticosteroids (TRR 0.51; 95% CI 0.26 to 1.00). There was a paucity of data on short-term and long-term adverse effects. These results should be interpreted with caution because the total number of randomised patients is relatively small and most trials differed considerably in patient characteristics, inhalation therapy and outcome definitions. AUTHORS' CONCLUSIONS Based on the results of the currently available evidence, inhalation corticosteroids initiated at ≥ 7 days of life for preterm infants at high risk of developing BPD cannot be recommended at this point in time. More and larger randomised, placebo-controlled trials are needed to establish the efficacy and safety of inhalation corticosteroids.
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Affiliation(s)
- Wes Onland
- Department of Neonatology, Emma Childrens’ Hospital AMC,University of Amsterdam, Meibergdreef 9,
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16
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Reyburn B, Martin RJ, Prakash YS, MacFarlane PM. Mechanisms of injury to the preterm lung and airway: implications for long-term pulmonary outcome. Neonatology 2012; 101:345-52. [PMID: 22940624 PMCID: PMC3567481 DOI: 10.1159/000337355] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Despite changes in the epidemiology of bronchopulmonary dysplasia (BPD), longer-term morbidity, particularly in the form of airway dysfunction, remains a substantial problem in former preterm infants. The stage for this respiratory morbidity may begin as early as the transition from fetal to neonatal life. Newer therapeutic approaches for BPD should be directed toward minimizing this longer-term respiratory morbidity. Neonatal animal models focused primarily on hyperoxic exposure may provide important insights into the pathogenesis of longer-term airway hyperreactivity in this population.
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Affiliation(s)
- Brent Reyburn
- Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio, USA
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17
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Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is a chronic disorder associated with prematurity. Systemic steroids induce at least a temporary improvement in respiratory function, but are associated with adverse side effects. Inhaled steroids have fewer side effects. OBJECTIVES To determine if inhaled corticosteroids are effective in alleviating the morbidity of bronchopulmonary dysplasia (BPD) compared to placebo. SEARCH STRATEGY We identified randomised, controlled trials (RCT) within the Cochrane Database, references from retrieved trials, hand searches of journals and contact with pharmaceutical companies and experts in this field. SELECTION CRITERIA Only randomised controlled trials involving infants with chronic lung disease of prematurity and treated with inhaled steroids versus placebo were included. Patients receiving systemic corticosteroids were excluded. Co-interventions included antenatal systemic steroids, routine neonatal intensive care, ventilatory support, surfactant replacement therapy, diuretics and bronchodilators. DATA COLLECTION AND ANALYSIS Four of the seven included trials were of good methodological quality. There were five parallel-group trials in ventilated infants. These were comparable in terms of population, co-interventions and need for increased inspired oxygen concentration. They differed in terms of type, dose and duration (7-28 days) of inhaled steroids. Two cross-over trials were performed in non-ventilated patients. An update search was conducted in June 2002, which identified an additional excluded study. MAIN RESULTS The inability to extubate during treatment was markedly reduced in infants treated with inhaled steroids; Peto Odds Ratio (OR) 0.12, 95% Confidence Interval (CI) 0.03 to 0.43. There was heterogeneity in this finding, however, with one study that contributed 30% of the total number of patients reporting no successful extubations in either treatment arm over one week. The risk of sepsis appeared similar between the two groups (N=3, OR=0.72, 95%CI: 0.21 to 2.43). The small number of trials precluded analysis to examine the effect of differences in drug, duration of therapy, delivery system, co-interventions, and disease severity. Reduced oxygen requirements were reported in one of the two trials performed in non-ventilated infants, but inadequate data reporting precluded pooling of data. AUTHORS' CONCLUSIONS In ventilated infants with BPD, inhaled steroids administered for 1 to 4 weeks improved the rate of extubation with no apparent increase in the risk of sepsis. No firm conclusion could be derived with regard to the efficacy of inhaled steroids in non-ventilated infants.
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Affiliation(s)
- Paula Lister
- Institute of Child Health, Great Ormond Street, London, UK
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18
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Pérez Pérez G, Navarro Merino M. [Bronchopulmonary dysplasia and prematurity. Short-and long-term respiratory changes]. An Pediatr (Barc) 2009; 72:79.e1-16. [PMID: 20004153 DOI: 10.1016/j.anpedi.2009.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 09/16/2009] [Accepted: 09/17/2009] [Indexed: 11/17/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most frequent chronic lung disease in premature children. With the inclusion of antenatal steroid therapy, surfactant use and novel mechanical ventilation strategies, survival of premature newborns has increased, whereupon the incidence of BPD has not only decreased but has also risen in extremely premature newborns. This has led to a high respiratory morbidity in the first 2-3 years of life, with numerous admissions to hospital and respiratory exacerbations mostly due to viral infections. Although there is a trend towards improvement, during school age and adolescence, respiratory symptoms may persist, due to changes in pulmonary function often showing a lower exercise capacity. Although BPD symptoms are similar to those of asthma, as there is limitation in airflow and bronchial hyperresponsiveness (BHR), pathophysiological mechanisms could be different in both diseases. On the other hand, isolated prematurity plays an important role in the child's respiratory pathology, proving that pulmonary function alterations in preterm children are present since the first months of life. A higher respiratory morbidity has also been observed in these children when compared to full-term newborns, not only during the first years of life but also subsequently. In this study, different aspects of chronic respiratory disease associated with prematurity will be analysed, drawing special attention to clinical symptoms, respiratory function changes, BHR and exercise capacity. All these aspects will be reviewed from early childhood until adolescence and young adult age. Similarities and differences between BPD and asthma will also be discussed.
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Affiliation(s)
- G Pérez Pérez
- Sección de Neumología Infantil, Hospital Universitario Virgen Macarena, Sevilla, España.
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19
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Affiliation(s)
- Eugenio Baraldi
- Department of Pediatrics, Unit of Respiratory Medicine and Allergy, Unit of Neonatal Intensive Care, University of Padua, School of Medicine, Padua, Italy.
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20
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Halvorsen T, Skadberg BT, Eide GE, Røksund O, Aksnes L, Øymar K. Characteristics of asthma and airway hyper-responsiveness after premature birth. Pediatr Allergy Immunol 2005; 16:487-94. [PMID: 16176395 DOI: 10.1111/j.1399-3038.2005.00314.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Asthma-like symptoms and airway hyper-responsiveness (AHR) are frequently reported in children subsequent to premature birth and bronchopulmonary dysplasia (BPD). There is limited knowledge on the mechanisms underlying these respiratory manifestations. Generally, childhood asthma and AHR is described within a context of inheritance, allergy and eosinophilic airway inflammation, and often in relation to cigarette exposures. We investigated these factors in relation to current asthma and AHR in a population-based cohort of 81 young people, born with gestational age < or = 28 wk or birth weight < or = 1000 g, and in a matched term-born control population. In the pre-term population, asthma and AHR were additionally studied in relation to neonatal respiratory morbidity. At follow up, more pre-term than control subjects had asthma. Forced expiratory volume in first second (FEV1) was reduced, AHR was substantially increased, and the level of the urinary leukotriene metabolite E4 (U-LTE4) was increased in the pre-term population compared to the term-born. In control subjects, asthma and AHR was associated with a pattern consistent with inheritance, allergy, airway inflammation, and cigarette exposures. In the pre-terms, asthma and AHR was either unrelated or less related to these factors. Instead, AHR was strongly related to a neonatal history of BPD and prolonged requirement for oxygen treatment. In conclusion, asthma and AHR subsequent to extremely premature birth differed from typical childhood asthma with respect to important features, and AHR was best explained by neonatal variables. These respiratory manifestations thus seem to represent a separate clinical entity.
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Affiliation(s)
- Thomas Halvorsen
- Department of Clinical Medicine, Section of Pediatrics, University of Bergen, Bergen, Norway.
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21
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Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is a chronic disorder associated with prematurity. Systemic steroids induce at least a temporary improvement in respiratory function, but are associated with adverse side effects. Inhaled steroids have fewer side effects. OBJECTIVES To determine if inhaled corticosteroids are effective in alleviating the morbidity of bronchopulmonary dysplasia (BPD) compared to 0-placebo. SEARCH STRATEGY We identified randomised, controlled trials (RCT) within the Cochrane Database, references from retrieved trials, hand searches of journals and contact with pharmaceutical companies and experts in this field. SELECTION CRITERIA Only randomised controlled trials involving infants with chronic lung disease of prematurity and treated with inhaled steroids versus placebo were included. Patients receiving systemic corticosteroids were excluded. Co-interventions included antenatal systemic steroids, routine neonatal intensive care, ventilatory support, surfactant replacement therapy, diuretics and bronchodilators. DATA COLLECTION AND ANALYSIS Four of the seven included trials were of good methodological quality. There were five parallel-group trials in ventilated infants. These were comparable in terms of population, co-interventions and need for increased inspired oxygen concentration. They differed in terms of type, dose and duration (7-28 days) of inhaled steroids. Two cross-over trials were performed in non-ventilated patients. MAIN RESULTS The inability to extubate during treatment was markedly reduced in infants treated with inhaled steroids; Peto Odds Ratio (OR) 0.12, 95% Confidence Interval (CI) 0.03 to 0.43. There was heterogeneity in this finding, however, with one study that contributed 30% of the total number of patients reporting no successful extubations in either treatment arm over one week. The risk of sepsis appeared similar between the two groups (N=3, OR=0.72, 95%CI: 0.21 to 2.43). The small number of trials precluded analysis to examine the effect of differences in drug, duration of therapy, delivery system, co-interventions, and disease severity. Reduced oxygen requirements were reported in one of the two trials performed in non-ventilated infants, but inadequate data reporting precluded pooling of data. REVIEWER'S CONCLUSIONS In ventilated infants with BPD, inhaled steroids administered for 1 to 4 weeks improved the rate of extubation with no apparent increase in the risk of sepsis. No firm conclusion could be derived with regard to the efficacy of inhaled steroids in non-ventilated infants.
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Affiliation(s)
- P Lister
- PICU, Addenbrookes Hospital, Hills Road, Cambridge, UK.
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