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Jankauskaite L, Wyder C, Del Torso S, Mamenko M, Trapani S, Grossman Z, Hadjipanayis A, Geitmann K, Matsui H, Saitoh A, Isayama T, Karara N, Montemaggi A, Ud Din FS, Størdal K. Over-investigation and overtreatment in pediatrics: a survey from the European Academy of Paediatrics and Japan Pediatric Society. Front Pediatr 2024; 12:1333239. [PMID: 38455393 PMCID: PMC10917967 DOI: 10.3389/fped.2024.1333239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Avoiding over-investigation and overtreatment in health care is a challenge for clinicians across the world, prompting the international Choosing Wisely campaign. Lists of recommendations regarding medical overactivity are helpful tools to guide clinicians and quality improvement initiatives. We aimed to identify the most frequent and important clinical challenges related to pediatric medical overactivity in Europe and Japan. Based on the results, we aim to establish a (European) list of Choosing Wisely recommendations. Methods In an online survey, clinicians responsible for child health care in Europe and Japan were invited to rate 18 predefined examples of medical overactivity. This list was compiled by a specific strategic advisory group belonging to the European Academy of Paediatrics (EAP). Participants were asked to rate on a Likert scale (5 as the most frequent/important) according to how frequent these examples were in their working environment, and how important they were considered for change in practice. Results Of 2,716 physicians who completed the survey, 93% (n = 2,524) came from 17 countries, Japan (n = 549) being the largest contributor. Pediatricians or pediatric residents comprised 89%, and 51% had 10-30 years of clinical experience. Cough and cold medicines, and inhaled drugs in bronchiolitis were ranked as the most frequent (3.18 and 3.07 on the Likert scale, respectively), followed by intravenous antibiotics for a predefined duration (3.01), antibiotics in uncomplicated acute otitis media (2.96) and in well-appearing newborns. Regarding importance, the above-mentioned five topics in addition to two other examples of antibiotic overtreatment were among the top 10. Also, IgE tests for food allergies without relevant medical history and acid blockers for infant GER were ranked high. Conclusion Overtreatment with antibiotics together with cough/cold medicines and inhaled drugs in bronchiolitis were rated as the most frequent and important examples of overtreatment across countries in Europe and Japan.
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Affiliation(s)
- Lina Jankauskaite
- Department of Paediatrics, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, Kaunas, Lithuania
- European Academy of Paediatrics, Brussels, Belgium
| | - Corinne Wyder
- European Academy of Paediatrics, Brussels, Belgium
- Paediatric Praxis Kurwerk, Burgdorf, Switzerland
| | - Stefano Del Torso
- European Academy of Paediatrics, Brussels, Belgium
- ChildCare WorldWide, Padova, Italy
| | - Marina Mamenko
- European Academy of Paediatrics, Brussels, Belgium
- Shupyk National Healthcare University of Ukraine, Kiev, Ukraine
- Ukrainian Academy of Paediatric Specialties, Kyiv, Ukraine
| | - Sandra Trapani
- European Academy of Paediatrics, Brussels, Belgium
- Department of Health Sciences, University of Florence, Florence, Italy
- Paediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Zachi Grossman
- European Academy of Paediatrics, Brussels, Belgium
- Adelson School of Medicine, Ariel University, Ariel, Israel
- Pediatric Clinic, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Adamos Hadjipanayis
- European Academy of Paediatrics, Brussels, Belgium
- Medical School, European University Cyprus, Nicosia, Cyprus
| | | | - Hikoro Matsui
- University of Tokyo and School of Medicine, Tokyo, Japan
- Japan Pediatric Society, Tokyo, Japan
| | - Akihiko Saitoh
- Japan Pediatric Society, Tokyo, Japan
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tetsuya Isayama
- Japan Pediatric Society, Tokyo, Japan
- Division of Neonatology, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Nora Karara
- European Academy of Paediatrics, Brussels, Belgium
- Paediatric Public Health Office, Berlin, Germany
| | | | - Farhan Saleem Ud Din
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Ketil Størdal
- European Academy of Paediatrics, Brussels, Belgium
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Department of Pediatric Research, Faculty of Medicine, University of Oslo, Oslo, Norway
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Selin S, Mecklin M, Korppi M, Heikkilä P. Twenty-one-year follow-up revealed guideline-concordant and non-concordant trends in intensive care of bronchiolitis. Eur J Pediatr 2023:10.1007/s00431-023-04940-2. [PMID: 36988679 PMCID: PMC10257585 DOI: 10.1007/s00431-023-04940-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
To evaluate the management of bronchiolitis in the paediatric intensive care unit (PICU) before and after publication of the national bronchiolitis guidelines in June 2015. All infants treated between 2016-2020 for bronchiolitis in the PICU of Tampere University Hospital at < 12 months of age were included. The data were retrospectively collected from electronic patient records. The current results reflecting the post-guideline era were compared with previously published results for the pre-guideline 2000-2015 period. These two studies used identical protocols. Forty-six infants treated in the PICU were included. During the post-guideline era, inhaled adrenaline was given to 26 (57%), salbutamol to 7 (15%), and hypertonic saline inhalations to 35 (75%) patients. Forty-three patients (94%) received high-flow oxygen therapy (HFOT). Seventeen patients (37%) were treated with nasal continuous positive airway pressure (CPAP) and 4 (9%) with mechanical ventilation. CONCLUSION When post-guideline years were compared with pre-guideline years, the use of bronchodilators decreased in agreement, but the use of inhaled saline increased in disagreement with the guidelines. The use of respiratory support increased, evidently because of an introduction of the non-invasive HFOT treatment modality. WHAT IS KNOWN • Oxygen supplementation and respiratory support, when needed, are the cornerstones of bronchiolitis treatment. • Medicines are frequently given to infants with bronchiolitis, especially if intensive care is needed, although evidence of their effectiveness is lacking. WHAT IS NEW • Nearly all (94%) infants who needed intensive care were treated with HFOT and 37% with nasal CPAP, and finally, only 9% were intubated, which reflects the effectiveness of non-invasive techniques. • When pre- and post-guideline eras were compared, use of racemic adrenaline decreased from 84 to 57%, but use of hypertonic saline increased up to 75%, which disagrees with the current guidelines.
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Affiliation(s)
- Sofia Selin
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Minna Mecklin
- Tampere Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Matti Korppi
- Tampere Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Paula Heikkilä
- Tampere Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland.
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Carlone G, Graziano G, Trotta D, Cafagno C, Aricò MO, Campodipietro G, Marabini C, Lizzi M, Fornaro M, Caselli D, Valletta E, Aricò M. Bronchiolitis 2021-2022 epidemic: multicentric analysis of the characteristics and treatment approach in 214 children from different areas in Italy. Eur J Pediatr 2023; 182:1921-1927. [PMID: 36807514 PMCID: PMC9943040 DOI: 10.1007/s00431-023-04853-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/23/2023]
Abstract
Bronchiolitis causes a remarkable number of hospitalizations; its epidemiology follows that of respiratory syncytial virus (RSV), its main pathogen. The aim of this study was to evaluate the presenting features, treatment approach, and impact of medical therapy in four pediatric hospitals in Italy. Data on infants < 24 months of age hospitalized with bronchiolitis in the 2021-2022 season were collected. Between October 2021 and February 2022, 214 children were admitted. Median hospital stay was 5 days; none of the patients died. The distribution of the presenting features is largely comparable in the 33 (15.8%) RSV-negative versus the 176 (84.2%) RSV-positive children; also, no difference was observed in medical therapy provided: duration of oxygen therapy, administration of steroid, and duration of hospital stay. Systemic steroids, inhalation, or antibiotic therapy were given to 34.6%, 79.4%, and 49.1% of children respectively. Of the 214 patients with bronchiolitis, only 19 (8.8%) were admitted to ICU. Conclusion: Our data suggest that, irrespective of treatments provided, RSV-positive and RSV-negative children had a similar clinical course. The results of our retrospective study further underline the need to improve adherence to existing guidelines on bronchiolitis treatment. What is Known: • Bronchiolitis is a common diseases with seasonal peak. The outcome is usually favorable but hospitalization and even ICU admission is not exceptional. What is New: • Children with RSV associated bronchiolitis do not have a different course and outcome. The analysis of the 2021-2022 cohort, following COVID pandemic peaking, did not show a different course and outcome. • Adherence to literature recommendation, i.e. to focus on oxygen and hydration therapy while avoiding unnecessary systemic therapy with steroid and antibiotics, should be improved.
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Affiliation(s)
- Giorgia Carlone
- grid.415245.30000 0001 2231 2265S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy
| | - Giusi Graziano
- grid.512242.2CORESEARCH (Center for Outcomes Research and Clinical Epidemiology), Pescara, Italy
| | - Daniela Trotta
- grid.415245.30000 0001 2231 2265S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy
| | - Claudio Cafagno
- grid.488556.2Pediatric Infectious Diseases, Children’s Hospital Giovanni XXIII, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Melodie O. Aricò
- grid.415079.e0000 0004 1759 989XDepartment of Pediatrics, G. B. Morgagni - L. Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Giacomo Campodipietro
- grid.6292.f0000 0004 1757 1758School of Pediatrics, University of Bologna, Bologna, Italy
| | - Claudio Marabini
- Department of Pediatrics and Neonatology, Provincial General Hospital, ASUR Marche- Area Vasta 3, Macerata, Italy
| | - Mauro Lizzi
- grid.415245.30000 0001 2231 2265S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy ,grid.412451.70000 0001 2181 4941School of Pediatrics, University of Chieti, Chieti, Italy
| | - Martina Fornaro
- Department of Pediatrics and Neonatology, Provincial General Hospital, ASUR Marche- Area Vasta 3, Macerata, Italy
| | - Desiree Caselli
- grid.488556.2Pediatric Infectious Diseases, Children’s Hospital Giovanni XXIII, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Enrico Valletta
- grid.415079.e0000 0004 1759 989XDepartment of Pediatrics, G. B. Morgagni - L. Pierantoni Hospital, AUSL Romagna, Forlì, Italy
| | - Maurizio Aricò
- S. Spirito Hospital, Azienda Sanitaria Locale Pescara, Pescara, Italy.
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Pereira RA, Oliveira de Almeida V, Zambrano M, Zhang L, Amantéa SL. Effects of nebulized epinephrine in association with hypertonic saline for infants with acute bronchiolitis: A systematic review and meta‐analysis. Health Sci Rep 2022; 5:e598. [PMID: 35509393 PMCID: PMC9059211 DOI: 10.1002/hsr2.598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/06/2022] [Indexed: 12/03/2022] Open
Abstract
Background Nebulized epinephrine and hypertonic saline have been extensively studied in infants with acute bronchiolitis, with conflicting results. Aims To evaluate the efficacy on length of stay (LOS), clinical severity scores (CSS), oxygen saturation (SaO2), and safety profile of nebulized epinephrine plus hypertonic saline (HS) in infants with acute bronchiolitis. Materials & Methods This is a systematic review and meta‐analysis. Outcomes were represented by mean differences (MD) or standard mean differences (SMD) and 95% confidence intervals (CIs) were utilized. Results Eighteen trials were systematically selected and 16 of them contributed to the meta‐analysis (1756 patients). Overall, a modest but significant positive impact was observed of the combination therapy on LOS (MD of –0.35 days, 95% CI −0.62 to −0.08, p = 0.01, I2 = 91%). Stratification by time of CSS assessment unveiled positive results in favor of the combination therapy in CSS assessed 48 and 72 h after the admission (SMD of −0.35, 95% CI −0.62 to −0.09, p = 0.008, I2 = 41% and SMD of −0.27, 95% CI −0.50 to −0.04, p = 0.02, I2 = 0%, respectively). No difference in SaO2 was observed. Additional data showed a consistent safety profile, with a low rate of adverse events (1%), most of them mild and transient. Conclusion Low‐quality evidence from this systematic review suggests that nebulized epinephrine plus HS may be considered as a safe and efficient therapy for decreasing LOS and CSS in infants with acute bronchiolitis, especially in those who require hospitalization for more than 48 h.
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Affiliation(s)
- Renan A. Pereira
- Department of Pediatrics Federal University of Health Sciences of Porto Alegre Porto Alegre Brazil
| | | | - Mariana Zambrano
- Department of Pediatrics Federal University of Health Sciences of Porto Alegre Porto Alegre Brazil
| | - Linjie Zhang
- Maternal‐Infant Department, Faculty of Medicine Federal University of Rio Grande Rio Grande Brazil
| | - Sérgio L. Amantéa
- Department of Pediatrics Federal University of Health Sciences of Porto Alegre Porto Alegre Brazil
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Shen Z, Zhang Y, Li H, Du L. Rapid typing diagnosis and clinical analysis of subtypes A and B of human respiratory syncytial virus in children. Virol J 2022; 19:15. [PMID: 35062975 PMCID: PMC8781464 DOI: 10.1186/s12985-022-01744-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 01/12/2022] [Indexed: 12/04/2022] Open
Abstract
Background Human respiratory syncytial virus (HRSV) is the leading pathogens causing acute respiratory infections (ARI) in children under five years old. We aimed to investigate the distribution of HRSV subtypes and explore the relationship between viral subtypes and clinical symptoms and disease severity. Methods From November 2016 to April 2017, 541 children hospitalized because of ARI were included in the study. Throat swabs were collected for analysis and all samples were tested by multiplex one-step qRT-PCR for quantitative analysis and typing of HRSV. Patients’ demographics, clinical symptoms as well as laboratory and imaging results were retrieved from medical records. Results HRSV was detected in 19.6% of children hospitalized due to ARI. HRSV-positive children were younger (P < 0.001), had a higher frequency of wheezing and pulmonary rales (P < 0.001; P = 0.003), and were more likely to develop bronchopneumonia (P < 0.001). Interleukin (IL) 10、CD4/CD8 (below normal range) and C-reactive protein levels between subtypes A and B groups were significantly different (P = 0.037; P = 0.029; P = 0.007), and gender differences were evident. By age-stratified analysis between subtypes A and B, we found significant differences in fever frequency and lymphocyte ratio (P = 0.008; P = 0.03) in the 6–12 months age group, while the 12. 1–36 months age group showed significant differences in fever days and count of leukocytes, platelets, levels aspartate aminotransferase, IL-6, lactate dehydrogenase and proportion CD4 positive T cells(P = 0.013; P = 0.018; P = 0.016; P = 0.037; P = 0.049; P = 0.025; P = 0.04). We also found a positive correlation between viral load and wheezing days in subtype A (P < 0.05), and a negative correlation between age, monocyte percentage and LDH concentration in subtype B (P < 0.05). Conclusions HRSV is the main causative virus of bronchopneumonia in infants and children. The multiplex one-step qRT-PCR not only provides a rapid and effective diagnosis of HRSV infection, but also allows its typing. There were no significant differences in the severity of HRSV infection between subtypes A and B, except significant gender-specific and age-specific differences in some clinical characteristics and laboratory results. Knowing the viral load of HRSV infection can help understanding the clinical features of different subtypes of HRSV infection.
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Sagar H, Dhal S. Managing bronchiolitis in pediatric patients: Current evidence. INDIAN JOURNAL OF RESPIRATORY CARE 2022. [DOI: 10.4103/ijrc.ijrc_153_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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7
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A New Trick for an Old Dog: L-Epinephrine Delivered Continuously in the Vapor Phase. Crit Care Explor 2021; 3:e0541. [PMID: 34604784 PMCID: PMC8480938 DOI: 10.1097/cce.0000000000000541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Inhaled L-epinephrine is a known treatment of severe croup and postextubation upper airway obstruction. L-epinephrine can be delivered continuously in the vapor phase, but the indications, safety, and efficacy of this novel practice have yet to be evaluated. Theoretical risks are tachycardia, hypertension, and dysrhythmias. The study objective was to describe patient characteristics and vital sign changes related to continuous vaporized L-epinephrine use in critically ill children with the hypothesis that it can be practically and safely administered to children with subglottic edema and lower airway obstruction.
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8
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Comparison of clinically related factors and treatment approaches in patients with acute bronchiolitis. Turk Arch Pediatr 2021; 55:376-385. [PMID: 33414655 PMCID: PMC7750333 DOI: 10.14744/turkpediatriars.2020.46144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 05/18/2020] [Indexed: 11/24/2022]
Abstract
Aim: Acute bronchiolitis is a lower respiratory tract infection caused by viral agents in children aged under two years. Treatment includes hydration, oxygen, nebulized salbutamol, and intravenous steroids. This study aimed to determine the clinically related factors, the effect of viral agents on the clinical picture, and the efficacy of treatment methods in patients admitted with acute bronchiolitis. Material and Methods: Patients aged under two years of age who were hospitalized with a diagnosis of moderate/severe acute bronchiolitis between March 2015 and March 2019 were included in the study. Demographic data, hospitalization time, body temperature, presence of congenital heart disease, history of atopy, acute-phase reactants, mean platelet volume values, and respiratory virus panel results were recorded. The treatment modalities, length of hospitalization, intensive care hospitalization, and high-flow nasal cannula oxygen therapy (HFNC) were recorded. Results: Four hundred twenty-two patients were included in the study. The duration of hospitalization was found to be significantly longer in patients aged under one year and in patients with acyanotic congenital heart disease. A single viral agent was detected in 69 (51.9%) patients. Rhinovirus was detected in 70 patients and RSV was detected in 37. The duration of hospitalization was found to be significantly shorter in patients who received only oxygen and/or intravenous fluid treatment compared with those who received nebulized salbutamol and/or intravenous steroids. In addition, and there was no significant difference between the groups in terms of HFNC and hospitalization in the intensive care unit. Conclusion: Rhinovirus was the most common cause of acute bronchiolitis in our study. It was observed that congenital heart disease prolonged the length of hospitalization. In the treatment approaches, it was observed that hydration and oxygen therapy were sufficient treatment methods for the patients, in accordance with the recommendations of the American Academy of Pediatrics, and giving nebulized therapy prolonged the hospitalization period due to the treatment discontinuation steps.
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Havdal LB, Nakstad B, Fjærli HO, Ness C, Inchley C. Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions. Eur J Pediatr 2021; 180:2473-2483. [PMID: 33834273 PMCID: PMC8285352 DOI: 10.1007/s00431-021-04057-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/13/2021] [Accepted: 03/29/2021] [Indexed: 01/11/2023]
Abstract
Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children < 24 months assessed at the emergency department for VLRTI for a 10-year period. To identify adverse events related to admission guidelines implementation, we reviewed patient records for all those discharged on primary contact followed by readmission within 14 days. During the study period, 3227 children younger than 24 months old were assessed in the ED for VLRTI. The proportion of severe adverse events among children who were discharged on their initial emergency department contact was low both before (0.3%) and after the intervention (0.5%) (p=1.0). Admission rates before vs. after the intervention were for previously healthy children > 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5).Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI. What is Known: • Viral lower respiratory tract infection, including bronchiolitis, is the most common cause of hospitalization for young children in the developed world. Treatment is mainly supportive, and hospitalization should be limited to the cases in need of therapeutic intervention. • Many countries have guidelines for the management of the disease, but the decision on whom to admit for inpatient treatment is often subjective and may vary even between physicians in the same hospital. What is New: • Implementation of admission criteria for viral lower respiratory tract infection may reduce the rate of hospital admissions without increasing adverse events.
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Affiliation(s)
- Lise Beier Havdal
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway. .,Division of Paediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Britt Nakstad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hans Olav Fjærli
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christian Ness
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
| | - Christopher Inchley
- Department of Pediatric and Adolescent Medicine, Akershus University Hospital, Sykehusveien 25, 1478, Nordbyhagen, Norway
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Klem N, Skjerven HO, Nilsen B, Brekke M, Vallersnes OM. Treatment for acute bronchiolitis before and after implementation of new national guidelines: a retrospective observational study from primary and secondary care in Oslo, Norway. BMJ Paediatr Open 2021; 5:e001111. [PMID: 34104804 PMCID: PMC8141443 DOI: 10.1136/bmjpo-2021-001111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/30/2021] [Accepted: 05/07/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Acute bronchiolitis treatment guidelines changed in Norway in 2013, no longer recommending the use of nebulised epinephrine. We aimed to assess whether these changes were successfully implemented in both primary and secondary care. Secondary aims were to compare the difference in management of acute bronchiolitis patients in primary and secondary care between 2009 and 2017. METHODS We retrospectively registered data on demographics, clinical features and management from electronic medical records of all infants (<12 months of age) diagnosed with acute bronchiolitis at a primary care centre (Oslo Accident and Emergency Outpatient Clinic) and a secondary care centre (Oslo University Hospital) in Norway in 2009, 2014 and 2017. All patient records were individually reviewed to ensure data accuracy. RESULTS We included 680 (36.3%) patients from primary care and 1195 (63.7%) from secondary care. There was a reduction in the use of nebulised epinephrine from 2009 to 2017 from 66.9% to 16.1% of cases (p<0.001) in primary care and from 59.1% to 4.9% (p<0.001) in secondary care. In parallel, there was an increase in the use of nebulised saline treatment, from 0.8% to 53.8% (p<0.001) in primary care and from 39.3% to 65.3% (p<0.001) in secondary care. The decrease in the use of nebulised racemic epinephrine occurred earlier in secondary care than in primary care; 13.4% vs 56.1%, respectively, in 2014. CONCLUSIONS Implementation of the new guidelines on the treatment of acute bronchiolitis was successfully implemented in both primary and secondary care.
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Affiliation(s)
- Nicolai Klem
- Department of General Practice, University of Oslo, Oslo, Norway.,Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| | | | - Beate Nilsen
- Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
| | - Mette Brekke
- General Practice Research Unit, University of Oslo, Oslo, Norway
| | - Odd Martin Vallersnes
- Department of General Practice, University of Oslo, Oslo, Norway.,Department of Emergency General Practice, Oslo Accident and Emergency Outpatient Clinic, City of Oslo Health Agency, Oslo, Norway
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Sautter M, Halvorsen T, Engan M, Clemm H, Bentsen MHL. Electromagnetic inductance plethysmography to study airflow after nebulized saline in bronchiolitis. Pediatr Pulmonol 2020; 55:3437-3442. [PMID: 32897652 DOI: 10.1002/ppul.25058] [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] [Received: 05/01/2020] [Revised: 08/17/2020] [Accepted: 09/01/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Spirometric effects from therapeutic interventions in infants with severe respiratory distress cannot readily be measured, hampering development of better treatment for acute bronchiolitis. Inhaled normal saline is regularly used in these infants, with little knowledge of how this influences lung physiology. OBJECTIVES Assess feasibility of infant lung function testing using electromagnetic inductance plethysmography (EIP) in a clinical setting in a busy pediatric department, and explore effects from inhaled normal saline on tidal flow-volume loops in infants with acute bronchiolitis. METHODS Observational study conducted at the Children's Clinic, Haukeland University Hospital, Bergen, Norway during the winters 2016 and 2017, enrolling children with bronchiolitis below six months of age. EIP was performed immediately before and 5 and 20 min after saline inhalation. EIP is a noninvasive method to measure tidal breathing parameters by quantifying volume changes in the chest and abdomen during respiration. The method consists of an electromagnet/antenna and a patient vest. RESULTS EIP was successfully applied in 36/45 (80%) enrolled infants at mean (standard deviation) age 2.9 (2.5) months, after a hospital stay of 2.2 (1.9) days. After saline inhalation, tidal expiratory to inspiratory time ratio (Te/Ti) had increased significantly, whereas the other relevant flow/volume parameters had changed numerically in a direction compatible with a more obstructive pattern. CONCLUSIONS EIP could successfully be used to obtain tidal breathing parameters in infants with respiratory distress and appears a promising tool for assessment of therapeutic interventions in bronchiolitis. Saline inhalations should be used with caution as placebo in intervention studies.
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Affiliation(s)
- Marie Sautter
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Thomas Halvorsen
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Mette Engan
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Hege Clemm
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
| | - Mariann H L Bentsen
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway.,Department of Pediatric and Adolescent Medicine, Haukeland University Hospital, Bergen, Norway
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12
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Schroeder AR, Destino LA, Ip W, Vukin E, Brooks R, Stoddard G, Coon ER. Day of Illness and Outcomes in Bronchiolitis Hospitalizations. Pediatrics 2020; 146:peds.2020-1537. [PMID: 33093138 DOI: 10.1542/peds.2020-1537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bronchiolitis is often described to follow an expected clinical trajectory, with a peak in severity between days 3 and 5. This predicted trajectory may influence anticipatory guidance and clinical decision-making. We aimed to determine the association between day of illness at admission and outcomes, including hospital length of stay, receipt of positive-pressure ventilation, and total cough duration. METHODS We compiled data from 2 multicenter prospective studies involving bronchiolitis hospitalizations in patients <2 years. Patients were excluded for complex conditions. We assessed total cough duration via weekly postdischarge phone calls. We used mixed-effects multivariable regression models to test associations between day of illness and outcomes, with adjustment for age, sex, insurance (government versus nongovernment), race, and ethnicity. RESULTS The median (interquartile range) day of illness at admission for 746 patients was 4 (2-5) days. Day of illness at admission was not associated with length of stay (coefficient 0.01 days, 95% confidence interval [CI]: -0.05 to 0.08 days), positive-pressure ventilation (adjusted odds ratio: 1.0, 95% CI: 0.9 to 1.1), or total cough duration (coefficient 0.33 days, 95% CI: -0.01 to 0.67 days). Additionally, there was no significant difference in day of illness at discharge in readmitted versus nonreadmitted patients (5.9 vs 6.4 days, P = .54). The median cough duration postdischarge was 6 days, with 65 (14.3%) patients experiencing cough for 14+ days. CONCLUSIONS We found no associations between day of illness at admission and outcomes in bronchiolitis hospitalizations. Practitioners should exercise caution when making clinical decisions or providing anticipatory guidance based on symptom duration.
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Affiliation(s)
- Alan R Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California;
| | - Lauren A Destino
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Wui Ip
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Elizabeth Vukin
- Department of Pediatrics, Primary Children's Hospital and School of Medicine, University of Utah, Salt Lake City, Utah
| | - Rona Brooks
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California.,Department of Pediatrics, John Muir Health, Walnut Creek, California; and
| | - Greg Stoddard
- Division of Biostatistics, Department of Population Health Sciences, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Eric R Coon
- Department of Pediatrics, Primary Children's Hospital and School of Medicine, University of Utah, Salt Lake City, Utah
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13
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Biban P, Conti G, Wolfler AM, Carlassara S, Gitto E, Rulli I, Moscatelli A, Micalizzi C, Savron F, Sagredini R, Genoni G, Binotti M, Caramelli F, Fae M, Pettenazzo A, Stritoni V, D'Amato L, Zito Marinosci G, Calderini E, Scalia Catenacci S, Berardi A, Torcetta F, Bonanomi E, Bonacina D, Ivani G, Santuz P. Efficacy and safety of exogenous surfactant therapy in patients under 12 months of age invasively ventilated for severe bronchiolitis (SURFABRON): protocol for a multicentre, randomised, double-blind, controlled, non-profit trial. BMJ Open 2020; 10:e038780. [PMID: 33077567 PMCID: PMC7574934 DOI: 10.1136/bmjopen-2020-038780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Some evidence indicates that exogenous surfactant therapy may be effective in infants with acute viral bronchiolitis, even though more confirmatory data are needed. To date, no large multicentre trials have evaluated the effectiveness and safety of exogenous surfactant in severe cases of bronchiolitis requiring invasive mechanical ventilation (IMV). METHODS AND ANALYSIS This is a multicentre randomised, placebo-controlled, double-blind study, performed in 19 Italian paediatric intensive care units (PICUs). Eligible participants are infants under the age of 12 months hospitalised in a PICU, suffering from severe acute hypoxaemic bronchiolitis, requiring IMV. We adopted a more restrictive definition of bronchiolitis, including only infants below 12 months of age, to maintain the population as much homogeneous as possible. The primary outcome is to evaluate whether exogenous surfactant therapy (Curosurf, Chiesi Pharmaceuticals, Italy) is effective compared with placebo (air) in reducing the duration of IMV in the first 14 days of hospitalisation, in infants suffering from acute hypoxaemic viral bronchiolitis. Secondary outcomes are duration of non-invasive mechanical ventilation in the post-extubation phase, number of cases requiring new intubation after previous extubation within 14 days from randomisation, PICU and hospital length of stay (LOS), duration of oxygen dependency, effects on oxygenation and ventilatory parameters during invasive mechanical respiratory support, need for repeating treatment within 24 hours of first treatment, use of other interventions (eg, high-frequency oscillatory ventilation, nitric oxide, extracorporeal membrane oxygenation), mortality within the first 14 days of PICU stay and before hospital discharge, side effects and serious adverse events. ETHICS AND DISSEMINATION The trial design and protocol have received approval by the Italian National Agency for Drugs (AIFA) and by the Regional Ethical Committee of Verona University Hospital (1494CESC). Findings will be disseminated through publication in peer-reviewed journals, conference/meeting presentations and media. TRIAL REGISTRATION NUMBER Clinicaltrials.gov, issue date 22 May 2019. NCT03959384.
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Affiliation(s)
- Paolo Biban
- Department of Neonatal and Paediatric Critical Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Giorgio Conti
- Paediatric Anesthesia and Intensive Care, Policlinico Universitario Agostino Gemelli, Roma, Italy
| | - Andrea Michele Wolfler
- Paediatric Anesthesia and Intensive Care, Ospedale dei Bambini Vittore Buzzi, Milano, Italy
| | - Silvia Carlassara
- Department of Neonatal and Paediatric Critical Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Eloisa Gitto
- Neonatal and Paediatric Intensive Care, Azienda Ospedaliera Universitaria G. Martino, Messina, Italy
| | - Immacolata Rulli
- Neonatal and Paediatric Intensive Care, Azienda Ospedaliera Universitaria G. Martino, Messina, Italy
| | - Andrea Moscatelli
- Paediatric Anesthesia and Intensive Care, Ospedale Giannina Gaslini, Genova, Italy
| | - Camilla Micalizzi
- Paediatric Anesthesia and Intensive Care, Ospedale Giannina Gaslini, Genova, Italy
| | - Fabio Savron
- Paediatric Anesthesia and Intensive Care, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Raffaella Sagredini
- Paediatric Anesthesia and Intensive Care, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Giulia Genoni
- Neonatal and Paediatric Intensive Care, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Marco Binotti
- Neonatal and Paediatric Intensive Care, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy
| | - Fabio Caramelli
- Paediatric Anesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - Monica Fae
- Paediatric Anesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - Andrea Pettenazzo
- Paediatric Intensive Care, Azienda Ospedaliera Universitaria Padova, Padua, Italy
| | - Valentina Stritoni
- Paediatric Intensive Care, Azienda Ospedaliera Universitaria Padova, Padua, Italy
| | - Luigia D'Amato
- Paediatric Anesthesia and Intensive Care, Ospedale Pediatrico Santobbono, Napoli, Italy
| | | | - Edoardo Calderini
- Paediatric Anesthesia and Intensive Care, Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Alberto Berardi
- Neonatal Intensive Care, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Francesco Torcetta
- Neonatal Intensive Care, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Ezio Bonanomi
- Paediatric Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Daniele Bonacina
- Paediatric Anesthesia and Intensive Care, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giorgio Ivani
- Paediatric Anesthesia and Intensive Care, Ospedale Infantile Regina Margherita Sant'Anna, Torino, Italy
| | - Pierantonio Santuz
- Department of Neonatal and Paediatric Critical Care, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
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14
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Angurana SK, Williams V, Takia L. Acute Viral Bronchiolitis: A Narrative Review. J Pediatr Intensive Care 2020; 12:79-86. [PMID: 37082471 PMCID: PMC10113010 DOI: 10.1055/s-0040-1715852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022] Open
Abstract
AbstractAcute viral bronchiolitis (AVB) is the leading cause of hospital admissions among infants in developed and developing countries and associated with increased morbidity and cost of treatment. This review was performed to guide the clinicians managing AVB in light of evidence accumulated in the last decade. We searched published English literature in last decade regarding etiology, diagnosis, treatment, and prevention of AVB using PubMed and Cochrane Database of Systematic Reviews. Respiratory syncytial virus is the most common causative agent. The diagnosis is mainly clinical with limited role of diagnostic investigations and chest radiographs are not routinely indicated. The management of AVB remains a challenge, as the role of various interventions is not clear. Supportive care in from of provision of heated and humidified oxygen and maintaining hydration are main interventions. The use of pulse oximetry helps to guide the administration of oxygen. Trials and systematic reviews evaluated various interventions like nebulized adrenaline, bronchodilators and hypertonic saline, corticosteroids, different modes of noninvasive ventilation (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and noninvasive positive pressure ventilation [NPPV]), surfactant, heliox, chest physiotherapy, and antiviral drugs. The interventions which showed some benefits in infants and children with AVB are adrenaline and hypertonic saline nebulization, HFNC, CPAP, NIV, and surfactant. The routine administration of antibiotics, bronchodilators, corticosteroids, steam inhalation, chest physiotherapy, heliox, and antiviral drugs are not recommended.
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Affiliation(s)
- Suresh K. Angurana
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vijai Williams
- Pediatric Intensive Care Unit, Gleneagles Global Hospitals, Perumbakkam, Chennai, India
| | - Lalit Takia
- Division of Pediatric Critical Care, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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15
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Yasin F, Afridi ZS, Mahmood Q, Khan AA, Condon S, Khan RA. Role of nebulized epinephrine in moderate bronchiolitis: a quasi-randomized trial. Ir J Med Sci 2020; 190:239-242. [PMID: 32651768 DOI: 10.1007/s11845-020-02293-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 06/28/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND/AIMS Bronchiolitis is the most common lower respiratory illness that characteristically affects the children below 2 years of age accounting about 2-3% of patients admitted to hospital each year [1-4]. We compared the effect of racemic epinephrine (RE) and 3% hypertonic saline (HS) nebulization on the length of stay (LOS) in the hospital. METHODS We looked at the infants with moderate bronchiolitis, from October 2013 to March 2014. Out of eighty cases, 16 in HS and 18 in RE groups were enrolled. At the time of admission, 0.2 ml of RE added to 1.8 ml of distilled water was nebulized to RE group, as compared with 2 ml of 3% HS in nebulized form. RE was re-administered if needed on 6 h in comparison with 3% HS at the frequency of 1 to 4 h. RESULTS One infant from RE group and three infants from HS group were excluded due to progression towards severe bronchiolitis. The LOS in RE group ranged between 18 and 160 h (mean 45 h), while in HS group, LOS was 18.50-206 h (mean 74.3 h). The LOS was significantly short in RE group (p value 0.015) which was statistically significant. CONCLUSION Racemic epinephrine nebulization as first-line medication may significantly reduce the length of hospital stay in infants with moderate bronchiolitis in comparison with nebulized HS.
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Affiliation(s)
- Faiza Yasin
- Department of Paediatric Medicine, University Hospital Kerry, Tralee, Ireland.
| | - Zahir Shah Afridi
- Department of Paediatric Medicine, University Hospital Kerry, Tralee, Ireland
| | - Qasim Mahmood
- Department of Paediatric Medicine, University Hospital Kerry, Tralee, Ireland
| | - Akhter Ali Khan
- Department of Paediatric Medicine, University Hospital Kerry, Tralee, Ireland
| | - Sharon Condon
- Department of Paediatric Medicine, University Hospital Kerry, Tralee, Ireland
| | - Rizwan Ahmed Khan
- Department of Paediatric Medicine, University Hospital Kerry, Tralee, Ireland
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16
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Griffiths B, Riphagen S, Lillie J. Management of severe bronchiolitis: impact of NICE guidelines. Arch Dis Child 2020; 105:483-485. [PMID: 30472669 DOI: 10.1136/archdischild-2018-315199] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 10/29/2018] [Accepted: 11/07/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To understand the impact of the National Institute for Health and Care Excellence (NICE) bronchiolitis guidelines on the management of children referred to paediatric intensive care unit (PICU) with bronchiolitis. DESIGN AND SETTING Data were collected on all children referred to a regional PICU transport service with the clinical diagnosis of bronchiolitis during the winter prior to the NICE consultation period (2011-2012) and during the winter after publication (2015-2016). Management initiated by the referring hospital was assessed. RESULTS There were 165 infants referred with bronchiolitis in epoch 1 and 187 in epoch 2. Nebuliser use increased from 28% in epoch 1 to 53% in epoch 2. Increased use of high-flow nasal cannula oxygen and reduction in continuous positive airway pressure use were observed. The use of antibiotics did not change between epochs. CONCLUSION The use of nebulised therapies has increased in the management of severe bronchiolitis despite national guidance to the contrary.
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Affiliation(s)
- Benedict Griffiths
- South Thames Retrieval Service, Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Shelley Riphagen
- South Thames Retrieval Service, Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Jon Lillie
- South Thames Retrieval Service, Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
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17
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Hunderi JOG, Rolfsjord LB, Carlsen KCL, Holst R, Bakkeheim E, Berents TL, Carlsen KH, Skjerven HO. Virus, allergic sensitisation and cortisol in infant bronchiolitis and risk of early asthma. ERJ Open Res 2020; 6:00268-2019. [PMID: 32201686 PMCID: PMC7073413 DOI: 10.1183/23120541.00268-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/27/2019] [Indexed: 11/23/2022] Open
Abstract
Background Acute bronchiolitis during infancy and human rhinovirus (HRV) lower respiratory tract infections increases the risk of asthma in atopic children. We aimed to explore whether specific viruses, allergic sensitisation or cortisol levels during acute bronchiolitis in infancy increase the risk of early asthma, using recurrent wheeze as a proxy. Methods In 294 children with a mean (range) age of 4.2 (0–12) months enrolled during hospitalisation for acute infant bronchiolitis, we analysed virus in nasopharyngeal aspirates, serum specific immunoglobulin E against food and inhalant allergens, and salivary morning cortisol. These factors were assessed by regression analyses, adjusted for age, sex and parental atopy, for risk of recurrent wheeze, defined as a minimum of three parentally reported episodes of wheeze at the 2-year follow-up investigation. Results At 2 years, children with, compared to without, recurrent wheeze had similar rates of respiratory syncytial virus (RSV) (82.9% versus 81.8%) and HRV (34.9% versus 35.0%) at the acute bronchiolitis, respectively. During infancy, 6.9% of children with and 9.2% of children without recurrent wheeze at 2 years were sensitised to at least one allergen (p=0.5). Neither recurrent wheeze nor incidence rate ratios for the number of wheeze episodes at 2 years were significantly associated with specific viruses, high viral load of RSV or HRV, allergic sensitisation, or morning salivary cortisol level during acute bronchiolitis in infancy. Conclusion In children hospitalised with acute infant bronchiolitis, specific viruses, viral load, allergic sensitisation and salivary morning cortisol did not increase the risk of early asthma by 2 years of age. In infants with acute bronchiolitis, specific viruses including human rhinovirus, viral load and/or allergic sensitisation did not increase the risk of asthma by 2 years of age.http://bit.ly/2tCE9Yd
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Affiliation(s)
- Jon Olav Gjengstø Hunderi
- Dept of Pediatrics and Adolescent Medicine, Østfold Hospital Trust, Grålum, Norway.,Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Leif Bjarte Rolfsjord
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Dept of Pediatrics, Innlandet Hospital Trust, Elverum, Norway
| | - Karin C Lødrup Carlsen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - René Holst
- Oslo Centre for Biostatistics and Epidemiology, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Egil Bakkeheim
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Teresa Løvold Berents
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Dept of Dermatology, Oslo University Hospital, Oslo, Norway
| | - Kai-Håkon Carlsen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Håvard Ove Skjerven
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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18
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House SA, Gadomski AM, Ralston SL. Evaluating the Placebo Status of Nebulized Normal Saline in Patients With Acute Viral Bronchiolitis: A Systematic Review and Meta-analysis. JAMA Pediatr 2020; 174:250-259. [PMID: 31905239 PMCID: PMC6990821 DOI: 10.1001/jamapediatrics.2019.5195] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In therapeutic trials for acute viral bronchiolitis, consistent clinical improvement in groups that received nebulized normal saline (NS) as placebo raises the question of whether nebulized NS acts as a treatment rather than a placebo. OBJECTIVE To measure the short-term association of nebulized NS with physiologic measures of respiratory status in children with bronchiolitis by analyzing the changes in these measures between the use of nebulized NS and the use of other placebos and the changes before and after nebulized NS treatment. DATA SOURCES MEDLINE and Scopus were searched through March 2019, as were bibliographies of included studies and relevant systematic reviews, for randomized clinical trials evaluating nebulized therapies in bronchiolitis. STUDY SELECTION Randomized clinical trials comparing children 2 years or younger with bronchiolitis who were treated with nebulized NS were included. Studies enrolling a treatment group receiving an alternative placebo were included for comparison of NS with other placebos. DATA EXTRACTION AND SYNTHESIS Data abstraction was performed per PRISMA guidelines. Fixed- and random-effects, variance-weighted meta-analytic models were used. MAIN OUTCOMES AND MEASURES Pooled estimates of the association with respiratory scores, respiratory rates, and oxygen saturation within 60 minutes of treatment were generated for nebulized NS vs another placebo and for change before and after receiving nebulized NS. RESULTS A total of 29 studies including 1583 patients were included. Standardized mean differences in respiratory scores for nebulized NS vs other placebo (3 studies) favored nebulized NS by -0.9 points (95% CI, -1.2 to -0.6 points) at 60 minutes after treatment (P < .001). There were no differences in respiratory rate or oxygen saturation comparing nebulized NS with other placebo. The standardized mean difference in respiratory score (25 studies) after nebulized NS was -0.7 (95% CI, -0.7 to -0.6; I2 = 62%). The weighted mean difference in respiratory scores using a consistent scale (13 studies) after nebulized NS was -1.6 points (95% CI, -1.9 to -1.3 points; I2 = 72%). The weighted mean difference in respiratory rate (17 studies) after nebulized NS was -5.5 breaths per minute (95% CI, -6.3 to -4.6 breaths per minute; I2 = 24%). The weighted mean difference in oxygen saturation (23 studies) after nebulized NS was -0.4% (95% CI, -0.6% to -0.2%; I2 = 79%). CONCLUSIONS AND RELEVANCE Nebulized NS may be an active treatment for acute viral bronchiolitis. Further evaluation should occur to establish whether it is a true placebo.
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Affiliation(s)
- Samantha A. House
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Anne M. Gadomski
- Research Institute, Bassett Medical Center, Cooperstown, New York
| | - Shawn L. Ralston
- Department of Pediatrics, Johns Hopkins Medical School, Baltimore, Maryland
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19
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Skjerven HO, Hunderi JOG, Carlsen KH, Rolfsjord LB, Nordhagen L, Berents TL, Bains KES, Buchmann M, Carlsen KCL. Allergic sensitisation in infants younger than one year of age. Pediatr Allergy Immunol 2020; 31:203-206. [PMID: 31594030 DOI: 10.1111/pai.13135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 09/18/2019] [Accepted: 09/30/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Håvard Ove Skjerven
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Jon Olav Gjengstø Hunderi
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Østfold Hospital Trust, Sarpsborg, Norway
| | - Kai-Håkon Carlsen
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Leif Bjarte Rolfsjord
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Innlandet Hospital Trust, Elverum, Norway
| | - Live Nordhagen
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway.,VID Specialized University, Oslo, Norway
| | | | - Karen Eline Stensby Bains
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Karin C Lødrup Carlsen
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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20
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Størdal K, Wyder C, Trobisch A, Grossman Z, Hadjipanayis A. Overtesting and overtreatment-statement from the European Academy of Paediatrics (EAP). Eur J Pediatr 2019; 178:1923-1927. [PMID: 31506723 DOI: 10.1007/s00431-019-03461-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/12/2019] [Accepted: 08/28/2019] [Indexed: 11/24/2022]
Abstract
Child health has improved considerably, partly due to increased availability of appropriate disease surveillance and treatment. Inappropriate testing and treatment may impose a risk. There is a large and unexplained variation in the use of tests and treatments for children between and within countries. This suggests that non-scientific factors determine their use. In an era of increasing availability of health services, pediatricians have an important role in balancing risks and benefits of available tests and treatments. Examples from the medical literature of overtesting and overtreatment challenge us to reconsider current practices. Antibiotic overuse, overtreatment of bronchiolitis, and non-indicated radiological procedures are found in common practice across Europe. Choosing Wisely is an initiative to improve the quality of care by reducing unnecessary testing and treatment.Conclusion: Clinicians have the challenge to find the optimal balance between too much and too little medicine-just appropriate.
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Affiliation(s)
- Ketil Størdal
- Norwegian Institute of Public Health, Oslo, Norway. .,Ostfold Hospital Trust, Grålum, Norway.
| | - Corinne Wyder
- Kinderaerzte KurWerk, Poststrasse 9, 3400, Burgdorf, Switzerland.,Department of Paediatrics, University of Bern, Bern, Switzerland
| | - Andreas Trobisch
- Department of Neonatology, Medical University Graz, Graz, Austria
| | - Zachi Grossman
- Maccabi Healthcare Services, Pediatric clinic, Tel Aviv, Israel
| | - Adamos Hadjipanayis
- Department of Paediatrics, Larnaca General Hospital, Larnaca, Cyprus.,Medical School, European University of Cyprus, Nicosia, Cyprus.,European Academy of Paediatrics, Brussels, Belgium
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21
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McCoy E, Chumpia M. Decreasing Racemic Epinephrine for Bronchiolitis in an Academic Children's Hospital. Hosp Pediatr 2019; 8:651-657. [PMID: 30237259 DOI: 10.1542/hpeds.2017-0214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Bronchiolitis is a leading cause of pediatric hospitalizations in the United States. Although the American Academy of Pediatrics recommends against routine use of bronchodilators in bronchiolitis management, racemic epinephrine was persistently used for this purpose at Le Bonheur Children's Hospital. Our aim was to decrease racemic epinephrine use for bronchiolitis by 50% within 8 months. METHODS Our multidisciplinary team used the Institute for Healthcare Improvement's Model for Improvement to develop an aim statement, choose metrics, and perform plan-do-study-act cycles to reduce racemic epinephrine use. We used focused education through in-person and online methods and provided direct feedback to residents, respiratory therapists, and nurses primarily caring for these children. The percentage of all patients admitted for bronchiolitis receiving at least 1 dose of racemic epinephrine was collected from the medical record and recorded on statistical process control charts for distribution to their work areas. Albuterol use and length of stay were collected as balancing measures. We used statistical process control charts to establish special cause variation and identify statistically significant differences in our measures. RESULTS During our intervention period, the percentage of bronchiolitis patients receiving at least 1 dose of racemic epinephrine to treat bronchiolitis decreased from an average of 26% to 5%, and similarly, albuterol use decreased from an average of 48% to 34%. There was no clinically significant difference in length of stay. CONCLUSIONS Using a multidisciplinary approach and focused education techniques may be an effective way to reduce racemic epinephrine use for children with bronchiolitis.
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Affiliation(s)
- Elisha McCoy
- Le Bonheur Children's Hospital, Memphis, Tennessee; and .,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Maryanne Chumpia
- Le Bonheur Children's Hospital, Memphis, Tennessee; and.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
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Daverio M, Da Dalt L, Panozzo M, Frigo AC, Bressan S. A two-tiered high-flow nasal cannula approach to bronchiolitis was associated with low admission rate to intensive care and no adverse outcomes. Acta Paediatr 2019; 108:2056-2062. [PMID: 31102551 DOI: 10.1111/apa.14869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 05/14/2019] [Accepted: 05/16/2019] [Indexed: 11/29/2022]
Abstract
AIM We aimed to describe the characteristics and outcomes of infants with bronchiolitis who received high-flow nasal cannula oxygen (HFNC) following a two-tiered approach. METHODS This retrospective study included 211 infants below 12 months of age needing oxygen therapy for bronchiolitis, between 2012 and 2017, on the general paediatric ward of the tertiary Paediatric Hospital of Padova, Italy. HFNC was used as first-line therapy for moderate to severe disease and as rescue therapy for deterioration on low-flow oxygen. RESULTS Median age was 61 days (IQR 31-126), and 57.3% were males. HFNC was used as first-line therapy in 35/211 (16.6%) infants and as rescue in 73/176 (41.5%) patients on low-flow oxygen. Overall 9/211 patients (4.3%) were admitted to intensive care, representing a HFNC failure of 9/108 (8.3%). Intensive care admissions did not significantly differ between initial low-flow oxygen therapy and HFNC (8/176, 4.5% versus 1/35, 2.8%, proportion difference 1.7%, 95%CI -10.2 to 6.7), or between initial and rescue HFNC (1/35, 2.8% versus 8/73, 10.9%; proportion difference 8.1%, 95%CI -4.5 to 18). Only two patients developed air leak and were treated conservatively. CONCLUSION A two-tiered approach to HFNC use in bronchiolitis was associated with low intensive care admissions and no adverse outcomes.
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Affiliation(s)
- Marco Daverio
- Paediatric Intensive Care Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
| | - Liviana Da Dalt
- Paediatric Emergency Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
| | - Matteo Panozzo
- Paediatric Emergency Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit Department of Cardiac Thoracic and Vascular Sciences University of Padova Padova Italy
| | - Silvia Bressan
- Paediatric Emergency Unit Department of Women's and Children's Health University Hospital of Padova Padova Italy
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Affiliation(s)
- Alyssa H Silver
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Joanne M Nazif
- Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
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24
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Heikkilä P, Korppi M. Oxygen administration in bronchiolitis: As humidified, or as heated and humidified? Pediatr Pulmonol 2019; 54:1343-1344. [PMID: 31050185 DOI: 10.1002/ppul.24349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Paula Heikkilä
- Tampere Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University and University Hospital, Tampere, Finland
| | - Matti Korppi
- Tampere Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University and University Hospital, Tampere, Finland
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25
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Rolfsjord LB, Skjerven HO, Bakkeheim E, Berents TL, Carlsen KH, Carlsen KCL. Quality of life, salivary cortisol and atopic diseases in young children. PLoS One 2019; 14:e0214040. [PMID: 31469854 PMCID: PMC6716779 DOI: 10.1371/journal.pone.0214040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 07/23/2019] [Indexed: 11/19/2022] Open
Abstract
Background Children with atopic disease may have reduced health-related quality of life (QoL) and morning cortisol. Possible links between QoL, morning cortisol and atopic disease are unclear. We aimed to determine if QoL was associated with morning salivary cortisol at two years of age, and if asthma, atopic dermatitis and/or allergic sensitisation influenced this association. Secondarily, we aimed to determine if QoL at one year of age was associated with salivary cortisol one year later. Methods and findings The Bronchiolitis All SE-Norway study included infants during hospitalisation for acute bronchiolitis in infancy (bronchiolitis group) and population-based control infants (controls). The present study included all 358 subjects with available Infant Toddler Quality of Life Questionnaire (ITQOL) from parents, consisting of 13 domains and morning salivary cortisol at two years of age. Answers from the same 0–100 score questionnaire, with optimal score 100 nine months after enrolment, was also available for 289 of these children at about one year of age. Recurrent bronchial obstruction was used as an asthma proxy. Atopic dermatitis was defined by Hanifin and Rajka criteria and allergic sensitisation by a positive skin prick test. Due to different inclusion criteria, we tested possible interactions with affiliation groups. Associations between QoL and cortisol were analysed by multivariate analyses, stratified by bronchiolitis and control groups due to interaction from affiliation grouping on results. At two years of age, QoL decreased significantly with decreasing cortisol in 8/13 QoL domains in the bronchiolitis group, but only with General health in the controls. The associations in the bronchiolitis group showed 0.06–0.19 percentage points changes per nmol/L cortisol for each of the eight domains (p-values 0.0001–0.034). The associations remained significant but diminished by independently including recurrent bronchial obstruction and atopic dermatitis, but remained unchanged by allergic sensitisation. In the bronchiolitis group only, 7/13 age and gender adjusted QoL domains in one-year old children were lower with lower cortisol levels at two years of age (p = 0.0005–0.04). Conclusions At two years, most QoL domains decreased with lower salivary cortisol among children who had been hospitalised for acute bronchiolitis in infancy, but for one domain only among controls. Recurrent bronchial obstruction and to a lesser extent atopic dermatitis, weakened these associations that nevertheless remained significant. After bronchiolitis, lower QoL in one-year old children was associated with lower salivary cortisol at two years.
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Affiliation(s)
- Leif Bjarte Rolfsjord
- Department of Paediatrics, Innlandet Hospital Trust, Elverum, Norway
- Division of Paediatrics and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- * E-mail:
| | - Håvard Ove Skjerven
- Division of Paediatrics and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Egil Bakkeheim
- Division of Paediatrics and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Kai-Håkon Carlsen
- Division of Paediatrics and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Karin C. Lødrup Carlsen
- Division of Paediatrics and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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26
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Wang ZY, Li XD, Sun AL, Fu XQ. Efficacy of 3% hypertonic saline in bronchiolitis: A meta-analysis. Exp Ther Med 2019; 18:1338-1344. [PMID: 31384334 PMCID: PMC6639771 DOI: 10.3892/etm.2019.7684] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/22/2018] [Indexed: 01/09/2023] Open
Abstract
A meta-analysis was performed to analyze the efficacy of 3% hypertonic saline (HS) in bronchiolitis. Pubmed and MEDLINE databases were searched for relevant articles. A total of 2 authors selected the articles according to the inclusion criteria and then data were carefully extracted. Weighted mean difference (WMD) with 95% confidence interval (95% CI) values were used to pool continuous data, including length of stay and clinical severity score (CSS). Relative risk (RR) with 95% CI was calculated to determine the association between 3% HS and re-admission. The pooled data revealed that infants treated with 3% HS exhibited shorter durations of hospitalization compared with those treated with normal saline (NS; WMD=-0.43; 95% CI=-0.70, -0.15). Subgroup analysis examining the combination of HS or NS with additional medication demonstrated that 3% HS with epinephrine significantly decreased the length of hospital stay, with a WMD=-0.62 (95% CI=-0.90, -0.33). The results indicated a lower CSS score in the 3% HS group compared with the NS group (SMD=-0.80; 95% CI=-1.06, -0.54). The pooled outcome indicated a beneficial effect of 3% HS on decreasing re-admission rates compared with NS (RR=0.93; 95% CI=0.70, 1.23). No potential publication bias was observed (Begg's, P=0.133; Egger's, P=0.576). In conclusion, 3% HS was demonstrated to be a more successful therapy compared with NS for infants with bronchiolitis.
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Affiliation(s)
- Zhi-Yong Wang
- Pediatric Department, Weifang Maternity and Child Care Hospital, Weifang, Shandong 261011, P.R. China
| | - Xiao-Dong Li
- Pediatric Department, Weifang Maternity and Child Care Hospital, Weifang, Shandong 261011, P.R. China
| | - Ai-Ling Sun
- Pediatric Department, Weifang Maternity and Child Care Hospital, Weifang, Shandong 261011, P.R. China
| | - Xue-Qin Fu
- Pediatric Department, Changyi People's Hospital, Changyi, Shandong 261300, P.R. China
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27
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Molecular characterization of circulating respiratory syncytial virus genotypes in Pakistani children, 2010-2013. J Infect Public Health 2019; 13:438-445. [PMID: 31229412 DOI: 10.1016/j.jiph.2019.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 05/17/2019] [Accepted: 05/18/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Data on the viral etiology of acute lower respiratory infections are scarce in Pakistan. Human respiratory syncytial virus (RSV) is an important cause of morbidity in children but no effective vaccine or antiviral therapy is currently available. As vaccines are expected to become available in the future, it is important to understand the epidemiology of locally prevalent RSV subtypes. This study aimed to define the molecular epidemiology of RSV (A and B) genotypes in Pakistani children under 5 years. METHODS World Health Organization case definitions for influenza-like illness (ILI) and severe acute respiratory illness (SARI) were used for case selection. Children under 5 years who presented with ILI or SARI at tertiary care hospitals from all provinces/regions, including the eight influenza sentinel sites, during October-April each year between 2010 and 2013 were enrolled. Demographic and clinical data of the children were recorded and nasopharyngeal/throat swabs taken for analysis. All samples were tested for RSV A and B using real-time polymerase chain reaction for non-influenza respiratory viruses. Specific oligonucleotide primers for RSV A and B were used for subtyping and sequencing of the G protein, followed by phylogenetic analysis. RESULTS A total of 1941 samples were included. RSV was detected in 472 (24%) children, with RSV A detected in 367 (78%) and RSV B in 105 (22%). The G protein of all RSV A strains clustered in the NA1/GA2 genotype while RSV B strains carried the signature 60 nucleotide duplication and were assigned to three BA genotypes: BA-9, BA-10 and the new BA-13 genotype. CONCLUSIONS This study highlights the importance of RSV as a viral etiologic agent of acute respiratory infections in children in Pakistan, and the diversity of RSV viruses. Continued molecular surveillance for early detection of prevalent and newly emerging genotypes is needed to understand the epidemiology of RSV infections in Pakistan.
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Jamal A, Finkelstein Y, Kuppermann N, Freedman SB, Florin TA, Babl FE, Dalziel SR, Zemek R, Plint AC, Steele DW, Schnadower D, Johnson DW, Stephens D, Kharbanda A, Roland D, Lyttle MD, Macias CG, Fernandes RM, Benito J, Schuh S. Pharmacotherapy in bronchiolitis at discharge from emergency departments within the Pediatric Emergency Research Networks: a retrospective analysis. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:539-547. [PMID: 31182422 DOI: 10.1016/s2352-4642(19)30193-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/07/2019] [Accepted: 04/08/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinical guidelines advise against pharmacotherapy in bronchiolitis. However, little is known about global variation in prescribing practices for bronchiolitis at discharge from emergency departments. We aimed to evaluate global variation in prescribing practice (ie, inhaled salbutamol, or oral or inhaled corticosteroids) for infants with bronchiolitis at discharge from emergency departments. METHODS We did a planned secondary analysis of a multinational, retrospective cohort study of the Pediatric Emergency Research Networks. Previously healthy infants (aged <12 months) who were discharged with bronchiolitis between Jan 1 and Dec 31, 2013 from 38 emergency departments in Australia and New Zealand, Canada, Spain and Portugal, the UK and Ireland, and the USA were included. The primary outcome was pharmacotherapy prescription at discharge from the emergency department. Secondary outcomes were revisits to the emergency department or hospitalisations for bronchiolitis within 21 days of discharge. FINDINGS Of 1566 infants discharged from the emergency department, 317 (20%) were prescribed pharmacotherapy. Corticosteroid prescriptions were infrequent, ranging from 0% (0 of 68 infants) in Spain and Portugal to 6% (25 of 452) in the USA. Salbutamol prescriptions ranged from 5% (22 of 432) in the UK and Ireland to 32% (146 of 452) in the USA. Compared with the UK and Ireland, the odds of prescription of pharmacotherapy were increased in Spain and Portugal (odds ratio [OR] 9·22, 95% CI 1·70-49·96), the USA (8·20, 2·79-24·11), Canada (5·17, 1·61-16·67), and Australia and New Zealand (1·21, 0·36-4·10). After adjustment for clustering by site, pharmacotherapy at discharge was associated with older age (per 1 month increase; OR 1·23, 95% CI 1·16-1·30), oxygen saturation (per 1% decrease from 100%; 1·09, 1·01-1·18), chest retractions (1·88, 1·26-2·79), network (p=0·00050), and site (p<0·00090). 303 (19%) of 1566 infants returned to the emergency department and 129 (43%) of 303 were hospitalised. Discharge pharmacotherapy was not associated with revisits (p=0·55) or subsequent hospitalisations (p=0·50). INTERPRETATION Use of ineffective medications in infants with bronchiolitis at discharge from emergency departments is common, with large differences in prescribing practices between countries and emergency departments. Enhanced knowledge translation and deprescribing efforts are needed to optimise and unify the management of bronchiolitis. FUNDING None.
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Affiliation(s)
- Alisha Jamal
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Nathan Kuppermann
- Department of Emergency Medicine and Department of Pediatrics, UC Davis School of Medicine, University of California, Sacramento, CA, USA
| | - Stephen B Freedman
- Section of Pediatric Emergency Medicine and Section of Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Todd A Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Division of Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, University of Melbourne, Melbourne, VIC, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, Auckland, New Zealand; Department of Surgery and Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, ON, Canada
| | - Dale W Steele
- Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, RI, USA; Department of Emergency Medicine, Department of Pediatrics, and Department of Health Services, Policy, and Practice, Brown University, Providence, RI, USA
| | - David Schnadower
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - David W Johnson
- Section of Pediatric Emergency Medicine and Section of Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Emergency Medicine, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Physiology and Pharmacology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Derek Stephens
- Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, MN, USA
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic Group, Leicester Royal Infirmary, Leicester, UK; SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK; Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, UK
| | - Charles G Macias
- Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Ricardo M Fernandes
- Department of Paediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Javier Benito
- Paediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada; Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
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Korppi M, Mecklin M, Heikkilä P. Review shows substantial variations in the use of medication for infant bronchiolitis between and within countries. Acta Paediatr 2019; 108:1016-1022. [PMID: 30614550 DOI: 10.1111/apa.14713] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/03/2018] [Accepted: 01/03/2019] [Indexed: 12/15/2022]
Abstract
AIM Meta-analyses of randomised controlled trials on infant bronchiolitis do not support medication. We summarised the current data and evaluated the real-life use of medication for infants treated for bronchiolitis in hospitals, including paediatric wards, emergency departments and paediatric intensive care units (PICU). METHODS We searched PubMed for studies published from 2009 to 2018 that provided data on the real-life use of adrenaline, salbutamol, corticosteroids or antibiotics for infants hospitalised for bronchiolitis. RESULTS The review identified 10 such studies and showed substantial variations in medication for infant bronchiolitis between different countries and even between different hospitals in the same country. A multi-centre study including 38 hospitals in eight countries reported that a mean of 29% infants admitted for bronchiolitis received drugs without any research-based evidence on their effectiveness, ranging from 9% in Australia and New Zealand to 58% in Spain and Portugal. In addition, an American prospective multi-centre study of 16 PICUs reported that bronchodilators were used by a mean of 60%, corticosteroids by 33% and antibiotics by 63%. Other studies reported that higher ages and a history of wheezing increased the use of medication. CONCLUSION There were substantial variations in bronchiolitis treatment between, and within, different countries.
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Affiliation(s)
- Matti Korppi
- Center for Child health Research Tampere University Hospital University of Tampere Tampere Finland
| | - Minna Mecklin
- Center for Child health Research Tampere University Hospital University of Tampere Tampere Finland
| | - Paula Heikkilä
- Center for Child health Research Tampere University Hospital University of Tampere Tampere Finland
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30
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van Ravenzwaaij D, Monden R, Tendeiro JN, Ioannidis JPA. Bayes factors for superiority, non-inferiority, and equivalence designs. BMC Med Res Methodol 2019; 19:71. [PMID: 30925900 PMCID: PMC6441196 DOI: 10.1186/s12874-019-0699-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 02/28/2019] [Indexed: 12/20/2022] Open
Abstract
Background In clinical trials, study designs may focus on assessment of superiority, equivalence, or non-inferiority, of a new medicine or treatment as compared to a control. Typically, evidence in each of these paradigms is quantified with a variant of the null hypothesis significance test. A null hypothesis is assumed (null effect, inferior by a specific amount, inferior by a specific amount and superior by a specific amount, for superiority, non-inferiority, and equivalence respectively), after which the probabilities of obtaining data more extreme than those observed under these null hypotheses are quantified by p-values. Although ubiquitous in clinical testing, the null hypothesis significance test can lead to a number of difficulties in interpretation of the results of the statistical evidence. Methods We advocate quantifying evidence instead by means of Bayes factors and highlight how these can be calculated for different types of research design. Results We illustrate Bayes factors in practice with reanalyses of data from existing published studies. Conclusions Bayes factors for superiority, non-inferiority, and equivalence designs allow for explicit quantification of evidence in favor of the null hypothesis. They also allow for interim testing without the need to employ explicit corrections for multiple testing.
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Affiliation(s)
- Don van Ravenzwaaij
- University of Groningen, Department of Psychology, Grote Kruisstraat 2/1, Heymans Building, Groningen, 9712, TS, The Netherlands.
| | - Rei Monden
- University of Groningen, Department of Psychology, Grote Kruisstraat 2/1, Heymans Building, Groningen, 9712, TS, The Netherlands.,University Medical Center Groningen, Groningen, The Netherlands
| | - Jorge N Tendeiro
- University of Groningen, Department of Psychology, Grote Kruisstraat 2/1, Heymans Building, Groningen, 9712, TS, The Netherlands
| | - John P A Ioannidis
- Departments of Medicine, of Health Research and Policy, of Biomedical Data Science, and of Statistics, and Meta-Research Innovation Center, Stanford, USA
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31
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Gjengstø Hunderi JO, Lødrup Carlsen KC, Rolfsjord LB, Carlsen K, Mowinckel P, Skjerven HO. Parental severity assessment predicts supportive care in infant bronchiolitis. Acta Paediatr 2019; 108:131-137. [PMID: 29889987 DOI: 10.1111/apa.14443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 05/14/2018] [Accepted: 06/07/2018] [Indexed: 11/25/2022]
Abstract
AIM In infants with acute bronchiolitis, the precision of parental disease severity assessment is unclear. We aimed to determine if parental assessment at the time of hospitalisation predicted the use of supportive care, and subsequently determine the likelihood that the infant with acute bronchiolitis would receive supportive care. METHODS From the Bronchiolitis ALL south-east Norway study, we included all 267, 0-12 month old, infants with acute bronchiolitis whose parents at the time of hospitalisation completed a three-item visual analogue scale (VAS) concerning Activity, Feeding and Illness. Respiratory rate, oxygen saturation (SpO2 ) and use of supportive care were recorded daily. By multivariate logistic regression analyses we included significant predictors available at hospital admission to predict the use of supportive care. RESULTS The parental Activity, Feeding and Illness VAS scores significantly predicted supportive care with odds ratios of 1.23, 1.26 and 1.36, respectively. The prediction algorithm included parental Feeding and Illness scores, SpO2 , gender and age, with an area under the curve of 0.76 (95% CI 0.69, 0.81). A positive likelihood ratio of 2.1 gave the highest combined sensitivity of 81% and specificity of 61%. CONCLUSION Parental assessment at hospital admission moderately predicted supportive care treatment in infants with acute bronchiolitis.
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Affiliation(s)
- Jon Olav Gjengstø Hunderi
- Department of Pediatrics and Adolescent Medicine Østfold Hospital Trust Sarpsborg Norway
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Karin C. Lødrup Carlsen
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Leif Bjarte Rolfsjord
- Institute of Clinical Medicine University of Oslo Oslo Norway
- Department of Pediatrics Innlandet Hospital Trust Elverum Norway
| | - Kai‐Håkon Carlsen
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Petter Mowinckel
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Håvard Ove Skjerven
- Division of Pediatric and Adolescent Medicine Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
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33
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O'Brien S, Borland ML, Cotterell E, Armstrong D, Babl F, Bauert P, Brabyn C, Garside L, Haskell L, Levitt D, McKay N, Neutze J, Schibler A, Sinn K, Spencer J, Stevens H, Thomas D, Zhang M, Oakley E, Dalziel SR. Australasian bronchiolitis guideline. J Paediatr Child Health 2019; 55:42-53. [PMID: 30009459 DOI: 10.1111/jpc.14104] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 06/01/2018] [Indexed: 11/29/2022]
Abstract
AIM Bronchiolitis is the most common lower respiratory tract disorder in infants aged less than 12 months, and research has demonstrated that there is substantial variation in practice patterns despite treatment being well defined. In order to align and improve the consistency of the management of bronchiolitis, an evidence-based guideline was developed for the Australasian population. METHODS The guideline development committee included representation from emergency and paediatric specialty medical and nursing personnel in addition to geographical representation across Australia and New Zealand - rural, remote and metropolitan. Formulation of the guideline included identification of population, intervention, comparator, outcomes and time questions and was associated with an extensive literature search from 2000 to 2015. Evidence was summarised and graded using the National Health and Medical Research Council and Grading of Recommendations Assessment, Development and Evaluation methodology, and consensus within the guideline group was sought using nominal group technique principles to formulate the clinical practice recommendations. The guideline was reviewed and endorsed by key paediatric health bodies. RESULTS The guideline consists of a usable clinical interface for bedside functionality supported by evidence summary and tables. The Grading of Recommendations Assessment, Development and Evaluation and National Health and Medical Research Council processes provided a systematic and transparent process to review and assess the literature, resulting in a guideline that is relevant to the management of bronchiolitis in the Australasian setting. CONCLUSION This is the first robust Australasian acute paediatric guideline and provides clear guidance for the management of the vast majority of patients seen in Australasian emergency departments and general paediatric wards with bronchiolitis.
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Affiliation(s)
- Sharon O'Brien
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Meredith L Borland
- Princess Margaret Hospital for Children, Perth, Western Australia, Australia.,Divisions of Paediatric and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth Cotterell
- Department of Paediatrics, School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - David Armstrong
- Department of Respiratory Medicine, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Franz Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Paul Bauert
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Christine Brabyn
- Emergency Department, Waikato District Health Board, Hamilton, New Zealand
| | - Lydia Garside
- General Paediatrics, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - David Levitt
- University of Queensland, Brisbane, Queensland, Australia
| | - Nicola McKay
- Children's Healthcare Network Western Region, Sydney, New South Wales, Australia
| | | | - Andreas Schibler
- University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Paediatric Critical Care Research Group (PCCRG), Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Kam Sinn
- Emergency Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Janine Spencer
- Department of Paediatrics, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Helen Stevens
- Children's Healthcare Network, Sydney, New South Wales, Australia
| | - David Thomas
- General Paediatrics, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Michael Zhang
- Emergency Department, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Ed Oakley
- Emergency Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Paediatric Emergency Medicine Centre of Research Excellence, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Paediatrics: Youth and Child Health, University of Auckland, Auckland, New Zealand
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Affiliation(s)
- Matti Korppi
- Center for Child health Research, Tampere University and University Hospital, Finland Arvo2 building, Tampere University, Tampere, Finland
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35
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Heikkilä P, Sokuri P, Mecklin M, Nuolivirta K, Tapiainen T, Peltoniemi O, Renko M, Korppi M. Using high-flow nasal cannulas for infants with bronchiolitis admitted to paediatric wards is safe and feasible. Acta Paediatr 2018; 107:1971-1976. [PMID: 29802651 DOI: 10.1111/apa.14421] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 05/08/2018] [Accepted: 05/23/2018] [Indexed: 12/17/2022]
Abstract
AIM Using a high-flow nasal cannula (HFNC) for infant bronchiolitis is increasingly common, but insufficiently studied. In this retrospective study, we examined the outcomes of HFNC and compared infants who did and did not respond to this oxygen delivery method. METHODS This 2012-2015 study of six Finnish hospitals focused on 88 infants under 12 months who received HFNC: 53 on paediatric wards and 35 in paediatric intensive care units (PICUs). We reviewed patient files for underlying factors, clinical parameters and HFNC treatment. The treatment failed if the patient was transferred to another respiratory support. RESULTS We found HFNC treatment was successful in 76 (86%) infants, including all 53 on the paediatric wards and 23/35 PICU patients. The responders' heart rates were significantly lower, and their oxygen saturation was significantly higher at 60 minutes after HFNC treatment started and then stayed relatively constant. Their respiratory rate was only significantly lower after 360 minutes. In non-responders, the respiratory rate initially decreased but was higher at 180 and 360 minutes after the start of HFNC. CONCLUSION We found preliminary evidence that oxygen support needs and heart rate were useful early predictors of HFNC therapy success in infants hospitalised with bronchiolitis, but respiratory rate was not.
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Affiliation(s)
- Paula Heikkilä
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Paula Sokuri
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Minna Mecklin
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Kirsi Nuolivirta
- Department of Paediatrics; Seinäjoki Central Hospital; Seinäjoki Finland
| | - Terhi Tapiainen
- Department of Paediatrics; PEDEGO Research Centre; Oulu University Hospital; Oulu University; Oulu Finland
| | - Outi Peltoniemi
- Department of Paediatrics; PEDEGO Research Centre; Oulu University Hospital; Oulu University; Oulu Finland
| | - Marjo Renko
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
- Department of Paediatrics; PEDEGO Research Centre; Oulu University Hospital; Oulu University; Oulu Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Palmu S, Mecklin M, Heikkilä P, Backman K, Peltola V, Renko M, Korppi M. National treatment guidelines decreased the use of racemic adrenaline for bronchiolitis in four Finnish university hospitals. Acta Paediatr 2018; 107:1966-1970. [PMID: 29752817 DOI: 10.1111/apa.14397] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/16/2018] [Accepted: 05/07/2018] [Indexed: 11/28/2022]
Abstract
AIM Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits. METHODS This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs. RESULTS There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years. CONCLUSION The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.
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Affiliation(s)
- Sauli Palmu
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Minna Mecklin
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Paula Heikkilä
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
| | - Katri Backman
- Department of Paediatrics; Kuopio University Hospital; University of Eastern Finland; Kuopio Finland
| | - Ville Peltola
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; University of Turku; Turku Finland
| | - Marjo Renko
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
- PEDEGO Research Unit; University of Oulu; Oulu University Hospital; Oulu Finland
| | - Matti Korppi
- Centre for Child Health Research; Tampere University and University Hospital; Tampere Finland
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Midulla F, Petrarca L, Frassanito A, Di Mattia G, Zicari AM, Nenna R. Bronchiolitis clinics and medical treatment. Minerva Pediatr 2018; 70:600-611. [PMID: 30334624 DOI: 10.23736/s0026-4946.18.05334-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bronchiolitis is the most common acute lower respiratory tract infection in infants and the first cause of hospitalization in this age group. Despite it has been studied for over 70 years, its management remains controversial and nowadays the treatment is only supportive. Pediatricians should be well acquainted with the clinical course of the disease. In particular, they should know that the severity of respiratory symptoms peaks between days 3-7 of the disease and dehydration is a key sign to consider for the management. In this review, we will discuss the most controversial points in the management of bronchiolitis according to six evidence-based guidelines, six clinical practice guidelines and five consensus-based reviews.
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Affiliation(s)
- Fabio Midulla
- Department of Pediatrics, Sapienza University, Rome, Italy -
| | - Laura Petrarca
- Department of Pediatrics, Sapienza University, Rome, Italy
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Bronchiolitis. PRINCIPLES AND PRACTICE OF PEDIATRIC INFECTIOUS DISEASES 2018. [PMCID: PMC7173594 DOI: 10.1016/b978-0-323-40181-4.00033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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39
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Piteau S. Update in Pediatric Hospital Medicine. UPDATE IN PEDIATRICS 2018. [PMCID: PMC7121028 DOI: 10.1007/978-3-319-58027-2_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Pediatric Hospital Medicine has significantly developed as a field over the past two decades. With the goal of improving care for hospitalized children, much of the research in this field has focused on reducing unnecessary interventions, optimizing necessary treatments, and reducing variability for common inpatient conditions. While this is far from an exhaustive chapter on the vast diversity and advances in this field, it focuses on the updates for some of the top diagnoses in hospital medicine and the major trends in the field. Updated management of acute viral bronchiolitis, urinary tract infections, neonatal infections, brief resolved unexplained events (formerly, apparent life-threatening events), and osteomyelitis are highlighted with emphasis on major management changes. In addition, and distinct to pediatric hospital medicine, the topics of overuse and high value care are discussed as they have gained momentum in influencing the way hospitalists think and practice.
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Affiliation(s)
- Shalea Piteau
- Chief/Medical Director of Pediatrics at Quinte Health Care, Assistant Professor at Queen’s University, Belleville, Ontario Canada
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40
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Mecklin M, Heikkilä P, Korppi M. Low age, low birthweight and congenital heart disease are risk factors for intensive care in infants with bronchiolitis. Acta Paediatr 2017; 106:2004-2010. [PMID: 28799175 DOI: 10.1111/apa.14021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/17/2017] [Accepted: 08/08/2017] [Indexed: 11/30/2022]
Abstract
AIM This study evaluated the incidence and risk factors for intensive care and respiratory support in infant bronchiolitis. METHODS This retrospective descriptive case-control study focused on 105 patients treated in the paediatric intensive care unit (PICU) and 210 controls treated in the emergency department or on the paediatric ward in Tampere University Hospital in Finland between 2000 and 2015. Statistically significant risk factors in nonadjusted analyses were included in the adjusted logistic regression. RESULTS The average age-specific annual incidence of bronchiolitis requiring PICU admission under the age of 12 months was 1.5/1000/year (range 0.18-2.59). Independently, significant risk factors for PICU admission were as follows: being less than two months old with an adjusted odds ratio (aOR) of 11.5, birthweight of <2000 g (aOR of 15.9), congenital heart disease (CHD) (aOR of 15.9), apnoea (aOR of 7.2) and the absence of wheezing (aOR of 2.2). Significant risk factors for needing respiratory support were a birthweight of <2000 g, an age of less than two months and CHD. CONCLUSION Less than 0.1% of infants under the age of 12 months were admitted to the PICU for bronchiolitis. Low age, low birthweight or prematurity and CHD were independently significant risk factors for both intensive care and respiratory support.
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Affiliation(s)
- Minna Mecklin
- Tampere Center for Child Health Research; University of Tampere and Tampere University Hospital; Tampere Finland
| | - Paula Heikkilä
- Tampere Center for Child Health Research; University of Tampere and Tampere University Hospital; Tampere Finland
| | - Matti Korppi
- Tampere Center for Child Health Research; University of Tampere and Tampere University Hospital; Tampere Finland
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Guo C, Sun X, Wang X, Guo Q, Chen D. Network Meta-Analysis Comparing the Efficacy of Therapeutic Treatments for Bronchiolitis in Children. JPEN. JOURNAL OF PARENTERAL AND ENTERAL NUTRITION 2017; 42:186-195. [PMID: 29388676 PMCID: PMC7166391 DOI: 10.1002/jpen.1030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 06/30/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND This study aims to compare placebo (PBO) and 7 therapeutic regimens-namely, bronchodilator agents (BAs), hypertonic saline (HS), BA ± HS, corticosteroids (CS), epinephrine (EP), EP ± CS, and EP ± HS-to determine the optimal bronchiolitis treatment. METHODS We plotted networks using the curative outcome of several studies and specified the relations among the experiments by using mean difference, standardized mean difference, and corresponding 95% credible interval. The surface under the cumulative ranking curve (SUCRA) was used to separately rank each therapy on clinical severity score (CSS) and length of hospital stay (LHS). RESULTS This network meta-analysis included 40 articles from 1995 to 2016 concerning the treatment of bronchiolitis in children. All 7 therapeutic regimens displayed no significant difference to PBO with regard to CSS in our study. Among the 7 therapies, BA performed better than CS. As for LHS, EP and EP ± HS had an advantage over PBO. Moreover, EP and EP ± HS were also more efficient than BA. The SUCRA results showed that EP ± CS is most effective, and EP ± HS is second most effective with regard to CSS. With regard to LHS, EP ± HS ranked first, EP ± CS ranked second, and EP ranked third. CONCLUSIONS We recommend EP ± CS and EP ± HS as the first choice for bronchiolitis treatment in children because of their outstanding performance with regard to CSS and LHS.
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Affiliation(s)
- Caili Guo
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Xiaomin Sun
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Xiaowen Wang
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Qing Guo
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
| | - Dan Chen
- Department of Respiratory, Children's Hospital of Zhengzhou City, Zhengzhou, Henan, China
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Elenius V, Bergroth E, Koponen P, Remes S, Piedra PA, Espinola JA, Korppi M, Camargo CA, Jartti T. Marked variability observed in inpatient management of bronchiolitis in three Finnish hospitals. Acta Paediatr 2017; 106:1512-1518. [PMID: 28544041 PMCID: PMC7159377 DOI: 10.1111/apa.13931] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 04/26/2017] [Accepted: 05/17/2017] [Indexed: 02/05/2023]
Abstract
AIM Infants hospitalised for bronchiolitis undergo examinations and treatments not supported by current research evidence and we investigated practice variations with regard to Finnish children under the age of two. METHODS This prospective, multicentre cohort study was conducted in paediatric units in three university hospitals in Finland from 2008 to 2010. Hospital medical records were reviewed to collect data on clinical course, testing and treatment. Data were analysed separately for children meeting our strict definition of bronchiolitis, aged under 12 months without a history of wheezing, and a loose definition, aged 12-23 months or with a history of wheezing. RESULTS The median age of the 408 children was 8.1 months. Clinical management varied between the three hospitals when stratified by strict and loose bronchiolitis subgroup definitions: complete blood counts ranged from 15-95% vs 16-94%, respectively, and the other measures were chest x-ray (16-91% vs 14-72%), intravenous fluids (2-47% vs 2-41%), use of nebulised epinephrine (10-84% vs 7-50%), use of salbutamol (18-21% vs 13-84%) and use of corticosteroids (6-23% vs 60-76%). CONCLUSION The clinical management of bronchiolitis varied considerably with regard to the three hospitals and the two definitions of bronchiolitis. A stronger commitment to evidence-based bronchiolitis guidelines is needed in Finland.
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Affiliation(s)
- Varpu Elenius
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; Turku Finland
| | - Eija Bergroth
- Department of Paediatrics; Kuopio University Hospital; Kuopio Finland
| | - Petri Koponen
- Department of Paediatrics; Tampere University Hospital; Tampere Finland
| | - Sami Remes
- Department of Paediatrics; Kuopio University Hospital; Kuopio Finland
| | - Pedro A. Piedra
- Departments of Molecular Virology and Microbiology and Pediatrics; Baylor College of Medicine; Houston TX USA
| | - Janice A. Espinola
- Department of Emergency Medicine; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Matti Korppi
- Department of Paediatrics; Tampere University Hospital; Tampere Finland
| | - Carlos A. Camargo
- Department of Emergency Medicine; Massachusetts General Hospital; Harvard Medical School; Boston MA USA
| | - Tuomas Jartti
- Department of Paediatrics and Adolescent Medicine; Turku University Hospital; Turku Finland
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Abstract
Bronchiolitis is a common cause of outpatient visits and hospitalization in children younger than age 2 years. Despite the frequency with which pediatricians manage this diagnosis, there is significant variability in care in both the inpatient and outpatient setting. This may be due in part to changing guidelines set forth by leading pediatric organizations such as the American Academy of Pediatrics, as increasing evidence emerges that traditional therapies are not effective. This article reviews current evidence-based practices for diagnosis and treatment of bronchiolitis, and provides an overview of inpatient management. [Pediatr Ann. 2017;46(7):e252-e256.].
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Berents TL, Carlsen KCL, Mowinckel P, Skjerven HO, Rolfsjord LB, Nordhagen LS, Kvenshagen B, Hunderi JOG, Bradley M, Thorsby PM, Carlsen KH, Gjersvik P. Weight-for-length, early weight-gain velocity and atopic dermatitis in infancy and at two years of age: a cohort study. BMC Pediatr 2017; 17:141. [PMID: 28592289 PMCID: PMC5463398 DOI: 10.1186/s12887-017-0889-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/22/2017] [Indexed: 01/22/2023] Open
Abstract
Background Overweight and atopic dermatitis (AD) are major health problems in most industrialised countries, but the relationship between overweight and AD in infants and young children is unclear. We investigated if weight-for-length at birth, in infancy and at two years, as well as early weight-gain velocity, are associated with the development of AD in early life. Methods Cohort study of infants (n = 642), all living in south-east Norway, hospitalized with acute bronchiolitis (n = 404) or recruited from the general population (n = 238), examined at mean age 5.1 months (enrolment) and at a two-year follow-up visit (n = 499; 78%) at mean age 24.6 months. Exposures were weight-for-length (g/cm) at birth, enrolment and two-year follow-up, and early weight-gain velocity (gram/month from birth to enrolment). Excessive weight-for-length was defined as weight-for-length >95th percentile of WHO child-growth standards. Data on weight-for-length at the three time points were obtained for 435, 428 and 473 children. AD was diagnosed according to the Hanifin & Rajka criteria or from a history of physician-diagnosed AD. We performed multivariate analyses with weight-for-length at birth, at enrolment and at the two-year follow-up visit and with early weight gain velocity for the endpoint AD at each visit. Results In adjusted analyses, excessive weight-for-length at enrolment was associated with concurrent AD (OR 3.03; 95% CI 1.23–7.50) and with AD at two years (OR 2.40; 1.11–5.17). In infants without AD, weight-for-length at enrolment increased the risk of AD at two years, with OR being 1.02 (95% CI 1.00–1.04) per increased gram/cm. AD at two years was not associated with concurrent excessive weight-for-length, nor was AD at any time associated with weight-for-length at birth or with early weight-gain velocity. Conclusions The results suggest that overweight in infancy may contribute to the development of AD in early life, highlighting the need for child health-care professionals to address potential overweight and atopic disease when advising infants’ caregivers. Trial registration ClinicalTrials.gov number, NCT00817466, EudraCT number, 2009–012667-34.
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Affiliation(s)
- Teresa Løvold Berents
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway. .,Department of Dermatology, Oslo University Hospital, Oslo, Norway.
| | - Karin Cecilie Lødrup Carlsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Paediatrics, Oslo University Hospital, Oslo, Norway
| | - Petter Mowinckel
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway
| | - Håvard Ove Skjerven
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Paediatrics, Oslo University Hospital, Oslo, Norway
| | - Leif Bjarte Rolfsjord
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Paediatrics, Innlandet Hospital, Oslo, Norway
| | | | | | - Jon Olav Gjengstø Hunderi
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Paediatrics, Oslo University Hospital, Oslo, Norway.,Department of Paediatrics, Østfold Hospital, Grålum, Norway
| | - Maria Bradley
- Department of Molecular Medicine, Karolinska Institutet at Karolinska University Hospital, Solna, Sweden
| | - Per Medbøe Thorsby
- Hormone Laboratory, Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Kai-Håkon Carlsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Paediatrics, Oslo University Hospital, Oslo, Norway
| | - Petter Gjersvik
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Dermatology, Oslo University Hospital, Oslo, Norway
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Rolfsjord LB, Bakkeheim E, Berents TL, Alm J, Skjerven HO, Carlsen KH, Mowinckel P, Sjöbeck AC, Carlsen KCL. Morning Salivary Cortisol in Young Children: Reference Values and the Effects of Age, Sex, and Acute Bronchiolitis. J Pediatr 2017; 184:193-198.e3. [PMID: 28284475 DOI: 10.1016/j.jpeds.2017.01.064] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 01/09/2017] [Accepted: 01/26/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To identify morning salivary cortisol reference values in infancy and at 2 years of age and to investigate the influence of age, sex and acute bronchiolitis. STUDY DESIGN In this South-East Norwegian cohort study, 308 children hospitalized with moderate to severe acute bronchiolitis in infancy in 2010-2011 were compared with 223 healthy controls included in 2012 by measuring morning salivary cortisol levels at inclusion and at 2 years of age. Samples were collected shortly after awakening after 6 am. The influences of age, sex, and acute bronchiolitis were assessed by regression analysis. RESULTS In infancy, cortisol values were higher in acute bronchiolitis, with an age- and sex-adjusted weighted mean group difference of 13.9 nmol/L (95% CI 8.1-19.7; P < .0001). The median level in reference group was 23.7 nmol/L (95% CI 9.7-119.6). At 2 years of age, sex but not inclusion groups differed, with significantly higher values in girls. The weighted mean of all boys' cortisol levels was 32.4 nmol/L, (95% CI 30.5-34.3), and all girls' levels were 36.9 nmol/L (95% CI 34.7-39.2; P < .003). CONCLUSIONS Salivary cortisol levels were higher at 2 years of age than in infancy in the reference group, were higher in girls than in boys at 2 years of age, and were higher in infants at the time of acute bronchiolitis than in healthy infants. TRIAL REGISTRATION ClinicalTrials.gov: NCT00817466.
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Affiliation(s)
- Leif Bjarte Rolfsjord
- Department of Pediatrics, Innlandet Hospital Trust, Elverum, Norway; Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo.
| | - Egil Bakkeheim
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - Teresa Løvold Berents
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo; Department of Dermatology, Oslo University Hospital, Norway
| | - Johan Alm
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Håvard Ove Skjerven
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo
| | - Kai-Håkon Carlsen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo
| | - Petter Mowinckel
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Norway
| | - Ann-Christine Sjöbeck
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden; Starbovägen 47, Vällingby, Sweden
| | - Karin Cecilie Lødrup Carlsen
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo
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Abstract
Viral bronchiolitis is a common clinical syndrome affecting infants and young children. Concern about its associated morbidity and cost has led to a large body of research that has been summarised in systematic reviews and integrated into clinical practice guidelines in several countries. The evidence and guideline recommendations consistently support a clinical diagnosis with the limited role for diagnostic testing for children presenting with the typical clinical syndrome of viral upper respiratory infection progressing to the lower respiratory tract. Management is largely supportive, focusing on maintaining oxygenation and hydration of the patient. Evidence suggests no benefit from bronchodilator or corticosteroid use in infants with a first episode of bronchiolitis. Evidence for other treatments such as hypertonic saline is evolving but not clearly defined yet. For infants with severe disease, the insufficient available data suggest a role for high-flow nasal cannula and continuous positive airway pressure use in a monitored setting to prevent respiratory failure.
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Affiliation(s)
- Todd A Florin
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Clinical Examination Does Not Predict Response to Albuterol in Ventilated Infants With Bronchiolitis. Pediatr Crit Care Med 2017; 18:e18-e23. [PMID: 27811530 DOI: 10.1097/pcc.0000000000000999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Bronchiolitis is a common respiratory infection in infants that is sometimes treated with albuterol. Response to albuterol is determined by clinical assessment, but this subjective determination is potentially unreliable. In this study, we compared providers' clinical assessment of response to albuterol with the measurement of response by pulmonary mechanics in intubated, sedated, and ventilated infants. DESIGN Before and 20 minutes following racemic albuterol therapy, a nurse, respiratory therapist, and physician performed simultaneous examinations and assessed response to albuterol in a population of intubated infants with bronchiolitis. Measurements of ventilator-derived pulmonary mechanics were obtained at these same times. SETTING This study was conducted in a PICU of a children's hospital. PATIENTS Seventy-five paired clinical assessments were made in 25 infants who were intubated and mechanically ventilated for severe bronchiolitis. INTERVENTIONS Pulmonary function measurements and clinical assessments before and after administration of albuterol. MEASUREMENTS AND MAIN RESULTS Response to albuterol was defined using a threshold of improvement in respiratory system resistance from baseline. Nine children (36%) had greater than 20% change and were deemed responders. Providers' discrimination of response was poor. The positive predictive values of nurses, respiratory therapists, and physicians were 38%, 25%, and 25%, respectively, and the negative predictive values were 67%, 54%, and 59%, respectively. Overall accuracy was 44% for nurses, 40% for respiratory therapists, and 48% for physicians. When comparing separate assessments of wheezing, aeration, and expiratory time, there was poor agreement between groups of providers in all variables (κ < 0.4 for each). CONCLUSIONS A provider's clinical assessment was not a reliable method for determining response to albuterol in children with bronchiolitis. Without assessment of pulmonary mechanics, caution should be used in classifying children with bronchiolitis as responders to albuterol.
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Caffarelli C, Santamaria F, Di Mauro D, Mastrorilli C, Mirra V, Bernasconi S. Progress in pediatrics in 2015: choices in allergy, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, nephrology, neurology, nutrition, oncology and pulmonology. Ital J Pediatr 2016; 42:75. [PMID: 27566421 PMCID: PMC5002164 DOI: 10.1186/s13052-016-0288-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 08/10/2016] [Indexed: 12/29/2022] Open
Abstract
This review focuses key advances in different pediatric fields that were published in Italian Journal of Pediatrics and in international journals in 2015. Weaning studies continue to show promise for preventing food allergy. New diagnostic tools are available for identifying the allergic origin of allergic-like symptoms. Advances have been reported in obesity, short stature and autoimmune endocrine disorders. New molecules are offered to reduce weight gain and insulin-resistance in obese children. Regional investigations may provide suggestions for preventing short stature. Epidemiological studies have evidenced the high incidence of Graves' disease and Hashimoto's thyroiditis in patients with Down syndrome. Documentation of novel risk factors for celiac disease are of use to develop strategies for prevention in the population at-risk. Diagnostic criteria for non-celiac gluten sensitivity have been reported. Negative effect on nervous system development of the supernumerary X chromosome in Klinefelter syndrome has emerged. Improvements have been made in understanding rare diseases such as Rubinstein-Taybi syndrome. Eltrombopag is an effective therapy for immune trombocytopenia. Children with sickle-cell anemia are at risk for nocturnal enuresis. Invasive diseases caused by Streptococcus pyogenes are still common despite of vaccination. No difference in frequency of antibiotic prescriptions for acute otitis media between before the publication of the national guideline and after has been found. The importance of timing of iron administration in low birth weight infants, the effect of probiotics for preventing necrotising enterocolitis and perspectives for managing jaundice and cholestasis in neonates have been highlighted. New strategies have been developed to reduce the risk for relapse in nephrotic syndrome including prednisolone during upper respiratory infection. Insights into the pathophysiology of cerebral palsy, arterial ischemic stroke and acute encephalitis may drive advances in treatment. Recommendations on breastfeeding and complementary feeding have been updated. Novel treatments for rhabdomyosarcoma should be considered for paediatric patients. Control of risk factors for bronchiolitis and administration of pavilizumab for preventing respiratory syncytial virus infection may reduce hospitalization. Identification of risk factors for hospitalization in children with wheezing can improve the management of this disease. Deletions or mutations in genes encoding proteins for surfactant function may cause diffuse lung disease.
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Affiliation(s)
- Carlo Caffarelli
- Clinica Pediatrica, Department of Clinical and Experimental Medicine, Azienda Ospedaliera-Universitaria, University of Parma, Parma, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Dora Di Mauro
- Clinica Pediatrica, Department of Clinical and Experimental Medicine, Azienda Ospedaliera-Universitaria, University of Parma, Parma, Italy
| | - Carla Mastrorilli
- Clinica Pediatrica, Department of Clinical and Experimental Medicine, Azienda Ospedaliera-Universitaria, University of Parma, Parma, Italy
| | - Virginia Mirra
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Sergio Bernasconi
- Pediatrics Honorary Member University Faculty, G D’Annunzio University of Chieti-Pescara, Chieti, Italy
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Rolfsjord LB, Skjerven HO, Carlsen KH, Mowinckel P, Bains KES, Bakkeheim E, Lødrup Carlsen KC. The severity of acute bronchiolitis in infants was associated with quality of life nine months later. Acta Paediatr 2016; 105:834-41. [PMID: 26970427 PMCID: PMC5074291 DOI: 10.1111/apa.13396] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 02/02/2016] [Accepted: 03/07/2016] [Indexed: 12/15/2022]
Abstract
Aim Acute bronchiolitis in infancy increases the risk of later asthma and reduced health‐related quality of life (QoL). We aimed to see whether the severity of acute bronchiolitis in the first year of life was associated with QoL nine months later. Methods The parents of 209 of 404 of children hospitalised for acute bronchiolitis in eight paediatric departments in south‐east Norway at a mean four months of age (range 0–12 months) completed the Infant/Toddler Quality of Life Questionnaire sent by mail nine months after the acute illness. Disease severity was measured by length of stay and the need for supportive treatment. Interactions with gender, inclusion age, prematurity, maternal ethnicity and maternal education were examined. Results Reduced QoL in four domains was associated with increased length of stay and need for ventilatory support. Physical abilities and general health were associated with both severity markers, whereas bodily pain and discomfort and change in health were associated with length of stay. Ventilatory support was more negatively associated with QoL than atopic eczema and also associated with reduced parental emotions and parental time. Conclusion The severity of acute bronchiolitis in infants was associated with reduced QoL nine months later.
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Affiliation(s)
- Leif Bjarte Rolfsjord
- Department of Paediatrics; Innlandet Hospital Trust; Elverum Norway
- Department of Paediatrics; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Håvard Ove Skjerven
- Department of Paediatrics; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Kai-Håkon Carlsen
- Department of Paediatrics; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Petter Mowinckel
- Department of Paediatrics; Oslo University Hospital; Oslo Norway
| | - Karen Eline Stensby Bains
- Department of Paediatrics; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Egil Bakkeheim
- Department of Paediatrics; Oslo University Hospital; Oslo Norway
| | - Karin C. Lødrup Carlsen
- Department of Paediatrics; Oslo University Hospital; Oslo Norway
- Faculty of Medicine; Institute of Clinical Medicine; University of Oslo; Oslo Norway
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50
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Teigen A, Wang S, Truong BT, Bjerknes K. Off-label and unlicensed medicines to hospitalised children in Norway. ACTA ACUST UNITED AC 2016; 69:432-438. [PMID: 27334565 PMCID: PMC5396330 DOI: 10.1111/jphp.12581] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/14/2016] [Indexed: 12/03/2022]
Abstract
Objectives The aim of this study was to investigate the use of off‐label (OL) and unlicensed (UL) medicines to hospitalised children in Norway, to add to the current knowledge on use of medicines in this vulnerable patient group. Methods The study was performed as a cross‐sectional prospective study. Medication was classified as on‐ or off‐label based on the comparison with the SmPC regarding age, indication, dosage, route of administration and handling of the product. UL products were classified as imported or pharmacy produced. Key findings More than 90% of children receiving medicines in our study were given OL or UL medicines. More patients received OL (83%) than UL (59%). Route of administration was the most frequently observed OL category. The vast majority of the OL prescriptions were for ‘off‐patent’ products. One‐third of products prescribed were UL. Conclusions The study confirms that medicines to children in hospital to a significant degree are being used outside or without authorisation, in spite of recent paediatric regulatory initiatives. More data are still needed on efficacy and safety of medicines used in children, data to be incorporated in the SmPC. In addition, suitable formulations are needed to ensure optimal dosing and adherence without risky manipulations.
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Affiliation(s)
- Arna Teigen
- Hospital Pharmacy Enterprises, South Eastern Norway, Oslo, Norway.,School of Pharmacy, University of Oslo, Oslo, Norway
| | - Siri Wang
- Department of Medicinal Product Assessment, Norwegian Medicines Agency, Oslo, Norway
| | - Bich Thuy Truong
- Hospital Pharmacy Enterprises, South Eastern Norway, Oslo, Norway.,School of Pharmacy, University of Oslo, Oslo, Norway
| | - Kathrin Bjerknes
- Hospital Pharmacy Enterprises, South Eastern Norway, Oslo, Norway
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