Office pediatrics: current perspectives on the outpatient evaluation and management of lower respiratory infections in children

Consensus Document on Community-Acquired Pneumonia in Children. SENP-SEPAR-SEIP

Community-acquired pneumonia (CAP) is a prevalent disease among children and is frequently associated with both diagnostic and therapeutic uncertainties. Consensus has been reached between SEPAR, SENP and SEIP, and their conclusions are as follows.

[Guidelines for the Management of Community Acquired Pneumonia in Children and Adolescents (Pediatric Community Acquired Pneumonia, pCAP) - Issued under the Responsibility of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Pulmonology (GPP)]

The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100 000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation > 92 % can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48 - 72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.

Blood biomarkers differentiating viral versus bacterial pneumonia aetiology: a literature review

Background and objectives

The goal of this literature review is to compare current studies regarding the accuracy of different serum markers in differentiating viral from bacterial pneumonia in the pediatric population with what is employed in the medical settings at present. Currently there is still a lack of significant research, that would give us evaluation on biomarkers benefits towards getting a definite diagnosis of pneumonia. Finding out the potential of biomarkers to differentiate between viral and bacterial pneumonia is also important because knowing the exact pathogen would prevent irrational use of antibiotics. At present, irrational, broad-spectrum antibiotic use and increasing antibiotic resistance in microorganisms are still one of the greatest challenges in clinical settings. The use of biomarkers in clinical practice would not only facilitate accurate diagnosis, but would also help to reduce the amount of antibiotics overuse.

Materials and methods

Literature search conducted on Medline and Google Scholar using a combination of terms. Articles that were in English and within ten years of the search date were manually sorted according to inclusion and exclusion criteria. Results: Initial search returned n = 13,408. After activating filters, n = 140 were identified of which n = 12 included for literature review.

Conclusions

Rise or drop in the concentration of a single marker is not accurate enough for predicting viral/bacterial community acquired pneumonia. This is because there is overlapping to a varying extent depending on the marker cut-off values, detection methods, analyses, the desired specificity, and sensitivity. Furthermore, the presence of mixed infection makes almost all markers suboptimal to be used universally. New markers such as MxA1 and HMGB1 gave promising results. However, to replicate a similar testing condition in a clinical environment may not be practical. Another approach is to make use of more than one marker and combine with clinical signs and symptoms. This may not be cost-effective in many clinical settings; nevertheless, in many studies, marker combination greatly improved the predictive power.

Lung Function in Wheezing Infants after Acute Lower Respiratory Tract Infection and Its Association with Respiratory Outcome

Background:

Wheezing is common in early childhood and remains an important health concern. The aim of this study was to assess the lung function of wheezing infants and to investigate the relationship between lung function and respiratory outcome.

Methods:

Infants <2 years of age with acute lower respiratory tract infection (ALRTI) who had undergone lung function tests were included in the study. They were assigned to wheeze or no wheeze group based on physical examination. Infants without any respiratory diseases were enrolled as controls. Lung function was measured during the acute phase and 3 months after ALRTI. One-year follow-up for infants with ALRTI was achieved.

Results:

A total of 252 infants with ALRTI who had acceptable data regarding tidal breathing were included in the final analysis. Compared with the control and the no wheeze groups, infants in the wheeze group had significantly decreased time to peak tidal expiratory flow as a percentage of total expiratory time (TPTEF/TE) (20.1 ± 6.4% vs. 34.4 ± 6.2% and 26.4 ± 8.3%, respectively, P < 0.0001) and significantly increased peak tidal expiratory flow (PTEF) (90.7 ± 26.3 ml/s vs. 79.3 ± 18.4 ml/s and 86.1 ± 28.0 ml/s, respectively, P < 0.01), sReff and Reff. The infants in the wheeze group still had lower TPTEF/TE and volume to peak tidal expiratory flow as a percentage of total expiratory volume (VPTEF/VE) than the no wheeze infants 3 months after the ALRTI. Moreover, there was a significant inverse relationship between TPTEF/TE, VPTEF/VE, and the recurrence of wheezing and pneumonia.

Conclusions:

Impaired lung function was present in wheezing infants with ALRTI and the deficits persisted. In addition, the lower level of TPTEF/TE and VPTEF/VE was a risk factor for poor respiratory outcome.

Vitamin D deficiency associated with increased incidence of gastrointestinal and ear infections in school-age children

BACKGROUND

Vitamin D deficiency (VDD) is highly prevalent among children worldwide. The effects of VDD include alterations of the immune response and increased risk of infection but little evidence exists in school-age children. We investigated the association of vitamin D status with morbidity in a prospective study of school-age children from Bogotá, Colombia.

METHODS

We measured plasma 25-hydroxyvitamin D (25(OH)D) concentrations in a random sample of 475 children (mean ± standard deviation age: 8.9 ± 1.6 years) and followed them for an academic year. Caregivers were asked to record daily information on the incidence of morbidity episodes using pictorial diaries. Baseline vitamin D status was classified according to 25(OH)D concentrations as deficient (<50 nmol/L), insufficient (≥50 and <75 nmol/L) or sufficient (≥75 nmol/L). We used Poisson regression to estimate incidence rate ratios and 95% confidence intervals for days with diarrhea, vomiting, diarrhea with vomiting, cough with fever and earache or discharge with fever, comparing vitamin D-deficient with vitamin D-sufficient children. Estimates were adjusted for child's age, sex and household socioeconomic status.

RESULTS

The prevalence of VDD was 10%; an additional 47% of children were vitamin D-insufficient. VDD was associated with increased rates of diarrhea with vomiting (adjusted incidence rate ratio: 2.05; 95% confidence interval: 1.19, 3.53) and earache/discharge with fever (adjusted incidence rate ratio: 2.36; 95% confidence interval: 1.26, 4.44). VDD was not significantly related to cough with fever.

CONCLUSIONS

These results suggest that VDD is related to increased incidence of gastrointestinal and ear infections in school-age children. The effect of correcting VDD on reducing risk of these infections needs to be tested in supplementation trials.

Approach to common bacterial infections: community-acquired pneumonia

Community-acquired pneumonia (CAP) occurs more often in early childhood than at almost any other age. Many microorganisms are associated with pneumonia, but individual pathogens are difficult to identify, which poses problems in antibiotic management. This article reviews the common as well as new, emerging pathogens, as well as the guidelines for management of pediatric CAP. Current guidelines for pediatric CAP continue to recommend the use of high-dose amoxicillin for bacterial CAP and azithromycin for suspected atypical CAP (usually caused by Mycoplasma pneumoniae) in children.

[Aetiology and diagnosis of community acquired pneumonia and its complicated forms]

Community Acquired Pneumonia (CAP) is a common childhood disease, involving several paediatric subspecialties in its diagnosis and treatment. This has prompted the Spanish Society of Paediatric Pulmonology (SENP) and the Spanish Society of Paediatric Infectious Diseases (SEIP) to prepare a consensus document on the diagnosis of CAP, assessing the practical aspects by means of evidence-based medicine. It discusses the aetiology and epidemiology, with the current changes and the validity of certain laboratory tests, such as acute phase reactants, microbiological and imaging techniques, guiding the paediatricians in the real value of these tests.

Constrictive pericarditis secondary to infection with Mycoplasma pneumoniae

Pericardial effusions can be insidious, variable in presentation, and may result from a wide variety of causes. We report here a rare case of pericardial effusion in a pediatric patient secondary to infection with Mycoplasma pneumoniae that progressed to cardiac tamponade and constrictive pericarditis. The differential diagnosis of pericardial effusion is reviewed as well as current treatments for pericardial effusions and constrictive pericarditis.

Bronchiolite del lattante

La bronchiolite è un’infezione virale stagionale delle vie respiratorie basse del lattante. Il suo agente causale principale è il virus respiratorio sinciziale. La comparsa di un distress respiratorio è legata all’intensità della risposta infiammatoria delle vie aeree. Benché si tratti di una malattia frequente, le cause della suscettibilità dei lattanti a questa infezione non sono conosciute. La diagnosi è clinica. Il trattamento è sintomatico in assenza di misure specifiche. I rapporti a medio e a lungo termine di un primo episodio di bronchiolite con le recidive e con l’asma non sono spiegati. Essi potrebbero dipendere dalla natura del virus in causa al momento del primo episodio e da fattori genetici individuali.

Update on epinephrine (adrenaline) for pediatric emergencies

PURPOSE OF REVIEW

Epinephrine (adrenaline) is a medication widely used in the pediatric emergency department. This article reviews the most recent evidence and recommendations behind the many applications of epinephrine as they apply to the care of children in emergency departments.

RECENT FINDINGS

Recent publications address epinephrine's role in the treatment of anaphylaxis, croup, asthma, bronchiolitis and as an adjunct to local anesthesia. Additionally, authors discuss epinephrine autoinjectors and the various routes of epinephrine administration.

SUMMARY

Epinephrine is the recommended first-line treatment for anaphylaxis and moderate-to-severe croup. Its role in asthma and bronchiolitis is less clear. Traditional beta2-agonists are seen as first-line therapies for moderate bronchiolitis and asthma exacerbations. Epinephrine may have a role for subsets of patients with both of these illnesses. The preferred route for parenteral treatment is intramuscular. Epinephrine is well tolerated as an adjunct to local anesthesia when used in digital blocks in digits with normal perfusion. Although autoinjectors allow faster access to epinephrine for anaphylaxis, there are many issues surrounding their use and indications.