Etiology analysis of nonspecific chronic cough in children of 5 years and younger

Paediatric asthma - all that wheezes is not necessarily asthma - current diagnostic and management strategies

PURPOSE OF REVIEW

Asthma is a frequently encountered chronic medical condition encountered in paediatrics, affecting 7% of children under the age of 18 in the United States. Although asthma is one of the more common conditions that is associated with wheezing, there is a broad differential diagnosis to consider. The purpose of this review is to describe other causes of wheezing outside of asthma in a paediatric population and discuss diagnostic and management strategies to consider when evaluating a child or adolescent with wheezing.

RECENT FINDINGS

The characteristics of the wheezing along with other associated signs and symptoms can be helpful in narrowing the differential diagnosis. The age and the past medical history of the patient are also important aspects to consider when determining next steps in the evaluation and management of paediatric wheezing. In addition to considering other causes of wheezing, it is often necessary to assess for the presence of underlying asthma, and recently updated asthma guidelines from the National Heart, Lung and Blood Institute provide a graded review of various recommendations for making the diagnosis and managing asthma in the clinical setting.

SUMMARY

It is important to maintain a broad differential diagnosis when evaluating a paediatric patient with wheezing.

A Narrative Review on Efficacy and Safety of Proton Pump Inhibitors in Children

Proton pump inhibitors (PPIs) are among the most prescribed drugs worldwide and include omeprazole, esomeprazole, lansoprazole, pantoprazole, and rabeprazole. Their use in pediatrics is approved for children older than 1 year, for the short-term treatment of symptomatic gastroesophageal reflux disease (GERD), healing of erosive esophagitis, treatment of peptic ulcer disease, and eradication of Helicobacter pylori. PPIs are also considered the standard of care for pediatric eosinophilic esophagitis. Despite the strict range of indications, the use of this class of molecules has increased in all pediatric age ranges. The long-term gastric acid suppression in children has been linked to increased risks of gastrointestinal and lower respiratory tract infections, bone fractures, and allergy. This study aims to provide a comprehensive overview of the mechanism of actions, use (and misuse) in infants and children, and safety of PPIs.

The effect of montelukast sodium plus budesonide on the clinical efficacy, inflammation, and pulmonary function in children with cough variant asthma

OBJECTIVE

The aim of this study is to explore the clinical efficacy of montelukast sodium (MKST) combined with budesonide (BUD) on children with cough variant asthma (CVA) and its influence on inflammation and pulmonary function (PF).

METHODS

One hundred and sixty-six children with CVA treated in the Affiliated Nanhua Hospital, University of South China from May 2017 to August 2019 were randomized into a joint group (JG, n=92) for the combination therapy of MKST and BUD, and a control group (CG, n=74) for BUD monotherapy. Their clinical symptoms, total response rates (RR), PF, and inflammatory factor expressions were evaluated before and after treatment. The adverse reactions during the treatment were statistically compared between the two groups, and the factors influencing the curative effect were analyzed using logistic regression.

RESULTS

The JG presented markedly less cough resolution times, expectoration and wheezing, and a shorter body temperature recovery time than the CG after the treatment. The post-treatment forced expiratory volume in 1 second (FEV1), the forced vital capacity (FVC), the FEV1/FVC and the peak expiratory flow (PEF) levels as well as the Asthma Control Test (ACT) scores were statistically higher in the JG than in the CG. The JG had notably lower IgE, TNF-α, and IL-8 levels than the CG after the treatment. The total RR in the JG was observably higher than it was in the CG after the treatment, but the total adverse reaction rate identified no evident difference between the two series. Children with a family history of allergies, a family medical history, low ACT scores, high IgE expressions, high TNF-α expressions, and high IL-8 expressions, as well as BUD intervention are at increased risk of reduced efficacy.

CONCLUSIONS

The reduction of efficacy in children with CVA results from multiple risk factors. MKST combined with BUD can ameliorate the PF of children with CVA, reduce their inflammatory factors, and improve the curative effect and the prognosis.

Fractional Exhaled Nitric Oxide (FeNO) Integrating Airway Hyperresponsiveness (AHR) Examination Promotes Etiologic Diagnosis and Treatment for Children with Chronic Cough

BACKGROUND Chronic cough is the main reason why parents seek medical treatment for their children. This study aimed to evaluate changes in airway function and inflammation levels and associated values in diagnosing and treating chronic cough. MATERIAL AND METHODS This study involved 118 children with chronic cough, including 45 cough-variant asthma (CVA) patients, 53 upper-airway cough syndrome (UACS) patients, and 20 post-infection cough (PIC) patients. Chronic cough was diagnosed as described by guidelines of the American College of Chest Physicians for evaluating chronic cough. Pulmonary ventilation function and airway hyperresponsiveness (AHR) were evaluated. Fractional exhaled nitric oxide (FeNO) levels and eosinophilic airway inflammation were measured. Eosinophil (EOS) count in sputum was also examined. CVA patients were treated with inhaled glucocorticoids, which have anti-inflammatory effects. RESULTS FeNO and sputum EOS levels were higher in CVA patients compared with UACS and PIC patients (P<0.05). CVA patients demonstrated significantly higher small airway indexes, including 25% forced expiratory flow (FEF), 50% FEF, and 75% FEF, compared with UACS and PIC patients (P<0.05). FeNO level was positively correlated with EOS in sputum (r=0.468, P=0.0001) and cough symptom scores (r=0.402, P<0.05). FeNO, EOS, and cough symptoms were significantly improved in CVA patients after glucocorticoid treatment. AHR was improved in all chronic cough patients after treatment. Cough-relief CVA patients demonstrated significantly higher FeNO levels compared with those without cough relief (P<0.05). CONCLUSIONS FeNO integrating pulmonary function and AHR examination can improve etiologic diagnosis and treatment for chronic cough in children.

Isolated night cough in children: how does it differ from wheeze?

It has been postulated that some children with recurrent cough but no wheeze have a mild form of asthma (cough variant asthma), with similar risk factors and an increased risk of future wheeze.

This longitudinal study compared risk factors for isolated night cough and for wheeze in the Leicester Respiratory Cohort in children aged 1, 4, 6 and 9 years and compared prognosis of children with isolated night cough, children with wheeze and asymptomatic children.

We included 4101 children aged 1 year, 2854 aged 4 years, 2369 aged 6 years and 1688 aged 9 years. The prevalence of isolated night cough was 10% at age 1 year and 18% in older children. Prevalence of wheeze decreased from 35% at 1 year to 13% at 9 years. Although several risk factors were similar for cough and wheeze, day care, reflux and family history of bronchitis were more strongly associated with cough, and male sex and family history of asthma with wheeze. Over one-third of preschool children with cough continued to cough at school age, but their risk of developing wheeze was similar to that of children who were asymptomatic at earlier surveys. Wheeze tracked more strongly throughout childhood than cough.

In conclusion, our study showed that only some risk factors for cough and wheeze were shared but many were not, and there was little evidence for an increased risk of future wheeze in children with isolated night cough. This provides little support for the hypothesis that recurrent cough without wheeze may indicate a variant form of asthma.

Children with isolated night cough do not have an increased risk of future wheeze, and risk factors for cough and wheeze only partially overlap.https://bit.ly/31IbXSC

Gastroesophageal reflux and respiratory diseases: does a real link exist?

INTRODUCTION

Gastro-esophageal reflux disease (GERD) indicates a gastroesophageal reflux that causes symptoms such as pain, and needs medical therapy, and may result in complications such as erosive esophagitis, aspiration pneumonia. Here, we review if it exists a real link between clinical presentation of some respiratory diseases such as asthma, chronic cough, cystic fibrosis and laryngopharyngitis and GERD.

EVIDENCE ACQUISITION

This review was conducted employing 2 databases: PubMed and Science Direct.

EVIDENCE SYNTHESIS

Asthma may lead to reflux, and reflux could exacerbate asthma or cause asthma-like symptoms. Prevalence of GERD in children with asthma ranged from as low 32% to as high 80%. There are several studies where the use of proton pump inhibitors (PPIs) and histamine H2 receptor antagonists lead to inconclusive results. The relation of chronic unexplained cough to GERD remains controversial in children and pediatric guidelines do not currently recommend empirical GERD treatment trials for pediatric chronic cough. Gastroesophageal reflux is more frequent in patients with cystic fibrosis (CF) than general population. Although PPIs are regularly prescribed in approximately half of the patients with CF, there are no specific guidelines for treatment of reflux in CF and it was shown that chronic treatment with PPIs was correlated to possible increased risk of exacerbations.

CONCLUSIONS

The pathogenesis of GER-related respiratory symptoms is multifactorial. The causal relationship between these two conditions may be difficult to prove also with the aid of supporting tests. Multichannel intraluminal impedance associated with pH-metry (pH/MII) detect all gastroesophageal reflux episodes accompanied with a bolus movement and classify GER episodes according to their content (liquid, gas and mixed), pH value and proximal extension. There are no consistent evidences confirming the validity of medical therapy in reflux with respiratory symptoms.

DIAGNOSTIC VALUE OF MORPHOLOGICAL CHANGES IN GASTROESOPHAGEAL REFLUX DISEASE IN BIOPSY MATERIAL OF THE DISTAL ESOPHAGUS IN ADOLESCENTS SICKLY WITH ACUTE RESPIRATORY DISEASES

The article dedicated to the problem of the diagnostic value of morphological changes in gastroesophageal reflux disease in the biopsy of the distal esophagus in pubertal children of childbearing age. Aim of the research is to investigate the diagnostic value of morphological changes in gastroesophageal reflux disease in esophageal biopsy material in adolescents sickly with acute respiratory diseases. Methodology. The objective of the study was achieved through examination of 90 adolescents (10 to 16 years old, average age 13.1±3.54 years) kept under observation at the Children’s Clinical Hospital No. 9 of Kyiv and on the basis of the Department of Pediatrics No. 1 Center of Primary Health Care No. 4 of the Desnianskyi district of Kyiv. All adolescents belonged to the group of sickly with a number of respiratory diseases averaging 6-8 times a year, lasting from 8 to 18 days (on average 12.8±5.41 days). All children have undergone endoscopic examination of the esophagus, stomach and duodenum with the esophagus mucosa biopsy using the OLYMPUS GIF-P3 flexible fiberscope. Results. It was found that the least valuable diagnostic feature in the morphological examination of the mucous membrane of the distal esophagus in the pain-causing children with GERD was thickening of the epithelium with a sensitivity of 13,0 %, a specificity of 96.0 %, and total value of 65.0 %. It has been proved that hyperplasia of cells of the basal layer of the mucous membrane of the distal esophagus at the GERD in the infected children is 46.7 % (specificity – 93.3 %, the total value is 75.6 %). Increase in the number of papillae and their prolongation in 33.3 % cases (sensitivity – 33.3 %, specificity – 93.3 %, overall diagnostic value – 70.8 %). Conclusion. The peculiarity of the morphological manifestations of GERD in childbearing children is dystrophic changes in keratocytes in the superficial parts of the multilayer squamous epithelium, which are detected at 100.0 % of patients (specificity is 93.3 %, total value is 96.8 %), with parakeratosis centers at 13.3 % of cases. It has been shown that a frequent and diagnostically valuable indication is inflammatory infiltration of the esophageal mucosa, which are verified in all cases (100.0 %, with dilatation and hyperemia in 46.7 % of patients (specificity – 40.0 %, total value – 81.3 %).