Children hospitalised with bronchiolitis in the first year of life have a lower quality of life nine months later

Effects of infant bronchiolitis on family life

Background

Bronchiolitis is a respiratory infection of viral origin and is often linked to syncytial respiratory virus. It is the most frequent cause of hospitalisation in children aged under 2 years and sometimes requires transfer to intensive care. Infectious complications may also arise in the short term, and longer-term progression towards asthma is also possible. The occurrence of bronchiolitis in children may affect families in different ways, and may have psychological, organisational, employment-related, and possibly financial consequences.

Objective

The aim of the study was to determine the familial and socioeconomic repercussions of bronchiolitis in infants.

Setting

Parents with a child with bronchiolitis between January 2021 and May 2022, who were registered at the site of the Association Française de Pédiatrie Ambulatoire (Mpedia site) or at the site of the Malin Programme, which serves families experiencing financial difficulties, were included in the study.

Participants

All parents consenting to participate in the study.

Results

A total of 2,059 valid questionnaires were retrieved: 1,318 (64%) were obtained from parents through the Mpedia website and 741 (36%) were obtained through the Malin Programme. Parents associated with the Malin Programme had more children, as well as higher rates of unemployment and financial difficulties, and required greater medical assistance. Hospitalisation was necessary in 37% of cases and was comparable between groups. During the illness, moderate to severe anxiety was present in 73% of parents; this percentage rose to 87% if the child required hospitalisation. Many parents reported effects on daily home (84%) and work life (90%), and 60% had taken a leave of absence from work.

Conclusion

Beyond the immediate or longer-term medical consequences of bronchiolitis in infants, the illness affects families in multiple ways and can lead to anxiety, as well as changes in day-to-day home and work life. Physicians should have greater awareness of these consequences and should strive to decrease their impact.

Towards optimum smoking cessation interventions during pregnancy: a household model to explore cost-effectiveness

BACKGROUND AND AIMS

Previous economic evaluations of smoking cessation interventions for pregnant women are limited to single components, which do not in isolation offer sufficient potential impact to address smoking cessation targets. To inform the development of more appropriate complex interventions, we (1) describe the development of the Economics of Smoking in Pregnancy: Household (ESIP.H) model for estimating the life-time cost-effectiveness of smoking cessation interventions aimed at pregnant women and (2) use a hypothetical case study to demonstrate how ESIP.H can be used to identify the characteristics of optimum smoking cessation interventions.

METHODS

The hypothetical intervention was based on current evidence relating to component elements, including financial incentives, partner smoking, intensive behaviour change support, cigarettes consumption and duration of support to 12 months post-partum. ESIP.H was developed to assess the life-time health and cost impacts of multi-component interventions compared with standard National Health Service (NHS) care in England. ESIP.H considers cigarette consumption, partner smoking and some health conditions (e.g. obesity) that were not included in previous models. The Markov model's parameters were estimated based on published literature, expert judgement and evidence-based assumptions. The hypothetical intervention was evaluated from an NHS perspective.

RESULTS

The hypothetical intervention was associated with an incremental gain in quitters (mother and partner) at 12 months postpartum of 249 [95% confidence interval (CI) = 195-304] per 1000 pregnant smokers. Over the long-term, it had an incremental negative cost of £193 (CI = -£779 to 344) and it improved health, with a 0.50 (CI = 0.36-0.69) increase in quality-adjusted life years (QALYs) for mothers, partners and offspring, with a 100% probability of being cost-effective.

CONCLUSIONS

The Economics of Smoking in Pregnancy: Household model for estimating cost-effectiveness of smoking cessation interventions aimed at pregnant women found that a hypothetical smoking cessation intervention would greatly extend reach, reduce smoking and be cost-effective.

Acute Neuro-Functional Morbidity Upon Discharge From the Pediatric Intensive Care Unit After Critical Bronchiolitis

BACKGROUND AND OBJECTIVE

Improved survival has shifted research focus toward understanding alternate PICU outcomes, including neurocognitive and functional changes. Bronchiolitis is a common PICU diagnosis, but its neuro-functional outcomes have not been adequately described in contemporary literature. The objective of the study is to describe the epidemiology and associated clinical characteristics of acute neuro-functional morbidity (ANFM) in critical bronchiolitis.

METHODS

Patients <2 years old admitted with bronchiolitis between 2014 and 2016 were identified. Demographics, medical history, length of stay (LOS), and need for intubation were collected. Children with a history of neurologic illness or illness associated with neurologic sequelae were termed "high risk"; others were termed "low risk." ANFM was defined both at PICU and hospital discharge as the presence of swallowing difficulty, nasogastric tube feeds, hypotonia, or lethargy. Variables were compared by using χ2 and Wilcoxon rank tests.

RESULTS

Among 417 children, 16.7% had ANFM, predominantly swallow difficulties (95.7%). Children with ANFM had lower weight (5.9 [4.4-8.2] vs 7.7 [5.5-9.7] kg, P = .001), longer LOS (6.6 [2.5-13.3] vs 1.9 [0.9-3.5] days, P < .001), intubation (51.4% vs 6.1%, P < .001) and high-risk status (37.1% vs 8.4%, P < .001). Among 362 low risk subjects, ANFM was identified in 44 (12%). In a multivariate logistic regression model, high-risk status, intubation, and ICU LOS were associated with ANFM. ANFM persisted to hospital discharge in 46% of cases.

CONCLUSIONS

One out of 6 patients with critical bronchiolitis had documentation consistent with ANFM at PICU discharge. Risk factors included previous neurologic conditions, longer LOS, and intubation. Many were low-risk and/or did not require intubation, indicating a risk for neuro-functional morbidities despite moderate acuity.

Feasibility, Efficacy, and Efficiency of eHealth-Supported Pediatric Asthma Care: Six-Month Quasi-Experimental Single-Arm Pretest-Posttest Study

BACKGROUND

Early detection of loss of asthma control can effectively reduce the burden of the disease. However, broad implementation in clinical practice has not been accomplished so far. We are in need of research investigating the operationalization of eHealth pediatric asthma care in practice, which can provide the most potential benefits in terms of adoption, efficiency, and effectiveness.

OBJECTIVE

The aim of this study was to investigate the technical and clinical feasibility, including an exploration of the efficacy and cost-efficiency, of an eHealth program implemented in daily clinical pediatric asthma practice.

METHODS

We designed an eHealth-supported pediatric asthma program facilitating early detection of loss of asthma control while increasing symptom awareness and self-management. In the 6-month program, asthma control was monitored by 4 health care professionals (HCPs) by using objective home measurements and the web-based Puffer app to allow timely medical anticipation and prevent treatment delay. Technical feasibility was assessed by technology use, system usability, and technology acceptance. Clinical feasibility was assessed by participation and patient-reported health and care outcomes and via a focus group with HCPs regarding their experiences of implementing eHealth in daily practice. The efficacy and cost-efficiency were explored by comparing pretest-posttest program differences in asthma outcomes (asthma control, lung function, and therapy adherence) and medical consumption.

RESULTS

Of 41 children, 35 children with moderate-to-severe asthma volunteered for participation. With regard to technical feasibility, the Puffer app scored a good usability score of 78 on the System Usability Scale and a score of 70 for technology acceptance on a scale of 1 to 100. Approximately 75% (18/24) of the children indicated that eHealth helped them to control their asthma during the program. HCPs indicated that home measurements and real time communication enabled them to make safe and substantiated medical decisions during symptom manifestations. With an average time commitment of 15 minutes by patients, eHealth care led to a 80% gross reduction (from €71,784 to €14,018, US $1=€0.85) in health care utilization, 8.6% increase (from 18.6 to 20.2, P=.40) in asthma control, 25.0% increase (from 2.8 to 3.5, P=.04) in the self-management level, and 20.4% improved (from 71.2 to 76.8, P=.02) therapy adherence.

CONCLUSIONS

eHealth asthma care seems to be technically and clinically feasible, enables safe remote care, and seems to be beneficial for pediatric asthma care in terms of health outcomes and health care utilization. Follow-up research should focus on targeted effectiveness studies with the lessons learned, while also enabling individualization of eHealth for personalized health care.

Long-term health-related quality-of-life data in subjects with a history of wheezing in early childhood

Background: Wheezing in early childhood has implications for respiratory morbidity in later life. Objectives: We evaluated respiratory health-related quality of life (HRQoL) in young adults ages 17-20 years with a history of early childhood wheezing. Methods: Between 1992 and 1993, 100 children ages < 24 months were treated in the hospital for a lower respiratory tract infection with wheezing, and we followed up this cohort. In 2010, 49 of the patients (cases) and 60 population-based controls attended a clinical follow-up. St. George's Respiratory Questionnaire (SGRQ) was used to evaluate respiratory HRQoL, expressed as symptom, activity, impact, and total scores. Results: The median (interquartile range) SGRQ symptom scores were higher (13.7 [3.8-29.1]) in the 49 subjects (cases) with early childhood wheezing compared with the 60 population controls (7.8 [0.0-18.3]; p = 0.019). However, there were no between-group differences in total scores or in other SGRQ domains. Current asthma was a major risk factor for reduced HRQoL. In univariate analyses, the median symptom scores were 20.2 in those with asthma and 7.8 in those without asthma (p < 0.001), and, in multivariate analyses, the odds ratio (OR) was 8.7 for high total scores (95% confidence intervals, 2.1-36.6). Other factors associated with reduced HRQoL were current allergy (OR 4.4 for symptom scores), overweight (OR 3.3 for activity scores), tobacco smoking (OR 4.3 for symptom scores), and female sex (OR 3.2 for impact score). Furthermore, we performed post hoc analyses by excluding those with asthma and those who smoked, and found no significant differences on SGRQ scores between the subjects (cases) and the controls. Conclusion: Hospitalization for wheezing in early childhood mainly had indirect effects on HRQoL by increasing the risk of asthma.

Quality of life, salivary cortisol and atopic diseases in young children

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.

Parent experiences and information needs related to bronchiolitis: A mixed studies systematic review

OBJECTIVE

To inform evidence-based knowledge products (i.e., infographics, videos, eBooks) of relevance to parents, we systematically reviewed evidence on parent experiences and information needs related to bronchiolitis.

METHODS

We searched Medline, CINAHL, PsycINFO, and ProQuest Dissertations & Theses Global, and scanned reference lists for studies published post-2000. We appraised quality in duplicate using the Mixed Methods Appraisal Tool (MMAT) and synthesized findings narratively.

RESULTS

We retrieved 797 records and included 29; 14 (48%) met >50% of MMAT criteria. Studies predominantly enrolled mothers. Most reported quantitatively on hospitalization experiences (n = 9, 31%), treatments (n = 5, 17%), or respiratory syncytial virus (RSV) prophylaxis (n = 9, 31%). Ten (34%) studies reported on information needs; 3 contributed qualitative data. Parents could not always identify bronchiolitis symptoms. During hospitalization, parents endured guilt and anxiety. Mothers wanted to take an active role in their child's care but often felt uninvolved. Barriers to RSV prophylaxis included transportation, scheduling, and insurance issues.

CONCLUSIONS

Evidence focused primarily on hospitalization, which parents found frightening. More information is needed on home care experiences and information preferences.

PRACTICE IMPLICATIONS

Timely education and support from healthcare providers may help to alleviate parents' fears and enhance involvement in their child's care.

The Burden and Long-term Respiratory Morbidity Associated with Respiratory Syncytial Virus Infection in Early Childhood

INTRODUCTION

The REGAL (RSV Evidence-a Geographical Archive of the Literature) series provide a comprehensive review of the published evidence in the field of respiratory syncytial virus (RSV) in Western countries over the last 20 years. The objective of this fifth publication was to determine the long-term respiratory morbidity associated with RSV lower respiratory tract infection (RSV LRTI) in early life.

METHODS

A systematic review was undertaken for articles published between January 1, 1995 and December 31, 2015. This was supplemented by inclusion of papers published whilst drafting the manuscript. Studies reporting data on the incidence and long-term wheezing and asthma following RSV LRTI in early life were included. Study quality and strength of evidence (SOE) were graded using recognized criteria.

RESULTS

A total of 2337 studies were identified of which 74 were included. Prospective, epidemiologic studies consistently demonstrated that RSV LRTI is a significant risk factor for on-going respiratory morbidity characterized by transient early wheezing and recurrent wheezing and asthma within the first decade of life and possibly into adolescence and adulthood (high SOE). RSV LRTI was also associated with impaired lung function in these children (high SOE). Respiratory morbidity has been shown to result in reduced quality of life and increased healthcare resource use (moderate SOE). The mechanisms through which RSV contributes to wheezing/asthma development are not fully understood, but appear to relate to the viral injury, preexisting abnormal lung function and/or other factors that predispose to wheezing/asthma, including genetic susceptibility, altered immunology, eosinophilia, and associated risk factors such as exposure to environmental tobacco smoke (high SOE).

CONCLUSION

There is growing evidence that RSV LRTI in early childhood is associated with long-term wheezing and asthma and impaired lung function. Future research should aim to fully elucidate the pathophysiological mechanisms through which RSV causes recurrent wheezing/asthma.

Morning Salivary Cortisol in Young Children: Reference Values and the Effects of Age, Sex, and Acute Bronchiolitis

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.

The severity of acute bronchiolitis in infants was associated with quality of life nine months later

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.

[Efficacy of fluticasone propionate aerosol versus budesonide suspension in treatment of recurrent wheezing caused by bronchiolitis]

OBJECTIVE

To investigate the efficacy of fluticasone propionate aerosol (flixotide) versus budesonide suspension in the treatment of recurrent wheezing caused by bronchiolitis.

METHODS

A total of 214 infants with newly diagnosed bronchiolitis were randomly divided into flixotide treatment (106 infants) and budesonide treatment groups (108 infants), and were given aerosol inhalation of flixotide or budesonide for 3 months after achieving remission of clinical symptoms. Another 136 infants with bronchiolitis who did not receive regular inhalation of corticosteroid after achieving remission of clinical symptoms were enrolled as the control group. The follow-up visits were performed for 1 year, and the effects of the two therapeutic methods on recurrent wheezing were evaluated.

RESULTS

Compared with the control group, both the flixotide and budesonide treatment groups had significantly fewer times of wheezing episodes within 1 year and a significantly lower recurrence rate of wheezing within the first 3 months after regular inhalation of corticosteroid, but no significant differences were observed between the two treatment groups. The amount of corticosteroid inhaled and hospital costs in the budesonide treatment group were significantly higher than in the flixotide treatment group (P<0.01).

CONCLUSIONS

Continuous inhalation of flixotide or budesonide after remission of clinical symptoms in children with bronchiolitis can reduce wheezing episodes and the recurrence of wheezing, and flixotide treatment is superior to budesonide treatment in the aspects of hospital costs and the amount of corticosteroid used.