Paediatric exercise training in prevention and treatment

Cardiac Rehabilitation and Cardiopulmonary Fitness in Children and Young Adults With Congenital Heart Diseases: A Critically Appraised Topic

Public health guidelines and a myriad of studies have proven that exercise is beneficial in the alleviation of various cardio-metabolic diseases. Congenital heart disease (ConHD) is one of the most frequently occurring congenital structural malfunctions in the pediatric population, affecting nine of every 1,000 live births. Only a few studies have established the impact of a structured exercise program on cardiopulmonary fitness in diverse groups of patients with ConHD. It is also alarming to know that a substantial number of these patients and their caregivers often remain very wary of exercise. Anxiety about exercise may increase the risk of developing morbid obesity and other long-term health complications of ConHD. The present review of a critically appraised topic is undertaken to answer the question, “Does structured exercise intervention (cardiac rehabilitation) improve cardiorespiratory fitness in children and young adults with ConHD?” Exercise science and the medical literature were searched for studies that engaged the use of aerobic exercise in patients with different ConHD diagnoses. The search yielded four studies after screening with the inclusion and exclusion criteria, which were further narrowed to three studies after a full-text review. These studies yielded results showing significant increments in peak exercise workload, duration, power output, peak oxygen uptake, or improved tissue oxygenation and muscle strength after an exercise training intervention. It is noteworthy that a group identified as “cyanotic palliated” exhibited the most significant impairment both at baseline and after the exercise intervention. This review provides level 1b medical evidence that a structured exercise program may improve cardiopulmonary fitness in patients with ConHD, which is likely to be beneficial to their overall physical, motor, and psychosocial development. The results of this review may be useful for alleviating the anxiety of patients and their caregivers about participation in structured exercise programs. This review should also motivate future research investigations to develop clinical guidelines for the management of patients with ConHD by adding exercise prescriptions to their daily therapeutic regimens.

Cardiac Concerns in the Pediatric Athlete

Cardiovascular disease remains the number one cause of death in Americans. It is no secret that exercise mitigates this risk. Exercise and regular physical activity are beneficial for physical health including aerobic conditioning, endurance, strength, mental health, and overall improved quality of life. Unfortunately, today many children and adolescents are sedentary, lacking the recommended daily amount of physical activity, leading to higher rates of obesity, cardiovascular disease, stroke, diabetes, anxiety, and depression. Given this rising concern, the World Health Organization launched a 12-year plan to improve physical activity in children and adolescents by reducing the inactivity rate by 15% in the world. How does this apply to children and adolescents with acquired or congenital heart disease?.

Exercise training in paediatric congenital heart disease: fit for purpose?

Exercise and physical activity (PA) have been shown to be effective, safe and feasible in both healthy children and children with congenital heart disease (CHD). However, implementing exercise training as an intervention is still not routine in children with CHD despite considerable evidence of health benefits and well-being. Understanding how children with CHD can safely participate in exercise can boost participation in PA and subsequently reduce inactivity-related diseases. Home-based exercise intervention, with the use of personal wearable activity trackers, and high-intensity interval training have been beneficial in adults' cardiac rehabilitation programmes. However, these remain underutilised in paediatric care. Therefore, the aims of this narrative review were to synthesise prescribed exercise interventions in children with CHD, identify possible limitation to exercise training prescription and provide an overview on how to best integrate exercise intervention effectively for this population into daily practice.

The adolescent athlete's heart; A miniature adult or grown-up child?

The systematic development of early age talent in sports academies has led to the professionalization of pediatric sport and the sports physician need to be aware of pediatric cardiological problems. Research into the medical cardiac care and assessment of the pediatric athlete are accumulating, but specific pediatric international guidelines are not available yet and reference data for ECG and echocardiography are incomplete, in particular for the age group <12 years of age. This article is an introduction to the physiological and diagnostics specifics of the pediatric athlete. The focus lies in the differences in presentation and diagnosis between pediatric and adult athletes for the most common pathologies. Reference data for electrical and structural adaptations to intensive exercise are sparse particularly in athletes aged below 12 years old. Training related changes include decrease of resting heart rate, increase of cardiac output, ventricular cavity size, and wall thickness. Cardiac hypertrophy is less pronounced in pediatric athletes, as HR mediated cardiac output increase to endurance exercise is the dominant mechanism in peripubertal children. As in adults, the most pronounced cardiovascular adaptations appear in classical endurance sports like rowing, triathlon, and swimming, but the specifics of pediatric ECG and echocardiographic changes need to be considered.

The Assessment of the Paediatric Athlete

The success of systematic early age talent development has led to the professionalisation of youth sports academies used by clubs and governing bodies alike, and sports physicians are nowadays commonly confronted with paediatric cardiological problems. Medical cardiac care of the paediatric athlete is however in its infancy, and the international guidelines that are present for adult athletes, are not yet available. Similarly, reference data for ECG and echocardiography are incomplete. The aim of this article is to provide and introduction to the cardiac care of the paediatric athlete to facilitate healthy and above all, safe talent development, but also provide guidance on how to distinguish adaptive, beneficial cardiovascular remodelling from underlying pathology of congenital or inherited cardiovascular disease. Differences in presentation, diagnosis and treatment between childhood and adult athletes are highlighted and can educate the reader in the emerging field of paediatric sports cardiology.

Effects of exercise training on physical and psychosocial health in children with chronic respiratory disease: a systematic review and meta-analysis

INTRODUCTION

Chronic disease in children is increasing, including the prevalence of chronic respiratory diseases such as asthma, cystic fibrosis (CF), bronchiectasis and bronchopulmonary dysplasia (BPD). The aim of this systematic review and meta-analysis was to evaluate the effects of exercise training on health outcomes in children with chronic respiratory disease.

METHOD

Five databases were searched for randomised controlled trials investigating the effects of exercise training on children with chronic respiratory disease. Following the PRISMA guidelines, eligible studies were identified and data were extracted. A meta-analysis was conducted for the outcomes cardiovascular fitness, lung function and quality of life (QoL).

RESULTS

The initial search returned 3688 papers. Twenty-seven (17 in children with asthma, 10 in children with CF) were included in the systematic review and 24 of these were included in the meta-analysis. No studies were identified in children with bronchiectasis or BPD. Included papers had a total of 1009 participants aged 8-20 years. In addition to cardiovascular fitness, lung function and QoL, studies also assessed pulmonary function, respiratory muscle strength, muscular strength and inflammation. Meta-analysis showed a large significant effect size in favour of exercise for cardiovascular fitness (peak VO2) (standard mean difference (SMD)=1.16, 95%  CI 0.61 to 1.70) and QoL (SMD=1.27, 95% CI 0.72 to 1.82) as well as a small, non-significant effect size for lung function (FEV1) (SMD=0.02, 95% CI -0.38 to 0.42).

CONCLUSION

Exercise training significantly improves cardiovascular fitness and QoL in children with asthma and CF. Further research is needed, particularly in children with bronchiectasis and BPD.

New Insights about How to Make an Intervention in Children and Adolescents with Metabolic Syndrome: Diet, Exercise vs. Changes in Body Composition. A Systematic Review of RCT

OBJECTIVE

To record which interventions produce the greatest variations in body composition in patients ≤19 years old with metabolic syndrome (MS).

METHOD

search dates between 2005 and 2017 in peer reviewed journals, following the PRISMA method (Preferred Reporting Items for Systematic reviews and Meta-Analyses). The selection criteria were: diagnostic for MS or at least a criterion for diagnosis; randomized clinical trials, ≤19 years of age; intervention programs that use diet and/or exercise as a tool (interventions showing an interest in body composition).

RESULTS

1781 clinical trials were identified under these criteria but only 0.51% were included. The most frequent characteristics of the selected clinical trials were that they used multidisciplinary interventions and were carried out in America. The most utilized parameters were BMI (body mass index) in kg/m² and BW (body weight) in kg.

CONCLUSIONS

Most of the clinical trials included had been diagnosed through at least 2 diagnostic criteria for MS. Multidisciplinary interventions obtained greater changes in body composition in patients with MS. This change was especially prevalent in the combinations of dietary interventions and physical exercise. It is proposed to follow the guidelines proposed for patients who are overweight, obese, or have diabetes type 2, and extrapolate these strategies as recommendations for future clinical trials designed for patients with MS.

A survey of exercise advice and recommendations in United Kingdom paediatric cardiac clinics

BACKGROUND

Physical activity and exercise have important health benefits for children and adolescents with CHD. The objective of this study was to survey the provision of advice and recommendations in United Kingdom paediatric CHD clinics.

METHODS

A three-page questionnaire was sent out to paediatric cardiac consultants in the United Kingdom, paediatric consultants with expertise in cardiology, and nursing staff (Paediatricians with Expertise in Cardiology Special Interest Group), as well as all members of the British Congenital Cardiovascular Association. The aim of this questionnaire was to determine the extent and scope of current information provision and to assess the importance that clinicians place on this advice.

RESULTS

There were 68 responses in total, and the data showed that, of these, 24 (36%) clinicians had never provided paediatric CHD patients with written advice about exercise. Only 27 (39%) clinicians provided physical activity advice at every appointment. Lack of time during consultation (n=39, 56.9%), lack of training (n=38, 55.2%), and uncertainty about appropriate recommendations (n=38, 55.2%) were identified as the main factors preventing clinicians from providing patients with advice about physical activity.

CONCLUSION

Although healthcare providers consider physical activity to be very important, the provision of clear, specific advice and recommendations is underutilised; therefore, more education and provision of resources to support the promotion of exercise need to be provided to clinicians and their support teams.

Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association

BACKGROUND

Kawasaki disease is an acute vasculitis of childhood that leads to coronary artery aneurysms in ≈25% of untreated cases. It has been reported worldwide and is the leading cause of acquired heart disease in children in developed countries.

METHODS AND RESULTS

To revise the previous American Heart Association guidelines, a multidisciplinary writing group of experts was convened to review and appraise available evidence and practice-based opinion, as well as to provide updated recommendations for diagnosis, treatment of the acute illness, and long-term management. Although the cause remains unknown, discussion sections highlight new insights into the epidemiology, genetics, pathogenesis, pathology, natural history, and long-term outcomes. Prompt diagnosis is essential, and an updated algorithm defines supplemental information to be used to assist the diagnosis when classic clinical criteria are incomplete. Although intravenous immune globulin is the mainstay of initial treatment, the role for additional primary therapy in selected patients is discussed. Approximately 10% to 20% of patients do not respond to initial intravenous immune globulin, and recommendations for additional therapies are provided. Careful initial management of evolving coronary artery abnormalities is essential, necessitating an increased frequency of assessments and escalation of thromboprophylaxis. Risk stratification for long-term management is based primarily on maximal coronary artery luminal dimensions, normalized as Z scores, and is calibrated to both past and current involvement. Patients with aneurysms require life-long and uninterrupted cardiology follow-up.

CONCLUSIONS

These recommendations provide updated and best evidence-based guidance to healthcare providers who diagnose and manage Kawasaki disease, but clinical decision making should be individualized to specific patient circumstances.