Diagnosis and management of asthma in preschoolers: A Canadian Thoracic Society and Canadian Paediatric Society position paper

Sex differences in sociodemographic, clinical, and laboratory variables in childhood asthma: A birth cohort study

BACKGROUND

There are marked sex differences in the prevalence and severity of asthma, both during childhood and adulthood. There is a relative lack of comprehensive studies exploring sexdifferences in pediatric asthma cohorts.

OBJECTIVE

To identify the most relevant sex differences in sociodemographic, clinical, and laboratory variables in a well-characterized large pediatric asthma cohort.

METHODS

We performed a cross-sectional analysis of the Mayo Clinic Olmsted County Birth Cohort. In the full birth cohort, we used a natural language-processing algorithm based on the Predetermined Asthma Criteria for asthma ascertainment. In a stratified random sample of 300 children, we obtained additional pulmonary function tests and laboratory data. We identified the significant sex differences among available sociodemographic, clinical, and laboratory variables.

RESULTS

Boys were more frequently diagnosed with having asthma than girls and were younger at the time of asthma diagnosis. There were no sex differences in relation to socioeconomic status. We identified a male predominance in the presence of a tympanostomy tube and a female predominance in the history of pneumonia. A higher percentage of boys had a forced expiratory volume in 1 second/forced vital capacity ratio less than 0.85. Blood eosinophilia and atopic sensitization were also more common in boys. Finally, boys had higher levels of serum periostin than girls.

CONCLUSION

This study described significant sex differences in a large pediatric asthma cohort. Overall, boys had earlier and more severe asthma than girls. Differences in blood eosinophilia and serum periostin provide insights into possible mechanisms of the sex bias in childhood asthma.

La prise en charge de l'asthme léger et très léger chez les enfants d'âge préscolaire, les enfants et les adolescents

Le présent point de pratique résume la mise à jour des lignes directrices de la Société canadienne de thoracologie publiée en 2021 sur le diagnostic et la prise en charge de l'asthme chez les enfants d'âge préscolaire, les enfants et les adultes. Ces nouvelles recommandations incluent, parmi les critères de contrôle de l'asthme, une diminution de la fréquence des symptômes diurnes et de l'utilisation de médicaments pour soulager l'asthme à un maximum de deux fois par semaine. Elles comprennent également l'évaluation du risque d'exacerbation de l'asthme, la non-utilisation de bêta-agonistes à courte durée d'action seuls au besoin chez les patients à plus fort risque d'exacerbation et la possibilité d'administrer du budésonide-formotérol au besoin aux jeunes de 12 ans ou plus qui sont incapables de prendre des corticostéroïdes inhalés au quotidien malgré une éducation sur l'asthme et un soutien importants. La préférence pour la prise quotidienne de corticostéroïdes inhalés afin de traiter l'asthme léger chez les enfants et la recommandation d'éviter les courts traitements intermittents de corticostéroïdes inhalés ne changent pas.

The management of very mild and mild asthma in preschoolers, children, and adolescents

This practice point summarizes recommendations from the Canadian Thoracic Society's 2021 "Guideline update: Diagnosis and management of asthma in preschoolers, children, and adults." New recommendations include: a decrease in the frequency of daytime symptoms and reliever use to ≤2 per week in the asthma control criteria; assessing for risk of asthma exacerbation; not using as-needed short-acting beta-agonists alone in patients at higher risk for exacerbation; and the option of as-needed budesonide/formoterol (bud/form) in those ≥12 years old if they are unable to take daily inhaled corticosteroids despite extensive asthma education and support. The preference for daily inhaled corticosteroids to manage mild asthma in children, and the recommendation against intermittent short courses of inhaled corticosteroids, are unchanged.

Preschool children's asthma medication: parental knowledge, attitudes, practices, and adherence

Introduction: As parents or legal guardians primarily care for children with asthma, understanding their knowledge, attitudes, and practices (KAP) barriers to treatment and medication adherence is of essential importance. This study aimed to analyze the KAP toward asthma medication and adherence among preschool-aged asthmatic children's parents and explore the factors influencing adherence. Methods: This cross-sectional study was conducted between February 2023 and April 2023. Parents of preschool children with asthma were asked to complete the questionnaire containing knowledge, attitude, practice dimensions, and demographic characteristics. The Morisky Medication Adherence Scale (MMAS) was used to investigate adherence. Results: A total of 632 valid questionnaires (154 male and 478 female) were included. Parents showed moderate knowledge (9.49 ± 2.86, 63.27%, possible range: 0-15) and moderate attitudes (26.18 ± 2.51, 74.80%, possible range: 7-35) towards asthma medication, while their practices (27.46 ± 5.26, 91.53%, possible range: 6-30) were proactive; however, medication adherence was low (4.84 ± 1.78, total score: 8). The attitude scores (OR = 1.10, 95% CI: 1.01-1.19, P=0.020), practice scores (OR = 1.16, 95%CI: 1.12-1.21, p < 0.001), and smoking (OR = 1.64, 95%CI: 1.14-2.37, p = 0.008) were associated with medication adherence. Discussion: Preschool-aged asthmatic children's parents showed moderate knowledge, attitudes, and proactive practice toward asthma medication. Continuous training and education programs should be provided for parents to improve asthma medication management in preschool children.

Asthmalitis? Diagnostic Variability of Asthma and Bronchiolitis in Children <24 Months

BACKGROUND AND OBJECTIVES

Bronchiolitis and asthma have similar acute clinical presentations in young children yet have opposing treatment recommendations. We aimed to assess the role of age and other factors in the diagnosis of bronchiolitis and asthma in children <24 months of age.

METHODS

We conducted a retrospective cross-sectional analysis of the Pediatric Health Information System database. We included children aged <2 years diagnosed with bronchiolitis, asthma, wheeze, or bronchospasm in emergency department or hospital encounters from 2017 to 2021. We described variation by age and between institutions. We used mixed-effects models to assess factors associated with a non-bronchiolitis diagnosis in children 12 to 23 months of age.

RESULTS

We included 554 158 encounters from 42 hospitals. Bronchiolitis made up 98% of encounters for children <3 months of age, whereas asthma diagnoses increased with age and were included in 44% of encounters at 23 months of age. Diagnosis patterns varied widely between hospitals. In children 12 to 23 months of age, the odds of a non-bronchiolitis diagnosis increased with month of age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.12-1.13), male sex (OR 1.37, 95% CI 1.35-1.40), non-Hispanic Black race (OR 1.54, 95% CI 1.50-1.58), number of previous encounters (OR 2.73, 95% CI 2.61-2.86, for 3 or more encounters), and previous albuterol use (OR 2.24, 95% CI 2.16-2.32).

CONCLUSIONS

Non-bronchiolitis diagnoses and the use of inhaled bronchodilators and systemic steroids for acute wheezing respiratory illness increase with month of age in children aged 0 to 23 months. Better definitions of clinical phenotypes of bronchiolitis and asthma would allow for more appropriate treatment in acute care settings, particularly in children 12 to 23 months of age.

Caregivers' Perceptions, Needs, and Data Sharing Concerns in mHealth Research on Pediatric Asthma: Cross-Sectional Survey Study

Background

Pediatric asthma is the most common chronic respiratory disease of childhood. Caregivers often report lacking knowledge in several aspects of asthma management at home. Although the use of mobile health (mHealth) tools, such as mobile apps, could facilitate asthma self-management and, simultaneously, the collection of data for research, few studies have explored the features that caregivers would like to see in such a tool and their perceptions on data sharing.

Objective

This study evaluates caregivers' perceived knowledge gaps in asthma management; their perceptions of certain features and resources that should be included in a potential mobile app; and any concerns that they may have regarding data sharing for research, including privacy and security concerns.

Methods

In this cross-sectional study, we surveyed 200 caregivers of children (aged 1-13 y) with asthma who were followed at a pediatric tertiary care center in Montreal, Canada. Anonymous data were collected through the institutional web-based survey platform. We collected the participants' answers by using a 5-category Likert scale ("completely agree," "agree," "neither agree nor disagree," "disagree," and "completely disagree"), multiple-choice questions, and free-text questions on the abovementioned topics. Descriptive statistics were performed, and answers were compared between caregivers of preschool-aged children and caregivers of school-aged children.

Results

Participating children's mean age was 5.9 (SD 3.4) years, with 54% (108/200) aged ≤5 years and 46% (92/200) aged >6 years. Overall, caregivers reported having adequate knowledge about asthma and asthma self-management. Nonetheless, they identified several desirable features for a mobile app focused on asthma self-management. The most frequently identified features included receiving alerts about environmental triggers of asthma (153/199, 76.9%), having videos that demonstrate symptoms of asthma (133/199, 66.8%), and being able to log children's asthma action plans in the app (133/199, 66.8%). Interestingly, more caregivers of preschool-aged children preferred textual information when compared to caregivers of school-aged children (textual information for explaining asthma: P=.008; textual information for the symptoms of asthma: P=.005). Caregivers were generally highly in favor of sharing data collected through a mobile app for research.

Conclusions

Caregivers of children with asthma in our study identified several desirable educational and interactive features that they wanted to have in a mobile app for asthma self-management. These findings provide a foundation for designing and developing mHealth tools that are relevant to caregivers of children with asthma.

Shifting Trends in Diagnosis of Asthma, Bronchiolitis, and Viral Pneumonia in Young Children

Over the last decade, there have been widespread efforts to reduce non-evidence-based therapies for viral bronchiolitis. We question whether this change in practice has inadvertently impacted the diagnosis and management of other pediatric lower-respiratory-tract illnesses. We used the Pediatric Health Information System (PHIS) and logistic regression to describe trends in relative diagnosis frequency of bronchiolitis, viral pneumonia, and reactive airway disease (RAD)/asthma as well as systemic corticosteroid use among children of the age range 1 to 4 years over a 10-year period. Among 169,207 children, the relative frequency of asthma/RAD diagnoses declined over a 10-year period, while bronchiolitis and viral pneumonia diagnoses increased among children of the age range 1 to 3 years and 2 to 4 years, respectively. Frequency of systemic corticosteroid use declined. We question whether the observed shift in diagnosis from asthma/RAD to bronchiolitis or viral pneumonia is reflective of true disease pathophysiology or if it represents an unintended consequence of campaigns surrounding bronchiolitis.

Bronchiolitis, Regardless of Its Etiology and Severity, Is Associated With Increased Risk of Asthma: A Population-Based Study

An association exists between severe respiratory syncytial virus (RSV)-bronchiolitis and a subsequent increased risk of recurrent wheezing (RW) and asthma. However, a causal relationship remains unproven. Using a retrospective population-based cohort study (339 814 children), bronchiolitis during the first 2 years of life (regardless of etiology and severity) was associated with at least a 3-fold increased risk of RW/asthma at 2-4 years and an increased prevalence of asthma at ≥5 years of age. The risk was similar in children with mild bronchiolitis as in those with hospitalized RSV-bronchiolitis and was higher in children with hospitalized non-RSV-bronchiolitis. The rate of RW/asthma was higher when bronchiolitis occurred after the first 6 months of life. Our results seem to support the hypothesis of a shared predisposition to bronchiolitis (irrespective of etiology) and RW/asthma. However, 60% of hospitalized bronchiolitis cases in our setting are due to RSV, which should be paramount in decision-making on imminent RSV prevention strategies.

A mobile health intervention for improving the technique of inhaled medications among children with asthma: A pilot study

Objective

BreatheSuite MDI is a Bluetooth-enabled inhaler attachment and mobile application which aims to improve asthma control. The objective was to compare pressurized metered dose inhaler (pMDI) technique and asthma control test (ACT) scores pre- and post-use of the device and mobile application. Secondary objectives were to assess user satisfaction and therapy adherence.

Methods

Patients between the ages of 8 and 18 were recruited from several pediatric asthma clinics. Technique and ACT scores were assessed at baseline. Users were given no prompts on technique during the first month of device use. For the subsequent three months, users were given technique scores through the mobile application after each inhaler use and provided weekly performance summaries. At the end of the study, technique and ACT scores were analyzed and an exit survey was completed. Conditional logistic regression was used to examine the association between well-controlled asthma (ACT score > 19) and the intervention.

Results

24 patients completed the study. Technique scores improved following the use of Breathesuite (44.19 vs. 62.54; P = 0.01). Well-controlled asthma did not significantly improve (OR = 1.20 [0.4-3.9], P = 0.76). 87% of study subjects agreed or strongly agreed that their asthma control improved while using BreatheSuite; 79% were satisfied with the device and mobile application; and 91% preferred using the device compared to a standard logbook to track inhaler usage.

Conclusions

In this pilot study, the use of BreatheSuite device was associated with improved technique scores. These results need to be confirmed by a randomized controlled trial. There was high user satisfaction with the BreatheSuite device.

Bronchodilator response after two methods of salbutamol nebulization in asthmatic children

Introduction

Salbutamol is used in bronchodilator response testing (BDRT), which is an important diagnostic tool in bronchial obstructive diseases. Most available studies compare the bronchodilator response of salbutamol administered with a pressurized metered-dose inhaler and salbutamol in a nebulization solution.

Aim

The spirometric evaluation of the bronchodilator response of two methods of salbutamol nebulization in asthmatic children.

Material and methods

A randomized, open, comparative study was conducted in which 132 children with partially controlled asthma and current bronchial obstruction determined by spirometry were enrolled. BDRT was conducted using salbutamol solution administered with either a continuous jet nebulizer (CON) or a breath-actuated jet nebulizer (BAN). The BAN group received half the dose of the drug compared to the CON group, i.e. 2.5 mg. Changes in FEV₁ and FEF25-75 after drug administration were calculated in relation to the baseline values.

Results

The change in FEV₁ after salbutamol administration was 16.9 ±9.7% in the BAN group and was statistically significantly higher than in the CON group (12.6 ±8.8%) (p = 0.026). The change in FEF25-75 was 37.7 ±23.2% in the BAN group and 32.7 ±25.5% in the CON group (p = 0.061). There were no statistically significant differences in the frequency of adverse events between the compared groups.

Conclusions

Salbutamol inhaled from BAN results in a better bronchodilator response than twice the nominal dose of this drug inhaled from CON, which is due to the absence of drug loss during the expiratory phase and therefore greater pulmonary deposition.

Effect of diagnosis delay on pulmonary function in children with asthma

BACKGROUND

The effects of a delayed diagnosis of asthma on lung function in children have not been well investigated. Therefore, a retrospective cohort study was conducted in a children's hospital to analyse the effect of delayed diagnosis time on lung function in children with asthma.

METHODS

We conducted a retrospective cohort study in Jinan Children's Hospital from January 1, 2010, to December 31, 2020. All children were divided into different groups according to the presence or absence of rhinitis, age at first onset (first coughing and wheezing attack) and delayed diagnosis duration (≤ 3 months, 3-12 months, 1-3 years, 3-5 years and > 5 years).

RESULTS

A total of 1,014 children with asthma were included in this study. The median (quartile) delay in asthma diagnosis among all participants was 11 (2, 26) months. The shortest delay in diagnosis time was on the same day of onset, and the longest delay in diagnosis time was 10 years. The median (quartile) duration of delayed diagnosis was 10 (2, 26) months in 307 asthmatic children without rhinitis and 11 (2, 26) months in 707 children with asthma and rhinitis (P < 0.05). The delayed diagnosis time was shorter among female children than among male children (P < 0.05), and the first %predicted forced volume capacity (FVC%pred) results for females were higher than those for males (P = 0.036). The children whose age at first asthma onset was ≤ 3 years had a longer delayed diagnosis duration than those whose age at first onset was > 3 years (P < 0.05). The FVC%pred and %predicted forced expiratory volume in 1 s (FEV1%pred) in the first and second pulmonary function tests were significantly lower in the five delayed diagnosis groups (all P < 0.05). After standardised treatment for 3-6 months, FVC%pred showed a significant difference in the third test among the 5 groups (P < 0.05), but the other pulmonary function indices showed no significant difference. Logistic regression analysis showed that longer delay and young age of onset were associated with lower lung function (P < 0.05), whereas sex, rhinitis and eczema had no significant effects (all P > 0.05) on FVC%pred and FEV1%pred.

CONCLUSION

Although delayed asthma diagnosis can lead to lung function impairment in children with asthma, lung function can be improved quickly after standardised treatment. Therefore, early asthma diagnosis and standardised treatment are very important.

Atopic asthma as a potentially significant but unrecognized risk factor for Kawasaki disease in children

OBJECTIVES

Childhood asthma is known to be associated with risks of both respiratory and non-respiratory infections. Little is known about the relationship between asthma and the risk of Kawasaki disease (KD). We assessed associations of asthma status and asthma phenotype (e.g. atopic asthma) with KD.

METHODS

We performed a population-based retrospective case-control study, using KD cases between January 1, 1979, and December 31, 2016, and two matched controls per case. KD cases were defined by the American Heart Association diagnostic criteria. Asthma status prior to KD (or control) index dates was ascertained by the two asthma criteria, Predetermined Asthma Criteria (PAC) and Asthma Predictive Index (API, a surrogate phenotype of atopic asthma). We assessed whether 4 phenotypes (both PAC + and API+; PAC + only; API + only, and non-asthmatics) were associated with KD.

RESULTS

There were 124 KD cases during the study period. The group having both PAC + and API + was significantly associated with the increased odds of KD, compared to non-asthmatics (odds ratio [OR] 4.3; 95% CI: 1.3 - 14.3). While asthma defined by PAC was not associated with KD, asthma defined by PAC positive with eosinophilia (≥4%) was significantly associated with the increased odds of KD (OR: 6.7; 95% CI: 1.6 - 28.6) compared to non-asthmatics. Asthma status defined by API was associated with KD (OR = 4.7; 95% CI: 1.4-15.1).

CONCLUSIONS

Atopic asthma may be associated with increased odds of KD. Further prospective studies are needed to determine biological mechanisms underlying the association between atopic asthma and increased odds of KD.

Enigma variations: The multi-faceted problems of pre-school wheeze

Numerous publications on wheezing disorders in children younger than 6 years have appeared in the medical literature over the last decades with the aim of shedding light on the mechanistic pathways (endotypes) and treatment. Nevertheless, there is yet no consensus as to the appropriate way to manage preschool wheeze mainly because of the lack of a clear definition of "preschool asthma" and the paucity of scientific evidence concerning its underlying endotypes. A symptom-based approach is inadequate since the human airway can respond to external stimuli with a limited range of symptoms and signs, including cough and wheeze, and these manifestations represent the final expression of many clinical entities with potentially different pathophysiologies requiring different individualized treatments. Hence, new studies challenge the symptom-based approach and promote the importance of managing the wheezy child based on the "airway phenotype." This will enable the clinician to identify not only the child with a serious underlying pathology (e.g., a structural airway disorder or immunodeficiency) who is in need of prompt and specific treatment but also increase the specificity of treatment for the child with symptoms suggestive of an "asthma" syndrome. In the latter case, focus should be given to the identification of treatable traits. This review summarizes the current understanding in management of preschool wheezing and highlights the unmet need for further research.

Global burden of asthma associated with high body mass index from 1990 to 2019

BACKGROUND

High body mass index (BMI) plays a key role in the progression of asthma and asthma related to high BMI resulted in a high burden of disease globally.

OBJECTIVE

This study aimed to explore the geographical and temporal trends in the global burden of asthma associated with high BMI from 1990 to 2019.

METHODS

This is a retrospective analysis with data based on the Global Burden of Disease Study 2019 database. The deaths, disability-adjusted life-years (DALYs), age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) were estimated according to sex, age and sociodemographic indexes (SDI) levels. Estimated annual percentage change (EAPC) was used to evaluate the variation trends of ASMR and ASDR from 1990 to 2019.

RESULTS

In 2019, the number of global asthma deaths and DALYs related to high BMI increased by 69.69% and 63.91% respectively compared with 1990, among which more deaths and DALYs occurred in females. The corresponding ASMR and ASDR showed a slightly decreasing tendency globally. South Asia accounted for the highest number of deaths and DALYs, with India ranked first worldwide in 2019. The number of deaths and DALYs mainly appeared in individuals 60-79 years old and 55-69 years old respectively from 1990 to 2019. The heaviest burden existed in the low-middle SDI region.

CONCLUSION

The global asthma burden associated with obesity increased in absolute value but the standardized burden decreased slightly. Large variations existed in the high BMI-related asthma burdens among sexes, ages and regions.

Assessment of level of asthma control and related factors in children attending pediatric respiratory clinics in Addis Ababa, Ethiopia

Background

Asthma is a common airways disease with significant morbidity and mortality in all ages. Studies of pediatric asthma control and its determinants yielded variable results across settings. However, there is paucity of data on asthma control and its factors in Ethiopian children. We aimed to assess the level of asthma control and the related factors in children attending pediatric respiratory clinics at three tertiary hospitals in Addis Ababa.

Methods

We conducted a cross-sectional study from March 1 to August 30, 2020 using standardized questionnaires and review of patient’s charts. Data was analyzed using SPSS software for window version 26.

Results

A total of 105 children (56.2% male) were included in the study. The mean age (± SD) and age at Asthma diagnosis (± SD) were 6 (± 3.3) and 4 (± 2.8) respectively. Uncontrolled asthma was present in 33 (31%) of children. Comorbidities (Atopic dermatitis and allergic Rhinitis (AOR = 4.56; 95% CI 1.1–18.70; P = 0.035), poor adherence to controller medications (AOR = 3.23; 95% CI 1.20–10.20; P = 0.045), inappropriate inhaler technique (AOR = 3.48; 95% CI 1.18–10.3; P = 0.024), and lack of specialized care (AOR = 4.72; 95% CI 1.13–19.80; P = 0.034) were significantly associated with suboptimal asthma control.

Conclusion

One-third of children attending pediatric respiratory clinics in Addis Ababa had uncontrolled Asthma. Treatment of comorbidities, training of appropriate inhaler techniques, optimal adherence to controllers, and proper organization of clinics should be emphasized to improve asthma control among children.

Tiotropium bromide as adjunct therapy in children with asthma: a clinical experience

Background

The Global Initiative for Asthma has only recently added tiotropium bromide as adjunct controller therapy in severe asthma (Step 4 or 5) in adults (2015) and children (2019). Although not yet approved for pediatric use by Health Canada, it has been occasionally offered by asthma specialists as a therapeutic trial in children with troublesome asthma or treatment for adverse effects. The objective of this study was to describe the indications and real-life clinical experience in initiating tiotropium in children with asthma.

Methods

We designed a retrospective mixed-method case series study of children aged 1–17 years who initiated tiotropium in our tertiary-care centre between 2013 and 2020. Clinical information was extracted from electronic medical records and tiotropium dispensing, from drug claims. Parents/children and physicians independently completed a questionnaire about treatment goals, perceived efficacy, safety, satisfaction, and lessons learned.

Results

The 34 (11 females; 23 males) children had a median (range) age of 9.1 (1.4–17.8) years. Children were primarily on Step 4 (85%) or 5 (6%) prior to tiotropium initiation, yet most (84%) did not increase their treatment step after tiotropium initiation. The physicians’ treatment goals were to improve asthma control, alleviate adverse effects of current therapy, and/or improve lung function. The most improved symptoms were coughing/moist cough, difficulty breathing, whistling breath, and bronchial secretions/mucus. Although most parents and physicians reported a significant benefit with tiotropium bromide, physicians particularly remarked, as their “lesson learned’, on the improvement in chronic symptoms in asthmatic children, particularly those with prominent moist cough and in lung function, in those with seemingly none (or incompletely) reversible obstruction as well as the ability to decrease the ICS and/or LABA dose to lessen adverse effects. A few physicians raised caution on the risk of lower adherence with an additional inhaler.

Conclusion

In children with severe asthma on Step 4 or 5, tiotropium bromide was primarily used as substitute, rather than additional, adjunct therapy to improve asthma control, alleviate adverse effects, and/or to improve lung function. The latter two indications, combined with its perceived effectiveness in children with prominent moist cough, also suggest additional indications of tiotropium to be formally explored.

Artificial intelligence-assisted clinical decision support for childhood asthma management: A randomized clinical trial

RATIONALE

Clinical decision support (CDS) tools leveraging electronic health records (EHRs) have been an approach for addressing challenges in asthma care but remain under-studied through clinical trials.

OBJECTIVES

To assess the effectiveness and efficiency of Asthma-Guidance and Prediction System (A-GPS), an Artificial Intelligence (AI)-assisted CDS tool, in optimizing asthma management through a randomized clinical trial (RCT).

METHODS

This was a single-center pragmatic RCT with a stratified randomization design conducted for one year in the primary care pediatric practice of the Mayo Clinic, MN. Children (<18 years) diagnosed with asthma receiving care at the study site were enrolled along with their 42 primary care providers. Study subjects were stratified into three strata (based on asthma severity, asthma care status, and asthma diagnosis) and were blinded to the assigned groups.

MEASUREMENTS

Intervention was a quarterly A-GPS report to clinicians including relevant clinical information for asthma management from EHRs and machine learning-based prediction for risk of asthma exacerbation (AE). Primary endpoint was the occurrence of AE within 1 year and secondary outcomes included time required for clinicians to review EHRs for asthma management.

MAIN RESULTS

Out of 555 participants invited to the study, 184 consented for the study and were randomized (90 in intervention and 94 in control group). Median age of 184 participants was 8.5 years. While the proportion of children with AE in both groups decreased from the baseline (P = 0.042), there was no difference in AE frequency between the two groups (12% for the intervention group vs. 15% for the control group, Odds Ratio: 0.82; 95%CI 0.374-1.96; P = 0.626) during the study period. For the secondary end points, A-GPS intervention, however, significantly reduced time for reviewing EHRs for asthma management of each participant (median: 3.5 min, IQR: 2-5), compared to usual care without A-GPS (median: 11.3 min, IQR: 6.3-15); p<0.001). Mean health care costs with 95%CI of children during the trial (compared to before the trial) in the intervention group were lower than those in the control group (-$1,036 [-$2177, $44] for the intervention group vs. +$80 [-$841, $1000] for the control group), though there was no significant difference (p = 0.12). Among those who experienced the first AE during the study period (n = 25), those in the intervention group had timelier follow up by the clinical care team compared to those in the control group but no significant difference was found (HR = 1.93; 95% CI: 0.82-1.45, P = 0.10). There was no difference in the proportion of duration when patients had well-controlled asthma during the study period between the intervention and the control groups.

CONCLUSIONS

While A-GPS-based intervention showed similar reduction in AE events to usual care, it might reduce clinicians' burden for EHRs review resulting in efficient asthma management. A larger RCT is needed for further studying the findings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02865967.

Heterogeneity of emergency treatment practices in wheezing preschool children

AIM

Our aim was to survey treatment practices used for preschool children with wheezing in emergency rooms (ER) focussing on inhalation device choice and handling, face mask use, salbutamol dosing and written instructions. We sought to assess whether current protocols are in line with published evidence and guidelines.

METHODS

This is a cross-sectional survey done in paediatric ER units located in Finnish municipalities with more than 10 000 inhabitants.

RESULTS

Of the 100 units contacted, 50% responded. More than 50% of the units used nebulisers. Only 13% of the units administered salbutamol in single puffs. More than 30% of the units lacked criteria on face mask use. Poor co-operation had no effect on the dose of salbutamol in 62% of the units. Ensuring tight mask-to-face seal was included in the training in 20% of the units. A written action plan was provided to the caregivers in 28% of the units.

CONCLUSION

ER treatment guidelines for preschool children with wheezing are poorly endorsed. Research is needed to identify approaches to guideline implementation that are specific for primary care. Clinical research should focus on strengthening recommendations that are currently not embraced. ER treatment protocols need to be updated and adherence to guidelines should be re-evaluated.

Respiratory outcomes in the first 10 years of life in children with gastroschisis: A retrospective cohort study

BACKGROUND

Little attention has been given to the long-term respiratory outcomes of children with gastroschisis. The purpose of this study was to determine if gastroschisis survivors have more respiratory illnesses in their first 10 years of life compared with age-matched controls.

METHODS

We performed a retrospective cohort study of all gastroschisis children born in Manitoba between 1991 and 2017. Gastroschisis cases were identified from a clinical database, and a date of birth-matched control cohort was constructed from a population-based data repository. International Classification of Disease codes were used to compare the risk and frequency of respiratory diagnoses for children with gastroschisis to date of birth-matched controls from 0-5 years of age and 5-10 years of age.

RESULTS

The 0-5 years of age analysis included 117 gastroschisis cases and 1205 date of birth-matched controls; children with gastroschisis had a higher risk of asthma (relative risk [RR] = 1.46; 95% confidence interval [CI]: 1.03, 2.55; p = .029), acute bronchitis/bronchiolitis (RR = 1.61; 95% CI: 1.27, 2.03; p < .001), pneumonia (RR = 1.99; 95% CI: 1.45, 2.72; p < .001), viral pneumonia (RR = 5.15; 95% CI: 1.79, 14.81; p = .007), and pneumonia due to unspecified organism (RR = 2.06; 95% CI: 1.45, 2.92; p < .001). Gastroschisis children 0-5 years of age were also diagnosed more frequently with bronchitis/bronchiolitis (RR = 2.14; 95% CI: 1.79, 2.57; p < .001) and viral pneumonia (RR = 8.10; 95% CI: 3.79, 17.31; p < .001). The 5-10 years of age analysis included 73 cases and 738 controls; no difference in the risk of respiratory illness was found for gastroschisis cases and controls in this age group. However, gastroschisis cases were more frequently diagnosed with bacterial pneumonia (RR = 3.03; 95% CI: 1.67, 5.51; p < .001) and influenza (RR = 3.03; 95% CI: 1.67, 5.51; p < .001).

CONCLUSION

Our study shows that children with gastroschisis have an increased risk of asthma and respiratory infections compared with children without gastroschisis, most noticeably in the first 5 years of life.

How Does the Canadian Acute Respiratory Illness and Flu Scale Relate to Other Scales in Pediatric Asthma Exacerbations?

Objectives: In children with asthma exacerbations, we evaluated the relationship between Canadian Acute Respiratory Illness and Flu Scale (CARIFS) scores and (a) Asthma Diary Scale (ADS) scores for 14 days; (b) Pediatric Asthma Caregiver's Quality of Life (QoL) Questionnaire (PACQLQ) scores on days 1, 7 and 14; (c) viral detection. We hypothesized that in children with acute asthma, CARIFS scores correlate with ADS and PACQLQ scores over time and that viruses have little impact on CARIFS scores.Methods: In children aged 2-16 years who presented with acute asthma to the Emergency Departments of 2 hospitals, we documented the clinical history, examination, asthma severity at baseline and on presentation. Eighteen respiratory pathogens were determined by PCR on nasopharyngeal aspirate (NPA) collected on recruitment. The parent(s) recorded their child's daily CARIFS and ADS and weekly PACQLQ for 14 days. We used Spearman's correlation to relate the scores of 108 children.Results: CARIFS scores correlated well with ADS scores throughout 14 days (r_s ranged 0.30-0.67). CARIFS and PACQLQ scores correlated -0.28, -0.14 and -0.44 on days 1, 7 and 14 respectively. There was no significant difference in CARIFS scores between children whose NPAs were PCR virus-positive or -negative over 14 days.Conclusions: CARIFS and ADS scores correlated well as a disease severity measure during the recovery period in children with acute asthma and this was not influenced by the virus state. The ADS may be used as an alternative in selected situations. The CARIFS reflects different aspects to acute asthma severity and QoL.

Association between asthma control trajectories in preschoolers and disease remission

INTRODUCTION

Early disease morbidity has been associated with asthma persistence in wheezing preschoolers; however, whether asthma control trajectories shortly after diagnosis could influence remission is unknown. We examined the association between asthma control trajectories 2 years post-diagnosis in preschoolers and subsequent disease remission.

METHODS

We conducted a multicentre population-based retrospective cohort study consisting of 48 687 children with asthma diagnosed before 5 years old and born between 1990 and 2013 in four Canadian provinces who had prolonged disease activity post-diagnosis. Prolonged disease activity was defined as one or more medical visits or medications for asthma every 6-month period for at least four of the six periods post-diagnosis. Follow-up began at 3 years post-diagnosis (at cohort entry). Remission was defined as 2 consecutive years without drug claims or medical visits for asthma or asthma-like conditions following cohort entry. Asthma control trajectories, ascertained over four 6-month periods following diagnosis using a validated index, were classified as: "controlled throughout", "improving control", "worsening control", "out of control throughout" and "fluctuating control". Adjusted Cox models estimated associations between asthma control trajectories and time to remission. A random effects meta-analysis summarised province-specific hazard ratios (HRs).

RESULTS

The pooled remission rate was 8.91 (95% CI 8.80-9.02) per 100 person-years. Compared with children controlled throughout, poorer asthma control was associated with incrementally lower hazard ratios of remission in four other trajectories: improving control (HR 0.89, 95% CI 0.82-0.96), fluctuating control (HR 0.78, 95% CI 0.71-0.85), worsening control (HR 0.68, 95% CI 0.62-0.75) and out of control throughout (HR 0.52, 95% CI 0.45-0.59).

CONCLUSIONS

Asthma control trajectories 2 years following a diagnosis in preschoolers were associated with remission, highlighting the clinical relevance of documenting control trajectories in early life.

Impact of a diagnostic therapeutic educational pathway program for asthma management in preschool children

Background

Preschool children with clinically-diagnosed asthma have a higher rate of emergency department visits and consume more resources for management than older children. However, no clinical trials have yet been performed measuring the impact of a combined diagnostic, therapeutic and educational pathway regimen for evaluation of wheezing control in children aged less than 6 years.

The purpose of the present study was to assess the impact of a pediatric program developed in Italy, the Diagnostic Therapeutic Educational Pathway (DTEP), for asthma management in children less than 6 years old attending an asthma referral center.

Methods

This is a retrospective population-based cohort study performed in children with asthma aged 0–5 years, attending at “Io e l’Asma center”, Brescia, Italy between September 2007 and December 2014. The incidence rates (IRs) of hospitalization, emergency room visits, use of outpatient services and drug usage for dyspnea, wheezing, or respiratory symptoms were evaluated for time periods prior to and after DTEP intervention.

Results

A total of 741 patients, aged 0–5 years completed the DTEP, including 391 and 350 children aged 0–2 and 3–5 years, respectively. The percentage of children aged 0–2 and 3–5 years showing improved control of wheezing symptoms during the 1st to 3rd visit interval as a result of the DTEP intervention increased from 39.5 to 60.9% and from 25.5 to 75.5%, respectively. During these periods, the IRs showed a significant decrease for all outcomes, from-8.6% to − 80.4%. Although specific IRs for drug prescriptions declined, particularly for LABA plus corticosteroids, antibiotics, and systemic corticosteroids, they increased for SABA, inhaled corticosteroid and leukotriene receptor antagonist usage.

Conclusions

The results suggest that a real-world assessment of the integrated DTEP program for preschool children provides evidence for improved wheezing control and reduction of adverse therapeutic related outcomes.

Patterns of respiratory health services utilization from birth to 5 years of children who experienced adverse birth outcomes

Introduction

Adverse birth outcomes have important consequences for future lung health. We evaluated patterns of respiratory health services utilization in early childhood among children born preterm (PTB), small and large for gestational age at term (SGA and LGA, respectively), and appropriate-for-gestational age at term.

Materials and methods

We conducted a population-based retrospective cohort study using administrative health data of all singleton live births in Alberta, Canada between 2005–2010. Data on hospitalizations and emergency department (ED) visits from birth to 5 years were collected for asthma, bronchitis, bronchiolitis, croup, influenza, pneumonia, and other acute upper and lower respiratory tract infections (other URTI and other LRTI, respectively). Adjusted rate ratios were estimated for respiratory ED visits and hospitalizations for adverse birth outcomes using the appropriate-for-gestational age at term group as reference. Age-specific trajectories of total respiratory health services utilization rates for each group were estimated in Poisson models.

Results

A total of 293,764 episodes of respiratory care from 206,994 children were analyzed. Very PTB children had the highest rates of health services use for all respiratory conditions, particularly for asthma, pneumonia, and bronchiolitis hospitalizations. Moderate/late PTB children also had elevated ED visits and hospitalizations for all respiratory conditions. Children born SGA showed high rates of ED visits for other LRTI, and of hospitalizations for bronchitis, bronchiolitis, and other URTI. Children born LGA had high rates of croup and other URTI ED visits, and of bronchiolitis and bronchiolitis hospitalizations. Age-specific trajectories showed a decreasing trend in the rates of total respiratory health service utilization from birth to five years of age for all groups studied. Children born PTB and LGA at term significantly required more respiratory health services over time compared to the reference group.

Conclusion

Patterns of paediatric respiratory health services utilization vary according to gestational age and fetal growth.

Determinants of cough and caregivers' quality of life in pediatric asthma exacerbations

OBJECTIVES

In hospitalized and nonhospitalized children with asthma exacerbations, we evaluated the determinants of (a) prolonged cough on day-14 and (b) asthma quality of life (QoL) questionnaires for parents (PACQLQ) on day-21. We hypothesized that children with more severe acute asthma are more likely to have prolonged cough and/or poorer PACQLQ during the recovery phase.

DESIGN

Prospective cohort study performed during 2009-2011.

METHODOLOGY

Two hundred and forty-four children aged 2-16 years presenting with acute asthma to the Emergency Departments of two hospitals were recruited. Clinical history, examination, baseline asthma severity, and acute asthma severity on presentation were documented. Validated daily cough diaries and weekly PACQLQ were recorded for 14 and 21 days, respectively.

RESULTS

34.4% and 32.2% of children who returned the daytime and nighttime cough diaries respectively had a prolonged cough. Those on regular inhaled corticosteroids (ICS) were significantly more likely to have a daytime or nighttime cough score of ≥1 on day-14 (odds ratio [OR_adjusted ] = 4.70, 95% confidence interval [CI] 1.65, 13.35, p = .004 and OR_adjusted  = 2.65, 95% CI 1.05, 6.69, p = .040, respectively). PACQLQ on day-21 was significantly poorer in younger children (mean difference [MD] = -0.04 per year, 95% CI -0.08, -0.01, p = .016), those on ICS (MD = -0.31, 95% CI -0.52, -0.09, p = .005), leukotriene antagonists (MD = -0.42, 95% CI -0.83, -0.02, p = .040) and in those who had an unplanned visit for asthma on day-21 (MD = -1.20, 95% CI -1.61, -0.78, p = .0001).

CONCLUSIONS

Post an acute asthma exacerbation, children on regular ICS were more likely to have prolonged cough and poorer QoL. While this may be reflective of asthma severity or control, its association deserves further evaluation.

Effects of Rurality and Geographical Distance on Unplanned Emergency Department Utilization for Children With Asthma: A Population Level Retrospective Cohort Study

BACKGROUND

Asthma is a highly prevalent chronic disease among Ontario children; however, the extent to which rural status and distance are associated with unplanned emergency department (ED) use by this population is largely unknown.

OBJECTIVE

To explore the impact of rurality and geographical distance to primary and specialist care services on healthcare utilization by analyzing the use of unplanned ED services.

METHODS

A population level retrospective cohort study of Ontario children ages 5-14 with newly diagnosed asthma was conducted using health administrative data from Institute for Clinical Evaluative Sciences (ICES). Adjusted logistic regression models were used to analyze the association between unplanned ED use with rural status and distance to general practitioner/family physician (GP/FP) and specialist healthcare services, while controlling for confounders.

RESULTS

In total, 19,732 individuals met the inclusion criteria. Individuals who lived in rural locations (OR 2.00, 95% CI 1.64-2.44) and travelled >50 km to a GP/FP (OR 1.25, 95% CI 1.06-1.48) or specialist (OR 1.20, 95% CI 1.05-1.38) were more likely to utilize an ED.

CONCLUSION

Children with asthma utilize healthcare services differently based on rural status and distance to services. To ensure equitable access to care, there is a need to accommodate for these factors in the planning and provision of asthma healthcare services.

Predictors of Hospitalization for Children With Croup, a Population-Based Cohort Study

OBJECTIVES

We sought to determine predictors of hospitalization for children presenting with croup to emergency departments (EDs), as well as predictors of repeat ED presentation and of hospital readmissions within 18 months of index admission. We also aimed to develop a practical tool to predict hospitalization risk upon ED presentation.

METHODS

Multiple deterministically linked health administrative data sets from Ontario, Canada, were used to conduct this population-based cohort study between April 1, 2006 and March 31, 2017. Children born between April 1, 2006, and March 31, 2011, were eligible if they had 1 ED visit with a croup diagnosis. Multivariable logistic regression was used to determine factors associated with hospitalization, subsequent ED visits, and subsequent croup hospitalizations. A multivariable prediction tool and associated scoring system were created to predict hospitalization risk within 7 days of ED presentation.

RESULTS

Overall, 1811 (3.3%) of the 54 981 eligible children who presented to an Ontario ED were hospitalized. Significant hospitalization predictors included age, sex, Canadian Triage and Acuity Scale score, gestational age at birth, and newborn distress. Younger patients and boys were more likely to revisit the ED for croup. Our multivariable prediction tool could forecast hospitalization up to a 32% probability for a given patient.

CONCLUSIONS

This study is the first population-based study in which predictors of hospitalization for croup based on demographic and historical factors are identified. Our prediction tool emphasized the importance of symptom severity on ED presentation but will require refinement before clinical implementation.

The course of asthma: A population-based 10-year study examining asthma remission in children diagnosed with asthma in preschool

BACKGROUND

The natural course of asthma may differ depending on the age of onset.

OBJECTIVE

To investigate predictors of asthma remission with a focus on the age of asthma onset.

METHODS

The study was a retrospective birth cohort of children with asthma in Saskatchewan, Canada. Using the Saskatchewan Ministry of Health databases, we identified children with a diagnosis of asthma in the first 6 years of life and who had at least 10 years of follow-up after diagnosis (n = 22 563). Of these, we included 6393 children either with persistent asthma (≥1 physician visit or hospitalization for asthma [PVHA] during each year of follow-up) and those who had remission (had PVHA in the first year after diagnosis but at some point during the follow-up no longer received PVHA until end of the study). We used survival analysis to examine associations between remission and age of asthma onset.

RESULTS

Of the study participants, 87.2% had early-onset (≤3 years) and 12.8% had late-onset (4-6 years) asthma. Over the 10-years of follow-up, the rate of asthma remission was 37 per 100 person-years. Early-onset asthma (hazard ratio [HR] = 1.10; 95%confidence interval [CI]: 1.01-1.20), being female (HR = 1.12; 95%CI: 1.07-1.18), living in a rural (HR = 1.20; 95%CI: 1.14-1.27) and medium urban (HR = 1.16; 95%CI: 1.08-1.26) location were positively associated with remission while history of atopy decreased likelihood of remission (HR = 0.73; 95%CI: 0.54-0.97).

CONCLUSION

Most children with asthma experienced remission, especially those with the onset of symptoms within the first 3 years of life.

A diagnostic codes-based algorithm improves accuracy for identification of childhood asthma in archival data sets

OBJECTIVE

While a single but truncated ICD code (493) had been widely used for identifying asthma in asthma care and research, it significantly under-identifies asthma. We aimed to develop and validate a diagnostic codes-based algorithm for identifying asthmatics using Predetermined Asthma Criteria (PAC) as the reference.

METHODS

This is a retrospective cross-sectional study which utilized two different coding systems, the Hospital Adaptation of the International Classification of Diseases, Eighth Revision (H-ICDA) and the International Classification of Diseases, Ninth Revision (ICD-9). The algorithm was developed using two population-based asthma study cohorts, and validated in a validation cohort, a random sample of the 1976-2007 Olmsted County Birth Cohort. Performance of the diagnostic codes-based algorithm for ascertaining asthma status against manual chart review for PAC (gold standard) was assessed by determining both criterion and construct validity.

RESULTS

Among eligible 267 subjects of the validation cohort, 50% were male, 70% white, and the median age at last follow-up was 17 (interquartile range, 8.7-24.4) years. Asthma prevalence by PAC through manual chart review was 34%. Sensitivity and specificity of the codes-based algorithm for identifying asthma were 82% and 98% respectively. Associations of asthma-related risk factors with asthma status ascertained by the code-based algorithm were similar to those by the manual review.

CONCLUSIONS

The diagnostic codes-based algorithm for identifying asthmatics improves accuracy of identification of asthma and can be a useful tool for large scale studies in a setting without automated chart review capabilities.

Vitamin D and Immunity in Infants and Children

The last couple of decades have seen an explosion in our interest and understanding of the role of vitamin D in the regulation of immunity. At the molecular level, the hormonal form of vitamin D signals through the nuclear vitamin D receptor (VDR), a ligand-regulated transcription factor. The VDR and vitamin D metabolic enzymes are expressed throughout the innate and adaptive arms of the immune system. The advent of genome-wide approaches to gene expression profiling have led to the identification of numerous VDR-regulated genes implicated in the regulation of innate and adaptive immunity. The molecular data infer that vitamin D signaling should boost innate immunity against pathogens of bacterial or viral origin. Vitamin D signaling also suppresses inflammatory immune responses that underlie autoimmunity and regulate allergic responses. These findings have been bolstered by clinical studies linking vitamin D deficiency to increased rates of infections, autoimmunity, and allergies. Our goals here are to provide an overview of the molecular basis for immune system regulation and to survey the clinical data from pediatric populations, using randomized placebo-controlled trials and meta-analyses where possible, linking vitamin D deficiency to increased rates of infections, autoimmune conditions, and allergies, and addressing the impact of supplementation on these conditions.

Expert artificial intelligence-based natural language processing characterises childhood asthma

INTRODUCTION

The lack of effective, consistent, reproducible and efficient asthma ascertainment methods results in inconsistent asthma cohorts and study results for clinical trials or other studies. We aimed to assess whether application of expert artificial intelligence (AI)-based natural language processing (NLP) algorithms for two existing asthma criteria to electronic health records of a paediatric population systematically identifies childhood asthma and its subgroups with distinctive characteristics.

METHODS

Using the 1997-2007 Olmsted County Birth Cohort, we applied validated NLP algorithms for Predetermined Asthma Criteria (NLP-PAC) as well as Asthma Predictive Index (NLP-API). We categorised subjects into four groups (both criteria positive (NLP-PAC⁺/NLP-API⁺); PAC positive only (NLP-PAC⁺ only); API positive only (NLP-API⁺ only); and both criteria negative (NLP-PAC^-/NLP-API^-)) and characterised them. Results were replicated in unsupervised cluster analysis for asthmatics and a random sample of 300 children using laboratory and pulmonary function tests (PFTs).

RESULTS

Of the 8196 subjects (51% male, 80% white), we identified 1614 (20%), NLP-PAC⁺/NLP-API⁺; 954 (12%), NLP-PAC⁺ only; 105 (1%), NLP-API⁺ only; and 5523 (67%), NLP-PAC^-/NLP-API^-. Asthmatic children classified as NLP-PAC⁺/NLP-API⁺ showed earlier onset asthma, more Th2-high profile, poorer lung function, higher asthma exacerbation and higher risk of asthma-associated comorbidities compared with other groups. These results were consistent with those based on unsupervised cluster analysis and lab and PFT data of a random sample of study subjects.

CONCLUSION

Expert AI-based NLP algorithms for two asthma criteria systematically identify childhood asthma with distinctive characteristics. This approach may improve precision, reproducibility, consistency and efficiency of large-scale clinical studies for asthma and enable population management.

Vitamin D in the prevention of exacerbations of asthma in preschoolers (DIVA): protocol for a multicentre randomised placebo-controlled triple-blind trial

INTRODUCTION

Preschoolers have the highest rate of emergency visits and hospitalisations for asthma exacerbations of all age groups, with most triggered by upper respiratory tract infections (URTIs) and occurring in the fall or winter. Vitamin D insufficiency is highly prevalent in Canadian preschoolers with recurrent asthma exacerbations, particularly in winter. It is associated with more URTIs and, in patients with asthma, more oral corticosteroid (OCS) use. Although evidence suggests that vitamin D supplements significantly decrease URTIs and asthma exacerbations requiring OCS, there is insufficient data in preschoolers. This study aims to determine the impact of vitamin D₃ supplementation on exacerbations requiring OCS, in preschoolers with recurrent URTI-induced asthma exacerbations.

METHODS AND ANALYSIS

This is a phase III, randomised, triple-blind, placebo-controlled, parallel-group multicentre trial of vitamin D₃ supplementation in children aged 1-5 years, with asthma triggered by URTIs and a recent history of frequent URTIs and OCS use. Children (n=865) will be recruited in the fall and early winter and followed for 7 months. They will be randomised to either the (1) intervention: two oral boluses of 100 000 international unit (IU) vitamin D₃ (3.5 months apart) with 400 IU vitamin D₃ daily; or (2) control: identical placebo boluses with daily placebo. The primary outcome is the number of exacerbations requiring OCS per child, documented by medical and pharmacy records. Secondary outcomes include number of laboratory-confirmed viral URTIs, exacerbation duration and severity, parent functional status, healthcare use, treatment deintensification, cost and safety.

ETHICS AND DISSEMINATION

This study has received ethical approval from all sites. Results will be disseminated via international conferences and manuscripts targeting paediatricians and respirologists, and to families of asthmatic children via our Quebec parents-partners outreach programme. If proven effective, findings may markedly influence the management of URTI-induced asthma in high-morbidity preschoolers and could be directly implemented into practice with an update to clinical guidelines.

TRIAL REGISTRATION NUMBER

NCT03365687.

Agreement between a health claims algorithm and parent-reported asthma in young children

INTRODUCTION

Asthma prevalence is commonly measured in national surveys by questionnaire. The Ontario Asthma Surveillance Information System (OASIS) developed a validated health claims diagnosis algorithm to estimate asthma prevalence. The primary objective was to assess the agreement between two approaches of measuring asthma in young children. Secondary objectives were to identify concordant and discordant pairs, and to identify factors associated with disagreement.

STUDY DESIGN AND SETTING

A measurement study to evaluate the agreement between the OASIS algorithm and parent-reported asthma (criterion standard). Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. Multivariable logistic regression was used to determine factors associated with disagreement.

RESULTS

Healthy children aged 1 to 5 years (n =3642) participating in the TARGet Kids! practice based research network 2008-2013 in Toronto, Canada were included. Prevalence of asthma was 14% and 6% by the OASIS algorithm and parent-reported asthma, respectively. The Kappa statistic was 0.43, sensitivity 81%, specificity 90%, PPV 34%, and NPV 99%. There were 3249 concordant and 393 discordant pairs. Statistically significant factors associated with asthma identified by OASIS but not parent report included: male sex, higher zBMI, and parent history of asthma. Males were less likely to have asthma identified by parent report but not OASIS.

CONCLUSION

The OASIS algorithm identified more asthma cases in young children than parent-reported asthma. The OASIS algorithm had high sensitivity, specificity, and NPV but low PPV relative to parent-reported asthma. These findings need replication in other populations.

Respiratory pathogens and clinical outcomes in children with an asthma exacerbation: A systematic review

BACKGROUND

In asthmatic children, respiratory pathogens are identified in 60%-80% of asthma exacerbations, contributing to a significant burden of illness. The role of pathogens in the clinical evolution of exacerbations is unknown.

OBJECTIVE

We systematically reviewed the association between the presence of pathogens and clinical outcomes in children with an asthma exacerbation.

METHOD

PubMed, EMBASE, BIOSIS, and the Cochrane Central Register of Controlled Trials were searched up to October 2016 for studies reporting on respiratory pathogen exposure and clinical outcome. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for quality assessment.

RESULTS

Twenty-eight observational studies (N = 4,224 children) reported on 112 different associations between exposure to any pathogen (n = 45), human rhinovirus (HRV; n = 34), atypical bacteria (n = 21), specific virus (n = 11), or bacteria (n = 1) and outcomes of exacerbation severity (n = 26), health care use (n = 38), treatment response (n = 19), and morbidity (n = 29). Restricting the analysis only to comparisons with a low to moderate risk of bias, we observed an association between HRV and higher exacerbation severity on presentation (regression p = .016) and between the presence of any pathogen and emergency department treatment failure (odds ratio [OR] = 1.57; 95% CI 1.04% to 2.37%). High-quality evidence for effect on morbidity or health care use is lacking.

CONCLUSIONS

Further research on the role of pathogen-treatment interaction and outcomes is required to inform the need for point-of-care, real-time testing for pathogens. Studies with a sufficiently large sample size that address selection bias, correctly adjust for confounding, and rigorously report core patient-centred outcomes are necessary to improve knowledge.

Long-term asthma-related readmissions: comparison between children admitted and not admitted to the intensive care unit for critical asthma

OBJECTIVES

To compare the time to asthma-related readmission between children admitted to the intensive care unit (ICU) for asthma and those with a non-ICU hospitalization in the United States and to explore risk factors associated with readmission among children admitted in the ICU.

METHODS

In this retrospective cohort study, we included children aged 2-17 years in the State Inpatient Database (2005-2014) from four U.S. states who were hospitalized for asthma. We compared the time to asthma-related readmissions and emergency department (ED) visit between children admitted and not admitted to the ICU using the log-rank test. Among those admitted to the ICU, we explored factors associated with readmission using Cox regression.

RESULTS

66 835 children were hospitalized for asthma, with 14.0% admitted to the ICU, and 12 844 were readmitted for asthma while 22 915 had an asthma-related ED visit. The time to asthma-related readmission was shorter in the ICU group compared to the non-ICU group (p < 0.001), but the time to asthma-related ED visit did not differ between the two groups (p = 0.43). Being preschool-aged, female, Black, and having lower household income and a longer length of stay during the initial hospitalization conferred a higher risk of asthma-related readmission among children admitted to the ICU. Preschool age and Medicaid were Florida-specific risk factors while Hispanic ethnicity was New York-specific.

CONCLUSION

Compared to children not admitted to the ICU, children admitted to the ICU for asthma were at increased risk of asthma-related readmission, with certain risk factors conferring an even higher risk.

Maternal history of asthma modifies the risk of childhood persistent asthma associated with maternal age at birth: Results from a large prospective cohort in Canada

BACKGROUND

Asthma is a prevalent disease that affects many Canadians. Persistent asthma can affect quality of life, and has multiple health implications. Maternal age at birth has been associated with many adverse health outcomes in children. Conflicting study results exist regarding maternal age at birth and childhood asthma. The association between maternal age at birth and persistent asthma in children is still unknown.

OBJECTIVE

To investigate the relationship between maternal age at birth and persistent asthma in children at ten years of age.

METHODS

This is a prospective cohort study including all children aged 0-2 years who took part in the first cycle of the National Longitudinal Survey of Children and Youths (NLSCY) and were followed every two years until eight to ten years of age in Cycle 5. An interaction term between maternal age at birth and maternal asthma history was introduced in a multivariate model to examine modification effects of maternal asthma history on the association.

RESULTS

Multivariate logistic regression demonstrated that older maternal age at birth was significantly associated with an increased risk of childhood persistent asthma in mothers with a history of asthma (OR = 1.20, 95% CI: 1.04-1.40, p = .016). No relationship was found in mothers without a history of asthma.

CONCLUSION

Maternal history of asthma has an impact on the association between maternal age at birth and childhood persistent asthma in children by age ten. The finding may help explain the inconsistent results in the literature regarding the risk of asthma associated with maternal age at birth.

Efficacy of treatment with montelukast, fluticasone propionate and budesonide liquid suspension for the prevention of recurrent asthma paroxysms in children with wheezing disorders

One-third of the children who suffer from first-time wheezing are estimated to experience recurrences; however, no standard therapeutic strategy with which to prevent these recurrences currently exists. A few studies have compared the three drugs commonly used for the treatment of persistent asthma in children to identify the most effective one for preventing recurrent wheezing. In this study, in an aim to determine the most effective of these drugs, we recruited patients <5 years of age with recurrent wheezing at our hospital, and assigned them randomly to either the oral montelukast [leukotriene receptor antagonist (LTRA)], the inhaled fluticasone propionate (FP), or the inhaled budesonide suspension (BUD) groups for 12-week treatments. We then determined the treatment efficacy (symptomatic improvement) by recording the number of wheezing episodes and emergency visits, the daily treatment cost, the mean accumulated down time and the patient compliance; we then compared the results among the groups. All treatments were found to be equally effective. The daily cost of inhaled FP was lower than that of oral LTRA and inhaled BUD (P<0.00001). The difference in the mean accumulated down time between these groups was not significant (P=0.132). The adherence (patient compliance) to LTRA was significantly higher than the adherence to inhaled corticosteroids (ICS) (P<0.017). On the whole, the findings of this study indicated that all three treatments prevented recurrent wheezing in our pediatric population. FP was found to be more convenient, to require fewer doses, and that it could be easily adjusted. Patient adherence/compliance to treatment was significantly better with LTRA than with ICS.

Emergency department visit count: a practical tool to predict asthma hospitalization in children

Objectives: Resource limitations and low rates of follow-up with primary care providers currently limit the impact of emergency department (ED)-based preventative strategies for children with asthma. A mechanism to recognize the children at highest risk of future hospitalization is needed to target comprehensive preventative interventions at discharge. The primary objective of this study was to determine whether frequency of ED visits predicts future asthma hospitalization in children.Methods: Children aged 2-16.99 years with asthma ED visits between 2012 and 2015 were identified through health administrative data. Survival analysis using Kaplan-Meier estimator and multivariable Cox regression models with time-varying covariates were used to quantify the number of ED visits in the previous year that would best predict hospitalization risk in the following year, after adjustment for age, sex, and presentation severity.Results: We identified 2669 patients with 3300 asthma ED visits. ED visit count was an independent predictor of future hospitalization risk (p < 0.001), demonstrating a dose-dependent response. Compared with zero previous visits, the adjusted hazard of future hospitalization in children with one visit or two or more visits was 2.9 (95% CI 1.6-5.0) and 4.4 (95% CI 1.9-10.4), respectively.Conclusions: ED visit count is a reliable predictor of future asthma hospitalization risk. Future studies could aim to validate these findings to support using ED visit count as a practical and objective tool to predict the children at the highest risk of future hospitalization and therefore, those who may benefit most from ED-based preventative interventions.

Asthma diagnosis in infants and preschool children: a systematic review of clinical guidelines

BACKGROUND AND AIM

The definition and diagnosis of asthma are the subject of controversy that is particularly intense in the case of individuals in the first years of life, due to reasons such as the difficulty of performing objective pulmonary function tests or the high frequency with which the symptoms subside in the course of childhood. Since there is no consensus regarding the diagnosis of asthma in preschool children, a systematic review has been carried out.

MATERIALS AND METHODS

A systematic search was made of the clinical guidelines published in the last 10 years and containing information referred to the concept or diagnosis of asthma in childhood - including the first years of life (infants and preschool children). A series of key questions were established, and each selected guide was analyzed in search of answers to those questions. The review protocol was registered in the international prospective register of systematic reviews (PROSPERO), with registration number CRD42017074872.

RESULTS

Twenty-one clinical guidelines were selected: 10 general guides (children and adults), eight pediatric guides and three guides focusing on preschool children. The immense majority accepted that asthma can be diagnosed from the first years of life, without requiring pulmonary function tests or other complementary techniques. The response to treatment and the exclusion of other alternative diagnoses are key elements for establishing the diagnosis. Only one of the guides denied the possibility of diagnosing asthma in preschool children.

CONCLUSIONS

There is generalized although not unanimous agreement that asthma can be diagnosed in preschool children.

Impact of two oral doses of 100,000 IU of vitamin D3 in preschoolers with viral-induced asthma: a pilot randomised controlled trial

Background

New evidence supports the use of supplemental vitamin D in the prevention of exacerbation of asthma; however, the optimal posology to sufficiently raise serum levels while maximising adherence is unclear. The objective was to ascertain the efficacy of high-dose vitamin D₃ in increasing serum vitamin D in preschoolers with asthma and provide preliminary data on safety and efficacy outcomes.

Methods

We conducted a 7-month, triple-blind, randomised, placebo-controlled, pilot trial of children aged 1–5 years with viral-induced asthma. Participants were allocated to receive two oral doses of 100,000 IU vitamin D₃ (intervention) or identical placebo (control) 3.5 months apart, once in the fall and once in the winter. Serum 25-hydroxyvitamin D (25OHD) was measured by tandem mass spectrometry at baseline, 10 days, 3.5 months, 3.5 months + 10 days, and 7 months. The main outcome was the change in serum 25OHD from baseline (Δ25OHD) over time and at 3.5 and 7 months; other outcomes included the proportion of children with 25OHD ≥ 75 nmol/L, safety, and adverse event rates.

Results

Children (N = 47) were randomised (intervention, 23; control, 24) in the fall. There was a significant adjusted group difference in the Δ25OHD (95% confidence interval) of 57.8 (47.3, 68.4) nmol/L, p < 0.0001), with a time (p < 0.0001) and group*time interaction effect (p < 0.0001), in favour of the intervention. A significant group difference in the Δ25OHD was observed 10 days after the first (119.3 [105.8, 132.9] nmol/L) and second (100.1 [85.7, 114.6] nmol/L) bolus; it did not reach statistical significance at 3.5 and 7 months. At 3.5 and 7 months, respectively, 63% and 56% of the intervention group were vitamin D sufficient (≥ 75 nmol/L) compared to 39% and 36% of the control group. Hypercalciuria, all without hypercalcaemia, was observed in 8.7% of intervention and 10.3% of control samples at any time point. Exacerbations requiring rescue oral corticosteroids, which appear as a promising primary outcome, occurred at a rate of 0.87/child.

Conclusion

Two oral boluses of 100,000 IU vitamin D_3,once in the fall and once in the winter, rapidly, safely, and significantly raises overall serum vitamin D metabolites. However, it is sufficient to maintain 25OHD ≥ 75 nmol/L throughout 7 months in only slightly more than half of participants.

Trial registration

ClinicalTrials.gov, NCT02197702 (23 072014). Registered on 23 July 2014.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3184-z) contains supplementary material, which is available to authorized users.

Question 3: Can we diagnose asthma in children under the age of 5 years?

The diagnosis of asthma in children under five years has been controversial due to changing concepts of what true asthma is in this age group. Previous diagnostic algorithms that used clinical indices to predict the persistence of asthma symptoms or phenotypes based on asthma triggers do not predict which children will benefit from asthma medication. A pragmatic approach to asthma diagnosis in this age group is based on identifying signs and symptoms of reversible airflow obstruction and documenting their response to asthma medication. Hopefully, this approach will provide clearer guidance to clinicians and improve asthma morbidity in these young children.

Biomarkers for Recurrent Wheezing and Asthma in Preschool Children

Wheezing is one of the characteristic symptoms of asthma, but all preschool children with wheezing are not diagnosed with asthma. Preschool children are not cooperative enough to participate in spirometry and invasive tests. Thus, there is no conventional method to diagnose asthma in preschool children. We reviewed studies on non-invasive biomarkers for assessing asthma in preschool children. Specimens that can be easily obtained by non-invasive methods are blood, exhaled breath and urine. Eosinophils, eosinophil cationic protein and eosinophil-derived neurotoxin (EDN) in blood are helpful in evaluating eosinophilic inflammation of the airways. Exhaled breath contains nitric oxide, volatile organic compounds, various cytokines and mediators as analytical components. Fraction of exhaled nitric oxide has been used to assess the degree of eosinophil inflammation and has been standardized in school-age children and adults, but not yet in preschool children. Exhaled breath condensate (EBC) pH and various cytokines/mediators that are detected in EBC seem to be promising biomarkers for assessing asthma, but need more standardization and validation. There are several biomarkers useful for assessing asthma, but none are ideal. Some biomarkers need standardized methods of obtaining samples from uncooperative preschool children for clinical use and require sufficient validation. Recently, another activated eosinophil marker, serum EDN, has shown promising results as a biomarker for recurrent wheezing and asthma in preschool children.

Asthma in the Preschool Age Child

Wheeze in preschool children (5 years of age and younger) is common. The majority of severe episodes are triggered by viral colds. Unlike atopic asthma in adults and young people, the underlying pathology of this condition is poorly understood, and the label of “preschool wheeze” should therefore not be regarded as a diagnosis but a description of symptoms. It is important to consider other causes of wheeze, but, for the most part, serious conditions such as cystic fibrosis and foreign body aspiration are associated with atypical features on careful history and examination. There remain significant uncertainties about the optimal management of children with this condition. Short-acting bronchodilators are indicated for the acute treatment of wheeze, and current evidence suggests that daily inhaled corticosteroid therapy is an effective preventive therapy, at least in a subgroup of children. Some trials suggest that preemptive therapy with inhaled corticosteroids may be as effective as regular inhaled corticosteroids. Since wheeze is intermittent for the majority of children, preemptive therapy is a logical approach. However, more studies are needed to confirm whether preemptive inhaled corticosteroids are as, or more, effective than regular preventer therapy.

Daily inhaled corticosteroids or montelukast for preschoolers with asthma or recurrent wheezing: A systematic review

BACKGROUND

Most international asthma guidelines recommend that children ≤5 years with asthma or recurrent wheezing be treated with daily low- moderate dose inhaled corticosteroids (ICS) as the preferred controller and leukotriene receptor antagonists (LTRA) as alternative therapy. There is no systematic review comparing the efficacy of ICS versus LTRA monotherapy in this age group.

OBJECTIVE

To compare the efficacy of daily ICS versus LTRA in preschoolers with asthma or recurrent wheezing.

METHODS

Randomized, prospective, controlled trials published by December 2017, with a minimum of 3-month therapy with daily ICS versus LTRA were identified. The co-primary outcomes were the number of wheezing episodes and daily symptom score. Secondary outcomes included unscheduled emergency visits, need of rescue systemic corticosteroids (SC), hospitalization for exacerbations, lung function, and adverse effects.

RESULTS

Of 29 trials identified, six studies (n = 3204 patients, 62% males, age range: 6-54 months) met the inclusion criteria; two were at low risk of bias. Five pertained to children with asthma; one to those with recurrent wheezing. No outcomes were similarly reported in the six studies, preventing meta-analysis. Based on trials at lowest risk of bias and the largest open-labelled studies, ICS was associated with better control of symptoms and less exacerbations than LTRA. And also less need for rescue SC. Insufficient data of high quality prevented firm conclusions on other secondary outcomes.

CONCLUSIONS

In preschoolers with asthma or recurrent wheezing, daily ICS appears more effective than daily LTRA for improving symptom control and decreasing exacerbations, particularly those requiring rescue SC, although the magnitude of benefit remains to be quantified.

Patient preferences for a touch screen tablet-based asthma questionnaire

OBJECTIVE

Assessment of asthma control and provision of asthma action plans are seldom performed in practice, partly due to limited time for physicians to ascertain required information. A patient-facing electronic asthma questionnaire could facilitate information collection. We sought to design a touch-tablet asthma questionnaire for use in the clinic waiting room and to describe patient preferences for the content of such a questionnaire.

METHODS

We created a questionnaire prototype based on best evidence and employed rapid-cycle design (semi-structured focus group testing; analysis; corresponding modifications and re-testing) with asthma patients aged ≥16 years. We analyzed transcripts using deductive and inductive content analysis. Quantitative measures included Likert-scale questions and questionnaire completion times.

RESULTS

There were 20 participants across five focus groups (15/20 (75%) female, age 49.1 ± 15.6 years). Content-related themes included: 1) comprehensibility (language) (how questionnaire language affected ease and accuracy of comprehension) and b) information collection (issues arising during information collection in the following identified subthemes: personal asthma symptoms and triggers; asthma control; asthma medications and contact information). Average questionnaire completion time was 11.7 ± 5.9 min. Summative Likert scale responses suggested high levels of question comprehension and confidence with responses.

CONCLUSIONS

Our analysis provides novel insight about how best to formulate and present asthma-related content in an electronic questionnaire. Such questionnaires might facilitate quality improvement by improving efficiency of data collection, enabling better assessment of asthma control and medication adherence, and personalization of asthma action plans. Future studies should measure real-world uptake of such a questionnaire and impact on care.