Intravenous magnesium sulfate for acute wheezing in young children: a randomised double-blind trial

Standard medical therapy with vs. without nebulised magnesium for children with asthma decompensation

Pediatric asthma is a common condition, and its exacerbations can be associated with significant morbidity and mortality. The role of nebulised magnesium as adjunct therapy for children with asthma exacerbations is still unclear. To compare clinical and functional outcomes for children with asthma exacerbation taking either nebulised magnesium sulfate added to standard medical therapy (SMT) versus SMT alone. PubMed, Embase, and Cochrane Library were systematically searched for randomised clinical trials (RCT) comparing the use of SMT with vs. without nebulised magnesium. The outcomes were respiratory rate, heart rate, % predicted peak expiratory flow rate (PEFR), % predicted forced expiratory volume (FEV1), peripheral O2 saturation, asthma severity scores, and need for intravenous (IV) bronchodilator use. Twelve RCTs and 2484 children were included. Mean age was 5.6 (range 2-17) years old, mean baseline % predicted FEV1 was 69.6%, and 28.66% patients were male. Children treated with magnesium had a significantly higher % predicted PEFR (mean difference [MD] 5.33%; 95% confidence interval [CI] 4.75 to 5.90%; p < 0.01). Respiratory rate was significantly lower in the magnesium group (MD -0.70 respirations per minute; 95% CI -1.24 to -0.15; p < 0.01). Need for IV bronchodilators, % predicted FEV1, heart rate, asthma severity scores, and O2 saturation were not significantly different between groups.

CONCLUSION

In children with asthma exacerbation, treatment with nebulised magnesium and SMT was associated with a statistically significant, but small improvement in predicted PEFR and respiratory rate, as compared with SMT alone.

WHAT IS KNOWN

• Magnesium sulfate has bronchodilating properties and aids in the treatment of asthma exacerbation when administered intravenously. • There is no significant evidence of benefit of nebulised magnesium as an adjunct therapy to the standard medical treatment for children with asthma exacerbations.

WHAT IS NEW

• Our study suggests nebulised magnesium sulfate may have a statistically significant, but small benefit in respiratory rate and peak expiratory flow rate. The addition of nebulised magnesium does not seem to increase adverse events.

Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations

BACKGROUND

Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission.

OBJECTIVE

To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions.

METHODS

Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration.

RESULTS

A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95).

CONCLUSIONS

Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.

Evaluation of Essential and Toxic Elements in the Blood of 0–14-Year-Old Children in Hunan, China From 2013 to 2019: A Retrospective Analysis

Objective

The aim was to investigate the distribution and correlation of Ca, Mg, Zn, Cu, Fe, Pb, and Cd in the blood of children aged 0–14 years in Hunan, China, which may serve to provide a basis for clinical guidance on child health.

Study Design

A retrospective analysis was carried out. Concentrations of all elements were determined by atomic absorption spectrophotometry. Distributions were analyzed and compared among different age, sex, and year groups by the Kruskal–Wallis test, the chi-square test, and the Fisher's exact test. Spearman's rank correlation coefficient was used to evaluate the association between every pair of elements.

Results

A total of 46,951 children were involved in this study from 2013 to 2019. The median blood levels of elements were 13.51 μmol/L (Cu), 58.69 μmol/L (Zn), 1.70 mmol/L (Ca), 1.40 mmol/L (Mg), 7.46 mmol/L (Fe), 35.00 μg/L (Pb), and 1.00 μg/L (Cd). Girls had a higher level of Ca and lower levels of Pb and Cd than boys. Cu and Ca showed an upward trend, and Mg and Pb showed a downward trend by year. Zn and Fe increased and Ca decreased significantly with age. The deficiency rates of Fe and Zn decreased significantly by year, while Ca and Cu increased significantly by year. Cd exposure in this area was relatively low.

Conclusion

Most children had normal levels of the essential elements Ca, Cu, and Mg and the toxic elements Pb and Cd. Severe deficiencies in Zn and Fe were observed in the relatively younger children but improved with age. Persistent efforts in reducing Pb exposure might still be needed.

Early versus delayed administration of intravenous magnesium sulfate for pediatric asthma

OBJECTIVE

This study aims to describe and examine the factors associated with the early administration of intravenous magnesium sulfate (IV Mg) in children presenting to the pediatric emergency department (ED) for an asthma exacerbation.

METHODS

Retrospective cohort study of children aged 5-11 years who received IV Mg in the pediatric ED between September 1, 2018 and August 31, 2019 for management of an asthma exacerbation. Primary outcome was administration of IV Mg in ≤60 min from ED triage ('early administration'). Comparison of clinical management and therapies in children who received early versus delayed IV Mg and the factors associated with early administration of IV Mg were examined.

RESULTS

Early (n = 90; 31.6%) IV Mg was associated with more timely bronchodilators (47 versus 68 min; p ≤ 0.001) and systemic corticosteroids (36 versus 46.5 min; p ≤ 0.001). There was no difference between the two cohorts in returns to the ED within 72 h (1.1% versus 2.1%; p = .99) or readmissions within 1 week one week (2.2% versus 0.5%; p = .2). Hypoxia (aOR = 3.76; 95% CI = 2.02-7.1), respiratory rate (aOR = 1.04; 95% CI = 1.02-1.07), retractions (aOR = 2.21; 95% CI = 1.25-3.94), and prior hospital use for asthma-related complaints (aOR = 2.1; 95% CI = 1.16-3.84) were significantly associated with early IV Mg.

CONCLUSIONS

Early administration of IV Mg was associated with more timely delivery of first-line asthma therapies, was safe, and improved ED throughput without increasing return ED visits or hospitalizations for asthma.

Use of magnesium sulfate in continuous infusion in patients with severe acute asthma, in a pediatric emergency room

INTRODUCTION

Asthma is a chronic disease, of high prevalence, with important morbidity and that can lead to death in childhood. The use of intravenous magnesium sulfate has been indicated in cases refractory to the initial management with inhaled bronchodilators and corticosteroids.

OBJECTIVE

To evaluate the use of magnesium sulfate in continuous infusion (50 mg/kg/h in 4 h) in children with severe acute asthma in a pediatric emergency room.

LOCATION

Ten-bed general pediatric emergency room, university hospital, tertiary, in southern Brazil.

PATIENTS

All children over 2 years old with severe acute asthma refractory to the initial treatment who received a continuous infusion of magnesium sulfate at a dose of 50 mg/kg/h in 4 h, from April 2017 to October 2019.

CONCLUSION

Based on this study, the use of continuous intravenous magnesium sulfate proved to be well tolerated, leading to improved respiratory status, and can be considered as a satisfactory adjunctive therapy in the management of severe acute asthma.

Magnesium sulphate for treating acute bronchiolitis in children up to two years of age

BACKGROUND

Acute bronchiolitis is a significant burden on children, their families and healthcare facilities. It mostly affects children younger than two years of age. Treatment involves adequate hydration, humidified oxygen supplementation, and nebulisation of medications, such as salbutamol, epinephrine, and hypertonic saline. The effectiveness of magnesium sulphate for acute bronchiolitis is unclear.

OBJECTIVES

To assess the effects of magnesium sulphate in acute bronchiolitis in children up to two years of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, CINAHL, and two trials registries to 30 April 2020. We contacted trial authors to identify additional studies. We searched conference proceedings and reference lists of retrieved articles. Unpublished and published studies were eligible for inclusion.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs, comparing magnesium sulphate, alone or with another treatment, with placebo or another treatment, in children up to two years old with acute bronchiolitis. Primary outcomes were time to recovery, mortality, and adverse events. Secondary outcomes were duration of hospital stay, clinical severity score at 0 to 24 hours and 25 to 48 hours after treatment, pulmonary function test, hospital readmission within 30 days, duration of mechanical ventilation, and duration of intensive care unit stay.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used GRADE methods to assess the certainty of the evidence.

MAIN RESULTS

We included four RCTs (564 children). One study received funding from a hospital and one from a university; two studies did not report funding sources. Comparator interventions differed among all four trials. Studies were conducted in Qatar, Turkey, Iran, and India. We assessed two studies to be at an overall low risk of bias, and two to be at unclear risk of bias, overall. The certainty of the evidence for all outcomes and comparisons was very low except for one: hospital re-admission rate within 30 days of discharge for magnesium sulphate versus placebo. None of the studies measured time to recovery, duration of mechanical ventilation, duration of intensive care unit stay, or pulmonary function. There were no events of mortality or adverse effects for magnesium sulphate compared with placebo (1 RCT, 160 children). The effects of magnesium sulphate on clinical severity are uncertain (at 0 to 24 hours: mean difference (MD) on the Wang score 0.13, 95% confidence interval (CI) -0.28 to 0.54; and at 25 to 48 hours: MD on the Wang score -0.42, 95% CI -0.84 to -0.00). Magnesium sulphate may increase hospital re-admission rate within 30 days of discharge (risk ratio (RR) 3.16, 95% CI 1.20 to 8.27; 158 children; low-certainty evidence). None of our primary outcomes were measured for magnesium sulphate compared with hypertonic saline (1 RCT, 220 children). Effects were uncertain on the duration of hospital stay in days (MD 0.00, 95% CI -0.28 to 0.28), and on clinical severity on the Respiratory Distress Assessment Instrument (RDAI) score at 25 to 48 hours (MD 0.10, 95% CI -0.39 to 0.59). There were no events of mortality or adverse effects for magnesium sulphate, with or without salbutamol, compared with salbutamol (1 RCT, 57 children). Effects on the duration of hospital stay were uncertain (magnesium sulphate: 24 hours (95% CI 25.8 to 47.4), magnesium sulphate + salbutamol: 20 hours (95% CI 15.3 to 39.0), and salbutamol: 24 hours (95% CI 23.4 to 76.9)). None of our primary outcomes were measured for magnesium sulphate + epinephrine compared with no treatment or normal saline + epinephrine (1 RCT,120 children). Effects were uncertain for the duration of hospital stay in hours (MD -0.40, 95% CI -3.94 to 3.14), and for RDAI scores (0 to 24 hours: MD -0.20, 95% CI -1.06 to 0.66; and 25 to 48 hours: MD -0.90, 95% CI -1.75 to -0.05).

AUTHORS' CONCLUSIONS

There is insufficient evidence to establish the efficacy and safety of magnesium sulphate for treating children up to two years of age with acute bronchiolitis. No evidence was available for time to recovery, duration of mechanical ventilation and intensive care unit stay, or pulmonary function. There was no information about adverse events for some comparisons. Well-designed RCTs to assess the effects of magnesium sulphate for children with acute bronchiolitis are needed. Important outcomes, such as time to recovery and adverse events should be measured.

Intravenous magnesium sulphate in children with acute wheeze: a nationwide survey

OBJECTIVE

Dutch guidelines recommend to consider intravenous magnesium sulfate (iv MgSO₄) as a treatment option in case of failure of first line treatment in both children with exacerbations of acute episodic viral wheeze (AEVW) and acute asthma (AA). The implications on the actual use of iv MgSO₄ iv in daily practice in both groups are unknown. Therefore, we conducted a cross-sectional nationwide survey to evaluate the use of iv MgSO₄ in children with AEVW and AA.

METHODS

A questionnaire was handed out to pediatricians and pediatric residents in one academic and six community teaching hospitals.

RESULTS

In 111 respondents, 76% reported regular use of iv MgSO₄ in children with AEVW and 96% in children with AA. In total 89% and 93% of users were convinced iv MgSO₄ was effective in children with AEVW and AA, respectively. Adverse effects, mainly hypotension, were identified by 23% and 17% of users in AEVW and AA, respectively. Most common reasons not to give MgSO₄ were lack of evidence and small amount of studies.

CONCLUSIONS

IV MgSO₄ is reported to be widely used in Dutch practice in both young children with AEVW and older children with AA by respondents, while the national guidelines advise only to consider this treatment option.

Pharmacotherapeutic strategies for critical asthma syndrome: a look at the state of the art

INTRODUCTION

'Critical Asthma Syndrome' (CAS) is an umbrella term proposed to include several forms of asthma, responsible for acute and life-threatening exacerbations. CAS requires urgent and adequate supportive and pharmacological treatments to prevent serious outcomes.

AREAS COVERED

The purpose of this review is to discuss current knowledge on the pharmacotherapeutic strategies for treatment of CAS.

EXPERT OPINION

Airflow limitation, airway wall edema, and mucus plugs are the pathophysiological targets of pharmacological therapies. Strategies to achieve these goals are based on the use of various classes of drugs. Inhaled beta2-agonists are the mainstay of the initial therapy of CAS. Inhaled anticholinergic agents may be considered in the treatment of CAS in addition to beta 2 agonists. Systemic corticosteroids should be administered as soon as possible in order to counteract airway inflammation and restore normal airway sensitivity. The effectiveness of pharmacological therapies in CAS is linked not only to the timely use of drugsbut also to the dosage and route of administration. Early recognition and aggressive treatment are essential for the management of CAS; however, prevention is the best cure. Although significant progress has been made, further efforts are needed to implement an optimal exacerbation prevention strategy.

Advances in the aetiology, management, and prevention of acute asthma attacks in children

Acute attacks of wheeze or asthma are among the most common reasons for paediatric hospital attendance, and the incidence of severe attacks in the UK is among the highest in Europe. Although most attacks are driven by infection, there are important differences in the underlying pathophysiology of asthma and wheeze between preschool and school-aged children. Allergen sensitisation, airway eosinophilia, and type 2 inflammation predominate in older children, whereas phenotypes in preschool children are variable, often including non-atopic episodes driven by neutrophilic infection. Currently, a universal approach is adopted towards management, but there is a need to make objective assessments of airway function, inflammation, and infection, both during the attack and during stable periods, to identify treatable traits and to target therapy if outcomes are to be improved. An assessment of the risk factors that led to the attack and early, focused follow-up are essential to ensure attacks never occur again.