American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis

Recent Progress toward the Discovery of Small Molecules as Novel Anti-Respiratory Syncytial Virus Agents

Respiratory syncytial virus (RSV) stands as the foremost cause of infant hospitalization globally, ranking second only to malaria in terms of infant mortality. Although three vaccines have recently been approved for the prophylaxis of adults aged 60 and above, and pregnant women, there is currently no effective antiviral drug for treating RSV infections. The only preventive measure for infants at high risk of severe RSV disease is passive immunization through monoclonal antibodies. This Perspective offers an overview of the latest advancements in RSV drug discovery of small molecule antivirals, with particular focus on the promising findings from agents targeting the fusion and polymerase proteins. A comprehensive reflection on the current state of RSV research is also given, drawing inspiration from the lessons gleaned from HCV and HIV, while also considering the impact of the recent approval of the three vaccines.

Better Guidelines and Policies: AAP's Partnership for Policy Implementation

OBJECTIVES

In 2005, the American Academy of Pediatrics founded the Partnership for Policy Implementation (PPI). The PPI has collaborated with authors to improve the quality of clinical guidelines, technical reports, and policies that standardize care delivery, improve care quality and patient outcomes, and reduce variation and costs.

METHODS

In this article, we describe how the PPI trained informaticians apply a variety of tools and techniques to these guidance documents, eliminating ambiguity in clinical recommendations and allowing guideline recommendations to be implemented by practicing clinicians and electronic health record (EHR) developers more easily.

RESULTS

Since its inception, the PPI has participated in the development of 45 published and 27 in-progress clinical practice guidelines, policy statements, technical and clinical reports, and other projects endorsed by the American Academy of Pediatrics. The partnership has trained informaticians to apply a variety of tools and techniques to eliminate ambiguity or lack of decidability and can be implemented by practicing clinicians and EHR developers.

CONCLUSIONS

With the increasing use of EHRs in pediatrics, the need for medical societies to improve the clarity, decidability, and actionability of their guidelines has become more important than ever.

Impact of universal immunization program with monoclonal antibody nirsevimab on reducing the burden of serious bronchiolitis that need pediatric intensive care

RSV bronchiolitis remains the leading cause of hospitalization in children under 1 year of age. It is estimated that 2-6% of cases will be hospitalized on pediatric intensive care units (PICUs). In October 2023, a universal immunization program with the monoclonal antibody nirsevimab was implemented in Catalonia. The aim of the study was to analyze the impact of the nirsevimab immunization on the burden of bronchiolitis admitted to a PICU and resulting changes in epidemiological, clinical, and microbiological characteristics comparing the pre-nirsevimab (pre-N) with the post-nirsevimab (post-N) period. This was a prospective, descriptive, and observational study. Patients with severe bronchiolitis admitted to reference children's hospital PICU, between September 2010 and February 2024 were included. Demographic and clinical data were collected and viral laboratory etiological diagnosis was carried out. 1531 patients were recruited, 1458 in the pre-N seasons and 73 after its introduction (58% males, median age 52 days), of which 67% were immunized with nirsevimab. The total number of PICU bronchiolitis admissions, the ratio, and the RSV etiology were significantly lower in the post-N period (p = 0.03, p < 0.001, and p = 0.039, respectively). Significant higher age at admission (p < 0.001) and lower hospital length of stay (p < 0.001) was observed comparing pre-N vs. post-N period.

CONCLUSION

Nirsevimab appears to have an important impact on reducing the number and length of stay of PICU admissions due to RSV bronchiolitis.

WHAT IS KNOWN

• Bronchiolitis is the most common viral infection of the lower respiratory tract in infants. • It represents 13% of the total pediatric intensive care admissions, typically during winter. This is one of the causes that produces a collapse in the health care systems all around the world.

WHAT IS NEW

• In October 2023, universal immunization with monoclonal antibody nirsevimab of all children under 6 months of age was started in the majority of autonomous communities in Spain. • Recent publications from the nirsevimab clinical trials have evidenced a high RSV protective effect, but data on its effect on real life patients who require pediatric intensive care unit admission are missing.

Pediatric pulmonology year in review-Pediatric pulmonary critical care

Pediatric pulmonary critical care literature has continued to grow in recent years. Our aim in this review is to narrowly focus on publications providing clinically-relevant advances in pediatric pulmonary critical care in 2023.

Bronchiolitis: Safely Doing Less Is the Next Big Thing

Bronchiolitis is a viral lower respiratory tract infection primarily affecting children younger than 2 years; a common cause of health care encounters, including hospitalization; and a considerable economic burden for health care systems in the United States and worldwide. The American Academy of Pediatrics (AAP) most recently updated its bronchiolitis guideline in 2014 and reaffirmed supportive care as the mainstay of treatment. Despite these recommendations, there is still significant variability in care provided for these children, especially in bronchodilator usage, radiography, and high-flow nasal cannula. Since the 2014 AAP guideline, many pediatric hospitalists have undertaken quality initiatives to improve the adherence to published guidelines, yet a large gap remains between what is recommended and what is practiced. This article presents research on the efficacy of common interventions as well as an introduction to diagnostics and treatments potentially on the horizon. [Pediatr Ann. 2024;53(6):e223-e228.].

Emergency Department Initiative to Decrease High-flow Nasal Cannula Use for Admitted Patients with Bronchiolitis

Background

Despite limited evidence, a high-flow nasal cannula (HFNC) is often used to treat mild to moderate (m/m) bronchiolitis. We aimed to decrease the rate of HFNC use in the pediatric emergency department (PED) for m/m bronchiolitis from a baseline of 37% to less than 18.5%.

Methods

A multidisciplinary team created a bronchiolitis pathway and implemented it in December 2019. A respiratory score (RS) in the electronic medical record objectively classified bronchiolitis severity as mild, moderate, or severe. We tracked HFNC utilization in the PED among patients with m/m bronchiolitis as our primary outcome measure between December 2019 and December 2021. We monitored the percentage of patients with an RS as a process measure. Interventions through four plan-do-study-act cycles included updating the hospital oxygen therapy policy, applying the RS to all patients in respiratory distress, modifying the bronchiolitis order set, and developing a bronchiolitis-specific HFNC order.

Results

Three hundred twenty-five patients were admitted from the PED with m/m bronchiolitis during the 11-month baseline period and 600 patients during the 25-month intervention period. The mean rate of HFNC utilization decreased from 37% to 17%. Despite a decrease in bronchiolitis encounters after the pandemic, in the spring of 2021, when volumes returned, we had a sustained HFNC utilization rate of 17%. RS entry increased from 60% to 73% in the intervention period.

Conclusions

A clinical pathway for bronchiolitis can lead to decreased use of HFNC for m/m bronchiolitis. Consistent RS, order set development with decision support, and education led to sustained improvement despite pandemic-related volumes.

Comparing nasal suction devices in children with bronchiolitis: A pilot randomized control trial

BACKGROUND/OBJECTIVES

Bronchiolitis is the most common cause of lower respiratory tract infections that lead to hospitalizations in infants and young children.

METHODS

In this randomized controlled pilot study, we compared two separate nasal suction devices, namely the over counter device by the brand name of NoseFrida and the standard hospital device NeoSucker, in hospitalized children with bronchiolitis to assess equivalence of length of stay within a ± 5-h equivalence margin and to compare readmission rates and associated complications. Additionally, parental satisfaction for the NoseFrida device was measured with a six question (5-point Likert scale) survey.

RESULTS

There were 20 patients randomized to the NeoSucker group and 24 randomized to the NoseFrida group. The mean length of stay for the NoseFrida group was 33.5 ± 25.4 h compared to 31.0 ± 15.6 h in the NeoSucker group, which did not establish equivalence within the ±5-h equivalence margin (p = 0.352). Parents were generally satisfied with the NoseFrida. Patients treated with the two devices had similar frequencies of deep suctioning and readmission within 48 h.

CONCLUSIONS

Although the mean length of stay was comparable for bronchiolitis patients treated with the NoseFrida and NeoSucker, the relatively small sample size and large amount of variability precluded demonstrating equivalence. Since this was a pilot, further studies are needed to evaluate the recommendation for the use of such devices in both the hospital setting and in the outpatient management of bronchiolitis.

Epidemiology of Medically Attended Respiratory Syncytial Virus Lower Respiratory Tract Infection in Japanese Children, 2011-2017

BACKGROUND

The objective was to report critical respiratory syncytial virus (RSV)-related epidemiological and healthcare resource utilization measures among Japanese children stratified by gestational and chronological age groups.

METHODS

The JMDC (formerly the Japan Medical Data Center) was used to retrospectively identify infants with or without RSV infection (beginning between 1 February 2011 and 31 January 2016, with follow-up through 31 December 2017). The incidence of RSV medically attended lower respiratory tract infection (MALRI) was captured by flagging hospitalizations, outpatient, and emergency department/urgent care visits with an RSV diagnosis code during the season.

RESULTS

Of 113 529 infants and children identified, 17 022 (15%) had an RSV MALRI (14 590 during the season). The RSV MALRI and hospitalization rates in the first 5 months were 14.3/100 child-years (CY) and 6.0/100 CY, respectively (13.4/100 and 5.8/100 CY for full-term infants and 20/100 and 6.8/100 CY for late preterm infants, respectively). Among those with ≥1 type of MALRI event during the RSV season, >80% of children had it by 24 months of chronological age, although this observation differed by prematurity status. Sixty percent of healthcare resource utilization measures started in the outpatient setting.

CONCLUSIONS

This study emphasizes the RSV burden in young children and critically highlights the data needed to make decisions about new preventive strategies.

Novel Approach for Detecting Respiratory Syncytial Virus in Pediatric Patients Using Machine Learning Models Based on Patient-Reported Symptoms: Model Development and Validation Study

BACKGROUND

Respiratory syncytial virus (RSV) affects children, causing serious infections, particularly in high-risk groups. Given the seasonality of RSV and the importance of rapid isolation of infected individuals, there is an urgent need for more efficient diagnostic methods to expedite this process.

OBJECTIVE

This study aimed to investigate the performance of a machine learning model that leverages the temporal diversity of symptom onset for detecting RSV infections and elucidate its discriminatory ability.

METHODS

The study was conducted in pediatric and emergency outpatient settings in Japan. We developed a detection model that remotely confirms RSV infection based on patient-reported symptom information obtained using a structured electronic template incorporating the differential points of skilled pediatricians. An extreme gradient boosting-based machine learning model was developed using the data of 4174 patients aged ≤24 months who underwent RSV rapid antigen testing. These patients visited either the pediatric or emergency department of Yokohama City Municipal Hospital between January 1, 2009, and December 31, 2015. The primary outcome was the diagnostic accuracy of the machine learning model for RSV infection, as determined by rapid antigen testing, measured using the area under the receiver operating characteristic curve. The clinical efficacy was evaluated by calculating the discriminative performance based on the number of days elapsed since the onset of the first symptom and exclusion rates based on thresholds of reasonable sensitivity and specificity.

RESULTS

Our model demonstrated an area under the receiver operating characteristic curve of 0.811 (95% CI 0.784-0.833) with good calibration and 0.746 (95% CI 0.694-0.794) for patients within 3 days of onset. It accurately captured the temporal evolution of symptoms; based on adjusted thresholds equivalent to those of a rapid antigen test, our model predicted that 6.9% (95% CI 5.4%-8.5%) of patients in the entire cohort would be positive and 68.7% (95% CI 65.4%-71.9%) would be negative. Our model could eliminate the need for additional testing in approximately three-quarters of all patients.

CONCLUSIONS

Our model may facilitate the immediate detection of RSV infection in outpatient settings and, potentially, in home environments. This approach could streamline the diagnostic process, reduce discomfort caused by invasive tests in children, and allow rapid implementation of appropriate treatments and isolation at home. The findings underscore the potential of machine learning in augmenting clinical decision-making in the early detection of RSV infection.

High-flow nasal cannula therapy for infants with bronchiolitis

BACKGROUND

Bronchiolitis is a common lower respiratory tract illness, usually of viral aetiology, affecting infants younger than 24 months of age and is the most common cause of hospitalisation of infants. It causes airway inflammation, mucus production and mucous plugging, resulting in airway obstruction. Effective pharmacotherapy is lacking and bronchiolitis is a major cause of morbidity and mortality. Conventional treatment consists of supportive therapy in the form of fluids, supplemental oxygen, and respiratory support. Traditionally, oxygen delivery is as a dry gas at 100% concentration via low-flow nasal prongs. However, the use of heated, humidified, high-flow nasal cannula (HFNC) therapy enables delivery of higher inspired gas flows of an air/oxygen blend, at 2 to 3 L/kg per minute up to 60 L/min in children. It can provide some level of continuous positive airway pressure (CPAP) to improve ventilation in a minimally invasive manner. This may reduce the need for invasive respiratory support, thus potentially lowering costs, with clinical advantages and fewer adverse effects.

OBJECTIVES

To assess the effects of HFNC therapy compared with conventional respiratory support in the treatment of infants with bronchiolitis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, and Web of Science (from June 2013 to December 2022). In addition, we consulted ongoing trial registers and experts in the field to identify ongoing studies, checked reference lists of relevant articles, and searched for conference abstracts. Date restrictions were imposed such that we only searched for studies published after the original version of this review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that assessed the effects of HFNC (delivering oxygen or oxygen/room air blend at flow rates greater than 4 L/minute) compared to conventional treatment in infants (< 24 months) with a clinical diagnosis of bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently used a standard template to assess trials for inclusion and extract data on study characteristics, risk of bias elements, and outcomes. We contacted trial authors to request missing data. Outcome measures included the need for invasive respiratory support and time until discharge, clinical severity measures, oxygen saturation, duration of oxygen therapy, and adverse events.

MAIN RESULTS

In this update we included 15 new RCTs (2794 participants), bringing the total number of RCTs to 16 (2813 participants). Of the 16 studies, 11 compared high-flow to low-flow, and five compared high-flow to CPAP. These studies included infants less than 24 months of age as stated in our selection criteria. There were no significant differences in sex. We found that when comparing high-flow to low-flow oxygen therapy for infants with bronchiolitis there may be a reduction in the total length of hospital stay (mean difference (MD) -0.65 days, 95% confidence interval (CI) -1.23 to -0.06; P < 0.00001, I2 = 89%; 7 studies, 1951 participants; low-certainty evidence). There may also be a reduction in the duration of oxygen therapy (MD -0.59 days, 95% CI -1 to -0.18; P < 0.00001, I2 = 86%; 7 studies, 2132 participants; low-certainty evidence). We also found that there was probably an improvement in respiratory rate at one and 24 hours, and heart rate at one, four to six, and 24 hours in those receiving high-flow oxygen therapy when compared to pre-intervention baselines. There was also probably a reduced risk of treatment escalation in those receiving high-flow when compared to low-flow oxygen therapy (risk ratio (RR) 0.55, 95% CI 0.39 to 0.79; P = 0.001, I2 = 43%; 8 studies, 2215 participants; moderate-certainty evidence). We found no difference in the incidence of adverse events (RR 1.2, 95% CI 0.38 to 3.74; P = 0.76, I2 = 26%; 4 studies, 1789 participants; low-certainty evidence) between the two groups. The lack of comparable outcomes in studies comparing high-flow and CPAP, as well as the small numbers of participants, limited our ability to perform meta-analysis on this group.

AUTHORS' CONCLUSIONS

High-flow nasal cannula therapy may have some benefits over low-flow oxygen for infants with bronchiolitis in terms of a greater improvement in respiratory and heart rates, as well as a modest reduction in the length of hospital stay and duration of oxygen therapy, with a reduced incidence of treatment escalation. There does not appear to be a difference in the number of adverse events. Further studies comparing high-flow nasal cannula therapy and CPAP are required to demonstrate the efficacy of one modality over the other. A standardised clinical definition of bronchiolitis, as well as the use of a validated clinical severity score, would allow for greater and more accurate comparison between studies.

Approaches to the Prevention and Treatment of Respiratory Syncytial Virus Infection in Children: Rationale and Progress to Date

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infection (LRTI) in children, and is associated with long-term pulmonary sequelae for up to 30 years after infection. The mainstay of RSV management is supportive therapy such as supplemental oxygen. Palivizumab (Synagis™-AstraZeneca), a monoclonal antibody targeting the RSV F protein site II, has been licensed for the prevention of RSV in high-risk groups since 1998. There has been recent promising progress in preventative strategies that include vaccines and long-acting, high-potency monoclonal antibodies. Nirsevimab (Beyfortus™-AstraZeneca/Sanofi), a monoclonal antibody with an extended half-life, has recently been registered in the European Union and granted licensure by the US Food and Drug Administration. Furthermore, a pre-fusion sub-unit protein vaccine has been granted licensure for pregnant women, aimed at protecting their young infants, following established safety and efficacy in clinical trials (Abrysvo™-Pfizer). Also, multiple novel antiviral therapeutic options are in early phase clinical trials. The next few years have the potential to change the landscape of LRTI through improvements in the prevention and management of RSV LRTI. Here, we discuss these new approaches, current research, and clinical trials in novel therapeutics, monoclonal antibodies, and vaccines against RSV infection in infants and children.

Costs and healthcare utilisation due to respiratory syncytial virus disease in paediatric patients in Italy: a systematic review

OBJECTIVES

Respiratory syncytial virus (RSV) is a frequent cause of acute lower respiratory infection in children, imposing a substantial economic burden on healthcare systems. This systematic review aimed to assess the economic burden and healthcare utilisation of RSV in children aged 0-59 months in Italy.

STUDY DESIGN

Systematic review.

METHODS

A systematic search of PubMed, Embase, Scopus, and the International HTA Database, including studies published in English or Italian, was conducted between January 2000 and July 2022. Inclusion criteria required studies to be conducted in Italy and provide data on the economic costs and healthcare resource utilisation related to RSV infections.

RESULTS

Out of 20,845 records screened, 18 articles met the inclusion criteria. Only one study provided comprehensive data on RSV disease costs, including hospitalisation, diagnostic tests, and medical procedures for infants with RSV-bronchiolitis. The mean cost per inpatient was higher for RSV-positive children (€5753.43 ± €2041.62) than that for RSV-negative children. Additionally, five studies reported a median length of hospital stay of 5 days for RSV-infected children, and four studies indicated a higher frequency of intensive care unit admissions for RSV-infected children than for those with other viral infections.

CONCLUSIONS

This is the first systematic review to examine the economic burden and healthcare utilisation of RSV in children aged 0-59 months in Italy. While limited data were available, the findings underscore the urgency to conduct further research and gather additional evidence on the costs and healthcare resource utilisation associated with RSV infections. Such efforts are essential for informing the development of effective prevention strategies for paediatric RSV infections in Italy.

Respiratory and Gut Microbiome Modification during Respiratory Syncytial Virus Infection: A Systematic Review

BACKGROUND

Respiratory syncytial virus (RSV) infection is a major cause of lower respiratory tract infection, especially in infants, and increases the risk of recurrent wheezing and asthma. Recently, researchers have proposed a possible association between respiratory diseases and microbiome alterations. However, this connection has not been fully established. Herein, we conducted a systematic literature review to evaluate the reported evidence of microbiome alterations in patients with RSV infection.

METHODS

The systematic literature review on the association between RSV and microbiome in humans was conducted by searching PubMed, EMBASE, Scopus, and CINAHL from 2012 until February 2022. The results were analyzed qualitatively, focusing on the relationship between microbiome and RSV infection with available key microbiome-related parameters.

RESULTS

In the 405 articles identified by searching databases, 12 (Respiratory tract: 9, Gut: 2, Both: 1) articles in line with the research aims were eligible for this qualitative review. The types of samples for the respiratory tract microbiome and the sequencing methods utilized varied from study to study. This review revealed that the overall microbial composition in both the respiratory tract and gut in RSV-infected patients was different from that in healthy controls. Our generated results demonstrated an increase in the abundance of Haemophilus and Streptococcus, which could contribute to the distinctive separation based on the beta diversity in the respiratory tract.

CONCLUSIONS

The respiratory tract and gut microbiome changed in patients with RSV infection. Further research with a well-organized longitudinal design is warranted to clarify the impact of microbiome alterations on disease pathogenesis.

Trends in emergency department visits for bronchiolitis, 1993-2019

INTRODUCTION

Bronchiolitis is a leading indication for pediatric emergency department (ED) visits and hospitalizations. Our objective was to provide a comprehensive review of national trends and epidemiology of ED visits for bronchiolitis from 1993 to 2019 in the United States.

METHODS

We retrospectively reviewed the National Hospital Ambulatory Medical Care Survey (NHAMCS) reporting of ED visits for bronchiolitis for children age <2 years from 1993 to 2019. Bronchiolitis cases were identified using billing codes assigned at discharge. The primary outcome was bronchiolitis ED visit rates, calculated using NHAMCS-assigned patient visit weights. We then evaluated for temporal variation in patient characteristics, facility location, and hospitalizations among the bronchiolitis ED visits.

RESULTS

There were an estimated 8 million ED visits for bronchiolitis for children <2 years between 1993 and 2019. Bronchiolitis ED visits rates ranged from 28 to 36 per 1000 ED visits from 1993 to 2010 and increased significantly to 65 per 1000 ED visits in the 2017-2019 time period (p < 0.001). There was no significant change over time in patient age, sex, race and ethnicity, insurance status, hospital type, or triage level upon ED presentation. Approximately half of bronchiolitis ED visits occurred in the winter months throughout the study period.

CONCLUSION

In this analysis of 27 years of national data, we identified a recent rise in ED visit rates for bronchiolitis, which have almost doubled from 2010 to 2019 following a period of relative stability between 1993 and 2010.

Neutrophil-to-Lymphocyte Ratio and the Systemic Immune-Inflammation Index: Biomarkers in Infants with Bronchiolitis: a Cross-Sectional Study

The use of a novel inflammatory indicator, the systemic immune-inflammatory index (SII), in pediatric patients with bronchiolitis remains unreported. Therefore, this study investigated the relationship between the SII and the neutrophil-to-lymphocyte ratio (NLR) in patients with respiratory syncytial virus (RSV) and non-RSV bronchiolitis and clinical severity prediction. This study analyzed the data of 155 patients aged <2 years who were hospitalized for viral bronchiolitis caused by RSV and/or other viral pathogens. The SII (platelet count × [neutrophil/lymphocyte]) was calculated and compared among patients with RSV mono-infections, other viral mono-infections, and RSV co-infections. Severity was defined by the number of days of supplemental oxygen treatment. The NLR and SII were significantly higher in the non-RSV mono-infection group than in the RSV mono-infection group, and the number of days of supplemental oxygen therapy was significantly higher in the RSV mono-infection group. No significant differences in the NLR, SII, or days of supplemental oxygen therapy were found between the RSV mono-infection and RSV co-infection groups. Although patients with RSV mono-infection showed more severe clinical findings than those without non-RSV mono-infection, the NLR and SII values were significantly higher in the non-RSV mono-infection group. Therefore, the NLR and SII do not appear to be very useful measurements for determining the severity of acute bronchiolitis attacks; however, lower NLR and SII values in the RSV group compared to the non-RSV group may be potential biomarkers for RSV infection. Therefore, further studies are warranted.

The changing virology and trends in resource utilization for bronchiolitis since COVID-19

BACKGROUND

Bronchiolitis is a viral respiratory illness most commonly caused by respiratory syncytial virus (RSV). COVID-19 disrupted typical patterns of viral transmission. Our study aimed to compare low value care for bronchiolitis in a tertiary emergency department (ED) in the United States from March 2017 to March 2022.

METHODS

This was a descriptive cohort study through a retrospective chart review from 2017 to 2022 analyzing ED visits for bronchiolitis including disposition, disease severity, chest radiographs, albuterol, and high flow nasal cannula usage. A year was a 12-month period from March to February.

RESULTS

From 2017 to 2020, there were over 2000 ED visits for bronchiolitis per year (3.1% of all ED visits), which decreased to 450 visits for bronchiolitis (1%) in 2020-2021. Human rhino/enterovirus was the most common virus detected (92%) at that time, and admission rates, albuterol, high flow nasal cannula, and chest radiographs were all higher. The summer of 2021 had the highest visits across the 5-study years with a return to previous rates of resource utilization.

CONCLUSIONS

Bronchiolitis ED visits due to RSV dramatically reduced during the first year of the COVID-19 pandemic in 2020, with over 80% reduction in bronchiolitis visits from 2018 to 2019. While all ED visits fell in 2020, the proportion of visits due to bronchiolitis also decreased. There was an increase in lower value care during the rhinovirus dominant, low census period. As restrictions lifted in 2021, there was a large resurgence of RSV in the atypical summer months with a return of previous rates of resource utilization.

Epidemiology and clinical severity of the serotypes of human parainfluenza virus in children with acute respiratory infection

BACKGROUND

Acute respiratory infections (ARI) are a threat to human health and survival, resulting in many paediatric hospitalisations. However, the epidemiological and clinical severity characteristics of the human parainfluenza virus (PIV), one of the most prevalent respiratory viruses, are not well understood in children.

METHODS

To identify the epidemiological features of PIV infection, in 2019, hospitalised children with ARI were screened using multiplex polymerase chain reaction (PCR) for PIV and 10 other common respiratory pathogens. Subtyping of randomly selected PIV-positive samples was performed using reverse transcription-PCR. Demographics, epidemiology, clinical manifestations, diagnosis, and outcomes were compared between PIV subtypes.

RESULTS

The annual detection rate for PIV was 14.9%, with a peak from April to September. Children under one year of age had the highest rate of PIV infection (45.5%) compared to other age groups. Of the 121 sequenced samples, 58.7%, 36.4% and 4.9% were positive for PIV-3, PIV-1 and PIV-2, respectively, and no PIV-4 was detected. Severe infections were associated with pre-existing underlying diseases and co-infections, but not with PIV serotype. After excluding cases of co-infection, we found that PIV-2 infection was associated with upper respiratory tract infections, whereas PIV-1 and PIV-3 mainly caused lower respiratory tract infections. Apart from the proportion of patients with fever, there were no significant differences among the three subtypes in terms of clinical symptoms, severity, and outcome.

CONCLUSION

Here, PIV was the main pathogen causing ARI in hospitalised children. Appropriate attention should be paid to children with underlying diseases and co-infections to prevent the worsening of severe PIV infection.

Seasonality and risk factor analysis of respiratory syncytial virus infection in children in Taiwan-A retrospective study from 1995 to 2005

Respiratory syncytial virus (RSV) is one of the important pathogens leading to acute respiratory tract infection in infants and young children. We aimed to investigate the seasonality of RSV infection in different parts of Taiwan and to delineate the risk factors for severe RSV infections. We collected RSV-infected patients' data by retrospective chart review. A total of 1740 RSV-infected children aged under 18 years were enrolled. The infection was acquired during hospitalization in 103 (7.1%) children, while none of them required ventilator support or needed intensive care before RSV infection. The need for intensive care or ventilator support was significantly associated with congenital heart disease (CHD), chronic lung disease, and neuromuscular diseases. Age <1 year and nosocomially acquired infection are also significant predictors for the need of intensive care. Only the presence of CHD, especially acyanotic CHD, was significantly associated with a fatal outcome. RSV infection occurs all year round. Monthly distribution of RSV infections in Northern Taiwan showed a bimodal pattern, with one peak from March to May, and another from August to October. The distribution in Southern Taiwan showed a single peak from April to July. The occurrence of RSV correlates positively with temperature and rain. The bimodal seasonal distribution pattern in Northern Taiwan may be a transitional pattern shifting from a single high winter peak in temperate areas to a wider summer peak in tropical areas. Continuous surveillance is needed to explore the possible effect of global warming on the seasonality of RSV infection.

Assessing the Impact of the COVID-19 Pandemic on the Severity of Pediatric Inflammatory Bowel Disease Admissions and New Diagnoses

Introduction

The COVID-19 pandemic has introduced new challenges to the diagnosis and management of pediatric inflammatory bowel disease (IBD). Many patients have had only limited access to their providers through telemedicine, and many chose to delay nonemergent treatment.

Methods

A retrospective chart review of patients with IBD seen by the Pediatric Gastroenterology Division at Doernbecher Children's Hospital from January 2018 to August 2021 was conducted. The study cohort was divided into 2 groups: those presenting before the onset of the COVID-19 pandemic (January 1, 2018 to February 28, 2020) and those presenting during the pandemic (March 1, 2020 to August 1, 2021). Variables collected included: age, sex, race, ethnicity, IBD type, insurance type, location of residence. Primary outcome measures selected focused on disease severity, initial type of treatment, or surgical intervention offered. A subgroup analysis of the new diagnosis patients was performed. Data were analyzed using independent t-tests, chi-squared analysis, and Wilcoxon rank sum tests.

Results

Two hundred and eleven patients met inclusion criteria, 107 (72 new diagnoses, 35 admissions) within the pre-COVID epoch and 104 (67 new diagnoses, 37 admissions) within the during-COVID epoch. Patients in the during-COVID epoch had higher fecal calprotectin level and were more likely to be started on a biologic as initial treatment. Patients admitted during COVID for IBD flare were more likely to require surgical intervention. Subgroup analysis of newly diagnosed patients revealed higher incidence of comorbid depression and anxiety.

Conclusions

Our review identified increased disease severity in newly diagnosed pediatric patients with IBD as well as pediatric patients admitted for flare during COVID. Increases in anxiety and depression rates during COVID may have contributed to worsened disease severity.

Predicting the RSV Surge: Pediatric RSV Patterns of the COVID Pandemic

Historically, respiratory syncytial virus (RSV) infection trends have been predictable. The COVID-19 pandemic and associated precautions impacted RSV disease patterns. RSV infection trends during the first year of the COVID-19 pandemic may have predicted the 2022 surge in pediatric RSV infections. A continued emphasis on increased viral testing will allow for early recognition and preparation for future public health crises.

Factors associated with salbutamol overuse in bronchiolitis

Numerous studies have shown that quality improvement methods can reduce the use of medications in the management of bronchiolitis. Our objective is to identify factors related to the overuse of salbutamol in the treatment of bronchiolitis before and after an improvement initiative. Observational study of sociodemographic and clinical factors associated with the use of salbutamol in children diagnosed with bronchiolitis. This was a secondary analysis of a prospective cohort study conducted at 135 primary care (PC) centers and eight pediatric emergency departments (ED) in the Osakidetza/Basque Health Service (Spain) in two epidemic seasons between which a bronchiolitis integrated care pathway (BICP) had been implemented: pre-intervention season from October 2018 to March 2019 and post-intervention season from October 2019 to March 2020. Generalized linear mixed models were used to estimate association of studied variables on use of salbutamol over the two seasons. Four thousand one hundred thirty-four ED attendances and 8573 PC visits were included, of which 1936 (46.8%). And 4067 (47.4%) occurred in the post-intervention period respectively. Six independent risk factors were associated with overuse of salbutamol in both seasons: age ≥ 1 year, aOR 2.32 (2.01 to 2.68) in PC centers, and aOR 6.84 (4.98 to 9.39) in EDs; being seen in the last third of the bronchiolitis season, aOR 1.82 (1.51 to 2.18) in PC centers and aOR 1.78 (1.19 to 2.64) in EDs; making more than one visit to the PC center, aOR 4.18 (3.32 to 5.27) or the ED, aOR 2.06 (1.59 to 2.66); being seen by a general practitioner, aOR 1.97 (1.58 to 2.46) in PC centers; and having a more severe episode, aOR 3.01 (1.89 to 4.79) in EDs.     Conclusion:There are factors associated with salbutamol overuse in children diagnosed with bronchiolitis in PC and emergency settings that persist after the deployment of quality improvement initiatives. What is Known: • Quality improvement initiatives have been shown to decrease the use of non-evidence-based treatments and testing in bronchiolitis. • The magnitude and pattern of change in the use of medications linked to the quality improvement initiatives are not uniform across the same health service. What is New: • Children diagnosed with bronchiolitis ≥ 1 year of age, seen in the last third of the bronchiolitis season, attending more than once, treated by a general practitioner, and/or with more severe episodes are more likely to be treated with salbutamol. • These factors may remain present despite the implementation of improvement initiatives focused on reducing the use of medications in the management of bronchiolitis.

Safety and Immunogenicity of an Investigational Respiratory Syncytial Virus Vaccine (RSVPreF3) in Mothers and Their Infants: A Phase 2 Randomized Trial

BACKGROUND

In a phase 1/2 study, a maternal respiratory syncytial virus vaccine candidate (RSVPreF3) demonstrated an acceptable safety profile and efficiently increased RSV-specific humoral immune responses in non-pregnant women.

METHODS

In this phase 2 observer-blind, placebo-controlled, randomized clinical trial (NCT04126213), the safety of RSVPreF3 (60 or 120 µg), administered during late second or third trimester, was evaluated in 213 18- to 40-year-old healthy pregnant women through 6 months postdelivery and their offspring through infancy; immunogenicity was evaluated through day 43 postdelivery and day 181 postbirth, respectively.

RESULTS

RSVPreF3 was well tolerated. No pregnancy-related or neonatal adverse events of special interest were considered vaccine/placebo related. In the 60 and 120 µg RSVPreF3 groups: (1) neutralizing antibody (nAb) titers in mothers increased 12.7- and 14.9-fold against RSV-A and 10.6- and 13.2-fold against RSV-B, respectively, 1 month postvaccination and remained 8.9-10.0-fold over prevaccination at day 43 postdelivery; (2) nAb titers were consistently higher compared to placebo recipients; (3) placental transfer ratios for anti-RSVPreF3 antibodies at birth were 1.62 and 1.90, respectively, and (4) nAb levels in infants were highest at birth and declined through day 181 postbirth.

CONCLUSIONS

RSVPreF3 maternal vaccination had an acceptable safety risk profile and induced robust RSV-specific immune responses with successful antibody transfer to their newborns.

CLINICAL TRIALS REGISTRATION

NCT04126213.

Does prophylactic antibiotics post pediatric pyeloplasty reduce the incidence of febrile UTIs?

PURPOSE

The use of postoperative prophylactic antibiotics in pediatric upper urinary tract reconstruction remains controversial. In this study, we examined whether low dose antibiotics administered following pediatric pyeloplasty reduce the incidence of febrile urinary tract infections at our institution. As a secondary outcome, in those patients with infection, additional analysis was performed to better quantify which patient population benefits the most from low dose prophylactic antibiotics.

METHODS

Institutional review board approval (IRB) was obtained. All methods were carried out in accordance with relevant guidelines and regulations. A retrospective study was performed in patients who underwent pyeloplasty (2011-2017) at our institution. Surgical approach (laparoscopic versus robotic assisted versus open, with or without internal JJ ureteral stent) were based on surgeon preference. Patients of 8 fellowship trained pediatric urologists were included in the study period. Patients with prior history of urologic interventions or other congenital genitourinary tract abnormalities were excluded. Demographics (age, gender, ethnicity, insurance status), prior history of culture proven urinary tract infection, surgical details (administration of perioperative antibiotics), and postoperative outcomes including; 1) re-admission 30 days post-surgery, 2) any urine cultures collected due to suspected urinary tract infection.

RESULTS

A total of 209 patients (149 boys, 60 girls) met our inclusion criteria with 55/209 (26%) receiving postoperative prophylactic antibiotics. The average age was 6 years (range: 2 months-18 years). Indwelling ureteral stent was used in 176 (84%) patients. Eleven patients (5%) had a culture-proven urinary tract infection within 30-days postoperatively. No significant differences were seen in postoperative complications or incidence of urinary tract infection when comparing surgical approaches, +/- ureteral stent, or the use of antibiotics. Secondary analysis noted statistically significant increase in post-operative urinary tract infection in younger children (2.8 v. 6.2 years, p = 0.02), those patients who had a positive preoperative urine culture (8/11, p = 0.01) and those with public health insurance (p = 0.038).

CONCLUSION

The incidence of postoperative urinary tract infection following pyeloplasty in our cohort was relatively low. There was a higher incidence of urinary tract infection in patients less than 3 years old. The use of antibiotics in patients post pyeloplasty did not appear to affect the incidence of post-operative urinary tract infection, however, they may have a role in children who have not yet potty trained and in patients with positive preoperative urine culture.

Comparison of serodiagnosis methods for community-acquired Mycoplasma pneumoniae respiratory tract infections in children

This study aimed to evaluate the diagnostic value of chemiluminescence immunoassay (CLIA), passive particle agglutination (PPA), and indirect immunofluorescence assay (IFA) in detecting Mycoplasma pneumoniae infection in children. Serum samples from 165 children with acute community-acquired respiratory tract infections were examined using CLIA, PPA, and IFA, and consistency coefficient, specificity, and sensitivity were analyzed. Compared with the PPA (titer ≥ 1:160), the consistency coefficients of the immunoglobulin(Ig)M-CLIA, immunoglobulin(Ig)G-CLIA and IgM-IFA methods were 93.94%, 75.76%, and 83.64%, respectively. The positive likelihood ratio (PLR) and specificity of IgM-CLIA was 19.40 and 95.49%, respectively. The consistency coefficient of (IgM+IgG)-CLIA and PPA (titer ≥ 1:160) was 89.1%, and the sensitivity and negative predictive value of (IgM+IgG)-CLIA were 96.88% and 98.94%, respectively. CLIA MP-IgM has high concordance with PPA, and its specificity and sensitivity are higher than those of CLIA MP-IgG and IFA MP-IgM, suggesting its better diagnosis of early MP infection. The sensitivity and negative predictive value of CLIA MP (IgM+IgG) were higher than those of PPA or IFA, indicating that it should be considered as a priority in the diagnosis of MP infection.

Impact of the publication of the Italian guidelines for bronchiolitis on the management of hospitalized children in Pisa, Italy

Bronchiolitis represents one of the major causes of hospitalization and mortality in children younger than 1 year, but its management continues to be heterogenous both in those who are hospitalized and in those who are not. To assess the impact of the publication of the Italian guidelines on bronchiolitis in October 2014, we analyzed data from children aged ≤12 months admitted for bronchiolitis at the University Hospital of Pisa from January 2010 to December 2019, dividing them into two groups based on whether admission was either preceding (Group 1) or following (Group 2) the publication of the guidelines. 346 patients (mean age 4.1 ± 2.8 months, 55% males) were admitted in the study period; 43.3%, 49.4%, and 7.3% of patients had mild, moderate or severe bronchiolitis, respectively. The mean length of hospital stay was 6.7 ± 2.9 days; 90.5% of the patients underwent nasal swab and 200 patients tested positive for RSV (in mono or coinfection with other viruses). We found no difference in RSV prevalence and severity distribution between the two groups, while we observed a significant reduction in the use of both chest X-rays (66.9% vs. 34.8%, p < 0.001), blood testing (93.4% vs. 58.2%, p < 0.001) and inhaled or systemic corticosteroids (93.1% vs. 47.8%, p < 0.001) in Group 2. No significant reduction in the use of antibiotics and of inhaled β2 agonists was found. Our data suggest that the publication of the Italian guidelines for bronchiolitis has contributed to improving the management of patients admitted for bronchiolitis in our Unit.

Review and Update of Active and Passive Immunization Against Respiratory Syncytial Virus

Respiratory syncytial virus (RSV) is the most common cause of lower respiratory tract infection (LRTI) in children, causing approximately 3.6 million hospitalizations per year, and has been associated with long-term pulmonary sequelae for up to 30 years after infection, yet preventative strategies and active treatment options remain elusive. The associated morbidity and healthcare related costs could be decreased substantially with the development of these much-needed medications. After an initial false start in the development of an RSV vaccine, gradual progress is now being made with the development of multiple vaccine candidates using numerous different mechanisms of action. Furthermore, nirsevimab, a new monoclonal antibody for the prevention of RSV, has recently been registered in the European Union. New novel treatments for RSV infection are also in the pipeline, which would provide the clinician with much needed ammunition in the management of the acute disease. The next few years have the potential to change the landscape of LRTI forever through the prevention and management of RSV LRTI and thereby decrease the mortality and morbidity associated with it. In this review, we discuss these new approaches, current research, and clinical trials in monoclonal antibody and vaccine development against RSV.

Development and validation of a nomogram for predicting severe respiratory syncytial virus-associated bronchiolitis

BACKGROUND

Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis and is related to the severity of the disease. This study aimed to develop and validate a nomogram for predicting severe bronchiolitis in infants and young children with RSV infection.

METHODS

A total of 325 children with RSV-associated bronchiolitis were enrolled, including 125 severe cases and 200 mild cases. A prediction model was built on 227 cases and validated on 98 cases, which were divided by random sampling in R software. Relevant clinical, laboratory and imaging data were collected. Multivariate logistic regression models were used to determine optimal predictors and to construct nomograms. The performance of the nomogram was evaluated by the area under the characteristic curve (AUC), calibration ability and decision curve analysis (DCA).

RESULTS

There were 137 (60.4%) mild and 90 (39.6%) severe RSV-associated bronchiolitis cases in the training group (n = 227) and 63 (64.3%) mild and 35 (35.7%) severe cases in the validation group (n = 98). Multivariate logistic regression analysis identified 5 variables as significant predictive factors to construct the nomogram for predicting severe RSV-associated bronchiolitis, including preterm birth (OR = 3.80; 95% CI, 1.39-10.39; P = 0.009), weight at admission (OR = 0.76; 95% CI, 0.63-0.91; P = 0.003), breathing rate (OR = 1.11; 95% CI, 1.05-1.18; P = 0.001), lymphocyte percentage (OR = 0.97; 95% CI, 0.95-0.99; P = 0.001) and outpatient use of glucocorticoids (OR = 2.27; 95% CI, 1.05-4.9; P = 0.038). The AUC value of the nomogram was 0.784 (95% CI, 0.722-0.846) in the training set and 0.832 (95% CI, 0.741-0.923) in the validation set, which showed a good fit. The calibration plot and Hosmer‒Lemeshow test indicated that the predicted probability had good consistency with the actual probability both in the training group (P = 0.817) and validation group (P = 0.290). The DCA curve shows that the nomogram has good clinical value.

CONCLUSION

A nomogram for predicting severe RSV-associated bronchiolitis in the early clinical stage was established and validated, which can help physicians identify severe RSV-associated bronchiolitis and then choose reasonable treatment.

Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study

Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.

Lung ultrasound systematic review shows its prognostic and diagnostic role in acute viral bronchiolitis

AIM

Lung ultrasound (LUS) has not been included in the current guidelines for the diagnosis of bronchiolitis so far, even though data concerning its effectiveness have been published.

METHODS

A systematic literature review was carried out to determine the role of LUS scores in the diagnosis and prognosis of patients aged 0-2 years with bronchiolitis, using MEDLINE, Scopus and ScienceDirect databases from their inception to December 2021.

RESULTS

A total of 18 studies matching our eligibility criteria were analysed for the purposes of this review and 1249 patients with bronchiolitis were included. The sonographic and radiological findings were comparable and chest radiography was found to have a higher sensitivity in ruling out severe complications such as concomitant pneumonia. The LUS scores were correlated to the clinical course of bronchiolitis and it was able to predict the need of admission in paediatric intensive care unit, the duration of hospitalisation and the need for respiratory support.

CONCLUSION

This review suggests that LUS could have both a diagnostic and a prognostic role in bronchiolitis during first evaluation in the emergency department and hospitalisation. Physicians could adjust management according to sonographic findings as a useful adjunct to the clinical ones.

Respective roles of non-pharmaceutical interventions in bronchiolitis outbreaks: an interrupted time-series analysis based on a multinational surveillance system

BACKGROUND

Bronchiolitis is a major source of morbimortality among young children worldwide. Non-pharmaceutical interventions (NPIs) implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 may have had an important impact on bronchiolitis outbreaks, as well as major societal consequences. Discriminating between their respective impacts would help define optimal public health strategies against bronchiolitis. We aimed to assess the respective impact of each NPI on bronchiolitis outbreaks in 14 European countries.

METHODS

We conducted a quasi-experimental interrupted time-series analysis based on a multicentre international study. All children diagnosed with bronchiolitis presenting to the paediatric emergency department of one of 27 centres from January 2018 to March 2021 were included. We assessed the association between each NPI and change in the bronchiolitis trend over time by seasonally adjusted multivariable quasi-Poisson regression modelling.

RESULTS

In total, 42 916 children were included. We observed an overall cumulative 78% (95% CI -100- -54%; p<0.0001) reduction in bronchiolitis cases following NPI implementation. The decrease varied between countries from -97% (95% CI -100- -47%; p=0.0005) to -36% (95% CI -79-7%; p=0.105). Full lockdown (incidence rate ratio (IRR) 0.21 (95% CI 0.14-0.30); p<0.001), secondary school closure (IRR 0.33 (95% CI 0.20-0.52); p<0.0001), wearing a mask indoors (IRR 0.49 (95% CI 0.25-0.94); p=0.034) and teleworking (IRR 0.55 (95% CI 0.31-0.97); p=0.038) were independently associated with reducing bronchiolitis.

CONCLUSIONS

Several NPIs were associated with a reduction of bronchiolitis outbreaks, including full lockdown, school closure, teleworking and facial masking. Some of these public health interventions may be considered to further reduce the global burden of bronchiolitis.

Prophylaxis protects infants with congenital heart disease from severe forms of RSV infection: an Italian observational retrospective study : Palivizumab prophylaxis in children with congenital heart disease

BACKGROUND

In children with congenital heart disease (CHD) respiratory syncytial virus (RSV) infection may have a severe course, with increased risk of morbidity and mortality, requiring hospital admission and intensive care. The aim of the present study was to evaluate the effect of prophylaxis with palivizumab in preventing RSV-associated hospitalization in infants with CHD.

METHODS

We carried out an observational, retrospective study in a paediatric cardiology division at a secondary-care centre in Italy, extracting from the database children with CHD who, from November 2004 to March 2022, matched the criteria for palivizumab prophylaxis, to evaluate the hospitalization rate in CHD patients with and without palivizumab prophylaxis and their RSV-related hospitalization characteristics compared with a group of children without CHD and no other underlying clinical conditions (control group, CG), hospitalized for RSV infection.

RESULTS

One hundred twenty-eight children with CHD were enrolled in the study, mainly (71.9%) with increased pulmonary flow, and received palivizumab prophylaxis. Twenty-seven received hospital care for bronchiolitis. Almost all CHD patients hospitalized for bronchiolitis (26 out of 27) received partial prophylaxis (≤ 3 doses). CHD patients with bronchiolitis stay longer in the hospital than control (14.4 ± 21.7 days vs 6.2 ± 2.3 days) some of which require intensive care (n = 4).

CONCLUSIONS

Our study provides evidence of the efficacy of palivizumab in protecting patients with hemodynamically significant CHD under the age of 2 years from RSV disease and its life-threatening complications. Reducing hospitalisation rate, morbidity, and mortality in this category of patients, passive immune prophylaxis with palivizumab may impact healthcare resource availability and utilisation.

Role of ultrasound in the treatment of pediatric infectious diseases: case series and narrative review

BACKGROUND

Infectious diseases are common in pediatric patients. In these patients, ultrasound is a useful imaging modality that involves no irradiation or sedation and can be performed repeatedly at the patient's bedside. The purpose of this review was to show pediatric cases with infectious disease that used ultrasound to decide the methods of treatment.

DATA SOURCES

Literature review was performed using Pubmed as the medical database source. No year-of-publication restriction was placed. The mesh terms used were: "ultrasound", "sonography", "infectious disease", "treatment", "antibiotics", "surgical intervention", "pediatric", "children", "deep neck abscess", "pyothorax", "empyema", "pneumonia", "urinary tract infection", "intra-abdominal abscess", "soft tissue infection", "septic arthritis", "osteomyelitis", and "surgical site infection".

RESULTS

We presented pediatric case series with infectious diseases, including deep neck abscess, pyothorax and empyema, pneumonia, urinary tract infection, intra-abdominal abscess, soft tissue infection, septic arthritis and osteomyelitis, and surgical-site infection. Ultrasound was useful for evaluating the extent and location of inflammation and abscess and for decision-making concerning surgical intervention.

CONCLUSION

Knowledge of these sonographic findings is important for sonographers during examinations and for physicians when determining the treatment plan and period of antibiotic therapy for infected lesions.

International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study

OBJECTIVES

We aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network of care, adjusted for patient-level characteristics. Secondary objectives were to determine the association between full-EBM and (1) hospitalisation and (2) emergency department (ED) revisits resulting in hospitalisation within 21 days.

DESIGN

A secondary analysis of a retrospective cohort study.

SETTING

38 paediatric EDs belonging to the Paediatric Emergency Research Network in Canada, USA, Australia/New Zealand UK/Ireland and Spain/Portugal.

PATIENTS

Otherwise healthy infants 2-11 months old diagnosed with bronchiolitis between 1 January 2013 and 31 December, 2013.

OUTCOME MEASURES

Primary outcome was management consistent with full-EBM, that is, no bronchodilators/corticosteroids/antibiotics, no chest radiography or laboratory testing. Secondary outcomes included hospitalisations during the index and subsequent ED visits.

RESULTS

1137/2356 (48.3%) infants received full-EBM (ranging from 13.2% in Spain/Portugal to 72.3% in UK/Ireland). Compared with the UK/Ireland, the adjusted ORs (aOR) of full-EBM receipt were lower in Spain/Portugal (aOR 0.08, 95% CI 0.02 to 0.29), Canada (aOR 0.13 (95% CI 0.06 to 0.31) and USA (aOR 0.16 (95% CI 0.07 to 0.35). EBM was less likely in infants with dehydration (aOR 0.49 (95% CI 0.33 to 0.71)), chest retractions (aOR 0.69 (95% CI 0.52 to 0.91)) and nasal flaring (aOR 0.69 (95% CI 0.52 to 0.92)). EBM was associated with reduced odds of hospitalisation at the index visit (aOR 0.77 (95% CI 0.60 to 0.98)) but not at revisits (aOR 1.17 (95% CI 0.74 to 1.85)).

CONCLUSIONS

Infants with bronchiolitis frequently do not receive full-EBM ED management, particularly those outside of the UK/Ireland. Furthermore, there is marked variation in full-EBM between paediatric emergency networks, and full-EBM delivery is associated with lower likelihood of hospitalisation. Given the global bronchiolitis burden, international ED-focused deimplementation of non-indicated interventions to enhance EBM is needed.

A pragmatic randomized controlled trial of rapid on-site influenza and respiratory syncytial virus PCR testing in paediatric and adult populations

Background

Rapid/point-of-care respiratory virus nucleic acid tests (NAT) may improve oseltamivir, antibiotic, diagnostic test, and hospital bed utilization. Previous randomized controlled trials (RCT) on this topic have not used standard procedures of an accredited healthcare and laboratory system.

Methods

We conducted a parallel RCT at two hospitals [paediatric = Alberta Children’s Hospital (ACH); primarily adult = Peter Lougheed Centre (PLC)]. Patients with a respiratory viral testing order were randomized to testing at either a central accredited laboratory (standard arm) or with a rapid polymerase chain reaction test at an on-site accredited laboratory followed by standard testing [rapid on-site test (ROST) arm] based on day of specimen receipt at the laboratory. Patients and clinicians were blinded to assignment.

The primary outcome for ACH was inpatient length of stay (LOS) and for PLC was the proportion of inpatients prescribed oseltamivir.

Results

706 patient encounters were included at ACH; 322 assigned to ROST (181 inpatients) and 384 to the standard arm (194 inpatients). 422 patient encounters were included at PLC; 200 assigned to ROST (157 inpatients) and 222 to the standard arm (175 inpatients).

The rate of oseltamivir prescription and number of doses given was reduced in PLC inpatients negative for influenza in the ROST arm compared to standard arm [mean 14.9% (95% CI 9.87–21.9) vs. 27.5% (21.0–35.2), p = 0.0135; mean 2.85 doses (SEM 2.39–3.32) vs. 4.17 doses (3.85–4.49) p = 0.022, respectively]. ROST also significantly reduced oseltamivir use at ACH, reduced chest radiographs (ACH), and laboratory test ordering (PLC), but not antibiotic prescriptions. ROST also reduced the median turnaround time by > 24 h (ACH and PLC).

The LOS at ACH was not significantly different between the ROST and standard arms [median 4.05 days (SEM 1.79–18.2) vs 4.89 days (2.07–22.9), p = 0.062, respectively].

No adverse events were reported.

Conclusions

In a RCT representing implementation of ROST in an accredited laboratory system, we found that a ROST improved oseltamivir utilization and is the first RCT to show reduced ancillary testing in both paediatric and adult populations. A larger study is required to assess reduction in paediatric LOS as ACH was underpowered. These findings help justify the implementation of rapid on-site respiratory virus testing for inpatients.

Trial registration ISRCTN, number 10110119, Retrospectively Registered, 01/12/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07796-3.

Point-of-Care Thoracic Ultrasound in Children with Bronchiolitis

OBJECTIVE

To characterize thoracic (lung and diaphragm) ultrasound findings in children < 2 y with bronchiolitis, evaluate correlation between lung ultrasound severity score (USS) and bronchiolitis severity score (BSS), and study the interobserver agreement of USS between study pediatrician and radiologist.

METHODS

In this prospective observational study, thoracic ultrasound was performed on children with bronchiolitis by the study pediatrician and USS score was assigned. A radiologist blinded to all clinical information, performed an independent thoracic ultrasound. Demographics, clinical course, and other relevant details were recorded.

RESULTS

Fifty-three children were enrolled; 29/53 patients (54.7%) were classified as mild bronchiolitis and 24/53 (45.2%) had moderate bronchiolitis as per clinical score; 13.2% (7/53) patients had both anterior and posterior subpleural consolidation and went on to require higher respiratory support either in the form of continuous positive airway pressure in 71.4% (5/7), oxygen for > 24 h in 14.2% (1/7), or heated humidified high-flow nasal cannula in 14.2% (1/7). These results were statistically significant (p < 0.001). A statistically significant correlation was found between the USS and type and duration of respiratory support (p value 0.002) and with the mean duration of hospital stay (p value < 0.001). There was significant correlation between the BSS and USS (p < 0.001). There was a very good agreement between the ultrasound findings of study pediatrician and radiologist (kappa 0.83).

CONCLUSION

The findings of lung ultrasound (LUS) are not specific for bronchiolitis. However, LUS can be used as a good prognostic tool in patients with bronchiolitis.

Reducing Unnecessary Treatment of Bronchiolitis Across a Large Regional Health Service in Spain

OBJECTIVES

A bronchiolitis integrated care pathway (BICP) proved useful in reducing the use of unnecessary medications at a local level. The aim of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019 and 2020 bronchiolitis season.

METHODS

We conducted a quality improvement (QI) initiative in 115 primary care (PC) centers and 7 hospitals in the Basque Country, Spain, from October 2019 to March 2020. The primary outcome measure was the percentage of children prescribed salbutamol comparing the rate to that in the previous bronchiolitis season (October 2018-March 2019). Secondary outcomes were the use of other medications. Balancing measures were hospitalization and unscheduled return rates.

RESULTS

We included 8153 PC visits, 3424 emergency department (ED) attendances, and 663 inpatient care episodes, of which 3817 (46.8%), 1614 (47.1%), and 328 (49.4%) occurred in the postintervention period, respectively. Salbutamol use decreased from 27.1% to 4.7%, 29.5% to 3.0%, and 44.4% to 3.9% (P &lt; .001) in PC centers, Eds, and hospital wards, respectively. In PC, corticosteroid and antibiotic prescribing rates fell from 10.1% to 1.7% and 13.7% to 5.1%, respectively (P &lt; .001). In EDs and hospital wards, epinephrine use rates fell from 14.2% to 4.2% (P &lt; .001) and 30.4% to 19.8% (P = .001), respectively. No variations were noted in balancing measures.

CONCLUSIONS

The scaling up of the BICP was associated with significant decreases in the use of medications in managing bronchiolitis across a regional health service without unintended consequences.

Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics

The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.

Bronchiolitis therapies and misadventures

Viral bronchiolitis, which is most commonly caused by an infection with the respiratory syncytial virus (RSV), can lead to respiratory difficulties in young children which may require hospitalization. Despite years of research and medical trials, the mainstay of bronchiolitis treatment remains supportive only. This review provides an overview of the history of different treatments for bronchiolitis, including those that failed, as well as new therapies that are under study. Future studies for the treatment of bronchiolitis should consider different age-groups, important subgroups (i.e., those with a prior history of wheezing, those with a family history of asthma and those with non-RSV viral etiologies) whose response to treatment may differ from that of the composite group.

Reduced miR-146a-5p Is a Biomarker of Infant Respiratory Diseases Contributing to Immune Dysregulation in Small Airway Epithelial Cells

Respiratory diseases such as bronchiolitis, and those with wheezing episodes, are highly important during infancy due to their potential chronicity. Immune response dysregulation is critical in perpetuating lung damage. Epigenetic modifications including microRNA (miRNA) post-transcriptional regulation are among the factors involved in alleviating inflammation. We evaluated the expression of miR-146a-5p, a previously described negative regulator of immunity, in infants with respiratory diseases, in order to study epigenetic regulation of the immune response. Nasopharyngeal aspirate (NPA) was obtained from infants with bronchiolitis (ongoing and post-disease) or with wheezing episodes in addition to healthy controls. Virus presence was determined by nested PCR, while miRNA and gene expression were studied in cells from NPAs using qPCR. Healthy small airway epithelial cells (SAECs) were used as an in vitro model. We observe a reduction in miR-146a-5p expression in infants with either of the two diseases compared to controls, suggesting the potential of this miRNA as a disease biomarker. Post-bronchiolitis, miR-146a-5p expression increases, though without reaching levels of healthy controls. MiR-146a-5p expression correlates inversely with the immune-related gene PTGS2, while its expression correlates directly with TSLP. When heathy donor SAECs are stimulated by poly:IC, we observe an increase in miR-146a-5p, with wounds having a synergistic effect. In conclusion, infants with respiratory diseases present reduced miR-146a-5p expression, possibly affecting immune dysregulation.

Pathogens and Pathogenesis in Wheezing Diseases in Children Under 6

Few studies have comprehensively assessed the roles of cytokine production in wheezing pathogenesis. Therefore, we undertook this study to determine the association between wheezing episodes and cytokines, and to provide further information on this topic. Firstly, we retrospectively collected I176 children, including 122 subjects with first wheezing and 54 subjects with recurrent wheezing, to analyze the etiology and clinical characteristics of children with wheezing diseases. Then, we collected 52 children with wheezing diseases and 25 normal controls to detect the expression of interferon-γ (IFN-γ), interleukin-4 (IL-4), IFN-γ/IL-4, IL-17A, IL-17E, IgE, matrix metalloproteinase-3 (MMP-3), and MMP-9 in serum or plasma. The results showed that boys under 3 years old with history of allergies were more likely to develop wheezing diseases. In our cohort, M. pneumoniae caused a greater proportion of wheezing in children than expected. The expression of IgE [18.80 (13.65-31.00) vs. 17.9 (10.15-21.60)], IL-4 [24.00 (24.00-48.00) vs. 23.00 (9.50-27.00)], IFN-γ [70.59 (41.63-116.46) vs. 49.83 (29.58-81.74)], MMP3 [53.40 (20.02-128.2) vs. 30.90 (13.80-50.95)], MMP9 [148.10 (99.30-276.10) vs. 122.10 (82.20-162.35)], IL-17A [80.55 (54.46-113.08) vs. 61.11 (29.43-93.87)], and IL-17E [1.75 (0.66-2.77) vs. 1.19 (0.488-2.1615)] were significantly increased in the wheezing group (p<0.05) compared to normal controls, while the level of IFN-γ/IL-4 had no significant difference between the two groups (1.24 ± 1.88 vs 0.68 ± 0.74, p>0.05). There was altered cytokine production in children with wheezing diseases which was quite similar to asthma pathogenesis. Sex, age, pathogen infection, and inflammation in our study were also risk factors for wheezing diseases.

Advances in diagnostic tools for respiratory tract infections. From tuberculosis to COVID19: changing paradigms?

Respiratory tract infections (RTI) are one of the commonest reasons for seeking healthcare, but are amongst the most challenging diseases in terms of clinical decision making. Proper and timely diagnosis is critical in order to optimize management and prevent further emergence of antimicrobial resistance by misuse, or overuse of antibiotics. Diagnostic tools for RTI include those involving syndromic and etiological diagnosis: from clinical and radiological features to laboratory methods targeting both pathogen detection and host biomarkers, as well as their combinations in terms of clinical algorithms. They also include tools for predicting severity and monitoring treatment response. Unprecedented milestones have been achieved in the context of the COVID-19 pandemic, involving the most recent applications of diagnostic technologies both at genotypic and phenotypic level, which have changed paradigms in infectious respiratory diseases in terms of why, how and where diagnostics are performed. The aim of this review is to discuss advances in diagnostic tools that impact clinical decision making, surveillance and follow-up of RTI and tuberculosis. If properly harnessed, recent advances in diagnostic technologies, including omics and digital transformation emerge as an unprecedented opportunity to tackle ongoing and future epidemics while handling antimicrobial resistance from a One Health perspective.

Summer Hospitalization and Bronchial Asthma Make Treatment of Respiratory Syncytial Virus Infection Difficult: A Retrospective Study in Japan

In recent years, epidemics of respiratory syncytial virus (RSV) have been seen in the summer in Japan. Patients hospitalized in the summer used a high-flow oxygen administration device more frequently than patients hospitalized in the winter. This study was a retrospective study to examine the variables associated with duration of oxygen therapy and severe cases. Subjects were pediatric patients diagnosed with RSV infection and hospitalized for treatment during the 5 years from April 2014 to March 2019. Data from 292 patients were analyzed. Duration of oxygen therapy was significantly associated with bronchial asthma (partial regression coefficient: 0.897, P = .004). Hospitalization in summer was significantly associated with severe condition (adjusted odds ratio: 4.07, 95% confidence interval: 1.16-14.27). The present study showed that bronchial asthma is a risk factor for prolonged oxygen therapy and infection in summer is a risk factor for progression to severe condition in cases of RSV infection.

Effects of public health measures during the SARS-CoV-2 pandemic on the winter respiratory syncytial virus epidemic: An interrupted time series analysis

BACKGROUND

Public health measures (PHM) designed to contain the spread of COVID-19 pandemic have influenced the epidemiological characteristics of other viral infections. Its impact on acute RSV bronchiolitis in infants of ≤24 months old has not been systematically studied in our setting.

OBJECTIVES

To describe the monthly pattern of visits to the Paediatric Emergency Department (PED) of patients 0 to 14 years of age, the rate of patients diagnosed with RSV acute bronchiolitis per thousand inhabitants of 0 to 24 months, and the rate of them requiring hospital admission during the winter 2020-2021, in the context of local and national COVID-19 restrictions and compare them to the four previous seasons.

METHODS

Interrupted time series analysis of patients assisted in the PED and diagnosed with or admitted for RSV acute bronchiolitis in a tertiary University Hospital from January 2016 to February 2020 (pre-intervention period) and from March 2020 to June 2021 (post-intervention period).

INTERVENTION

Preventive PHM implemented by the Spanish government weighted by the Containment and Health Index of the Oxford COVID-19 Government Response Tracker.

RESULTS

The intervention was followed by an immediate reduction of the rate of visits to the PED of -19.5 (95% confidence interval [CI] -24.0, -14.9) per thousand, and the rate of diagnoses and admissions for RSV acute bronchiolitis of -44.3 (95% CI -73.8, -14.8) and -1.4 (95% CI -2.7, -0.1) per thousand, respectively, with a delayed rebound.

CONCLUSIONS

After the implementation of PHM to prevent the spread of SARS-CoV-2 infection, an immediate and important decline in the visits to the PED was observed, with an upward change thereafter. There was also an initial reduction in the diagnoses of and admissions by RSV acute bronchiolitis. An upward trend was observed six to nine months after the usual time of the winter RSV epidemic, coinciding with the relaxation of the preventive PHM.

Stakeholder Perspectives on Hospitalization Decisions and Shared Decision-Making in Bronchiolitis

OBJECTIVES

Our objective was to elicit clinicians' and parents' perspectives about decision-making related to hospitalization for children with bronchiolitis and the use of shared decision-making (SDM) to guide these decisions.

METHODS

We conducted individual, semistructured interviews with purposively sampled clinicians (pediatric emergency medicine physicians and nurses) at 2 children's hospitals and parents of children age <2 years with bronchiolitis evaluated in the emergency department at 1 hospital. Interviews elicited clinicians' and parents' perspectives on decision-making and SDM for bronchiolitis. We conducted an inductive analysis following the principles of grounded theory until data saturation was reached for both groups.

RESULTS

We interviewed 24 clinicians (17 physicians, 7 nurses) and 20 parents. Clinicians identified factors in 3 domains that contribute to hospitalization decision-making for children with bronchiolitis: demographics, clinical factors, and social-emotional factors. Although many clinicians supported using SDM for hospitalization decisions, most reported using a clinician-guided decision-making process in practice. Clinicians also identified several barriers to SDM, including the unpredictable course of bronchiolitis, perceptions of parents' preferences for engaging in SDM, and parents' emotions, health literacy, preferred language, and comfort with discharge. Parents wanted the opportunity to express their opinions during decision-making about hospitalization, although they often felt comfortable with the clinician's decision when adequately informed.

CONCLUSIONS

Although clinicians and parents of children with bronchiolitis are supportive of SDM, most hospitalization decision-making is clinician guided. Future investigation should evaluate how to address barriers and implement SDM in practice, including training clinicians in this SDM approach.

Clinical Burden of Respiratory Syncytial Virus in Hospitalized Children Aged ≤5 years (INSPIRE Study)

Background

Respiratory syncytial virus (RSV) is a leading cause of hospitalizations in children (≤5 years of age); limited data compare burden by age.

Methods

This single-center retrospective study included children (≤5 years of age) hospitalized for >24 hours with reverse-transcription polymerase chain reaction (RT-PCR)–confirmed RSV infection (2015–2018). Hospital length of stay (LOS), intensive care unit (ICU) admissions, ICU LOS, supplemental oxygen, and medication use were assessed. Multivariate logistic regression analyses identified predictors of hospital LOS >5 days.

Results

Three hundred twelve patients had RSV infection (ages 0 to <6 months [35%], 6 to <12 months [15%], 1 to <2 years [25%], and 2–5 years [25%]); 16.3% had predefined comorbidities (excludes preterm infants). Median hospital LOS was 5.0 days and similar across age; 5.1% (16/312) were admitted to ICU (ICU LOS, 5.0 days), with those aged 0 to <6 months admitted most frequently (10/108 [9.3%]). Supplemental oxygen was administered in 57.7% of patients, with similar need across ages. Antibiotics were administered frequently during hospitalization (43.6%). Predictors of prolonged LOS included pneumonia (odds ratio [OR], 2.33), supplemental oxygen need (OR, 5.09), and preterm births (OR, 3.37). High viral load (RT-PCR RSV cycle threshold value <25) was associated with greater need for supplemental oxygen.

Conclusions

RSV causes substantial burden in hospitalized children (≤5 years), particularly preterm infants and those aged <6 months.

Bronchiolitis, epidemiological changes during the SARS-CoV-2 pandemic

BACKGROUND

Bronchiolitis is the most common viral infection of the lower respiratory tract in infants under 2 years of age. The aim of this study was to analyze and compare the seasonal bronchiolitis peaks before and during the SARS-CoV-2 pandemic.

METHODS

Descriptive, prospective, and observational study. Patients with severe bronchiolitis admitted to the Pediatric Intensive Care Unit (PICU) of a referral tertiary hospital between September 2010 and June 2021 were included. Demographic data were collected. Viral laboratory-confirmation was carried out. Each season was analyzed and compared. The daily average temperature was collected.

RESULTS

1116 patients were recruited, 58.2% of them males. The median age was 49 days. Respiratory syncytial virus (RSV) was isolated in 782 cases (70.1%). In April 2021, the first and only case of bronchiolitis caused by SARS-CoV-2 was identified. The pre- and post-pandemic periods were compared. There were statistically significant differences regarding: age, 47 vs. 73 days (p = 0.006), PICU and hospital length of stay (p = 0.024 and p = 0.001, respectively), and etiology (p = 0.031). The peak for bronchiolitis in 2020 was non-existent before week 52. A delayed peak was seen around week 26/2021. The mean temperature during the epidemic peak was 10ºC for the years of the last decade and is 23ºC for the present season.

CONCLUSION

The COVID-19 pandemic outbreak has led to a clearly observable epidemiological change regarding acute bronchiolitis, which should be studied in detail. The influence of the environmental temperature does not seem to determine the viral circulation.

Analysis of the Consumption of Drugs Prescribed for the Treatment of Asthma in Belgian Children

(1) Asthma is one of the most common chronic diseases in the world among children. The main purpose of this study was to analyze the consumption of asthma medications in order to investigate asthma in children (2-18 years) and the association with health care consumption; (2) a retrospective study using anonymized administrative data for 2013-2018 from the third largest Belgian health insurer was conducted; (3) in 2018, 12.9% of children received at least one asthma medication and 4.4% received at least two packages with a minimum of 30 days between purchases. Preschool children (2-6 years) were three times more likely to take asthma medication than older children (7-18 years). ICS, in combination or not with LABA, were the most dispensed drugs among children. Children with asthma medications were almost twice as likely to receive antibiotics, more likely to end up in the emergency room, and twice as likely to be hospitalized; (4) most children took ICS, according to the GINA guidelines. High rates of nebulization in young children were observed, despite the recommendation to use an inhaler with a spacing chamber as much as possible. Finally, children who took asthma medications were more likely to end up in the ER or be hospitalized.