Maternal asthma and maternal smoking are associated with increased risk of bronchiolitis during infancy

Prenatal cigarette smoke exposure sensitizes acetaminophen-induced liver injury by modulating miR-34a-5p in male offspring mice

Introduction: Cigarette smoke (CS) exacerbates the severity of diseases not only in lungs, but also in systemic organs having no direct contact with smoke. In addition, smoking during pregnancy can have severe health consequences for both the mother and the fetus. Therefore, our aim was to evaluate effects of prenatal exposure to CS on acetaminophen (APAP)-induced acute liver injury (ALI) in offspring. Methods: Female C57BL/6 mice on day 6 of gestation were exposed to mainstream CS (MSCS) at 0, 150, 300, or 600 μg/L for 2 h a day, 5 days a week for 2 weeks using a nose-only exposure system. At four weeks old, male offspring mice were injected intraperitoneally with a single dose of APAP at 300 mg/kg body weight to induce ALI. Results: Maternal MSCS exposure significantly amplified pathological effects associated with ALI as evidenced by elevated serum alanine aminotransferase levels, increased hepatocellular apoptosis, higher oxidative stress, and increased inflammation. Interestingly, maternal MSCS exposure reduced microRNA (miR)-34a-5p expression in livers of offspring. Moreover, treatment with a miR-34a-5p mimic significantly mitigated the severity of APAP-induced hepatotoxicity. Overexpression of miR-34a-5p completely abrogated adverse effects of maternal MSCS exposure in offspring with ALI. Mechanistically, miR-34a-5p significantly decreased expression levels of hepatocyte nuclear factor 4 alpha, leading to down-regulated expression of cytochrome P450 (CYP)1A2 and CYP3A11. Discussion: Prenatal exposure to MSCS can alter the expression of miRNAs, even in the absence of additional MSCS exposure, potentially increasing susceptibility to APAP exposure in male offspring mice.

Personalized Infant Risk Prediction for Severe Respiratory Syncytial Virus Lower Respiratory Tract Infection Requiring Intensive Care Unit Admission

Background

Currently, there are no available tools to identify infants at the highest risk of significant morbidity and mortality from respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) who would benefit most from RSV prevention products. The objective was to develop and internally validate a personalized risk prediction tool for use among all newborns that uses readily available birth/postnatal data to predict RSV LRTI requiring intensive care unit (ICU) admission.

Methods

We conducted a population-based birth cohort study of infants born from 1995 to 2007, insured by the Tennessee Medicaid Program, and who did not receive RSV immunoprophylaxis during the first year of life. The primary outcome was severe RSV LRTI requiring ICU admission during the first year of life. We built a multivariable logistic regression model including demographic and clinical variables available at or shortly after birth to predict the primary outcome.

Results

In a population-based sample of 429 365 infants, 713 (0.2%) had severe RSV LRTI requiring ICU admission. The median age of admission was 66 days (interquartile range, 37-120). Our tool, including 19 variables, demonstrated good predictive accuracy (area under the curve, 0.78; 95% confidence interval, 0.77-0.80) and identified infants who did not qualify for palivizumab, based on American Academy of Pediatrics guidelines, but had higher predicted risk levels than infants who qualified (27% of noneligible infants with >0.16% predicted probabilities [lower quartile for eligible infants]).

Conclusions

We developed a personalized tool that identified infants at increased risk for severe RSV LRTI requiring ICU admission, expected to benefit most from immunoprophylaxis.

Key risk factors of asthma-like symptoms are mediated through infection burden in early childhood

BACKGROUND

Risk factors of asthma-like symptoms in childhood may act through an increased infection burden because infections often trigger these symptoms.

OBJECTIVE

We sought to investigate whether the effect of established risk factors of asthma-like episodes in early childhood is mediated through burden and subtypes of common infections.

METHODS

The study included 662 children from the Copenhagen Prospective Studies on Asthma in Childhood 2010 mother-child cohort, in which infections were registered prospectively in daily diaries from age 0 to 3 years. The association between established risk factors of asthma-like episodes and infection burden was analyzed by quasi-Poisson regressions, and mediation analyses were performed for significant risk factors.

RESULTS

In the first 3 years of life, the children experienced a median of 16 (interquartile range, 12-23) infectious episodes. We found that the infection burden significantly (PACME < .05) mediated the association of maternal asthma (36.6% mediated), antibiotics during pregnancy (47.3%), siblings at birth (57.7%), an asthma exacerbation polygenic risk score (30.6%), and a bacterial airway immune score (80.2%) with number of asthma-like episodes, whereas the higher number of episodes from male sex, low birth weight, low gestational age, and maternal antibiotic use after birth was not mediated through an increased infection burden. Subtypes of infections driving the mediation were primarily colds, pneumonia, gastroenteritis, and fever, but not acute otitis media or acute tonsillitis.

CONCLUSIONS

Several risk factors of asthma-like symptoms in early childhood act through an increased infection burden in the first 3 years of life. Prevention of infectious episodes may therefore be beneficial to reduce the burden of asthma-like symptoms in early childhood.

Exposure to outdoor air pollution and risk of hospitalization for bronchiolitis in an urban environment: A 9-year observational study

BACKGROUND

Outdoor air pollution is supposed to influence the course of bronchiolitis, but the evidence is limited. The present study aimed at evaluating the role of outdoor air pollutants on hospitalization for bronchiolitis.

METHODS

Infants aged ≤12 months referred for bronchiolitis to our Pediatric Emergency Department in Bologna, Italy, from 1 October 2011 to 16 March 2020 (nine epidemic seasons) were retrospectively included. Daily concentrations of benzene (C6 H6 ), nitrogen dioxide (NO2 ), particulate matter ≤2.5 μm (PM2.5 ), and ≤10 μm (PM10 ), and the mean values of individual patient exposure in the week and the 4 weeks before hospital access were calculated. The association between air pollutants exposure and hospitalization was evaluated through logistic regression analysis.

RESULTS

A total of 2902 patients were enrolled (59.9% males; 38.7% hospitalized). Exposure to PM2.5 in the 4 weeks preceding bronchiolitis was identified as the main parameter significantly driving the risk of hospitalization (odds ratio [95% confidence interval]: 1.055 [1.010-1.102]). After stratifying by season, higher values of other outdoor air pollutants were found to significantly affect hospitalization: 4-week exposure to C6 H6 (Season 2011-2012, 4.090 [1.184-14.130]) and PM2.5 (Season 2017-2018, 1.282 [1.032-1.593]), and 1-week exposure to C6 H6 (Season 2012-2013, 6.193 [1.552-24.710]), NO2 (Season 2013-2014, 1.064 [1.009-1.122]), PM2.5 (Season 2013-2014, 1.080 [1.023-1.141]), and PM10 (Season 2018-2019, 1.102 [0.991-1.225]).

CONCLUSION

High levels of PM2.5 , C6 H6 , NO2 , and PM10 may increase the risk of hospitalization in children affected by bronchiolitis. Open-air exposure of infants during rush hours and in the most polluted areas should be avoided.

Clinical features and later prognosis of replicable early-life wheeze clusters from two birth cohorts 12 years apart

BACKGROUND

Clustering techniques can define the heterogeneity of asthma and wheezing. Defining early-life wheezing clusters and associated asthma risk could potentially inform patient management strategies. Clustering models that yield replicable cluster groups will have greater validity and clinical utility. This study sought to identify early-life wheezing clusters that are translatable into clinical practice and assess their stability over time in two whole-population birth cohorts established a decade apart from the same geographical location.

METHODS

Nonparametric K-means cluster analysis was performed separately on two birth cohorts from the Isle of Wight, UK; the Isle of Wight Birth Cohort (IOWBC) and Food Allergy and Intolerance Research Cohort (FAIR), using clinically defining variables in wheezing subjects in the first 3-4 years. Associations of resulting clusters with potential early-life risk factors and 10-year asthma outcomes were further assessed.

RESULTS

Five clusters were identified in both cohorts: (1) infantile-onset-transient-non-atopic-wheeze, (2) infantile-onset-persistent-non-atopic-wheeze, (3) infantile-onset-atopic-wheeze, (4) early-childhood-onset-non-atopic-wheeze, and (5) early-childhood-onset-atopic-wheeze. Two atopic wheezing clusters (3 and 5) were associated with greatest early-life wheeze frequency, highest wheeze persistence, and asthma prevalence at 10 years. Cluster 1 was commonest but had lowest early-life wheeze frequency and asthma prevalence at 10 years. Cluster 2, characterized by limited atopy but recurrent infantile respiratory infections and ongoing early-life wheezing, had high 10-year asthma prevalence only in IOWBC.

CONCLUSIONS

Early-life wheeze comprises several disease clusters (two more severe and three mild-moderate) with differing relationships to later childhood asthma, which can be replicated over time supporting their potential validity and clinical utility.

Improving Asthma Outcomes During Pregnancy in Underserved Communities

It is known that poor asthma control is common in pregnancy, and asthma in general disproportionally affects underserved communities. However, there is a paucity of data examining strategies to improve asthma control specifically among pregnant women from vulnerable populations. Identified barriers to optimal asthma care in other underserved groups include health literacy, financial constraints, cultural differences, and poor environmental controls. These deficiencies may also be targets for multimodal interventions geared toward improving asthma outcomes for underserved women during pregnancy.

Beliefs about medicines and adherence to asthma medications during pregnancy

OBJECTIVE

Discontinuation of, and non-adherence to, inhaled corticosteroids (ICS) for asthma treatment is a significant issue in pregnancy. This study characterized beliefs about medicines in pregnant women with asthma and investigated associations with ICS adherence.

METHODS

Pregnant women with relatively mild asthma (n = 302) were grouped according to ICS use and self-reported adherence (≥80% doses taken). They completed questions about dislike of asthma medications and the validated Beliefs about Medicines Questionnaire (BMQ), which consists of ten questions about asthma medicines ("necessity" questions about maintaining health, or "concern" questions about adverse effects), and eight general medicine questions, scored on five-point Likert scales. The Necessity Concerns differential (N-C) was calculated, with positive scores indicating that the patient perceives the benefits of medicines to outweigh the risks.

RESULTS

ICS was used by 87 (29%) women, with 49 (56%) self-reporting adherence. Of the 22% who disliked taking asthma medications during pregnancy, 20% had the belief that the medication was unsafe. ICS users had a significantly higher BMQ necessity score and higher necessity-concern differential score than nonusers; when adjusted for covariates, ICS non-adherence was associated with a lower necessity score (p = 0.015). Women adherent to ICS were more likely to agree to "my health at present depends on my asthma medication" compared to non-adherent ICS users.

CONCLUSIONS

ICS non-adherence was not associated with having relatively more concerns about asthma medicines; however, ICS users were more likely to perceive that the benefits of medication use outweighed any risks. Interventions to improve asthma medication adherence in pregnancy are needed.

Asthma in pregnancy - Management, maternal co-morbidities, and long-term health

Asthma is the most prevalent chronic disease in pregnancy, and as symptoms can change with pregnancy, and exacerbations of asthma are common, regular review of asthma symptoms, the provision of self-management education, and appropriate medication use are the hallmarks of management. Co-morbidities are also prevalent among pregnant women with asthma, with obesity, gestational diabetes, hypertension, rhinitis, depression, and anxiety, more common among women with asthma than women without asthma. Less is known about reflux, obstructive sleep apnoea and vocal cord dysfunction, along with nutritional deficiencies to iron and vitamin D. Maternal asthma impacts the offspring's long-term health, particularly in increasing the risk of early life wheeze and asthma in childhood. While breastfeeding may modify the risk of infant wheeze, less is known about the mechanisms involved. More research is needed to further understand the relationship between asthma in pregnancy and the risk of poor neurodevelopmental outcomes, such as autism.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

In utero exposures to mint-flavored JUUL aerosol impair lung development and aggravate house dust mite-induced asthma in adult offspring mice

There are few reports concerning electronic nicotine delivery system (ENDS) use during pregnancy and no studies on asthma in prenatally JUUL-exposed offspring. Here, we tested the hypothesis that in utero JUUL exposure causes unfavorable birth outcomes and lasting pulmonary health effects in adult offspring. BALB/c dams were exposed to either air or mint-flavored JUUL aerosol, 1-hr/d, 20 consecutive days during gestation. Offspring were sacrificed on post-natal day (PND) 0 or at 11-week of age, following house dust mite (HDM) challenge. Gene expression was assessed in the uterine/placental tissue of the dams and lung responses were assessed in offspring at PND0 and at 11 weeks of age. JUUL-exposed offspring exhibited decreased body weights and lengths at PND0. These birth outcomes were accompanied by dysregulation of 54 genes associated with hypoxia and oxidative stress in the uterine/placental tissues of JUUL-exposed dams, as well as 24 genes in the lungs of the offspring related to Wnt signaling, plus 9 genes related to epigenetics, and 7 genes related to inflammation. At 11 weeks of age, JUUL + HDM exposed mice exhibited pulmonary inflammation when compared to their respective air + HDM controls. Additionally, the JUUL + HDM exposure dysregulated several genes associated with allergies and asthma. Further, the JUUL + HDM females showed decreased methylation of the promoter region of the Il10ra gene. Taken together, our mouse model shows that inhalation of JUUL aerosols during pregnancy affects the intrauterine environment, impairs lung development, and heightens the effects of allergic airway responses later in life.

Association between secondhand marijuana smoke and respiratory infections in children

BACKGROUND

Little is known about the effects of secondhand marijuana smoke on children. We aimed to determine caregiver marijuana use prevalence and evaluate any association between secondhand marijuana smoke, childhood emergency department (ED) or urgent care (UC) visitation, and several tobacco-related illnesses: otitis media, viral respiratory infections (VRIs), and asthma exacerbations.

METHODS

This study was a cross-sectional, convenience sample survey of 1500 subjects presenting to a pediatric ED. The inclusion criteria were as follows: caregivers aged 21-85 years, English- or Spanish-speaking. The exclusion criteria were as follows: children who were critically ill, medically complex, over 11 years old, or using medical marijuana.

RESULTS

Of 1500 caregivers, 158 (10.5%) reported smoking marijuana and 294 (19.6%) reported smoking tobacco. Using negative-binomial regression, we estimated rates of reported ED/UC visits and specific illnesses among children with marijuana exposure and those with tobacco exposure, compared to unexposed children. Caregivers who used marijuana reported an increased rate of VRIs in their children (1.31 episodes/year) compared to caregivers with no marijuana use (1.04 episodes/year) (p = 0.02).

CONCLUSIONS

Our cohort did not report any difference with ED/UC visits, otitis media episodes, or asthma exacerbations, regardless of smoke exposure. However, caregivers of children with secondhand marijuana smoke exposure reported increased VRIs compared to children with no smoke exposure.

IMPACT

Approximately 10% of caregivers in our study were regular users of marijuana. Prior studies have shown that secondhand tobacco smoke exposure is associated with negative health outcomes in children, including increased ED utilization and respiratory illnesses. Prior studies have shown primary marijuana use is linked to negative health outcomes in adults and adolescents, including increased ED utilization and respiratory illnesses. Our study reveals an association between secondhand marijuana smoke exposure and increased VRIs in children. Our study did not find an association between secondhand marijuana smoke exposure and increased ED or UC visitation in children.

Breast milk-derived extracellular vesicle miRNAs are associated with maternal asthma and atopy

Background: Breast milk-derived extracellular vesicle (EV) miRNAs may program child health outcomes associated with maternal asthma and atopy. The authors investigated associations between maternal asthma/atopy and EV miRNAs in the Programming of Intergenerational Stress Mechanisms cohort. Methods: Breast milk-derived EV miRNAs collected 6.1 ± 5.9 weeks postnatally (n = 80 mothers) were profiled using the TaqMan OpenArray Human MicroRNA Panel. The authors assessed associations using adjusted robust regression. Results: Nine EV miRNAs were associated with asthma during pregnancy (a priori criteria: nominal p < 0.05; |B_regression| >0.2). miR-1290 was associated with asthma and atopy during pregnancy (p < 0.05; |B_regression| >0.2). Enriched Kyoto Encyclopedia of Genes and Genomes pathways included TGF-β signaling and extracellular matrix-receptor interaction (false discovery rate <0.05). Conclusion: In this study, maternal asthma and atopy were associated with breast milk-derived EV miRNAs. Additional studies are needed to understand whether EV miRNAs have direct effects on infant and child health.

Modifiable environmental factors predispose term infants to bronchiolitis but bronchiolitis itself predisposes to respiratory sequelae

INTRODUCTION

Viral bronchiolitis is a common lower respiratory tract infection in infants. Environmental and genetic factors can favor respiratory tract infections.

AIM

The aim of this study is to analyze risk factors for bronchiolitis and to investigate the predisposing factors for developing transient wheezing and asthma through a 6-year follow-up after hospitalization for bronchiolitis compared with a group of healthy controls that belonged to Piccolipiù cohort, who never had bronchiolitis.

METHODS

We enrolled 645 infants hospitalized with bronchiolitis. A structured questionnaire was used to obtain demographic and clinical data. At 6 years of age, 370 cases and 183 controls were investigated for the presence of asthma by the structured questionnaire, for prick test and for spirometry, and were classified to asthmatic, transient wheezing, and no wheezing/no asthma.

RESULTS

Breastfeeding was an independent protective factor (odds ratio [OR]: 0.3, 95% confidence interval [95% CI]: 0.2-0.4, p < 0.001) and tobacco smoke was a risk factor for the development of bronchiolitis (OR: 2.1, 95% CI: 1.4-3.1, p < 0.001). Analyzing follow-up, bronchiolitis increased the risk of developing transient wheezing by 12.9 (95% CI: 6.3-26.1, p < 0.001) and of developing asthma by 4.6 (95% CI: 1.9-10.7, p < 0.001). A positive family history of atopy increased the risk of developing asthma by 3.1 (95% CI: 1.4-6.7, p = 0.005). Asthmatic patients had a lower % FEV1, a lower % flow-volume curve (FVC), and a lower FEV1/FVC value, and they had more frequently positive skin prick test.

CONCLUSION

Bronchiolitis is influenced by environmental factors: tobacco smoke increases its risk and breastfeeding is a protective factor. At the end of 6 years of follow-up, bronchiolitis is a significant risk factor to have pre-school wheezing and asthma.

Risk Factors Associated With Bronchiolitis in Puerto Rican Children

OBJECTIVE

The objective of this study was to identify frequency, severity, and risk factors associated with bronchiolitis in Puerto Rican children.

METHODS

A cross-sectional was study performed at 4 emergency departments of Puerto Rico's metropolitan area, between June 2014 and May 2015. We included children younger than 24 months, with a clinical diagnosis of bronchiolitis, who were born and living in Puerto Rico at the time of recruitment. A physician-administered questionnaire inquiring about the patient's medical, family, and social history and a bronchiolitis severity assessment were performed. Daily weather conditions were monitored, and aeroallergens were collected with an air sample and precision weather station within the metropolitan area to evaluate environmental factors.

RESULTS

We included 600 patients for 12 months. More than 50% of the recruited patients had a previous episode of bronchiolitis, of which 40% had been hospitalized. Older age (odds ratio [OR], 18.3; 95% confidence interval [CI], 9.2-36.5), male sex (OR, 1.6; 95% CI, 1.1-2.4), history of asthma (OR, 8.9; 95% CI, 3.6-22), allergic rhinitis (OR, 3.6; 95% CI, 1.8-7.4), and smoke exposure by a caretaker (OR, 2.3; 95% CI, 1.2-4.4) were predictors of bronchiolitis episodes. Bronchiolitis episodes were associated with higher severity score (P = 0.040), increased number of atopic factors (P < 0.001), and higher number of hospitalizations (P < 0.001).

CONCLUSIONS

This study identifies Puerto Rican children who may present a severe clinical course of disease without traditional risk factors. Atopy-related factors are associated with frequency and severity of bronchiolitis. Puerto Rican children present risk factors related to atopy earlier in life, some of which may be modified to prevent the subsequent development of asthma.

Association between Glucose-6-Phosphate Dehydrogenase Deficiency and Asthma

Background: Among the determinants contributing to the pathogenesis of asthma, antioxidant genetic factors play a leading role. Glucose-6-phosphate dehydrogenase (G6PD) is an enzyme that is competent to detoxify free radicals. Although a relationship between G6PD deficiency and asthma has been previously reported, the literature is still scanty. In this study, we test this hypothesis in a large cohort of patients from Sardinia, Italy. Methods: A retrospective case–control study was performed using data from 11,829 clinical records of outpatients referred to a teaching hospital for a medical visit. In total, 455 cases (asthma-positive) and 11,374 controls (asthma-negative) were compared for G6PD status using multivariable analysis, adjusting for all covariates. Results: Overall, G6PD deficiency was detected in 11.2% of study participants and was associated with an increased risk of asthma (odds ratio (OR) 1.63; 95% confidence interval (CI) 1.27–2.10). Additional variables significantly associated with asthma were female sex (OR 1.66; 95% CI 1.34–2.06), overweight/obesity (OR 1.56; 95% CI 1.27–1.92), smoking (OR 1.44; 95% CI 1.449–3.963), and high socioeconomic status (OR 1.40; 95% CI 1.16–1.70), whereas age was inversely related with asthma (OR 0.49; 95% CI 0.39–0.61). Conclusions: Our study shows that G6PD deficiency is an independent risk for asthma. These findings suggest that G6PD should be assessed in asthmatic patients for better risk stratification.

Effect of prenatal and postnatal exposure to tobacco in the development of acute bronchiolitis in the first two years of life

INTRODUCTION

Environmental exposure to tobacco increases the risk of respiratory disease in infants. However, the impact of maternal smoking on the development of acute bronchiolitis has hardly been assessed. The aim of this study was to determine the incidence of acute bronchiolitis and to analyse the effect of prenatal and postnatal maternal smoking on the development of this disease.

PATIENTS AND METHODS

A prospective, observational study was performed on healthy newborns from a third level hospital born between October 2015 and February 2016. Questionnaires were completed by the mothers at discharge from maternity and followed-up for two years. These collected information about prenatal and postnatal smoking, lifestyle, family and personal history, and the development of bronchiolitis. A bivariate and multivariate logistic regression analysis was performed.

RESULTS

A total of 223 newborns were included, of whom 13.9% were exposed to tobacco smoking during gestation, 21.4% in the postnatal period, and 12.4% in both times. The incidence of bronchiolitis was 28.7% at one year of life, and 34.5% at two years. The multivariate analysis demonstrated that the prenatal and postnatal exposure to tobacco is an independent risk factor for the development of bronchiolitis (OR 4.38; 95% CI; 1.63-11.76), while prolonged breastfeeding is a protective factor (OR 0.13; 95% CI; 0.04-0.48). Other factors that were statistically significant were: atopic dermatitis (OR 2.91; 95% CI; 1.26-6.73), and gestational age (OR 1.42; 95% CI; 1.08-1.88).

CONCLUSIONS

Children exposed to prenatal and postnatal maternal smoking have a higher risk of suffering bronchiolitis. Reducing the smoking habit in women that intend to become pregnant must be a priority in preventive medicine.

Rhinovirus bronchiolitis, maternal asthma, and the development of asthma and lung function impairments

BACKGROUND

Children with a history of rhinovirus (RV) positive bronchiolitis have a high risk of developing subsequent asthma. Maternal asthma might also increase this risk. The aim of this study was to investigate the combined effects of hospitalization for RV positive bronchiolitis in infancy and a history of maternal asthma on the development of asthma at preschool age.

METHODS

This is a prospective cohort study of 139 preschool-aged children, with a history of hospital admission for bronchiolitis in infancy, followed-up to ascertain asthma and asthma-like symptoms, skin prick allergy test positivity, and lung function measured pre- and post-bronchodilator using impulse oscillometry.

RESULTS

Children with a past hospitalization for RV positive bronchiolitis (42.4% of all) and a history of maternal asthma (36.7% of all) had the greatest prevalence and risk ratio (RR) for doctor-diagnosed asthma (prevalence 81.8% and RR 2.10, 95% confidence interval [CI] 1.37-3.19, p = .001), use of inhaled corticosteroids (68.2% and RR 2.17, 95% CI 1.19-3.99, p = .001) and short-acting β-agonists in the last 12 months (95.2% and RR 1.49, 95% CI 1.17-1.89, p = .001), as compared to those with RV negative bronchiolitis and no maternal asthma history. More children in this group had an abnormal airway resistance (33.3% and adjusted risk ratio [aRR] 3.11, 95% CI 1.03-9.47, p = .045) and reactance (27.8% and aRR 2.11, 95% CI 1.06-4.26, p = .035) at 5 Hz, as compared to those with RV negative bronchiolitis and no maternal asthma history.

CONCLUSION

Hospitalization for RV positive bronchiolitis in early life combined with a history of maternal asthma identifies a subgroup of children with a high asthma burden while participants with only one of the two risk factors had intermediate risk for asthma.

Respiratory Outcome of the Former Premature Infants

The research aims to identify the respiratory pathology during the first two years of life in premature infants with gestational ages between 30-34 weeks and the risk factors for these conditions (familial, prenatal, and neonatal).

There were investigated 31 premature infants with gestational ages between 30-34 weeks and the incidence of bronchopulmonary dysplasia, infections with the respiratory syncytial virus, or other viral infections requiring hospitalization, recurrent wheezing, and nasal colonization with pathogenic bacteria were noted. Also, regression models for each type of respiratory pathology as a function of the antenatal (smoking in the family, atopy, mother’s age) and neonatal (gestational age, respiratory distress syndrome, duration of the treatment with antibiotics, use of the reserve antibiotics) factors were elaborated.

Respiratory distress syndrome was present in 20 premature infants, and 19 infants received respiratory support. Two former premature infants presented with bronchopulmonary dysplasia, 3 with severe respiratory syncytial virus infections, 7 with recurrent wheezing, and 16 with viral infections requiring hospitalization. Respiratory distress syndrome and severe viral infections were more frequently found in families of smokers. Low gestational age and familial atopy were identified as good predictors of severe respiratory syncytial virus infections (p< 0.03)

Premature infants with gestational ages between 30-34 weeks present with the risk of appearance of respiratory diseases during the first two years of life, especially disorders of the airways. Familial atopy and low gestational age represent independent risk factors for severe respiratory syncytial virus infections.

The Effect of Parental Smoking on Voice-Related Quality of Life in the Pediatric Population

OBJECTIVES

Exposure to cigarette smoke has significant effects on the respiratory mucosa. However, little is known about the effects of household smoke exposure on children's voice-related quality of life. The aim of this study was to elucidate the effect of parental smoking (PS) on voice-related quality of life in the pediatric population.

SUBJECTS AND METHODS

The Pediatric Voice-related Quality of Life (PVRQoL) instrument was administered to the parents of 104 healthy children without any known voice disorder. The children were evaluated in two groups. The first group of children had no PS history and no household smoke exposure (non-PS group), in the second group, at least one parent of the child consumed tobacco products in the house (PS group). Social emotional and physical functional subdomains of the PVRQoL were also calculated.

RESULTS

A total of 104 surveys were analyzed. The overall percentage of dysphonia in the PS group was 23.6%, whereas it was 6.1% in the non-PS group. The mean PVRQoL scores were 89.1 (±13.8) in the PS group and 97.7 (±4.7) in the non-PS group (P < 0.001). The mean physical functional-PVRQoL score was 35.4 (±7.2) in the PS group and 39.0 (±6.0) in the non-PS group. The mean social emotional-PVRQoL scores were 51.2 (±9.3) in the PS group and 57.2 (±5.6) in the non-PS group. The overall voice quality was significantly lower in the PS group than in the non-PS group.

CONCLUSION

Exposure to PS has negative effects on voice-related quality of life in children that cannot be underestimated. Parents should be informed about the detrimental effects of passive smoking on the voice quality of their children. Inclusion of items in pediatric voice surveys about PS that lead to dysphonia would be suggested.

Effect of asthma exacerbation during pregnancy in women with asthma: a population-based cohort study

The association between asthma exacerbation during pregnancy and adverse maternal and child health outcomes have not been investigated appropriately. Our objective was to determine the short- and long-term intergenerational effect of asthma exacerbation in pregnant women with asthma.A population cohort study was conducted using data from the Ontario asthma surveillance system and population-level health administrative data. Asthma exacerbation in pregnant women with asthma was defined as at least one of the following criteria: at least five physician visits, or one emergency department visit or one hospital admission for asthma during pregnancy. Pregnancy complications, adverse perinatal outcomes and early childhood respiratory disorders were identified using International Classification of Disease codes (9th and 10th revisions).The cohort consisted of 103 424 singleton pregnancies in women with asthma. Asthma exacerbation in pregnant women with asthma was associated with higher odds of pre-eclampsia (OR 1.30, 95% CI 1.12-1.51) and pregnancy-induced hypertension (OR 1.17, 95% CI 1.02-1.33); babies had higher odds of low birthweight (OR 1.14, 95% CI 1.00-1.31), preterm birth (OR 1.14, 95% CI 1.01-1.29) and congenital malformations (OR 1.21, 95% CI 1.05-1.39). Children born to women with asthma exacerbation during pregnancy had elevated risk of asthma (OR 1.23, 95% CI 1.13-1.33) and pneumonia (OR 1.12, 95% CI 1.03-1.22) during the first 5 years of life.Asthma exacerbation during pregnancy in women with asthma showed increased risk of pregnancy complications, adverse perinatal outcomes and early childhood respiratory disorders in their children, indicating that appropriate asthma management may reduce the risk of adverse health outcomes.

In utero tobacco smoke exposure alters lung inflammation, viral clearance, and CD8+T-cell responses in neonatal mice infected with respiratory syncytial virus

Maternal smoking during pregnancy and exposure of infants to cigarette smoke are strongly associated with adverse health effects in childhood including higher susceptibility to respiratory viral infections. Human respiratory syncytial virus (HRSV) is the most important cause of lower respiratory tract infection among young infants. Exacerbation of respiratory disease, including HRSV bronchiolitis and higher susceptibility to HRSV infection, is well correlated with previous smoke exposure. The mechanisms of recurrence and susceptibility to viral pathogens after passive smoke exposure are multifactorial and include alteration of the structural and immunologic host defenses. In this work, we used a well-established mouse model of in utero smoke exposure to investigate the effect of in utero smoke exposure in HRSV-induced pathogenesis. Sample analysis indicated that in utero exposure led to increased lung inflammation characterized by an increased influx of neutrophils to the airways of the infected mice and a delayed viral clearance. On the other hand, decreased HRSV-specific CD8+T-cell response was observed. These findings indicate that cigarette smoke exposure during pregnancy alters HRSV-induced disease as well as several aspects of the neonatal immune responses.

How Maternal BMI Modifies the Impact of Personalized Asthma Management in Pregnancy

BACKGROUND

Maternal asthma is associated with perinatal complications and respiratory illness in offspring. Obesity increases asthma exacerbation risk in pregnancy and risk of wheeze in offspring.

OBJECTIVES

In this secondary analysis of a randomized controlled trial, we investigated the influence of maternal body mass index, gestational weight gain (GWG), and fractional exhaled nitric oxide (F_ENO)-based management on asthma exacerbations in pregnancy and offspring wheeze.

METHODS

A total of 220 women were randomized to asthma treatment adjustment according to symptoms (control group), or F_ENO and symptoms (F_ENO group). Exacerbations were recorded prospectively. Height and weight were measured at baseline, and in late pregnancy. GWG was categorized according to Institute of Medicine guidelines. A validated parent-completed questionnaire assessed infant wheeze-related outcomes.

RESULTS

F_ENO-based management was associated with a significantly lower incidence rate ratio for maternal exacerbations in nonobese mothers (0.52, 95% confidence interval [CI], 0.31-0.88, P = .015, n = 129), and women with GWG within recommendations (0.35, 95% CI, 0.12-0.96, P = .042, n = 43), but not for obese mothers (0.59, 95% CI, 0.32-1.08, P = .089, n = 88), or women with excess GWG (0.58, 95% CI, 0.32-1.04, P = .07, n = 104). Recurrent bronchiolitis occurred in 5.3% (n = 1) of infants born to non-overweight mothers, 16.7% (n = 3) of infants of overweight mothers, and 21.7% (n = 5) of infants of obese mothers in the control group. In the F_ENO group, 2 infants of obese mothers had recurrent bronchiolitis (7.1%, P = .031).

CONCLUSIONS

The benefits of F_ENO-based management are attenuated among obese mothers and those with excess GWG, indicating the importance of weight management in contributing to improved asthma management in pregnancy.

Maternal childhood and lifetime traumatic life events and infant bronchiolitis

BACKGROUND

Viral bronchiolitis is a common respiratory infection that often affects term, otherwise healthy infants. A small literature suggests maternal stress during pregnancy is associated with bronchiolitis. However, the association between maternal exposure to lifetime traumatic stress, including traumatic events occurring in childhood or throughout the life course, and bronchiolitis has not been studied previously.

OBJECTIVES

To investigate the association between maternal exposure to total lifetime and childhood traumatic stress events and infant bronchiolitis.

METHODS

We studied mother-infant dyads enrolled in a prospective prenatal cohort, recruited 2006-2011, and Tennessee Medicaid. During pregnancy, we assessed maternal lifetime exposure to types of traumatic events by questionnaire. We captured bronchiolitis diagnoses in term, non-low birthweight infants' first 12 months using linked Medicaid data. In separate models, we assessed the association of maternal lifetime traumatic events (0 to 20 types) and a subset of traumatic events that occurred during childhood (0 to 3: family violence, sexual, and physical abuse) and infant bronchiolitis using multivariable log-binomial models.

RESULTS

Of 629 women, 85% were African American. The median count (interquartile range) of lifetime traumatic events was 3 (2, 5); 42% reported ≥1 childhood traumatic event. Among infants, 22% had a bronchiolitis diagnosis (0 to 2 lifetime traumatic events: 24%; 3 events: 20%; 4 to 5 events: 18%; 6 or more events: 24%). Total maternal lifetime traumatic events were not associated with bronchiolitis in multivariable analyses. For maternal childhood traumatic events, the risk of infant bronchiolitis increased with number of event types reported: adjusted Risk ratios were 1.12 (95% confidence interval [CI] 0.80, 1.59), 1.31 (95% CI 0.83, 2.07), and 2.65 (95% CI 1.45, 4.85) for 1, 2, and 3 events, respectively, vs none.

CONCLUSIONS

Infants born to women reporting multiple types of childhood trauma were at higher risk for bronchiolitis. Further research is needed to explore intergenerational effects of traumatic experiences.

Vitamin D status in pregnant women with asthma and its association with adverse respiratory outcomes during infancy

BACKGROUND

Vitamin D may influence pregnancy and infant outcomes, especially infant respiratory health. This study aimed to examine vitamin D status in pregnant women with asthma, and whether higher vitamin D levels are associated with fewer adverse respiratory outcomes in their infants.

METHODS

Pregnant women with asthma, recruited from John Hunter Hospital Newcastle Australia (latitude 33°S), had serum total 25-hydroxyvitamin-D (25(OH)D) measured at 16 and 35 weeks gestation. Infant respiratory outcomes were collected at 12 months by parent-report questionnaire. Mother-infant dyads were grouped by serum 25(OH)D during pregnancy: 25(OH)D < 75 nmol/L (at both time-points) versus 25(OH)D ≥ 75 nmol/L (at one or both time-points).

RESULTS

In 52 pregnant women with asthma, mean serum 25(OH)D levels were 61 (range 26-110) nmol/L at 16 weeks, and 65 (range 32-116) nmol/L at 35 weeks, gestation. Thirty-one (60%) women had 25(OH)D < 75 nmol/L at both time-points; 21 (40%) had 25(OH)D ≥ 75 nmol/L at one or both time-points. Maternal 25(OH)D < 75 nmol/L during pregnancy was associated with a higher proportion of infants with "wheeze ever" at 12 months, compared with 25(OH)D ≥ 75 nmol/L (71 versus 43%, p = .04). Infant acute-care presentations (45 versus 13%, p = .02) and oral corticosteroid use (26 versus 4%, p = .03) due to "asthma/wheezing" were higher in the maternal group with 25(OH)D < 75 nmol/L, versus ≥75 nmol/L.

CONCLUSIONS

Most pregnant women with asthma had low vitamin D status, which persisted across gestation. Low maternal vitamin D status was associated with greater risk of adverse respiratory outcomes in their infants, a group at high risk of developing childhood asthma.

Transient Tachypnea of the Newborn Is Associated With an Increased Risk of Hospitalization Due to Respiratory Syncytial Virus Bronchiolitis

BACKGROUND

Transient tachypnea of the newborn (TTN) is a self-limiting respiratory disorder, resulting from a failure to clear the lungs of perinatal fluid. As similar pathophysiologic features are present in children with respiratory syncytial virus (RSV) bronchiolitis, we hypothesized that these two conditions may be connected.

METHODS

This was a population-based cohort study that included all children born in term (≥37 weeks of gestation) without congenital malformations in Finland between 1996 and 2015. Children diagnosed with TTN (International Statistical Classification of Diseases and Related Health Problems, 10th Revision [ICD-10] code P22.1) after birth and children hospitalized because of RSV bronchiolitis (ICD-10 code J21.0) during first year of life were identified from the Medical Birth Register and National Hospital Discharge Register, respectively, and the data were linked. Logistic regression was used to analyze the association between these two conditions.

RESULTS

Of the 1,042,045 children included in the study cohort, 16,327 (1.57%) were diagnosed with TTN at birth and 12,345 (1.18%) were hospitalized because of RSV bronchiolitis during the first year of life. The rate of RSV hospitalization was higher in children with a history of TTN compared with children without TTN diagnosis [260/16,327 (1.59%) vs. 12,085/1,025,718 (1.18%), respectively; P value <0.0001]. After adjusting for gestational age at birth, mode of delivery, gender, birth weight, multiple births, older siblings and maternal smoking, TTN was associated with increased risk for RSV hospitalization (odds ratio: 1.31, 95% confidence interval: 1.16-1.48).

CONCLUSIONS

TTN diagnosis after birth was associated with increased risk for RSV hospitalization during the first year of life.

Prenatal and postnatal tobacco smoke exposure and risk of severe bronchiolitis during infancy

BACKGROUND

Maternal prenatal smoking has adverse effects on the growing fetus including those of respiratory nature. Although postnatal smoke exposure is a risk factor for respiratory infections, the effects of prenatal smoking independent of postnatal smoke exposure are less established. We hypothesized that both maternal prenatal smoking, and postnatal smoke exposure are risk factors for severe bronchiolitis during infancy.

METHODS

We performed a case-control study of 1353 children born between 1996 and 2011 at a single teaching hospital. Cases were admitted to the same hospital for bronchiolitis during infancy. Maternal prenatal smoking was collected from birth records. Postnatal smoke exposure was collected from review of electronic health records. Multivariable logistic regression was used to evaluate the independent associations of the two smoking variables with severe bronchiolitis.

RESULTS

6% of cases were exposed to maternal prenatal smoking, compared with 4% of controls (P = 0.10). Postnatal smoke exposure was present in the households of 17% of cases compared with 3% of controls (P < 0.001). In a multivariable model with both smoking variables and adjustment for 10 covariates, maternal prenatal smoking was not a significant risk factor for severe bronchiolitis (adjusted OR = 1.02, 95%CI 0.56-1.84). By contrast, postnatal smoke exposure was associated with >300% increased odds (adjusted OR 4.19, 95%CI 2.51-6.98).

CONCLUSIONS

Although maternal prenatal smoking has many known adverse effects, it was not associated with increased odds of severe bronchiolitis in either unadjusted or multivariable analyses. Postnatal smoke exposure was a consistently strong risk factor. Our findings support ongoing efforts to decrease infant exposure to ambient smoke.

Risk factors for severe bronchiolitis caused by respiratory virus infections among Mexican children in an emergency department

Severe bronchiolitis is the most common reason for hospitalization among children younger than 2 years. This study analyzed the prevalence of community-acquired respiratory virus infection and the risk factors for hospitalization of Mexican children with severe bronchiolitis treated in an Emergency department.This retrospective study included 134 children 2 years or younger with severe viral bronchiolitis, and 134 healthy age-matched controls. The study period was September 2012 to January 2015. We determined the viral etiology and coinfections with multiple viruses and compared the risk factors detected in children with severe viral bronchiolitis with those in the control group.A total of 153 respiratory viruses in these 134 patients, single or mixed infections, were identified: respiratory syncytial virus (RSV) type A or B was the most frequently detected (23.6% and 17.6%, respectively), followed by rhinovirus (RV; 16.3%) and parainfluenza virus (PIV) type 3 (12.4%). Coinfections of 2 respiratory viruses were found in 14.2% of cases; all cases had either RSV type A or B with another virus, the most common being parainfluenza virus or rhinovirus. Exposure to cigarette smoking was independently associated with hospitalization for severe bronchiolitis (OR, 3.5; 95% CI, 1.99-6.18; P = .0001), and having completed the vaccination schedule for their age was a protective factor against adverse outcome (OR, 0.55; 95% CI, 0.35-0.87; P = .010).RSV is a common infection among young children with severe bronchiolitis; thus, developing a vaccine against RSV is essential. Campaigns to reinforce the importance of avoiding childhood exposure to cigarette smoke are also needed.

Tobacco Use and Smoke Exposure in Children: New Trends, Harm, and Strategies to Improve Health Outcomes

PURPOSE OF REVIEW

Every day in the USA, approximately 4000 adolescents begin smoking and the adolescent brain is particularly susceptible to nicotine addiction. We present current pediatric trends on tobacco use and exposures, various new products used by adolescents, the adverse biological and behavioral effects of tobacco use and exposures, and tobacco control strategies to eliminate tobacco-related illnesses and deaths in the pediatric population.

RECENT FINDINGS

Twelve-20% of women continue to smoke during pregnancy. New research reveals cognitive differences and behavior-control disorders are seen in elementary school children from prenatal and postnatal exposures. Traditional cigarette smoking has decreased in adolescents; novel and appealing tobacco products have captured their attention, particularly electronic cigarettes, and rates double and often triple from middle to high school. Children with asthma and those living in multi-housing units have higher rates of secondhand smoke exposure than non-asthmatics and children living in single-home dwellings. There is no "safe or risk-free" level of tobacco use or exposure. Tobacco use and exposure in childhood and adolescence must be decreased using evidenced-based strategies to improve child health.

Effect of long-term maternal smoking on the offspring's lung health

Maternal smoking during pregnancy contributes to long-term health problems in offspring, especially respiratory disorders that can manifest in either childhood or adulthood. Receptors for advanced glycation end products (RAGE) are multiligand receptors abundantly localized in the lung, capable of responding to by-products of reactive oxygen species and proinflammatory responses. RAGE signaling is a key regulator of inflammation in cigarette smoking-related pulmonary diseases. However, the impact of maternal cigarette smoke exposure on lung RAGE signaling in the offspring is unclear. This study aims to investigate the effect of maternal cigarette smoke exposure (SE), as well as mitochondria-targeted antioxidant [mitoquinone mesylate (MitoQ)] treatment, during pregnancy on the RAGE-mediated signaling pathway in the lung of male offspring. Female Balb/c mice (8 wk) were divided into a sham group (exposed to air), an SE group (exposed to cigarette smoke), and an SE + MQ group (exposed to cigarette smoke with MitoQ supplement from mating). The lungs from male offspring were collected at 13 wk. RAGE and its downstream signaling, including nuclear factor-κB and mitogen-activated protein kinase family consisting of extracellular signal-regulated kinase 1, ERK2, c-JUN NH2-terminal kinase (JNK), and phosphorylated JNK, in the lung were significantly increased in the SE offspring. Mitochondrial antioxidant manganese superoxide dismutase was reduced, whereas IL-1β and oxidative stress response nuclear factor (erythroid-derived 2)-like 2 were significantly increased in the SE offspring. Maternal MitoQ treatment normalized RAGE, IL-1β, and Nrf-2 levels in the SE + MQ offspring. Maternal SE increased RAGE and its signaling elements associated with increased oxidative stress and inflammatory cytokines in offspring lungs, whereas maternal MitoQ treatment can partially normalize these changes.

Role of Parental Smoking in Severe Bronchiolitis: A Hospital Based Case-Control Study

Objective. Bronchiolitis is one of the commonest causes of hospitalization of infants and young children in Bangladesh. About 21% of under 5 children attending different hospitals of Bangladesh have bronchiolitis. Fifty percent (50%) men and three percent (3%) women of Bangladesh are smokers. Parental smoking is an important risk factor for both susceptibility and severity of bronchiolitis. The aim of this study was to find out the role of parental smoking in severe bronchiolitis. Design. Case-control study. Place and Duration of Study. The study was conducted in the Department of Paediatrics, Sylhet MAG Osmani Medical College Hospital, Bangladesh, from July 2013 to December 2015. Patients and Methods. Sixty-four patients admitted into the ward with severe bronchiolitis were enrolled as cases and sixty-four suitably matched apparently healthy children attending EPI centre and outpatient department presenting with nonrespiratory illness were enrolled as controls. Sample size was calculated using Guilford and Frucher formula. The technique was systematic random sampling. Every second case satisfying the inclusion and exclusion criteria was enrolled in the study. Results. The mean age of the patients was 7.53 (SD ± 4.75) months. Forty (62.5%) patients were male and twenty four (37.5%) patients were female. Male-to-female ratio was 1.7 : 1. Most of the cases (60.95%) came from low socioeconomic background. More than half of the cases (53.13%) were not exclusively breastfed babies. Mean length of hospital stay was 6.41 (SD ± 2.82) days. Thirty eight (59%) cases and twenty six (34%) controls were exposed to parental smoking. Result was highly significant (p = 0.005). Odds ratio was 2.8 (95% CI from 1.36 to 5.72). Conclusion. Exposure to parental smoking causes a statistically significant (p = 0.005, odds ratio = 2.8) increase in the risk of developing severe bronchiolitis in the first year of life.

The Role of Nicotine in the Effects of Maternal Smoking during Pregnancy on Lung Development and Childhood Respiratory Disease. Implications for Dangers of E-Cigarettes

Use of e-cigarettes, especially among the young, is increasing at near-exponential rates. This is coupled with a perception that e-cigarettes are safe and with unlimited advertising geared toward vulnerable populations, the groups most likely to smoke or vape during pregnancy. There is now wide appreciation of the dangers of maternal smoking during pregnancy and the lifelong consequences this has on offspring lung function, including the increased risk of childhood wheezing and subsequent asthma. Recent evidence strongly supports that much of the effect of smoking during pregnancy on offspring lung function is mediated by nicotine, making it highly likely that e-cigarette use during pregnancy will have the same harmful effects on offspring lung function and health as do conventional cigarettes. In fact, the evidence for nicotine being the mediator of harm of conventional cigarettes may be most compelling for its effects on lung development. This raises concerns about both the combined use of e-cigarettes plus conventional cigarettes by smokers during pregnancy as well as the use of e-cigarettes by e-cigarette-only users who think them safe or by those sufficiently addicted to nicotine to not be able to quit e-cigarette usage during pregnancy. Thus, it is important for health professionals to be aware of the risks of e-cigarette usage during pregnancy, particularly as it pertains to offspring respiratory health.

Prenatal Versus Postnatal Tobacco Smoke Exposure and Intensive Care Use in Children Hospitalized With Bronchiolitis

OBJECTIVE

Among children hospitalized with bronchiolitis, we examined the associations between in utero exposure to maternal cigarette smoking, postnatal tobacco smoke exposure, and risk of admission to the intensive care unit (ICU).

METHODS

We performed a 16-center, prospective cohort study of hospitalized children aged <2 years with a physician admitting diagnosis of bronchiolitis. For 3 consecutive years, from November 1, 2007 until March 31, 2010, site teams collected data from participating families, including information about prenatal maternal smoking and postnatal tobacco exposure. Analyses used chi-square, Fisher's exact, and Kruskal-Wallis tests and multivariable logistic regression.

RESULTS

Among 2207 enrolled children, 216 (10%) had isolated in utero exposure to maternal smoking, 168 (8%) had isolated postnatal tobacco exposure, and 115 (5%) experienced both. Adjusting for age, sex, race, birth weight, viral etiology, apnea, initial severity of retractions, initial oxygen saturation, oral intake, and postnatal tobacco exposure, children with in utero exposure to maternal smoking had greater odds of being admitted to the ICU (adjusted odds ratio [aOR] 1.51, 95% confidence interval [CI] 1.14-2.00). Among children with in utero exposure to maternal smoking, those with additional postnatal tobacco exposure had a greater likelihood of ICU admission (aOR 1.95, 95% CI 1.13-3.37) compared to children without postnatal tobacco smoke exposure (aOR 1.47, 95% CI 1.05-2.04).

CONCLUSIONS

Maternal cigarette smoking during pregnancy puts children hospitalized with bronchiolitis at significantly higher risk of intensive care use. Postnatal tobacco smoke exposure may exacerbate this risk. Health care providers should incorporate this information into counseling messages.

Maternal smoking in pregnancy and its influence on childhood asthma

Maternal smoking in pregnancy (MSP) is a large modifiable risk factor for pregnancy related mortality and morbidity and also the most important known modifiable risk factor for asthma. This review summarises the effects of MSP throughout infancy, childhood and adolescence with regards to asthma (development and severity). Firstly, the direct damage caused by nicotine on fetal lung development, fetal growth and neuronal differentiation is discussed, as well as the indirect effects of nicotine on placental functioning. Secondly, the effects of MSP on later immune functioning resulting in increased infection rate are summarised and details are given on the effects of MSP modulating airway hyperreactivity, reducing lung function and therefore increasing asthma morbidity. Furthermore, epigenetic effects are increasingly being recognised. These can also result in transgenerational detrimental effects induced by cigarette smoke. In summary, the causal relationship between MSP and asthma development is well documented and presents a major health problem for generations to come. The high prevalence of MSP is alarming and epigenetic effects of nicotine on immune functioning potentiate this danger. A considerable part of the increase in asthma prevalence worldwide is due to MSP.

Pre-birth cohort study of atopic dermatitis and severe bronchiolitis during infancy

BACKGROUND

Infants hospitalized for bronchiolitis (i.e. severe bronchiolitis) are at increased risk of childhood asthma. There are many known risk factors for severe bronchiolitis, including cardiac and pulmonary diseases. Less is known about the association between atopic diseases and risk of severe bronchiolitis. We sought to further examine risk factors for severe bronchiolitis, focusing on atopic dermatitis (AD).

METHODS

We conducted a nested cohort study within the Massachusetts General Hospital Obstetric Maternal Study (MOMS), a prospective cohort of pregnant women enrolled during 1998-2006. Children of mothers enrolled in MOMS were included in the analysis if they received care within our health system (n = 5407). Potential risk factors for bronchiolitis and hospitalization data were extracted from the children's electronic health records; we also examined pregnancy and perinatal risk factors collected from the underlying MOMS data.

RESULTS

During the first year of life, 125 infants (2.3%) had severe bronchiolitis. Eighteen of these patients had AD; 11 (61%) were diagnosed with AD prior to bronchiolitis hospitalization. In unadjusted analyses, AD was associated with severe bronchiolitis (χ(2) 14.6; p < 0.001). In multivariable analyses adjusting for nine known risk factors for severe bronchiolitis, including demographics, birth season, disposition at birth, cardiac disease, maternal parity, and delivery mode, AD was associated with increased odds of severe bronchiolitis (odds ratio 2.72, 95% confidence interval 1.60-4.63).

CONCLUSIONS

Atopic dermatitis is significantly associated with severe bronchiolitis in infancy. The mechanism of the AD-bronchiolitis association is unclear and merits further study; this research may shed light on the pathogenesis of asthma.

SmokeHaz: Systematic Reviews and Meta-analyses of the Effects of Smoking on Respiratory Health

BACKGROUND

Smoking tobacco increases the risk of respiratory disease in adults and children, but communicating the magnitude of these effects in a scientific manner that is accessible and usable by the public and policymakers presents a challenge. We have therefore summarized scientific data on the impact of smoking on respiratory diseases to provide the content for a unique resource, SmokeHaz.

METHODS

We conducted systematic reviews and meta-analyses of longitudinal studies (published to 2013) identified from electronic databases, gray literature, and experts. Random effect meta-analyses were used to pool the findings.

RESULTS

We included 216 articles. Among adult smokers, we confirmed substantially increased risks of lung cancer (risk ratio (RR), 10.92; 95% CI, 8.28-14.40; 34 studies), COPD (RR, 4.01; 95% CI, 3.18-5.05; 22 studies), and asthma (RR, 1.61; 95% CI, 1.07-2.42; eight studies). Exposure to passive smoke significantly increased the risk of lung cancer in adult nonsmokers and increased the risks of asthma, wheeze, lower respiratory infections, and reduced lung function in children. Smoking significantly increased the risk of sleep apnea and asthma exacerbations in adult and pregnant populations, and active and passive smoking increased the risk of tuberculosis.

CONCLUSIONS

These findings have been translated into easily digestible content and published on the SmokeHaz website.

Wheezing and risk factors in the first year of life in Cantabria, Spain. The EISL study

OBJECTIVES

To determine the prevalence of wheezing during the first year of life in Cantabria, Spain and its associated risk factors.

METHODOLOGY

A cross-sectional, multicentre, descriptive epidemiological study was carried out in a representative sample of 958 infants in the first year of life, born in Cantabria. A previously validated and standardised written questionnaire was completed by the parents of infants seen between 12 and 15 months of age in the Primary Care Centres.

RESULTS

The prevalence of wheezing was 32.7%. A relationship was found with male gender (OR 1.38, 95%CI [1.05-1.81]), the presence of a sibling (OR 2.43 [1.38-3.98]), attending nursery school (OR 2.40 [1.71-3.35]), exclusive breastfeeding for <3 months (OR 1.47 [1.12-1.93]), a first cold at ≤3 months (OR 2.07 [1.56-2.74]), asthma in siblings (OR 2.17 [1.25-3.77]), parental allergic rhinitis (OR 1.62 [1.10-2.37]) and paracetamol use >1 a week (OR 2.49 [1.31-4.73]), and maternal smoking during pregnancy (OR 2.18 [1.51-3.15]). The prevalence of recurrent wheezing (≥3 episodes) was 14.3%. Significant associations were observed with the male gender (OR 1.79 [1.23-2.60]), attending nursery school (OR 2.92 [1.96-4.35]), first cold at ≤3 months (OR 2.11 [1.46-3.04]), eczema (OR 1.92 [1.21-3.04]), maternal asthma (OR 1.77 [1.00-3.14]), exclusive breastfeeding for <3 months (OR 1.53 [1.06-2.22]), and maternal smoking during pregnancy (OR 1.53 [1.05-2.22]).

CONCLUSIONS

One third of the infants experienced wheezing during the first year of life; those who were less exclusively breastfed, attended nursery school, presented eczema, family asthma or allergic rhinitis, and maternal smoking during pregnancy.

Ferolla F, Hijano DR, Acosta PL, Erviti A, Polack FP. Alcohol during pregnancy worsens acute respiratory infections in children

AIM

This study explored whether alcohol consumption during pregnancy increased the risk of life-threatening respiratory infections in children.

METHODS

We prospectively evaluated children under the age of two years admitted to hospitals in Buenos Aires, Argentina, with severe acute respiratory infections during the winters of 2011 and 2012. Information on maternal alcohol consumption during the third trimester of pregnancy was collected using standardised questionnaires and categorised as never, low if it was once a week and high if it was equal or more than once a week.

RESULTS

Of the 3423 children hospitalised with acute respiratory infection, 2089 (63.7%) had respiratory syncytial virus (RSV). Alcohol consumption during the last trimester was reported by 398 mothers (12.4%) and categorised as low (n = 210, 6.5%) or high (n = 188, 5.9%). A greater effect on life-threatening respiratory infection, defined as oxygen saturation of or up to 87%, was observed with higher alcohol intake due to all viruses and specifically RSV in the logistic regression analyses. Alcohol consumption was strongly associated with life-threatening disease, particularly in boys whose adjusted odds ratio rose from 3.67 to 13.52 when their mothers drank alcohol.

CONCLUSION

Alcohol consumption during pregnancy was associated with life-threatening respiratory infections in boys.

Effects of home visiting and maternal mental health on use of the emergency department among late preterm infants

OBJECTIVE

To describe use of the emergency department (ED) among late preterm versus term infants enrolled in a home visiting program and to determine whether home visiting frequency was associated with outcome differences.

DESIGN

Retrospective, cohort study.

SETTING

Regional home visiting program in southwest Ohio from 2007–2010.

PARTICIPANTS

Late preterm and term infants born to mothers enrolled in home visiting. Program eligibility requires ≥ one of four characteristics: unmarried, low income, < 18 years, or suboptimal prenatal care.

METHODS

Data were derived from vital statistics, hospital discharges, and home visiting records. Negative binomial regression was used to determine association of ED visits in the first year with late preterm birth and home visit frequency, adjusting for maternal and infant characteristics.

RESULTS

Of 1,804 infants, 9.2% were born during the late preterm period. Thirty-eight percent of all infants had at least one ED visit, 15.6% had three or more. No significant difference was found between the number of ED visits for late preterm and term infants (39.4% vs. 37.8% with at least one ED visit, p = .69). In multivariable analysis, late preterm birth combined with a maternal mental health diagnosis was associated with an ED incident rate ratio (IRR) of 1.26, p = .03; high frequency of home visits was not significant (IRR = .92, p = .42).

CONCLUSIONS

Frequency of home visiting service over the first year of life is not significantly associated with reduced ED visits for infants with at-risk attributes and born during the late preterm period. Research on how home visiting can address ED use, particularly for those with prematurity and maternal mental health conditions, may strengthen program impact and cost benefits.

RSV infection among children born moderately preterm in a community-based cohort

We aimed to determine the rates of proven respiratory syncytial virus (RSV) hospitalization and disease severity among children born moderately preterm (MP, gestational age [GA] 32-36 weeks, n = 964), children born full-term (FT, GA 38-42 weeks, n = 572), and children born early preterm (EP, GA <32 weeks, n = 524). Our second aim was to identify risk factors for RSV hospitalization among MP. We extracted data from parental questionnaires and medical records, retrieved from a community-based cohort of children aged 43-49 months. The RSV hospitalization rates of MP were higher than FT (3.9 vs. 1.2 %, relative rate 3.2; 95 % confidence interval (CI) 1.4-7.1) and equal to EP (3.9 vs. 3.2 %, relative rate 1.2; 95 % CI 0.7-2.1). MP were hospitalized at an earlier age than EP. Disease severity (based on the type of treatment and hospitalization length) was equal in all groups. Risk factors for RSV hospitalization in MP were younger age and lower birth weight. In multivariable analyses, shorter GA and passive smoking independently increased the likelihood of RSV hospitalization in MP.

CONCLUSION

The rates of hospitalization due to proven RSV infection are higher in MP than FT and not different between MP and EP. No difference in disease severity was observed. Among MP, the rates of RSV hospitalization are higher for lower GA and when exposed to passive smoking.

Implementing a clinical practice guideline for the treatment of bronchiolitis in a high-risk Hispanic pediatric population

INTRODUCTION

Bronchiolitis is the leading cause of hospitalization among infants and young children. Because of its frequency, a clinical practice guideline for bronchiolitis was implemented in this population in an effort to decrease costs and the number of diagnostic evaluations performed and medications used without increasing length of stay or transfers to the pediatric intensive care unit.

METHODS

A retrospective chart review of 322 pediatric admissions to a rural community hospital was conducted (169 before guideline implementation and 153 after guideline implementation), and data were categorically stratified into three groups for comparison purposes. Descriptive statistics were used to analyze the data, with a p value < .05 defining significance.

RESULTS

During the project period, patients with a mean age of 9.6 months were admitted to the hospital with bronchiolitis. Statistically significant decreases in cost per day and decreases in use of antibiotics and chest radiographs were achieved without increasing length of stay or pediatric intensive care unit transfers.

DISCUSSION

This project demonstrated feasibility in implementing an evidence-based clinical practice guideline in a rural hospital to improve patient outcomes.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Differential DNA methylation profiles of infants exposed to maternal asthma during pregnancy

BACKGROUND

Asthma is a complex disease that involves both genetic factors and environmental exposures. Aberrant epigenetic modifications, such as DNA methylation, may be important in asthma development. Fetal exposure to maternal asthma during critical periods of in utero development may lead to epigenetic alterations that predispose infants to a greater risk of developing asthma themselves. We investigated alterations in the DNA methylation profile of peripheral blood from infants exposed to maternal asthma during pregnancy.

METHODS

Peripheral blood was collected from 12-month-old infants born to women with (n = 25) and without (n = 15) doctor diagnosed asthma during pregnancy. Genomic DNA was extracted, bisulfite converted, and hybridized to Infinium Methylation 27 arrays (Illumina), containing over27,000 CpGs from 14,495 genes. CpG loci in only autosomal genes were classified as differentially methylated at the 99% level (P < 0.01, |DiffScore| > 22 and delta beta >0.06).

RESULTS

There were 70 CpG loci, corresponding to 67 genes that were significantly differentially methylated. Twelve CpG loci (11 genes) showed greater than 10% comparative difference in DNA methylation, including hyper-methylated loci of FAM181A, MRI1, PIWIL1, CHFR, DEFA1, MRPL28, AURKA, and hypo-methylated loci of NALP1L5, MAP8KIP3, ACAT2, and PM20D1 in maternal asthma. Methylation of MAPK8IP3 was significantly negatively correlated with maternal blood eosinophils (r = -0.38; P = 0.022), maternal eNO (r = -0.44; P = 0.005), and maternal serum total IgE (r = -0.39, P = 0.015). Methylation of AURKA negatively correlated with maternal hemoglobin (r = -0.43; P = 0.008), infants height (r = -0.51; P < 0.001) and weight (r = -0.36; P = 0.021). Methylation of PM20D1 was lower in infants born to mothers with asthma on inhaled corticosteroid treatment. Methylation of PM20D1 was lower and MRI1 was higher in infants born to atopic mothers without asthma.

CONCLUSIONS

In an Australian study population, exposure to maternal asthma during pregnancy is associated with differential methylation profiles of infants' peripheral blood DNA, which may act as risk factors for future asthma development.

Physical, behavioral, and cognitive effects of prenatal tobacco and postnatal secondhand smoke exposure

The purpose of this review is to examine the rapidly expanding literature regarding the effects of prenatal tobacco and postnatal secondhand smoke (SHS) exposure on child health and development. Mechanisms of SHS exposure are reviewed, including critical periods during which exposure to tobacco products appears to be particularly harmful to the developing fetus and child. The biological, biochemical, and neurologic effects of the small fraction of identified components of SHS are described. Research describing these adverse effects of both in utero and childhood exposure is reviewed, including findings from both animal models and humans. The following adverse physical outcomes are discussed: sudden infant death syndrome, low birth weight, decreased head circumference, respiratory infections, otitis media, asthma, childhood cancer, hearing loss, dental caries, and the metabolic syndrome. In addition, the association between the following adverse cognitive and behavioral outcomes and such exposures is described: conduct disorder, attention-deficit/hyperactivity disorder, poor academic achievement, and cognitive impairment. The evidence supporting the adverse effects of SHS exposure is extensive yet rapidly expanding due to improving technology and increased awareness of this profound public health problem. The growing use of alternative tobacco products, such as hookahs (a.k.a. waterpipes), and the scant literature on possible effects from prenatal and secondhand smoke exposure from these products are also discussed. A review of the current knowledge of this important subject has implications for future research as well as public policy and clinical practice.

A systematic review of predictive modeling for bronchiolitis

PURPOSE

Bronchiolitis is the most common cause of illness leading to hospitalization in young children. At present, many bronchiolitis management decisions are made subjectively, leading to significant practice variation among hospitals and physicians caring for children with bronchiolitis. To standardize care for bronchiolitis, researchers have proposed various models to predict the disease course to help determine a proper management plan. This paper reviews the existing state of the art of predictive modeling for bronchiolitis. Predictive modeling for respiratory syncytial virus (RSV) infection is covered whenever appropriate, as RSV accounts for about 70% of bronchiolitis cases.

METHODS

A systematic review was conducted through a PubMed search up to April 25, 2014. The literature on predictive modeling for bronchiolitis was retrieved using a comprehensive search query, which was developed through an iterative process. Search results were limited to human subjects, the English language, and children (birth to 18 years).

RESULTS

The literature search returned 2312 references in total. After manual review, 168 of these references were determined to be relevant and are discussed in this paper. We identify several limitations and open problems in predictive modeling for bronchiolitis, and provide some preliminary thoughts on how to address them, with the hope to stimulate future research in this domain.

CONCLUSIONS

Many problems remain open in predictive modeling for bronchiolitis. Future studies will need to address them to achieve optimal predictive models.

Association of folic acid supplementation during pregnancy and infant bronchiolitis

Viral bronchiolitis affects 20%-30% of infants; because there is no known effective treatment, it is important to identify risk factors that contribute to its pathogenesis. Although adequate folate intake during the periconceptional period prevents neural tube defects, animal data suggest that higher supplementation may be a risk factor for child respiratory diseases. Using a population-based retrospective cohort of 167,333 women and infants, born in 1995-2007 and enrolled in the Tennessee Medicaid program, we investigated the association between the filling of folic acid-containing prescriptions and infant bronchiolitis. We categorized women into the following 4 groups in relation to the first trimester: "none" (no prescription filled), "first trimester only," "after first trimester," and "both" (prescriptions filled both during and after the first trimester). Overall, 21% of infants had a bronchiolitis diagnosis, and 5% were hospitalized. Most women filled their first prescriptions after the fifth to sixth weeks of pregnancy, and most prescriptions contained 1,000 µg of folic acid. Compared with infants born to women in the "none" group, infants born to women in the "first trimester only" group had higher relative odds of bronchiolitis diagnosis (adjusted odds ratio = 1.17, 95% confidence interval: 1.11, 1.22) and greater severity (adjusted odds ratio = 1.16, 95% confidence interval: 1.11, 1.22). This study's findings contribute to an understanding of the implications of prenatal nutritional supplement recommendations for infant bronchiolitis.

Epidemiological and genetic characteristics associated with the severity of acute viral bronchiolitis by respiratory syncytial virus

OBJECTIVE

to assess the epidemiological and genetic factors associated with severity of acute viral bronchiolitis (AVB) by respiratory syncytial virus (RSV).

DATA SOURCE

the key words "bronchiolitis", "risk factor", "genetics" and "respiratory syncytial virus", and all combinations among them were used to perform a search in the PubMed, SciELO, and Lilacs databases, of articles published after the year 2000 that included individuals younger than 2 years of age.

DATA SYNTHESIS

a total of 1,259 articles were found, and their respective summaries were read. Of these, 81 were selected, which assessed risk factors for the severity of AVB, and were read in full; the 60 most relevant studies were included. The epidemiologic factors associated with AVB severity by RSV were prematurity, passive smoking, young age, lack of breastfeeding, chronic lung disease, congenital heart disease, male gender, ethnicity, viral coinfection, low weight at admission, maternal smoking during pregnancy, atopic dermatitis, mechanical ventilation in the neonatal period, maternal history of atopy and/or asthma during pregnancy, season of birth, low socioeconomic status, Down syndrome, environmental pollution, living at an altitude > 2,500 meters above sea level, and cesarean section birth. Conversely, some children with severe AVB did not present any of these risk factors. In this regard, recent studies have verified the influence of genetic factors on the severity of AVB by RSV. Polymorphisms of the TLRs, RANTES, JUN, IFNA5, NOS2, CX3CR1, ILs, and VDR genes have been shown to be associated with more severe evolution of AVB by RSV.

CONCLUSION

the severity of AVB by RSV is a phenomenon that depends on the varying degrees of interaction among epidemiological, environmental, and genetic variables.