The Incidence and Short-term Outcomes of Acute Respiratory Illness with Cough in Children from a Socioeconomically Disadvantaged Urban Community in Australia: A Community-Based Prospective Cohort Study

Cough Hypersensitivity Syndrome: Why Its Use Is Inappropriate in Children

In children and adults, chronic cough is a common symptom presenting to health professionals worldwide. It is internationally accepted that children with chronic cough should be managed with pediatric specific management guidelines. The newly proposed clinical entity of 'cough hypersensitivity syndrome' has gained significant attention in adult literature. Given the significant differences between childhood and adult chronic cough, including in respiratory physiology and anatomy, and cough sensitivity, we address the suitability of the use of cough hypersensitivity syndrome in children. We explore these differences between childhood and adult chronic cough, explain what cough hypersensitivity is and highlight why the term cough hypersensitivity syndrome should not be used in children.

Evaluation of an mHealth Intervention (Growin' Up Healthy Jarjums) Designed With and for Aboriginal and Torres Strait Islander Mothers: Engagement and Acceptability Study

BACKGROUND

Aboriginal and Torres Strait Islander women have access to and interest in mobile health (mHealth), although few culturally relevant, evidence-based mHealth programs are available. We codeveloped an mHealth program in New South Wales with Aboriginal and Torres Strait Islander women, focusing on women's and children's health and well-being.

OBJECTIVE

This study aims to assess the engagement with and acceptability of the Growin' Up Healthy Jarjums program among mothers caring for Aboriginal and Torres Strait Islander children aged <5 years and assess the acceptability of the program among professionals.

METHODS

Women were given access to Growin' Up Healthy Jarjums-a web-based application, a Facebook (Meta Platforms, Inc) page, and SMS text messages-for 4 weeks. Short videos of health professionals presenting health information were tested within the application and on the Facebook page. Engagement with the application was examined through the number of log-ins, page views, and links used on the application. Engagement with the Facebook page was examined through likes, follows, comments, and the reach of posts. Engagement with the SMS text messages was examined through the number of mothers who opted out, and engagement with the videos was examined through the number of plays and videos watched and duration of the video watched. The acceptability of the program was examined through posttest interviews with mothers and focus groups with professionals.

RESULTS

A total of 47 participants joined the study (n=41, 87%, mothers and n=6, 13%, health professionals). Interviews were completed by 78% (32/41) of the women and 100% (6/6) health professionals. Of the 41 mothers, 31 (76%) women accessed the application, 13 (42%) scrolled the main page only, and 18 (58%) clicked on other pages. There were 48 plays and 6 completions of the 12 videos. The Facebook page received 49 page likes and 51 followers. The post with the most reach was a supportive and affirming cultural post. No participants opted out of the SMS text messages. Almost all mothers (30/32, 94%) reported that Growin' Up Healthy Jarjums was useful, and all mothers reported that the program was culturally appropriate and easy to use. Of the 32 mothers, 6 (19%) mothers reported technical problems with accessing the application. Moreover, 44% (14/32) of mothers suggested improvements to the application. All the women reported that they would recommend the program to other families.

CONCLUSIONS

This study demonstrated that the Growin' Up Healthy Jarjums program was perceived useful and culturally appropriate. SMS text messages had the highest engagement, followed by the Facebook page and then the application. This study identified areas for technical and engagement-related improvements to the application. A trial is needed to assess the effectiveness of the Growin' Up Healthy Jarjums program at improving health outcomes.

Yardstick for managing cough. Part 2: in children

Nationwide statistics in the United States and Australia reveal that cough of undifferentiated duration is the most common complaint for which patients of all ages seek medical care in the ambulatory setting. Management of chronic cough is one of the most common reasons for new patient visits to respiratory specialists. Because symptomatic cough is such a common problem and so much has been learned about how to diagnose and treat cough of all durations but especially chronic cough, this 2-part yardstick has been written to review in a practical way the evidence-based guidelines most of which have been developed from high-quality systematic reviews on how best to manage cough of all durations in adults, adolescents, and children. Chronic cough in children is often benign and self-limiting. Using established and validated protocols and specific pointers (clues in history, findings on examination) can aid the clinician in identifying causes when present and improve outcomes. In this manuscript, part 2 of the 2-part series, we provide evidence-based, expert opinion recommendations on the management of chronic cough in the pediatric patient (<14 years of age).

Bronchiectasis - Exercise as Therapy (BREATH): rationale and study protocol for a multi-center randomized controlled trial

Background

Globally, bronchiectasis (BE) unrelated to cystic fibrosis (CF) is recognized as a major cause of respiratory morbidity, mortality, and healthcare utilization. Children with BE regularly experience exacerbations of their condition resulting in frequent hospitalizations and decreased health-related quality of life (HR-QoL). Guidelines for the treatment and management of BE call for regular exercise as a means of improving aerobic fitness and HR-QoL. Moreover, research in adults with BE has shown that exercise can reduce the frequency of exacerbations, a potent predictor of future lung function decline and respiratory morbidity. Yet, to date, the health benefits resulting from therapeutic exercise have not been investigated in children with BE. The BREATH, Bronchiectasis - Exercise as Therapy, trial will test the efficacy of a novel 8-week, play-based therapeutic exercise program to reduce the frequency of acute exacerbations over 12 months in children with BE (aged ≥ 4 and < 13 years). Secondary aims are to determine the cost-effectiveness of the intervention and assess the program’s impact on aerobic fitness, fundamental movement skill (FMS) proficiency, habitual physical activity, HR-QoL, and lung function.

Methods

This multi-center, observer-blinded, parallel-group (1:1 allocation), randomized controlled trial (RCT) will be conducted at three sites. One hundred and seventy-four children ≥ 4 and < 13 years of age with BE will be randomized to a developmentally appropriate, play-based therapeutic exercise program (eight, 60-min weekly sessions, supplemented by a home-based program) or usual care. After completing the baseline assessments, the number of exacerbations and secondary outcomes will be assessed immediately post-intervention, after 6 months of follow-up, and after 12 months of follow-up. Monthly, parental contact and medical review will document acute respiratory exacerbations and parameters for cost-effectiveness outcomes.

Discussion

The BREATH trial is the first fully powered RCT to test the effects of a therapeutic exercise on exacerbation frequency, fitness, movement competence, and HR-QoL in children with bronchiectasis. By implementing a developmentally appropriate, play-based exercise program tailored to the individual needs of children with bronchiectasis, the results have the potential for a major paradigm shift in the way in which therapeutic exercise is prescribed and implemented in children with chronic respiratory conditions. The exercise program can be readily translated. It does not require expensive equipment and can be delivered in a variety of settings, including the participant’s home. The program has strong potential for translation to other pediatric patient groups with similar needs for exercise therapy, including those with obesity, childhood cancers, and neurological conditions such as cerebral palsy.

Trial registration

Australian and New Zealand Clinical Trials Register (ANZCTR) ACTRN12619001008112

Prevalence, Risk Factors and Impacts Related to Mould-Affected Housing: An Australian Integrative Review

In response to an Australian governmental inquiry into biotoxin-related illness, the purpose of this integrative review is to bring together the current state of evidence on the prevalence, risk factors and impacts related to mould-affected housing in an Australian context, in order to inform building, housing and health research, practice and policy. The robust integrative review methodology simultaneously sought quantitative and qualitative studies and grey literature from multiple disciplines, identifying only 45 studies directly relating to Australian housing and indoor mould. Twenty-one studies highlight negative health impacts relating to indoor residential mould, with asthma, respiratory, allergy conditions and emerging health concerns for chronic multiple-symptom presentation. The majority of studies reported risk factors for indoor mould including poor housing conditions, poor-quality rental accommodation, socioeconomic circumstance, age-related housing issues and concerns for surface/interstitial condensation and building defects in newer housing. Risks for indoor mould in both older and newer housing raise concerns for the extent of the problem of indoor mould in Australia. Understanding the national prevalence of housing risks and “root cause” associated with indoor mould is not conclusive from the limited existing evidence. Synthesis of this evidence reveals a lack of coverage on: (1) national and geographical representation, (2) climatical coverage, (3) housing typologies, (4) housing defects, (5) maintenance, (6) impact from urbanisation, and (7) occupant’s behaviour. This integrative review was key in identifying emerging housing and health concerns, highlighting gaps in data and implications to be addressed by researchers, practice and policy and acts as a comprehensive holistic review process that can be applied to other countries.

Predictors of the Development of Protracted Bacterial Bronchitis following Presentation to Healthcare for an Acute Respiratory Illness with Cough: Analysis of Three Cohort Studies

We describe the prevalence and risk factors for protracted bacterial bronchitis (PBB) following healthcare presentation for an acute cough illness in children. Data from three studies of the development of chronic cough (CC) in children were combined. PBB was defined as a wet cough of at least 4-weeks duration with no identified specific cause of cough that resolved following 2–4 weeks of appropriate antibiotics. Anterior nasal swabs were tested for 17 viruses and bacteria by polymerase chain reaction. The study included 903 children. Childcare attendance (adjusted relative risk (aRR) = 2.32, 95% CI 1.48–3.63), prior history of chronic cough (aRR = 2.63, 95% CI 1.72–4.01) and age <2-years (<12-months: aRR = 4.31, 95% CI 1.42–13.10; 12-<24 months: aRR = 2.00, 95% CI 1.35–2.96) increased risk of PBB. Baseline diagnoses of asthma/reactive airways disease (aRR = 0.30, 95% CI 0.26–0.35) or bronchiolitis (aRR = 0.15, 95% CI 0.06–0.38) decreased risk. M. catarrhalis was the most common organism (52.4%) identified in all children (PBB = 72.1%; no PBB = 50.2%, p < 0.001). We provide the first data on risks for PBB in children following acute illness and a hypothesis for studies to further investigate the relationship with wheeze-related illnesses. Clinicians and parents/guardians should be aware of these risks and seek early review if a wet cough lasting more than 4-weeks develops the post-acute illness.

Development of a Maternal and Child mHealth Intervention with Aboriginal and Torres Strait Islander Mothers: A Co-Design Approach (Preprint)

Background

Objective

Methods

Results

Conclusions

Medication and healthcare use, parent knowledge and cough in children: A cohort study

INTRODUCTION

Cough is an important contributor to the health burden of children and their families. There are limited data describing healthcare utilization and medication use over the course of a cough illness beyond the initial presentation. Our primary objective was to describe medication and healthcare use in children with a respiratory illness with cough as a symptom over the course of the illness.

METHODS

A cohort study of children aged less than 15-years presenting to three primary healthcare centers and three emergency departments with a cough illness between July 7, 2015 and October 6, 2018. Children with immunosuppression, known chronic lung diseases (except asthma) and those requiring hospitalization at screening were excluded. The primary outcomes were cough-related frequency and type of healthcare seeking and medication use up to 28 days following enrolment.

RESULTS

Data for 465 children were analyzed; median age 2.2-years (interquartile range = 1.1-5.3). Cough at Day 28 persisted in 117 children (25.2%). Overall, 436 (94%) children received medications in the week before and/or 4 weeks following enrolment. Half with upper respiratory tract infections were prescribed antibiotics. Among children with no diagnosis of asthma, reactive airways disease or croup (n = 404), 16.8% were given steroids. Fifty-eight percent of children sought healthcare at least once before their baseline presentation (median = 1, range = 0-20) and 49.7% had at least one further presentation in the following 28 days.

CONCLUSIONS

High healthcare utilization, inappropriate medication use, and suboptimal parent knowledge regarding cough suggests targeted education is needed to improve management and reduce cough burden.

Risk Factors for Chronic Cough in Young Children: A Cohort Study

Background and Objective: Data on the predictors of chronic cough development in young children are scarce. Our primary objective was to examine the factors associated with young children developing a chronic cough, with a focus on childcare attendance. Methods: A secondary analysis of data collected in a prospective cohort study of children presenting to three emergency departments and three primary healthcare centers in southeast Queensland, Australia. Eligible children where those aged <6-years presenting with cough and without known underlying chronic lung disease other than asthma. Children were followed for 4 weeks to ascertain cough duration. The primary outcome was persistent cough at day-28. Logistic regression models were undertaken to identify independent predictors of chronic cough including sensitivity analyses that accounted for children with unknown cough status at day-28. Results: In 362 children, 95 (26.2%) were classified as having chronic cough. In models that included only children for whom cough status was known at day-28, symptom duration at enrolment, age <12 months [adjusted odds ratio (aOR) 4.5, 95% confidence interval (CI) 1.1, 18.7], gestational age (aOR 3.2, 95%CI 1.4, 7.9), underlying medical conditions (aOR 2.6, 95% CI 1.3, 5.5), a history of wheeze (aOR 2.6, 95% CI 1.4, 4.8) and childcare attendance (aOR 2.3, 95% CI 1.2, 4.4) were independent predictors of chronic cough. Amongst childcare attendees only, 64 (29.8%) had chronic cough at day-28. The strongest predictor of chronic cough amongst childcare attendees was continued attendance at childcare during their illness (aOR = 12.9, 95% CI 3.9, 43.3). Conclusion: Gestational age, underlying medical conditions, prior wheeze and childcare attendance are risk factors for chronic cough in young children. Parents/careers need to be aware of the risks associated with their child continuing to attend childcare whilst unwell and childcare centers should reinforce prevention measures in their facilities.

Respiratory, birth and health economic measures for use with Indigenous Australian infants in a research trial: a modified Delphi with an Indigenous panel

Background

There is significant disparity between the respiratory health of Indigenous and non-Indigenous Australian infants. There is no culturally accepted measure to collect respiratory health outcomes in Indigenous infants. The aim of this study was to gain end user and expert consensus on the most relevant and acceptable respiratory and birth measures for Indigenous infants at birth, between birth and 6 months, and at 6 months of age follow-up for use in a research trial.

Methods

A three round modified Delphi process was conducted from February 2018 to April 2019. Eight Indigenous panel members, and 18 Indigenous women participated. Items reached consensus if 7/8 (≥80%) panel members indicated the item was ‘very essential’. Qualitative responses by Indigenous women and the panel were used to modify the 6 months of age surveys.

Results

In total, 15 items for birth, 48 items from 1 to 6 months, and five potential questionnaires for use at 6 months of age were considered. Of those, 15 measures for birth were accepted, i.e., gestational age, birth weight, Neonatal Intensive Care Unit (NICU) admissions, length, head circumference, sex, Apgar score, substance use, cord blood gas values, labour, birth type, health of the mother, number people living in the home, education of mother and place of residence. Seventeen measures from 1-to 6 months of age were accepted, i.e., acute respiratory symptoms (7), general health items (2), health care utilisation (6), exposure to tobacco smoke (1), and breastfeeding status (1). Three questionnaires for use at 6 months of age were accepted, i.e., a shortened 33-item respiratory questionnaire, a clinical history survey and a developmental questionnaire.

Conclusions

In a modified Delphi process with an Indigenous panel, measures and items were proposed for use to assess respiratory, birth and health economic outcomes in Indigenous Australian infants between birth and 6 months of age. This initial step can be used to develop a set of relevant and acceptable measures to report respiratory illness and birth outcomes in community based Indigenous infants.

Effectiveness of a chronic cough management algorithm at the transitional stage from acute to chronic cough in children: a multicenter, nested, single-blind, randomised controlled trial

BACKGROUND

Chronic (lasting at least 4 weeks) cough in children is an important cause of morbidity. An algorithmic approach to the management of coughs in children evaluated in observational studies and a randomised controlled trial (RCT) enrolled children referred with median cough duration of 16 weeks to specialist centres. We investigated whether applying an evidence-based cough management algorithm in non-specialist settings earlier, once cough persisted for more than 4 weeks, improved cough resolution compared with usual care.

METHODS

We undertook a multicentre, single-blind RCT nested within a prospective cohort study of children (<15 years) in Australia presenting to three primary care or three hospital emergency departments with an acute respiratory illness with cough. Children were excluded if they had a known diagnosis of an underlying chronic medical condition (excluding asthma) or had an immunosuppressive illness or were taking immunomodulating drugs for more than 2 weeks in the preceding 30 days, or had severe symptoms requiring inpatient hospitalisation. Children were followed up for 8 weeks; those with a persistent cough at day 28 were randomly assigned to the cough management algorithm or to usual care. Randomisation was stratified by reason for presentation, study site, and cough duration (4 weeks to <6 weeks vs ≥6 weeks) using computer-generated permuted blocks (block size of four) with a 1:1 allocation. The primary outcome was the proportion of children with cough resolution at day 56 (defined as resolved if the child did not cough for at least 3 days and nights since day 28 or a more than 75% reduction in their average day and night cough score). Absolute risk differences (RD_absolute) were calculated by modified intention-to-treat analysis (ITT). This trial is registered with the Australia New Zealand Clinical Trials Registry, ACTRN12615000132549.

FINDINGS

Between July 7, 2015, and Oct 31, 2018, 1018 children were screened, 509 were enrolled in the cohort study, and of 115 children in the ITT analysis, 57 were randomly assigned to the intervention group and 58 to the control group. Children had a median age of 1·6 years (IQR 1·0-4·5); 45 (39%) of 115 were Indigenous, and 59 (51%) were boys. By day 56, 33 (58%) of 57 children in the intervention group achieved cough resolution compared with 23 (40%) 58 in the control group; cough resolution was unknown in 12 (21%) of 57 children receiving the intervention and in 13 (22%) of 58 receiving the control. The RD_absolute assuming children with an unknown cough outcome were still coughing at day 56 was 18·3% (95% CI 0·3-36·2); the number needed-to-treat for benefit was five (95% CI 3-364); the adjusted odds ratio was 1·5 (95% CI 1·3-1·6), favouring the intervention group.

INTERPRETATION

This study suggests an evidence-based cough management algorithm improves cough resolution in community-based children in the early phases of chronic cough. However, larger studies to confirm these findings in primary care are required.

FUNDING

National Health and Medical Research Council.

Objectively measured physical activity and sedentary behaviour in children with bronchiectasis: a cross-sectional study

Background

Bronchiectasis is a major contributor to respiratory morbidity and health care utilization in children and youth. Current treatment guidelines for bronchiectasis recommend participation in regular physical activity (PA) to improve aerobic fitness and quality of life (QoL). However, no previous study has assessed physical activity and sedentary behavior in this patient group, and the extent to which children with bronchiectasis meet guidelines for PA is unknown. In the absence of such data, we objectively measured the PA of children with bronchiectasis and compared them to current guidelines.

Methods

Forty-six children with bronchiectasis between 4 to 14 years (mean age 7.5 ± 2.6 years) were recruited from the Queensland Children’s Hospital, Brisbane. Daily time in sedentary, light, and moderate-to-vigorous PA (MVPA) was measured objectively over 7 days using the ActiGraph GT3X+ accelerometer and compared their values to current guidelines (minimum 60 min of MVPA daily). Compliance with the daily guideline and average daily steps counts were compared to normative data from two population–based health surveys of healthy children.

Results

We had complete measurements from 36 children. On average, they accumulated 48.6 min of MVPA daily and were sedentary for ~ 7 h/day. There was no statistical difference in these values between sexes or weekdays vs. weekends. Only 2 (5.6%) children met the 60-min daily MVPA recommendation compared to 42.1% of healthy children. Children with bronchiectasis accumulated 8229 steps/day (boys: 8422 ± SD 473, girls: 8037 ± 594), well below the recommended 12,000 steps/day. In comparison, daily step counts in healthy children ranged from 11,500–14,500 steps/day.

Conclusion

Children with bronchiectasis are insufficiently active for health benefit and would substantially benefit from programs to promote PA and reduce sedentary behavior.

Wet Cough and Nasal Symptoms in Children: Can We Do Better?

The causes of chronic cough in children are mainly dependent on the setting and age of the child. Protracted bacterial bronchitis is a frequent cause of morbidity in childhood, and antibiotic treatment is beneficial. Prompt recognition and early treatment is important both to prevent inappropriate use of asthma medications and also progression to bronchiectasis, but the diagnosis should not be made uncritically, because chronic wet cough is not necessarily due to lower airway disease. Upper Airway Cough Syndrome (UACS) is considered by some to cause chronic cough in childhood. Underlying UACS are many common conditions, including allergic rhinitis, adenoiditis and rhinosinusitis. Diagnosis relies on a combination of clinical criteria that are relatively sensitive but non-specific. The role of nasal endoscopy in children with chronic cough and signs suggesting UACS is unclear. Nasal saline solution irrigation is commonly used in UACS, but most studies have methodological biases, and efficacy data are scanty. Randomized controlled trials are urgently required. However, if saline washes, rather than oral antibiotics, can effectively treat some children with wet cough associated with upper airway conditions, antibiotic resistance could potentially be reduced. There is a need to further study wet cough and not to assume it to be equivalent to lower airway infection in all children.