Does inhaled steroid therapy help emerging asthma in early childhood?

Elissa M Abrams, Stanley J Szefler, Allan B Becker. The Lancet Respiratory Medicine. Online first 3 August 2017.

Although early childhood wheeze is common, persistent asthma is less common. However, of those children who do progress to persistent asthma, lung function abnormalities and airway remodelling can already be seen early in life and can increase in magnitude with time. There has been a general expectation that early use of inhaled corticosteroid (ICS) could change the natural history of asthma if started in the young child with wheeze. Despite this expectation, the role of ICS therapy in altering the natural course of disease in children with emerging asthma is not well defined. Here we discuss the potential use of ICS therapy to alter the natural disease course in children at risk of persistent asthma (defined as wheeze and presence of airflow limitation or airway hyper-reactivity, or both). We present new information suggesting a more personalised treatment approach in which children might benefit from daily or intermittent ICS therapy. We also provide an overview of other emerging therapies that might be useful in disease modification for the wheezing young child at risk of persistent asthma.

Burden of child and adolescent obesity on health services in England

Viner RM, Kinra S, Nicholls D, et al. Burden of child and adolescent obesity on health services in England. Archives of Disease in Childhood Published Online First: 01 August 2017. doi: 10.1136/archdischild-2017-313009


Objective To assess the numbers of obese children and young people (CYP) eligible for assessment and management at each stage of the childhood obesity pathway in England.

Design Pathway modelling study, operationalising the UK National Institute for Health and Care Excellence guidance on childhood obesity management against national survey data.

Setting Data on CYP aged 2–18 years from the Health Survey for England 2006 to 2013.

Main outcome measures Clinical obesity (body mass index (BMI) >98th centile), extreme obesity (BMI ≥99.86th centile); family history of cardiovascular disease or type 2 diabetes; obesity comorbidities defined as primary care detectable (hypertension, orthopaedic or mobility problems, bullying or psychological distress) or secondary care detectable (dyslipidaemia, hyperinsulinaemia, high glycated haemoglobin, abnormal liver function).

Results 11.2% (1.22 million) of CYP in England were eligible for primary care assessment and for community lifestyle modification. 2.6% (n=283 500) CYP were estimated to be likely to attend primary care. 5.1% (n=556 000) were eligible for secondary care referral. Among those aged 13–18 years, 8.2% (n=309 000) were eligible for antiobesity drug therapy and 2.4% (90 500) of English CYP were eligible for bariatric surgery. CYP from the most deprived quintile were 1.5-fold to 3-fold more likely to be eligible for obesity management.

Conclusions There is a mismatch between population burden and available data on service use for obesity in CYP in England, particularly among deprived young people. There is a need for consistent evidence-based commissioning of services across the childhood obesity pathway based on population burden

International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England

Harron K, Gilbert R, Cromwell D, et al.   International comparison of emergency hospital use for infants: data linkage cohort study in Canada and England
BMJ Qual Saf Published Online First: 12 June 2017. doi: 10.1136/bmjqs-2016-006253

Objectives  To compare emergency hospital use for infants in Ontario (Canada) and England.
Methods We conducted a population-based data linkage study in infants born ≥34 weeks’ gestation between 2010 and 2013 in Ontario (n=253 930) and England (n=1 361 128). Outcomes within 12 months of postnatal discharge were captured in hospital records. The primary outcome was all-cause unplanned admissions. Secondary outcomes included emergency department (ED) visits, any unplanned hospital contact (either ED or admission) and mortality. Multivariable regression was used to evaluate risk factors for infant admission.
Results The percentage of infants with ≥1 unplanned admission was substantially lower in Ontario (7.9% vs 19.6% in England) while the percentage attending ED but not admitted was higher (39.8% vs 29.9% in England). The percentage of infants with any unplanned hospital contact was similar between countries (42.9% in Ontario, 41.6% in England) as was mortality (0.05% in Ontario, 0.06% in England). Infants attending ED were less likely to be admitted in Ontario (7.3% vs 26.2%), but those who were admitted were more likely to stay for ≥1 night (94.0% vs 55.2%). The strongest risk factors for admission were completed weeks of gestation (adjusted OR for 34–36 weeks vs 39+ weeks: 2.44; 95% CI 2.29 to 2.61 in Ontario and 1.66; 95% CI 1.62 to 1.70 in England) and young maternal age.
Conclusions Children attending ED in England were much more likely to be admitted than those in Ontario. The tendency towards more frequent, shorter admissions in England could be due to more pressure to admit within waiting time targets, or less availability of paediatric expertise in ED. Further evaluations should consider where best to focus resources, including in-hospital, primary care and paediatric care in the community.

Full text is available here

Child under nutrition project

A report about the current undernourishment of children in England | Patients Association

The project was undertaken by the Patients Association and funded by a non-restricted education grant from Abbott. A cross-section of health and care staff in four sites – Bradford, Cornwall, Tower Hamlets and Birmingham – were interviewed. Parents were also interviewed in Bradford and Cornwall.

The findings reveal examples of positive efforts in working with children and families across agencies, particularly by public health teams, community and acute health staff; but many are overstretched and unable to meet demand for the types of information and guidance that people need. The report’s recommendations include:

  • Awareness of under-nutrition should be raised among both professionals and the public
  • New and existing training and guidance for professionals should include the identification and treatment of under-nutrition
  • National guidance and a care pathway should be developed specifically for undernutrition.

The full report is available here

The paediatrician’s role in mental health

Mental health is increasingly acknowledged as an integral part of a paediatrician’s work. This article aims to cover six important areas that will be useful to the general paediatrician | Paediatrics and Child Health

In the first part of the article I will tackle: why mental health is an important part of paediatric care, what kind of mental health difficulties do children encounter and how should paediatricians initially approach emotional and behavioural problems? In the second part I will describe the emotional problems encountered in paediatric services, how to understand behavioural problems and how to manage both of these in paediatric practice. Practical approaches and advice are provided in each section.

Full reference: Davie, M. (2017) The paediatrician’s role in mental health. Paediatrics and Child Health. Published online: 28 July 2017

Risk Stratification in Pediatric Acute Respiratory Distress Syndrome

This study aims to describe the epidemiology of patients with PARDS across Asia and evaluate whether the Pediatric Acute Lung Injury Consensus Conference risk stratification accurately predicts outcome in PARDS | Critical Care Medicine

Objectives: The Pediatric Acute Lung Injury Consensus Conference developed a pediatric specific definition for acute respiratory distress syndrome (PARDS). In this definition, severity of lung disease is stratified into mild, moderate, and severe groups. We aim to describe the epidemiology of patients with PARDS across Asia and evaluate whether the Pediatric Acute Lung Injury Consensus Conference risk stratification accurately predicts outcome in PARDS.

Measurements and Main Results: Data on epidemiology, ventilation, adjunct therapies, and clinical outcomes were collected. Patients were followed for 100 days post diagnosis of PARDS. A total of 373 patients were included. There were 89 (23.9%), 149 (39.9%), and 135 (36.2%) patients with mild, moderate, and severe PARDS, respectively. The most common risk factor for PARDS was pneumonia/lower respiratory tract infection (309 [82.8%]). Higher category of severity of PARDS was associated with lower ventilator-free days (22 [17-25], 16 [0-23], 6 [0-19]; p < 0.001 for mild, moderate, and severe, respectively) and PICU free days (19 [11-24], 15 [0-22], 5 [0-20]; p < 0.001 for mild, moderate, and severe, respectively). Overall PICU mortality for PARDS was 113 of 373 (30.3%), and 100-day mortality was 126 of 317 (39.7%). After adjusting for site, presence of comorbidities and severity of illness in the multivariate Cox proportional hazard regression model, patients with moderate (hazard ratio, 1.88 [95% CI, 1.03-3.45]; p = 0.039) and severe PARDS (hazard ratio, 3.18 [95% CI, 1.68, 6.02]; p < 0.001) had higher risk of mortality compared with those with mild PARDS.

Conclusions: Mortality from PARDS is high in Asia. The Pediatric Acute Lung Injury Consensus Conference definition of PARDS is a useful tool for risk stratification.

Full reference: Wong, J, J-M. et al. (2017) Risk Stratification in Pediatric Acute Respiratory Distress Syndrome: A Multicenter Observational Study. Critical Care Medicine. Published online: July 26 2017


Very preterm birth not associated with mood & anxiety disorders

Do very-preterm or very-low-weight babies develop anxiety and mood disorders later in life? Researchers have concluded a study to answer this question | ScienceDaily

The team studied nearly 400 individuals from birth to adulthood. Half of the participants had been born before 32 weeks gestation or at a very low birth weight (less than 3.3 pounds), and the other half had been born at term and normal birth weight. They assessed each participant when they were 6, 8 and 26 years old using detailed clinical interviews of psychiatric disorders.

“Previous research has reported increased risks for anxiety and mood disorders, but these studies were based on small samples and did not include repeated assessments for over 20 years,”

Their results? At age 6, children were not at an increased risk of any anxiety or mood disorders, but by age 8 — after they had entered school — more children had an anxiety disorder. By 26, there was a tendency to have more mood disorders like depression, but the findings were not meaningfully different between the two groups.

This study is the first investigation of anxiety and mood disorders in childhood and adulthood using clinical diagnoses in a large whole-population study of very preterm and very-low-birth-weight individuals as compared to individuals born at term.

The team also found that having a romantic partner who is supportive is an important factor for good mental health because it helps protect one from developing anxiety or depression. However, the study found fewer very-preterm-born adults had a romantic partner and were more withdrawn socially.