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

 

Factors predicting antibiotic prescription and referral to hospital for children with respiratory symptoms

Rebnord, I.K. et al. (2017) BMJ Open. 7:e012992.

Objectives: Acute respiratory infections and fever among children are highly prevalent in primary care. It is challenging to distinguish between viral and bacterial infections. Norway has a relatively low prescription rate of antibiotics, but it is still regarded as too high as the antimicrobial resistance is increasing. The aim of the study was to identify predictors for prescribing antibiotics or referral to hospital among children.

 

Conclusions: CRP values >20 mg/L, findings on ear examination, use of paracetamol and no vomiting in the past 24 hours were significantly associated with antibiotic prescription. Affected respiration was a predictor for referral to hospital. The parents’ assessment was also significantly associated with the outcomes.

Read the full abstract and article here

Etiology of Acute Respiratory Infections in Infants

Kumar, P. et al. (2017) Pediatric Infectious Disease Journal. 36(1) pp. 25–30

B0004785 Parainfluenza virus, TEM

Image source: David Gregory & Debbie Marshall – Wellcome Images // CC BY-NC-ND 4.0

Background: There is paucity of studies on etiology of acute respiratory infections (ARI) in infants. The objective of this study is to document incidence and etiology of ARI in infants, their seasonal variability and association of clinical profile with etiology.

 

Conclusion: In this cohort of infants, ARI incidence was 1.8 episodes per year per infant; 95% were upper respiratory tract infections. Viruses were identified in 63.3% episodes, and the most common viruses detected were rhinovirus, respiratory syncytial virus and parainfluenza virus.

Read the full abstract here

Burden of Recurrent Respiratory Tract Infections in Children

Toivonen, L. et al. (2016) Pediatric Infectious Disease Journal35(12) pp. e362–e369

 

B0004413 Reovirus particles

Image source: David Gregory & Debbie Marshall – Wellcome Images // CC BY-NC-ND 4.0

Image shows colour-enhanced image of reovirus particles

Background: The burden of recurrent respiratory infections is unclear. We identified young children with recurrent respiratory infections in order to characterize the clinical manifestations, risk factors and short-term consequences.

Conclusions: Children with recurrent respiratory infections frequently use health care services and antibiotics, undergo surgical procedures and are at risk for asthma in early life. Having older siblings increases the risk of recurrent infections.

Read the full abstract here

Limited Evidence on the Management of Respiratory Tract Infections in Down’s Syndrome: A Systematic Review

Manikam, L. et al. (2016) Pediatric Infectious Disease Journal. 35(10) pp. 1075–1079

https://creativecommons.org/licenses/by-sa/3.0/deed.en

Image source: Nevit Dilmen – Wikipedia // CC BY-SA 3.0

MRI image showing sinusitis. Edema and mucosal thickening appears in both maxillary sinuses.

Aims: To systematically review the effectiveness of preventative and therapeutic interventions for respiratory tract infections (RTIs) in people with Down’s syndrome.

Methods: Databases were searched for any published and ongoing studies of respiratory tract diseases in children and adults with Down’s syndrome. These databases were searched for controlled trials, cohort studies and controlled before–after studies. Trial registries were searched for ongoing studies. Initially, all study types were included to provide a broad overview of the existing evidence base. However, those with a critical risk of bias were excluded using the Cochrane Risk of Bias tool.

Results: A total of 13,575 records were identified from which 5 studies fulfilled the eligibility criteria and 3 fulfilled our criteria for data extraction. One randomized controlled trial of moderate risk of bias compared zinc therapy with placebo. Outcome data were only reported for 50 (78%) children who presented with extreme symptoms; no benefit of zinc therapy was found. One non-randomized controlled trial with serious risk of bias included 26 children and compared pidotimod (an immunostimulant) with no treatment; pidotimod was associated with fewer upper RTI recurrences compared with no treatment (1.43 vs. 3.82). A prospective cohort study with moderate risk of bias compared 532 palivizumab treated children with 233 untreated children and found that children treated with palivizumab had fewer respiratory syncytial virus-related hospitalization (23 untreated and 8 treated), but the same number of overall RTI-related hospitalizations (73 untreated and 74 treated) in the first 2 years of life.

Conclusions: The evidence base for the management of RTIs in people with Down’s syndrome is incomplete; current studies included children only and carry a moderate to serious risk of bias. Methodologic rigorous studies are warranted to guide clinicians in how best to prevent and treat RTIs in children with Down’s syndrome.

Read the abstract here

Vitamin D – Can the sunshine vitamin help reduce asthma attacks?

Ware, L. Evidently Cochrane. Published online: 6 September 2016

What’s the story?

It seems to me that vitamin D – also known as the ‘sunshine vitamin’ – is very much in the limelight (or should that be sunlight?) right now. Its role in maintaining a healthy skeleton is well known but it may have other important actions. Low levels of vitamin D have been linked to an increased risk of asthma attacks in children and adults with asthma. It is thought that vitamin D has anti-inflammatory and antimicrobial functions in the lungs, which may explain why it could be beneficial.

What did the Cochrane review find with regard to vitamin D andasthma?

The recent systematic review from the Cochrane Airways Group found nine double-blind randomised placebo-controlled trials of vitamin D in children and adults with asthma, which evaluated the risk of having an asthma attack and/or the level of symptom control. Two studies were in adults and involved 658 participants; seven studies were in children with 435 participants. The studies were conducted in Canada, India, Japan, Poland, UK and USA. Most of the participants had mild to moderate asthma and continued their regular asthma medication for the duration of the trial. The studies lasted from six to twelve months.

High quality evidence showed that giving vitamin D reduced the average number of asthma attacks and the risk of Emergency Department attendances and hospital admissions. These results can be represented diagrammatically :

exacerbations-small-1024x512

Image source: Evidently Cochrane

hospitalisations-small-1024x512

Image source: Evidently Cochrane

There was no evidence to indicate that vitamin D brought about an improvement in lung function tests or in day-to-day symptoms. It was safe at the doses given.

Read the full blog post here

Read the full review here

Decision-making tool may help doctors cut unnecessary antibiotic prescribing

ScienceDaily | Published online: 1 September 2016

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Respiratory tract infections (RTI) with cough are the most common reason children are prescribed antibiotics by their doctors, but up to a third of prescriptions may be unnecessary. A new study of over 8000 children has identified seven key predictors which could help general practitioners (GPs) and nurses in primary care identify low risk children who are less likely to need antibiotics, according to new research published in The Lancet Respiratory Medicine.

The authors estimate that if antibiotic prescribing in this low risk group was halved, and even if it increased to 90% in high risk patients, the new tool could reduce antibiotic prescribing to children with RTI and coughs by 10% overall, similar to other interventions used to combat antibiotic resistance.

The proposed tool called STARWAVe uses seven predictors of future hospitalization that can be easily identified by doctors and nurses during a patient visit — short illness (less than 3 days), high temperature (?37.8°C on examination or parent reported severe fever in the previous 24 hours), aged under 2 years, respiratory distress, wheeze, asthma, and moderate/severe vomiting in the previous 24 hours. Children presenting with no more than one of these items are deemed at very low risk of future complications. The authors say that the rule now needs externally validating in a randomised trial, but could be a useful tool to improve the targeting of antibiotics to reduce the growing threat of antibiotic resistance.

View the original research articles here and here.

Read the full commentary here