Exacerbations In Children Research Articles

Asthma exacerbations in Reunion Island: Environmental factors

IntroductionReunion Island is a French overseas department characterized by a tropical climate with 2 distinct seasons. While the prevalence of asthma among adults in Reunion Island is close to that in mainland France, mortality and hospitalization rates are twice as high. To date, however, no epidemiological studies have evaluated the influence of environmental factors in asthma exacerbations in Reunion Island. MethodsFrom January 2010 to June 2013, 1157 residents of Saint-Denis visited the emergency rooms of the Centre hospitalier universitaire site Nord de Saint-Denis for asthma. After exclusion of children under the age of 3, 864 visits were analyzed. These were correlated with the following daily factors: pollens and molds, meteorological parameters (temperature, precipitation levels, humidity and relative humidity levels, wind), pollutants (sulfur dioxide (SO2), nitrogen oxide (NOx), and the fine particles PM10 and PM2.5), and the influenza virus. The correlation between these factors was evaluated using the DLNM and GO-GARCH models. ResultsOf the 864 analyzed visits, 532 were by pediatric patients (aged 3 to 16 years) and 332 by adult patients (aged over 16 years). In adults, pollens positively correlated with asthma exacerbations were Urticaceae, Oleaceae, Moraceae, and Chenopodiaceae. In children, these were Urticaceae, Oleaceae, Poaceae, and Myrtaceae. Molds positively correlated with asthma exacerbations in adults were ascospores and basidiospores. Only basidiospores were positively correlated with exacerbations in children. Temperature was positively correlated with exacerbations in both adults and children. The pollutants PM10 and NOx were positively correlated with exacerbations in children. Influenza epidemics were strongly correlated with exacerbations in both adults and children. ConclusionOur analysis shows that in Reunion Island, asthma is exacerbated by pollens (Urticaceae, Oleaceae, Moraceae, Chenopodiaceae in adults; Urticaceae, Oleaceae, Poaceae, Myrtaceae in children), molds (ascospores and basidiospores in adults; basidiospores in children), temperature, influenza, and the pollutants PM10 and NOx (in children).

MiRNA Expression Profile in the Airways is Altered during Pulmonary Exacerbation in Children with Cystic Fibrosis-A Preliminary Report.

MicroRNAs are small non-coding RNAs that regulate immune response and inflammation. We assumed that miRNAs may be involved in the immune response during cystic fibrosis pulmonary exacerbations (CFPE) and that altered expression profile in the airways and blood may underlie clinical outcomes in CF pediatric patients. Methods: We included 30 pediatric patients diagnosed with cystic fibrosis. The biologic material (blood, sputum, exhaled breath condensate) was collected during pulmonary exacerbation and in stable condition. The miRNA expression profile from blood and sputum (n = 6) was done using the next-generation sequencing. For validation, selected four miRNAs were analyzed by qPCR in exosomes from sputum supernatant and exhaled breath condensate (n = 24). NGS analysis was done in Base Space, correlations of gene expression with clinical data were done in Statistica. Results: The miRNA profiling showed that four miRNAs (miR-223, miR-451a, miR-27b-3p, miR-486-5p) were significantly altered during pulmonary exacerbation in CF patients in sputum but did not differ significantly in blood. MiRNA differently expressed in exhaled breath condensate (EBC) and sputum showed correlation with clinical parameters in CFPE. Conclusion: MiRNA expression profile changes in the airways during pulmonary exacerbation in CF pediatric patients. We suggest that miRNA alterations during CFPE are restricted to the airways and strongly correlate with clinical outcome.

Heavy precipitation and asthma exacerbation risk among children: A case-crossover study using electronic health records linked with geospatial data

Extreme precipitation events may be an important environmental trigger for asthma exacerbations in children. We used a time stratified case-crossover design and data from a large electronic health record database at the Children's Hospital of Philadelphia (CHOP) to estimate associations of daily heavy precipitation (defined as > 95th percentile of the summertime distribution) with asthma exacerbation among children. We defined control days as those falling on the same day of the week within the same month and year as the case. We restricted our primary analyses to the summer months in years 2011–2016 and used conditional logistic regression models to estimate associations between heavy precipitation and acute asthma exacerbations in both outpatient (primary care, specialty care, and emergency department) and inpatient settings. We investigated numerous individual-level (e.g., age, sex, eczema diagnosis) and environmental measures (e.g., greenspace, particulate matter) as potential effect modifiers. The analysis include 13,483 asthma exacerbations in 10,434 children. Odds of asthma exacerbation were 11% higher on heavy precipitation vs. no precipitation days (95% CI: 1.02–1.21). There was little evidence of effect modification by most measures. These results suggest that heavy summertime precipitation events may contribute to asthma exacerbations. Further research using larger datasets from other health systems is needed to confirm these results, and to explore underlying mechanisms.

Pediatric acute asthma scoring systems: a systematic review and survey of UK practice.

BackgroundAcute exacerbations of asthma are common in children. Multiple asthma severity scores exist, but current emergency department (ED) use of severity scores is not known.MethodsA systematic review was undertaken to identify the parameters collected in pediatric asthma severity scores. A survey of Paediatric Emergency Research in the United Kingdom and Ireland (PERUKI) sites was undertaken to ascertain routinely collected asthma data and information about severity scores. Included studies examined severity of asthma exacerbation in children 5–18 years of age with extractable severity parameters.ResultsSixteen articles were eligible, containing 17 asthma severity scores. The severity scores assessed combinations of 15 different parameters (median, 6; range, 2–8). The most common parameters considered were expiratory wheeze (15/17), inspiratory wheeze (13/17), respiratory rate (10/17), and general accessory muscle use (9/17). Fifty‐nine PERUKI centers responded to the questionnaire. Twenty centers (33.1%) currently assess severity, but few use a published score. The most commonly recorded routine data required for severity scores were oxygen saturations (59/59, 100%), heart rate, and respiratory rate (58/59, 98.3% for both). Among well‐validated scores like the Pulmonary Index Score (PIS), Pediatric Asthma Severity Score (PASS), Childhood Asthma Score (CAS), and the Pediatric Respiratory Assessment Measure (PRAM), only 6/59 (10.2%), 3/59 (5.1%), 1/59 (1.7%), and 0 (0%) of units respectively routinely collect the data required to calculate them.ConclusionStandardized published pediatric asthma severity scores are infrequently used. Improved routine data collection focusing on the key parameters common to multiple scores could improve this, facilitating research and audit of pediatric acute asthma.

S06.2 Evaluation of LCI during pulmonary exacerbation in children with cystic fibrosis

S06.2 Evaluation of LCI during pulmonary exacerbation in children with cystic fibrosis

The cellular and humoral immune response to influenza vaccination is comparable in asthmatic and healthy subjects

ABSTRACT Annual influenza vaccination is recommended as a preventive measure for all patients with asthma since asthma exacerbations in children and adults are associated to viral infections including influenza. There is concern about the adequate immune response in asthmatics with ICS treatment. The production of antibodies to influenza in asthmatics has been demonstrated. However, cellular immunity is poorly understood. The aim of the study was to compare the humoral and cellular immune responses to influenza vaccine in asthmatic and healthy subjects. Twenty-five asthmatic patients attending the Allergy and Clinical Immunology Service at the Hospital General de Mexico and 25 healthy adults were included. Blood samples were obtained before, 4 and 12 months after immunization with influenza vaccine, influenza-specific antibodies were determined by the hemagglutination inhibition test and influenza-specific memory B, TCD4+, and TCD8 + lymphocytes were determined by flow cytometry. All the asthmatic patients received ICS treatment. The Geometric Mean titers for all influenza serotypes were similar in both groups; seropositivity and the cellular immune response increased in both groups over time and was comparable. Influenza vaccination in asthmatic patients with immunotherapy and ICS achieved protective antibody levels and cellular immunity over time comparable to healthy subjects.

Dynamics of humoral immunity in gingival fluid during combined immunotherapy in pediatric patients with exacerbation of chronic granulomatous periodontitis

Chronic granulating periodontitis among children has a high prevalence, which determines the relevance of its research, medical and social significance. The exacerbation of the disease is accompanied by various disorders in the immune system and, above all, at the local level. However, changes in local humoral immunity in children with exacerbation of chronic granulating periodontitis (CGP) have not been studied. Impact of modern immunomodulators and, in particular, Derinat, on pathological changes of local parameters of humoral immunity was not analyzed in pediatric patients with this disorder.The aim of this work is to study local humoral immunity parameters during CGP exacerbation in children and on the background of combined therapy with Derinat, Unidox-Solutab, and Tycveolum (oil extract from pumpkin seeds).The analysis of immunological disorders in gingival fluid was performed in 93 children aged 12-14 years with exacerbation of chronic granulating periodontitis, who underwent examination and treatment in Belgorod city pediatric dental clinic, and at the Department of Pediatric Dentistry of Belgorod State National Research University in 2013-2015. The patients included in the study were divided into 2 groups: control group (n = 48), receiving conventional treatment, and the main group (n = 45), who, in addition to standard therapy, were treated with Derinat, Unidox-Solutab and Tycveolum. Contents of immunoglobulins in gingival fluid were determined by turbidimetric method using the Microlab-300 photometer. Lysozyme and lactoferrin were studied by solid-phase enzyme immunoassay.Exacerbation of chronic granulating periodontitis in childhood is associated with a representative decrease of sIgA, IgA, lysozyme and lactoferrin in gingival fluid, and increased levels of IgM and IgG. Upon treatment with innovative therapy, including derinate, as one of the components, in CGP patients, there was a significant improvement of immune parameters on the 14th day of observation. Normalization of all studied parameters of local immunity was noted in the patients of main group by the 30 th day of observation. Meanwhile, only some immunological parameters reached normal reference values in the control group of patients. Conclusion. The identified new mechanisms of Derinat effects upon humoral immunity and it’s effective use during exacerbation of chronic granulomatous periodontitis in children.

Respiratory infections regulated blood cells IFN‐β‐PD‐L1 pathway in pediatric asthma

BackgroundRespiratory infections, in general, and rhinovirus infection specifically are the main reason for asthma exacerbation in children and programmed cell death protein 1 ligand (PD‐L1) expression inhibits T cell responses.ObjectiveCould the interferon (IFN) type I expression in peripheral blood mononuclear cells (PBMCs) improve disease exacerbation in pediatric asthma?ResultsHere we found increased level of PD‐L1 messenger RNA (mRNA) in total blood cells isolated from preschool children with virus‐induced asthma, with lower percentage of forced expiratory volume in 1 second and with high serum levels of the C‐reactive‐protein.Conclusions and Clinical RelevanceThese data indicate that, in the presence of infection in the airways of preschool children, worse asthma is associated with induced PD‐L1 mRNA expression in blood cells. Further, type I IFN, IFN‐β, a cytokine that is involved in the clearance of infections, was found to be associated with a better lung function in asthmatic children. These data suggest that improving peripheral blood IFN type I expression in PBMCs in pediatric asthma could improve disease exacerbation due to suppressing PD‐L1 expression in blood cells.

Vitamin D receptor polymorphisms are associated with severity of wheezing illnesses and asthma exacerbations in children

Single nucleotide polymorphisms (SNPs) of the vitamin D receptor (VDR) gene have shown linkage and association with asthma development in multiple cohort studies. However, the majority of investigations have focused on asthma phenotypes in cohorts with stable disease. We investigated the relationship between VDR SNPs and the frequency and severity of acute episodes of wheeze/asthma in a cohort of Australian children, as the ability to identify children at risk of more severe exacerbations could lead to personalized and improved genotype-specific treatment pathways. We successfully genotyped five SNPs of the VDR gene (rs2525046, rs9729, rs1544410 (BsmI), rs22239179, and rs2228570 (FokI)) in 657 children presenting to a tertiary children’s hospital with acute asthma, bronchiolitis, or a wheezing illness. The relationships between VDR SNPs and exacerbation severity scores, β2-agonist use, and frequency of respiratory exacerbations were analysed using multiple regression. The rs2525046 (FokI) CT genotype was associated with higher VDR mRNA intensity levels (p = 0.007) compared to the CC genotype. A trend towards significance (p=0.056) was identified between the rs2525046 TT genotype and higher VDR mRNA intensity levels compared to the CC genotype. Children with rs2228570 AA genotype had higher exacerbation severity scores (p=0.001) and poorer β2-agonist treatment response (doses at 6 h: p = 0.009 and 12 h: p=0.033) compared to those with the GG genotype. Children with rs1544410 (BsmI) TT genotype had lower exacerbation severity scores (p = 0.005) compared to those with the CC genotype. Children with rs2228570 GA genotype presented to and/or were admitted to hospital more times since birth with respiratory (p = 0.011) and wheezing (p = 0.021) illnesses than children with the GG genotype. No associations were identified between rs9729, rs2525046 and r2239179 polymorphisms and acute wheezing/asthma variables. These findings suggest that genetic variants at the VDR locus may play a role in acute wheeze/asthma severity in children.

Linking environmental exposures to molecular regulation of inflammation via epigenetic histone signatures in an exacerbation prone pediatric asthma cohort

Abstract Environmental exposures, such as air pollution, are correlated with asthma susceptibility and airway inflammation. Epigenetic mechanisms can translate these exposures to regulation of molecular pathways that drive asthma pathogenesis. Indeed, specific epigenetic modifications have been linked to regulation of asthma-associated inflammation. Yet, there have been no studies linking environmental exposures to direct regulation of molecular mechanisms driving dysfunction of inflammation in pediatric asthma. Here we examined a cohort of exacerbation prone pediatric asthmatics tracking exposure through multiple air monitoring methods, including personalized vest monitors, stationary monitors, and Colorado DPHE monitors. We performed ChIP-seq examining histone modifications in PBMCs and integrated the epigenetic data with the environmental exposure data from the air pollution monitors. Our results statistically linked specific histone modifications in PBMCs to specific types of environmental exposures within the pediatric asthmatics. Annotation of these histone modifications to proximal genes identified a potential immune program regulating asthma inflammation. Concomitant examination of the PBMC transcriptome enabled functional analysis of epigenetic regulation of these immune genes. The resultant molecular profiles can be used to identify biomarkers for patient stratification and disease course prediction. Moreover, these studies identify a potential link between the molecular programming associated with environmental exposures and regulation of key biological pathways, which alter immune cell activity that ultimately can increase asthma exacerbation in children.

Cost of hospitalization for bronchiectasis exacerbation in children.

Despite paediatric bronchiectasis being recognized increasingly worldwide, prior reports of hospitalization costs for bronchiectasis in children are lacking. This study aimed to (i) identify health service costs of hospitalizations and (ii) factors associated with these costs in children admitted to an Australian paediatric hospital following an acute exacerbation of their bronchiectasis. Demographic and hospital resource use data were prospectively recorded for 100 hospitalizations in 80 children aged <18 years admitted consecutively to the QCH, Brisbane, Australia. Costs (2016 AUD) were obtained from the hospital's Finance Department. Linear regressions, with bootstrap resampling to quantify uncertainty, were used to estimate factors affecting cost of hospitalization. The 100 hospitalizations (48 males) had a median (IQR) age of 6.04 (4.04-9.85) years. Their mean (SD) LOS was 12.30 (4.60) days. The mean (SD) direct health service cost was AUD 30 182 (13 998) per hospitalization. The greatest contributor to costs was health professional wages, accounting for 70% of the cost per episode. LOS, younger age at admission and number of bronchiectatic lobes affected were associated with higher costs, whilst HITH service was associated with lower cost. The cost to families on average was AUD 2669.50 (SD: 991.50) per hospitalization when accounting for lost wages and opportunity cost. The per episode healthcare cost burden of hospitalizations for paediatric bronchiectasis exacerbations is substantial. Interventions that prevent hospitalized exacerbations and reduce severity of childhood bronchiectasis with even moderate effectiveness are likely to result in substantial hospital costs savings.

Treatment Benefit with Omalizumab in Children by Indicators of Asthma Severity

Greater severity in childhood asthma negatively impacts functioning and quality of life. Omalizumab is effective in children aged 6 years or older with moderate to severe persistent asthma, but predicting responsiveness in severe disease requires further study. To assess response to omalizumab treatment among children using indicators of asthma severity. Post hoc analyses of randomized placebo-controlled studies of omalizumab (Inner-City Anti-IgE Therapy for Asthma [ICATA], IA05, and Preventative Omalizumab or Step-up Therapy for Fall Exacerbations [PROSE]) stratified by body mass index, eosinophil count, fractional exhaled nitric oxide levels, and baseline severity indicators (baseline percent predicted FEV1, previous hospitalizations, asthma exacerbations). Poisson regression analysis examined exacerbation rate reductions for body mass index, biomarkers, and severity indicators. Children aged 6 to 11 years in IA05 (N= 576; 56% white, 17% black, 26% other/missing), ICATA (N= 237; 55% black, 43% Hispanic), and PROSE (N= 342; 59% black, 35% Hispanic) were included. Trends indicative of greater exacerbation rate change ([omalizumab - placebo]/placebo) were observed for low baseline lung function (IA05 percent predicted FEV1: <90%, 36% reduction, 95% CI,-53.3 to-13.5; ≥90%, 22% reduction, 95% CI,-52.1 to 27.5), previous hospitalizations (ICATA: 46% reduction with, 95% CI,-69.7 to-3.9; 24% reduction without, 95% CI,-48.1 to 10.3), frequent baseline exacerbations (IA05: ≥3, 42% reduction, 95% CI,-60.4 to-14.1; <3, 20% reduction, 95% CI,-45.2 to-15.9), and high baseline eosinophil count (IA05: ≥300 cells/μL, 39% reduction, 95% CI,-56.4 to-14.7; <300 cells/μL, 5% reduction, 95% CI,-40.6 to 52.1). Omalizumab reduces exacerbations in children with moderate to severe persistent allergic asthma, and may provide greater benefit in children with more severe asthma subtypes.

Observational human studies in allergic diseases: design concepts and highlights of recent National Institute of Allergy and Infectious Diseases-funded research.

To present and discuss key design concepts for optimizing the impact of observational studies in the field of allergy and to highlight recent findings from NIAID-funded research networks. We discuss three concepts. First, the benefit of prospective, longitudinal observational studies exemplified by recent findings on the seasonal nature of all rhinitis phenotypes in children with asthma and the protective effects of high house dust allergen content during the first year of life on the development of asthma at age 7 years. Second, the benefit of detailed (deep) phenotyping exemplified by the identification of a MALT1 gene variant as a strong genetic link to peanut allergy and the determination that atopic dermatitis with food allergy constitutes a distinct cutaneous endotype, compared with atopic dermatitis alone. Third, the benefit of hypothesis-generating research combined with prospective design and deep phenotyping as exemplified by the unveiling of potential pathophysiologic pathways leading to asthma exacerbations in children, after a 'cold'. Observational studies can be highly impactful if designed well. Longitudinal study design, deep phenotyping, and hypothesis-generating research are three major design concepts that should be considered in the development of these studies.

Corona Virus Disease 2019 and Paediatric Inflammatory Bowel Diseases: Global Experience and Provisional Guidance (March 2020) from the Paediatric IBD Porto Group of European Society of Paediatric Gastroenterology, Hepatology, and Nutrition.

ABSTRACTIntroduction:With the current coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised about the risk to children with inflammatory bowel diseases (IBD). We aimed to collate global experience and provide provisional guidance for managing paediatric IBD (PIBD) in the era of COVID-19.Methods:An electronic reporting system of children with IBD infected with SARS-CoV-2 has been circulated among 102 PIBD centres affiliated with the Porto and Interest-group of ESPGHAN. A survey has been completed by major PIBD centres in China and South-Korea to explore management during the pandemic. A third survey collected current practice of PIBD treatment. Finally, guidance points for practice have been formulated and voted upon by 37 PIBD authors and Porto group members.Results:Eight PIBD children had COVID-19 globally, all with mild infection without needing hospitalization despite treatment with immunomodulators and/or biologics. No cases have been reported in China and South Korea but biologic treatment has been delayed in 79 children, of whom 17 (22%) had exacerbation of their IBD. Among the Porto group members, face-to-face appointments were often replaced by remote consultations but almost all did not change current IBD treatment. Ten guidance points for clinicians caring for PIBD patients in epidemic areas have been endorsed with consensus rate of 92% to 100%.Conclusions:Preliminary data for PIBD patients during COVID-19 outbreak are reassuring. Standard IBD treatments including biologics should continue at present through the pandemic, especially in children who generally have more severe IBD course on one hand, and milder SARS-CoV-2 infection on the other.Supplemental digital content:An infographic accompanying this article can be found at.

Respiratory viruses: What is their role in acute exacerbations in children with cystic fibrosis?

Respiratory viruses (RVs) are frequently present in the airways of patients with cystic fibrosis (CF) during pulmonary exacerbations (PEx). This prospective, longitudinal study was performed to examine the role of RVs in acute exacerbations in children with CF. Sputum samples or additional midturbinate swabs were tested from all children using a polymerase chain reaction panel. The primary aims of the study were to determine the prevalence and etiologic role of RVs in exacerbations of CF and to compare changes with RV-positive and RV-negative infections. The secondary aims were to determine the predictive factors for RV-related exacerbations. From 50 patients with PEx, 23 (48.9%) sputum samples were virus-positive. With a combination of sputum and swab, viral positivity increased to 56%. The virus-positive group presented more frequently with hypoxia (oxygen saturation <93%) than the virus-negative group (P = .048). Virus-positive exacerbations were not associated with an increase in colonization rates or greater lung function decline over 12 months. RVs frequently present during PEx of CF. However, predicting viral infections is difficult in this group. Only the presence of hypoxia may raise the suspicion of an accompanying viral agent. The combination of sputum and nasal swab samples increases the diagnostic yield in viral infections of CF. Despite their high frequency, the presence of RVs had no impact on clinical outcomes, such as a decline in lung function and increased colonization rates.

Risk of wheezing and asthma exacerbation in children treated with paracetamol versus ibuprofen: a systematic review and meta-analysis of randomised controlled trials

BackgroundParacetamol and ibuprofen are the most commonly used medications for fever and pain management in children. While the efficacy appears similar with both drugs, there are contradictory findings related to adverse events. In particular, incidence of wheezing and asthma among children taking paracetamol compared to ibuprofen, remain unsettled.MethodsWe conducted a meta-analysis of randomized controlled trials (RCTs) that compared wheezing and asthma exacerbations in children taking paracetamol versus ibuprofen. A comprehensive search was conducted in five databases. RCTs reporting on cases of wheezing or asthma exacerbations in infants or children after the administration of paracetamol or ibuprofen were included. The pooled effect size was estimated using the Peto’s odds ratio.ResultsFive RCTs with 85,095 children were included in the analysis. The pooled estimate (OR 1.05; 95%CI 0.76–1.46) revealed no difference in the odds of developing asthma or presenting an exacerbation of asthma in children who received paracetamol compared to ibuprofen. When the analysis was restricted to RCTs that examined the incidence of asthma exacerbation or wheezing, the pooled estimate remained similar (OR 1.01; 95%CI 0.63–1.64). Additional bias adjusted quality effect sensitivity model yielded similar results (RR 1.03; 95%CI 0.84–1.28).ConclusionAlthough, Ibuprofen and paracetamol appear to have similar tolerance and safety profiles in terms of incidence of asthma exacerbations in children, we suggest high quality trials with clear definition of asthma outcomes after receiving ibuprofen or paracetamol at varying doses with longer follow-up are warranted for any conclusive finding.

Latent Class Analysis of School-Age Children at Risk for Asthma Exacerbation

Factors responsible for asthma exacerbations in children are complex and may differ from those that drive asthma severity. To identify latent classes of children at risk for asthma exacerbation and determine whether latent class assignment is useful in the prediction of future exacerbation. Latent class analysis was performed on 513 children aged 6 to 17 years at risk for asthma exacerbation, with 31 variables encompassing demographics, medical history, treatment, symptoms, lung function, sensitization, and type 2 inflammation. Primary and secondary outcomes included exacerbation occurrence by 12 months and time to first exacerbation, respectively. Four latent classes were identified with differing demographic features, sensitization and type 2 inflammatory markers, prior exacerbation severity and health care utilization, and lung function. Exacerbations occurred in 22.4% of class 1 ("lesser sensitization with normal lung function"), 27.9% of class 2 ("lesser sensitization with prior severe exacerbation and normal lung function"), 45.3% of class 3 ("multiple sensitization with reversible airflow limitation"), and 64.3% of class 4 ("multiple sensitization with partially reversible airflow limitation") (P < .001). Time to exacerbation also followed similar trends and was shortest in the latent classes with multiple sensitization and airflow limitation (P < .001). Outcomes were driven largely by children with exacerbation-prone asthma (defined as ≥3 exacerbations in the prior year), who were present in each class but most strongly represented in classes 3 and4. Children at risk for asthma exacerbation are a heterogeneous group. Sensitization, prior exacerbation severity, and lung function variables may be particularly useful in identifying children at greatest risk for future exacerbation.

Efficacy of Macrolides on Acute Asthma or Wheezing Exacerbations in Children with Recurrent Wheezing: A Systematic Review and Meta-analysis.

The role of macrolides for treatment of children with acute asthma or wheezing exacerbations is unclear. The aim of this systematic review was to evaluate the effectiveness of macrolides in children with recurrent wheezing presenting with acute asthma or wheezing exacerbation. We conducted an electronic search in MEDLINE, EMBASE, CINAHL, LILACS, CENTRAL, and ClinicalTrials.gov. Randomized controlled trials of macrolides (any macrolide) compared with placebo or standard treatment in children up to 18years with recurrent wheezing/asthma presenting with an acute exacerbation. Primary outcomes were need for hospitalization and/or time of acute asthma/wheezing symptoms resolution; secondary outcomes were duration of stay in the emergency department (ED)/clinic, severity of symptoms of the index episode, use of additional systemic corticosteroids or short active β-2 agonists, changes in lung function measures, ED visit/hospitalization during first week after index episode, time to next exacerbation, or adverse effects (AEs). Only three studies met the inclusion criteria (n = 334 children, 410 treated episodes); two studies included recurrent wheezers and the third included asthmatic children. There was no difference in hospitalization between groups, but children treated with macrolides had a significantly lower time to symptoms resolution than controls, although the magnitude of benefit remains to be quantified due to no normal distribution data presented. There was no difference in time to next episode of exacerbation (HR 0.96; 95% CI 0.71-1.28; I2 = 0%; p = 0.77). In one study, children receiving macrolides had a significant decrease in the severity of symptoms, decrease use of salbutamol, and another study showed improved lung function. No study evaluated antibiotic resistance development. Limited evidence support that a macrolide trial could be considered in children with acute asthma or recurrent wheezing exacerbation.

Primary care provider preferences for glucocorticoid management of acute asthma exacerbations in children

Objective Primary care providers (PCP) frequently care for children with acute asthma exacerbations in the outpatient setting. The objective of this study is to evaluate PCP preferences and perceptions regarding oral glucocorticoids prescribed from both outpatient primary care and ED settings for the treatment of children with acute asthma exacerbations. Methods PCPs belonging to the Colorado Chapter of the American Academy of Pediatrics were surveyed between February and May 2019. Survey items were generated by a multidisciplinary team and underwent content and criteria validation and pilot testing. Survey items evaluated PCP preferred oral glucocorticoid and dosing regimen for children with acute asthma exacerbations, provider- and patient-level factors contributing to glucocorticoid preferences, and perception of glucocorticoid regimens in terms of treatment failure, resolution of symptoms and adherence. Results A total of 109 of 600 (18.2%) PCPs responded. Equal proportions of PCPs reported preferring oral prednisone/prednisolone (50.5%) and oral dexamethasone (49.5%) for children with acute asthma exacerbations. Forty-four percent of PCPs reported no preference in type of glucocorticoid utilized by surrounding emergency departments (EDs). However, for children receiving dexamethasone in the ED but with persistent symptoms on PCP follow-up, 50.5% of PCPs would switch patients to prednisone/prednisolone. PCPs did not perceive more treatment failure or rapid resolution of symptoms with dexamethasone but reported better adherence with dexamethasone. Conclusion There is variability in PCP glucocorticoid management of pediatric acute asthma exacerbations. There is a need for further investigations to evaluate for differences in clinical outcomes based on PCP glucocorticoid treatment choices.

Role of Inhaled Corticosteroids for Asthma Exacerbation in Children: An Updated Meta-Analysis.

Background:Several studies showed that inhaled corticosteroids (ICS) may be a potential treatment in acute asthma exacerbation in children. This study was an update meta-analysis on the roles of ICS in the management of acute asthma exacerbation in children presenting to the hospital.Materials and Methods:Published articles with key words of ICS for asthma exacerbation, asthma attacks, and acute asthma in children aged under 18 years in the hospital setting with outcome of hospital admission between 2009 and 2018 were enrolled. The databases used in this study were Medline, Scopus, and Web of Science. Odds ratio of comparison between ICS and other treatments on hospital admissions was calculated.Results:There were 311 eligible studies met the searching criteria; seven eligible studies for the analysis; comprised of three meta-analysis and four added studies. The ICS had a significant reduction in hospital admission compared with placebo in overall with odds ratio of 0.63 (95% confidence interval [CI]: 0.41–0.96) and in moderate-to-severe group with odds ratio of 0.17 (95% CI: 0.05–0.51). Comparing with systemic corticosteroid (SC), ICS had significantly lower hospital admissions overall and in mild-to-moderate group with odds ratios of 0.63 and 0.26, respectively. The combination of ICS and SC had odds ratio of 0.75 (95% CI: 0.57–0.99) over SC in moderate-to-severe asthma exacerbation.Conclusions:ICS significantly reduced hospital admission in asthma exacerbation in children. It may be used alone for mild-to-moderate asthma exacerbation and combination with SC for moderate-to-severe asthma exacerbation.