Severity In Infants Research Articles

The Effect of Secondhand Smoke Exposure on Bronchiolitis Severity in Infants With and Without Familial Atopy

RATIONALE: Both secondhand smoke exposure (SHS) and familial atopy are risk factors for asthma; however, studies have been inconsistent regarding an association of atopy with bronchiolitis severity. METHODS: Among 618 mother-child dyads enrolled in the Tennessee Children's Respiratory Initiative at the time of infant acute viral respiratory illness (ARI), 2004-2008, we examined the association of both familial atopy (first degree relative with asthma, allergic rhinitis, or atopic dermatitis) and SHS on severity of infant ARI using an ordinal bronchiolitis severity score (BSS) with higher values indicating more severe disease, and length of hospitalization (LOS) among those hospitalized. Multiple linear regression analysis was used for adjusted effects of SHS and familial atopy on infant outcomes. RESULTS: Demographics of infants exposed to SHS vs. those without SHS included lower birth weight, higher Medicaid enrollment, and less breastfeeding (p < 0.01). In the subset with bronchiolitis (N = 455), infants with SHS had a higher BSS (Median [Interquartile range] 7.0 [4.5,9.0] than infants without SHS 6.0 [IQR: 3.5,8.5], p = 0.016). Among hospitalized infants with familial atopy, those with SHS had an increased LOS compared to those without SHS (3 [2,6] vs. 2.5 [2,4], p = 0.007). There was no difference in LOS by SHS among infants without familial atopy (p = 0.658). CONCLUSIONS: SHS is an important risk factor for infant bronchiolitis severity, and the impact of SHS on bronchiolitis morbidity is greater among infants with familial atopy.

Perception and management of fever in infants up to six months of age: A survey of US pediatricians

BackgroundA fever is an increase in the body's temperature above normal. This study examined how US pediatricians perceive and manage fever generally versus fever occurring after vaccination in infants up to six months of age.MethodsA web-based survey of 400 US pediatricians subscribing to the Physician Desk Reference was conducted in December 2008. Data were collected on the respondents' socio-demographics, number of years in practice, type of practice, their definition of fever severity in infants, and their recommendations for managing fever. Generalized Estimating Equations were used to estimate the odds of a pediatrician recommending an emergency room visit (ER) or a hospital admission, office visits, or other treatment option, as a function of infant's age, temperature, whether the infant has recently received a vaccine, and whether the fever was reported during or after office hours, adjusting for practice type and socio-demographic variables.ResultsOn average, the 400 responding pediatricians' (64% were female, average age of 49 years, years in practice = 20 years) threshold for extremely serious fever was ≥39.5°C and ≥ 40.0°C for infants 0-2 month and >2-6 month of age respectively. Infants were more likely to be referred to an ER or hospital admission if they were ≤ 2 months of age (Odds Ratio [OR], 29.13; 95% Confidence interval [95% CI], 23.69-35.82) or >2-4 months old (OR 3.37; 95% CI 2.99-3.81) versus > 4 to 6 months old or if they had a temperature ≥ 40.0°C (OR 21.06; 95% CI 17.20-25.79) versus a temperature of 38.0-38.5°C. Fever after vaccination (OR 0.29; 95% CI 0.25-0.33) or reported during office hours (OR 0.17; 95% CI 0.15-0.20) were less likely to result in referral to ER or hospital admission.ConclusionWithin this sample of US pediatricians, perception of the severity of fever in infants, as well as the response to infant fever are likely to depend on the infant's age. Recommendations for the management of fever in infants are likely to depend on fever severity level, the infant age, timing in relation to recent vaccination, and the time of day fever is reported. Our results indicate that US pediatricians are more concerned about general fever than fever following vaccination.

906 Comparison the Effectiveness of Boiled Black Tea with Boiled Water on Severity of Infants' Conjunctivitis

906 Comparison the Effectiveness of Boiled Black Tea with Boiled Water on Severity of Infants' Conjunctivitis

Long-Term Symptoms of Depression and Anxiety in Mothers of Infants with Congenital Heart Defects

To examine the relationship between the severity of infants' congenital heart defects (CHD) and their mothers' symptoms of depression and anxiety from pregnancy to 18 months postpartum. Mothers of infants with mild, moderate, or severe CHD (n=162) and mothers (n=44,400) within the Norwegian Mother and Child Cohort Study were assessed with an eight-item short version (SCL-8) of the Hopkins Symptom Checklist-25 at the 30th week of gestation and at 6 and 18 months postpartum. Only the postpartum mental health trajectory of mothers of infants with severe CHD deviated from the mental health trajectory of the cohort at 6 and 18 months postpartum, showing significantly elevated levels of depression and anxiety symptoms. The results elucidate the relationship between infants' CHD severity and maternal symptoms of depression and anxiety, possibly identifying a specifically vulnerable patient dyad in need of postoperative interventions.

Effect of a new synbiotic mixture on atopic dermatitis in infants: a randomized‐controlled trial

Clinical trials investigating the therapeutic effect of probiotics on atopic dermatitis (AD) show inconsistent results. Better results can possibly be achieved by combining probiotics with prebiotics, i.e. synbiotics. To investigate the therapeutic effect of a synbiotic mixture on the severity of AD in infants. In a double-blind, placebo-controlled multi-centre trial, 90 infants with AD [SCORing Atopic Dermatitis (SCORAD) score > or =15], aged < 7 months and exclusively formula fed, were randomly assigned to receive either an extensively hydrolysed formula with Bifidobacterium breve M-16V and a galacto-/fructooligosaccharide mixture (Immunofortis), or the same formula without synbiotics for 12 weeks. The primary outcome was severity of AD, assessed using the SCORAD index. A secondary outcome measure was intestinal microbiota composition. There was no difference in SCORAD score improvement between the synbiotic and the placebo group. The synbiotic group did have a significantly higher percentage of bifidobacteria (54.7% vs. 30.1%, P<0.001) and significantly lower percentages of Clostridium lituseburense/Clostridium histolyticum (0.5 vs. 1.8, P=0.02) and Eubacterium rectale/Clostridium coccoides (7.5 vs. 38.1, P<0.001) after intervention than the placebo group. In the subgroup of infants with IgE-associated AD (n=48), SCORAD score improvement was significantly greater in the synbiotic than in the placebo group at week 12 (-18.1 vs. -13.5 points, P=0.04). This synbiotic mixture does not have a beneficial effect on AD severity in infants, although it does successfully modulate their intestinal microbiota. Further randomized-controlled trials should explore a possible beneficial effect in IgE-associated AD.

Heart Failure in Children

Why is heart failure in children important? If we just consider the number of individuals affected, adult heart failure is clearly a more compelling public health problem. However, the relatively small numbers belie the overall economic and social impact of pediatric heart failure. When a child is admitted to the hospital for heart failure, the costs are considerably higher for children than adults because of the frequent need for surgical or catheter-based intervention. The demands of medical care can fray the family structure and adversely affect parental economic productivity. When a child dies of heart failure, the economic impact is magnified enormously because of the number of potentially productive years lost per death. For these and other reasons, heart failure in children is a serious public health concern. In addition, growing numbers of children with heart failure are reaching adulthood because of the successful application of medical and surgical heart failure therapies and the improved outcomes of congenital heart surgery. A greater understanding of the pathophysiology of heart failure in childhood may help inform therapeutic strategies once these children become adults. Furthermore, given the recent explosion of research in the impact of cardiac development and cardiogenetics on pediatric cardiovascular disease, it is not outside the realm of possibility for a pediatric discovery to be made that will also benefit adults with heart failure. We may not yet be able to agree on a definition of heart failure, but the cardinal symptoms, dyspnea, anasarca (“dropsy”), and cachexia, were well recognized in antiquity.1 These symptoms were not specific for cardiac pathology, and it was not until the 17th century, when William Harvey definitively identified the heart as an organ that pumped blood rather than generating heat, that the heart could begin to be understood as a source of dyspnea, edema, and …

Quantification of mitral-valve regurgitation in a paediatric population by real-time three-dimensional echocardiography

Evaluation of mitral-regurgitation (MR) severity in infants is challenging. Real-time three-dimensional echocardiography (RT3DE) allows accurate left-ventricular volumetric measurements in adults. To validate RT3DE by measuring stroke volume in a normal paediatric population, then to use this new method to calculate regurgitant volume in paediatric patients with MR. Fifty-four patients, aged one week to 19 years, (29 without and 25 with MR) had two-dimensional echocardiography coupled with RT3DE left-ventricular volumetric acquisition. Stroke volume was calculated by the Doppler method at the aortic annulus (SV(D)). End-systolic and end-diastolic left-ventricular volumes were measured using the QLab semi-automated method; three-dimensional stroke volume (SV(3D)) was calculated as their difference. In the MR group, regurgitant volume was calculated by the PISA method (RV(PISA)) and as the difference between SV(3D) and SV(D) (RV(3D)). Regurgitant fraction was also evaluated by these methods (RF(PISA) and RF(3D)). Measurement feasibility was 88%. In the normal group, SV(3D) (27.9+/-18.1 ml) was highly correlated with SV(D) (30.7+/-19.6 ml; r=0.98; p<0.000). In the MR group, RV(PISA) (15.7+/-14.4 ml) and RV(3D) (11.0+/-10.2 ml) were well correlated (r=0.83; p<0.001). Regurgitant fractions were also well correlated (RF(PISA)=30.4+/-17.0%; RF(3D)=24.3+/-15.9%; r=0.79, p=0.006). RT3DE is a simple, rapid and reliable method for evaluating stroke volume in children and may, therefore, be useful for evaluating regurgitant volume and fraction in paediatric patients with MR.

Dengue in Vietnamese Infants—Results of Infection‐Enhancement Assays Correlate with Age‐Related Disease Epidemiology, and Cellular Immune Responses Correlate with Disease Severity

The pathogenesis of severe dengue is not well understood. Maternally derived subneutralizing levels of dengue virus-reactive IgG are postulated to be a critical risk factor for severe dengue during infancy. In this study, we found that, in healthy Vietnamese infants, there was a strong temporal association between the Fc-dependent, dengue virus infection-enhancing activity of neat plasma and the age-related epidemiology of severe dengue. We then postulated that disease severity in infants with primary infections would be associated with a robust immune response, possibly as a consequence of higher viral burdens in vivo. Accordingly, in infants hospitalized with acute dengue, the activation phenotype of peripheral-blood NK cells and CD8+ and CD4+ T cells correlated with overall disease severity, but HLA-A*1101-restricted NS3(133-142)-specific CD8+ T cells were not measurable until early convalescence. Plasma levels of cytokines/chemokines were generally higher in infants with dengue shock syndrome. Collectively, these data support a model of dengue pathogenesis in infants whereby antibody-dependent enhancement of infection explains the age-related case epidemiology and could account for antigen-driven immune activation and its association with disease severity. These results also highlight potential risks in the use of live attenuated dengue vaccines in infants in countries where dengue is endemic.

Maternal Antibody and Viral Factors in the Pathogenesis of Dengue Virus in Infants

The pathogenesis of dengue in infants is poorly understood. We postulated that dengue severity in infants would be positively associated with markers of viral burden and that maternally derived, neutralizing anti-dengue antibody would have decayed before the age at which infants with dengue presented to the hospital. In 75 Vietnamese infants with primary dengue, we found significant heterogeneity in viremia and NS1 antigenemia at hospital presentation, and these factors were independent of disease grade or continuous measures of disease severity. Neutralizing antibody titers, predicted in each infant at the time of their illness, suggested that the majority of infants (65%) experienced dengue hemorrhagic fever when the maternally derived neutralizing antibody titer had declined to <1 : 20. Collectively, these data have important implications for dengue vaccine research because they suggest that viral burden may not solely explain severe dengue in infants and that neutralizing antibody is a reasonable but not absolute marker of protective immunity in infants.

Age‐Specific Questionnaires Distinguish GERD Symptom Frequency and Severity in Infants and Young Children: Development and Initial Validation

Two gastroesophageal reflux disease (GERD) symptom questionnaires were developed and tested prospectively in a pilot study conducted in infants (1 through 11 months) and young children (1 through 4 years) with and without a clinical diagnosis of GERD. A pediatric gastroenterologist made the clinical diagnosis of GERD. Parents or guardians at 4 study sites completed the questionnaires, providing information on the frequency and severity of symptoms appropriate to the 2 age cohorts. In infants, symptoms assessed were back arching, choking or gagging, hiccups, irritability, refusal to feed and vomiting or regurgitation. In young children, symptoms assessed were abdominal pain, burping or belching, choking when eating, difficulty swallowing, refusal to eat and vomiting or regurgitation. Respondents were asked to describe additional symptoms. Symptom frequency was the number of occurrences of each symptom in the 7 days before completion of the questionnaire. Symptom severity was rated from 1 (not at all severe) to 7 (most severe). An individual symptom score was calculated as the product of symptom frequency and severity scores. The composite symptom score was the sum of the individual symptom scores. The mean composite symptom and individual symptom scores were higher in infants (P<0.001 and P<0.05, respectively) and young children (P<0.001 and P<0.05, respectively) with GERD than controls. Vomiting/regurgitation was particularly prevalent in infants with GERD (90%). Both groups with GERD were more likely to experience greater severity of symptoms. We found the GERD Symptom Questionnaire useful in distinguishing infants and young children with symptomatic GERD from healthy children.

Evaluating illness severity for very low birth weight infants: CRIB or CRIB-II?

Background. Estimating the risk of in-hospital mortality provides essential information in the neonatal intensive care unit (NICU). The clinical risk index for babies (CRIB) is a widely used, risk-adjustment instrument to determine illness severity in infants of gestational age ⩽ 31 wks, or birth weight ⩽ 1,500 g, recently updated and simplified into a five-items scoring system (CRIB-II).Aim. The accuracy values of CRIB and CRIB-II scores in predicting in-hospital mortality were compared in a tertiary level, minimal intubation policy NICU setting.Methods. A total of 147 very low birth weight (VLBW) infants were examined. Both CRIB and CRIB-II scores were calculated for each newborn, and death before hospital discharge was selected as the outcome measure. Comparisons were performed by receiver-operating characteristic (ROC) curve analysis, and the area under the curve (AUC) was used as a measure of predictor accuracy.Results. Mean AUCs for CRIB, CRIB-II, gestational age and birth weight in identifying neonatal mortality in VLBW infants ranged from 0.924 (CRIB) to 0.869 (gestational age). No significant differences were found for the AUCs of CRIB versus CRIB-II, CRIB versus gestational age, CRIB versus birth weight, CRIB-II versus gestational age, or CRIB-II versus birth weight.Conclusions. Our findings show that; 1) CRIB and CRIB-II show similar accuracy values in predicting in-hospital neonatal mortality in VLBW infants; and 2) neither score offers an advantage in predicting mortality, as compared to gestational age or birth weight, thus suggesting that treatment modalities may modify predictive accuracy.

66 Evaluating Illness Severity for Very Low Birth Weight Infants: Crib or Crib-II ?

Background: The clinical risk index for babies (CRIB) is a risk-adjustment instrument used worldwide to determine illness severity in infants born at less than 31 weeks' gestation, or having 1500 g birth weight or lower. However, the appropriateness of CRIB has been questioned, and CRIB has very recently been updated and simplified into a five-items scoring system (CRIB-II) for infants born at less than 32 weeks' gestation, in order to improve its accuracy. Here, we compared the accuracy of CRIB and CRIB-II scores in predicting mortality for VLBW infants in a small unit. Methods: A total of 147 NICU-admitted VLBW infants with data available for both CRIB and CRIB-II were enrolled in the study (M:70, F:77; mean ± SD: 28.6 ± 2.5 weeks; birth weight: 1070 ± 325 g). Major non-lethal malformations were present in 3 (2.04%) infants and minor birth defects were observed in 7 (4.76%). Extremely low birth weight infants were 59 (40.15% of total; M:27, F:32). Newborns with lethal congenital abnormalities, metabolic disorders or undergoing complex cardiac surgery were excluded. Both CRIB and CRIB-II scores were calculated for each newborn. Neonatal mortality (death before hospital discharge) was selected as the outcome measure. Results: The median CRIB and CRIB-II scores were 2.0 (range:0–16), and 8.0 (range:3–20), respectively. A significant positive correlation between CRIB and CRIB-II was observed (P <0.0001), with a mortality rate of 11.56% (17/147). Newborns with unfavourable outcome (M:8, F:9) had a significantly lower birth weight (696±205 g vs. 1130±300; p<0.0001), gestational age (25.7±2.9 weeks vs. 29.08±2.1 weeks; p<0.0001), CRIB (median [25th-75th percentiles]: 8.0 vs. 2.0, P<0.0001) and CRIB-II (14.0 vs. 8.0, P <0.0001) than surviving infants. Mean AUCs for CRIB, CRIB-II, gestational age and birth weight in identifying neonatal mortality in VLBW infants ranged from 0.924 (CRIB) to 0.869 (gestational age). No significant differences were observed for the AUCs of CRIB vs. CRIB-II (P=0.34), CRIB vs. gestational age (P=0.18), CRIB vs. birthweight (P=0.24), CRIB-II vs. gestational age (P=0.62), or CRIB-II vs. birth weight (P=86). Conclusion: Our main findings suggest that CRIB and CRIB-II have comparable accuracy in predicting neonatal mortality in VLBW infants. Although our observed mortality rate is higher than that reported for the original CRIB-II population, differences between the two proportions are not statistically significant (P =0.16).

Cytokine gene polymorphism moderate illiness severity in infants with respiatory syncytial virus (RSV) infection

Cytokine gene polymorphism moderate illiness severity in infants with respiatory syncytial virus (RSV) infection

Cytokine gene polymorphisms moderate illness severity in infants with respiratory syncytial virus infection

Illness severity and frequency of complications in infants with respiratory syncytial virus (RSV) infection may be influenced by the local elaboration of cytokines. Cytokine gene polymorphisms moderate severity of illness in various inflammatory and infectious diseases. We performed cytokine genotyping on 77 infants hospitalized with confirmed RSV infection to determine whether specific cytokine gene polymorphisms are associated with illness severity or complications. DNA was extracted from buccal brushings and assayed for tumor necrosis factor (TNF)-α, interferon (IFN)-γ, interleukin (IL)-6 and IL-10, and transforming growth factor (TGF)-β1 genotypes using polymerase chain reaction–sequence-specific primer technology. Clinical outcomes consisted of severity scores of lower respiratory illness, blood oxygen saturation, lengths of oxygen supplementation, and intensive care unit (ICU) and hospital stays, and the presence or absence of pneumonia and otitis media. IFN-γ genotype was related to severity of lower respiratory illness, duration of ICU stay, and frequency of otitis media. Additionally, IL-6 genotype was related to the length of oxygen (O 2) supplementation and hospital stay, IL-10 genotype to the frequency of pneumonia, and TGF-β1 genotype to O 2 saturations at presentation. There were no associations between TNF-α genotype and any of the outcome parameters. These results demonstrate that certain cytokine gene polymorphisms contribute to illness severity and complications during RSV infection in infants. If future prospective studies confirm these observations, cytokine genotyping may be a useful tool for identifying “at risk” infants who may benefit from the selective use of preventive or early intervention treatments for RSV.

Association of cytokine responses with disease severity in infants with respiratory syncytial virus infection

Aim: To explore the relationship between cytokine responses and severity of respiratory syncytial virus (RSV) infection in infants. Methods: Intracellular interleukin‐4 (IL‐4) and interferon‐γ (IFN‐γ) expression in peripheral blood CD3+ and CD8+ lymphocytes was measured by four‐colour flow cytometry. Serum IL‐12, IL‐4 and IFN‐γ levels were also determined by enzyme‐linked immunosorbent assay. Results: The frequency of IL‐4 and IFN‐γ expression in CD3+CD8‐ cells was the same in RSV‐infected, non‐RSV‐infected and control infants and in those with RSV bronchiolitis or RSV pneumonia, indicating that no Th2 predominance exists in the acute phase of RSV infection and RSV bronchiolitis. Furthermore, RSV‐infected infants had a more frequent IFN‐γ expression in CD3+CD8+ cells than controls, and they also showed a much lower serum IL‐4/IFN‐γ ratio because of decreased IL‐4 and elevated IFN‐γ, the latter being most prominent in RSV bronchiolitis. The serum IL‐12 level in RSV‐infected infants was the same as in control infants, while those with non‐RSV infections had a much higher level. Serum IL‐12, IFN‐γ and frequency of IFN‐γ expression in CD3+CD8+ cells in mild RSV infection were much higher than in controls, while no difference existed between severe cases and controls. Conclusion: Type 2 cytokine predominance was not found in the acute phase of RSV infection and RSV bronchiolitis, but both were accompanied by enhanced production of IFN‐γ and a much higher serum IFN‐γ level than in healthy controls, especially in those with RSV bronchiolitis, suggesting a role in causing airway obstruction. IFN‐γ and IL‐12 may also play a protective role in RSV infections by diminishing viral replication, and high levels of IL‐12 and IFN‐γ may be associated with lessening of the severity of infection.

Association of cytokine responses with disease severity in infants with respiratory syncytial virus infection

To explore the relationship between cytokine responses and severity of respiratory syncytial virus (RSV) infection in infants. Intracellular interleukin-4 (IL-4) and interferon-gamma (IFN-gamma) expression in peripheral blood CD3+ and CD8+ lymphocytes was measured by four-colour flow cytometry. Serum IL-12, IL-4 and IFN-gamma levels were also determined by enzyme-linked immunosorbent assay. The frequency of IL-4 and IFN-gamma expression in CD3+CD8- cells was the same in RSV-infected, non-RSV-infected and control infants and in those with RSV bronchiolitis or RSV pneumonia, indicating that no Th2 predominance exists in the acute phase of RSV infection and RSV bronchiolitis. Furthermore, RSV-infected infants had a more frequent IFN-gamma expression in CD3+CD8+ cells than controls, and they also showed a much lower serum IL-4/ IFN-gamma ratio because of decreased IL-4 and elevated IFN-gamma, the latter being most prominent in RSV bronchiolitis. The serum IL-12 level in RSV-infected infants was the same as in control infants, while those with non-RSV infections had a much higher level. Serum IL-12, IFN-gamma and frequency of IFN-gamma expression in CD3+CD8+ cells in mild RSV infection were much higher than in controls, while no difference existed between severe cases and controls. Type 2 cytokine predominance was not found in the acute phase of RSV infection and RSV bronchiolitis, but both were accompanied by enhanced production of IFN-gamma and a much higher serum IFN-gamma level than in healthy controls, especially in those with RSV bronchiolitis, suggesting a role in causing airway obstruction. IFN-gamma and IL-12 may also play a protective role in RSV infections by diminishing viral replication, and high levels of IL-12 and IFN-gamma may be associated with lessening of the severity of infection.

Effects of Formal Support on Mothers' Adaptation to the Hospital-to-Home Transition of High-Risk Infants: The Benefits and Costs of Helping

94 mothers were randomly assigned to a control group or to a group who received a formal support program designed to aid their adaptation to the transition from hospital to home care of high-risk infants. Mothers' predischarge need for support and the severity of infants' predischarge medical problems moderated program effects assessed 6 months after NICU discharge. Positive effects of the program on mothers' sense of competence, perceived control, and responsiveness were evident for mothers who had needed the most support. But at low levels of need for support, participation in the program had negative effects on these outcomes. A similar pattern was found for the effects of the program on mothers' positive mood as a function of the severity of infants' medical problems. Secondary findings suggest why some mothers may benefit from formal support after NICU discharge and others may experience at least temporary disruptions in their adaptation from such support.