Severe asthma in children: Description of a large multidisciplinary clinical cohort.

BACKGROUND: Children with severe asthma have substantial morbidity and healthcare utilization. Pediatric severe asthma is a heterogeneous disease, and a multidisciplinary approach can improve the diagnosis and management of these children. METHODS: We reviewed the electronic health records for patients seen in the Severe Asthma Clinic (SAC) at UPMC Children's Hospital of Pittsburgh between August 2012 and October 2019. RESULTS: Of the 110 patients in whom we extracted data, 46% were female, 48% were Black/African American, and 41% had ≥1 admission to the pediatric intensive care unit (PICU) for asthma. Compared to patients without a PICU admission, those with ≥1 PICU admission were more likely to be non-White (64.4% vs. 41.5%, p = 0.031) and more atopic (eosinophil count geometric mean = 673 vs. 319 cells/mm3 , p = 0.002; total IgE geometric mean = 754 vs. 303 KU/L, p = 0.003), and to have lower pre-bronchodilator FEV1 (58.6% [±18.1%] vs. 69.9% [±18.7%], p = 0.002) and elevated FeNO (60% vs. 22%, p = 0.02). In this cohort, 84% of patients were prescribed high-dose ICS/LABA and 36% were on biologics. Following enrollment in the SAC, severe exacerbations decreased from 3.2/year to 2.2/year (p < 0.0001); compared to the year before joining the SAC, in the following year the group had 106 fewer severe exacerbations. CONCLUSIONS: This large cohort of children with severe asthma had a high level of morbidity and healthcare utilization. Patients with a history of PICU admissions for asthma were more likely to be nonwhite and highly atopic, and to have lower lung function. Our data support a positive impact of a multidisciplinary clinic on patients with severe childhood asthma.

Culturally Sensitive Interventions in Pediatric Primary Care Settings: A Systematic Review.

CONTEXT: Culturally sensitive interventions in the pediatric primary care setting may help reduce health disparities. Less is known on the development of these interventions, their target groups, and their feasibility, acceptability, and impact on health outcomes. OBJECTIVE: We conducted a systematic review to describe culturally sensitive interventions developed for the pediatric primary care setting. DATA SOURCES: PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo (January 2000 to July 2020). STUDY SELECTION: Studies were eligible for inclusion if they were (1) original research on an intervention with an evaluation, (2) within a pediatric primary care setting, (3) not limited to education for providers, (4) not limited to interpreter use, and (5) based in the United States. DATA EXTRACTION: The following were extracted: study topic, study design, intervention, cultural sensitivity strategies and terminology, setting, target group, sample size, feasibility, acceptability, and health outcomes. RESULTS: Twenty-five studies described 23 interventions targeting a variety of health topics. Multiple cultural sensitivity strategies were used, most commonly sociocultural (83%). Most interventions (57%) were focused on Hispanic/Latino families. Interventions were generally reported as being feasible and acceptable; some also changed health outcomes. LIMITATIONS: Small samples and heterogenous methods subject to bias were used. Relevant articles may have been missed because of the variety of terms used to describe cultural sensitivity. CONCLUSIONS: The included articles provide preliminary evidence that culturally sensitive interventions can be feasible and effective and may help eliminate disparities for patients from communities with barriers to equitable care.

Nutritional status and lung function in children with pancreatic-sufficient cystic fibrosis.

BACKGROUND: There is a strong association between nutrition and long-term FEV1 in cystic fibrosis (CF), but studies have been driven by data from subjects with pancreatic insufficiency (PI-CF). We thus evaluated the association between body mass index (BMI) and FEV1 percent-predicted (FEV1pp) in children with pancreatic sufficiency (PS-CF) and contrasted it with the association in PI-CF. METHODS: We utilized data from the CF Foundation Patient Registry. The cohort included children born 1995-2010, diagnosed <2 years of age, and who had annualized data on BMI percentile and FEV1pp at ages 6-16 years. Pancreatic status was defined based on pancreatic enzyme replacement therapy. The association between BMI and FEV1 was evaluated using linear and mixed-effects longitudinal regression. RESULTS: There were 424 children with PS-CF and 7,849 with PI-CF. The association between BMI and FEV1 differed significantly by pancreatic status: each 10-pct higher BMI was associated with 2% [95%CI = 1.9-2.1] higher FEV1pp in PI-CF, compared to just 0.9% [0.5-1.3] in PS-CF (PINTERACTION < 0.001). Within the at-risk nutritional category (BMI <25pct), each 10-pct higher BMI was associated with 5% higher FEV1pp in PI-CF, but no significant increase in PS-CF. Moreover, in PS-CF, overweight/obesity (BMI ≥85pct) was associated with decreasing FEV1pp. In addition, FEV1pp decline through age 20 years in youth with PS-CF was modest (-0.6% per year) and independent of BMI (BMI*age PINTERACTION = 0.37). CONCLUSIONS: In children with PS-CF, BMI remains an important determinant of lung function. However, it may be less critical to attain a BMI >50th percentile; and BMI ≥85th percentile may be detrimental.

"Give them the door but don't push them through it": Family Attitudes Toward Physician-Led Spiritual Care in Pediatric Palliative Medicine.

Little is known about pediatric caregivers' perceptions of religious or spiritual (R/S) care provided by physicians. We conducted a qualitative, semistructured interview study to understand perceptions of pediatric caregivers toward physician-led R/S care. Participants were 20 primary caregivers whose children were hospitalized and receiving palliative care services. Interviews were audio recorded, transcribed verbatim, and analyzed using constant comparative methods. Three recurrent themes emerged regarding physician-led R/S care: (1) Most caregivers view providing R/S care as a positive sign of physician empathy, while a minority (3/20) prefer to keep R/S and medical care separate, (2) many caregivers prefer R/S care from a physician with whom they have a close relationship and/or share a faith background, and (3) physicians should open the door, but allow families to lead conversations about R/S care. Caregivers have mixed perceptions on physicians engaging in R/S care; most prefer that families set the direction of R/S care for themselves and their loved ones. Physicians should be trained to evaluate families' spiritual backgrounds and needs in ways that respectfully open the door to these conversations.

Glycemic control and FEV1 recovery during pulmonary exacerbations in pediatric cystic fibrosis-related diabetes.

RATIONALE: Whether short-term glucose control in cystic fibrosis-related diabetes (CFRD) is associated with FEV1 recovery during acute pulmonary exacerbations is unclear. METHODS: Data from all patients with CFRD ages 6-21 years hospitalized in 2010-2016 for pulmonary exacerbations at our CF Center were analyzed, including CFRD status at each encounter, all FEV1 recorded during each exacerbation, and relevant clinical covariates. Glucose control was analyzed using meter blood glucose area under the curve (AUC) indices. The primary outcome was FEV1 recovery. RESULTS: Patients with CFRD who finished IV antibiotics at home were treated for longer than those fully treated in the hospital (22.2 vs. 13.8 days). In those who finished treatment at home, poor inpatient glycemic control was associated with lower lung function improvement: when comparing the 75th to the 25th percentile of each glycemic index (i.e., "poorer" vs. "better" glycemic control), FEV1 recovery at discharge was 20.1% lower for glucose AUC (95%CI -0.4%, -39.9%); 20.9% lower for 48-h AUC (95%CI -2.7%, -39.1%); and 28.2% lower for AUC/day (95%CI -7.1%, -49.3%). Similar results were found at the end of IV antibiotics and at clinic follow-up. Likewise, patients with poor glycemic control had a lower slope of inpatient FEV1 recovery. Analysis in patients with normal glucose tolerance was largely non-significant. No associations were found between hemoglobin A1c and FEV1 recovery. CONCLUSIONS: In patients with CFRD who complete IV antibiotic treatment at home, poor inpatient glycemic control is associated with worse FEV1 recovery despite longer duration of treatment.

Weight Loss for Children and Adults with Obesity and Asthma. A Systematic Review of Randomized Controlled Trials.

Background: Asthma and obesity are major public health problems, affecting hundreds of millions of people worldwide. Obesity is associated with increased asthma risk and severity, and lower asthma-related quality of life. Objective: In this systematic review, we aimed to evaluate whether weight loss in subjects with obesity and asthma leads to improvement in asthma-related outcomes. Data Sources and Extraction: We searched PubMed and Google Scholar for all studies in English published January 2000-December 2018. Studies were included if they were randomized, controlled clinical trials (RCTs) for overweight/obese children or adults with asthma, with sufficient data to assess outcomes and study quality. Non-randomized and non-controlled studies were excluded, as well as those in subjects without overweight/obesity, or with non-asthmatic controls. Synthesis: We identified four RCTs involving children (total n = 246) and six involving adults (n = 502). All interventions were designed for weight loss and varied from dietary restrictions to multifactorial interventions with exercise training and cognitive behavioral therapy; the duration of intervention ranged from 8 weeks to 18 months. All RCTs reported successful improvements in weight or body mass index (-0.14 standard deviation scores to -15.9% BMI reduction in children, 1.8%-14.5% weight loss in adults). RCTs generally reported improvements in asthma-related quality of life and, to some degree, asthma control. RCTs involving adults also reported improvements in lung function (FEV1, FVC, TLC), while RCTs in children showed less consistent results. Conclusions: These findings suggest that weight loss in subjects with obesity and asthma may improve asthma outcomes. However, there was wide variability in populations studied, baseline and post-intervention assessments, follow-up length, outcome definition and reporting, and statistical approaches, which hindered the ability to compare studies, perform a pooled analysis, or assess generalizability. Primary Source of Funding: U.S. National Institutes of Health (NIH).