Probability of successful inhaled corticosteroids cessation in preschool wheezers: a predictive score.

Nearly all asthma predictive tools estimate the future risk of asthma development. However, there is no tool to predict the probability of successful ICS cessation at an early age. Therefore, we aimed to determine the predictors of successful ICS cessation in preschool wheezers, and developed a simple predictive tool for clinical practice. This was a retrospective cohort study involving preschool wheezers who had undergone an ICS therapeutic trial during 2015-2020 at the University Hospital, Southern, Thailand. A predictive scoring system was developed using a nomogram to estimate the probability of successful ICS cessation. We calculated area under ROC curve and used a calibration plot for assessing the tool's performance. A total of 131 medical records were eligible for analysis. Most of the participants were male (68.9%). More than half of the preschool wheezers had successful ICS cessation after an initial therapeutic trial regimen. The predictors of less successful ICS cessation were perinatal oxygen use [OR 0.10 (0.01, 0.70), P = 0.02], allergic rhinitis [OR 0.20 (0.08, 0.56), P = 0.002], blood eosinophil count > 500 cell/mm3 [OR 0.20 (0.06, 0.67), P = 0.008], and previous ICS use > 6 months [OR 0.30 (0.09, 0.72), P = 0.009]. CONCLUSIONS: Predictors of less successful ICS cessation were the following: perinatal oxygen use, allergic rhinitis, blood eosinophil count > 500 cell/mm3, and previous ICS use > 6 months. A simple predictive score developed in this study may help general practitioners to be more confident in making a decision regarding the discontinuation of ICS after initial therapeutic trials. WHAT IS KNOWN: • Early allergic sensitization is associated with reduced chances of inhaled corticosteroid cessation at school age. • Prolonged ICS is associated with the emergence of adverse effect and discontinuing too early can result in recurrence symptoms. WHAT IS NEW: • Requirement of oxygen support within 7 days after birth in term neonate is a postnatal factor associated with less successful ICS cessation. • We propose a simple predictive tool with easily available clinical parameters (perinatal oxygen use, allergic rhinitis, blood eosinophil count, parental asthma history, and duration of previous ICS use) to determine the timing of inhalational corticosteroid cessation in preschool wheezers.

Practical recommendations for home-nebulized corticosteroid use in children aged ≤ 5 years with asthma: A review and advisory group consensus.

BACKGROUND: Despite nebulized budesonide being identified by the Global Initiative for Asthma report as a viable alternative to inhaled corticosteroids (ICS) delivered by pressurized metered-dose inhalers (pMDIs) with spacers, practical guidance on nebulized corticosteroid use in the pediatric population remains scarce. OBJECTIVE: To review the current literature and provide practical recommendations for nebulized budesonide use in children aged ≤ 5 years with a diagnosis of asthma. METHODS: A group of 15 expert pediatricians in the respiratory and allergy fields in Thailand developed Delphi consensus recommendations on nebulized budesonide use based on their clinical expertise and a review of the published literature. Studies that evaluated the efficacy (effectiveness) and/or safety of nebulized budesonide in children aged ≤ 5 years with asthma were assessed. AR patients. RESULTS: Overall, 24 clinical studies published between 1993 and 2020 met the inclusion criteria for review. Overall, results demonstrated that nebulized budesonide significantly improved symptom control and reduced exacerbations, asthma-related hospitalizations, and the requirement for oral corticosteroids compared with placebo or active controls. Nebulized budesonide was well tolerated, with no severe or drug-related adverse events reported. Following a review of the published evidence and group consensus, a treatment algorithm as per the Thai Pediatric Asthma 2020 Guidelines was proposed, based on the availability of medications in Thailand, to include nebulized budesonide as the initial treatment option alongside ICS delivered by pMDIs with spacers in children aged ≤ 5 years. CONCLUSIONS: ThNebulized budesonide is an effective and well-tolerated treatment option in children aged ≤ 5 years with asthma.

Structural lung abnormalities on computed tomography correlate with asthma inflammation in bronchoscopic alveolar lavage fluid.

Objective: Image scoring systems have been developed to assess the severity of specific lung abnormalities in patients diagnosed with various pulmonary diseases except for asthma. A comprehensive asthma imaging scoring system may identify specific abnormalities potentially linking these to inflammatory phenotypes.Methods: Computed tomography (CT) images of 88 children with asthma (50 M/38 F, mean age 7.8 ± 5.4 years) acquired within 12 months of bronchoscopic alveolar lavage fluid (BALF) sampling that assessed airway inflammation cell types were reviewed along with CT images of 49 controls (27 M/22 F, mean age 3.4 ± 2.2 years). Images were scored using a comprehensive scoring system to quantify bronchiectasis (BR), bronchial wall thickening (BWT), ground glass opacity, mucus plugging (MP), consolidations, linear densities (LD), and air trapping (AT). Each category was scored 0-2 in each of six lobar regions (with lingula separated from left upper lobe).Results: Absolute average overall scores of the controls and children with asthma were 0.72 ± 1.59 and 5.39 ± 5.83, respectively (P < 0.0001). Children with asthma scored significantly higher for BR (N = 20, 0.33 ± 0.80, P = 0.0002), BWT (N = 28, 0.72 ± 1.40, P < 0.0001), MP (N = 28, 0.37 ± 1.12, P = 0.0052), consolidation (N = 31, 0.67 ± 1.22, P < 0.0001), LD (N = 58, 1.12 ± 1.44, P < 0.0001), and AT (N = 52, 1.78 ± 2.31, P < 0.0001). There was a significant difference between the BR score of children with positive inflammatory response in BALF (N = 53) and those who were negative for airway inflammation cells (0.14 ± 0.36, P = 0.040).Conclusions: Significant lung structural abnormalities were readily identified on CT of children with asthma, with image differentiation of those with an inflammatory response on BALF. Chest imaging demonstrates potential as a noninvasive clinical tool for additional characterization of asthma phenotypes.

Determinants of Lung Function at Age 8.5 Years in a Birth Cohort of Thai Children.

BACKGROUND AND AIMS: Early life factors have reported the associations with impaired lung function in later life. In the present study, the birth cohort was followed up longitudinally to investigate the determinants of lung function in Thai children. METHODS: Cohort subjects were recruited from children born in Songkhla Province in southern Thailand. Data collections were obtained starting from antenatal, at birth, and at 1, 5 and 8.5 years of age. Spirometry was assessed at age 8.5 years. The variables investigated included birth weight, smoke exposure, respiratory diseases during the newborn period and during the first year of life, and asthma diagnosed at age 5 or 8.5 years. RESULTS: Of 1056 subjects, 892 (84.5%) subjects completed the spirometric measurements. The presence of asthma was the only factor that was significantly associated with a lower forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio, forced expiratory flow at 25-75% vital capacity (FEF25-75%VC) and peak expiratory flow rate (PEFR). The regression analysis found that asthma was significantly associated with a lower FEV1/FVC ratio, FEF25-75%VC, and PEFR value with estimated coefficients ± standard error of -1.27 ± 0.55%, p = 0.02; -131.8 ± 48.2 ml/s, p = 0.006; and -166.2 ± 65.0 ml/s, p = 0.01, respectively. Asthma diagnosed at age 5 or 8.5 years was more likely among children who had lower respiratory tract illness during the first year of life. The odds ratio for the association was 4.81 (95% confidence interval 2.14-10.83, p < 0.001). CONCLUSION: The main factor associated with lower lung function in Thai cohort subjects was the present of asthma by age 5 or 8.5 years and early respiratory illness was the risk factor for asthma in childhood period.

Severity and Mortality Predictors of Pediatric Acute Respiratory Distress Syndrome According to the Pediatric Acute Lung Injury Consensus Conference Definition.

OBJECTIVES: The objective of this study was to assess the prevalence, severity, and outcomes of pediatric acute respiratory distress syndrome in a resource-limited country. In addition, we sought to explore the predisposing factors that predicted the initial severity, a change from mild to moderate-severe severity, and mortality. DESIGN: Retrospective study. SETTING: PICU in Songklanagarind Hospital, Songkhla, Thailand. PATIENTS: Children 1 month to 15 years old with acute respiratory failure admitted to the PICU from January 2013 to December 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: From a total of 1,738 patients admitted to PICU, 129 patients (prevalence 7.4%) were diagnosed as pediatric acute respiratory distress syndrome using the Pediatric Acute Lung Injury Consensus Conference definition. The patients were categorized by severity. Fifty-seven patients (44.2%) were mild, 35 (27.1%) were moderate, and 37 (28.1%) were severe. After multivariable analysis was performed, factors significantly associated with moderate to severe disease at the initial diagnosis were Pediatric Risk of Mortality III score (odds ratio, 1.08; 95% CI, 1.03-1.15; p = 0.004), underlying oncologic/hematologic disorder (odds ratio, 0.32; 95% CI, 0.12-0.77; p = 0.012), and serum albumin level (odds ratio, 0.46; 95% CI, 0.27-0.80; p = 0.006), whereas underlying oncologic/hematologic disorder (odds ratio, 5.33; 95% CI, 1.33-21.4) and hemoglobin (odds ratio, 0.63; 95% CI, 0.44-0.89) predicted the progression of this syndrome within 7 days. The 30-day all-cause mortality rate was 51.2% (66/129). The predictors of mortality were the Pediatric Risk of Mortality III score (odds ratio, 1.12; 95% CI, 1.02-1.24; p = 0.017), underlying oncologic/hematologic disorder (odds ratio, 7.81; 95% CI, 2.18-27.94; p = 0.002), receiving systemic steroids (odds ratio, 4.04; 95% CI, 1.25-13.03; p = 0.019), having air leak syndrome (odds ratio, 5.45; 95% CI, 1.57-18.96; p = 0.008), and presenting with multiple organ dysfunction (odds ratio, 7.41; 95% CI, 2.00-27.36; p = 0.003). CONCLUSIONS: The prevalence and mortality rate of pediatric acute respiratory distress syndrome in a developing country are high. The oncologic/hematologic comorbidity had a significant impact on the severity of progression and mortality.

Clinical presentation and outcome in congenital pulmonary malformation: 25 year retrospective study in Thailand.

BACKGROUND: Congenital pulmonary malformations (CPM) are a group of rare abnormal lung development lesions that can have various presentations. The aim of this study was to define the differences in the clinical presentations of CPM in neonates, infants, and children, and to review the outcomes. METHODS: A retrospective study was conducted at a tertiary care hospital in southern Thailand between 1992 and 2016. RESULTS: Fifty-four patients were diagnosed with CPM, and the median age at onset was 1.7 months (IQR, 0.03-10 months). There were 33 cases (61.1%) of congenital pulmonary airway malformations, two (3.7%) of bronchogenic cyst, eight of (14.8%) congenital lobar emphysema, seven of (13.0%) pulmonary sequestrations, and four of (7.4%) congenital lung cysts. Twenty patients under 1 month old and 16 patients who were 1-12 months old had symptoms of respiratory distress. In contrast, 13 patients >1 year old had symptoms of pulmonary infection. There were significant differences in the numbers of patients who had cyanosis (P = 0.006), cough (P < 0.001), and fever (P < 0.001) between the three age groups. Thirty-eight patients (70%) required surgical treatment involving lobectomy (78.9%). Median follow-up duration was 28.1 months (IQR, 3.7-9.4 months). Nine of 10 patients had abnormal lung function tests, and 80.6% of patients had no subsequent limitations in physical activities. CONCLUSIONS: Respiratory distress is the important clinical feature in neonates and infants, whereas the signs of pulmonary infection usually occur in children >1 year old. Good outcomes usually occur after surgery but need long-term follow up including lung function assessment.

Effectiveness of a Telephone Counseling Intervention in Reducing Passive Smoking Among Children.

Legislative smoking bans that prohibit smoking in public places have successfully reduced passive smoking in public areas. However, smokers only partially adhere to smoking restrictions in their homes. Young children are particularly vulnerable to exposure to tobacco smoke because they spend more time at home. In this study, we designed an intervention program based on an empowerment theory to reduce passive smoking among children. The priority participants were nonsmoking mothers living with smokers who smoke in the presence of children. The aim of this randomized control trial study was to examine the effectiveness of this intervention in reducing children's exposure to tobacco smoke at home. The intervention group received tailored educational brochures and two follow-up counseling telephone calls at 2 and 8 weeks, which provided resources to support the mothers to increase their knowledge, skill, and self-confidence in promoting behavior shaping of smokers. The control group received only tailored educational brochures. We found the intervention group demonstrated a higher rate of maternal actions to reduce their children's exposure to smoke and a higher rate than the control group of attempts to avoid smoking in the presence of children at the 16-week follow-up. These results suggest that the intervention helped reduce passive smoking among children. These findings highlight the need to empower and train mothers to help them develop rules for smoking at home. These interventions could be applied in the home of children who live with smokers who are unable or unwilling to quit smoking.

A Longitudinal Study of a Selected Pediatric Asthmatic Population with Normal and Abnormal Spirometry at Baseline: An Emphasis on Treatment Outcomes.

Purpose: It is still unclear whether considering abnormal spirometry as a marker for disease control can help physicians adjust asthma controllers in children because of the scarcity of pediatric studies. We aimed to investigate the prevalence of abnormal spirometry in a selected pediatric asthmatic population and its effect on longitudinal outcomes. Patients and Methods: This retrospective cohort study was conducted at the Songklanagarind Hospital, Thailand. Children with asthma aged <18 years were recruited for review if they attended the clinic and underwent acceptable spirometry with bronchodilator responsiveness (BDR) tests after receiving asthma treatment for at least 3 months between January 2011 and June 2022. Differences in baseline characteristics, atopic factors, asthma treatment, and outcomes were analyzed between the normal and abnormal spirometry groups over a 12-month post-spirometry period. Results: The mean age of the 203 enrolled patients was 10.9 ± 2.6 years. Abnormal spirometry, defined as airflow limitation or the presence of BDR, was observed in 58.1% of patients. No significant differences were observed in baseline characteristics, atopic factors, asthma treatment, or outcomes between the normal and abnormal spirometry groups. Further analysis of 107 patients with abnormal spirometry with symptom control revealed that physicians adjusted the asthma controller based on spirometry and symptoms in 84 and 23 patients, respectively. There was no significant difference in the loss of disease control over the 12-month post-spirometry period between the two groups. Conclusion: Abnormal spirometry was found in 58.1% of treated school-aged patients with asthma. Abnormal spirometry results were not associated with poor asthma outcomes during the 12-month follow-up. Both symptom-based and spirometry-based adjustments of asthma controllers resulted in comparable symptom control over a 12-month follow-up period in the selected population.

Chest X-ray findings of COVID-19 pneumonia in children: Experiences in a multicenter study in Thailand.

INTRODUCTION: Although chest X-ray is commonly used to diagnose COVID-19 pneumonia, few studies have explored findings in pediatric patients. This study aimed to reveal chest X-ray characteristics in children with COVID-19 pneumonia and compare between non-severe and severe cases. METHODS: This multicenter, nationwide retrospective study included all children aged 0 to 15 years who were admitted to 13 medical facilities throughout Thailand with COVID-19 pneumonia between January 2020 and October 2021. We analyzed the demographics, clinical features, and chest X-ray results of these children, and compared differences between the non-severe and severe groups. RESULTS: During the study period, 1018 children (52% male, median age 5 years) were admitted with COVID-19 pneumonia. Most chest radiographic findings showed bilateral (51%) patchy/ground glass opacities (61%) in the central area (64%). Only 12% of the children exhibited typical classification for COVID-19 pneumonia, whereas 74% of chest radiographs were categorized as indeterminate. Comorbidities including chronic lung diseases [adjusted OR (95%CI): 14.56 (3.80-55.75), P-value <0.001], cardiovascular diseases [adjusted OR (95%CI): 7.54 (1.44-39.48), P-value 0.017], genetic diseases [adjusted OR (95%CI): 28.39 (4.55-177.23), P-value <0.001], clinical dyspnea [adjusted OR (95%CI): 12.13 (5.94-24.77), P-value <0.001], tachypnea [adjusted OR (95%CI): 3.92 (1.79-8.55), P-value 0.001], and bilateral chest X-ray infiltrations [adjusted OR (95%CI): 1.99 (1.05-3.78), P-value 0.036] were factors associated with severe COVID-19 pneumonia. CONCLUSION: Most children with COVID-19 pneumonia had indeterminate chest X-rays according to the previous classification. We suggest using chest X-rays in conjunction with clinical presentation to screen high-risk patients for early detection of COVID-19 pneumonia.

Unusual presentation of alveolar capillary dysplasia with misalignment of the pulmonary veins in a child with respiratory syncytial virus pneumonia: A case report.

Alveolar capillary dysplasia with misalignment of the pulmonary veins (ACDMPV) is a rare congenital diffuse lung disorder, with a fatal course during the neonatal period. We describe an 18-month-old boy who presented with respiratory syncytial virus pneumonia and pulmonary hypertensive crisis requiring extracorporeal membrane oxygenation. Exome sequencing revealed a FOXF1 frameshift variant, NM_001451.2:c.995_998delACTC, inherited from his asymptomatic mother. Genetic findings were compatible with histopathology findings from a lung biopsy. Based on the disease course, histopathology, and outcomes of this case, we believe ACDMPV should be considered a possibility in an infant presenting with hypoxemic respiratory failure, resistant pulmonary hypertension, and vasodilator-induced pulmonary edema. Genetic testing can contribute to the diagnostic process.

Predictive parameters and model for extubation outcome in pediatric patients.

Background: Prolonged mechanical ventilation is associated with significant morbidity in critically ill pediatric patients. In addition, extubation failure and deteriorating respiratory status after extubation contribute to increased morbidity. Well-prepared weaning procedures and accurate identification of at-risk patients using multimodal ventilator parameters are warranted to improve patient outcomes. This study aimed to identify and assess the diagnostic accuracy of single parameters and to develop a model that can help predict extubation outcomes. Materials and methods: This prospective observational study was conducted at a university hospital between January 2021 and April 2022. Patients aged 1 month to 15 years who were intubated for more than 12 h and deemed clinically ready for extubation were enrolled. A weaning process with a spontaneous breathing trial (SBT), with or without minimal setting, was employed. The ventilator and patient parameters during the weaning period at 0, 30, and 120 min and right before extubation were recorded and analyzed. Results: A total of 188 eligible patients were extubated during the study. Of them, 45 (23.9%) patients required respiratory support escalation within 48 h. Of 45, 13 (6.9%) were reintubated. The predictors of respiratory support escalation consisted of a nonminimal-setting SBT [odds ratio (OR) 2.2 (1.1, 4.6), P = 0.03], >3 ventilator days [OR 2.4 (1.2, 4.9), P = 0.02], occlusion pressure (P0.1) at 30 min ≥0.9 cmH2O [OR 2.3 (1.1, 4.9), P = 0.03], and exhaled tidal volume per kg at 120 min ≤8 ml/kg [OR 2.2 (1.1, 4.6), P = 0.03]; all of these predictors had an area under the curve (AUC) of 0.72. A predictive scoring system to determine the probability of respiratory support escalation was developed using a nomogram. Conclusion: The proposed predictive model, which integrated both patient and ventilator parameters, showed a modest performance level (AUC 0.72); however, it could facilitate the process of patient care.

Persistent Asthma at School Age: Associated Factors in Preschool Children with Asthma.

Most patients with childhood asthma present their first symptoms at preschool age. Identifying modifiable risks and protective factors at an early age may help develop asthma prevention and control strategies. This study aimed to identify factors at preschool age that are associated with persistent asthma at school age. This retrospective observational study included preschool children with asthma from 2015 to 2020 at a university hospital in Southern Thailand. In total, 189 eligible participants (70.9% boys; median age, 7.6 [6.7, 8.5] years) were included. Wheeze characteristics included early transient wheeze, persistent wheeze, and late-onset wheeze that accounted for 55%, 27.5%, and 19.5% of the patients, respectively. Approximately 20% of the participants had persistent asthma. Breastfeeding was a protective factor (odds ratio [OR] 0.4 [0.2, 0.9], p = 0.04). The modifiable risk factors were siblings living in the same household (OR 2.6 [1.1, 6.2], p = 0.02) and residence in an industrial area (OR 3.8 [1.4, 10.5], p = 0.009). Additionally, presence of allergic rhinitis was associated with an increased risk of persistent asthma at school age (OR 3.6 [1.6, 8.2], p = 0.002). Early therapeutic interventions targeting modifiable factors provide a window of opportunity to prevent persistent asthma at school age.

Predictors of high-flow nasal cannula failure in pediatric patients with acute respiratory distress.

BACKGROUND: Heated humidified high-flow nasal cannula (HFNC) has gained popularity recently and is considered a standard respiratory support tool for pediatric patients with acute respiratory distress. However, data are limited on the bedside parameters that can predict HFNC failure in pediatric patients. PURPOSE: To evaluate the performance of SpO2/FiO2 (SF) ratio, pediatric respiratory rate-oxygenation (pROX) index, and clinical respiratory score (CRS), for predicting the HFNC outcomes. METHODS: This prospective observational study included 1- month to 15-year-old patients with acute respiratory distress who required HFNC support. The HFNC setting, vital signs, CRS, and treatment outcomes were recorded. Data were analyzed to determine the predictors of HFNC failure. RESULTS: Eighty-two children participated in the study, 16 of whom (19.5%) did not respond to HFNC treatment (failure group). Pneumonia was the main reason for intubation (62.5%). Predictors of HFNC failure at 12 hours were: SF index ≤166 (sensitivity, 62.5%; specificity, 87.8%; area under the curve [AUC], 0.75), pROX index <132 (sensitivity, 68.7%; specificity, 84.8%; AUC, 0.77), and CRS ≥6 (sensitivity, 87.5%; specificity, 96.9%; AUC, 0.92). CONCLUSION: The CRS was the most accurate predictor of HFNC failure in pediatric patients. A CRS ≥ 6 at 12 hours after HFNC initiation and pROX, a newly modified parameter, are helpful indicators of HFNC failure.

Treatment and outcomes of chylothorax in children: 20-year experience of a single institute.

Background: Chylothorax is an uncommon cause of pleural effusion in children. This study aimed to determine the characteristics, treatment strategies, and outcomes of chylothorax in children from a single institute. Methods: The 65 episodes of chylothorax in patients aged 0-15 years who were diagnosed and received treatment in Songklanagarind Hospital between January 2001 and December 2020 were retrospectively review and analyzed. Results: Of the 65 episodes, 80% were postoperative chylothorax, and were mostly related to cardiac surgery. The most common treatment strategy employed was dietary modification (64.6%). Octreotide was used as adjunctive therapy in 33.8%. Most cases of chylothorax were successfully treated by conservative treatment, while 10.7% required surgical therapy. The median time to resolution of chylothorax was 21 days [interquartile range (IQR): 8-33 days]. Young children aged <1 year were more likely to require mechanical ventilation and develop ventilator-associated pneumonia and catheter-related complications. The factors associated with death or prolonged hospitalization (>28 days) were non-postoperative chylothorax, use of total parental nutrition (TPN) >14 days, hypoalbuminemia, and ventilator-associated pneumonia. Conclusions: Most (89.2%) cases of chylothorax were successfully treated conservatively using dietary modification and octreotide therapy. The modifiable risk factors for death or prolonged hospitalization were use of TPN >14 days and hypoalbuminemia.

Development and validation of the predictive score for pediatric COVID-19 pneumonia: A nationwide, multicenter study.

BACKGROUND: Due to the possibility of asymptomatic pneumonia in children with COVID-19 leading to overexposure to radiation and problems in limited-resource settings, we conducted a nationwide, multi-center study to determine the risk factors of pneumonia in children with COVID-19 in order to create a pediatric pneumonia predictive score, with score validation. METHODS: This was a retrospective cohort study done by chart review of all children aged 0-15 years admitted to 13 medical centers across Thailand during the study period. Univariate and multivariate analyses as well as backward and forward stepwise logistic regression were used to generate a final prediction model of the pneumonia score. Data during the pre-Delta era was used to create a prediction model whilst data from the Delta one was used as a validation cohort. RESULTS: The score development cohort consisted of 1,076 patients in the pre-Delta era, and the validation cohort included 2,856 patients in the Delta one. Four predictors remained after backward and forward stepwise logistic regression: age < 5 years, number of comorbidities, fever, and dyspnea symptoms. The predictive ability of the novel pneumonia score was acceptable with the area under the receiver operating characteristics curve of 0.677 and a well-calibrated goodness-of-fit test (p = 0.098). The positive likelihood ratio for pneumonia was 0.544 (95% confidence interval (CI): 0.491-0.602) in the low-risk category, 1.563 (95% CI: 1.454-1.679) in the moderate, and 4.339 (95% CI: 2.527-7.449) in the high-risk. CONCLUSION: This study created an acceptable clinical prediction model which can aid clinicians in performing an appropriate triage for children with COVID-19.

Acquired tracheo-oesophageal fistula in a child with unrecognised tracheal foreign body.

We report the case of a 6-month-old girl who presented with recurrent pneumonia and growth failure. After full examination, she was diagnosed with long-standing, unrecognised tracheal foreign body, which was then successfully removed. However, her chronic respiratory symptoms did not improve, and she also had feeding intolerance. The persistence of symptoms indicated a second bronchoscopy and finally an acquired tracheo-oesophageal fistula was diagnosed. This case emphasises the challenges in diagnosis of an inhaled foreign body in young children. Late diagnosis of this condition can cause significant morbidities. A high index of suspicion and careful investigation are very important to prevent long-term complications.

Practice, self-confidence and understanding of pediatric obstructive sleep apnea survey among pediatricians.

BACKGROUND: Pediatricians play an important role in the screening, diagnosis and management of childhood obstructive sleep apnea (OSA). This study used a questionnaire to explore the knowledge, self-confidence and general practices of childhood OSA among Thai pediatricians. METHODS: This was a descriptive cross-sectional survey study, using a newly developed questionnaire; including: 21 knowledge items, 4 self-confidence items, questions regarding OSA screening, number of OSA cases per month and OSA management. RESULTS: A total of 307, convenient pediatricians; from different types of hospitals across all regions of Thailand, participated in this study. The median, total knowledge score was 19 (range 14‒21). Two-thirds of the respondents felt confident/extremely confident in their ability to identify and manage children with OSA. The average number of OSA cases reported by pediatricians was 5.9 cases per month. During a general medical check-up, 86.6% of the respondents did not routinely ask about OSA symptoms. Significant odds ratios (ORs) for the use of montelukast, as the first-line drug for OSA in young children, were observed in pediatric allergists and pulmonologists (adjusted OR 2.58, 95% CI 1.11-6.01 and adjusted OR 2.20, 95% CI 1.2-4.02) (P = 0.008), respectively, compared to general pediatricians and other sub-specialties. CONCLUSIONS: Pediatricians had a high level of overall OSA knowledge, and good self-confidence in identifying and managing children with OSA. However, a low recognition rate and unawareness of OSA screening were observed.

Outcomes of very low birth weight infants in Songklanagarind Hospital.

OBJECTIVE: To determine the mortality and morbidity rates of very low birth weight (VLBW) infants in Songklanagarind Hospital. MATERIAL AND METHOD: A retrospective study of all infants with birth weight < 1,500 g admitted to the neonatal intensive care unit between January 2003 and December 2006. RESULTS: A total of 178 VLBW infants, met the enrollment criteria, with mean (+/- standard deviation-SD) birth weight and gestational age of 1,123 +/- 273 g and 29 +/- 3 weeks, respectively. Forty-two (23.6%) were referred from other hospitals. The overall mortality rate was 27.0%. Perinatal risk factors of mortality were birth weight < 1,000 g (p < 0.01), congenital anomalies (p < 0.01), and Apgar score at 1 minute < or = 5 (p < 0.01). Among the 130 (73.0%) survivors to discharge, 92 (70.8%) survived without major morbidity. The major morbidities were moderate/severe bronchopulmonary dysplasia, retinopathy of prematurity stage 3, necrotizing enterocolitis stage > or = 2 and intraventricular hemorrhage grade > or = III in 31 (23.8%), 12 (9.2%), 4 (3.1%) and 2 (1.5%) infants, respectively. CONCLUSION: The mortality rate of VLBW infants in Songklanagarind Hospital was similar to other developing countries, although greater than in developed countries. Among survivors, the major morbidity rates were acceptable.

Effectiveness of Protocolized Sedation Utilizing the COMFORT-B Scale in Mechanically Ventilated Children in a Pediatric Intensive Care Unit.

Appropriate sedation in mechanically ventilated patients is important to facilitate adequate respiratory support and maintain patient safety. However, the optimal sedation protocol for children is unclear. This study assessed the effectiveness of a sedation protocol utilizing the COMFORT-B sedation scale in reducing the duration of mechanical ventilation in children. This was a nonrandomized prospective cohort study compared with a historical control. The prospective cohort study was conducted between November 2015 and August 2016 and included 58 mechanically ventilated patients admitted to the pediatric intensive care unit (PICU). All patients received protocolized sedation utilizing the COMFORT-B scale, which was assessed every 12 hours after intubation by a single assessor. The prospective data were compared with retrospective data of 58 mechanically ventilated patients who received sedation by usual care from November 2014 to August 2015. Fifty percent of 116 patients were male and the mean age was 22 months (interquartile range [IQR]: 6.6-68.4). Patients in the intervention group showed no difference in the duration of mechanical ventilation (median 4.5 [IQR: 2.2-10.5] vs. 5 [IQR: 3-8.8] days). Also, there were no significant differences in the PICU length of stay (LOS; median 7 vs. 7 days, p = 0.59) and hospital LOS (median 18 vs. 14 days, p = 0.14) between the intervention and control groups. The percentages of sedative drugs, including fentanyl, morphine, and midazolam, in each group were not statistically different. The COMFORT-B scale with protocolized sedation in mechanically ventilated pediatric patients in the PICU did not reduce the duration of mechanical ventilation compared with usual care.

Gastropleural fistula masquerading as chylothorax in a child with lymphoma.

We report the case of an 8-year-old boy with diffuse large B cell lymphoma who developed a right-sided spontaneous pneumothorax with pleural effusion after recovery from septic shock. The pleural fluid was thought to be malignancy-associated chylothorax concomitant with complicated pleural effusion due to a milky-like appearance, a high level of triglycerides and Gram-negative bacteria staining in the fluid. He was put on total parental nutrition and octreotide for 2 weeks, but did not improve. The laboratory results also showed a persistent bacterial infection in the pleural fluid despite appropriate antibiotics. Eventually, a CT scan revealed a fistulous tract between the right pleural cavity and the stomach. Fistula repair was successful by right open thoracotomy with decortication. Even though the gastropleural fistula is a very rare condition in paediatric patients, the physician should consider this diagnosis in a patient who has an unusual presentation or refractory chylothorax-like pleural effusion.