Secondhand smoke exposure, illness severity, and resource utilization in pediatric emergency department patients with respiratory illnesses.

OBJECTIVE: Hospital-based data reveal that children who have secondhand smoke exposure (SHSe) experience severe respiratory illnesses and greater resource utilization. Our objective was to assess the relationship between SHSe and illness severity/resource utilization among children presenting to the pediatric emergency department (PED) with three common respiratory conditions-asthma, bronchiolitis, and pneumonia. METHODS: A retrospective review of a yearlong consecutive sample of PED patients with SHSe status documentation and asthma, bronchiolitis, or pneumonia diagnoses was performed. PED illness severity/resource utilization variables included triage categorization, initial oxygen saturation, evaluation/testing (influenza A & B, respiratory syncytial virus, chest X-ray), procedures/interventions performed (supplemental oxygen, suctioning, intubation), medications administered, and disposition. Logistic and linear regression models were conducted to determine differences in each diagnosis group while controlling for sociodemographics, medical history, seasonality, and insurance type. RESULTS: There were 3,229 children with documentation of SHSe status and an asthma (41%), bronchiolitis (36%), or pneumonia (23%) diagnosis. Across diagnosis groups, approximately 1/4 had positive documentation of SHSe. Asthmatic children with SHSe were more likely to receive corticosteroids (odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.19, 2.44) and/or magnesium sulfate (OR = 1.66, 95% CI = 1.14, 2.40). Children with SHSe and bronchiolitis were more likely to receive racemic epinephrine (OR = 2.48, 95% CI = 1.21, 5.08), have a chest X-ray (OR = 1.36, 95% CI = 1.00, 1.85), and/or be admitted (OR = 1.46, 95% CI = 1.09, 1.95). No differences in illness severity/resource utilization were identified for children with pneumonia. CONCLUSIONS: SHS-exposed children with asthma or bronchiolitis have greater illness severity/resource utilization. Our findings highlight the importance of SHSe assessment, cessation, and research efforts in the PED setting.

Vitamin D deficiency and acute lower respiratory infections in children younger than 5 years: identification and treatment.

INTRODUCTION: Acute lower respiratory infection (ALRI) is a leading cause of childhood mortality. Research suggests that vitamin D deficiency (VDD) puts children at risk for ALRI. The purpose of this review is to examine ALRI and VDD in children 5 years and younger. Common etiologies, diagnosis, prevention, treatment of ALRI, and recommendations for vitamin D supplementation are summarized. METHOD: Databases were searched for studies investigating VDD and ALRI in children. Independent reviewers assessed the internal validity of the studies. RESULTS: Of 18 studies examined, VDD was found to be associated with increased risk or severity of ALRI in 13 studies; associations were not found in 4 studies. In one study it was found that high maternal vitamin D levels was associated with ALRI in infants. DISCUSSION: Vitamin D supplementation is a low-cost, low-risk intervention that providers should consider for children, especially those at high risk for ALRI. Practitioners should follow current recommendations when prescribing vitamin D supplementation for infants and children.

Frequency, duration and predictors of bronchiolitis episodes of care among infants ≥32 weeks gestation in a large integrated healthcare system: a retrospective cohort study.

BACKGROUND: Bronchiolitis is common in the first two years of life and is the most frequent cause of hospitalization in this age group. No previous studies have used an episode-of-care analysis to describe the frequency, duration, and predictors of bronchiolitis episodes of care during the first two years. METHODS: We conducted a retrospective cohort study of 123,264 infants ≥32 weeks gestation born at 6 Northern California Kaiser Permanente hospitals between 1996 and 2002. We used electronic medical records to concatenate hospital, emergency department and outpatient health care encounters for bronchiolitis into discrete episodes of care. We used descriptive statistics to report frequency and duration of bronchiolitis episodes and used logistic regression to assess the effect of gestational age and other clinical and demographic predictors on the outcome of bronchiolitis episodes. RESULTS: Among all infants, the rate of bronchiolitis episodes was 162 per 1000 children during the first 2 years of life; approximately 40% required >1 day of medical attention with a mean duration of 7.0 ± 5.9 days. Prematurity was associated with increased risk of bronchiolitis episodes and longer duration. Bronchiolitis episodes rates per 1000 infants were 246 for 32-33 weeks gestational age, 204 for 34-36 weeks, and 148-178 for >36 weeks. Male gender, African-American and Hispanic race/ethnicity, and parental history of asthma were associated with an increased risk of having a bronchiolitis episode and/or longer duration. CONCLUSIONS: Bronchiolitis episodes of care are frequent during the first two years of life and the duration ranges from 1 to 27 days. Prematurity was associated with more frequent and longer duration of bronchiolitis episodes of care, which may reflect illness severity and/or perceived vulnerability.

Clinical trial of vitamin A as adjuvant treatment for lower respiratory tract infections.

OBJECTIVE: To test the efficacy of a high dose of vitamin A as adjuvant treatment for radiographically confirmed cases of acute lower respiratory tract infection (ALRI). DESIGN: Randomized, double-masked, placebo-controlled clinical trial. SETTING: Two large urban hospitals in Guatemala City. PATIENTS: Sequential sample of 263 children aged 3 to 48 months, identified in the emergency departments and admitted to the hospital. INTERVENTIONS: Vitamin A (100,000 IU for children less than 1 year of age, and 200,000 IU for older children) or placebo in addition to standard treatment for ALRI which included antibiotics, oxygen, bronchodilators, and intravenously administered solutions. MEASUREMENTS AND MAIN RESULTS: The children were assessed every 8 hours. There were neither statistically nor clinically significant differences by treatment group in the rate of normalization in respiratory rate, oxygen saturation, temperature, or clinical score. Duration of hospitalization was not different by treatment group. Adverse outcomes (mechanical ventilation, prolonged hospitalization, readmission or transfer, and death) were equally distributed between the two groups. CONCLUSIONS: Treatment with high doses of vitamin A over and above standard care for infants and children with non-measles-related ALRI is not efficacious for the current episode. Additional trials among populations in which vitamin A deficiency is more prevalent and severe should be considered.

PIP: During October 1991 to March 1993, in Guatemala, clinical researchers conducted a randomized, double-blind, placebo-controlled clinical trial of 263 pediatric patients aged 3-48 months at the Hospital Roosevelt and the Guatemalteco Social Security Institute Hospital, both in Guatemala City. They aimed to determine the efficacy of a high dose of vitamin A (100,000 IU for children under 1 year of age and 200,000 IU for older children) as adjuvant treatment for radiographically confirmed cases of non-measles-related acute lower respiratory tract infection (ALRI). All the children received standard treatment for ALRI (antibiotics, oxygen, bronchodilators, and intravenously administered solutions). 132 children also received vitamin A and 131 received a placebo. Clinicians evaluated the childrens' condition every 8 hours. The two groups were essentially the same in duration of hospitalization; the rate of normalization in the respiratory rate, oxygen saturation, temperature, and clinical score; and adverse outcomes (mechanical ventilation, prolonged hospitalization, readmission or transfer, and death). These findings indicate that high doses of vitamin A in addition to standard treatment for non-measles-related ALRI lack efficacy for the current ALRI episode.