Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline.

Background: Premature birth affects millions of neonates each year, placing them at risk for respiratory disease due to prematurity. Bronchopulmonary dysplasia is the most common chronic lung disease of infancy, but recent data suggest that even premature infants who do not meet the strict definition of bronchopulmonary dysplasia can develop adverse pulmonary outcomes later in life. This post-prematurity respiratory disease (PPRD) manifests as chronic respiratory symptoms, including cough, recurrent wheezing, exercise limitation, and reduced pulmonary function. This document provides an evidence-based clinical practice guideline on the outpatient management of infants, children, and adolescents with PPRD. Methods: A multidisciplinary panel of experts posed questions regarding the outpatient management of PPRD. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. Results: The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Recommendations were developed for or against three common medical therapies and four diagnostic evaluations in the context of the outpatient management of PPRD. Conclusions: The panel developed recommendations for the outpatient management of patients with PPRD on the basis of limited evidence and expert opinion. Important areas for future research were identified.

Tobacco smoke exposure and fractional exhaled nitric oxide levels among U.S. adolescents.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) can objectively guide clinical practice in the assessment, diagnosis, and treatment of eosinophilic airway inflammation. FeNO values may be affected by current smoking, but the role of tobacco smoke exposure (TSE) is understudied. OBJECTIVE: This study investigated the associations between biochemically validated and self-reported TSE and FeNO levels among U.S. nonsmoking adolescents without asthma. METHODS: National Health and Nutrition Examination Survey 2007-2012 data were used. TSE was assessed via serum cotinine and self-reported measures. We assessed FeNO continuously and using cutpoints of >35 ppb and >50 ppb to indicate likely eosinophilic inflammation in children and adults, respectively. We conducted linear and logistic regression adjusting for potential covariates. RESULTS: Overall, 34.0% of adolescents had low cotinine (0.05-2.99 ng/ml), 6.2% had high cotinine (≥3.00 ng/ml), and 11.9% had home TSE. Compared to adolescents with no/minimal cotinine, adolescents with high cotinine were at reduced odds to have FeNO >35 ppb (adjusted odds ratio [aOR] = 0.54, 95%CI = 0.43,0.69). Adolescents with low cotinine had lower FeNO values (ß = -2.05, 95%CI = -3.61,-0.49), and were also at decreased odds to have FeNO >35 ppb (aOR = 0.74, 95%CI = 0.66,0.83) and FeNO >50 ppb (aOR = 0.62, 95%CI = 0.53,0.72). Adolescents with home TSE were at reduced odds to have FeNO >50 ppb (aOR = 0.72, 95%CI = 0.57,0.91) than adolescents without home TSE. Adolescents with a higher number of cigarettes/day smoked inside their home were at reduced odds to have FeNO >35 ppb (OR = 0.98, 95%CI = 0.97,0.99) and FeNO >50 ppb (OR = 0.98, 95%CI = 0.96,0.99). CONCLUSIONS: TSE was associated with decreased FeNO levels. The addition of TSE may be clinically important when interpreting thresholds for FeNO.

Home Oxygen Therapy for Children. An Official American Thoracic Society Clinical Practice Guideline.

BACKGROUND: Home oxygen therapy is often required in children with chronic respiratory conditions. This document provides an evidence-based clinical practice guideline on the implementation, monitoring, and discontinuation of home oxygen therapy for the pediatric population. METHODS: A multidisciplinary panel identified pertinent questions regarding home oxygen therapy in children, conducted systematic reviews of the relevant literature, and applied the Grading of Recommendations, Assessment, Development, and Evaluation approach to rate the quality of evidence and strength of clinical recommendations. RESULTS: After considering the panel's confidence in the estimated effects, the balance of desirable (benefits) and undesirable (harms and burdens) consequences of treatment, patient values and preferences, cost, and feasibility, recommendations were developed for or against home oxygen therapy specific to pediatric lung and pulmonary vascular diseases. CONCLUSIONS: Although home oxygen therapy is commonly required in the care of children, there is a striking lack of empirical evidence regarding implementation, monitoring, and discontinuation of supplemental oxygen therapy. The panel formulated and provided the rationale for clinical recommendations for home oxygen therapy based on scant empirical evidence, expert opinion, and clinical experience to aid clinicians in the management of these complex pediatric patients and identified important areas for future research.

When reach exceeds touch: Student experiences in a cross-sector community-based academic-practice partnership.

OBJECTIVE: A partnership between three nursing programs, multiple high-needs public school districts and a local asthma coalition was developed as a way to build shared capacity aimed at improving health outcomes for children with asthma. This article explores student perceptions of their clinical experiences teaching asthma self-management within a regional cross-sector, community-based, multi-site academic-practice partnership. DESIGN: Nursing faculty from three Long Island, New York-based nursing programs within the partnership jointly created a qualitative focus group methodology to more fully understand the phenomena of interest. A set of open-ended interview questions guided the sessions. SAMPLE: Through purposive sampling, 42 undergraduate nursing students participated in 60-min focus group sessions. MEASUREMENT: Focus group data were transcribed. Content analysis, coding, and theme development was carried out collaboratively. The unit of analysis was the individual participant responses informed by group interaction. A researcher diary was maintained. RESULTS: One overarching theme and three sub-themes emerged from the data, reflecting student understandings in the areas of positioning, professional/personal identity, and social awareness. Ongoing analysis revealed patterns across the data sets linking student learning and the goals, milieu and workings of the partnership. CONCLUSIONS: Findings suggest that the context of a thriving community-based academic-practice partnership, established to improve population health outcomes, offered unique clinical learning opportunities for students through exposure to the values, ideas, and innovation of the partnership itself.

Climate Change and Children's Health: Building a Healthy Future for Every Child.

Observed changes in temperature, precipitation patterns, sea level, and extreme weather are destabilizing major determinants of human health. Children are at higher risk of climate-related health burdens than adults because of their unique behavior patterns; developing organ systems and physiology; greater exposure to air, food, and water contaminants per unit of body weight; and dependence on caregivers. Climate change harms children through numerous pathways, including air pollution, heat exposure, floods and hurricanes, food insecurity and nutrition, changing epidemiology of infections, and mental health harms. As the planet continues to warm, climate change's impacts will worsen, threatening to define the health and welfare of children at every stage of their lives. Children who already bear higher burden of disease because of living in low-wealth households and communities, lack of access to high quality education, and experiencing racism and other forms of unjust discrimination bear greater risk of suffering from climate change hazards. Climate change solutions, advanced through collaborative work of pediatricians, health systems, communities, corporations, and governments lead to immediate gains in child health and equity and build a foundation for generations of children to thrive. This technical report reviews the nature of climate change and its associated child health effects and supports the recommendations in the accompanying policy statement on climate change and children's health.

Climate Change and Children's Health: Building a Healthy Future for Every Child.

The warming of our planet matters to every child. Driven by fossil fuel-generated greenhouse gas emissions, climate conditions stable since the founding of modern pediatrics in the mid-nineteenth century have shifted, and old certainties are falling away. Children's physical and mental health are threatened by climate change through its effects on temperature, precipitation, and extreme weather; ecological disruption; and community disruption. These impacts expose and amplify existing inequities and create unprecedented intergenerational injustice. Fossil fuel extraction and combustion cause harm today and reach centuries into the future, jeopardizing the health, safety, and prosperity of today's children and future generations. Appreciating the unique vulnerability of their patients, pediatricians have become leading health advocates for climate actions necessary to protect all living and future children. Policies that reduce reliance on fossil fuels and promote cleaner air, facilitate walking and bicycling, encourage more sustainable diets, increase access to nature, and develop more connected communities lead to immediate gains in child health and equity, and build a foundation for generations of children to thrive.

Care recommendations for the respiratory complications of esophageal atresia-tracheoesophageal fistula.

Tracheoesophageal fistula (TEF) with esophageal atresia (EA) is a common congenital anomaly that is associated with significant respiratory morbidity throughout life. The objective of this document is to provide a framework for the diagnosis and management of the respiratory complications that are associated with the condition. As there are no randomized controlled studies on the subject, a group of experts used a modification of the Rand Appropriateness Method to describe the various aspects of the condition in terms of their relative importance, and to rate the available diagnostic methods and therapeutic interventions on the basis of their appropriateness and necessity. Specific recommendations were formulated and reported as Level A, B, and C based on whether they were based on "strong", "moderate" or "weak" agreement. The tracheomalacia that exists in the site of the fistula was considered the main abnormality that predisposes to all other respiratory complications due to airway collapse and impaired clearance of secretions. Aspiration due to impaired airway protection reflexes is the main underlying contributing mechanism. Flexible bronchoscopy is the main diagnostic modality, aided by imaging modalities, especially CT scans of the chest. Noninvasive positive airway pressure support, surgical techniques such as tracheopexy and rarely tracheostomy are required for the management of severe tracheomalacia. Regular long-term follow-up by a multidisciplinary team was considered imperative. Specific templates outlining the elements of the clinical respiratory evaluation according to the patients' age were also developed.

US pediatric pulmonology workforce.

AIM: Children with respiratory conditions benefit from care provided by pediatric pulmonologists. As these physicians are a small portion of the overall pediatric workforce, it is necessary to understand the practices and career plans of these specialists. METHODS: An internet survey was developed by the American Academy of Pediatrics Division of Workforce and Medical Education Policy and sent to members of the American Academy of Pediatrics and American College of Chest Physicians who identified as pediatric pulmonary physicians. RESULTS: Responses were received from 485 physicians and were compared to the results of a similar survey done in 1997. Of those completing the survey, 63% were male and 37% female, with increased number of females since the earlier poll. The average calculated age was 56 years. They worked 54 h per week, down from 59 h in the prior survey. Pediatric pulmonologists are overwhelmingly clinicians (92%) with major responsibilities for administration (79%), teaching (78%), and research. Basic science research was rarely reported (7%). Pediatric pulmonologists felt that referrals had become more complicated in the recent past. Nearly all planned to maintain Pediatric Pulmonology Sub-board certification, though one third planned to cut back on clinical workload in the next decade. Many were concerned that the number needed in the profession in a decade would be inadequate with significant concerns about funding for those positions. CONCLUSION: Overall, these results reflect the current state of the workforce and the need to monitor the supply of practitioners in the future.

Community health screenings can complement public health outreach to minority immigrant communities.

OBJECTIVES: We sought to provide culturally competent, community-based respiratory health screening and education in minority communities with high concentrations of Latino immigrants on Long Island and to assess the impact of this intervention on their decision to seek medical care. METHODS: Seven health care screenings were performed in communities with high concentrations of immigrants from Latin America. A subgroup of participants who identified themselves as Hispanic/Latino were analyzed. After completion of a respiratory health questionnaire and spirometry, screening scores were calculated, education provided, and recommendations were made for medical evaluation in those who screened positive. A positive screen was defined as abnormal respiratory symptoms, abnormal spirometry, or both. Follow-up contacts were made at 1, 6, and 12 months to assess compliance with the recommendation to seek care in those who screened positive. RESULTS: High positive screening rates for both men (64%) and women (61%) were found. Of the participants who screened positive and were advised to seek medical care, 52% did so. Compliance with the recommendation to seek care was associated with the presence of an identified medical provider at baseline. Of those who screened positive and who did not comply with team's recommendation, 75% were unable to identify a health care provider. CONCLUSIONS: A significant number of participants who screened positive could not identify a health care provider and did not follow-up with the recommendation to seek medical evaluation. Community-based screenings provide an opportunity to access at-risk immigrant populations for health screening and education, and to facilitate referral and access to medical services.

Determining the Relative Burden of Childhood Asthma at the Local Level by Surveying School Nurses.

Schools are effective venues for providing pediatric asthma education programs. Resources are limited, however, so ideally, these programs should be provided to schools with the highest prevalence. National and state asthma surveillance data cannot be extrapolated to local geographic areas. The objective of this study was to survey local schools on Long Island to obtain this information. Survey forms were mailed to the school nurses at every school in Nassau and Suffolk Counties, New York, in 2004, 2006, 2008, and 2010 asking for the number of children with asthma and the number who had permission to access rescue medication in the school. School nurses completed and returned the forms. We analyzed data from elementary and high schools separately, as high-school students often carry their medications with them without obtaining permission. Of the 3,327 surveys sent, 2,060 (61.9%) were returned and 1,807 (54.3%) could be included in the analyses. Overall, asthma prevalence increased from 7.6% in 2004 to 8.7% in 2010. This mirrored the New York State and national trends, although the rates we found were generally lower. The rate of asthmatic children with permission to access rescue medication in school was about the same throughout the study period (39.7% in 2004 and only 42.3% in 2010). Both rates were lower in elementary schools in low socioeconomic areas. These methods allowed us to compare the burden of childhood asthma in individual responder schools in a relatively large geographic area.

Unusual presentation of a cutaneous bronchogenic cyst in an asymptomatic neonate.

Cutaneous presentations of bronchogenic cysts are rare in all age groups. Previous reports of cutaneous manifestations of bronchogenic cysts have been described as nodular, adherent masses, most frequently with a suprasternal location. We report a unique presentation of an infant with a pedunculated, anterior chest wall mass, which was identified as a bronchogenic cyst.