Association of vitamin D with disease severity in infants with bronchiolitis.

Vitamin D's role in immune system regulation and its contribution to host defenses against respiratory infections may have implications for bronchiolitis pathophysiology. This cross-sectional study aimed to determine the association between the clinical severity of bronchiolitis and serum vitamin D levels in infants. Infants aged 1 month to 12 months, diagnosed with bronchiolitis, and healthy controls attending routine immunization were enrolled. Baseline characteristics were recorded, including clinical details, bronchiolitis severity, and course during hospital stay. Bronchiolitis severity score (BSS) was used to score the severity. A 1-2 ml serum sample was obtained for vitamin D levels estimation. The median age of cases (n = 64; 65.6% male) was 5 [3, 8] months, and that of the control group (n = 30) was 3 [2, 9] months. No statistically significant differences were observed between the two groups in age, gender, weight, mode of delivery, family history of atopy/asthma, feeding pattern, smoke exposure, and daily vitamin D supplementation. The median vitamin D levels were not significantly different between the groups (p = 0.68). Among infants with bronchiolitis, 62.5% had vitamin D insufficiency (≤ 20 ng/ml). A significantly higher median BSS indicates that infants with vitamin D insufficiency exhibited more severe disease (p = 0.019). Although a negative correlation between BSS and vitamin D levels was noted, it did not reach statistical significance [rs = (-)0.17; p = 0.16]. CONCLUSION:  Infants with Vitamin D insufficiency experienced more severe bronchiolitis with elevated BSS scores. It highlights the potential role of vitamin D deficiency in severe bronchiolitis. WHAT IS KNOWN: • Vitamin D level is low in infants with bronchiolitis. WHAT IS NEW: • Infant with low vitamin D level experienced more severe bronchiolitis.

Comparison of Telemedicine versus In-Person Visit for Control of Asthma in Children aged 7-17 years: A Randomized Controlled Trial.

OBJECTIVES: To compare asthma control between telemedicine and in-person visit in children aged 7 to 17 y. METHODS: A non-inferiority randomized-controlled trial was conducted at a pediatric chest clinic, involving a total of 192 patients, with 96 children in each group of telemedicine and in-person follow-up. RESULTS: There was a significant improvement in the mean asthma control test (ACT)/ Childhood asthma control test (C-ACT) scores from baseline to three months in both groups, with no significant difference in the change of means between the two groups. The mean difference in ACT/C-ACT score at three months in the telemedicine and in-person visit group was -0.35; 95% CI (-1.30 to +0.10) [p-value 0.09]. There was a significant change in the mean Pediatric Quality of Life index (PQLI) scores from 57.2 ± 10.2 to 66.82 ± 7.99 in the telemedicine group and from 56.1 ± 11.7 to 66.71 ± 4.66 in the in-person visit group, however the mean difference in PQLI score in both the groups was not significant (p = 0.91). There was no significant difference in the number of asthma exacerbations (4 vs. 1) between telemedicine and in-person visit (p = 0.10). The mean telemedicine satisfaction questionnaire score in this study was 3.8 ± 0.7, which indicates that most of the parents were satisfied with the telemedicine follow-up process. CONCLUSIONS: This study revealed that telemedicine is non-inferior to in-person visit for follow-up of children with asthma and can be used as an alternative to in-person visit for the management of asthma, especially in remote settings and pandemic situations.

Vitamin D and Respiratory Diseases : Based on 11th Dr. I. C. Verma Excellence in Research Award for Young Pediatricians Delivered as Oration on 15th Oct. 2023.

The significance of Vitamin D has been appreciated beyond bone health and calcium metabolism. The importance of Vitamin D in respiratory health has been recognized due to its immunomodulatory and anti-microbial properties. The hypothesis is that Vitamin D could have a significant role in the pathogenesis of respiratory diseases and may represent a novel preventive and therapeutic strategy. Furthermore, enumerable observational studies established the association of Vitamin D deficiency with respiratory diseases such as asthma, bronchiolitis, pneumonia, tuberculosis, etc. However, experimental studies have not shown the encouraging results. This brief review will summarize and discuss the synthesis and metabolism of Vitamin D, the prevalence of Vitamin D deficiency in children, its role in the pathogenesis of various childhood respiratory diseases, and an overview of the therapeutic trials assessing the role of Vitamin D supplementation in childhood respiratory diseases.

Expert group recommendation on inhaled mucoactive drugs in pediatric respiratory diseases: an Indian perspective.

Background: Currently, there are no guidelines or consensus statements about the usage of inhaled mucoactive drugs in pediatric respiratory disease conditions from an Indian perspective. Objective: To develop a practical consensus document to help pediatricians in clinical decision-making when choosing an appropriate mucoactive drug for the management of specific respiratory disease conditions. Methods: A committee of nine experts with significant experience in pediatric respiratory disease conditions and a microbiological expert constituted the panel. An electronic search of the PubMed/MEDLINE, Cochrane Library, Scopus, and Embase databases was undertaken to identify relevant articles. Various combinations of keywords such as inhaled, nebulized, mucoactive, mucolytic, mucokinetic, expectorants, mucoregulators, mucociliary clearance, respiratory disorders, pediatric, cystic fibrosis (CF), non-CF bronchiectasis, acute wheezing, asthma, primary ciliary dyskinesia (PCD), critically ill, mechanical ventilation, tracheomalacia, tracheobronchomalacia, esophageal atresia (EA), tracheoesophageal fistula (TEF), acute bronchiolitis, sputum induction, guideline, and management were used. Twelve questions were drafted for discussion. A roundtable meeting of experts was conducted to arrive at a consensus. The level of evidence and class of recommendation were weighed and graded. Conclusions: Inhaled mucoactive drugs (hypertonic saline, dry powder mannitol, and dornase alfa) can enhance mucociliary clearance in children with CF. Experts opined that hypertonic saline could be beneficial in non-CF bronchiectasis, acute bronchiolitis, and PCD. The current state of evidence is inadequate to support the use of inhaled mucoactive drugs in asthma, acute wheezing, tracheomalacia, tracheobronchomalacia, and EA with TEF.

Utility of systemic immune-inflammation Index as a serum biomarker to differentiate between complicated and simple para-pneumonic effusion.

The systemic immune-inflammation index (SII) is a novel inflammatory biomarker. Simple and complicated para-pneumonic effusion (PPE) are two significant complications of pneumonia. We evaluated the efficacy of the systemic immune inflammation index (SII) to differentiate between the two. Records of all children up to 18 years of age admitted between April 2019 and September 2022 and diagnosed with Simple or complicated PPE were retrospectively evaluated. SII and other biomarkers were compared between both groups. ROC with the Youden index was used to estimate the discriminative value of SII. Fifty children were enrolled with a median (IQR) age of 81.5 (36.7, 133.5) months; 31 (62%) were male. Thirty-one (62%) had complicated PPE, and 19 (38%) had simple PPE. SII was significantly higher in complicated PPE (p=0.007). Good areas under the curve (AUCs) were found for CRP (0.771) and SII (0.736) to differentiate complicated from simple PPE. The best cut-off value for SII to differentiate complicated PPE from simple PPE was 1557×103µL, with a sensitivity of 82.4% and specificity of 57.6%. SII can be used as a screening tool to differentiate between complicated and simple PPE at the time of presentation.

Effect of Long-term Inhaled Corticosteroids on the Hypothalamic-Pituitary-Adrenal Axis in Children with Asthma.

OBJECTIVES: To assess the effect of the long-term use of inhaled corticosteroids (ICS) on the hypothalamic-pituitary-adrenal (HPA) axis. METHODS: Children (5-18 y) diagnosed with asthma and on ICS therapy for ≥6 mo were included. In the first step, screening with fasting at 8 AM, cortisol level was measured; a value <15 mcg/dl was considered low. Children with low fasting cortisol levels were subjected to adreno-corticotropic hormone (ACTH) stimulation test in the second step. Post-ACTH stimulation, cortisol level <18 mcg/dl was considered to have HPA axis suppression. RESULTS: A total of 78 children (males 55, 70.5%) diagnosed with asthma, with a median age of 11.5 (8, 14) y, were enrolled. The median duration of ICS use was 12 (12-24) mo. The median value of post-ACTH stimulation cortisol level was 22.5 (20.6, 25.5) mcg/dl, and a value <18 mcg/dl was observed in 4 (5.1%; 95% CI 0.2-10%) children. There was statistically no significant correlation between low post-ACTH stimulation cortisol level with ICS dose (p = 0.23) and asthma control (p = 0.67). None of the children had clinical features of adrenal insufficiency. CONCLUSIONS: In this study, a few children had low post-ACTH stimulation cortisol values; however, none had clinical evidence of HPA axis suppression. Therefore, ICS is a safe drug in children for treating asthma, even for long-term use.

Relationship of Serum Periostin With Asthma Control in Children: Single Center Experience.

OBJECTIVE: To determine the association between serum periostin levels and asthma control in children. METHODS: Children aged 6-17 years with physician-diagnosed asthma were enrolled in the study. Age-matched (±2 years) control children, who visited our outpatient department with non-respiratory complaints, were also enrolled. RESULTS: A total of 90 children (60 with asthma and 30 control subjects) with a mean (SD) age of 12.1 (2.77) years were enrolled. Children with asthma had significantly higher median (IQR) periostin levels than the controls [23.5 (22,26) vs 22 (19.4, 22.96); P= 0.04]. On multivariable logistic regression analysis, serum periostin levels were associated with poor asthma control in children [OR (95% CI), 1.12 (1.01-1.24); P= 0.02]. Age, body mass index, IgE levels, eosinophil count, forced expiratory volume in first minute (FEV1) and presence of allergic rhinitis did not have any association with asthma control. CONCLUSION: Asthmatic children have a high serum periostin level, and its higher levels are associated with poor asthma control.

Clinical Profile, Follow-up, and Role of Neuroimaging in Pediatric Guillain-Barré Syndrome in the COVID Era: An Ambispective Study.

Background: To define the varied presentations of Guillain-Barré syndrome in children in the COVID era and 6 months' follow-up outcome. Methods: Ambispective study of 15 months' duration involving children with Guillain-Barré syndrome aged 1 month to 18 years at a tertiary care pediatric hospital. They were categorized into groups A and B based on COVID-19 serology testing. Hughes Disability Scale was used for disability assessment. Modified Rankin scale was used for improvement assessment in follow-up. Results: Of 19 children with Guillain-Barré syndrome, 9 (47%) were females and 10 (53%) were males. Groups A and B had children with negative (8) and positive serology (11), respectively. The most common presentation in both groups was motor weakness. Post-COVID pediatric Guillain-Barré syndrome presented with variants of Guillain-Barré syndrome rather than the classical form (P = .03). In group B, patients with elevated inflammatory markers had poor response to intravenous immunoglobulin, and 5 of 11 patients had good response to pulse steroids, probably depicting an inflammation-predominant pathology. Conclusion: Post-COVID Guillain-Barré syndrome in children presented with Guillain-Barré syndrome variants rather than the classic form. Neuroimaging is of great value in both confirming Guillain-Barré syndrome diagnosis and excluding differentials. Patients with elevated inflammatory markers and residual weakness may be given a pulse steroid trial.

Evaluation of Chronic Cough in Children Using Management Algorithm: A Prospective Cohort Study.

OBJECTIVE: To assess the use of a standardized evaluation algorithm [American College of Chest Physician (ACCP) 2006] in children with chronic cough. METHODS: In this prospective cohort study, children with chronic cough were evaluated as per the ACCP 2006 diagnostic algorithm. All children were followed regularly at an interval of 2-4 wk. The study's endpoint was for the patient being cough free for four weeks either following treatment or naturally. RESULTS: The mean age of the 87 studied children (52 male, 35 female) was 11.9±3 y. Forty children (45.9%) had specific cough pointers on history and examination. Radiograph showed abnormalities in 12 (13.8%) children, and spirometry showed a reversible obstructive pattern on spirometry in 6 (6.9%) among 47 (54%) children without specific cough pointers. After a detailed evaluation, 16 (18.3%) children had no remarkable findings and were reviewed after two weeks. Spontaneous resolution of cough occurred in 6 children. A trial of inhalational corticosteroids (ICS) (9 children) or antibiotics (1 child) was given to the rest of the ten children. Specific underlying diagnoses could be established in 80 (91.9%) children. The most common etiology identified in the study was asthma and asthma-like illnesses (n = 52; 59.8%), followed by upper airway cough syndrome (n = 13; 14.9%) and tuberculosis (n = 9; 10.4%). Eighty-four (96.5%) children had complete resolution of cough during follow-up. The mean time to resolution in the study was 33.6±16.8 d. CONCLUSIONS: This study demonstrated that the ACCP 2006 algorithm is effective in establishing the underlying etiology and managing children with chronic cough.

Cryptosporidiosis in Yellow Nail Syndrome - A Rare Case Report.

BACKGROUND: Cryptosporidium species infection causes malabsorption and severe diarrhea in immunocompromised hosts. Association of Yellow Nail Syndrome (YNS) and Cryptosporidiosis is rare and has not been reported till date. Immunity can also be affected in this case of YNS is associated with autoimmune disorders. CASE PRESENTATION: Here, we describe a case of persistent diarrhea in an 8 month old YNS patient. Modified Ziehl-Neelsen staining and Saffranine-Methylene blue revealed oocyts of Cryptosporidium species. Following appropriate treatment, the patient's symptoms improved and the patient was discharged in a hemodynamically stable condition. DISCUSSION: Cryptosporidiosis is a significant cause of morbidity and mortality in immunocompromised patients. YNS per se as well as treatment including steroids leads to immunosuppression in individuals making them susceptible host for opportunistic infections like Cryptosporidiosis. CONCLUSION: Clinicians should be aware of the condition and screen for Cryptosporidiosis in any immunocompromised patients with diarrheal symptoms, as parasitic infection like this are opportunistic in them.

Relationship of Peripheral Blood Counts with Asthma Control.

OBJECTIVE: To determine the association between blood eosinophil and neutrophil counts with asthma control. METHODS: This retrospective study, conducted in tertiary care hospital of western India, evaluated the hospital electronic medical record (HEMR) of children aged 5 to 18 y who were diagnosed with asthma as per the Global Initiative for Asthma (GINA) guidelines in the pediatric chest clinic (PCC). Eosinophil and neutrophil counts were recorded from HEMR and asthma control was determined as per the GINA guidelines on follow-up. RESULTS: A total of 742 children attended the PCC in the last 2 y from March 2017 to February 2019; out of which, blood eosinophil and neutrophil counts were done in 116 children with asthma. The median eosinophil and neutrophil count were 0.46 (0.13, 0.78) × 109/L and 5.08 (3.50, 7.53) × 109/L cells, respectively. Eosinophil count was significantly higher in children with well-controlled asthma as compared to partly/uncontrolled asthma [median eosinophil count 0.46 (0.13, 0.78) vs. 0.40 (0.1, 0.66) × 109/L; p = 0.04]; while the neutrophil count was significantly higher in children with partly/uncontrolled asthma as compared to well-controlled asthma [median neutrophil 6.54 (4.32, 7.92) vs. 4.85 (2.96, 6.86) × 109/L; p = 0.04]. CONCLUSIONS: High lung function is associated with good asthma control. Although not independently associated, the high absolute eosinophil counts (AEC) is associated with better asthma control, while high absolute neutrophil counts (ANC) is associated with poor asthma control.

Post-COVID-19 Immune-Mediated Neurological Complications in Children: An Ambispective Study.

BACKGROUND: The neurological manifestation following a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is varied, and till now, only a few studies have reported the same. METHODS: We used retrospective data from May to July 2021 and prospective study data from August to September 2021, including that from children aged between one month and 18 years who presented to a tertiary care referral center with the neurological manifestation and had a history of coronavirus disease 2019 (COVID-19) infection or exposure and positive SARS-CoV-2 serology. The neuroradiological manifestations were further categorized as in a predesigned proforma. RESULTS: Case records of the 18 children who fulfilled the criteria were included in the study; among them, seven (38.8%) were male and 11 (61.1%) were female. Predominant presentation in our study group was status epilepticus (six of 18) and Guillain-Barré syndrome (five of 18). Other manifestations included stroke (two of 18), demyelinating syndromes (three of 18), and autoimmune encephalitis (two of 18). Most of the children had favorable outcomes except for one mortality in our cohort. CONCLUSIONS: Delayed complications following SARS-CoV-2 infection are seen in children. A temporal correlation was noted between the COVID-19 infection and the increasing number of neurological cases after the second wave. Steroids could be beneficial while treating such patients, especially in the presence of high inflammatory markers. Testing for SARS-CoV-2 serology during the pandemic can give a clue to the underlying etiology. Further multicentric studies are required to understand the varied neurological manifestations following SARS-CoV-2 infection in children.