The role of high carbohydrate-rich food intake and severity of asthma exacerbation in children between 2 to 6 years aged.

INTRODUCTION: Over the last decades, dietary habits in developing countries have been characterized by low intake of fruits and vegetables and high consumption of sweetened drinks. Most of the evidence linking carbohydrate intake and asthma comes from children over 6 years of age. The aim of this study was to examine the association between macronutrient intake and the severity of asthma exacerbations in children aged 2-6 years. METHODS: We performed a cross-sectional study that included all children aged 2-6 years hospitalized due to an asthma exacerbation. Dietary data were collected using a food frequency questionnaire (FFQ) validated in the Colombian population. The GINA classification of acute asthma was used to define the severity. To identify factors independently associated with asthma exacerbation severity, we fit the data to ordinal logistic regression. RESULTS: During the study period, 228 cases of patients with asthma exacerbation were included. Asthma severity was dose-dependently associated with protein and carbohydrate-rich intake. The variables included in the multivariable analysis included reactive C protein (OR 1.05, CI 95% (1.03-1.07)), smoking at home (OR 3.92 (1.82-8.44)), atopic dermatitis (OR 3.82 (1.59-9.21)), and protein and carbohydrate-rich food intake (OR 0.11 (0.03-0.33)) and (OR 2.42 (1.09-5.80)), respectively. CONCLUSION: High carbohydrate-rich food intake is associated with the severity of asthma exacerbation adjusted by other known risk factors such as atopy, smoking, and reactive C protein. This evidence should motivate the development of public health policies to control the consumption of sugar-rich products in children under 6 years.

Cost utility of fractional exhaled nitric oxide monitoring for the management of children asthma.

INTRODUCTION: Fractional exhaled nitric oxide is a simple, non-invasive measurement of airway inflammation with minimal discomfort to the patient and with results available within a few minutes. This study aimed to evaluate the cost-effectiveness of asthma management using fractional exhaled nitric oxide monitoring in patients between 4 and 18 years of age. METHODS: A Markov model was used to estimate the cost-utility of asthma management using fractional exhaled nitric oxide monitoring versus asthma management without using fractional exhaled nitric oxide monitoring (standard therapy) in patients between 4 and 18 years of age. Cost data were obtained from a retrospective study on asthma from a tertiary center, in Medellin, Colombia, while probabilities of the Markov model and utilities were obtained from the systematic review of published randomized clinical trials. The analysis was carried out from a societal perspective. RESULTS: The model showed that fractional exhaled nitric oxide monitoring was associated with a lower total cost than standard therapy (US $1333 vs. US $1452 average cost per patient) and higher QALYs (0.93 vs. 0.92 average per patient). The probability that fractional exhaled nitric oxide monitoring provides a more cost-effective use of resources compared with standard therapy exceeds 99% for all willingness-to-pay thresholds. CONCLUSION: Asthma management using fractional exhaled nitric oxide monitoring was cost-effective for treating patients between 4 and 18 years of age with mild to moderate allergic asthma. Our study suggests evidence that could be used by decision-makers to improve clinical practice guidelines, but this should be replicated in different clinical settings.

For which infants with viral bronchiolitis could it be deemed appropriate to use albuterol, at least on a therapeutic trial basis?

Although there is increasing evidence showing that infants with viral bronchiolitis exhibit a high degree of heterogeneity, a core uncertainty shared by many clinicians is with regard to understanding which patients are most likely to benefit from bronchodilators such as albuterol. Based on our review, we concluded that older infants with rhinovirus (RV) bronchiolitis, especially those with a nasopharyngeal microbiome dominated by Haemophilus influenzae; those affected during nonpeak months or during non-respiratory syncytial virus (RSV) predominant months; those with wheezing at presentation; those with clinical characteristics such as atopic dermatitis or a family history of asthma in a first-degree relative; and those infants infected with RSV genotypes ON1 and BA, have the greatest likelihood of benefiting from albuterol. Presently, this patient profile could serve as the basis for rational albuterol administration in patients with viral bronchiolitis, at least on a therapeutic trial basis, and it could also be the starting point for future targeted randomized clinical trials (RCTs) on the use of albuterol among a subset of infants with bronchiolitis.

The cost-effectiveness of hypertonic saline inhalations for infant bronchiolitis.

BACKGROUND: Pharmacological treatment for bronchiolitis is primarily supportive because bronchodilators, steroids, and antibiotics, show little benefit. Clinical studies have suggested that nebulized 3% hypertonic solution is useful for infants with bronchiolitis. This study aims to evaluate the cost-effectiveness of the HS inhalations in infant bronchiolitis in a tropical country. METHODS: Decision tree analysis was used to calculate the expected costs and QALYs. All cost and use of resources were collected directly from medical invoices of 193 patient hospitalized with diagnosis of bronchiolitis in tertiary centers, of Rionegro, Colombia. The utility values applied to QALYs calculations were collected from the literature. The economic analysis was carried out from a societal perspective. RESULTS: The model showed that nebulized 3% hypertonic solution, was associated with lower total cost than controls (US $200vs US $240 average cost per patient), and higher QALYs (0.92 vs 0.91 average per patient); showing dominance. A position of dominance negates the need to calculate an incremental cost-effectiveness ratio. CONCLUSION: The nebulized 3% hypertonic solution was cost-effective in the inpatient treatment of infant bronchiolitis. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other tropical countries.

Predictors of prolonged length of hospital stay or readmissions for acute viral lower respiratory tract infections among infants with a history of bronchopulmonary dysplasia.

Length of hospital stay and readmissions are outcome measures that have been largely overlooked in many studies that have evaluated the clinical evolution of pediatric patients with bronchopulmonary dysplasia (BPD). The aim of the present study was to identify predictors of prolonged hospitalizations or readmissions for acute lower respiratory infections (ALRIs) in infants with BPD. In a prospective cohort study, we determined independent predictors of prolonged hospitalizations or readmissions for ALRIs during the first 2 years of life in a population of infants with BPD living in Bogota, Colombia. Of a total of 138 patients included in the study, 83 (60.1%) had at least one hospitalization for ALRI during the follow-up period. After controlling for potential confounders, we found that independent predictors of prolonged hospitalizations or readmissions for ALRIs included male gender (OR = 3.09; CI 95% 1.27-7.52; P = 0.013), ambulatory oxygen therapy between 90 and 119 days (OR = 3.21; CI 95% 1.00-10.24; P = 0.049), ambulatory oxygen therapy equal to or greater than 120 days (OR = 5.73; CI 95% 2.01-16.32; P = 0.001), gestational age at birth (OR = 1.35; CI 95% 1.03-1.76; P = 0.026), birth weight (OR = 0.997; CI 95% 0.996-0.999; P = 0.010), and duration of breastfeeding equal to or greater than 6 months (OR = 0.39; CI 95% 0.16-0.96; P = 0.039). The factors identified can be taken into account when planning policies to reduce duration of hospital stay and readmissions in infants with BPD.

Predictors of severe disease in a hospitalized population of children with acute viral lower respiratory tract infections.

Although predictors of severe viral acute lower respiratory infections (ALRIs) in children have been reported, there have been few research studies performed in low- and middle-income countries (LMIC). The aim of the present study was to determine predictors of disease severity in a population of Colombian children <5 years of age with ALRI. In a prospective cohort study, we determined independent predictors of severe ALRI in a hospitalized population of children under 5 years old with ALRI during a 1-year period. We included both underlying disease conditions and the infecting respiratory viruses as predictor variables of severe disease. We defined severe disease as the necessity of pediatric intensive care unit admission. Of a total of 1,180 patients admitted with a diagnosis of ALRI, 416 (35.3%) were included because they were positive for any kind of respiratory virus. After controlling for potential confounders, it was found that a history of pulmonary hypertension (RR 3.62; CI 95% 2.38-5.52; P < 0.001) and a history of recurrent wheezing (RR 1.77; CI 95% 1.12-2.79; P = 0.015) were independent predictors of severe disease. The present study shows that respiratory viruses are significant causes of ALRI in infants and young children in Colombia, a typical tropical LMIC, especially during the rainy season. Additionally, the results of the present study show that clinical variables such as a history of pulmonary hypertension and a history of recurrent wheezing are more relevant for predicting ALRI severity than the infecting respiratory viruses.

Exploratory analysis of the economically justifiable price of nirsevimab for healthy late-preterm and term infants in Colombia.

INTRODUCTION: Respiratory syncytial virus infection is the leading cause of lower respiratory infection globally. Recently, nirsevimab has been approved to prevent respiratory syncytial virus (RSV) infection. This study explores the economically justifiable price of nirsevimab for preventing RSV infection in Colombia's children under 1 year of age. MATERIALS AND METHODS: A static model was developed using the decision tree microsimulation to estimate the quality-adjusted costs and life years of two interventions: a single intramuscular dose of nirsevimab versus not applying nirsevimab. This analysis was made during a time horizon of 1 year and from a societal perspective. RESULTS: The annual savings in Colombia associated with this cost per dose ranged from U$ 2.5 to 4.1 million. Based on thresholds of U$ 4828, U$ 5128, and U$ 19 992 per QALY evaluated in this study, we established economically justifiable drug acquisition prices of U$ 21.88, U$ 25.04, and U$ 44.02 per dose of nirsevimab. CONCLUSION: the economically justifiable cost for nirsevimab in Colombia is between U$ 21 to U$ 44 per dose, depending on the willingness to pay used to decide its implementation. This result should encourage more studies in the region that optimize decision-making processes when incorporating this drug into the health plans of each country.

Association between fractional exhaled nitric oxide and therapeutic adherence to controller management in pediatric asthma patients.

OBJECTIVES: Guidelines for asthma management recommend, before establishing additional therapeutic behaviors, to confirm correct use and adequate therapeutic adherence to treatment. Evidence exists on the use of fractional exhaled nitric oxide (FeNO) values for monitoring therapeutic adherence in adults. It is important to establish whether there is a correlation between FeNO and therapeutic adherence in children. This study aims to provide new knowledge about the relationship between FeNO and therapeutic adherence in asthmatic children. MATERIALS AND METHODS: Analytical cross-sectional study including asthma patients 5-18 years of age, attending follow-up at Hospital Militar Central (HMC) between May and November 2022 in Colombia. A sociodemographic survey was carried out, followed by the Pediatric Inhaler Adherence Questionnaire (PIAQ), and asthma control test (ACT) or childhood asthma control test (cACT). We defined adequate therapeutic adherence as not missing a single application of inhaled steroids in the last 15 days according to PIAQ. A poisson regression model was carried out including relevant predictors for therapeutic adherence such as FeNO values, age, tobacco exposure at home, atopy, and time since initiation of use of inhaled controller. RESULTS: Eighty-two children with a median age of 10 years (interquartile range: 7-12 years) were included. Adequate therapeutic adherence was reported by 68.3%. After adjusting for age, sex, exposure to cigarette smoke, duration of controller therapy, and atopy, FeNO < 20 ppb was independently associated with adequate therapeutic adherence (RR = 1.5, p = .04, 95% confidence interval: 1.03-2.19). CONCLUSIONS: FeNO values seem to be useful to identify pediatric patients with asthma who have adequate adherence to inhaled steroids in a MIC.

Predictors of poor outcomes of respiratory syncytial virus acute lower respiratory infections in children under 5 years of age in a middle-income tropical country based on the National Public Health Surveillance System.

OBJECTIVES: The aim of the present study is to gain insight into the identification of region-specific factors associated with poor outcomes in children under 5 years of age with confirmed respiratory syncytial virus acute lower respiratory infection (RSV-ALRI) living in Colombia, a middle-income country, based on the National Public Health Surveillance System of the country. METHODS: An analytical cross-sectional study was conducted using epidemiological data from the records of morbidity and mortality of respiratory infections as registered in the surveillance system report of the National Institute of Health of Colombia 2018, including children under 5 years of age with confirmed RSV-ALRI. Predictor variables included demographic and clinical variables, as well as variables measured after hospital attendance. Outcome variables analyzed were respiratory failure, the need for pediatric intensive care unit admission, and mortality. RESULTS: Of a total of 8470 patients with a diagnosis of ALRI, we selected 1215 (14.3%) that were under 5 years of age and were positive for RSV. After controlling for potential confounders, it was found that age, gender, socioeconomic stratum, incomplete pneumococcal conjugate vaccine 13 immunization for age, cardiac disease, and malnutrition as comorbidities, chest X-ray findings, and development of sepsis independently predicted poor outcomes among the patients analyzed. CONCLUSIONS: The identified predictors for poor outcomes in RSV-affected children may be helpful for guiding efficient and targeted national and/or regional programs and public policies to assist in achieving Goal 3 of the Sustainable Development Goals adopted by the United Nations in 2015.

Budget impact analysis of high-flow nasal cannula for infant bronchiolitis: the Colombian National Health System perspective.

BACKGROUND: High-flow nasal cannula is a non-invasive ventilation system that was introduced as an alternative to continuous positive airway pressure), with a marked increase in its use in pediatric care settings. However, the expected budget impact of this intervention has not been explicitly estimated. This study aimed to evaluate the budget impact of the high-flow nasal cannula for acute bronchiolitis in Colombia. METHODS: A budget impact analysis was performed to evaluate the potential financial impact deriving from high-flow nasal cannula during 2020. The analysis considered a 5-year time horizon and Colombian National Health System perspective. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which a high-flow nasal cannula is reimbursed, from the cost of the conventional treatment without a high-flow nasal cannula (supplemental oxygen through a nasal cannula up to a maximum of 2 liters per minute). Univariate one-way sensitivity analyses were performed. RESULTS: In the base-case analysis the 5-year costs associated with high-flow nasal cannula and no- high-flow nasal cannula were estimated to be US$159,585,618 and US$172,751,689 respectively, indicating savings for Colombian National Health equal to US$13,166,071 if the high-flow nasal cannula is adopted for the routine management of patients with acute bronchiolitis. This result was robust in univariate sensitivity one-way analysis. CONCLUSION: High-flow nasal cannula was cost-saving in emergency settings for treating infants with acute bronchiolitis. This evidence can be used by decision-makers in our country to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.

The cost-utility of early use of high-flow nasal cannula in bronchiolitis.

BACKGROUND: High-flow nasal cannula (HFNC) oxygen is a non-invasive ventilation system that was introduced as an alternative to CPAP (continuous positive airway pressure), with a marked increase in its use in pediatric care settings. This study aimed to evaluate the cost-effectiveness of early use of HFNC compared to oxygen by nasal cannula in an infant with bronchiolitis in the emergency setting. METHODS: A decision tree model was used to estimate the cost-effectiveness of HFNC compared with oxygen by nasal cannula (control strategy) in an infant with bronchiolitis in the emergency setting. Cost data were obtained from a retrospective study on bronchiolitis from tertiary centers in Rionegro, Colombia, while utilities were collected from the literature. RESULTS: The QALYs per patient calculated in the base-case model were 0.9141 (95% CI 0.913-0.915) in the HFNC and 0.9105 (95% CI 0.910-0.911) in control group. The cost per patient was US$368 (95% CI US$ 323-411) in HFNC and US$441 (95% CI US$ 384-498) per patient in the control group. CONCLUSIONS: HFNC was cost-effective HFNC compared to oxygen by nasal cannula in an infant with bronchiolitis in the emergency setting. The use of this technology in emergency settings will allow a more efficient use of resources, especially in low-resource countries with high prevalence of bronchiolitis .

[Food protein-induced enterocolitis syndrome in a patient with pseudo-Bartter syndrome associated with cystic fibrosis. A case report]. / Enterocolitis inducida por proteínas alimentarias en un paciente con síndrome de pseudo-Bartter asociado a fibrosis quística. Reporte de un caso.

INTRODUCTION: Food protein-induced enterocolitis is a non-immunoglobulin E-mediated food allergy with acute manifestations like recurrent vomiting, dehydration, and shock. It is a rare pathology that requires a high index of suspicion. Pseudo-Bartter syndrome (metabolic alkalosis, hypokalemia and hypochloremia in the absence of tubulopathy) is an infrequent complication of cystic fibrosis. CASE REPORT: A 5-month-old boy with recurrent vomiting, dehydration, and shock; who had been breastfed and had consumed baby formula three hours prior to the onset of symptoms. Laboratory tests confirmed hyponatremia, hypochloremic metabolic alkalosis, and hypokalemia in absence of tubulopathy; two iontophoresis showed altered results, stool elastase was decreased, and genetic sequencing confirmed the diagnosis of cystic fibrosis. The provocation test confirmed food protein-induced enterocolitis syndrome. CONCLUSION: Recurrent vomiting and dehydration after the intake of milk formula must lead to suspicion of food protein-induced enterocolitis syndrome. If pseudo-Bartter syndrome is found, cystic fibrosis must be ruled out.

Introducción: La enterocolitis inducida por proteínas alimentarias es una alergia alimentaria no mediada por inmunoglobulina E, manifestada en forma aguda por vómito recurrente, deshidratación y choque. Es una patología inusual que requiere alto índice de sospecha. El pseudo-Bartter (alcalosis metabólica, hipocaliemia e hipocloremia en ausencia de tubulopatía) es una complicación infrecuente de fibrosis quística. Reporte de caso: Niño de cinco meses de edad con vómito recurrente, deshidratación y choque, alimentado con lactancia materna, pero que consumió fórmula tres horas previas al inicio de síntomas. Los exámenes de laboratorio confirmaron hiponatremia, alcalosis metabólica hipoclorémica e hipocalemia sin tubulopatía; dos iontoforesis mostraron resultados alterados; la elastasa en materia fecal se encontró disminuida y la secuenciación genética confirmó el diagnóstico de fibrosis quística. La prueba de provocación confirmó enterocolitis inducida por proteínas alimentarias. Conclusión: El vómito recurrente y la deshidratación tras la ingesta de fórmula láctea deben hacer sospechar un enterocolitis inducida por proteínas alimentarias. Ante el hallazgo de pseudo-Bartter se debe descartar fibrosis quística.

The cost-utility of intravenous magnesium sulfate for treating asthma exacerbations in children.

INTRODUCTION: Although evidence supports the use of intravenous magnesium sulfate (MS) in asthma exacerbations, MS continues to be considered a second-line drug for managing pediatric asthma exacerbations. This study aimed to evaluate the cost-utility of MS in asthma exacerbations. METHODS: We used a decision tree model to estimate the cost-utility of MS compared to treatment without MS (control group) in children with asthma exacerbations. Cost data were obtained from a retrospective study from tertiary centers in Rionegro, Colombia, while utilities were collected from the literature. Probabilistic sensitivity analysis was carried out using the Monte Carlo technique with a simulation of a hypothetical cohort of 10 000 patients to generate expected cost utilities with 95% confidence intervals. We used a cost-effectiveness acceptability curve to evaluate the uncertainty surrounding the cost-utility of MS. RESULTS: The model showed that MS had a lower total cost than the control group (US $1149 vs US $1598 average cost per patient) and higher quality-adjusted life years (0.60 vs 0.52 average per patient), showing dominance. The probability that MS provides a more cost-effective use of resources compared with standard therapy exceeds 99% for all willingness-to-pay thresholds. CONCLUSION: Intravenous MS was less expensive and more effective than treatment without intravenous MS in children with asthma exacerbations. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate its results in other middle-income countries.

Validation of a new predictive model to improve risk stratification in bronchopulmonary dysplasia.

We need a better risk stratification system for the increasing number of survivors of extreme prematurity suffering the most severe forms of bronchopulmonary dysplasia (BPD). However, there is still a paucity of studies providing scientific evidence to guide future updates of BPD severity definitions. Our goal was to validate a new predictive model for BPD severity that incorporates respiratory assessments beyond 36 weeks postmenstrual age (PMA). We hypothesized that this approach improves BPD risk assessment, particularly in extremely premature infants. This is a longitudinal cohort of premature infants (≤32 weeks PMA, n = 188; Washington D.C). We performed receiver operating characteristic analysis to define optimal BPD severity levels using the duration of supplementary O2 as predictor and respiratory hospitalization after discharge as outcome. Internal validation included lung X-ray imaging and phenotypical characterization of BPD severity levels. External validation was conducted in an independent longitudinal cohort of premature infants (≤36 weeks PMA, n = 130; Bogota). We found that incorporating the total number of days requiring O2 (without restricting at 36 weeks PMA) improved the prediction of respiratory outcomes according to BPD severity. In addition, we defined a new severity category (level IV) with prolonged exposure to supplemental O2 (≥120 days) that has the highest risk of respiratory hospitalizations after discharge. We confirmed these findings in our validation cohort using ambulatory determination of O2 requirements. In conclusion, a new predictive model for BPD severity that incorporates respiratory assessments beyond 36 weeks improves risk stratification and should be considered when updating current BPD severity definitions.

Predictors of hospitalization for acute lower respiratory infections during the first two years of life in a population of preterm infants with bronchopulmonary dysplasia.

BACKGROUND: There have been few research studies aimed at obtaining a better understanding of the prediction of subsequent respiratory morbidity at follow-up in infants with a previous history of bronchopulmonary dysplasia (BPD) living in low- and middle-income countries (LMIC). The aim of the present study was to identify predictors of hospitalization for acute lower respiratory infections (ALRIs) in a population of infants with a history of BPD living in a LMIC. METHODS: In a prospective cohort study, we determined independent predictors of the number of hospitalizations for ALRIs during the first two years of life in a population of infants with a history of BPD living in Bogota, Colombia. In multivariate analyses, we included both clinico-demographic variables and underlying disease characteristics as predictor variables of hospitalization for ALRIs. RESULTS: Of a total of 138 patients included in the study, 83 (60.1%) had at least one hospitalization for ALRI during the follow-up period. Independent predictors of the number of hospitalizations for ALRIs included duration of neonatal ventilatory support (IRR 1.02; CI 95% 1.00-1.03; p = 0.010), duration of subsequent ambulatory oxygen therapy (IRR 2.06; CI 95% 1.16-3.64; p = 0.013), and breastfeeding in females (IRR 0.35; CI 95% 0.14-0.84; p = 0.019). CONCLUSIONS: Duration of mechanical ventilation, duration of subsequent ambulatory oxygen therapy, and breastfeeding in females were independently associated with the number of hospitalizations for ALRIs in our population of infants with a history of BPD.

Quality assessment of acute viral bronchiolitis clinical practice guidelines.

RATIONALE, AIMS AND OBJECTIVES: Recently, in an attempt to reduce variability in clinical practice and produce better results for patients, several clinical practice guidelines (CPGs) for the appropriate diagnosis and management of bronchiolitis in infants have been developed. However, the quality of available CPGs for bronchiolitis management has not yet been systematically evaluated. The aim of this study was to assess the quality of acute viral bronchiolitis CPGs. METHOD: We performed a systematic and exhaustive search of CPGs on bronchiolitis published from 2000 to 2014. Three independent appraisers assessed the quality of the CPGs using the Appraisal of Guidelines Research and Evaluation (AGREE) II instrument. A standardized score was calculated for each of the six domains, and the CPGS were rated as recommended, recommended with modifications, or not recommended. RESULTS: Six CPGs published between the years 2000 and 2014 were selected from a total of 111 citations. There was substantial agreement among reviewers (ICC: 0.75; 95% CI, 0.61-0.89). The domains that scored the highest were 'scope and purpose', with a mean value of 92.1% (range: 77.8-100%), and 'clarity of presentation' [83.3% (69.4-91.7%)]. Those that scored the lowest were 'applicability' [44.3% (8.3-77.1%)], and 'stakeholder involvement' [66.7% (47.2-94.4%)]. Three CPGS were evaluated as being recommended with modifications, and only two were recommended for use in clinical practice. CONCLUSIONS: Available bronchiolitis CPGs vary in quality, and the findings of the present study are useful for identifying aspects or domains where there is room for improvement in future CPGs.