The effect of 3% and 6% hypertonic saline in viral bronchiolitis: a randomised controlled trial.

Bronchiolitis is a common disorder in young children that often results in hospitalisation. Except for a possible effect of nebulised hypertonic saline (sodium chloride), no evidence-based therapy is available. This study investigated the efficacy of nebulised 3% and 6% hypertonic saline compared with 0.9% hypertonic saline in children hospitalised with viral bronchiolitis. In this multicentre, double-blind, randomised, controlled trial, children hospitalised with acute viral bronchiolitis were randomised to receive either nebulised 3%, 6% hypertonic saline or 0.9% normal saline during their entire hospital stay. Salbutamol was added to counteract possible bronchial constriction. The primary endpoint was the length of hospital stay. Secondary outcomes were need for supplemental oxygen and tube feeding. From the 292 children included in the study (median age 3.4 months), 247 completed the study. The median length of hospital stay did not differ between the groups: 69 h (interquartile range 57), 70 h (IQR 69) and 53 h (IQR 52), for 3% (n=84) and 6% (n=83) hypertonic saline and 0.9% (n=80) normal saline, respectively, (p=0.29). The need for supplemental oxygen or tube feeding did not differ significantly. Adverse effects were similar in the three groups. Nebulisation with hypertonic saline (3% or 6% sodium chloride) although safe, did not reduce the length of stay in hospital, duration of supplemental oxygen or tube feeding in children hospitalised with moderate-to-severe viral bronchiolitis.

Nocturnal apnea in Chiari type I malformation.

UNLABELLED: A 4-year-old girl presented with sleep-disordered breathing. Her parents described breathing pauses of up to 20 s and progressive tiredness during the day. Obstructive apneas from an enlarged adenoid were thought to be the most probable cause. However, an adenotomy did not resolve the problem. Polysomnography demonstrated central apneas, and cerebral magnetic resonance imaging revealed a Chiari type I malformation. We describe the differential diagnosis of apnea in children and the role of polysomnography in the distinction between obstructive and central apneas. CONCLUSION: This case illustrates that, in children with apnea, it is important to consider central causes as well as the more common obstructive causes, even in the absence of additional neurological signs or symptoms.

Structural lung changes, lung function, and non-invasive inflammatory markers in cystic fibrosis.

Cystic fibrosis (CF) lung disease is characterized by chronic airway inflammation and recurrent infections, resulting in (ir)reversible structural lung changes and a progressive decline in lung function. The objective of this study was to investigate the relationship between non-invasive inflammatory markers (IM) in exhaled breath condensate (EBC), lung function indices and structural lung changes, visualized by high resolution computed tomography (HRCT) scans in CF. In 34 CF patients, lung function indices (forced expiratory volume in 1 s, forced vital capacity [FVC], residual volume, and total lung capacity [TLC]) and non-invasive IM (exhaled nitric oxide, and condensate acidity, nitrate, nitrite, 8-isoprostane, hydrogen peroxide, interferon-gamma) were assessed. HRCT scans were scored in a standardized and validated way, a composite score and component scores were calculated. In general, the correlations between non-invasive IM and structural lung changes, and between IM and lung function were low (correlation coefficients <0.40). Patients with positive sputum Pseudomonas cultures had higher EBC nitrite levels and higher parenchymal HRCT subscores than patients with Pseudomonas-negative cultures (p < 0.05). Multiple linear regression models demonstrated that FVC was significantly predicted by hydrogen peroxide in EBC, and the scores of bronchiectasis and mosaic perfusion (Pearson correlation coefficient R = 0.78, p < 0.001). TLC was significantly predicted by 8-isoprostane, nitrate, hydrogen peroxide in EBC, and the mucous plugging subscore (R = 0.92, p < 0.01). Static and dynamic lung function indices in this CF group were predicted by the combination of non-invasive IM in EBC and structural lung changes on HRCT imaging. Future longitudinal studies should reveal whether non-invasive monitoring of airway inflammation in CF adds to better follow-up of patients.

An asthma-related quality of life instrument is unable to identify asthmatic children with major psychosocial problems.

Evidence shows that psychosocial problems among children and adolescents with asthma interfere with adherence to treatment and therefore need attention in asthma care. It is unknown whether the already frequently implemented asthma-related quality of life (QoL) instruments reflect psychosocial problems in children with asthma. The aim of this study was to assess the relationship between asthma-related QoL and psychosocial problems and to determine whether an asthma-related QoL instrument is able to identify those children and adolescents with asthma with major psychosocial problems. In a multicenter study psychosocial problems (Strengths and Difficulties Questionnaire) and asthma-related QoL (Pediatric Asthma (Caregivers) Quality of Life Questionnaire) were obtained in children and adolescents with asthma aged 6-16 years and their caregivers. A total of 339 children and adolescents (response rate 95%) from four pediatric outpatient clinics in the Netherlands with doctor-diagnosed asthma participated. Of the caregivers, 43% reported major or minor psychosocial problems of their child or adolescent which is two times more than in the reference group, whereas the percentage of adolescents reporting psychosocial problems was comparable to a reference population. Adolescents and caregivers reported few impairments in asthma-related QoL (median score between 6.2 and 7.0). However, an optimal asthma-related QoL did not rule out major psychosocial problems: 10% of the adolescents with an optimal asthma-related QoL score reported major psychosocial problems. And in one out of seven children with an optimal caregiver's asthma-related QoL score, major psychosocial problems were reported. The prevalence of psychosocial problems in children and adolescents with asthma is considerable. Assessment of asthma-related QoL alone is insufficient to identify those children with major psychosocial problems. We recommend the implementation of psychosocial screening, besides assessment of asthma-related QoL, in routine pediatric asthma care, to improve asthma management.

No differences in physical activity in (un)diagnosed asthma and healthy controls.

To establish whether asthma affects physical activity levels in children (aged 7-10 years) we evaluated physical activity levels in children with undiagnosed asthma (UDA), diagnosed asthma (DA), and healthy controls (HCs). A cross-sectional community-based study was performed which included a parental questionnaire on their child's respiratory health, and testing of airway reversibility and bronchial hyperresponsiveness (BHR). DA was defined as the parents' confirmation of a physician's diagnosis of asthma in the past 12 months. UDA was defined by asthma symptoms combined with airway reversibility or BHR in children without a physician's diagnosis of asthma. Physical activity was measured during 5 days with an accelerometer and a diary, and with the habitual activity estimation scale which reviews the physical activity during the past 2 weeks. The final study population comprised 1,614 children of whom 81 (5%) had DA, 130 (8%) UDA, and 202 HCs. Baseline FEV(1) % was lowest in children with UDA (UDA FEV(1) 94% predicted, DA FEV(1) 98% predicted, HCs FEV(1) 100% predicted). Using the three methods, no differences were found in the physical activity between children with UDA, DA, and HCs. Childhood asthma does not appear to be associated with a decreased level of daily physical activity in our study population.

Sputum Induction in Children Is Feasible and Useful in a Bustling General Hospital Practice.

We prospectively studied the feasibility and effectiveness of sputum induction in obtaining good quality sputum and its subsequent bacterial yield in children with clinically suspected acute lower-respiratory-tract infection (aLRTI). Good quality sputum was collected in 89/98 (91%) patients. Sputum cultures revealed ≥1 bacterial pathogens in 22 cases (25%). Adverse events were infrequent and mild (6%). Sputum induction is feasible in young children and leads to an increased number of etiological diagnoses of aLRTI.

Four of a kind: asthma control, FEV1, FeNO, and psychosocial problems in adolescents.

BACKGROUND: Many adolescents have poor asthma control and are at high risk for psychosocial problems. However, structured assessment of asthma control or psychosocial problems is still not implemented in routine asthma care. Pediatricians typically rely on their clinical view and physiological measurements. To date, it is unknown whether clinical and patient reported outcomes are interrelated. Furthermore, there is no consensus on who should be the informant; the adolescent or his caregiver. STUDY AIM(S): This study aimed to assess the relationship between patient and caregiver reported outcomes [Asthma Control Questionnaire and Strengths and Difficulties Questionnaire (SDQ)] and physiological parameters (FEV1 and Fractional exhaled Nitric Oxide) in adolescents (aged 11-16) with asthma. METHODS: A multicenter observational study was performed in four Dutch pediatric outpatient departments. Association between asthma control, physiological parameters, and results of psychosocial questionnaires completed by both adolescent and caregiver was analyzed. RESULTS: Forty-eight adolescents and their caregivers participated in this study. Asthma was uncontrolled in about 30%. Asthma control was not associated with age, gender, FEV1, FeNO, or psychosocial problems. Agreement between adolescents and caregivers about how well asthma was controlled was moderate (κ = 0.577, P < 0.01). DISCUSSION: Asthma control, physiological parameters, and psychosocial problems are different domains of health status. It could be suggested to use validated patient and caregiver reported outcomes in routine adolescent asthma care. CONCLUSION: Patient and caregiver reported outcomes on asthma control and the presence of psychosocial problems add valuable, unique information to physiological parameters in adolescent asthma management.

Excessive body weight is associated with additional loss of quality of life in children with asthma.

BACKGROUND: Asthma and excessive body weight frequently coexist, whereas the exact relationship between the 2 diseases is unknown. OBJECTIVE: To study whether asthma combined with excessive body weight has a greater effect on quality of life in children than the separate effects of asthma or excessive body weight alone. METHODS: In a cross-sectional design, 1758 school children (age 7-10 years) participated: 4 study groups were composed of children with asthma and with/without excessive body weight, and healthy controls with/without excessive body weight. Diagnosis of asthma was defined by either a doctor's diagnosis or by core questions of the International Study of Asthma and Allergies in Childhood questionnaire in combination with either reversible airway obstruction or bronchial hyperresponsiveness. Excessive body weight was defined by using international cutoff points for body mass index. Quality of life was evaluated by the Pediatric Asthma Quality of Life Questionnaire. RESULTS: For all domains of quality of life, children with both asthma and excessive body weight had lower scores than children with either asthma alone or excessive body weight alone. Compared with healthy controls, the score was 25% lower in children with asthma and excessive body weight, 14% lower in children with asthma and normal weight, and only 1% lower in overweight controls. CONCLUSION: Excessive body weight is associated with an additional decrease in quality of life in children with asthma. CLINICAL IMPLICATIONS: Clinicians should be aware of the interaction between asthma and excessive body weight and the effect on quality of life and should give extra attention to children with both conditions.

Quality of life in children with undiagnosed and diagnosed asthma.

This study describes the impact of undiagnosed and diagnosed asthma on quality of life in schoolchildren aged 7-10 years and their caregivers in a cross-sectional community-based study. Diagnosed asthma was defined as the parents' confirmation of a physician's diagnosis of asthma. Undiagnosed asthma was defined by asthma symptoms combined with airway reversibility or bronchial hyperresponsiveness. Quality of life was evaluated in all children with asthma and a sample of healthy controls by the Pediatric Asthma Quality of Life Questionnaire, and by the Paediatric Asthma Caregiver's Quality of Life Questionnaire. We studied the impact of breathing problems on school absence. Compared with healthy controls, quality of life scores among children and their caregivers were lower if the child had asthma (P < 0.05), with lowest scores in diagnosed asthma (P < 0.05 compared with undiagnosed asthma). Children with asthma reported more school absence (P < 0.05), with highest absence rate in those with diagnosed asthma. In conclusion, both undiagnosed and diagnosed asthma have a significant impact on the quality of life of both children and their caregivers.