Acute bronchiolitis in infancy as risk factor for wheezing and reduced pulmonary function by seven years in Akershus County, Norway

BACKGROUND: Acute viral bronchiolitis is one of the most common causes of hospitalisation during infancy in our region with respiratory syncytial virus (RSV) historically being the major causative agent. Many infants with early-life RSV bronchiolitis have sustained bronchial hyperreactivity for many years after hospitalisation and the reasons for this are probably multifactorial. The principal aim of the present study was to investigate if children hospitalised for any acute viral bronchiolitis during infancy in our region, and not only those due to RSV, had more episodes of subsequent wheezing up to age seven years and reduced lung function at that age compared to children not hospitalised for acute bronchiolitis during infancy. A secondary aim was to compare the hospitalised infants with proven RSV bronchiolitis (RS+) to the hospitalised infants with non-RSV bronchiolitis (RS-) according to the same endpoints. METHODS: 57 infants hospitalised at least once with acute viral bronchiolitis during two consecutive winter seasons in 1993–1994 were examined at age seven years. An age-matched control group of 64 children, who had not been hospitalised for acute viral bronchiolitis during infancy, were recruited from a local primary school. Epidemiological and clinical data were collected retrospectively from hospital discharge records and through structured clinical interviews and physical examinations at the follow-up visit. RESULTS: The children hospitalised for bronchiolitis during infancy had decreased lung function, more often wheezing episodes, current medication and follow-up for asthma at age seven years than did the age matched controls. They also had lower average birth weight and more often first order family members with asthma. We did not find significant differences between the RSV+ and RSV- groups. CONCLUSION: Children hospitalised for early-life bronchiolitis are susceptible to recurrent wheezing and reduced pulmonary function by seven years compared to age-matched children not hospitalised for early-life bronchiolitis. We propose that prolonged bronchial hyperreactivity could follow early-life RSV negative as well as RSV positive bronchiolitis

Viral lower respiratory tract infections-strict admission guidelines for young children can safely reduce admissions

Viral lower respiratory tract infection (VLRTI) is the most common cause of hospital admission among small children in high-income countries. Guidelines to identify children in need of admission are lacking in the literature. In December 2012, our hospital introduced strict guidelines for admission. This study aims to retrospectively evaluate the safety and efficacy of the guidelines. We performed a single-center retrospective administrative database search and medical record review. ICD-10 codes identified children 90 days 65.3% vs. 53.3% (p<0.001); for healthy children ≤ 90 days 85% vs. 68% (p<0.001); and for high-risk comorbidities 74% vs. 71% (p=0.5). Conclusion: After implementation of admission guidelines for VLRTI, there were few adverse events and a significant reduction in admissions to the hospital from the emergency department. Our admission guidelines may be a safe and helpful tool in the assessment of children with VLRTI

Clinical features and inflammatory markers in pediatric pneumonia: a prospective study

Abstract In this prospective, observational study on previously healthy children 92% in multivariate logistic regression, OR 1.09 (95% CI 1.05 to 1.14) and OR 0.23 (95% CI 0.06 to 0.82), respectively. Combining high CRP values (>80 mg/L) and elevated white blood cell (WBC) count provided specificity >85%, positive likelihood ratios >3, but sensitivity <46% for both radiographic proven and bacterial pneumonia. Conclusion: With relatively high specificity and likelihood ratio CRP, WBC count and hypoxemia may be beneficial in ruling in a positive chest radiograph in suspected pneumonia and bacterial etiology in proven pneumonia, but with low sensitivity, the clinical utility is limited

Assessing Severity in Pediatric Pneumonia: Predictors of the Need for Major Medical Interventions

Objective: The aim of this study was to determine potential predictors of the need for major medical interventions in the context of assessing severity in pediatric pneumonia. Methods: This was a prospective, cohort study of previously healthy children and adolescents younger than 18 years presenting to the pediatric emergency room with clinically suspected pneumonia and examining both the full cohort and those with radiologically confirmed pneumonia. The presence of hypoxemia (peripheral oxygen saturation ≤92%), age-specific tachypnea, high temperature (≥38.5°C), chest retraction score, modified Pediatric Early Warning Score, age, C-reactive protein, white blood cell (WBC) count, and chest radiograph findings at first assessment were analyzed by univariate and multivariate analyses to examine their predictive ability for the need for major medical interventions: supplemental oxygen, supplemental fluid, respiratory support, intensive care, or treatment for complications during admission. Results: Fifty percent of the 394 cases of suspected pneumonia and 60% of the 265 cases of proven pneumonia were in need of 1 or more medical interventions. In multivariate logistic regression, only the presence of hypoxemia (odds ratios, 3.66 and 3.83 in suspected and proven pneumonia, respectively) and chest retraction score (odds ratios, 1.21 and 1.31, respectively for each 1-point increase in the score) significantly predicted the need for major medical interventions in both suspected and proven pneumonia. Specificity of 94% or greater, positive likelihood ratio of 6.4 or greater, and sensitivity of less than 40% were found for both hypoxemia and chest retraction score in predicting major medical interventions. C-reactive protein and white blood cell count were not associated with the need for these interventions, whereas multifocal radiographic changes were. Conclusions: Hypoxemia and an assessment of chest retractions were the predictors significantly able to rule in more severe pneumonia, but with a limited clinical utility given their poor ability to rule out the need for major medical interventions. Future validation of these findings is needed

Assessing severity in pediatric pneumonia. Predictors of the need for major medical interventions

Objective: The aim of this study was to determine potential predictors of the need for major medical interventions in the context of assessing severity in pediatric pneumonia. Methods: This was a prospective, cohort study of previously healthy children and adolescents younger than 18 years presenting to the pediatric emergency room with clinically suspected pneumonia and examining both the full cohort and those with radiologically confirmed pneumonia. The presence of hypoxemia (peripheral oxygen saturation ≤92%), age-specific tachypnea, high temperature (≥38.5°C), chest retraction score, modified Pediatric Early Warning Score, age, C-reactive protein, white blood cell (WBC) count, and chest radiograph findings at first assessment were analyzed by univariate and multivariate analyses to examine their predictive ability for the need for major medical interventions: supplemental oxygen, supplemental fluid, respiratory support, intensive care, or treatment for complications during admission. Results: Fifty percent of the 394 cases of suspected pneumonia and 60% of the 265 cases of proven pneumonia were in need of 1 or more medical interventions. In multivariate logistic regression, only the presence of hypoxemia (odds ratios, 3.66 and 3.83 in suspected and proven pneumonia, respectively) and chest retraction score (odds ratios, 1.21 and 1.31, respectively for each 1-point increase in the score) significantly predicted the need for major medical interventions in both suspected and proven pneumonia. Specificity of 94% or greater, positive likelihood ratio of 6.4 or greater, and sensitivity of less than 40% were found for both hypoxemia and chest retraction score in predicting major medical interventions. C-reactive protein and white blood cell count were not associated with the need for these interventions, whereas multifocal radiographic changes were. Conclusions: Hypoxemia and an assessment of chest retractions were the predictors significantly able to rule in more severe pneumonia, but with a limited clinical utility given their poor ability to rule out the need for major medical interventions. Future validation of these findings is needed. Key Words: pneumonia, sensitivity and specificity, severity predictors (Pediatr Emer Care 2017;00: 00–00

Thymus activity measured by T-cell receptor excision circles in patients with different severities of respiratory syncytial virus infection

Background Respiratory syncytial virus (RSV) infection is an important cause of hospitalization in previously healthy infants. Immunological mechanisms predisposing infants to severe disease are poorly understood. Early biomarkers for disease severity may assist clinical decisions. We investigated T-cell receptor excision circles (TREC), episomal DNA made during thymic T-cell receptor rearrangement, and a marker for thymus activity, both during disease and in neonatal screening cards as a risk factor for RSV disease severity. Methods One hundred thirteen patients hospitalized with RSV infection <12 months of age, grouped by disease severity, were available for this investigation, in which we conducted both a prospective and a case-control study. The prospective study included 47 RSV positive infants (mild n = 13, moderate n = 10, severe n = 24). TREC counts were determined by PCR of DNA extracted from EDTA-blood collected on hospitalization, and corrected for lymphocytes using ANCOVA. The case-control study included 85 newborns who later in infancy became RSV positive (mild n = 32, moderate n = 24, severe n = 29) and 47 newborns who never developed RSV disease as healthy controls included from health centres in the same catchment area. TRECs were measured using DNA extracted from dry blood spots from stored neonatal screening cards, followed by PCR. Student’s T-test compared patients with controls, ANOVA compared disease severity groups. Results During RSV infection patients in the severe disease group had significantly lower (p = 0.017) TREC/200 μL blood compared to the other two disease groups, after correction for lymphocyte count. Newborn TREC levels, were significantly higher in RSV patients compared to controls (p < 0.0001). No significant differences in TREC copies at birth were found between disease severities. Conclusion During acute RSV infection a lower number of TREC is found in the severe disease group. TREC has potential as an immunological marker for severe RSV infection. Higher neonatal TREC counts indicate that infants later presenting with severe RSV do not have reduced thymic activity at birth and probably no congenital T-cell defect