Nasal high flow in room air for hypoxemic bronchiolitis infants

Background: Bronchiolitis is the most common reason for hospital admission in infants, with one third requiring oxygen therapy due to hypoxemia. It is unknown what proportion of hypoxemic infants with bronchiolitis can be managed with nasal high-flow in room air and their resulting outcomes. Objectives and Settings: To assess the effect of nasal high-flow in room air in a subgroup of infants with bronchiolitis allocated to high-flow therapy in a recent multicenter randomized controlled trial. Patients and Interventions: Infants allocated to the high-flow arm of the trial were initially treated with room air high-flow if saturations were ≥85%. Subsequently, if oxygen saturations did not increase to ≥92%, oxygen was added and FiO2 was titrated to increase the oxygen saturations. In this planned sub-study, infants treated during their entire hospital stay with high-flow room air only were compared to infants receiving either standard-oxygen or high-flow with oxygen. Baseline characteristics, hospital length of stay and length of oxygen therapy were compared. Findings: In the per protocol analysis 64 (10%) of 630 infants commenced on high-flow room air remained in room air only during the entire stay in hospital. These infants on high-flow room air were on average older and presented with moderate hypoxemia at presentation to hospital. Their length of respiratory support and length of stay was also significantly shorter. No pre-enrolment factors could be identified in a multivariable analysis. Conclusions: In a small sub-group of hypoxemic infants with bronchiolitis hypoxemia can be reversed with the application of high-flow in room air only

Antibiotics for community acquired lower respiratory tract infections (LRTI) secondary to Mycoplasma pneumoniae in children (Review)

BackgroundMycoplasma pneumoniae (M. pneumoniae) is widely recognised as an important cause of community-acquired lower respiratory tract infection (LRTI) in children. Pulmonary manifestations are typically tracheobronchitis or pneumonia but M. pneumoniae is also implicated in wheezing episodes in both asthmatic and non-asthmatic individuals. Although antibiotics are used to treat LRTI, a review of several major textbooks offers conflicting advice for the use of antibiotics in the management of M. pneumoniae LRTI in children.ObjectivesTo determine whether antibiotics are effective in the treatment of childhood LRTI secondary to M. pneumoniae infections acquired in the community.Search strategyWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, issue 1), which contains the Acute Respiratory Infection Group\u27s Specialized Register; MEDLINE (1966 to February 2005); and EMBASE (1980 to December 2004).Selection criteriaRandomised controlled trials comparing antibiotics commonly used for treating M. pneumoniae (i.e. macrolide, tetracycline or quinolone classes) versus placebo, or antibiotics from any other class in the treatment of children under 18 years of age with community acquired LRTI secondary to M. pneumoniae.Data collection and analysisThe authors independently selected trials for inclusion and assessed methodological quality. Relevant data were extracted and analysed separately and any disagreements were resolved by consensus.Main resultsA total of 1352 children were enrolled from six studies. The number of children from one study was unavailable. Data interpretation was significantly limited by the inability to extract data that specifically referred to children with M. pneumoniae. Clinical response did not differ between the children randomised to a macrolide antibiotic and the children randomised to a non-macrolide antibiotic. There were no studies comparing relevant antibiotics with placebo.Authors\u27 conclusionsThis review found insufficient evidence to draw any conclusions about the efficacy of antibiotics for LRTI secondary to M. pneumoniae in children. The use of antibiotics for M. pneumoniae LRTI has to be individualised and balanced with possible adverse events associated with antibiotic use. There is a need for high quality, double-blinded randomised controlled trials to assess the efficacy and safety of antibiotics for LRTI secondary to M. pneumoniae in children

Characteristics of infants with positional abnormal head shapes and their physiotherapy service at an Australian community health facility

Amy Leung,1 Pauline Watter,2 John Gavranich31Department of Physiotherapy, Royal Children's Hospital, 2Physiotherapy Division, School of Health Rehabilitation Science, The University of Queensland, Brisbane, Queensland, Australia; 3Child and Family Health Services, West Moreton Health Service District, Queensland, AustraliaPurpose: There is limited biographic information regarding infants presenting with abnormal head shape in Australia and little discussion of the effect of different cutoff values for diagnosis of plagiocephaly. This study aimed to 1) describe the biographic characteristics of infants with positional abnormal head shapes referred for physiotherapy management; 2) explore their access to physiotherapy services and intervention outcomes; and 3) explore the impact of using different modified Cranial Vault Asymmetry Index (mCVAI) cutoff points in plagiocephaly classification.Patients and methods: This retrospective community health record audit included the total cohort of infants referred over concerns about abnormal head shape to a pediatric physiotherapy service at a community health center in Australia from January 2004 to December 2007 (N=126 valid cases). Data retrieved included: demographic data; birth history; positioning; initial physiotherapy assessment; and factors associated with physiotherapy intervention and outcomes.Results: Of the 126 charts (65 males), 106 infants (84.1%) presented with plagiocephaly, ten (7.9%) with brachycephaly, and ten (7.9%) with combined deformities. Most biographic data from this study were similar to those reported in the literature. The mean age ± standard deviation (SD) of infants at referral was 11.29±7.84 weeks, with about 4-weeks wait for assessment. For the plagiocephalic group, there was significant reduction in mCVAI mean value from assessment (-5.44%±2.95%) to discharge (-4.41%±2.66%) (t[df=60] =-5.396; 95% confidence interval [CI]: -1.66%, -0.76%; P<0.001) and significant change in the Argenta Clinical Classification categories (P<0.001) after physiotherapy intervention. There was a reduction of approximately 10% in infants classified with significant plagiocephaly when the mCVAI cutoff point increased by 1%.Conclusion: Characteristics of Australian infants presenting with plagiocephaly, brachycephaly, and combined conditions were similar to other reports. Infants with positional head deformities can benefit from physiotherapy intervention. The cutoff point of mCVAI at -6% is proposed to be appropriate for the provision of ongoing physiotherapy service.Keywords: plagiocephaly, brachycephaly, modified cranial vault asymmetry index, cutoff poin

Test-retest reproducibility of the 1000 Hz tympanometry test in newborn and six-week-old healthy infants

This study aimed to evaluate the test-retest reproducibility of the high frequency tympanometry (HFT) test measured in healthy infants. A total of 273 newborn babies (106 males and 147 females) were assessed twice (Test 1 and Test 2) on the same day, followed by two more assessments (Test 3 and Test 4) for 118 babies (48 males and 70 females) who returned six weeks later. Five HFT measures including the peak compensated static admittance and component compensated static admittance were assessed for test-retest reproducibility. The results showed no significant differences in mean values of the HFT results between the test and retest conditions for newborn (Test 1/ Test 2) and six-week-old babies (Test 3/ Test 4). High reproducibility for all HFT measures was found for both age groups, as judged by the high intra-correlation coefficients of between 0.75 and 0.95. Normal variations of the HFT measures were established using the 90% range of absolute test-retest difference. Changes in test-retest findings exceeding the 95th percentile values may be considered significant, indicating possible functional changes

Multicentre, randomised trial to investigate early nasal high—flow therapy in paediatric acute hypoxaemic respiratory failure: a protocol for a randomised controlled trial—a Paediatric Acute respiratory Intervention Study (PARIS 2)

Acute hypoxaemic respiratory failure (AHRF) in children is the most frequent reason for non-elective hospital admission. During the initial phase, AHRF is a clinical syndrome defined for the purpose of this study by an oxygen requirement and caused by pneumonia, lower respiratory tract infections, asthma or bronchiolitis. Up to 20% of these children with AHRF can rapidly deteriorate requiring non-invasive or invasive ventilation. Nasal high-flow (NHF) therapy has been used by clinicians for oxygen therapy outside intensive care settings to prevent escalation of care. A recent randomised trial in infants with bronchiolitis has shown that NHF therapy reduces the need to escalate therapy. No similar data is available in the older children presenting with AHRF. In this study we aim to investigate in children aged 1 to 4 years presenting with AHRF if early NHF therapy compared with standard-oxygen therapy reduces hospital length of stay and if this is cost-effective compared with standard treatment.The study design is an open-labelled randomised multicentre trial comparing early NHF and standard-oxygen therapy and will be stratified by sites and into obstructive and non-obstructive groups. Children aged 1 to 4 years (n=1512) presenting with AHRF to one of the participating emergency departments will be randomly allocated to NHF or standard-oxygen therapy once the eligibility criteria have been met (oxygen requirement with transcutaneous saturatio

Maternal intramuscular dexamethasone versus betamethasone before preterm birth (ASTEROID): a multicentre, double-blind, randomised controlled trial

Background: Antenatal corticosteroids given to women before preterm birth improve infant survival and health. However, whether dexamethasone or betamethasone have better maternal, neonatal, and childhood health outcomes remains unclear. We therefore aimed to assess whether administration of antenatal dexamethasone to women at risk of preterm birth reduced the risk of death or neurosensory disability in their children at age 2 years compared with betamethasone. We also aimed to assess whether dexamethasone reduced neonatal morbidity, had benefits for the mother, or affected childhood body size, blood pressure, behaviour, or general health compared with betamethasone. Methods: In this multicentre, double-blind, randomised controlled trial, we recruited pregnant women from 14 maternity hospitals in Australia and New Zealand that could provide care to preterm babies. Women were eligible for study inclusion if they were at risk of preterm birth before 34 weeks of gestation, had a singleton or twin pregnancy, and had no contraindications to antenatal corticosteroids. We randomly assigned women (1:1) to receive two intramuscular injections of either 12 mg dexamethasone (dexamethasone sodium phosphate) or 11·4 mg betamethasone (Celestone Chronodose), 24 h apart. The randomisation schedule used balanced, variable blocks that were stratified by hospital, gestational age, and number of fetuses (singleton or twins). We masked all participants, staff, and assessors to treatment groups. Analyses were by intention to treat. The primary outcome was death or neurosensory disability at age 2 years (corrected for prematurity). This study is registered with ANZCTR, ACTRN12608000631303. Findings: Between Jan 28, 2009, and Feb 1, 2013, we randomly assigned 1346 (78%) women who were pregnant with 1509 fetuses to groups: 679 (50%) women were assigned to receive dexamethasone and 667 (50%) women were assigned to receive betamethasone. 27 (4%) fetuses, infants, or children in the dexamethasone group and 28 (4%) fetuses, infants, or children in the betamethasone group died before age 2 years. The primary outcome of death or neurosensory disability at age 2 years was determined for 603 (79%) of 763 fetuses whose mothers received dexamethasone and 591 (79%) of 746 fetuses whose mothers received betamethasone. We found a similar incidence of death or neurosensory disability in the dexamethasone (198 [33%] of 603 infants) and betamethasone groups (192 [32%] of 591 infants; adjusted relative risk [adjRR] 0·97, 95% CI 0·83 to 1·13; p=0·66). 18 (3%) of 679 women in the dexamethasone group and 28 of 667 (4%) women in the betamethasone group reported side-effects. Discomfort at the injection site, the most frequent side-effect, was less likely in the dexamethasone group than in the betamethasone group (six [1%] women vs 17 [3%] women; p=0·02). Interpretation: The incidence of survival without neurosensory disability at age 2 years did not differ between dexamethasone and betamethasone treatment. Our findings indicate that either antenatal corticosteroid can be given to women before preterm birth to improve infant and child health. Funding: National Health and Medical Research Council (Australia)