Challenges of children’s healthcare system in the European Union countries and Lithuania

Vaikų sveikatos priežiūros poreikių pokyčiai skatina Europos šalis peržiūrėti vaikų sveikatos priežiūros sistemas, kad visiems vaikams būtų prieinama efektyvi ir tinkama sveikatos priežiūra. Atlikta atrinktų mokslinių publikacijų, rekomendacijų ir studijų apžvalga parodė Europos šalių vaikų sveikatos priežiūros sistemų skirtumus, ypač pirminės vaikų sveikatos priežiūros organizavimo. Išskiriamos trys vaikų pirminės sveikatos priežiūros sistemos: pediatrinė, šeimos gydytojo ir mišri. Ne visos šalys vadovaujasi PSO Europos regiono biuro parengta Vaikų ir paauglių sveikatos strategija 2015-2020 m., skirta padėti šalims įdiegti įrodymais pagrįstą sistemą, siekiant patobulinti vaikų ir paauglių poreikius atitinkančią sveikatos priežiūrą. Pastebima, kad vaiko centriškumo principas nėra įdiegtas ne tik daugelio šalių sveikatos priežiūros sistemose, bet ir kitose gyvenimo srityse. Modeliuojant bendrą sveikatos priežiūros sistemą, neišskiriant vaikų, dažniausiai remiamasi didžiosios gyventojų dalies – suaugusiųjų poreikiais, nuvertinant vaikų poreikius. Vaikystės sveikatos problemos gali turėti įtakos visam gyvenimui. Sveikatos priežiūros netolygumų problemos sprendimas, mažinant socialinių veiksnių įtaką sveikatai, apsaugotų vaikų populiaciją. Kūdikių mirtingumo rodikliai žemesni tose Europos šalyse, kuriose geresnė ekonominė situacija ir didesnis dėmesys skiriamas gyventojų gerovei. Augančio vaiko sveikatos priežiūros poreikiai yra specifiniai daugelyje sričių, pradedant specifinėmis žiniomis, kurių reikia vaikų ligų gydymui ir baigiant vaikų atstovavimo ypatumais, todėl sveikatos priežiūros paslaugos turi būti pritaikytos vaikams, o specialistai turi turėti specifinių kompetencijų. Raktažodžiai: vaikų sveikata, vaikų sveikatos priežiūros iššūkiai, pirminė sveikatos priežiūra, vaikų sveikatos rodikliai.The changing needs of children’s health care encourage European countries to review their children’s healthcare systems to make effective and appropriate healthcare available to all children. An overview of selected scientific publications, recommendations and studies showed differences between countries in European children’s healthcare systems, especially in the organization of primary health care. Three primary care systems for children are distinguished: pediatric, family doctor and mixed. Not all countries follow the WHO European Office’s Children’s and Adolescent Health Strategy 2015-2020 to help countries put in place an evidence-based system to improve health care that meets the needs of children and adolescents. It is noted that the principle of centricity of the child is not introduced only in healthcare systems in many countries but also in other areas of life. When modeling the overall healthcare system without excluding children, the majority of the population is based on the needs of adults to underestimate children’s needs. Childhood health problems can have an impact throughout their lives. Addressing health inequalities by reducing the impact of social factors on health would protect the pediatric population. Infant mortality rates are lower in European countries with a better economic situation and greater focus on the well-being of the population. The health care needs of a growing child are specific in many areas, from the specific knowledge needed to treat children’s diseases to the peculiarities of their representation. Therefore, health care services need to be adapted to children and professionals need to have specific competencies. Keywords: children‘s health, children’s health care challenges, primary health care, children‘s health indicators

Significance of dietotherapy on the clinical course of atopic dermatitis

The aim of this study was to determine the efficiency of individual balanced replacement diet in treatment of children with atopic dermatitis, to compare the course of atopic dermatitis and gastrointestinal disorders, as well as the data of skin patch test after a one-year period of dietary treatment. Patients and methods. The study group included 154 children (their age varied from 6 months to 18 years) with atopic dermatitis, for whomfood allergens were determined by allergic skin tests (skin prick and patch). These children were recommended an individual balanced replacement diet, where possible food allergens were replaced by other products that do not cause allergic reactions. After a one-year dietary treatment, 109 (70.8%) children (such number came for the second study) were tested repeatedly. The following aspects were evaluated for all these children: clinical course of atopic dermatitis (children’s mothers provided answers about exacerbation of allergic rash during the last 12 months, gastrointestinal disorders, and usedmedicines), severity of the progress of atopic dermatitis (SCORADindex). Besides, skin patch test with 25 food allergens was carried out. Results. Children who followed dietary recommendations were younger than children who failed to follow dietary recommendations because of a variety of reasons (P=0.01). Even 49 (62.8%) patients who followed dietary recommendations have shown the following results during the second test: allergic rash disappeared and they did not have to take medicines against allergy anymore. Patients who followed their individual dietary recommendations more rarely suffered from severe allergic rash problems during a 12-month period (P=0.01) and they had to take fewer medicines against allergy, compared to children who did not follow their dietary recommendations (P=0.001). Clinical course of atopic dermatitis in children who followed individual dietary recommendations was easier compared to children who did not follow such recommendations (P=0.001). During a one-year dietary treatment, 28.2% of children with atopic dermatitis became more tolerant to earlier food allergens. After the comparison of skin patch test results (before dietary treatment and after a one-year period), it was determined that only skin patch tests against buckwheat, oat, beef, and cacao did not change statistically significantly. Results of skin patch tests against other food products were found to be positive more rarely. Besides, children who followed their dietary recommendations suffered from gastrointestinal disorders more rarely as compared to children who did not follow their dietary recommendations (P=0.01). They suffered less from abdominal pain (P=0.01), abdominal distention (P=0.044), and constipation (P=0.035). Conclusions. Individual balanced replacement diet for children with atopic dermatitis helped to fully control nutrition of sick children from various age groups and had a positive effect on the clinical course of atopic dermatitis. Patients who followed their individual dietary recommendations suffered from severe allergic rash more rarely and they had to take fewer medicines against allergy as compared to children who did not follow dietary recommendations. Clinical course of atopic dermatitis in children who followed individual dietary recommendations was easier as compared to children who did not follow such recommendations. One-third of children with atopic dermatitis became more tolerant to earlier food allergens during a one-year period. After a oneyear dietotherapy treatment, positive patch test reactions to many food products appeared to be more rarely, except for buckwheat, oat, beef, and cacao. Besides, children who followed their dietary recommendations suffered from gastrointestinal disorders (abdominal pain, abdominal distention, and constipation) significantly more rarely as compared to children who did not follow their dietary recommendations

Lower airway virology in health and disease - from invaders to symbionts

Studies of human airway virome are relatively recent and still very limited. Culture-independent microbial techniques showed growing evidence of numerous viral communities in the respiratory microbial ecosystem. The significance of different acute respiratory viruses is already known in the pathogenesis of chronic conditions, such as asthma, cystic fibrosis (CF), or chronic obstructive lung disease (COPD), and their exacerbations. Viral pathogens, such as influenza, metapneumovirus, parainfluenza, respiratory syncytial virus, or rhinovirus, have been associated with impaired immune response, acute exacerbations, and decrease in lung function in chronic lung diseases. However, more data have attributed a role to Herpes family viruses or the newly identified Anelloviridae family of viruses in chronic diseases, such as asthma, idiopathic pulmonary fibrosis (IPF), or CF. Impaired antiviral immunity, bacterial colonization, or used medication, such as glucocorticoids or antibiotics, contribute to the imbalance of airway microbiome and may shape the local viral ecosystem. A specific part of virome, bacteriophages, frames lung microbial communities through direct contact with its host, the specific bacteria known as Pseudomonas aeruginosa or their biofilm formation. Moreover, antibiotic resistance is induced through phages via horizontal transfer and leads to more severe exacerbations of chronic airway conditions. Morbidity and mortality of asthma, COPD, CF, and IPF remains high, despite an increased understanding and knowledge about the impact of respiratory virome in the pathogenesis of these conditions. Thus, more studies focus on new prophylactic methods or therapeutic agents directed toward viral–host interaction, microbial metabolic function, or lung microbial composition rearrangement

Microbial colonization of the lower airways after insertion of a cuffed endotracheal tube in pediatric patient

Background. Ventilator-associated pneumonia (VAP) still remains a common device-associated hospital acquired infection in pediatric and adult intensive care units. The aim of our study was to determine ways of microbial transmission to the lower airways in intubated patients admitted to a single tertiary-care pediatric intensive care unit. Methods. This was a prospective observational study. A total of 284 sample sets (oropharyngeal swabs, swabs from the lumen of the proximal tip of an endotracheal tube, and bronchoalveolar lavage samples) were collected from 62 consecutive pediatric patients intubated for > 24 hours. Pulsed-field gel electrophoresis was performed on all isolated pathogens, which were later identified by MALDI biotyper (MALDI-TOF mass spectrometry). Results. Overall colonization rates were high and did not differ significantly at different time points in the oropharynx (75%–100%) and the lower airways (50%–76.5%). The endotracheal tube was colonized at lower rates: on day 1–3 (28.8%), on day 4–6 (52.7%), on day 7–9 (61.8%) and on day 10-12 (52.9%) (P < 0.001). A total of 191 matched sample sets from the lower airways and at least one site above were collected from 46 (74.2%) patients. In the oropharynx-lower airways group, Candida spp. (76.9%) and upper airway bacteria (63.2%); in the endotracheal tube-lower airway group, S. aureus (15.7%) and upper airway bacteria (21.1%); in the oropharynx-endotracheal tube-lower airway group, Enterobacteriaceae (70.8%) prevailed (P < 0.001). The mean survival (entrance) time to lower airways for the Acinetobacter/Pseudomonas/Stenotrophomonas group was 8.28 ± 0.81 days; for the Enterobacteriaceae group, 5.63 ± 0.41; and for Candida spp. group, 3.00 ± 0.82 days (P < 0.005). Conclusions. Oropharyngeal contamination of the lower airways is the most important route of colonization. Different pathogens enter the lower airways at different time intervals from the insertion of an endotracheal tube

Relevance of nasal potential difference in diagnosis of cystic fibrosis among children

Objective. To estimate significance of nasal potential difference (NPD) for the diagnosis of cystic fibrosis (CF) in children with clinical symptoms relevant to the disease, positive sweat test results, and/or supported by genetic analysis. Material and methods. Basal NPD measurement according to E. Alton’s modification was performed in 50 children with CF clinical symptoms supported by positive sweat test results, in 50 children with other obstructive lung diseases, and in 50 healthy children volunteers. A subgroup of 17 children with diagnosis confirmed by detected both mutations in the CF transmembrane regulatory gene was analyzed individually. Results. Basal NPD medium value recorded in 50 children with clinical symptoms of CF, supported by positive sweat test results and/or genetic analysis was -28.0±10.2 mV. Basal NPD medium value in the subgroup of children with detected both CF gene mutations (n=17) was higher than in the subgroup of children with undetected both CF gene mutations (n=33) (-37.1±7.0 mV vs. -23.4±8.3 mV, P<0.001). Basal NPD medium value in patients with other obstructive lung diseases and in healthy children was significantly lower than in the group of children with clinical symptoms of CF, who had positive sweat test results and/or CF gene mutations (consequently -18.1±3.6 mV and -15.5±4.3 mV vs.-28.0±10.2 mV, P<0.001). Conclusion. Basal NPD is a valuable tool for CF diagnosis in children, but further studies are necessary to establish NPD values related with CF genotype and to diminish intra subject variability of this test