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Pollak M, Shapira M, Gatt D, Golan-Tripto I, Goldbart A, Hazan G. Transient Tachypnea of the Newborn and the Association with Preschool Asthma. Ann Am Thorac Soc 2025; 22:881-886. [PMID: 40382764 DOI: 10.1513/annalsats.202408-873oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Accepted: 02/19/2025] [Indexed: 05/20/2025] Open
Abstract
Rationale: Transient tachypnea of the newborn (TTN) is characterized by respiratory distress in neonates, resulting from delayed clearance of fetal lung fluid. Although traditionally considered a self-limited condition, recent studies have indicated a potential association between TTN and an increased risk for respiratory infections during infancy. Objectives: This study investigates the possible link between TTN and healthcare utilization for asthma during childhood. Methods: This retrospective, case-control study used nationwide electronic records from Clalit Healthcare Services, Israel. The study included term infants born between 2011 and 2018 who were diagnosed with TTN (TTN+) and a control group without TTN (TTN-). The primary outcomes were asthma-related healthcare utilization up to age 6 years. Propensity score matching was used to adjust for potential confounders. Results: The study included 645 children with TTN and 187,809 in the TTN- group. In prematching analysis, the TTN+ group had a higher incidence of cesarean delivery and male sex. Postmatching, demographic, and clinical differences were balanced. Children in the TTN+ group had significantly higher rates of emergency room visits for asthma (2.05 times higher; P value (Pv) < 0.001; 95% confidence interval [CI], 1.46-2.89), asthma diagnoses (38% increase; Pv < 0.001; 95% CI, 1.18-1.51), and prescriptions for short-acting β-agonists (28% increase; Pv = 0.002; 95% CI, 1.1-2.89) than control subjects. These associations remained significant after adjusting for confounders. Conclusions: The findings suggest that TTN may be associated with a higher risk of developing asthma in childhood. This study may enhance our understanding of the potential long-term respiratory implications of TTN and could inform clinical follow-up strategies for affected infants.
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Affiliation(s)
- Mordechai Pollak
- Adelson School of Medicine, Ariel University, Ariel, Israel
- Pediatric Pulmonary Unit, Laniado Hospital, Netanya, Israel
- Pediatric Pulmonary Institute, Schneider Children's Hospital, Petah Tikva, Israel
| | - Moria Shapira
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel; and
| | - Dvir Gatt
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel; and
- Pediatric Pulmonary Unit, Saban Children's Hospital, Soroka University Medical Center, Beer Sheva, Israel
| | - Inbal Golan-Tripto
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel; and
- Pediatric Pulmonary Unit, Saban Children's Hospital, Soroka University Medical Center, Beer Sheva, Israel
| | - Aviv Goldbart
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel; and
- Pediatric Pulmonary Unit, Saban Children's Hospital, Soroka University Medical Center, Beer Sheva, Israel
| | - Guy Hazan
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel; and
- Pediatric Pulmonary Unit, Saban Children's Hospital, Soroka University Medical Center, Beer Sheva, Israel
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Bush A. Update in paediatric asthma. Curr Opin Pulm Med 2025; 31:279-286. [PMID: 39973758 DOI: 10.1097/mcp.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2025]
Abstract
PURPOSE OF REVIEW The field of paediatric asthma is rapidly moving, with the advent of new biologicals for severe asthma and increased understanding of preschool wheeze amongst other developments and insights. RECENT FINDINGS There is increasing evidence of efficacy in children for biologics directed against Type 2 inflammation (especially mepolizumab and dupilumab) as well encouraging evidence that Tezepelumab may be effective against Type 2 low phenotypes. The importance of airway remodelling and infection in the pathophysiology of preschool wheeze is increasingly appreciated. The treatment of preschool wheeze is moving from symptom-based to biomarker driven therapies. Other important areas are prediction of risk of asthma attacks, the SMART regime, the importance of climate change and reducing greenhouse gas emissions from inhalers while ensuring adequate therapy for young children, the association of early adverse environmental factors including childhood poverty and deprivation and the switch to race-neutral lung function equations. SUMMARY We are increasingly moving towards personalized medicine and the use of biomarkers to guide treatment of wheeze at all ages, but we need to move from counting cells to determining their functional status. Airway wall structural changes rather than inflammation may drive the progression of preschool wheeze to school age asthma.
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Affiliation(s)
- Andrew Bush
- National Heart and Lung Institute, Imperial College, and Imperial Centre for Paediatrics and Child Health, Consultant Paediatric Chest Physician, Royal Brompton Hospital, London, UK
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3
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Mohammed Abdul Wajid L, Saglani S, Nagakumar P, Heath G. Managing preschool wheeze: a qualitative study of parents' views and experiences. Arch Dis Child 2025; 110:352-357. [PMID: 39663004 DOI: 10.1136/archdischild-2024-327781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 11/27/2024] [Indexed: 12/13/2024]
Abstract
OBJECTIVE The aim of this study was to explore parents' views and experiences of managing preschool wheeze, including opinions on the use of investigations to inform treatment pathways. DESIGN Purposive sampling was used to recruit 16 participants from 14 families across England and Wales. Qualitative data were collected via semi-structured interviews with parents of children aged 1-5 years with preschool wheeze, conducted on Microsoft (MS) Teams. Data were transcribed and analysed using thematic analysis, facilitated by NVivo software package. RESULTS Analysis generated four themes: (1) pathway to diagnosis, (2) medication management, (3) living with preschool wheeze and (4) improving preschool wheeze healthcare. Findings suggest a negative impact of preschool wheeze on families' lives, including high levels of worry and limiting capacity for work and travel. Barriers to effective management of preschool wheeze included inconsistent terminologies and diagnostic uncertainty alongside limited education and management support. Other barriers included parental concerns about medications, delayed investigations and challenges with accessing specialist care. Parents were in favour of performing investigations to guide treatment pathways. CONCLUSION Parents' views highlight the problem of diagnosing and treating preschool wheeze at multiple system levels. To improve management and ensure that services for children with preschool wheeze are effective, there is an urgent need for consistent terminology, a unified approach to guide investigations and treatments and for upskilling healthcare professionals in primary and secondary care.
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Affiliation(s)
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Prasad Nagakumar
- Paediatric Respiratory Medicine, Birmingham Women's and Children's Hospital NHS Trust, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Gemma Heath
- Institute of Health and Neurodevelopment, Aston University, Birmingham, UK
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Hillson K, Saglani S, Custovic A. Preschool wheeze and asthma endotypes- implications for future therapy. Expert Rev Respir Med 2024; 18:1025-1039. [PMID: 39655566 DOI: 10.1080/17476348.2024.2440468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 12/06/2024] [Indexed: 12/14/2024]
Abstract
INTRODUCTION Preschool wheeze and school-aged asthma present a large healthcare burden. Both conditions are now recognized to be heterogeneous, with similar symptom presentation but likely different underlying lung pathology. AREAS COVERED Current treatment options for preschool wheeze are constrained by extrapolations from the management of school-aged children with asthma. While most cases of asthma at school age are caused by classical atopic, eosinophilic, Type-2 driven asthma, only a quarter of preschool children with wheeze fall into this category. Targeting treatment to specific underlying mechanisms resulting in preschool wheeze may alter the progression to school age asthma. Novel biologics have revolutionized the management of severe, treatment-resistant school age asthma, but a limited evidence base limits their use in young children. There are several potential future non-steroid-based treatment options in development, of which bacterial lysates show the most promise. EXPERT OPINION Effective treatment of preschool wheeze may preserve lung function into later life, which may alter the progression trajectory toward school age asthma. Endotype-driven management will enable more effective treatment of both preschool wheeze and school age asthma.
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Affiliation(s)
- Kushalinii Hillson
- National Heart and Lung Institute, Imperial College London, London, UK
- Paediatric Respiratory Medicine Department, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Paediatric Respiratory Medicine Department, Royal Brompton Hospital, London, UK
- NIHR Imperial Biomedical Research Centre (BRC), London, UK
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
- NIHR Imperial Biomedical Research Centre (BRC), London, UK
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Makrinioti H, Fainardi V, Bonnelykke K, Custovic A, Cicutto L, Coleman C, Eiwegger T, Kuehni C, Moeller A, Pedersen E, Pijnenburg M, Pinnock H, Ranganathan S, Tonia T, Subbarao P, Saglani S. European Respiratory Society statement on preschool wheezing disorders: updated definitions, knowledge gaps and proposed future research directions. Eur Respir J 2024; 64:2400624. [PMID: 38843917 DOI: 10.1183/13993003.00624-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 05/05/2024] [Indexed: 07/28/2024]
Abstract
Since the publication of the European Respiratory Society (ERS) task force reports on the management of preschool wheezing in 2008 and 2014, a large body of evidence has accumulated suggesting that the clinical phenotypes that were proposed (episodic (viral) wheezing and multiple-trigger wheezing) do not relate to underlying airway pathology and may not help determine response to treatment. Specifically, using clinical phenotypes alone may no longer be appropriate, and new approaches that can be used to inform clinical care are needed for future research. This ERS task force reviewed the literature published after 2008 related to preschool wheezing and has suggested that the criteria used to define wheezing disorders in preschool children should include age of diagnosis (0 to <6 years), confirmation of wheezing on at least one occasion, and more than one episode of wheezing ever. Furthermore, diagnosis and management may be improved by identifying treatable traits, including inflammatory biomarkers (blood eosinophils, aeroallergen sensitisation) associated with type-2 immunity and differential response to inhaled corticosteroids, lung function parameters and airway infection. However, more comprehensive use of biomarkers/treatable traits in predicting the response to treatment requires prospective validation. There is evidence that specific genetic traits may help guide management, but these must be adequately tested. In addition, the task force identified an absence of caregiver-reported outcomes, caregiver/self-management options and features that should prompt specialist referral for this age group. Priorities for future research include a focus on identifying 1) mechanisms driving preschool wheezing; 2) biomarkers of treatable traits and efficacy of interventions in those without allergic sensitisation/eosinophilia; 3) the need to include both objective outcomes and caregiver-reported outcomes in clinical trials; 4) the need for a suitable action plan for children with preschool wheezing; and 5) a definition of severe/difficult-to-treat preschool wheezing.
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Affiliation(s)
- Heidi Makrinioti
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- H. Makrinioti and V. Fainardi contributed equally to the manuscript
| | - Valentina Fainardi
- Department of Medicine and Surgery, Paediatric Clinic, University of Parma, Parma, Italy
- H. Makrinioti and V. Fainardi contributed equally to the manuscript
| | - Klaus Bonnelykke
- Department of Pediatrics, University of Copenhagen, Copenhagen, Denmark
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, Imperial NIHR Biomedical Research Centre, and Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Lisa Cicutto
- Community Research Department, National Jewish Health, University of Colorado, Denver, CO, USA
| | - Courtney Coleman
- Patient Involvement and Engagement, European Lung Foundation, Sheffield, UK
| | - Thomas Eiwegger
- Department of Pediatric and Adolescent Medicine, University Hospital St Pölten, St Pölten, Austria
- Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, ON, Canada
- Department of Immunology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Claudia Kuehni
- Institute of Social and Preventive Medicine, Bern, Switzerland
| | - Alexander Moeller
- Department of Respiratory Medicine, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Eva Pedersen
- Institute of Social and Preventive Medicine, Bern, Switzerland
| | - Marielle Pijnenburg
- Department of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Thomy Tonia
- Institute of Social and Preventive Medicine, Bern, Switzerland
| | - Padmaja Subbarao
- SickKids Research Institute, Toronto, ON, Canada
- S. Saglani and P. Subbarao contributed equally to the manuscript
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, Imperial NIHR Biomedical Research Centre, and Centre for Paediatrics and Child Health, Imperial College London, London, UK
- S. Saglani and P. Subbarao contributed equally to the manuscript
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Adamiec A, Cieślik M, Mączka K, Tarnoruda J, Jensen S, Chawes B, Bønnelykke K, Konradsen JR, Söderhäll C, Makrinioti H, Camargo CA, Hasegawa K, Ambrożej D, Jartti T, Ruszczyński M, Feleszko W. A systematic review and meta-analysis on absolute eosinophil counts and the risk of asthma in preschool children with wheezing: An EAACI Task Force Report. Pediatr Allergy Immunol 2024; 35:e14078. [PMID: 38339981 DOI: 10.1111/pai.14078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 02/12/2024]
Abstract
Preschool children with wheezing disorders pose diagnostic and therapeutic challenges and consume substantial healthcare resources. Peripheral eosinophil blood count (EBC) has been proposed as a potential indicator for future asthma development. This review by the European Academy of Allergy and Clinical Immunology (EAACI) Preschool Wheeze Task Force aimed to provide systematic evidence for the association between increased EBC and the risk of future asthma, as well as to identify potential cutoff values. In February 2023, a search of PubMed, EMBASE, and Cochrane Library databases was conducted to identify studies comparing EBCs in preschool children with wheezing who continued to wheeze later in life and those who did not. Included observational studies focused on children aged <6 years with a wheezing disorder, assessment of their EBCs, and subsequent asthma status. No language or publication date restrictions were applied. Among the initial 3394 studies screened, 10 were included in the final analysis, involving 1225 patients. The data from these studies demonstrated that high EBC in preschool children with wheezing is associated with future asthma development, with odds ratios of 1.90 (95% CI: 0.45-7.98, p = .38), 2.87 (95% CI: 1.38-5.95, p < .05), and 3.38 (95% CI: 1.72-6.64, p < .05) for cutoff values in the <300, 300-449, and ≥450 cells/μL ranges, respectively. Defining a specific cutoff point for an elevated EBC lacks consistency, but children with EBC >300 cells/μL are at increased risk of asthma. However, further research is needed due to the limitations of the included studies. Future investigations are necessary to fully elucidate the discussed association.
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Affiliation(s)
- Aleksander Adamiec
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Maja Cieślik
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
| | - Katarzyna Mączka
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Tarnoruda
- Department of Paediatrics, Medical University of Warsaw Children's Hospital, Warsaw, Poland
| | - Signe Jensen
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jon R Konradsen
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Cilla Söderhäll
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Heidi Makrinioti
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Dominika Ambrożej
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Tuomas Jartti
- Department of Paediatrics, Turku University Hospital and Turku University, Turku, Finland
- PEDEGO Research Unit, Medical Research Centre, University of Oulu, Turku, Finland
- Department of Pediatrics, Oulu University Hospital, Turku, Finland
| | - Marek Ruszczyński
- Department of Paediatrics, Medical University of Warsaw Children's Hospital, Warsaw, Poland
| | - Wojciech Feleszko
- Department of Paediatric Pneumonology and Allergy, Medical University of Warsaw Children's Hospital, Warsaw, Poland
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Salehian S, Fleming L, Saglani S, Custovic A. Phenotype and endotype based treatment of preschool wheeze. Expert Rev Respir Med 2023; 17:853-864. [PMID: 37873657 DOI: 10.1080/17476348.2023.2271832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Preschool wheeze (PSW) is a significant public health issue, with a high presentation rate to emergency departments, recurrent symptoms, and severe exacerbations. A heterogenous condition, PSW comprises several phenotypes that may relate to a range of pathobiological mechanisms. However, treating PSW remains largely generalized to inhaled corticosteroids and a short acting beta agonist, guided by symptom-based labels that often do not reflect underlying pathways of disease. AREAS COVERED We review the observable features and characteristics used to ascribe phenotypes in children with PSW and available pathobiological evidence to identify possible endotypes. These are considered in the context of treatment options and future research directions. The role of machine learning (ML) and modern analytical techniques to identify patterns of disease that distinguish phenotypes is also explored. EXPERT OPINION Distinct clusters (phenotypes) of severe PSW are characterized by different underlying mechanisms, some shared and some unique. ML-based methodologies applied to clinical, biomarker, and environmental data can help design tools to differentiate children with PSW that continues into adulthood, from those in whom wheezing resolves, identifying mechanisms underpinning persistence and resolution. This may help identify novel therapeutic targets, inform mechanistic studies, and serve as a foundation for stratification in future interventional therapeutic trials.
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Affiliation(s)
- Sormeh Salehian
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Adnan Custovic
- NIHR Imperial Biomedical Research Centre (BRC), London, UK
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Bush A. Basic clinical management of preschool wheeze. Pediatr Allergy Immunol 2023; 34:e13988. [PMID: 37492909 DOI: 10.1111/pai.13988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
Preschool wheeze is very common and often difficult to treat. Most children do not require any investigations; only a detailed history and physical examination to ensure an alternative diagnosis is not being missed; and the differential diagnosis, and hence investigation protocols for the child in whom a major illness is suspected, shows geographical variation. The pattern of symptoms may be divided into episodic viral and multiple trigger to guide treatment, but the pattern of symptoms must be re-assessed regularly. However, symptom patterns are a poor guide to underlying pathology. Attention to the proper use of spacers, and adverse environmental exposures such as tobacco smoke exposure, is essential. There are no disease-modifying therapies, so therapy is symptomatic. This paper reviews recent advances in treatment, including new data on the place of leukotriene receptor antagonists, prednisolone for acute attacks of wheeze, and antibiotics, based on new attempts to understand the underlying pathology in a way that is clinically practical.
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Affiliation(s)
- Andrew Bush
- Imperial College, London, UK
- National Heart and Lung Institute, London, UK
- Royal Brompton Harefield NHS Foundation Trust, London, UK
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Fitzpatrick AM, Grunwell JR, Cottrill KA, Mutic AD, Mauger DT. Blood Eosinophils for Prediction of Exacerbation in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1485-1493.e8. [PMID: 36738927 PMCID: PMC10164693 DOI: 10.1016/j.jaip.2023.01.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although clinical features of type 2 inflammation have been associated with poorer longitudinal outcomes in preschool children with recurrent wheezing, it remains difficult to predict which children are at highest risk for poor outcomes during a routine clinical encounter. OBJECTIVE We tested the hypothesis that prespecified cut points of blood eosinophil counts would predict exacerbation and treatment response outcomes in preschool children with recurrent wheezing and that prediction could be improved with the addition of a second biomarker. METHODS Data from 3 clinical trials of 1,074 preschool children aged 12 to 71 months with recurrent wheezing were merged. The primary outcome was the occurrence of any exacerbation during follow-up. Secondary outcomes included the annualized rate of wheezing exacerbations and the occurrence of any exacerbation requiring hospitalization. Exploratory analyses focused on exacerbation outcomes, offline exhaled nitric oxide concentrations, and caregiver-reported asthma control scores after inhaled corticosteroid treatment initiation. RESULTS Each blood eosinophil cut point was associated with increased odds of exacerbation, higher exacerbation rates, and greater hospitalization occurrence in preschool children with recurrent wheezing. However, outcome detection was improved in children with more elevated blood eosinophil counts. Addition of a second biomarker of type 2 inflammation improved outcome detection and was further associated with an improved response to initiation of daily inhaled corticosteroids in exploratory analyses. However, the specificity of blood eosinophils was poor. CONCLUSIONS Although validation studies are warranted, blood eosinophil cut points may be useful for clinical assessment and future studies of exacerbation and treatment response in preschool children with recurrent wheezing.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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de Araújo Gueiros Lira GV, Pontes da Silva GA, Sarinho ESC. Caregiver's sense of coherence and adherence to paediatric asthma treatment. Paediatr Respir Rev 2023; 45:45-51. [PMID: 36842951 DOI: 10.1016/j.prrv.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
Asthma is a chronic respiratory condition that needs to be well controlled to avoid compromising patients' quality of life. In the paediatric population, the role of caregivers is essential in this process. Moreover, adequate asthma control is integral to a child's emotional well-being and to improving the child's ability to participate fully in family and social life. One of the main reasons for uncontrolled asthma is low adherence to treatment, by patients and caregivers. Identifying factors mediating the involvement and participation of caregivers through evaluations of caregivers' sense of coherence can help in the adoption of strategies aimed at effectively directing adherence behaviour through educational and motivational interventions. The goal of this review article is to provide an overview of the sense of coherence as a construct of Antonovsky's salutogenic theory, and to identify its role as a key piece in the successful management of asthma in children.
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Affiliation(s)
- Georgia Véras de Araújo Gueiros Lira
- Allergy and Immunology Research Centre, Federal University of Pernambuco, Recife, Pernambuco, Brazil; Department of Paediatrics, Medical Sciences Centre, Federal University of Pernambuco, Recife, Brazil; Graduate Program in Child and Adolescent Health, Federal University of Pernambuco, Recife, Pernambuco, Brazil.
| | - Giselia Alves Pontes da Silva
- Department of Paediatrics, Medical Sciences Centre, Federal University of Pernambuco, Recife, Brazil; Graduate Program in Child and Adolescent Health, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Emanuel Sávio Cavalcanti Sarinho
- Allergy and Immunology Research Centre, Federal University of Pernambuco, Recife, Pernambuco, Brazil; Department of Paediatrics, Medical Sciences Centre, Federal University of Pernambuco, Recife, Brazil; Graduate Program in Child and Adolescent Health, Federal University of Pernambuco, Recife, Pernambuco, Brazil
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Exhaled Breath Analysis for Investigating the Use of Inhaled Corticosteroids and Corticosteroid Responsiveness in Wheezing Preschool Children. J Clin Med 2022; 11:jcm11175160. [PMID: 36079088 PMCID: PMC9456576 DOI: 10.3390/jcm11175160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/28/2022] Open
Abstract
Exhaled breath analysis has great potential in diagnosing various respiratory and non-respiratory diseases. In this study, we investigated the influence of inhaled corticosteroids (ICS) on exhaled volatile organic compounds (VOCs) of wheezing preschool children. Furthermore, we assessed whether exhaled VOCs could predict a clinical steroid response in wheezing preschool children. We performed a crossover 8-week ICS trial, in which 147 children were included. Complete data were available for 89 children, of which 46 children were defined as steroid-responsive. Exhaled VOCs were measured by GC-tof-MS. Statistical analysis by means of Random Forest was used to investigate the effect of ICS on exhaled VOCs. A set of 20 VOCs could best discriminate between measurements before and after ICS treatment, with a sensitivity of 73% and specificity of 67% (area under ROC curve = 0.72). Most discriminative VOCs were branched C11H24, butanal, octanal, acetic acid and methylated pentane. Other VOCs predominantly included alkanes. Regularised multivariate analysis of variance (rMANOVA) was used to determine treatment response, which showed a significant effect between responders and non-responders (p < 0.01). These results show that ICS significantly altered the exhaled breath profiles of wheezing preschool children, irrespective of clinical treatment response. Furthermore, exhaled VOCs were capable of determining corticosteroid responsiveness in wheezing preschool children.
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Abstract
When a child with severe asthma (asthma defined clinically for the purposes of this review as wheeze, breathlessness, and chest tightness sometimes with cough) does not respond to treatment, it is important to be sure that an alternative or additional diagnosis is not being missed. In school age children, the next step is a detailed protocolized assessment to determine the nature of the problem, whether within the airway or related to co-morbidities or social/environmental factors, in order to personalize the treatment. For example, those with refractory difficult asthma due to persistent non-adherence may benefit from using budesonide and formoterol combined in a single inhaler [single maintenance and reliever treatment (SMART)] as both a reliever and preventer. For those with steroid-resistant Type 2 airway inflammation, the use of biologicals such as omalizumab and mepolizumab should be considered, but for mepolizumab at least, there is a paucity of pediatric data. Protocols are less well developed in preschool asthma, where steroid insensitive disease is much more common, but the use of two simple measurements, aeroallergen sensitization, and peripheral blood eosinophil count, allows the targeted use of inhaled corticosteroids (ICSs). There is also increasing evidence that chronic airway infection may be important in preschool wheeze, increasing the possibility that targeted antibiotics may be beneficial. Asthma in the first year of life is not driven by Type 2 inflammation, so beyond avoiding prescribing ICSs, no evidence based recommendations can be made. In the future, we urgently need to develop objective biomarkers, especially of risk, so that treatment can be targeted effectively; we need to address the scandal of the lack of data in children compared with adults, precluding making evidence-based therapeutic decisions and move from guiding treatment by phenotypes, which will change as the environment changes, to endotype based therapy.
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Affiliation(s)
- Andrew Bush
- National Heart and Lung Institute, Imperial College, London, United Kingdom.,Imperial Centre for Paediatrics and Child Health, London, United Kingdom.,Royal Brompton Hospital, London, United Kingdom
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