Asthma

Pediatric Pharmacology for the Primary Care Provider: Advances and Limitations

Despite >1 in 5 children taking prescription drugs in the United States, off-label drug use is common. To increase the study of drugs in children, regulatory bodies have enacted legislation to incentivize and require pediatric drug studies. As a result of this legislation, novel trial approaches, and an increase in personnel with pediatric expertise, there have been numerous advancements in pediatric drug development. With this review, we aim to highlight developments in pediatric pharmacology over the past 6 years for the most common disease processes that may be treated pharmacologically by the pediatric primary care provider. Using information extracted from label changes between 2018 and 2023, the published literature, and Clinicaltrials.gov, we discuss advances across multiple therapeutic areas relevant to the pediatric primary care provider, including asthma, obesity and related disorders, mental health disorders, infections, and dermatologic conditions. We highlight instances in which new drugs have been developed on the basis of a deeper mechanistic understanding of illness and instances in which labels have been expanded in older drugs on the basis of newly available data. We then consider additional factors that affect pediatric drug use, including cost and nonpharmacologic therapies. Although there is work to be done, efforts focused on pediatric-specific drug development will increase the availability of evidence-based, labeled guidance for commonly prescribed drugs and improve outcomes through the safe and effective use of drugs in children.

Quality-of-Life Assessment in Children with Mild to Moderate Bronchial Asthma

Background and Objectives: Assess the quality of life of children aged 2-10 with mild to moderate bronchial asthma. To evaluate the general health condition of children with mild and moderate severity bronchial asthma. To determine health changes in children with mild- and moderate-severity bronchial asthma as they grow older. To evaluate the impact of mild- and moderate-severity bronchial asthma on children's daily and social activities, physical health, emotional state, and general well-being. Materials and Methods: A comparative cross-sectional study was conducted in March-June 2020. Parents or guardians of 2-10-year-old children without bronchial asthma and children with mild to moderate bronchial asthma were interviewed after receiving their written informed consent. The questionnaire was based on the standardized quality-of-life quiz SF-36. A total of 248 questionnaires were collected-106 from the parents or guardians of children with bronchial asthma and 142 from parents/guardians of children without bronchial asthma. For further analysis, 106 children without bronchial asthma and with no chronic conditions were selected. Quantitative variables were compared using the Mann-Whitney U test and qualitative data using the chi-square (χ2) criteria. Quantitative data were described by giving means, medians, and standard deviations (SD); qualitative features by giving relative frequencies. Statistical data were analyzed using SPSS and Excel 2020. Results: Children with mild and moderate asthma exhibit poorer health compared to their healthy counterparts. Only 20.7% of respondents with asthma reported excellent or very good health, contrasting with 64.1% of healthy children (p < 0.001). As children with asthma age, their general condition improves, with 46.2% showing improvement in the past year, while 42.5% of healthy children had a stable condition (p < 0.05). In various activities, children with asthma face more constraints than healthy children (p < 0.05), including energetic activities (sick-59.5%; healthy-10.3%), moderate activities (sick-24.5%; healthy-4.7%), climbing stairs (sick-22.7%; healthy-3.8%), and walking over 100 m (sick-9.4%; healthy-0%). Children with asthma are more likely to experience exhaustion, anxiety, tiredness, lack of energy, and restraint in public activities (p < 0.05). Conclusions: Parents/caregivers of children with mild to moderate bronchial asthma rate their health worse than those of healthy children do. As children with mild to moderate bronchial asthma grow, the disease impact on their overall well-being decreases. Children with mild to moderate bronchial asthma, compared to healthy children, experience more limitations in vigorous or moderate activities; face more difficulties climbing stairs or walking more than 100 m; frequently feel exhaustion, anxiety, fatigue, or lack of energy; and encounter restrictions in social activities.

Impulse oscillometry bronchodilator response in preschool children

BACKGROUND

In preschoolers, performing an acceptable spirometry and measuring bronchodilator response (BDR) is challenging; in this context, impulse oscillometry (IOS) represents a valid alternative. However, more studies on the standardization of BDR for IOS in young children are required.

OBJECTIVE

The objective of the study was to identify optimal thresholds to define a positive BDR test with IOS in preschoolers with suspected asthma.

METHODS

Children aged 3-6 years with suspected asthma and their lung function investigated with both IOS and spirometry pre- and post-BDR were retrospectively analyzed. The spirometric BDR was defined as positive when the change of FEV1 was ≥12% or ≥200 mL. The oscillometric BDR was defined as positive in case of change of at least -40% in R5, +50% in X5, and -80% in AX.

RESULTS

Among 72 patients, 36 (age 5.2 ± 1 years; 64% boys) were selected for the subsequent analysis according to ATS/ERS quality criteria of measurements; specifically, 19 patients did not meet IOS and 36 did not meet spirometry criteria. The spirometric BDR was found positive in seven subjects (19.4%); conversely, a positive oscillometric BDR was identified in four patients (11.1%). No patient presented a positive BDR response with both methods. In IOS, the mean decrease in R5 and AX was 19.9% ± 10% and 44% ± 22.1%, and the mean increase in X5 was 23.3% ± 17.8%, respectively. A decrease in R5 of 25.7% (AUC 0.77, p = .03) and an increase in X5 of 25.7% (AUC 0.75, p = .04) showed the best combination of sensitivity and specificity to detect an increase of FEV1 ≥ 12% and/or ≥200 mL.

CONCLUSION

The IOS represents a valid alternative to spirometry to measure BDR in preschool children and should be the gold standard in this age group. We are considering a decrease of 26% in R5 and an increase of 26% in X5 as diagnostic threshold for BDR.

Improving Health Equity and Outcomes for Children and Adolescents: The Role of School-Based Health Centers (SBHCs)

School-based health centers (SBHCs) provide a critical point of access to youth in low-resource communities. By providing a combination of primary care, reproductive health, mental health, vision, dental, and nutrition services, SBHCs improve the health, wellbeing, and academic achievement of the students they serve. SBHCs operate in collaboration with schools and community primary care providers to optimize the management of chronic health conditions and other health concerns that may result in suboptimal scholastic achievement and other quality of life measures. Conveniently located in or near school buildings and providing affordable, child- and adolescent-focused care, SBHCs reduce barriers to youth accessing high quality health care. SBHCs provide essential preventive care services such as comprehensive physical examinations and immunizations to students without a primary care provider, assist in the management of chronic health conditions such as asthma, and provide reproductive and sexual health services such as the provision of contraceptives, screening and treatment for sexually transmitted infections (STIs), and management of pregnancy. Additionally, some SBHCs provide vision screenings, dental care, and nutrition counseling to students who may not otherwise access these services. SBHCs have been demonstrated to be a cost-effective model of health care delivery, reducing both health care and societal costs related to illness, disability, and lost productivity.

Influence of the gut and airway microbiome on asthma development and disease

There are ample data to suggest that early-life dysbiosis of both the gut and/or airway microbiome can predispose a child to develop along a trajectory toward asthma. Although individual studies show clear associations between dysbiosis and asthma development, it is less clear what (collection of) bacterial species is mechanistically responsible for the observed effects. This is partly due to issues related to the asthma diagnosis and the broad spectrum of anatomical sites, sample techniques, and analysis protocols that are used in different studies. Moreover, there is limited attention for potential differences in the genetics of individuals that would affect the outcome of the interaction between the environment and that individual. Despite these challenges, the first bacterial components were identified that are able to affect the transcriptional state of human cells, ergo the immune system. Such molecules could in the future be the basis for intervention studies that are now (necessarily) restricted to a limited number of bacterial species. For this transition, it might be prudent to develop an ex vivo human model of a local mucosal immune system to better and safer explore the impact of such molecules. With this approach, we might move beyond association toward understanding of causality.

A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations

Background

Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation.

Methods

We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications.

Results

The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months.

Conclusions

This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.

Effect of accelerated rehabilitation nursing programmes on surgical site wound infection in patients undergoing laparoscopic cholecystectomy: A meta-analysis

This study aims to evaluate the effect of an accelerated rehabilitation nursing programme on the incidence of surgical site wound infections in patients undergoing laparoscopic cholecystectomy. Relevant studies regarding the use of an accelerated rehabilitation nursing programme in laparoscopic cholecystectomy were retrieved from databases, including PubMed, Web of Science, the Cochrane Library, EMBASE, CNKI and Wanfang Database. The search was conducted from the inception of each database until June 2023. Two independent researchers performed the literature screening, data collection and quality assessment of the included studies. Odds ratio (OR) and 95% confidence interval (CI) were used as the measures of effect. Statistical analysis was conducted using Stata 17.0, and a sensitivity analysis and publication bias evaluation were performed. A total of 21 studies involving 2480 patients (1179 in the intervention group and 1301 in the control group) were included. The meta-analysis revealed that the incidence of surgical site wound infections in the intervention group was significantly lower than in the control group (1.18% vs. 5.99%, OR: 0.322, 95% CI: 0.168-0.556, p < 0.001). Current evidence suggests that implementing accelerated rehabilitation nursing programmes for patients undergoing laparoscopic cholecystectomy has a clinically significant effect, leading to a substantial reduction in the incidence of surgical site wound infections. However, owing to the low quality of some of the included studies, further high-quality, multicentre, large-sample randomised controlled trials are required to validate the conclusions of this study.

The Child Opportunity Index and asthma morbidity among children younger than 5 years old in Washington, DC

BACKGROUND

Place-based social determinants of health are associated with pediatric asthma morbidity. However, there is little evidence on how social determinants of health correlate to the disproportionately high rates of asthma morbidity experienced by children <5 years old.

OBJECTIVES

This study sought to evaluate census tract associations between the Child Opportunity Index ±COI) and at-risk rates (ARRs) for pediatric asthma-related emergency department (ED) encounters and hospitalizations in Washington, DC.

METHODS

This was a cross-sectional study of children <5 years old with physician-diagnosed asthma included in the DC Asthma Registry between January 2018 and December 2019. Census tract COI score (1-100) and its 3 domains (social/economic, health/environmental, and educational) were the exposures (source: www.diversitydatakids.org). ED and hospitalization ARRs (outcomes) were created by dividing counts of ED encounters and hospitalizations by populations with asthma for each census tract and adjusted for population-level demographic (age, sex, insurance), clinical (asthma severity), and community (violent crime and limited English proficiency) covariates.

RESULTS

Within a study population of 3806 children with a mean age of 2.4 ± 1.4 years, 2132 (56%) had 5852 ED encounters, and 821 (22%) had 1418 hospitalizations. Greater census tract overall COI, social/economic COI, and educational COI were associated with fewer ED ARRs. There were no associations between the health/environmental COI and ED ARRs or between the COI and hospitalization ARRs.

CONCLUSION

Improving community-level social, economic, and educational opportunity within specific census tracts may reduce ED ARRs in this population.

miR-20b attenuates airway inflammation by regulating TXNIP and NLRP3 inflammasome in ovalbumin-induced asthmatic mice

OBJECTIVES

Asthma is a chronic inflammatory disorder of the airway and is associated with pyroptosis. microRNAs (miRNAs) underlie pathogenic mechanism in asthma. This study is expected to evaluate the role of miR-20b in asthma-induced airway inflammation via regulating thioredoxin-interacting protein (TXNIP) and NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome.

METHODS

The asthmatic mouse model was established via ovalbumin (OVA) induction. Expressions of miR-20b, TXNIP, and NLRP3 in lung tissues were determined. Bronchial hyperresponsiveness was appraised, cells in bronchoalveolar lavage fluid were counted and categorized, and histopathological damage was observed. Levels of inflammatory and pyroptotic cytokines were measured. The binding relationship of miR-20b and TXNIP was testified. Co-location and interaction between TXNIP and NLRP3 were detected. Mice were infected with the lentivirus packaged with pcDNA3.1-TXNIP or pcDNA3.1-NLRP3 for joint experiments to observe the pathological changes of mice.

RESULTS

miR-20b was poorly expressed, while TXNIP and NLRP3 were highly expressed in OVA-induced mice. miR-20b overexpression attenuated airway inflammation and pyroptosis, manifested by alleviation of histopathological damage, declined numbers of total cells and inflammatory cells, lowered bronchial hyperresponsiveness, decreased levels of pro-inflammatory and pyroptotic cytokines, and increased anti-inflammatory cytokines. miR-20b targeted TXNIP and inhibited TXNIP expression, and TXNIP can bind to NLRP3 and upregulated NLRP3 expression. Upregulation of TXNIP or NLRP3 could reverse the protecting role of miR-20b overexpression in OVA-induced mice.

CONCLUSION

miR-20b inhibited TXNIP expression to reduce the binding of TXNIP and NLRP3, thus restricting pyroptosis and airway inflammation of asthmatic mice.

The Footprint of Microbiome in Pediatric Asthma-A Complex Puzzle for a Balanced Development

Considered to be of greater complexity than the human genome itself, the microbiome, the structure of the body made up of trillions of bacteria, viruses, and fungi, has proven to play a crucial role in the context of the development of pathological processes in the body, starting from various infections, autoimmune diseases, atopies, and culminating in its involvement in the development of some forms of cancer, a diagnosis that is considered the most disabling for the patient from a psychological point of view. Therefore, being a cornerstone in the understanding and optimal treatment of a multitude of ailments, the body's microbiome has become an intensively studied subject in the scientific literature of the last decade. This review aims to bring the microbiome-asthma correlation up to date by classifying asthmatic patterns, emphasizing the development patterns of the microbiome starting from the perinatal period and the impact of pulmonary dysbiosis on asthmatic symptoms in children. Likewise, the effects of intestinal dysbiosis reflected at the level of homeostasis of the internal environment through the intestine-lung/vital organs axis, the circumstances in which it occurs, but also the main methods of studying bacterial variability used for diagnostic purposes and in research should not be omitted. In conclusion, we draw current and future therapeutic lines worthy of consideration both in obtaining and maintaining remission, as well as in delaying the development of primary acute episodes and preventing future relapses.

Protecting Children's Health: Asthma and Climate Change

ABSTRACT

Children are particularly vulnerable to the impacts of climate change. Their lungs are developing, making children with asthma especially susceptible to temperature extremes, variations in precipitation, poor air quality, and changes in pollen and flora. Structural and social determinants of health, such as racism and poverty, that disproportionately affect children of color are linked to higher rates of asthma and negative effects of climate change. These factors lead to increased absences from school and social activities, loss of work for caregivers, and increased health care costs, thus negatively affecting children, their families, and the greater community. Nurses must support caregivers and children to link climate change to asthma care, be involved in health education; climate change mitigation and adaptation strategies and policies; and develop the evidence to address climate change and asthma strategies. We address the impacts of climate change on children with asthma and nursing adaptation responses.

CTRP3 regulates NF-κB and TGFβ1/Smad3 pathways to alleviate airway inflammation and remodeling in asthmatic mice induced by OVA

BACKGROUND

Asthma is a common illness with chronic airway inflammation. C1q/tumor necrosis factor (TNF)-related protein 3 (CTRP3) plays a vital role ininflammatory response, but its effect on asthma is imprecise. Herein, we analyzed the functions of CTRP3 in asthma.

METHODS

The BALB/c mice were randomized into four groups: control, ovalbumin (OVA), OVA+vector, and OVA+CTRP3. The asthmatic mice model was established by OVA stimulation. Overexpression of CTRP3 was implemented by the transfection of corresponding adeno-associated virus 6 (AAV6). The contents of CTRP3, E-cadherin, N-cadherin, smooth muscle alpha-actin (α-SMA), phosphorylated (p)-p65/p65, transforming growth factor-beta 1 (TGFβ1), and p-Smad3/Smad3 were determined by Western blot analysis. The quantity of total cells, eosinophils, neutrophils, and lymphocytes in bronchoalveolar lavage fluid (BALF) was assessed by using a hemocytometer. The contents of tumor necrosis factor-α and interleukin-1β in BALF were examined by enzyme-linked immunesorbent serologic assay. The lung function indicators and airway resistance (AWR) were measured. The bronchial and alveolar structures were evaluated by hematoxylin and eosin staining and sirius red staining.

RESULTS

The CTRP3 was downregulated in mice of OVA groups; however, AAV6-CTRP3 treatment markedly upregulated the expression of CTRP3. Upregulation of CTRP3 diminished asthmatic airway inflammation by decreasing the number of inflammatory cells and the contents of proinflammatory factors. CTRP3 markedly lessened AWR and improved lung function in OVA-stimulated mice. Histological analysis found that CTRP3 alleviated OVA-induced airway remodeling in mice. Moreover, CTRP3 modulated NF-κB and TGFβ1/Smad3 pathways in OVA-stimulated mice.

CONCLUSION

CTRP3 alleviated airway inflammation and remodeling in OVA-induced asthmatic mice via regulating NF-κB and TGFβ1/Smad3 pathways.

Relationship Between Physical Activity and Adult Asthma Control Using NHANES 2011-2020 Data

BACKGROUND The purpose of this study was to determine whether PA is associated with asthma control using data from the National Health and Nutrition Examination Survey (NHANES) for 2011-2020. We did not find a relationship between physical activity (PA) and asthma control. MATERIAL AND METHODS In this study, we measured asthma control by counting asthma attacks and emergency room visits for asthma in the past year. Physical activity was divided into recreational physical activity and work physical activity. A total of 3158 patients (≥20 years old) were included in the study, of which 2375 were in the asthma attack group and 2844 were in the emergency care group, with indicators of asthma control and physical activity as dichotomous variables. Multiple sets of covariates were selected, such as age, gender, and race. Multiple logistic regression analysis and subgroup analysis were used to analyze the data. RESULTS Active workload was significantly correlated with acute asthma attacks, but the relationship with emergency care was not statistically significant. We found that the relationship between physical activity and emergency care was influenced by race, education, and economic level. CONCLUSIONS The amount of work activity was correlated with acute asthma attacks, and the relationship between physical activity and emergency case was influenced by race, education, and economic level.

Drugs Prescribed for Asthma and Their Adverse Effects on Dental Health

Asthma is a chronic, heterogeneous respiratory pathology characterized by reversible airway inflammation. Therapeutics focus on symptom reduction and control, aimed at preserving normal pulmonary function and inducing bronchodilatation. The objective of this review is to describe the adverse effects produced by anti-asthmatic drugs on dental health, according to the reported scientific evidence. A bibliographic review was carried out on databases, such as Web of science, Scopus, and ScienceDirect. Most anti-asthmatic medications are administered using inhalers or nebulizers, making it impossible to avoid contact of the drug with hard dental tissues and oral mucosa, and thus promoting a greater risk of oral alterations, mainly due to decreases in the salivary flow and pH. Such changes can cause diseases, such as dental caries, dental erosion, tooth loss, periodontal disease, bone resorption, as well as fungal infections, such as oral candidiasis.

CTNNAL1 enhances glucocorticoid sensitivity in HDM-induced asthma mouse model through deactivating hsp90 signaling pathway

AIMS

Adhesion molecules play vital roles in the induction of airway hyperresponsiveness (AHR) or airway inflammation. The down-regulation of catenin alpha-like 1 (CTNNAL1) in the bronchial epithelial cells of asthma patients and mice models has been noted in our previous study. In this work, we further explore the underlying mechanism of CTNNAL1 in asthma.

MAIN METHODS

We constructed a house dust mite (HDM)-induced asthma animal model on control mice and applied CTNNAL1-siRNA transfection to create CTNNAL1-deficient mice.

KEY FINDINGS

We documented much more severe airway inflammation and increased leukocyte infiltration in the lungs of the CTNNAL1-deficient mice comparing to control mice, along with elevated expression of inflammatory cytokines. Dexamethasone (DEX) treatment led to less reduced inflammation in CTNNAL1-deficient mice compared with control mice. Immunoprecipitation confirmed the interaction between heat shock protein90 (hsp90) and CTNNAL1. The expression of hsp90 was upregulated after CTNNAL1 silencing. Meanwhile, the use of hsp90 inhibitor geldanamycin significantly decreased the expression of NR3C1, ICAM-1 and the ratio of p-p65/p65 in CTNNAL1-silenced 16HBE14o- cells. Both geldanamycin and DEX could function to suppress the expression of ICAM-1 and the phosphorylation level of p65. Nevertheless, the anti-inflammatory effect of DEX proved less potent than geldanamycin in the CTNNAL1-silenced group. The combined therapy of geldanamycin and DEX significantly decreased the inflammatory responses in CTNNAL1-deficient HBE cells than DEX monotherapy.

SIGNIFICANCE

Our study corroborates that CTNNAL1 deficiency induced aggravated airway inflammation and rendered insensitivity to glucocorticoids via triggering hsp90 signaling pathway.

Social Risks and Health Care Utilization Among a National Sample of Children With Asthma

OBJECTIVES

Prior studies using single-center populations have established associations between social risks and health care utilization among children with asthma. We aimed to evaluate associations between social risks and health care utilization among a nationally representative sample of children with asthma.

STUDY DESIGN

In this cross-sectional study, we utilized the 2018-2019 National Survey of Children's Health to identify children 2 to 17 years old with asthma. Using the Healthy People (HP) 2030 social determinants of health (SDOH) framework, we identified 31 survey items assessing 18 caregiver-identified social risks as exposure variables and classified them into the 5 HP SDOH domains (Economy, Education, Health care, Community, and Environment). Primary outcome was caregiver-reported health care utilization. Associations between individual social risks and total number of SDOH domains experienced with health care utilization were assessed.

RESULTS

The weighted study population included 8.05 million children, 96% of whom reported ≥1 social risk. Fourteen social risks, spanning all 5 SDOH domains, were significantly associated with increased health care utilization. The 3 risks with the highest adjusted odds ratios (aOR) of health care utilization included: experiencing discrimination (aOR 3.26 [95% confidence interval (CI): 1.75, 6.08]); receiving free/reduced lunch (aOR 2.16, [95% CI 1.57, 2.98]); and being a victim of violence (aOR 2.11, [95% CI 1.11, 4]). Children with risks across more SDOH domains reported significantly higher health care utilization.

CONCLUSIONS

Among our national population of children with asthma, social risks are prevalent and associated with increased health care utilization, highlighting their potential contribution to pediatric asthma morbidity.

Skin Barrier Function and Infant Tidal Flow-Volume Loops-A Population-Based Observational Study

Background: The relationship between the skin barrier- and lung function in infancy is largely unexplored. We aimed to explore if reduced skin barrier function by high transepidermal water loss (TEWL), or manifestations of eczema or Filaggrin (FLG) mutations, were associated with lower lung function in three-month-old infants. Methods: From the population-based PreventADALL cohort, 899 infants with lung function measurements and information on either TEWL, eczema at three months of age and/or FLG mutations were included. Lower lung function by tidal flow-volume loops was defined as a ratio of time to peak tidal expiratory flow to expiratory time (tPTEF/tE) <0.25 and a tPTEF <0.17 s (<25th percentile). A high TEWL >8.83 g/m2/h (>75th percentile) denoted reduced skin barrier function, and DNA was genotyped for FLG mutations (R501X, 2282del4 and R2447X). Results: Neither a high TEWL, nor eczema or FLG mutations, were associated with a lower tPTEF/tE. While a high TEWL was associated with a lower tPTEF; adjusted OR (95% CI) 1.61 (1.08, 2.42), the presence of eczema or FLG mutations were not. Conclusions: Overall, a high TEWL, eczema or FLG mutations were not associated with lower lung function in healthy three-month-old infants. However, an inverse association between high TEWL and tPTEF was observed, indicating a possible link between the skin barrier- and lung function in early infancy.

Oximetría de pulso en enfermedades respiratorias

El pulsioxímetro es un dispositivo que utiliza principios de espectrofotometría y fotopletismografía para la medición de la saturación de oxígeno arterial, así como el ciclo cardiaco y respiratorio, lo que resulta útil para monitorear pacientes con compromisorespiratorio. En este trabajo se realiza una revisión bibliográfica de los principios físicos del pulsioxímetro y sus avances más recientes en pacientes con enfermedad pulmonar obstructiva crónica (EPOC), asma y COVID-19. Se encontró que la oximetría de pulso es una herramienta confiable y eficaz en el diagnóstico y la prevención de complicaciones en pacientes con estas enfermedades respiratorias.

Six Diagnoses of Separation: Impact of COVID-19 on Pediatric Emergency Department Visits: A Multicenter Study

BACKGROUND

Coronavirus disease 2019 (COVID-19) arrived in the New York metropolitan area in early March 2020. Recommendations were made to self-quarantine within households and limit outside visits, including those to clinics and hospitals, to limit the spread of the virus. This resulted in a decrease in pediatric emergency department (ED) visits. However, it is unclear how this affected visits for some common diagnoses such as anxiety, appendicitis, asthma, headaches, seizures, and urinary tract infection (UTI). These diagnoses were chosen a priori, as they were felt to represent visits to the ED, for which the diagnoses would likely not be altered based on COVID exposure or quarantine due to their acute nature.

OBJECTIVES

Our goal was to investigate the effect of COVID-19 on common pediatric diagnoses seen in the pediatric ED using a large multihospital database.

METHODS

We conducted a retrospective cohort study of consecutive pediatric patients (age ≤ 21 years) between March 1 and November 30 in 2019 and 2020 in 28 hospital EDs within 150 miles of New York City. We compared the change in the number of visits from 2019 to 2020 for the following diagnoses: anxiety, appendicitis, asthma, headache, seizures, and UTI.

RESULTS

Our database contained 346,230 total pediatric visits. From 2019 to 2020, total visits decreased by 61%. Decreases for specific diagnoses were 75% for asthma, 64% for headaches, 47% for UTI, 32% for anxiety, 28% for seizures, and 18% for appendicitis (p value for each comparison < 0.0001).

CONCLUSIONS

We found a marked decrease in ED visits for six common pediatric diagnoses after COVID-19 arrived in our area. We suspect that this decrease was due to recommendations to quarantine and fear of contracting the virus. Further studies on other diagnoses and potential complications due to the delay in seeking care are needed.

Airway Bacterial Biodiversity in Exhaled Breath Condensates of Asthmatic Children-Does It Differ from the Healthy Ones?

Asthma etiopathology is still not fully determined. One of its possible causes can be found in airway microbiome dysbiosis. The study's purpose was to determine whether there are any significant differences in the bacterial microbiome diversity of lower airways microbiota of asthmatic children, since knowledge of this topic is very scarce. To the authors' knowledge, this is the first research using exhaled breath condensates in children's lower airways for bacterial assessment. Exhaled breath condensates (EBC) and oropharyngeal swabs were obtained from pediatric asthmatic patients and a healthy group (n = 38, 19 vs. 19). The microbial assessment was conducted through genetic material PCR amplification, followed by bacterial 16S rRNA amplicon sequencing. Collected data were analyzed, in terms of taxonomy and alpha and beta diversity between assessed groups. Swab samples are characterized by higher species richness compared to exhaled breath condensates (Shannon diversity index (mean 4.11 vs. 2.867, p = 9.108 × 10^-8), observed features (mean 77.4 vs. 17.3, p = 5.572 × 10^-11), and Faith's phylogenetic diversity (mean 7.686 vs. 3.280 p = 1.296 × 10^-10)). Asthmatic children had a higher abundance of bacterial species (Shannon diversity index, mean 3.029 vs. 2.642, p = 0.026) but more even distribution (Pielou's evenness, mean 0.742 vs. 0.648, p = 0.002) in EBC than healthy ones; the same results were observed within pediatric patients born naturally within EBC samples. In children with a positive family history of allergic diseases, alpha diversity of lower airway material was increased (Shannon's diversity index p = 0.026, Faith's phylogenetic diversity p = 0.011, observed features p = 0.003). Class Gammaproteobacteria and Bacilli were less abundant among asthmatics in the exhaled breath samples. The most dominant bacteria on a phylum level in both sample types were Firmicutes, followed by Proteobacteria and Actinobacteriota. The obtained outcome of higher bacterial diversity of lower airways among asthmatic patients indicates a further need for future studies of microbiota connection with disease pathogenesis.

Targeting non-coding RNA H19: A potential therapeutic approach in pulmonary diseases

Non-coding RNA is still one of the most popular fields in biology research. In recent years, people paid more attention to the roles of H19 in lung diseases, which expressed abnormally in various pathological process. Therefore, this review focus on the regulatory role of H19 in asthma, pulmonary arterial hypertension (PAH), idiopathic pulmonary fibrosis (IPF), lung injury, pneumonia, lung cancer, etc. And the potential therapeutic agents and molecular treatments of H19 are collected. The aim is to demonstrate its underlying mechanism in pulmonary diseases and to guide the basic research targeting H19 into clinical drug translation.

School Nurses on the Front Lines of Healthcare: Emergencies Associated With Sport and Physical Activities (Part 3): Shortness of Breath in a Pediatric Athlete During a Track Event

Sport participation is an important part of the development, both physically and mentally, of children and adolescents in the United States. Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life-threatening illnesses or injuries may occur. It is important for the school nurse to recognize potential life-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow-up at their primary healthcare provider's office, or directly to the closest emergency department [ED] via Emergency Medical Services [EMS]). This article specifically describes the initial assessment and management of shortness of breath in an adolescent athlete during a track event.

Interaction between serum cotinine and body mass index on asthma in the children: a cross-sectional study

Background

The purpose of this study was to explore the interaction between serum cotinine (a marker of environmental tobacco smoke exposure) and body mass index (BMI) on asthma in children.

Methods

This cross-sectional study relied on representative samples of American children included in the National Health and Nutrition Examination Survey in 1999–2018. Multivariate logistic regression analyses were to evaluate the association between serum cotinine level, BMI z-score and asthma. Serum cotinine was dichotomized at 0.0436 ng/mL. Interactions were examined by the estimated joint effect of BMI and serum cotinine levels. We also performed interaction analyses in age and ethnicity subgroups.

Results

Among the 11,504 children aged 3 to 12 years included in the analysis, 15.86% (n = 1852) had childhood asthma, 15.68% (n = 1837) were overweight, and 17.31% (n = 2258) were obese. Compared to low serum cotinine, high serum cotinine was significantly associated with asthma [odds ratio (OR) = 1.190, 95% confidence interval (CI): 1.004–1.410]. Overweight (OR = 1.275, 95%CI: 1.079–1.506) and obesity (OR = 1.636, 95%CI: 1.354–1.977) were significantly associated with asthma compared with normal weight. The adjusted attributable proportion of interaction = 0.206 (95%CI: 0.075–0.337) and the adjusted synergy index = 1.617 (95%CI: 1.126–2.098) indicated that there was a significant synergistic effect of serum cotinine levels and BMI on asthma. In males, females, non-Hispanic White and other Hispanic, there were synergistic interactions between serum cotinine levels and BMI on asthma.

Conclusion

A synergistic interaction between serum cotinine and overweight/obesity on childhood asthma was found. For children with asthma, both intensive weight interventions in overweight or obese children and intensive passive smoking interventions in children exposed to the environment may be important.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03571-0.

Social Determinants of Health and At-Risk Rates for Pediatric Asthma Morbidity

BACKGROUND AND OBJECTIVES

Compared with population-based rates, at-risk rates (ARRs) account for underlying variations of asthma prevalence. When applied with geospatial analysis, ARRs may facilitate more accurate evaluations of the contribution of place-based social determinants of health (SDOH) to pediatric asthma morbidity. Our objectives were to calculate ARRs for pediatric asthma-related emergency department (ED) encounters and hospitalizations by census-tract in Washington, the District of Columbia (DC) and evaluate their associations with SDOH.

METHODS

This population-based, cross-sectional study identified children with asthma, 2 to 17 years old, living in DC, and included in the DC Pediatric Asthma Registry from January 2018 to December 2019. ED encounter and hospitalization ARRs (outcomes) were calculated for each DC census-tract. Five census-tract variables (exposures) were selected by using the Healthy People 2030 SDOH framework: educational attainment, vacant housing, violent crime, limited English proficiency, and families living in poverty.

RESULTS

During the study period, 4321 children had 7515 ED encounters; 1182 children had 1588 hospitalizations. ARRs varied 10-fold across census-tracts for both ED encounters (64-728 per 1000 children with asthma) and hospitalizations (20-240 per 1000 children with asthma). In adjusted analyses, decreased educational attainment was significantly associated with ARRs for ED encounters (estimate 12.1, 95% confidence interval [CI] 8.4 to 15.8, P <.001) and hospitalizations (estimate 1.2, 95% CI 0.2 to 2.2, P = .016). Violent crime was significantly associated with ARRs for ED encounters (estimate 35.3, 95% CI 10.2 to 60.4, P = .006).

CONCLUSION

Place-based interventions addressing SDOH may be an opportunity to reduce asthma morbidity among children with asthma.

Asthma and Vitamin D Deficiency: Occurrence, Immune Mechanisms, and New Perspectives

Asthma, as a chronic inflammatory condition of the airways, has a considerable prevalence among children. Vitamin D might play a role in asthma pathogenesis by affecting the development of the lung, regulating the immune responses, and remodeling of airway smooth muscle (ASM). Study results on the association between the serum level of vitamin D and asthma severity have suggested a converse relationship between lower vitamin D levels and more severe clinical courses. However, they are not consistent in these findings and have shown insignificant correlations, as well. The possible effects of vitamin D on asthma have led researchers to consider this vitamin a potential prophylactic and therapeutic tool for managing children with variant degrees of asthma. Adding vitamin D to the routine corticosteroid therapy of asthmatic children is another field of interest that has shown promising results. In this narrative review study, we aim to elaborate on the existing knowledge on the role of vitamin D in asthma pathogenesis and prognosis, explain the controversies that exist on the effectiveness of treating patients with vitamin D supplements, and make a general conclusion about how vitamin D actually is linked to asthma in children.

Probiotics in Children with Asthma

A type-2 immune response usually sustains wheezing and asthma in children. In addition, dysbiosis of digestive and respiratory tracts is detectable in patients with wheezing and asthma. Probiotics may rebalance immune response, repair dysbiosis, and mitigate airway inflammation. As a result, probiotics may prevent asthma and wheezing relapse. There is evidence that some probiotic strains may improve asthma outcomes in children. In this context, the PROPAM study provided evidence that two specific strains significantly prevented asthma exacerbations and wheezing episodes. Therefore, oral probiotics could be used as add-on asthma therapy in managing children with asthma, but the choice should be based on documented evidence.

Les β2-agonistes pour la bronchiolite virale

Question

Au mois de février, un bébé de 9 mois est amené à ma clinique d’urgence rurale après un épisode de 2 jours de toux et de congestion, et de 1 jour de difficultés respiratoires. Une auscultation des poumons révèle des sons diffus, de faibles sibilances et des crépitants. En tenant compte de l’âge du bébé, de la symptomatologie et de la saison hivernale, le diagnostic probable est une bronchiolite. Les β2-agonistes inhalés sont-ils un traitement approprié pour un tel patient?

Réponse

Il n’est pas indiqué d’utiliser des β2-agonistes inhalés chez les enfants de 2 ans et moins souffrant de bronchiolite. La sibilance fait le plus souvent partie des critères diagnostiques d’une bronchiolite, qui est une infection virale des voies respiratoires inférieures chez les jeunes enfants. Au contraire de l’asthme, la bronchiolite ne compte pas parmi ses symptômes la contraction des muscles lisses du poumon. Le traitement de la bronchiolite exige des soins de soutien, et il n’a pas été démontré que les interventions pharmacologiques, comme les β2-agonistes, les corticostéroïdes et les antibiotiques, raccourcissaient la durée de la maladie, diminuaient sa gravité ou réduisaient les taux d’hospitalisation. Il pourrait y avoir un sous-groupe de nourrissons souffrant de bronchiolite qui répondraient à un traitement aux β2-agonistes; toutefois, ce groupe n’a pas encore été entièrement défini dans la littérature jusqu’ici.

[Not Available]

Question

A 9-month-old baby presented to my rural emergency department with 2 days of cough and congestion and 1 day of breathing difficulties in the month of February. An auscultation examination of the lungs indicated there were scattered, faint wheezes and coarse sounds. Based on the baby’s age, symptomatology, and the winter season, the likely diagnosis was bronchiolitis. Are inhaled β₂-agonists an appropriate treatment for this patient?

Answer

The use of inhaled β₂-agonists in children younger than 2 years of age with bronchiolitis is not indicated. Wheezing is most commonly part of the diagnosis of bronchiolitis, a lower respiratory viral infection in young children. Unlike with asthma, smooth muscle constriction in the lungs is not a symptom of bronchiolitis. Treatment of bronchiolitis requires supportive care, but pharmaceutical interventions such as β₂-agonists, steroids, and antibiotics have not been shown to decrease length of illness, illness severity, or hospitalization rates. There may be a subgroup of infants with bronchiolitis who respond to β₂-agonists treatment; however, this group has not been fully identified in the literature to date.

Sophoraflavanone G from Sophora flavescens Ameliorates Allergic Airway Inflammation by Suppressing Th2 Response and Oxidative Stress in a Murine Asthma Model

Sophoraflavanone G (SG), isolated from Sophora flavescens, has anti-inflammatory and anti-tumor bioactive properties. We previously showed that SG promotes apoptosis in human breast cancer cells and leukemia cells and reduces the inflammatory response in lipopolysaccharide-stimulated macrophages. We investigated whether SG attenuates airway hyper-responsiveness (AHR) and airway inflammation in asthmatic mice. We also assessed its effects on the anti-inflammatory response in human tracheal epithelial cells. Female BALB/c mice were sensitized with ovalbumin, and asthmatic mice were treated with SG by intraperitoneal injection. We also exposed human bronchial epithelial BEAS-2B cells to different concentrations of SG to evaluate its effects on inflammatory cytokine levels. SG treatment significantly reduced AHR, eosinophil infiltration, goblet cell hyperplasia, and airway inflammation in the lungs of asthmatic mice. In the lungs of ovalbumin-sensitized mice, SG significantly promoted superoxide dismutase and glutathione expression and attenuated malondialdehyde levels. SG also suppressed levels of Th2 cytokines and chemokines in lung and bronchoalveolar lavage samples. In addition, we confirmed that SG decreased pro-inflammatory cytokine, chemokine, and eotaxin expression in inflammatory BEAS-2B cells. Taken together, our data demonstrate that SG shows potential as an immunomodulator that can improve asthma symptoms by decreasing airway-inflammation-related oxidative stress.

MALT1 in asthma children: A potential biomarker for monitoring exacerbation risk and Th1/Th2 imbalance-mediated inflammation

BACKGROUND

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 (MALT1) participates in the immune-related allergic response and inflammation flare, while its clinical role in asthma children is still unknown. Herein, this study aimed to investigate MALT1 expression, and its correlation with exacerbation risk, T helper (Th)1, Th2 cells (and their secreted cytokines), as well as inflammatory cytokines in asthma children.

METHODS

Sixty children with asthma exacerbation and 60 children with remission asthma were enrolled in this study; then their blood MALT1, Th1, Th2 cells, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interferon-gamma (IFN-γ), and interleukin-4 (IL-4) were detected. Besides, blood MALT1 in another 20 health controls was also determined.

RESULTS

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 was highest in children with asthma exacerbation, followed by children with remission asthma, and lowest in health controls (p < 0.001). MALT1 could distinguish children with asthma exacerbation from children with remission asthma (area under the curve (AUC): 0.757, 95% CI: 0.670-0.843). In children with asthma exacerbation, MALT1 was negatively linked with IFN-γ (p = 0.002) and Th1 cells (p = 0.050), but positively related to Th2 cells (p = 0.027) and exhibited a positive correlation trend (without statistical significance) with IL-4 (p = 0.066); meanwhile, MALT1 was positively correlated with exacerbation severity (p = 0.010) and TNF-α (p = 0.003), but not linked with IL-6 (p = 0.096). In children with remission asthma, MALT1 only was negatively associated with Th1 cells (p = 0.023), but positively linked with TNF-α (p = 0.023).

CONCLUSION

Mucosa-associated lymphoid tissue lymphoma translocation protein 1 serves as a potential biomarker for monitoring exacerbation risk and Th1/Th2 imbalance-mediated inflammation of asthma children.

A multi‐disciplinary approach to chronic cough in children

Objectives

(1) To highlight the important causes of chronic and recurrent cough in children. (2) To discuss multidisciplinary approach to management of chronic/recurrent pediatric cough.

Methods

Review of scholarly articles, guidelines, expert panels via PubMed and Google Scholar.

Conclusion

Chronic cough (CC) in children is mainly attributed to persistent bacterial bronchitis, asthma, nonspecific cough, and gastroesophageal reflux disease (GERD) symptoms. A multi‐disciplinary approach is cost‐effective and aids with earlier diagnosis and appropriate treatment. Congenital or acquired narrowing of the subglottis is the leading ENT cause for recurrent croup (RC) in children. Laryngeal cleft‐type 1 is commonly seen in children with recurrent aspiration and CC. Children are usually referred to pulmonologists for wet cough not responding to treatment. Eosinophilic esophagitis (EoE) and GERD should be considered in the differential diagnosis of CC in children with both respiratory symptoms and failure to thrive.

Level of Evidence: 2a

CTNNAL1 participates in the regulation of mucus overproduction in HDM‐induced asthma mouse model through the YAP‐ROCK2 pathway

Our previous study indicated that adhesion molecule catenin alpha‐like 1(CTNNAL1) is downregulated in airway epithelial cells of asthma patients and asthma animal model but little is known about how the CTNNAL1 affects asthma pathogenesis. To reveal the direct relationship between asthma and CTNNAL1, CTNNAL1‐deficient mouse model in bronchopulmonary tissue was constructed by introducing CTNNAL1‐siRNA sequence using adeno‐associated virus (AAV) as vector. The mouse model of asthma was established by stimulation of house dust mite (HDM). After HDM‐challenged, there was marked airway inflammation, especially mucus hypersecretion in the CTNNAL1‐deficient mice. In addition, the CTNNAL1‐deficient mice exhibited an increase of lung IL‐4 and IL‐13 levels, as well as a significant increase of goblet cell hyperplasia and MUC5AC after HDM exposure. The expression of Yes‐associated protein (YAP), protein that interacted with α‐catenin, was downregulated after CTNNAL1 silencing and was upregulated due to its overexpression. In addition, the interaction between CTNNAL1 and YAP was confirmed by CO‐IP. Besides, inhibition of YAP could decrease the secretion of MUC5AC, IL‐4 and IL‐13 in CTNNAL1‐deficient 16HBE14o‐cells. Above results indicated us that CTNNAL1 regulated mucus hypersecretion through YAP pathway. In addition, the expression of ROCK2 increased when CTNNAL1 was silenced and decreased after YAP silencing, and inhibition of YAP decreased the expression of ROCK2 in CTNNAL1‐deficient HBE cells. Inhibition of ROCK2 decreased MUC5AC expression and IL‐13 secretion. In all, our study demonstrates that CTNNAL1 plays an important role in HDM‐induced asthma, mediating mucus secretion through the YAP‐ROCK2 pathway.

Randomized trial of a portable HEPA air cleaner intervention to reduce asthma morbidity among Latino children in an agricultural community

BACKGROUND

Data on pediatric asthma morbidity and effective environmental interventions in U.S. agricultural settings are few. We evaluated the effectiveness of HEPA air cleaners on asthma morbidity among a cohort of rural Latino children.

METHODS

Seventy-five children with poorly controlled asthma and living in non-smoking homes were randomly assigned to asthma education alone or along with HEPA air cleaners placed in their sleeping area and home living room. The Asthma Control Test (ACT) score, asthma symptoms in prior 2 weeks, unplanned clinical utilization, creatinine-adjusted urinary leukotriene E4 (uLTE4 [ng/mg]), and additional secondary outcomes were evaluated at baseline, six, and 12 months. Group differences were assessed using multivariable-adjusted generalized estimating equations. Incident rate ratios of ever experiencing the metrics of poorer asthma health during follow-up (suboptimal asthma management) were estimated using Poisson regression models in secondary analysis.

RESULTS

Mean child age was 9.2 and 8.6 years in intervention and control groups, respectively, and two-thirds of participants were male. Primary analysis of repeated measures of ACT score did not differ between groups (HEPA group mean change compared to controls 10% [95% CI: - 12-39%]). A suggestion of greater decrease in uLTE4 (ng/mg creatinine) was observed (- 10% [95% CI: - 20 -1%]). Secondary analysis showed children with HEPAs were less likely to have an ACT score meeting a clinically defined cutoff for poorly controlled asthma using repeated measures (IRR: 0.45 [95% CI: 0.21-0.97]). In Poisson models, intervention participants had reduced risk of ever meeting this cutoff (IRR: 0.43 [95% CI: 0.21-0.89]), ever having symptoms in the past 2 weeks (IRR: 0.71 [95% CI: 0.52-0.98]), and lower risk of any unplanned clinical utilization (IRR: 0.35 [95% CI: 0.13-0.94]) compared to control participants.

DISCUSSION

The HAPI study showed generally improved outcomes among children in the HEPA air cleaner group. However, primary analyses did not meet statistical significance and many outcomes were subjective (self-report) in this unblinded study, so findings must be interpreted cautiously. HEPA air cleaners may provide additional benefit for child asthma health where traditional asthmagens (traffic, tobacco smoke) are not prominent factors, but larger studies with more statistical power and blinded designs are needed.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04919915 . Date of retrospective registration: May 19, 2021.

Climate Change and State of the Science for Children's Health and Environmental Health Equity

INTRODUCTION

Climate change is impacting the physical and mental health of children and families. This is a state of the science update regarding the impacts of climate change for pediatric-focused health care providers and advanced practice registered nurses.

METHOD

Using an equity lens, the authors reviewed and synthesized current literature regarding the adverse impacts of climate change.

RESULTS

The poor and communities of color are disproportionately impacted by climate change. Physical health impacts include increased vector and water-born infectious diseases, increases in asthma and respiratory infections, and undernutrition. Social disruptions lead to human trafficking. Climate change is associated with mental health concerns, including anxiety and posttraumatic stress after natural disasters.

DISCUSSION

As clinicians, pediatric-focused providers, and advanced practice registered nurses should use multipronged and interdisciplinary approaches to address or prevent the adverse impacts of climate change. Advocacy at all government levels is necessary to safeguard children and vulnerable populations.

Chronic pediatric diseases and risk for reading difficulties: a narrative review with recommendations

Literacy is a major social determinant of health, rooted in skills that develop during early childhood. Children arriving at kindergarten unprepared to learn to read are more likely to have low reading proficiency thereafter. General and health literacy are highly correlated, affecting understanding of health conditions, treatment adherence, and transition to self-care and adult healthcare services. The American Academy of Pediatrics (AAP) recommends literacy and school readiness promotion during well-visits and neurodevelopmental surveillance is emphasized across primary and subspecialty care. While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and chronic medical conditions are less appreciated and under-researched. This review applies an eco-bio-developmental framework to explore literacy across five complex chronic conditions affecting millions of children worldwide: asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease. In each, integration of an efficient reading brain network may be impacted by direct factors, such as ischemia, anesthesia, and/or medications, and also indirect factors, such as altered parent-child routines, hospital stays, and missed school. By integrating literacy into care management plans for affected children, pediatric primary care and specialty providers are poised to identify risks early, target guidance and interventions, and improve academic and health outcomes. IMPACT: While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and/or chronic medical conditions such as asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease are substantial, less appreciated, and under-researched. General and health literacy are highly correlated, with implications for the understanding one's health condition, treatment adherence, and transitioning to self-care, which is especially important for children with complex and/or chronic illness. Pediatric primary care and specialty providers are poised to integrate reading and literacy into care management plans for children with complex and/or chronic illness, including early screening, guidance, support, and interventions.

Barrier Impairment and Type 2 Inflammation in Allergic Diseases: The Pediatric Perspective

Allergic diseases represent a global burden. Although the patho-physiological mechanisms are still poorly understood, epithelial barrier dysfunction and Th2 inflammatory response play a pivotal role. Barrier dysfunction, characterized by a loss of differentiation, reduced junctional integrity, and altered innate defence, underpins the pathogenesis of allergic diseases. Epithelial barrier impairment may be a potential therapeutic target for new treatment strategies Up now, monoclonal antibodies and new molecules targeting specific pathways of the immune response have been developed, and others are under investigation, both for adult and paediatric populations, which are affected by atopic dermatitis (AD), asthma, allergic rhinitis (AR), chronic rhinosinusitis with nasal polyps (CRSwNP), or eosinophilic esophagitis (EoE). In children affected by severe asthma biologics targeting IgE, IL-5 and against IL-4 and IL-13 receptors are already available, and they have also been applied in CRSwNP. In severe AD Dupilumab, a biologic which inhibits both IL-4 and IL-13, the most important cytokines involved in inflammation response, has been approved for treatment of patients over 12 years. While a biological approach has already shown great efficacy on the treatment of severe atopic conditions, early intervention to restore epithelial barrier integrity, and function may prevent the inflammatory response and the development of the atopic march.

Characteristics and outcomes associated with two asthma quality of care measures

OBJECTIVE

We investigated asthma quality measures to understand patient characteristics associated with non-attainment of quality care and measure the association with asthma-related emergency department (ED) visits or inpatient hospitalizations (IPs).

METHODS

Using administrative data from ALL Kids, Alabama's Children's Health Insurance Program, from 2013 to 2019 we calculated non-attainment of the Medication Management for Asthma (MMA) and Asthma Medication Ratio (AMR) quality measures. Patient characteristics and asthma-related ED visits and IPs associated with non-attainment of the MMA and AMR measures were assessed using logit regression models and Marginal effects at the mean.

RESULTS

Among 2528 children with asthma, 53.2% failed to attain the MMA measure and 8.5% the AMR measure. Prior asthma-related ED visits or IP stays increased likelihood of non-attainment by 14.8 percentage points (95% CI 8.6-20.9) for MMA and 7.3 percentage points (95% CI 2.8-11.8) for AMR. Among 868 children (34.3%) with three years of continuous enrollment, AMR non-attainment was associated with a 6.1 percentage point increase in ED or IP utilization (95% CI 1.3-10.9), however MMA non-attainment was not associated with either outcome. Prior ED visit/IP stay was associated with a 17.2 percentage point (95% CI 8.3-26.1) increase in the likelihood of a subsequent ED visit/IP stay among those with non-attainment MMA and a 15.5 percentage point increase (95% CI 6.9-24.2) for non-attainment AMR.

CONCLUSIONS

Patient characteristics associated with non-attainment of asthma quality measures presents actionable evidence to guide improvement efforts as non-attainment AMR increases the risk of subsequent ED visits and IP stays.

Spirometry reference equations for children from a Middle Eastern population

BACKGROUND

Spirometry is a clinically useful test that can be used to assess lung function among children. Different equations had been formulated to determine the spirometric reference values depending on several individual characteristics. However, the widely used equations do not produce perfect suitability for Middle Eastern children.

OBJECTIVES

This study aims to formulate Middle Eastern-specific equations that may be applicable for other populations in the region.

METHODS

The spirometric data were collected from Jordanian children between the ages of 6 and 17 years. The collected data were used to formulate customised reference equations for Middle Eastern children using generalised additive models for location, scale and shape. The newly formulated equation results were compared with Global Lung Initiative 2012 (GLI-2012) equations predicted values.

RESULTS

Spirometric values for 1576 healthy participants (870 males) were used to formulate the new equations. The assessment of z-scores produced by the present study equations and GLI-2012 indicated that the new equations were more suitable than GLI-2012 for Middle Eastern children. In-depth analysis of the results indicated that the suitability of GLI-2012 equations varied between different age points.

CONCLUSION

This study formulated new spirometric reference equations for Middle Eastern children that can improve the diagnosis and management of different respiratory conditions.

E3 Ubiquitin Ligase March1 Facilitates OX40L Expression in Allergen-Stimulated Dendritic Cells Through Mediating the Ubiquitination of HDAC11

Background

It was demonstrated that membrane-associated RING-CH 1 (March 1) might play an important role in the pathogenesis of asthma.

Methods

The levels of mRNA and protein were measured by qRT-PCR and Western blot, respectively. Immunofluorescence assay was used to determine whether March1 co-locates with HDAC11. Co-immunoprecipitation was performed to examine the combination of proteins. Moreover, luciferase assay was used to measure the promoter activity of genes.

Results

The mRNA and protein levels of both March1 and OX40 ligand (OX40L) were increased in the dendritic cells (DCs) from asthmatic children and asthmatic animals. Histone deacetylase 11 (HDAC11) protein was decreased in the DCs from asthmatic children and asthmatic model. Increasing of March1 or decreasing of March1 only affect the expression of HDAC11 in protein level. Besides, increasing of HDAC11 could inhibit OX40L expression, and decreasing of HDAC11 promoted OX40L expression in house dust mites (HDMs)-treated DCs. Increasing of HDAC11 notably reversed the promotion of March1 to OX40L expression. Our data further proved that March1 reduced the protein level of HDAC11 through inducing ubiquitination and degradation. HDAC11 combined with krüppel-like factor 4 (KLF4) to decrease the activity of OX40L gene promoter, thus to downregulate the level of OX40L.

Conclusion

Overall, our data showed that HDAC11 promoted KLF4-dependent OX40L decreasing. However, March1 promoted OX40L expression through enhancing the ubiquitination and degradation of HDAC11 and subsequent blocking the inhibition of HDAC11 to OX40L.

Evaluation of efficiency and safety of oral corticosteroid therapy in children patients with exacerbations of asthma: A protocol for systematic review and meta-analysis

BACKGROUND

Asthma is the most frequently occurring obstructive airway disease, it inflicts the highest morbidity among children. Among the paediatric populace, severe exacerbations of asthma are a common reason behind patient consultations and hospitalizations. Oral corticosteroids are a primary component in the treatment of asthma exacerbations; however, there is controversy regarding how corticosteroids functions.

METHODS

The present review will conduct a search on MEDLINE, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Chinese BioMedical Literature. The search will cover the databases from their beginning to May 2021. The search aims to identify all the randomized controlled studies on oral corticosteroids in treating children with asthma exacerbations. Two independent authors will choose studies, perform data extraction, and use an appropriate tool to assess the bias risk in the selected articles. Moreover, a sensitivity analysis will be performed to assess the robustness of the results. The RevMan (version 5.3) software will be employed to perform data synthesis and statistical analysis.

RESULTS

This study will examine the efficiency and safeness of oral corticosteroid therapy to treat children with asthma exacerbations by pooling the results of individual studies.

CONCLUSION

The findings of this study will provide vigorous evidence to judge whether oral corticosteroid therapy is an efficiency strategy to treat patients with asthmatic exacerbations.

OSF REGISTRATION NUMBER

May 20, 2021.osf.io/3ghjt. (https://osf.io/3ghjt/).

GLCCI1 reduces collagen deposition and airway hyper-responsiveness in a mouse asthma model through binding with WD repeat domain 45B

Asthma is a serious public health problem worldwide, without effective therapeutic methods. Our previous study indicated that glucocorticoid‐induced transcript 1 gene (GLCCI1) knockout reduces the sensitivity to glucocorticoid in asthmatic mouse. Here, we explored the role and action mechanism of GLCCI1 in asthma development. In ovalbumin‐sensitized mice, airway resistance and tissue damage increased, the production of inflammatory cytokines were up‐regulated, GLCCI1 expression was reduced and autophagy was activated. Increasing of GLCCI1 inhibited human and mouse airway epithelial cell (AEC) autophagy, while decreasing of GLCCI1 promoted autophagy. Furthermore, we found that GLCCI1 bound with WD repeat domain 45B (WDR45B) and inhibited its expression. Increasing of WDR45B partly reversed the inhibition of GLCCI1 to autophagy‐related proteins expression and autophagosome formation in vitro. Increasing of WDR45B in vivo reversed the improvement of GLCCI1 on airway remodelling in asthma and the inhibition to autophagy level in lung tissues. Overall, our data showed that GLCCI1 improved airway remodelling in ovalbumin‐sensitized mice through inhibiting autophagy via combination with WDR45B and inhibiting its expression. Our results proved a new idea for asthma treatment.

Paediatrics: how to manage acute asthma exacerbations

Background

Asthma is the most common chronic disease of childhood and a major source of childhood health burden worldwide. These burdens are particularly marked when children experience characteristic ‘symptom flare-ups’ or acute asthma exacerbations (AAEs). AAE are associated with significant health and economic impacts, including acute Emergency Department visits, occasional hospitalizations, and rarely, death. To treat children with AAE, several medications have been studied and used.

Methods

We conducted a narrative review of the literature with the primary objective of understanding the evidence of their efficacy. We present this efficacy evidence in the context of a general stepwise management pathway for paediatric AAEs. This framework is developed from the combined recommendations of eight established (inter)national paediatric guidelines.

Discussion

Management of paediatric AAE centres around four major care goals: (1) immediate and objective assessment of AAE severity; (2) prompt and effective medical interventions to decrease respiratory distress and improve oxygenation; (3) appropriate disposition of patient; and (4) safe discharge plans. Several medications are currently recommended with varying efficacies, including heliox, systemic corticosteroids, first-line bronchodilators (salbutamol/albuterol), adjunctive bronchodilators (ipratropium bromide, magnesium sulfate) and second-line bronchodilators (aminophylline, i.v. salbutamol, i.v. terbutaline, epinephrine, ketamine). Care of children with AAE is further enhanced using clinical severity scoring, pathway-driven care and after-event discharge planning.

Conclusions

AAEs in children are primarily managed by medications supported by a growing body of literature. Continued efforts to study the efficacy of second-line bronchodilators, integrate AAE management with long-term asthma control and provide fair/equitable care are required.

Impact of obstructive sleep apnea on assisted ventilation in children with asthma exacerbation

OBJECTIVE

To determine the impact of obstructive sleep apnea (OSA) on asthma exacerbation severity in children hospitalized for asthma exacerbation.

HYPOTHESIS

OSA is associated with greater use of invasive mechanical ventilation (IMV) and noninvasive mechanical ventilation (NIMV) in children hospitalized for asthma exacerbation.

STUDY DESIGN

A retrospective cohort study.

PATIENT-SUBJECT SELECTION

Hospitalization records of children aged 2-18 years admitted for acute asthma exacerbation were obtained for 2000, 2003, 2006, 2009, and 2012 from the Kids' Inpatient Database.

METHODOLOGY

The primary exposure was OSA, the primary outcome was IMV, and secondary outcomes were NIMV, length of hospital stay (LOS), and inflation-adjusted cost of hospitalization. Multivariable logistic regression, negative binomial, and linear regression were conducted to ascertain the impact of OSA on primary and secondary outcomes. Exploratory analyses investigated the impact of obesity on primary and secondary outcomes.

RESULTS

Among 564,467 hospitalizations for acute asthma exacerbation, 4209 (0.75%) had OSA. Multivariable regression indicated that OSA was associated with IMV (adjusted odds ratio [OR], 5.33 [95% confidence interval, CI: 4.35-6.54], p < .0001), NIMV (adjusted OR, 8.30 [95% CI: 6.56-10.51], p < .0001), longer LOS (adjusted incidence rate ratio, 1.34 [95% CI 1.28-1.43], p < .0001), and greater inflation-adjusted cost of hospitalization (adjusted β, 0.38 [95% CI: 0.33-0.43], p < .0001). Obesity was also significantly associated IMV, NIMV, longer LOS, and greater inflation-adjusted cost of hospitalization. There was no interaction between OSA and obesity.

CONCLUSION

OSA is an independent risk factor for IMV, NIMV, longer LOS, and elevated inflation-adjusted costs of hospitalization in children hospitalized for asthma exacerbation.

Inpatient management of an acute asthma exacerbation using clinical care pathways

Asthma exacerbations remain a leading cause of hospitalization in the pediatric population, and many children who require hospitalization for status asthmaticus are managed using clinical care pathways (CPGs). Clinical care pathways are often created or adopted by healthcare systems in order to establish specific, evidence-based guidelines that standardize and coordinate quality care in both the emergency room and inpatient settings. This paper reviews the use of these guidelines and the updated evidence-based recommendations regarding best-practice for acute asthma care of hospitalized children, including the 2020 recommendations from the National Asthma Education and Prevention Program Expert Panel (NAEPP).

Nebulized albuterol delivery is associated with decreased skeletal muscle strength in comparison with metered-dose inhaler delivery among children with acute asthma exacerbations

OBJECTIVE

Albuterol is a β2-agonist and causes an intracellular shift of potassium from the interstitium. Whole-body hypokalemia is known to cause skeletal muscle weakness, but whether this occurs as a result of hypokalemia from the intracellular shift during albuterol treatment is unknown. We sought to determine if albuterol total dose or route of administration (nebulization and/or metered-dose inhaler) is associated with skeletal muscle weakness.

METHODS

This was a prospective observational study using convenience sampling. Skeletal muscle strength was measured before and after 1 hour of albuterol treatment using a hand-grip dynamometer in participants aged 5-17 years with acute asthma exacerbation in the emergency department. We examined associations of albuterol dose and route of administration with changes in grip strength.

RESULTS

Among 50 participants, 10 received continuous albuterol by nebulizer and 40 received albuterol by metered-dose inhaler. The median (interquartile range) in change of grip was -7.8% (interquartile range, -23.3, +5.1) for those treated with a nebulizer and +2.4% (interquartile range, -5%, +12.7%) for those treated with a metered-dose inhaler (P = 0.036 for the difference). In a multiple linear regression model adjusted for the pretreatment Acute Asthma Intensity Research Score and age, participants treated with a nebulizer had a 12.9% decrease in skeletal muscle strength compared with those treated with a metered-dose inhaler.

CONCLUSION

Higher doses of albuterol administered via nebulization result in decreased skeletal muscle strength in patients with acute asthma; whereas, albuterol administration via metered-dose inhalers showed no effect on skeletal muscle strength.