Incidence and risk factors for long COVID in children with COVID-19 pneumonia

BACKGROUND AND OBJECTIVE

There are only a few reports of long COVID including pulmonary function in children after COVID-19 pneumonia. We determined the incidence of long COVID and abnormal pulmonary function in those children and identify risk factors.

METHODS

This cohort study enrolled children admitted with COVID-19 pneumonia during 2021-2022. We gathered clinical characteristics during admission and at follow-up 3 months after.

RESULTS

We determined the incidence of long COVID at 39.7% (95% confidence interval [CI]: 30.7%-49.1%). All severe pneumonia cases consistently reported persistent symptoms. Exercise intolerance, cough, and fatigue were the three most common persistent symptoms in 26 (22.4%), 21 (18.1%), and 18 (15.5%) of the patients, respectively. At the follow-up, 21 cases (18.1%) demonstrated persistent abnormal chest radiographs. Three cases (6.9%) demonstrated restrictive ventilatory defects. Among those, one case (2.3%) demonstrated concomitant diffusion defect. Three cases (6.0%) demonstrated exercise-induced hypoxemia after the 6-minute walk test. Comparing spirometry variables between children with long COVID and without revealed significant difference of FEF25-75 (z score) between two groups. Age [adjusted OR (95% CI): 1.13 (1.05-1.22), p value 0.002], allergic diseases [adjusted OR (95% CI): 4.05 (1.36-12.06), p value 0.012], and living in polluted areas [adjusted OR (95% CI): 2.73 (1.18-6.33), p value 0.019] were significantly associated with long COVID.

CONCLUSION

A significant percentage of children developed long COVID after COVID-19 pneumonia. We should give additional attention to those who have exercise intolerance, chronic cough, or fatigue, especially older children, severe cases, children with allergic diseases, and those living in polluted areas.

Impact of respiratory care training and family support using telemedicine on tracheostomized children admitted with respiratory infection after discharge

OBJECTIVE

Children with tracheostomies usually require a long hospital stay, high healthcare costs and caregiver burden. With the help of telemedicine, this study attempted to determine how home respiratory care training and family support affected admission days, admission costs, ICU admission rates, and caregivers' confidence.

METHODS

We enrolled children with tracheostomies who were admitted between 2020 and 2022 with respiratory infections. Before discharge, we evaluated the knowledge and skills of the caregivers and gave them practice in home respiratory care while providing them with structured feedback using a checklist, a peer-to-peer mentor assignment, a virtual home visit, teleeducation, and teleconsultation via a mobile application. We compared the admission days, admission costs, and ICU admission rates one year following the program with the historical control one year earlier.

RESULTS

Forty-eight children with tracheostomies were enrolled. Thirteen percent of those had a 1-year readmission. The median [IQR] number of admission days decreased from 55 [15-140] to 6 [4-17] days (p value < 0.001). The median [IQR] admission costs decreased from 300,759 [97,032 - 1,132,323] to 33,367 [17,898-164,951] baht (p value < 0.001). The ICU admission rates decreased from 43.8% to 2.1% (p value < 0.001). Immediately after the program, caregivers' confidence increased from 47.9% to 85.5% (p value < 0.001).

CONCLUSIONS

This respiratory care training and telehealth program decreased admission days, admission costs, and ICU admission rates for children with tracheostomies admitted with respiratory infections. The confidence of caregivers was also increased immediately after the program.

Practical recommendations for home-nebulized corticosteroid use in children aged ≤ 5 years with asthma: A review and advisory group consensus

BACKGROUND

Despite nebulized budesonide being identified by the Global Initiative for Asthma report as a viable alternative to inhaled corticosteroids (ICS) delivered by pressurized metered-dose inhalers (pMDIs) with spacers, practical guidance on nebulized corticosteroid use in the pediatric population remains scarce.

OBJECTIVE

To review the current literature and provide practical recommendations for nebulized budesonide use in children aged ≤ 5 years with a diagnosis of asthma.

METHODS

A group of 15 expert pediatricians in the respiratory and allergy fields in Thailand developed Delphi consensus recommendations on nebulized budesonide use based on their clinical expertise and a review of the published literature. Studies that evaluated the efficacy (effectiveness) and/or safety of nebulized budesonide in children aged ≤ 5 years with asthma were assessed. AR patients.

RESULTS

Overall, 24 clinical studies published between 1993 and 2020 met the inclusion criteria for review. Overall, results demonstrated that nebulized budesonide significantly improved symptom control and reduced exacerbations, asthma-related hospitalizations, and the requirement for oral corticosteroids compared with placebo or active controls. Nebulized budesonide was well tolerated, with no severe or drug-related adverse events reported. Following a review of the published evidence and group consensus, a treatment algorithm as per the Thai Pediatric Asthma 2020 Guidelines was proposed, based on the availability of medications in Thailand, to include nebulized budesonide as the initial treatment option alongside ICS delivered by pMDIs with spacers in children aged ≤ 5 years.

CONCLUSIONS

ThNebulized budesonide is an effective and well-tolerated treatment option in children aged ≤ 5 years with asthma.

Effect of Threshold Inspiratory Muscle Training on Functional Fitness and Respiratory Muscle Strength Compared to Incentive Spirometry in Children and Adolescents With Obesity: A Randomized Controlled Trial

BACKGROUND

To determine the effect of threshold inspiratory muscle training (IMT) on functional fitness and respiratory muscle strength (RMS) compared to incentive spirometry (IS) in children/adolescents with obesity.

METHODS

A total of 60 obese children/adolescents aged 8-15 years were randomized into the threshold IMT group (n = 20), the IS group (n = 20), or the control group (n = 20). The IMT group performed 30 inspiratory breaths with the intensity set at 40% of baseline maximal inspiratory pressure (MIP) twice daily for 8 weeks; the IS group performed 30 breaths with sustained maximum inspiration twice daily for 8 weeks; and, the control group was assigned no training device for 8 weeks. Six-min walk test (6-MWT), RMS, and spirometry were compared between baseline and 8 weeks.

RESULTS

Six-MWT distance (528.5 ± 36.2 vs. 561.5 ± 35.2 m, p = 0.002) and MIP (121.2 ± 26.8 vs. 135.3 ± 32.1%Predicted, p = 0.03) were significantly improved after 8 weeks of IMT training. There was no significant difference in any evaluated pulmonary function parameters between baseline and 8 weeks in the IS or control groups; however, 6-MWT distance demonstrated a trend toward significant improvement in the IS group (526.9 ± 59.1 vs.549.0 ± 50.6 m, p = 0.10). No significant difference among groups was found for any variable relative to change from baseline to post-training.

CONCLUSION

Eight weeks of threshold IMT training significantly improved both inspiratory muscle strength (MIP) and functional fitness (6-MWT) in children/adolescents with obesity. Eight weeks of IS training yielded a trend toward significantly improved functional fitness.

Comparing Adherence of Continuous and Automatic Positive Airway Pressure (CPAP and APAP) in Obstructive Sleep Apnea (OSA) Children

OBJECTIVES

The treatment outcomes of pediatric obstructive sleep apnea (OSA) are affected by positive airway pressure (PAP) therapy adherence, which may be affected by the type of device used. Continuous PAP (CPAP) devices deliver a continuous and fixed air pressure level, whereas automatic PAP (APAP) devices automatically adjust the pressure to meet changing needs during sleep. The adherence, tolerance and consistency of OSA-children's use of CPAP and APAP devices were compared.

STUDY DESIGN

One-year, observational cohort study.

METHODS

Twenty-seven OSA-children were enrolled. Fourteen (52%) used CPAP, and 13 (48%) used APAP. The adherence, tolerance, and consistency of the PAP usage by the two groups were compared.

RESULTS

Overall, 11 of the 27 children (41%) showed good PAP adherence. The CPAP patients averaged 4.9 h of device usage on the days used, for 60% of days, with 6 of 14 (43%) demonstrating good adherence. In comparison, the APAP patients averaged 3.2 h for 55% of days, with 5 of 13 (38%) exhibiting good adherence. The 2 groups showed no differences in their adherence, tolerance, or consistency of device usage (P values, 0.816, 0.609, and 0.720, respectively). Although the adherence of both groups improved in the second 6 months, it was without statistical significance (P values, 0.400 and 0.724). Age, sex, baseline apnea-hypopnea index, comorbidities, prescribed period, device type, mask type, and caregiver education-level were not risk factors for poor PAP adherence.

CONCLUSIONS

No differences in the adherence, tolerance, or consistency of the children's use of CPAP and APAP were revealed in this small inhomogeneous cohort study with limited resources.

A rare case of mediastinal lymphatic venous malformations in children

We report a case of mediastinal lymphatic venous malformations (LVM) in a 11-year-old boy who presented with chest pain after jumping into a swimming pool, with review of the literature. A superior mediastinal mass was incidentally found from the chest x-ray. Chest computed tomography revealed a large heterogenous mass at the left-sided mediastinum containing fat, minimal enhancing solid portion, non-enhancing cystic portion and calcification. Because of the large size of the mass, the patient underwent tumour removal. Operative findings gave a definitive diagnosis of mediastinal LVM. The patient had an uneventful clinical course and was discharged without complication. This report highlights that it is possible to misdiagnose mediastinal LVM especially if its predominant portion is lymphatic tissue with only minimal contrast enhancement. Tissue biopsy must be avoided because it may lead to haemorrhagic complication.

Obesity Indices for Predicting Functional Fitness in Children and Adolescents With Obesity

Objectives: We aimed to determine the obesity indices that affect 6-min walk test (6-MWT) distance in children and adolescents with obesity and to compare the 6-MWT distance of obese subjects with that of normal-weight subjects. Methods: Obese children and adolescents aged 8-15 years and normal-weight age- and gender-matched controls were enrolled. All participants performed the 6-MWT; respiratory muscle strength (RMS), including maximal inspiratory pressure and maximal expiratory pressure; and spirometry. Data between groups were compared. In the obesity group, correlation between obesity indices and pulmonary function testing (6-MWT, RMS, and spirometry) was analyzed. Results: The study included 37 obese and 31 normal-weight participants. The following parameters were all significantly lower in the obesity group than in the normal-weight group: 6-MWT distance (472.1 ± 66.2 vs. 513.7 ± 72.9 m; p = 0.02), forced expiratory volume in one second/forced vital capacity (FEV₁/FVC) (85.3 ± 6.7 vs. 90.8 ± 4.5%; p < 0.001), forced expiratory flow rate within 25-75% of vital capacity (FEF_25-75%) (89.8 ± 23.1 vs. 100.4 ± 17.3 %predicted; p = 0.04), and peak expiratory flow (PEF) (81.2 ± 15 vs. 92.5 ± 19.6 %predicted; p = 0.01). The obesity indices that significantly correlated with 6-MWT distance in obese children and adolescents were waist circumference-to-height ratio (WC/Ht) (r = -0.51; p = 0.001), waist circumference (r = -0.39; p = 0.002), body mass index (BMI) (r = -0.36; p = 0.03), and chest circumference (r = -0.35; p = 0.04). WC/Ht was the only independent predictor of 6-MWT distance by multiple linear regression. Conclusions: Children and adolescents with obesity had a significantly shorter 6-MWT distance compared with normal-weight subjects. WC/Ht was the only independent predictor of 6-MWT distance in the obesity group.

Nonspecific interstitial pneumonia in refractory systemic juvenile idiopathic arthritis responded to tocilizumab treatment

BACKGROUND

Nonspecific interstitial pneumonia (NSIP) is a rare pulmonary complication in systemic juvenile idiopathic arthritis (SJIA).

OBJECTIVE

To present a case with NSIP in SJIA METHODS: Case report RESULTS: We report the case of a 4-year-old boy with SJIA complicated by macrophage activation syndrome (MAS) refractory to conventional therapy, and who later developed NSIP confirmed by high-resolution computerized tomography of the chest and lung histopathology. The patient received tocilizumab, a monoclonal antibody to interleukin-6 receptor, to control his disease. Data relating to tocilizumab treatment of NSIP in refractory SJIA is limited.

CONCLUSIONS

The data from this case report suggests that NSIP could be a pulmonary complication of SJIA complicated by MAS that is refractory to conventional therapy. Early initiation of tocilizumab should be considered to achieve disease remission in this pediatric patient population.

Cut-off values for positive bronchodilator response in healthy Thai preschool children using forced oscillation technique

BACKGROUND

Forced oscillation technique (FOT) requires minimal patient cooperation and is particularly useful in young children. Bronchodilator test is a valuable tool for wheezy and asthmatic patients. The cut-off value for bronchodilator response by FOT in healthy Thai children has not been reported.

OBJECTIVE

To determine the cut-off values for positive bronchodilator response in healthy Thai preschool children using pseudorandom FOT.

METHODS

FOT was used to measure respiratory function at baseline and after 400 mcg MDI salbutamol in healthy Thai children aged 3-6 years. Respiratory resistance (Rrs) and reactance (Xrs) at 6, 8, and 10 Hz were collected. Pre- and post-bronchodilator tests were compared using paired t-test. Absolute and percent changes after bronchodilator were calculated and their cut-off values were defined as mean ± 1.96 SD. Correlation between each of those and baseline data was analyzed using Pearson's correlation coefficient.

RESULTS

Of the 150 enrolled children, FOT measurement at baseline and after bronchodilator was successfully completed in 111 children (51 boys). The mean ± standard deviation age, height, and arm span was 5.2 ± 1.1 years, 109.3 ± 8.7 cm, and 107.2 ± 9.1 cm, respectively. No correlation was observed between any absolute or percent changes in bronchodilator response and gender, age, height, or arm span. The cut-off values established for bronchodilator response by percent change were, as follows: Rrs6: -23%, Rrs8: -20%, Rrs10: -20%, Xrs6: 36%, Xrs8: 60%, and Xrs10: 43%.

CONCLUSIONS

The cut-off values identified in this study will be useful for evaluating bronchodilator response by FOT in wheezy and asthmatic young children.

Practical considerations of nebulized corticosteroid in children with acute asthmatic exacerbation: A consensus

BACKGROUND

Acute asthmatic exacerbation in children causes economic burdens both directly and indirectly. The GINA guideline does mention the use of inhaled or oral corticosteroids in the treatment of asthmatic exacerbation, it provides little practical guidance on the use of nebulized corticosteroid.

OBJECTIVE

To review and recommend the practical considerations in the use of nebulized corticosteroid in children with acute asthmatic exacerbation.

METHODS

This consensus was developed by a group of expert pediatricians in respiratory and allergy fields in Thailand. The recommendations were made based on a review of published studies and clinical opinions. The eligible studies were confined to those published in English, and randomized controlled trials and meta-analyses involving nebulized corticosteroids in asthmatic exacerbation in children aged between 1-18 years.

RESULTS

There were 13 randomized controlled-trial studies published from 1998 to 2017. Nine of the 13 studies compared nebulized with systemic corticosteroid conducted in moderate to severe exacerbation, while the remaining four compared nebulized corticosteroid with placebo conducted in mild to severe exacerbation. The admission rate was significantly lower in severe exacerbation (one study) and pooled four mild to severe exacerbation studies comparing with placebo (p 0.022). Other clinical parameters were significantly improved with nebulized corticosteroid such as clinical scores, systemic corticosteroid/bronchodilator use, or shorter ER stays. Only one study used fluticasone, while the other 12 studies conducted by budesonide (92.31%).

CONCLUSION

Nebulized corticosteroid may offer an effective therapeutic option for the management of acute exacerbation of asthma in all severities. Nebulized budesonide is the preferred corticosteroid.

Asthma-like symptoms as a presentation of antiphospholipid syndrome

We herein report a case of antiphospholipid syndrome (APS) primarily presenting with asthma-like symptoms that had been misdiagnosed as severe asthma. Patients presenting with severe asthma symptoms along with systemic thrombosis should be systematically evaluated for APS.

Severe obesity is a risk factor for severe obstructive sleep apnea in obese children

OBJECTIVE

To determine the association between degree of obesity and severity of OSA in Thai children

MATERIAL AND METHOD

The present retrospective study recruited obese children aged 3 to 15 years who had habitual snoring and underwent polysomnography (PSG) between January 2009 and June 2010. Obesity was defined as percentage of ideal weight for height (%W/H) > or = 120 and was classified as mild (%W/H of 120-139), moderate (140-159), severe (160-199) and morbid (> or = 200). OSA was classified as severe (AHI > or = 10) and non-severe (AHI < 10).

RESULTS

Of 73 obese children, the mean age was 9.92 +/- 3.42 years of which 60.3% were boys. The mean +/- SD of BMI was 28.38 +/- 5.99 kg/m2 and %W/H +/- SD was 162.63 +/- 26 26. Gender age, height, weight and BMI were not significantly different between severe and non-severe OSA groups. However, the %W/H of the severe OSA group (171.38% +/- 29.54%) was significantly greater than the non-severe group (157.19% +/- 22.68%) (p = 0.02). Severe to morbid obesity (OR 2.80, 95% CI 1.06-7.42; p = 0.038) and enlarged tonsils at least 3+ (OR 3.28, 95% CI 1.22-8.81; p = 0.018) were the risk factors for severe OSA.

CONCLUSION

Severe to morbid obesity was a predicting factor for severe OSA. These results suggested that severely obese children with snoring should have early recognition for severe OSA, which is highly contributing to multiple sequalae.

Clinical presentation and lung function of children hospitalized with 2009 pandemic influenza A (H1N1) pneumonia

To determine the clinical presentation and subsequent lung function following pneumonia caused by 2009 pandemic influenza A (H1N1), pH1N1, in children aged 5-15 years hospitalized from June to September 2009, we contacted patients meeting the criterion 3-6 months post-hospitalization. Of the 88 patients contacted, 31 (35.2%) had pH1N1 and 57 (64.8%) had infections due to other viral pathogens (non-pH1N1), the mean age was 10.4 years and 52 (59%) were boys. Compared to non-pH1N1 patients, the pH1N1 patients were more likely to have a high fever (96.8% vs 77.2%, p = 0.03), sore throat (58.1% vs 33.3%, p = 0.03), and injected pharynx (80.6% vs 40.4%, p = 0.001). At 3-6 months after pneumonia onset, means for FVC, FEV1, FEV1/FVC, FEF25-75%, and PEF were within normal limit in both the pH1N1 and non-pH1N1 groups. Five (28%) of 18 pH1N1 children and 4 (20%) of 20 non-pH1N1 children had abnormal lung function results. All were restrictive type. In conclusion, pH1N1 pneumonia were more likely to present with high fever, sore throat, and pharyngeal injection than pneumonia from other viruses. About one quarter of the children who had pH1N1 had restrictive lung function 3-6 months after infection. This number did not differ from the non-pH1N1 group.

Assessment of bronchodilator responsiveness in preschool children using forced oscillations

BACKGROUND

The forced oscillation technique (FOT) requires minimal patient cooperation and is feasible in preschool children. Few data exist on respiratory function changes measured using FOT following inhaled bronchodilators (BD) in healthy young children, limiting the clinical applications of BD testing in this age group. A study was undertaken to determine the most appropriate method of quantifying BD responses using FOT in healthy young children and those with common respiratory conditions including cystic fibrosis, neonatal chronic lung disease and asthma and/or current wheeze.

METHODS

A pseudorandom FOT signal (4-48 Hz) was used to examine respiratory resistance and reactance at 6, 8 and 10 Hz; 3-5 acceptable measurements were made before and 15 min after the administration of salbutamol. The post-BD response was expressed in absolute and relative (percentage of baseline) terms.

RESULTS

Significant BD responses were seen in all groups. Absolute changes in BD responses were related to baseline lung function within each group. Relative changes in BD responses were less dependent on baseline lung function and were independent of height in healthy children. Those with neonatal chronic lung disease showed a strong baseline dependence in their responses. The BD response in children with cystic fibrosis, asthma or wheeze (based on both group mean data and number of responders) was not greater than in healthy children.

CONCLUSIONS

The BD response assessed by the FOT in preschool children should be expressed as a relative change to account for the effect of baseline lung function. The limits for a positive BD response of -40% and 65% for respiratory resistance and reactance, respectively, are recommended.

Pre-flight testing of preterm infants with neonatal lung disease: a retrospective review

BACKGROUND

The low oxygen environment during air travel may result in hypoxia in patients with respiratory disease. However, little information exists on the oxygen requirements of infants with respiratory disease planning to fly. A study was undertaken to identify the clinical factors predictive of an in-flight oxygen requirement from a retrospective review of hypoxia challenge tests (inhalation of 14-15% oxygen for 20 minutes) in infants referred for fitness to fly assessment.

METHODS

Data from 47 infants (median corrected age 1.4 months) with a history of neonatal lung disease but not receiving supplemental oxygen at the time of hypoxia testing are reported. The neonatal and current clinical information of the infants were analysed in terms of their ability to predict the hypoxia test results.

RESULTS

Thirty eight infants (81%) desaturated below 85% and warranted prescription of supplemental in-flight oxygen. Baseline oxygen saturation was >95% in all infants. Age at the time of the hypoxia test, either postmenstrual or corrected, significantly predicted the outcome of the hypoxia test (odds ratio 0.82; 95% confidence intervals 0.62 to 0.95; p = 0.005). Children passing the hypoxia test were significantly older than those requiring in-flight oxygen (median corrected age (10-90th centiles) 12.7 (3.0-43.4) v 0 (-0.9-10.9) months; p < 0.0001).

CONCLUSIONS

A high proportion of ex-preterm infants not currently requiring supplemental oxygen referred for fitness-to-fly assessment and less than 12 months corrected age are at a high risk of requiring in-flight oxygen. Referral of this patient group for fitness to fly assessment including a hypoxia test may be indicated.

Theophylline toxicity in Thai children

Theophylline is a useful drug in the treatment of respiratory diseases with bronchospasm but it has very narrow safety margin. The study was carried out in 44 admitted Thai children with plasma theophylline levels > 20 microg/ml to determine the association between blood levels and symptoms of theophylline toxicity. The prevalence of theophylline toxicity (plasma theophylline level > 20 microg/ml) in Thai children is about 11%. Thirty-four percent of the patients who had theophylline levels less than 30 microg/ml and 78% of those who had levels more than 30 microg/ml had symptoms of theophylline toxicity. The symptoms were related to the gastrointestinal tract (34%), cardiovascular system (18.2%), neurological system (6.8%) and metabolism (54.5%). The possible causes of theophylline toxicity were respiratory tract infection, theophylline overdosage, interaction with other drugs, impairment of liver function, congenital heart disease and theophylline usage in neonates. Theophylline is still a useful drug but should be used with caution. Theophylline levels should be checked in every child who receives theophylline.

PRISM score and factors predicting mortality of patients with respiratory failure in the pediatric intensive care unit

A total of 96 patients with respiratory failure who required mechanical ventilation admitted to the PICU, Chulalongkorn Hospital from July 1998 to June 1999 were reviewed to evaluate the PRISM score for mortality prediction and to identify factors that might influence the outcome. The statistical difference in outcome between the 2 groups (survivors and non-survivors) were underlying diseases, age, maximum positive inspiratory pressure (PIP), maximum positive end expiratory pressure (PEEP), maximum fractional inspiratory oxygen (FiO2) and PRISM score (p < 0.05). However, based on the original logistic regression equation, the predicted mortality from PRISM score in our study was much lower than our actual mortality (2.4% vs 26.0%). The sensitivity and specificity of mortality predicted by PRISM score calculated at cut-off r = 0.0 (expected mortality = 50%) was 4 per cent and 97 per cent respectively. In conclusion, the original PRISM score underpredicted the mortality outcome in our patients with respiratory failure. This suggests that PRISM score is population dependent and should be modified before being used with our patients.