|Home | About | Journals | Submit | Contact Us | Français|
S. Haque‐Lobbes. Kinderarztpraxis, Vechelde, Germany
BackgroundIsolation of bacteria in respiratory tract infections (RTI) is virtually impossible in a paediatric primary care setting. Chest x ray, the standard for diagnosing lower respiratory tract infections (LRTI) is not usually available in the primary care clinic.
AimThe object of this investigation was to assess the value of trans‐thoracic ultrasonography in detecting lower respiratory tract infections in children.
MethodRestrospective review of all patients attending a single‐handed general paediatric practice with RTI over a period of 22 months. Patients with clinical features of LRTI in whom antibacterial treatment would have been an option were selected as having at least two or more of the following: cough >1 week, fever >38.5°C, tachypnoea (adjusted for age) and inspiratory crackles. Trans‐thoracic ultrasonography (US) was performed on these children by the same examiner using a 5 MHz probe. Patients with abnormal US scans also had chest x rays. Those with normal US scans were followed up clinically. Those with unequivocal US findings had a repeat US within 24–48 h to detect any rapid changes. All the patients who were clinically unwell to have US also had blood tests including Mycoplasma pneumoniae titres.
ResultsFrom 01.01.2005 until 01.11.2006 there was a total of 883 children aged 0–<18 years who attended the surgery with RTI. 88 of these patients (9%) met clinical criteria for possible LRTI and were ultrasonically scanned. 33 children (3%) had evidence of either consolidation, pleural effusion or both on US. 6 of these had raised Mycoplasma pneumoniae titres (range: 1:340 to 1:1280, normal 1: <40). They were exempted from chest x rays and treated with Clarithromycin. In 3 children the parents declined x ray. Of the 24 patients with abnormal US changes who had chest x rays, 23 showed x ray changes which matched the US findings in site and extent. Those with no clear US abnormalities were not treated with antibiotics. They did not develop any further complications. None of these 883 children required hospitalisation. Out of the total of 883 children presenting with RTI, antibiotics for LRTI were only prescribed in 33 cases.
ConclusionTrans‐thoracic ultrasonography can detect lower respiratory tract infections in children and may be a useful guide for determining the need for further investigations and antibacterial therapy.
S. John‐Legere, J. Vyas, T. David, F. Child, C. Gore. Royal Manchester Children's Hospitals, Manchester, UK
RationaleThe prevalence of antibiotic hypersensitivity/allergy in children with cystic fibrosis (CF) is unclear. Reports from adult studies suggest a rapidly rising prevalence and poor standard of documentation with resulting difficulties in tailoring future treatment.
AimsTo establish the prevalence of documented antibiotic hypersensitivity reactions and assess the quality of this documentation in children with CF.
MethodsSurvey of antibiotic hypersensitivity and audit of documentation of reactions in retrospective case note review of all children with CF (n=189) attending a tertiary paediatric respiratory centre (May–August 2006). Documentation of allergic reaction to antibiotics audited against standard derived from literature and good medical practice.
ResultsAcceptable data available on 188/189 patients. An antibiotic “allergy” was recorded for 23/188 (12%) patients; 17/23 reacted to one antibiotic, 3/23 to two, 3/23 to three antibiotics. Causative were: beta‐lactam antibiotics (15/23), penicillins (8/23), co‐trimoxazole (4/23), aminoglycosides (3/23), ciprofloxacin (2/23). No database for documentation of allergic reactions in children with CF was available in the hospital pharmacy. No gold standard for documentation/investigation of reactions to antibiotics available in‐house. None of the drug allergies was documented on front cover of notes (old system) and none documented in the designated space/red alert card inside the files (new system). “Known allergy” was documented on admission clerking or care‐pathways in 67–83%. Only 25–36% of prescription charts had the “known allergy” documented in the designated space. Specific documentation of reaction: date (17/23), temporal relationship (13/23), reaction‐type (14/23), acute management (10/23). No child was investigated for antibiotic allergy.
ConclusionPrevalence of documented antibiotic allergy was high at 12%. General documentation of presence/absence of drug allergy was poor and recording of reaction‐type suboptimal. No identifiable plans for investigation and/or future use of “offending” drug were found. Poor documentation restricts/will restrict choice of treatment for patients. This needs to be addressed by establishing clear gold standards for recording and investigation of antibiotic allergies.
B. Enderby1, P. Boit1, P. Spanel2, D. Smith1, W. Lenney1. 1Institute of Science and Technology in Medicine, School of Medicine, Keele University, Stoke on Trent, UK; 2V Cermak Laboratory, J Heyovsky Institute of Physical Chemistry, Dolejskova, Prague, Czech Republic
AimsThe measurement of volatile gases in exhaled breath is an exciting concept in children. Work in adults has defined values in health and in disease. We wish to study children with asthma and cystic fibrosis but our first aim is to validate the methodology and establish normative values in children of different ages. Initial work has examined the indirect measurement of exhaled breath using Nalophan bags.
MethodsGas samples were collected from healthy siblings of children attending our OP department. The samples were incubated at 37°C, prior to analysis to maintain their stability. They were then analysed using the selected ion flow tube mass spectrometry (SIFT‐MS) technique, for the presence of trace gases using H30+, NO+ and O2+ pre‐cursor ions in multiple and in full scan modes.
ResultsSamples were taken from 12 children. The mean age of children studied was 3.6 years (2.3–9.3). The values shown below, were similar to those in adults, with the exception of isoprene. In vitro studies in cystic fibrosis have shown marked elevations of HCN and propanol. We are now refining the methodology to enable children of varying ages to breathe directly into the machine, recording on‐line real‐time breath analysis in both health and disease.
ConclusionsSIFT‐MS is a viable technique which can be used in children as well as in adults. It has the prospect of identifying surrogate markers of infection and inflammation, thereby aiding early diagnosis and better management of children with chronic lung disease.
Turner C, Spanel P, Smith D (2006) Diskin A, Spanel P, Smith D (2003)
G. Venkatachalam1, J. S. G. Kothandapani2, V. Sekaran1, T. Sangaralingam1. 1Pilgrim Hospital, Boston, UK; 2Royal Liverpool Children's Hospital, Liverpool, UK; 3Institute of Child Health, Chennai, India
ObjectivesTo determine the efficacy of salbutamol by metered dose inhaler with spacer and facemask (MDI‐S) compared to nebuliser.
MethodsIn a prospective, double blind, randomised clinical trial, 180 asthmatic children between 1 and 5 years of age with a pulmonary score of 6 (pulmonary score include respiratory rate, wheezing and retractions, each rated on a 0–3 scale) were assigned to a maximum of three cycles of either MDI‐S treatment or nebuliser treatment with an interval of 20 minutes. The dose of the salbutamol used in the MDI‐S group was 100 μg/puff, with a total of four puffs per cycle and the dose of salbutamol used in the nebuliser group was 2.5 mg per cycle. Patients were recruited from an emergency department at an urban academic paediatric institute. Mean age in the MDI‐S group and in the nebuliser group was 3.67 (SD 0.97) and 3.56 (SD 0.89) respectively (p=0.475). Children who presented with associated symptoms such as fever and children who had received any kind of asthma medication just before the randomisation were excluded from the study. The primary outcome measures were reduction in pulmonary score from 6 to 2 and improvement in oxygen saturation. The secondary outcome measures were number of cycles needed to reach pulmonary score 2 and percentage of change in heart rate. These parameters were collected after 20 minutes of each cycle.
ResultsThere was no significant difference in mean pulmonary score at the end of third cycle between MDI‐S and nebuliser groups (1.63 (0.5) v 1.36 (0.5), respectively; p=0.198). The mean oxygen saturation at the end of the third cycle between MDI‐S and nebuliser groups (97.75 (0.93) v 97.63 (0.50) respectively; p=0.074). Number of children who entered the third cycle of treatment was 17.77% in the MDI‐S group and 12.22% in the nebuliser group. This difference is not statistically significant. Mean heart rate in the MDI group and the nebuliser group (113.87 (11.08) v 107 (6.84), respectively; p=0.120) at the end of third cycle is not statistically significant.
ConclusionSalbutamol administered by MDI‐S is an efficacious and cost‐effective alternative to nebulisation in children with acute asthma of moderate severity who present at a large urban emergency department.
SRSmithAcad Emerg Med20007 pp 569
G. Prasad1, M. Desai2, P. Davies2, R. Rayner3, D. Mittal4, R. Mudgal5. 1University Hospital of North Staffordshire, Stoke‐on‐Trent, UK; 2Birmingham Children's Hospital, Birmingham, UK; 3Newcross Hospital, Wolverhampton, UK; 4Manor Hospital, Walsall, UK; 5Russells Hall Hospital, Dudley, UK
Aims(1) To assesses response to Montelukast using multiple patient centred outcomes and to categorise the subjects into low and high response groups. (2) To identify the clinical profile associated with high response by studying the correlation between response groups and the demographic and clinical characteristics.
MethodsChildren with persistent asthma, not adequately controlled with inhaled corticosteroids were recruited in a multicentre, prospective observational study. After a run‐in period of 2 weeks, subjects were treated with oral Montelukast for 4 weeks at a dose appropriate for the age. We used physician's evaluation score and the Paediatric Asthma Care giver Diary for assessment. Changes in the scores pre and post treatment and other outcomes of asthma control were considered in measuring the response. The range of response was categorised as high or low by weighting the scores in some of the domain based on the extent of fall.
ResultsTwenty children aged 2–14 years were recruited. After 4 weeks of Montelukast treatment, there was a reduction in day symptom score in 65% (p=0.005), night symptoms scores in 75% (p=0.001) and rescue inhaler use score in 75% (p=0.001) of subjects on physician's evaluation. The percentage of subjects experiencing an asthma attack was reduced by 55% and the unscheduled visit at GPs surgery or hospital was reduced by 65% (p=0.001). The data collected in the Paediatric Asthma Caregiver Diary also showed reduction in the median day time score by 85%, night score by 66.6% and a reduction in day inhaler use by 60.6%. All these results were statistically significant. The proportion of high and low responders was 60:40. Children younger than 4 years, those with a past medical history of Bronchiolitis and viral induced wheeze and those exposed to environmental tobacco smoke were more in the high response group (in the range of 69 to 83%) which were not statistically significant.
ConclusionMontelukast when used in a real life setting as add on therapy was effective in improving multiple outcomes of asthma control. We were able to identify some patient characteristics associated with high response although statistically not significant. When multiple outcomes are measured it is impractical to categorise subjects into responders and non‐responders.
L. Hobson1, M. Everard2. 1Sheffield University, Sheffield; 2Sheffield Children's Hospital, Sheffield, UK
IntroductionThe annual epidemics of respiratory syncytial virus (RSV) infection affect individuals are probably explained by poor herd immunity and the existence of a dormant reservoir of virus that is activated by an unknown trigger. The virus causes particular problems in infants, the elderly and patients with COPD.
MethodsHuman monocyte derived dendritic cells (DCs) were exposed on a single occasion to two forms of RSV labeled with a fluorescent expresser genes (gfpRSV or rrRSV) during the epidemic season. The cultures were maintained for many months with fresh DCs being added at monthly intervals. The culture were variously exposed to 600 ppb nitric oxide for 15 minutes, nitric oxide (NO) donors and NO inhibitors outside of the RSV epidemic season.
ResultsDCs only exhibited evidence of viral replication and productive infection as manifest by fluorescence and infection of HeLa cells during the RSV epidemic season unless exposed to the above agents when there was again evidence of vigorous and productive infection. These results suggest that the virus may remain dormant within human DCs, that pattern of replication and dormancy in DCs mimic the natural epidemics and that replication can be triggered by exogenous sources of nitric oxide and iNOS inhibitors.
ConclusionsThe results would suggest that human pulmonary DCs act as a reservoir for the virus between epidemics and that replication can be triggered by exogenous sources of NO such as atmospheric NO levels and smoke inhalation. Understanding the interaction of virus and DCs may provide important insights into disease mechanisms and suggest novel strategies for the production of an effective vaccine.
G. Koshy, A. Delpisheh, E. B. Faragher, S. Rizwan, B. J. Brabin. Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, Merseyside, UK
IntroductionChildhood obesity is a growing crisis affecting millions of children around the world and in developed countries in particular.
MethodsA retrospective cross sectional survey was conducted to determine the association between childhood growth patterns, asthma prevalence and maternal smoking during pregnancy. A total of 1964 schoolchildren aged 5–11 years in Merseyside were evaluated using a standardised parent‐completed questionnaire and children's height and weight measured.
ResultsMean (standard deviation) birth weight and current body mass index were 3350 (586) g and 17.1 (1.8) kg/m2 respectively. Mean age was 7.2 (2.1) years and 29% had doctor‐diagnosed asthma. Overall 14% of children were overweight and 9.1% were obese. These proportions were 29.4% and 12.3% among asthmatic children (p=0.02, compared to non‐asthmatic children). The corresponding proportions were 26.2% and 11.5% respectively in children of mothers who smoked during pregnancy (p<0.001, compared to children born to non‐smoking mothers). Covariate adjustments for household socioeconomic status and child's age indicated that the development of obesity in later childhood was significantly associated with childhood asthma (RR=2.4, 95% CI 1.5–3.8) and maternal smoking during pregnancy (RR=1.8, 95% CI 1.3–2.5).
ConclusionObesity was more frequent in asthmatic children and in those whose mothers smoked during pregnancy. Community surveillance should consider these additional risks in obese children. Improved understanding of the mechanisms underlying these associations is required.
P. Kenia, A. Sapare, A. Moir, S. Nichani, M. Chilvers. University Hospitals of Leicester NHS Trust, Leicester, Leicestershire, UK
AimTo review the indications for tracheostomy and related morbidity and mortality in the paediatric population over the last 7 years.
MethodRetrospective case note analysis of children aged 0–16 years with tracheostomy performed at the Leicester Royal Infirmary between 1999 and November 2006.
ResultsForty eight children were given tracheostomies in the review period. In the first year, only one tracheostomy was performed and this increased to an average of 8.2/year in the last 4 years. Male:female ratio was 22:26 and age at which tracheostomy was performed ranged from 2 days to 15 years. 36 (75%) children were under one year, and 8 (16.7%) were less than a month of age. The commonest indication for tracheostomy was primary obstructive upper airway problems (58.3%). The remaining indications were for prolonged ventilation (18.8%), failed extubation (20.8%) and central apnoea (2.1%). 32 children underwent a laryngotracheobronchoscopy prior to tracheostomy and 28 had abnormal findings. 96% of children were inpatients for >2 weeks post tracheostomy. 50% of children returned to hospital for infections or problems related to their tracheostomy on more than three occasions. 19 children (39.6%) were orally fed, whereas 13 (27.1%) were primarily fed via gastrostomy and 16 (33.3%) used nasogastric tube feeding as the primary route. Ongoing care for these children was offered by a multidisciplinary team including regular home visits. The average length of cannulation for the overall group was 23.9 months whereas the range was 1–81 months. For those who were eventually decannulated, the average cannulation was for 13.3 months. To date, 25 (52.1%) children remain cannulated, whereas 14 (29.2%) have been successfully decannulated. Four (8.3%) children have been transferred out of Leicester and no follow‐up is available for them. Five (10.4%) children died and of these 3 (6.3%) deaths were directly related to the tracheostomy.
ConclusionThe number of children having a tracheostomy in our institute has increased over the last 7 years. The indications for tracheostomy are appropriate. The procedure is associated with morbidity and potential mortality. A centralised, multidisciplinary team approach is required for successful care of these children.
G. Roberts1, H. Inskip2, J. Poole2, J. Lucas1, K. Godfrey2, J. Warner1. Southampton Women's Survey Study Group2. 1University Child Health, University of Southampton, Southampton, UK; 2MRC Epidemiology Resource Centre, University of Southampton, Southampton, UK
IntroductionPrevious data (Lucas, AJRCCM 2004;170:534) suggested that rapid postnatal weight gain, a potential marker of foetal growth restriction, is associated with impaired infant lung function in the first few months of life.
AimsTo examine the relation between greater early postnatal weight gain and respiratory health in the first year of life.
MethodsWe analysed data from infants born into the Southampton Women's Survey (http://www.swsurvey.soton.ac.uk) between 30/12/98 and 31/12/03. A total of 1835 (93%) infants were reviewed at 6 and 12 months of age. A questionnaire ascertaining infant feeding and respiratory symptoms and illnesses was administered at each assessment. All were skin‐prick tested at 12 months. Weight gain in the first 6 months was derived from weight at birth and at 6 months using electronic scales. A modified Cox regression was used to investigate whether each of the endpoints (wheeze, lower respiratory tract infection (LRTI) and atopy) were influenced by these exposures, with results expressed as prevalence ratios (95% CIs) (STATA V9). Results were adjusted for gestation, gender, breast feeding, smoking, maternal asthma, atopy and maternal education and paternal asthma.
ResultsIn the first year of life, 45% of infants experienced wheeze, 28% had a LRTI and 11% were atopic on skin testing. Birth weight was not significantly associated with infant wheeze, LRTI or atopy but weight gain in the first 6 months was positively associated with wheeze (1.08 (0.99–1.17)) and LRTI (1.12 (1.01–1.25)). In the multivariate model, female gender was protective for wheeze (0.79 (0.67–0.94]), LRTI (0.75 (0.60–0.94)) and atopy (0.62 (0.43–0.90)); longer gestation was protective for LRTI (0.89 (0.81–0.98)), breast feeding was protective for wheeze (0.93 (0.88–0.99)); maternal smoking during pregnancy (but not after) increased the risk of wheeze (1.31 (1.05–1.64)) and LRTI (1.45 (1.08–1.93)).
ConclusionThese results support the hypothesis that greater postnatal weight gain is linked with infant respiratory morbidity but not atopy. The associations with infant weight gain could reflect exclusively postnatal influences, or could partly reflect prenatal influences that lead to greater infant weight gain; serial prenatal ultrasound data in this cohort will allow examination of this issue.
P. Davies1, N. Maxwell1, B. Spiller1, E. Remold‐O'Donnell2, S. Kotecha1. 1Department of Child Health, Cardiff University, Cardiff, UK; 2Department of Pediatrics, Harvard University, Boston, USA
AimsAn imbalance between proteases, particularly elastase, and anti‐proteases, such as alpha 1‐antitrypsin, have been implicated in the development of classical chronic lung disease of prematurity (CLD). “New” CLD affects extremely preterm infants and our aim was to examine the imbalance of elastase and its primary inhibitor alpha 1‐antitrypsin in these infants and to investigate the role of serpin B1, a newer anti‐elastase protein that has not previously been measured in the neonatal lung.
MethodsPreterm infants (<32 weeks gestation) ventilated for respiratory failure were recruited, with controls consisting of term infants ventilated for non‐respiratory reasons. Serial bronchoalveolar lavages were performed until extubation. Active elastase levels (functional assays), total alpha 1‐antitrypsin and serpin B1 levels (western blot) were assessed for all lavages.
ResultsFrom 42 infants recruited, free elastase activity was detected at some point in 8/16 CLD infants and 2/16 infants whose respiratory distress syndrome (RDS) resolved, p<0.01; also in 2/5 infants who died and 1/5 term controls. However, elastase was detected in only 17/105 samples from CLD infants occurring as episodic peaks, compared to 3/45 from RDS infants, 2/22 of infants who died and 2/24 of controls. Low levels of alpha 1‐antitrypsin/elastase complex were detected in most samples although this increased significantly when free elastase activity was present. Interestingly, in some lavages functional, unbound alpha 1‐antitrypsin was found to coexist with free elastase. No significant difference in maximum serpin B1 concentrations were observed between CLD (median 341 mg/ml) and RDS (244 mg/ml; p=0.39) groups. However, when free elastase was present, significant elevations in total serpin B1 and serpin B1/elastase complex were observed. In some infants, peaks of serpin B1 occurred in the absence of free elastase and on these occasions a coincident elevation in alpha 1‐antitrypsin/elastase complex occurred, indicating active elastase being successfully bound.
ConclusionsElastase activity was present in an increased proportion of CLD infants but to a lesser degree than in classical CLD and only occurring as episodic spikes. The ability of the serpin B1 to significantly increase in response to elevated elastase activity represents a novel component of the anti‐elastase defence that may be important in reducing proteolytic tissue injury.
A. Greenough1, J. Alexander1, P. A. J. Chetcuti1, W. Lenney1, N. J. Shaw1, J. Boorman1, J. Turner1. 1Division of Asthma, Allergy & Lung Biology, King's College London, London, UK; 2North Staffordshire Hospital, Stoke‐on‐Trent, UK; 3Leeds General Infirmary, Leeds, UK; 4North Staffordshire Hospital, Stoke‐on‐Trent, UK; 5Liverpool Women's Hospital, Liverpool, UK; 6Abbott Laboratories Ltd, Maidenhead, UK; 7Premier Research Group plc, Crowthorne, UK
BackgroundIn prematurely born infants with chronic lung disease (CLD), repiratory syncytial virus (RSV) hospitalisation has been demonstrated to be associated with increased healthcare use and related cost of care in the first five years after birth.
ObjectiveTo determine whether RSV hospitalisation in the first two years is associated with ongoing chronic respiratory morbidity, as indicated by increased healthcare use and associated costs in years 5–7 in prematurely born children who had CLD.
DesignA retrospective review of readmissions, outpatient attendances and community care and prescriptions particularly related to respiratory problems in years 5–7 inclusive was undertaken. From the data collected the cost of care was calculated. Comparison was made of the results of children who had had at least one hospitalisation in the first two years for proven RSV infection (RSV group, n=29) to those who had an admission for probable bronchiolitis (bronchiolitis group, n=13), an admission for another respiratory cause (respiratory group, n=41) or a non‐respiratory or no admission (non‐respiratory group, n=77).
Participants160 of an original cohort of 235 infants who had a median gestational age 27 (range 22–33) weeks.
ResultsThe cost of care for outpatient visits (p=0.0396) and respiratory related prescriptions (p=0.0106) differed significantly between the four groups. Those differences related to the RSV group having a higher cost of care than the non respiratory group for outpatient visits (mean cost £742 v £ 426, p=0.0396) and respiratory‐related prescriptions (p=0.0650)
ConclusionIn prematurely born children who had had CLD, RSV hospitalisation in the first two years is associated with an increased healthcare use and cost of care even when they are aged 5–7 years.