Pediatric Pulmonology最新文献

Background: The Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) both recommend a combination inhaled corticosteroid (ICS)/formoterol inhaler to replace short-acting beta-agonists (SABA) as the preferred reliever therapy for Steps 3 and 4 of their asthma treatment strategies (known as Single Maintenance and Reliever Therapy or SMART). The extent of adoption and factors influencing use among pediatric asthma specialists remain unclear.

Objective: To gain a better understanding of SMART prescribing practices and factors that facilitate or impede its use in the United States among pediatric asthma specialists.

Methods: An electronic survey on SMART knowledge and practices was distributed to pediatric pulmonology division directors for dissemination to pediatric asthma specialists in allergy and pulmonology divisions.

Results: Sixty-eight completed survey responses were received between March and October of 2024. All asthma specialists were familiar with SMART, and over 90% were comfortable with its implementation in pediatric asthma. However, there was wide variability in the percentage of patients advised to use their prescribed maintenance ICS/formoterol inhaler as a reliever that did not correlate with the comfort level of the clinician or years in clinical practice, but did correlate with the region of practice.

Conclusions: Despite GINA/NAEPP recommending SMART, there is substantial variation in its implementation among pediatric asthma specialists. Survey results indicate that pediatric asthma specialists are comfortable with its use, but that improvement in EMR efficiency and consistent insurance coverage are needed to increase SMART adoption.

Background: The Eastern Mediterranean has climatic conditions that increase exposure to aeroallergens due to higher pollen counts and dust storms. The association of atopy with measures of respiratory health, including fractional exhaled nitric oxide (FeNO) and pulmonary function among asthmatic children during dust and pollen periods has not been assessed.

Objective: Examine the association between allergic sensitization and respiratory health in children with asthma during dust and pollen seasons in the Eastern Mediterranean.

Methods: We conducted an analysis of prospectively collected respiratory health data from schoolchildren with asthma in Cyprus and Crete-Greece during spring and fall of 2019 and 2021. Children were assessed 3 to 4 times over 4 months, including evaluation of allergic sensitization by skin prick tests (SPTs). Mixed effect models were applied, adjusting for potential confounders, including study year, location, weeks on study, age and sex.

Results: There were 131 children included (77 atopic and 54 non-atopic; mean (SD) age = 9.5 (1.6) years; 65% boys). Over the study period, atopic children exhibited 113.71% (95% CI: 68.08%, 171.73%) higher FeNO concentrations and reduced FEV₁/FVC% (-2.62, 95% CI: -5.00, -0.24) compared to non-atopic children. FeNO concentrations were positively associated with the degree of sensitization, as reflected by sensitization to perennial aeroallergens and the number of positive SPT results.

Conclusion: Atopic children with asthma may experience greater morbidity compared to non-atopic children during dust and pollen periods. Given the long-range transport of desert dust, clinicians both within and beyond the Eastern Mediterranean should be aware of this health concern.

Introduction: There is uncertainty about the cost-effectiveness of treatment options for children and adolescents with uncontrolled asthma despite inhaled corticosteroid (ICS) treatment.

Methods: A Markov state-transition model was developed to simulate costs from the perspective of the National Health Service in the UK and health outcomes associated with low, medium and high dose ICS, ICS in combination with long-acting β₂-adrenoceptor agonists (LABAs) or leukotriene receptor antagonists (LTRAs), and LTRA monotherapy. Healthcare resource use and health state utilities were identified from literature searches. Transition probabilities were derived from a systematic review and network meta-analysis. Total costs and quality-adjusted life years were computed, and incremental cost-effectiveness ratios estimated over a 1-year time horizon. Parameter, structural and probabilistic sensitivity analyses were performed.

Results: Compared with low-dose ICS, medium-dose ICS and ICS + LABA had incremental cost-effectiveness ratios of £255,555 and £304,956 per quality-adjusted life year gained, respectively. High-dose ICS, LTRA alone and in combination with ICS were dominated by alternatives which were less costly and associated with a greater number of quality-adjusted life years. The incremental cost-effectiveness ratio for medium-dose ICS reduced to £14,797 per quality-adjusted life year gained when the transition probabilities were increased to reflect a higher risk of asthma exacerbation. ICS + LABA became cost effective with a > 60% reduction in inhaler price.

Conclusions: Treatment escalation beyond low-dose ICS in children and adolescents with uncontrolled asthma may only be cost-effective in the UK if the prices of alternatives reduce or treatment is targeted to those at higher risk of asthma exacerbations.

Objective: To examine whether exposure to fine particulate matter (PM_2.5) during the first year after neonatal intensive care unit (NICU) discharge is associated with asthma by age 5 among infants with bronchopulmonary dysplasia (BPD).

Methods: We conducted a retrospective cohort study of 337 infants with BPD, born between 2010 and 2019, who survived to discharge with clinical follow-up in the Children's Hospital of Philadelphia Care Network through age 5. Daily residential census block group PM_2.5 exposures were estimated using a spatiotemporal machine-learning model and averaged over the first year after NICU discharge. Modified Poisson regression models with robust standard errors quantified associations of PM2.5 with asthma by age 5, adjusting for neonatal clinical factors, insurance, neighborhood deprivation, and race/ethnicity.

Results: By age 5 years, 169 (50.1%) infants had an asthma diagnosis. Mean annual PM_2.5 exposure was 8.8 µg/m³ (SD 1.1). Each 1 µg/m³ increment of PM_2.5 was associated with higher asthma risk (unadjusted RR 1.14, 95% CI: 1.03-1.25; fully adjusted aRR 1.19, 95% CI: 1.03-1.37). Compared to the lowest exposure tertile (mean 7.6 µg/m³), adjusted rates of asthma tended to be higher as exposure increased: Tertile 2 (mean 8.7 µg/m³, aRR 1.31; 95% CI: 0.98-1.74), Tertile 3 (mean 10.0 µg/m³, aRR 1.68, 95% CI: 1.17-2.4).

Conclusions: Exposure to higher ambient PM_2.5 in the year after NICU discharge was associated with asthma by age 5 among children with BPD. These findings highlight early-life air quality as a modifiable determinant of long-term respiratory outcomes in infants with BPD.

Introduction: Applications of genetic and genomic testing are increasing in clinical practice. However, access to genetic counselors (GCs), who can provide information and support to patients and providers, is limited and in high demand. We sought community feedback on a centralized cystic fibrosis-specific genetic counseling telehealth service (CFgc-T) as a novel, equitable solution.

Methods: We conducted virtual focus groups using semi-structured interview guides for service providers (GCs), referrers (CF center and newborn screening [NBS] program staff), consumers (people with CF [pwCF], their partners, parents of pwCF or positive CF NBS results), and payors. Transcripts were coded, deductive and inductive methods were used to identify core service model features, and the Consolidated Framework for Implementation Research (CFIR) guided assessment of barriers and facilitators to inform model design. We then prepared a video description of the CFgc-T model and sought feedback via survey from clinicians at 287 CF care centers and 52 consumers.

Results: Across 15 focus groups (n = 67 participants), experience with a GC (not necessarily CF-specific) varied. Referrers and providers supported CF-specific GC access, emphasizing the importance of scheduling flexibility, availability, and addressing systemic barriers (e.g., insurance, licensure, language). Consumers desired accurate, digestible information. Participants expressed concerns about discussing sensitive topics over telehealth, technology barriers, and cost; consumers were amenable to paying typical co-pays for valuable, accessible service. Additionally, 26 consumers and 67 clinicians provided feedback via survey. Overall, 58% of clinicians expressed interest in becoming a pilot site in a future implementation study, and 96% of consumers would refer family and friends to the CFgc-T service.

Conclusions: A centralized CFgc-T service staffed by GCs with CF expertise could improve equitable access to CF-specific genetic counseling and was viewed favorably by key community members. Telehealth delivery may help resolve workforce shortages in specialties where few GCs have relevant expertise, offering a scalable, equitable model for care.

Background: Recurrent pneumonia (RP) is a common diagnosis in children, leading to increased morbidity rates, frequent hospitalizations, and longer treatments. Asthma has traditionally been the most common underlying cause. However, recently, other conditions have emerged. Therefore, our goal was to systematically analyze and compare the changes in the underlying causes of RP.

Methods: We searched four databases from their inception until November 2024 for studies in children under 18 years with RP, where the underlying causes were described. To compare changes in the prevalence of underlying causes, we divide them into periods I (1999-2013) and II (2014-2024).

Results: Twenty-two studies (n = 3440 children with RP) met the final criteria for analysis. In 94% of the patients, an underlying cause was identified. Among the 39 underlying conditions described, the top ten were asthma (15.9%), aspiration (14.1%), congenital heart diseases [CHD] (13.2%), lung/airway congenital malformations (10.7%), immunodeficiency (10.4%), bronchial hyperresponsiveness [BHR] (8.0%), neurological causes (8.02%), atopy (7.3%), gastroesophageal reflux disease [GERD] (4.5%), and recurrent upper respiratory tract infections [URTIs] (3.7%). Notably, compared to Period I, a significant decrease was observed in asthma, aspiration, BHR, chronic rhinosinusitis, recurrent URTIs, middle lobe syndrome, CF, infections, obesity, foreign body aspiration, and pulmonary hemosiderosis/hemorrhage in Period II. In contrast, during Period II, a significant increase in lung/airway congenital malformations, immunodeficiency, CHD, atopy, neurological causes, PCD, bronchopulmonary dysplasia, hematologic diseases, and oromotor incoordination was observed.

Conclusions: In the last decade, the underlying causes of RP have changed, emphasizing the need for a more comprehensive and tailored diagnostic approach.

Background: Repeat hospitalisations among asthmatic children pose a significant burden on the healthcare system. Identifying risk factors for asthma readmission may help detect at-risk children and promote effective interventions. The study aimed to identify risk factors for asthma readmission among children aged 2-17 years in New South Wales (NSW), Australia.

Methods: A retrospective birth cohort study was conducted using linked administrative data. The study cohort included children born in NSW between 2005 and 2015 who had at least one asthma-related hospitalisation. Risk factors for early and late readmissions, along with their risk ratios, were identified using modified Poisson regression models.

Results: From 2007 to 2022, a total of 27,430 children were hospitalised. Among them, 17.9% of children experienced early readmissions, and 82.1% experienced late readmissions. In the adjusted multivariable model, risk factors for early readmissions included children's age 2-4 years (adjusted Relative Risk [aRR] 1.71; 95% confidence interval [CI] 1.49-1.99), no older siblings (1.26; 95% CI 1.11-1.42), length of stay (LOS) ≥ 2days (1.42; 95% CI 1.26-1.61), intensive care unit (ICU) admission (2.27; 95% CI 1.47-3.50), underlying chronic comorbidities and/or congenital anomalies (1.27; 95% CI 1.11-1.46), and having admissions related to allergies or eczema (1.54; 95% CI 1.30-1.83). Risk factors for late readmissions included children's age 2-4 years (1.93; 95% CI 1.80-2.06), no older siblings (1.09; 95% CI 1.04-1.15), residence in the poor neighbourhoods and in major cities, and index admission during spring or summer, LOS ≥ 2days (1.21; 95% CI 1.14-1.27), and having admission related to allergies or eczema (1.40; 95% CI 1.30-1.50).

Conclusion: Risk factors for asthma readmission among children vary according to the timing of readmission. Risk stratification and targeted post-discharge follow-up for at-risk children may reduce the overall burden of asthma readmissions.