Emergency department management of pediatric acute asthma: an evidence-based review

Zelicof Paul A, Rutherford KA, Abuso SM. Emergency department management of pediatric acute asthma: an evidence-based review. Pediatr Emerg Med Pract. 2023 Jul;20(7):1-28. Epub 2023 Jul 1. PMID: 37352408.

Tradimus, CC BY-SA 3.0, via Wikimedia Commons

Asthma is the most common chronic disease of childhood. Although home action plans and the use of maintenance medications have improved daily management and control of asthma, many children still require emergency department care at least once per year. Emergency clinicians must be able to manage patients with acute asthma exacerbations and determine their safe disposition. This issue reviews the current evidence-based emergency department management recommendations for moderate to severe acute asthma in pediatric patients. Timely use of bronchodilators and systemic corticosteroids, as well as adjunct modalities, are discussed. Current challenges in asthma management related to vaping and COVID-19 are also addressed.

Septic shock: early rapid recognition and ongoing management

Mariana Miranda, Simon Nadel, Septic shock: early rapid recognition and ongoing management, Paediatrics and Child Health, Volume 33, Issue 5,
2023, Pages 134-143, https://doi.org/10.1016/j.paed.2023.02.003.

Paediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, current evidence-base for interventions and suggest possible areas of improvement. Controversy remains regarding accurate definitions for paediatric sepsis, resuscitation fluid volume and type, choice of vasoactive agents for use in resuscitation and antibiotic choices. Many adjunctive therapies have been suggested with theoretical benefit, although few have proven beneficial. Definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices. Early diagnosis and aggressive intervention with timely antibiotics, fluid resuscitation and vasoactive medications are the most important interventions in to improve outcomes. The implementation of protocols, resource-adjusted sepsis bundles and advanced technologies will impact on reducing sepsis mortality.

Intravenous bronchodilator choices in acute severe and life-threatening asthma

William FS. Sellers, Mike FM. James, Intravenous bronchodilator choices in acute severe and life-threatening asthma, Paediatrics and Child Health, Volume 33, Issue 5, 2023, Pages 119-124,
https://doi.org/10.1016/j.paed.2023.02.001.

When inhaled therapy fails to reverse bronchospasm during a severe asthma attack, intramuscular epinephrine and intravenous (IV) magnesium sulphate (MgSO₄), salbutamol, and aminophylline reach bronchial smooth muscle cells by the vascular route. There is no consensus on how long to wait before abandoning inhaled therapy, little agreement on which IV drug to use first, in what order, what dose to use, and IV delivery speed. IV therapy can begin with MgSO₄ 40 mg–75 mg⁻¹ as a bolus rather than over 20 minutes, followed by salbutamol 15 mg.kg⁻¹ over 10 minutes. Aminophylline is still used even though it is proscribed in some asthma guidelines. In the Netherlands the selective phosphodiesterase inhibitor enoximone (Perfan™) is used IV in status asthmaticus but is unlicensed for UK use in asthma. Escalation to IV therapy should begin as soon as nebulized therapy and steroid are seen to be ineffective. This article discusses the reasons for the use or non-use of each IV drug and the potential benefits of using of MgSO₄ followed by salbutamol.

Diagnosis and management of children with adrenal insufficiency

Joanne Blair, Diagnosis and management of children with adrenal insufficiency, Paediatrics and Child Health, Volume 33, Issue 7,
2023, Pages 175-182, https://doi.org/10.1016/j.paed.2023.04.001

Adrenal insufficiency (AI) is a rare diagnosis. Symptoms may be vague, easily overlooked or attributed to more common childhood diagnoses. Early diagnosis and treatment is essential as untreated AI may present as adrenal crisis, a potentially fatal condition. Adrenal insufficiency may result from lesions at all levels of the hypothalamic pituitary adrenal axis. Accurate diagnosis is essential as the treatment and prognosis of AI differs according to the site and nature of the lesion. Cortisol is secreted in a circadian manner. Cortisol concentrations rise from the early hours of the morning, peak 30 minutes after waking before falling throughout the day and overnight. Childhood AI is treated with hydrocortisone, which has a short half-life, requiring three to four daily doses. Modified release formulations, which achieve a more physiological cortisol profile and require less frequent dosing, are in development and may become available to children. During periods of illness and injury, children with AI are at risk of adrenal crisis. It is essential that parents and carers are educated in the management of ‘sick days’, can recognise symptoms of adrenal crisis and seek medical advice appropriately. In turn, it is essential that medical staff know how to manage an adrenal crisis in children and young people. This article briefly reviews the physiology of the hypothalamic pituitary adrenal axis, causes of AI, options for treatment, methods of monitoring for the adequacy of treatment, and finally the treatment of children with AI during illness and surgery.

Current understanding and management of paediatric diabetic ketoacidosis

Daniel Leach, Sumana Chatterjee, Proteek Sen, et al. Current understanding and management of paediatric diabetic ketoacidosis,
Paediatrics and Child Health, Volume 33, Issue 7, 2023, Pages 206-215,
https://doi.org/10.1016/j.paed.2023.04.006.

Diabetic Ketoacidosis (DKA) is a serious complication of insulin deficiency. It is typically seen in children and young people with Type 1 Diabetes Mellitus, either at first presentation, or in established disease, for instance due to poor compliance, equipment failure, or concurrent illness. Insulin deficiency leads to hyperglycaemia causing osmotic fluid loss, dehydration and electrolyte derangement. Osmotic symptoms of polyuria and polydipsia due to hyperglycaemia may give way to oliguria or anuria as circulatory insufficiency develops. Unable to utilise glucose, cells default to alternative mechanisms of energy production resulting in the accumulation of ketone bodies. Kussmaul breathing may compensate partially for the worsening acidosis. Untreated, DKA results in progressively worsening acidosis, development of shock, coma and ultimately death. Clear guidelines for the management of DKA in children and young people exist once a diagnosis is made. However, evidence for these guidelines is limited and remains the subject of ongoing debate. Diligence is required to ensure that fluid and insulin is delivered appropriately, and to identify early the complications of both DKA and its treatment, such as cerebral oedema. In this article reviews the current state of DKA management with key practice points.

Epidemiology and risk factors for thrombosis in children and newborns: systematic evaluation and meta-analysis

Song S, Li Z, Zhao G, Li X, et al. Epidemiology and risk factors for thrombosis in children and newborns: systematic evaluation and meta-analysis. BMC Pediatr. 2023 Jun 15;23(1):292. doi: 10.1186/s12887-023-04122-x. PMID: 37322473

Background: Thrombosis is a serious condition in children and neonates. However, the risk factors for thrombosis have not been conclusively determined. This study aimed to identify the risk factors for thrombosis in children and neonates in Intensive Care Unit (ICU) through a meta-analysis to better guide clinical treatment.

Methods: A systematic search of electronic databases (PubMed, Embase, Cochrane Library, WOS, CNKI, Wanfang, VIP) was conducted to retrieve studies from creation on 23 May 2022. Data on the year of publication, study design, country of origin, number of patients/controls, ethnicity, and type of thrombus were extracted. The publication bias and heterogeneity between studies were assessed, and pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using fixed or random effects models.

Results: A total of 18 studies met the inclusion criteria. The incidence of thrombosis in children was 2% per year (95% CI 1%-2%, P < 0.01). Infection and sepsis (OR = 1.95, P < 0.01), CVC (OR = 3.66, [95%CL 1.78-7.51], P < 0.01), mechanical ventilation (OR = 2.1, [95%CL1.47-3.01], P < 0.01), surgery (OR = 2.25, [95%CL1.2-4.22], P < 0.01), respiratory distress (OR = 1.39, [95%CL0.42-4.63], P < 0.01), ethnicities (OR = 0.88, [95%CL 0.79-0.98], P = 0.78), gestational age (OR = 1.5, [95%CL1.34-1.68], P = 0.65)were identified as risk factors for thrombosis.

Conclusions: This meta-analysis suggests that CVC, Surgery, mechanical ventilation, Infection/sepsis, gestational age, Respiratory distress, and different ethnicities are risk factors for thrombosis in children and neonates in ICU. These findings may help clinicians to identify high-risk patients and develop appropriate prevention strategies.

Pain assessment tools for use in infants: a meta-review

Arabiat D, Mörelius E, Hoti K, et ak. Pain assessment tools for use in infants: a meta-review. BMC Pediatr. 2023 Jun 19;23(1):307. doi: 10.1186/s12887-023-04099-7. PMID: 37337167

Background: Identifying pain in infants is challenging due to their inability to self-report pain, therefore the availability of valid and reliable means of assessing pain is critical.

Objective: This meta-review sought to identify evidence that could guide the selection of appropriate tools in this vulnerable population.

Methods: We searched Scopus, Medline, Embase, CINAHL, MIDRIS, EMCare and Google Scholar for eligible systematic reviews. Eligible reviews documented psychometric properties of available observational tools used to assess pain in infants.

Results: A total of 516 reviews were identified of which 11 met our inclusion criteria. We identified 36 pain assessment tools (evaluated in 11 reviews) of which seven were reported in at least three reviews. The level of evidence reported on the psychometric properties of pain assessment tools varied widely ranging from low to good reliability and validity, whilst there are limited data on usability and clinical utility.

Conclusions: Currently, no observer administered pain assessment tool can be recommended as the gold standard due to limited availability and quality of the evidence that supports their validity, reliability and clinical utility. This meta-review attempts to collate the available evidence to assist clinicians to decide on what is the most appropriate tool to use in their clinical practice setting. It is important that researchers adopt a standard approach to evaluating the psychometric properties of pain assessment tools and evaluations of the clinical utility in order that the highest level of evidence can be used to guide tool selection.

Children born preterm admitted to paediatric intensive care for bronchiolitis: a systematic review and meta-analysis

van Hasselt TJ, Webster K, Gale C et al. Children born preterm admitted to paediatric intensive care for bronchiolitis: a systematic review and meta-analysis. BMC Pediatr. 2023 Jun 29;23(1):326. doi: 10.1186/s12887-023-04150-7. PMID: 37386478;

Background: To undertake a systematic review of studies describing the proportion of children admitted to a paediatric intensive care unit (PICU) for respiratory syncytial virus (RSV) and/or bronchiolitis who were born preterm, and compare their outcomes in PICU with children born at term.

Methods: We searched Medline, Embase and Scopus. Citations and references of included articles were searched. We included studies published from the year 2000 onwards, from high-income countries, that examined children 0-18 years of age, admitted to PICU from the year 2000 onwards for RSV and/or bronchiolitis. The primary outcome was the percentage of PICU admissions born preterm, and secondary outcomes were observed relative risks of invasive mechanical ventilation and mortality within PICU. We used the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies to assess risk of bias.

Results: We included 31 studies, from 16 countries, including a total of 18,331 children. Following meta-analysis, the pooled estimate for percentage of PICU admissions for RSV/bronchiolitis who were born preterm was 31% (95% confidence interval: 27% to 35%). Children born preterm had a greater risk of requiring invasive ventilation compared to children born at term (relative risk 1.57, 95% confidence interval 1.25 to 1.97, I² = 38%). However, we did not observe a significant increase in the relative risk for mortality within PICU for preterm-born children (relative risk 1.10, 95% confidence interval: 0.70 to 1.72, I² = 0%), although the mortality rate was low across both groups. The majority of studies (n = 26, 84%) were at high risk of bias.

Conclusions: Among PICU admissions for bronchiolitis, preterm-born children are over-represented compared with the preterm birth rate (preterm birth rate 4.4% to 14.4% across countries included in review). Preterm-born children are at higher risk of mechanical ventilation compared to those born at term.

Comparison of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for the diagnosis of neonatal sepsis: a systematic review and meta-analysis

Bai L, Gong P, Jia X, et al. Comparison of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for the diagnosis of neonatal sepsis: a systematic review and meta-analysis. BMC Pediatr. 2023 Jun 30;23(1):334. doi: 10.1186/s12887-023-04094-y. PMID: 37391699

To compare the performance of Neutrophil-to-Lymphocyte Ratio (NLR) with that of Platelet-to-Lymphocyte Ratio (PLR) in diagnosing neonatal sepsis (NS).

Methods

PubMed and Embase were searched for relevant studies from the inception of the databases to May, 2022. The pooled sensitivity (SEN), specificity (SPE), and area under the receiver operator characteristic curve (AUC) were measured.

Results

Thirteen studies involving 2610 participants were included. The SEN, SPE, and AUC of NLR were 0.76 (95%CI: 0.61–0.87), 0.82 (95%CI: 0.68–0.91), and 0.86 (95%CI: 0.83–0.89), respectively, and those of PLR were 0.82 (95%CI: 0.63–0.92), 0.80 (95%CI: 0.24–0.98), and 0.87 (95%CI: 0.83–0.89), respectively. Significant heterogeneity was observed among the studies. Subgroup analysis and meta-regression showed that types of sepsis (p = 0.01 for SEN), gold standard (p = 0.03 for SPE), and pre-set threshold (p<0.05 for SPE) might be the sources of heterogeneity for NLR, whereas the pre-set threshold (p<0.05 for SPE) might be the source of heterogeneity for PLR.

Conclusions

NLR and PLR would be of great accuracy for the diagnosis of NS, and the two indicators have similar diagnostic performance. However, the overall risk of bias was high, and significant heterogeneity was identified among the included studies. The results of this study should be interpreted prudently, and the normal or cut-off values and the type of sepsis should be considered. More prospective studies are needed to further support the clinical application of these findings.

The effect of early childhood respiratory infections and pneumonia on lifelong lung function: a systematic review

Collaro, A. J., McElrea, M. S., Marchant, J. M., et al (2023). The effect of early childhood respiratory infections and pneumonia on lifelong lung function: a systematic review. The Lancet. Child & adolescent health, 7(6), 429–440.

Early childhood respiratory infections, including pneumonia, are an important global public health issue, with more than 40 million annual cases resulting in approximately 650 000 deaths. A growing number of published studies have examined the effects of early childhood lower respiratory tract infections (LRTIs) or pneumonia on lung function, particularly as part of large early-life exposure studies. To our knowledge, there is no published systematic review of these data. We searched PubMed, Embase, and Web of Science for studies published between database inception and May 12, 2022. Case-control, cohort, and cross-sectional studies were included if they reported forced expiratory volume in 1 s (FEV₁) or forced vital capacity (FVC) values of participants older than 5 years. Article titles and abstracts were screened in Rayyan before retrieval, assessment, and data extraction of the full text. Primary outcome measures were differences in mean FEV₁ or FVC values between exposed groups (ie, children aged ≤5 years with LRTIs) and non-exposed groups. This study is registered with PROSPERO, CRD42021265295. Database searches yielded 3070 articles, and 14 studies were included in this systematic review, providing a total of 23 276 participants, including 9969 children and 13 307 adults. Eight of 14 articles reported significant reductions in FEV₁ values, and six of 12 studies reported reductions in FVC values in children and adults with a history of early childhood LRTIs or pneumonia, compared with unexposed controls (p<0·05). Most studies reporting reductions in lung function described deficits consistent with a restrictive spirometry pattern. Only two of 14 studies reported data from low-income and middle-income countries or disadvantaged populations in middle-income and high-income countries, and there were scarce data available on the effect of LRTI severity and recurrence on lung function. LRTIs in early childhood could be associated with a restrictive spirometry pattern in later childhood and adulthood. Data are needed from low-income and middle-income nations, and from disadvantaged populations in middle-income and high-income countries in which early childhood respiratory infection burden is disproportionately high. Data are also needed on the effect of LRTI severity and recurrence on future lung function.