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BackgroundThe imposition of lockdowns during the severe acute respiratory syndrome coronavirus-2 pandemic led to a significant decrease in pediatric care utilization in 2020. After restrictions were loosened, a surge in pediatric respiratory disease was observed in pediatric wards. The aim of this study was to quantify the effect of the lockdown(s) on the incidence of pediatric respiratory disease. MethodsFor this multicenter retrospective study, emergency department (ED) visit and admission data between January 2017 and September 2021 was collected from eight general hospitals in the Netherlands. Clinical diagnoses were extracted and categorized in groups ("communicable infectious disease," "all respiratory infections," "upper respiratory tract infection," "lower respiratory tract infection," and "asthma/preschool wheezing"). The incidence of admissions and ED visits during 2020 and 2021 was compared to the incidence in 2017-2019. ResultsSuccessive lockdowns resulted in a maximum decrease of 61% and 57% in ED visits and admissions, respectively. After loosening restrictions during the summer of 2021, a 48% overall increase in ED visits and 31% overall increase in admission numbers was observed in July compared to the average July in 2017-2019. This was explained by a 381% increase in ED visits and a 528% increase in ward admissions due to overall respiratory infections, mainly due to lower respiratory tract infections. ConclusionsSuccessive lockdowns in the spring and winter of 2020 and 2021 led to a decreased incidence of communicable infections, especially respiratory tract infections. The resulting lack of pediatric immunity resulted in an off-season surge in care utilization at an unexpected moment.

Extrapulmonary manifestations of bronchiolitis have been previously studied, with some identifying right ventricle (RV) diastolic/systolic dysfunction. We hypothesized that severe cases of bronchiolitis would have cardiac dysfunction resulting an increase in N-terminal pro-hormone B-type natriuretic peptide (NT-proBNP) values and worse outcomes. Therefore, the objective was to evaluate the existence of cardiac dysfunction and to determine its association with severe bronchiolitis.This prospective cohort study included children hospitalized for bronchiolitis under 1-year old between January 2019 and March 2020. At admission, an echocardiography was performed and plasma levels of NT-proBNP were measured. To analyze outcomes, the cohort was divided into two groups based on the need for positive pressure respiratory support (PPRS), and both were compared to healthy infants.bivariant analysis, significant differences p 0.05.One hundred eighty-one patients were included; median age was 2 months. Seventy-three patients required PPRS. Compared to controls, patients requiring PPRS showed worse RV systolic function, with lower tricuspid annular-plane systolic excursion (p = 0.002) and parameters of worse right and left diastolic function (trans-tricuspid E and A wave [p = 0.004 and p = 0.04, respectively] and tricuspid tissue doppler imaging [TDI] e' [p = 0.003], trans-mitral E and mitral TDI a' [p = 0.02 and p = 0.005, respectively]). An NT-ProBNP greater than 3582 pg/dl predicts the need for longer necessity of PPRS in patients younger than 2 months.In addition to the expected RV systolic dysfunction, patients with severe bronchiolitis have parameters of global diastolic worse function possibly secondary to intrinsic myocardial involvement. NT-ProBNP values at admission had strong discriminatory power to predict worse outcomes.

High-flow nasal cannula (HFNC) therapy is widely used for children with bronchiolitis, but its optimal role remains uncertain. Our institution created and later revised a clinical pathway guiding HFNC initiation and weaning.A retrospective review of 1690 bronchiolitis encounters was conducted. Trends in the duration of HFNC and hours spent weaning HFNC as proportions of the monthly hospital length of stay (LOS) for bronchiolitis, hospital LOS, and escalation of care were compared using interrupted time series (ITS) models across three study periods: Baseline (HFNC managed at provider discretion), Intervention 1 (pathway with initiation at 0.5 L/kg/min and escalation up to 2 L/kg/min), and Intervention 2 (revised pathway, initiation at the maximum rate of 2 L/kg/min). Both pathway iterations provided titration and weaning guidance. Maximum respiratory scores were used to adjust for case severity.After adjustment for severity and time, both HFNC duration and HFNC weaning time (as a proportion of monthly LOS) decreased at the start of Intervention 1, but subsequently increased. During Intervention 2, both these measures trended downward, returning to baseline. Total LOS did not change in the baseline or intervention periods. Escalation of care did not differ from baseline to the end of Intervention 2.Initiating HFNC at higher flow rates with weaning guidance for children hospitalized with bronchiolitis was associated with a reduction in HFNC duration without differences in LOS or escalation of care. These findings suggest that standardization through clinical pathways can limit HFNC duration in bronchiolitis.

To evaluate the effects of four flow rates on the functional residual capacity (FRC) and pulmonary ventilation distribution while using a high-flow nasal cannula (HFNC).Our hypothesis is that flow rates below 1.5 L·kgsup-1/sup·minsup-1/suplead to FRC loss and respiratory distress.A single-center, prospective clinical study.Infants diagnosed with acute viral bronchiolitis were given HFNC.Through a prospective clinical study, the effects of four different flow rates, 2.0, 1.5, 1.0, and 0.5 L·kgsup-1/sup·minsup-1/sup, on FRC and the pulmonary ventilation pattern were evaluated using electrical impedance tomography. The impedance variation (delta Z), end-expiratory lung volume (EELZ), respiratory rate, heart rate, respiratory distress score, and saturation/fraction of inspired oxygen ratio (SpOsub2/sub/FsubI/subOsub2/sub), were also evaluated at each flow rate.Among the 11 infants included, There was a decrease in respiratory distress score at a flow rate of 1.5 L·kgsup-1/sup·minsup-1/sup(*p = 0.021), and at a flow rate of 2.0 L·kgsup-1/sup·minsup-1/sup(**p = 0.003) compared to 0.5 L·kgsup-1/sup·minsup-1/sup. There was also a small but significant increase in SpOsub2/sub/FiOsub2/subat flow rates of 1.5 (*p = 0.023), and 2.0 L·kgsup-1/sup·minsup-1/sup(**p = 0.008) compared to 0.5 L·kgsup-1/sup·minsup-1/sup. There were no other significant changes in the clinical parameters. In the global EELZ measurements, there was a significant increase under a flow rate of 2.0 L·kgsup-1/sup·minsup-1/supas compared to 0.5 L·kgsup-1/sup·minsup-1/sup(p = 0.03). In delta Z values, there were no significant variations between the different flow rates.The ∆EELZ increases at the highest flow rates were accompanied by decreased distress scores and improved oxygenation.

Bronchiolitis is the most frequent cause of hospitalization in infants younger than 1 year of age. We sought to evaluate the correlation between lymphocyte count and clinical manifestation in infants hospitalized with bronchiolitis.We performed a retrospective cohort study evaluating 1297 children hospitalized for bronchiolitis from 2004 to 2019. A nasal washing was tested for 14 respiratory viruses by PCR. A clinical severity score, ranging 0-8, was assigned at hospital admission. History and clinical course were recorded for each infant. Patients were divided in 3 groups according to lymphocyte count tertiles. Parents of enrolled patients have been phoned annually over 5 years to evaluate respiratory sequelae.A total of 433 children had 2914.2 ± 745.5/mmInfants with low lymphocyte count are more likely to have a worse clinical course of bronchiolitis.

Objective To determine whether high-flow nasal cannula oxygen (HFNCO) provided enhanced respiratory support in bronchiolitis than low-flow oxygen (LFO). Methods We conducted a prospective, randomized controlled trial in children between 1 and 24 months diagnosed with moderate-to-severe bronchiolitis requiring oxygen therapy. Participants received LFO via face mask (6-10 L/min) or HFNCO (2 L/kg/min). Primary outcomes were the time that heart rate (HR) and respiratory rate (RR) return to their normal range for age and the time that baseline clinical respiratory score (CRS) regress to a lower severity score. Secondary outcomes were changes in HR, RR, and CRS over time, length of stay (LOS), duration of oxygen requirement, treatment failure, and adverse event (AE). Results Eighty-seven children were enrolled (48 in LFO; 39 in HFNCO). The time that HR and RR baseline values reached their normal range for age was shorter in HFNCO therapy (2.0 h [1.0-4.0] vs. 12.0 h [2.0-24.0], and 4.0 h [2.0-12.0] vs. 24.0 h [4.0-48.0], respectively; p < 0.001); additionally, the improvement in CRS emerged more quickly in children treated with HFNCO (2.0 h [1.0-4.0] vs. 4.0 h [2.0-24.0]; p = 0.003). While the duration of oxygen requirement (19.0 h [4.0-30.0] vs. 29.5 h [14.0-45.7]; p = 0.009) and treatment failure (3% vs. 21%) was statistically lower in children who received HFNCO, there were no differences in LOS and AE between groups. Conclusion HFNCO may provide enhanced respiratory support with a notable improvement in HR, RR, and CRS than LFO. Comprehensive studies are needed to assess the clinical efficacy of HFNCO therapy., Ege University Research Foundation [17-2.1/18], Ege University Research Foundation, Grant/Award Number: 17-2.1/18

Bronchiolitis is common reason for infant hospitalization. The aim of our systematic review and meta-analysis was to evaluate helium-oxygen (heliox) in bronchiolitis.We screened 463 studies, assessed 22 of them, and included six randomized controlled trials. Primary outcomes were the need for continuous positive airway pressure (CPAP) or intubation, hospitalization duration, and change in the modified Woods Clinical Asthma Scale (M-WCAS). We calculated mean differences with 95% confidence intervals (CIs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes.Six studies (five double- and one single-blinded) with 560 infants were included. The risk of bias was high in one, moderate in four, and low in one. The RR for the need for CPAP (three studies) was 0.87 (CI: 0.56-1.35), and for intubation (four studies) was 1.39 (CI: 0.53-3.63), heliox compared to air-oxygen. The hospital stay (four studies) was 0.25 days longer (CI: -0.22 to 0.71) in the heliox group. The mean decrease in M-WCAS from the baseline (three studies) was 1.90 points (CI: 1.46-2.34) greater in the heliox group.We found low-quality evidence that heliox does not reduce the need for CPAP, intubation, or length of hospitalization for bronchiolitis. Based on the M-WCAS scores, heliox seems to relieve respiratory distress symptoms rapidly after its initiation. The included studies had high heterogeneity in their methods and included relatively mild cases of bronchiolitis. A larger randomized controlled trial with more severe cases of bronchiolitis with enough power to analyze the need for intubation is needed in the future.

Accurate and readily available biomarkers to predict the clinical course of bronchiolitis would enable enhanced decision-making in this setting. We explored the relationship of several biochemical parameters available at the pediatric emergency care setting with the need of advanced respiratory support (ARS): continuous positive airway pressure (CPAP), biphasic positive airway pressure (BiPAP), or invasive mechanical ventilation (MV) in bronchiolitis.Single-center, prospective, observational, including infants aged less than 12 months diagnosed with acute bronchiolitis at the Pediatric Emergency Department. Determination of plasmatic values of several laboratory tests was performed at the time of hospital admission. Multivariate logistic analysis identified independent predictors for need of ARS.From October 1, 2018 to May 1, 2020, we recruited 149 infants (58% males; median age of 1 [0.5-2.5] month). Thirty-seven (25%) cases required ARS. After adjusting by age, bacterial superinfection, and comorbidities in the multivariate analysis, only higher levels of glycemia (p = 0.001), C-reactive protein (CRP) (p = 0.028), CRP/albumin ratio (p = 0.032), and NT-proBNP (p = 0.001) remained independently associated with ARS. These biomarkers reached moderate prediction accuracy with area under the curve of receiver operator curve curves ranging from 0.701 to 0.830 (p = 0.001). All they presented relatively high specificity (0.75-0.84) and negative predictive values (0.77-0.89) with low sensitivity and positive predictive values. They also correlated significantly with length of stay hospitalization (p = 0.001).Increased plasmatic levels of CRP, CRP/albumin ratio, glycemia, and NT-proBNP at hospital admission are associated with the need for ARS in infants with acute bronchiolitis.

Background The heterogeneity of bronchiolitis may imply or reflect a different predisposition to respiratory sequelae. Objective Our aim was to investigate whether, among infants hospitalized with bronchiolitis, different clinical profiles extracted by latent class analysis (LCA) are associated with different risks of wheezing. Methods Over 15 consecutive epidemic seasons (2004–2019), we prospectively enrolled infants

Viral bronchiolitis is a common lower respiratory tract infection in infants. Environmental and genetic factors can favor respiratory tract infections.The aim of this study is to analyze risk factors for bronchiolitis and to investigate the predisposing factors for developing transient wheezing and asthma through a 6-year follow-up after hospitalization for bronchiolitis compared with a group of healthy controls that belonged to Piccolipiù cohort, who never had bronchiolitis.We enrolled 645 infants hospitalized with bronchiolitis. A structured questionnaire was used to obtain demographic and clinical data. At 6 years of age, 370 cases and 183 controls were investigated for the presence of asthma by the structured questionnaire, for prick test and for spirometry, and were classified to asthmatic, transient wheezing, and no wheezing/no asthma.Breastfeeding was an independent protective factor (odds ratio [OR]: 0.3, 95% confidence interval [95% CI]: 0.2-0.4, p 0.001) and tobacco smoke was a risk factor for the development of bronchiolitis (OR: 2.1, 95% CI: 1.4-3.1, p 0.001). Analyzing follow-up, bronchiolitis increased the risk of developing transient wheezing by 12.9 (95% CI: 6.3-26.1, p 0.001) and of developing asthma by 4.6 (95% CI: 1.9-10.7, p 0.001). A positive family history of atopy increased the risk of developing asthma by 3.1 (95% CI: 1.4-6.7, p = 0.005). Asthmatic patients had a lower % FEV1, a lower % flow-volume curve (FVC), and a lower FEV1/FVC value, and they had more frequently positive skin prick test.Bronchiolitis is influenced by environmental factors: tobacco smoke increases its risk and breastfeeding is a protective factor. At the end of 6 years of follow-up, bronchiolitis is a significant risk factor to have pre-school wheezing and asthma.

BACKGROUND Although international guidelines and Cochrane reviews emphasize that therapies do not alter the natural course of acute viral bronchiolitis (AVB), they are still prescribed frequently. This survey evaluated self-reported management of AVB by Swiss pediatricians in 2019 and compared it with previous surveys. METHODS We performed a cross-sectional online survey of all board-certified pediatricians in Switzerland in November 2019 and compared reported use of therapies with that reported in the 2001 and 2006 surveys. We used multivariable ordered logistic regression to assess factors associated with reported prescription of bronchodilators, corticosteroids, antibiotics and physiotherapy. RESULTS Among 1618 contacted board-certified pediatricians, 884 returned the questionnaires (55% response rate). After exclusions were applied, 679 were included in the final analysis. Paediatricians working in primary care reported using therapeutics more frequently than those working in a hospital setting, either always or sometimes: bronchodilators 53% vs 38%, corticosteroids 37% vs 23% and antibiotics 39% vs 22%. The opposite occurred with physiotherapy: 53% reported prescribing it in hospital and 44% in primary care. There was an overall decrease in the prescription of therapeutics and interventions for AVB from 2001 to 2019. The proportion who reported "always" prescribing corticosteroids decreased from 71% to 2% in primary care, and of those "always" prescribing bronchodilators from 55% to 1% in hospitals. CONCLUSION Although we observed a significant decrease since 2001, more effort is required to reduce the use of unnecessary therapies in children with AVB. This article is protected by copyright. All rights reserved.

Introduction: Endemic coronaviruses have been found in acute bronchiolitis, mainly as a coinfecting virus. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been responsible for respiratory illness in hospitalized children. The characteristics of patients with bronchiolitis have not been extensively described. Methods: Cross-sectional study of patients with bronchiolitis and SARS-CoV-2 infection enrolled in a prospective multicenter cohort of children hospitalized with COVID-19 in Spain from March 1, 2020 to February 28, 2021. Results: Twelve of 666 children infected with SARS-CoV-2 who required hospital admission met the diagnostic criteria for bronchiolitis (1.8%). Median age was 1.9 months (range: 0.4-10.1). Six cases had household contact with a confirmed or probable COVID-19 case. Main complaints were cough (11 patients), rhinorrhea (10), difficulty breathing (8), and fever (8). Eleven cases were classified as mild or moderate and one as severe. Laboratory tests performed in seven patients did not evidence anemia, lymphopenia, or high C-reactive protein levels. Chest X-rays were performed in six children, and one case showed remarkable findings. Coinfection with metapneumovirus was detected in the patient with the most severe course; Bordetella pertussis was detected in another patient. Seven patients required oxygen therapy. Albuterol was administered in four patients. One patient was admitted to the pediatric intensive care unit. Median length of admission was 4 days (range: 3-14). No patient died or showed any sequelae at discharge. Two patients developed recurrent bronchospasms. Conclusion: SARS-CoV-2 infection does not seem to be a main trigger of severe bronchiolitis, and children with this condition should be managed according to clinical practice guidelines. Instituto de Salud Carlos III (Ministry of Economy, Industry and Competitiveness) 4.090 JCR (2021) Q1, 21/130 Pediatrics 0.927 SJR (2021) Q1, 49/320 Pediatrics, Perinatology and Child Health No data IDR 2021 UEM

BACKGROUND: The seasonality of respiratory syncytial virus (RSV) epidemics have been disrupted during the COVID-19 pandemic, possibly because of lockdowns and social restrictions reducing viral transmission. Given uncertainties around the severity of upcoming RSV bronchiolitis epidemics, debate exists whether palivizumab (RSV prophylaxis) should be administered to infants with Congenital Diaphragmatic Hernia (CDH), who may be vulnerable due to lung hypoplasia and pulmonary hypertension. AIM: To evaluate (1) if CDH infants have higher risk of admission with RSV bronchiolitis than infants in the general population; (2) if palivizumab prophylaxis may reduce this risk. METHODS: We included all eligible studies examining the risk(s) of RSV-positive bronchiolitis requiring hospital admission in (1) CDH infants without palivizumab prophylaxis versus infants in the general population and (2) CDH infants with prophylaxis versus CDH infants without prophylaxis. The primary outcome evaluated was the risk of admission with RSV bronchiolitis. Data are reported descriptively and meta-analysed when appropriate. RESULTS: Three eligible retrospective cohort studies were identified: one study found CDH to be an independent risk factor for RSV hospitalisation (odds ratio, 3.30; 95% confidence interval [CI], 2.01-4.4); two studies compared RSV hospitalisation rates in CDH patients who had palivizumab versus those that did not. The pooled risk ratio was 1.11 (95% CI, 0.29-4.23; p = .88). Overall, the quality of evidence was considered poor and one study was industry funded. CONCLUSION: Whether CDH infants are at particular risk of severe bronchiolitis remains unclear. There is no evidence from this current systematic review that CDH infants should routinely receive palivizumab vaccination prophylaxis.

Seasonal epidemics of influenza and the respiratory syncytial virus are the cause of substantial morbidity and mortality among children. During the global COVID-19 pandemic, the epidemiology of these viruses seems to have changed dramatically. In Australia and New Zealand, a significant decrease in both influenza and bronchiolities have been noticed during usual peak seasons. Data from early months of winter seasons in Europe are showing similar trends. This current scenario imposes a reconsideration of the paradigm that toddlers and young schoolchildren are the main drivers of seasonal RSV outbreaks and respiratory epidemics in general. In this paper, we summarize current literature, address current knowledge or role of adults in the respiratory syncitial virus epidemiology, describe the lessons learned from pertussis epidemics and call the international community to better understand the community transmission dynamics of respiratory infections in all age-groups. This can allow the establishment of better and more affordable preventive measures in the whole population level, which can ultimately save millions of child lives.

BACKGROUND: Evidence shows that activation of pulmonary vascular endothelium and neutrophils are involved in the pathophysiology of acute bronchiolitis. We hypothesized that levels of markers of endothelial activation and leukocyte counts are associated with requirement and duration of respiratory support.METHODS: Thirty-four infants with bronchiolitis and eight controls were included. Nasopharyngeal swabs and blood samples were taken at admission. Serum levels of Angiopoietin (Ang)-1, Ang-2, sP-selectin, sE-selectin, vascular cell adhesion molecule-1 (sVCAM-1), intercellular adhesion molecule-1 (sICAM-1), and leukocyte counts were measured. For univariate analysis, bronchiolitis cases were grouped into two groups, namely those not requiring and those requiring any form of respiratory support. To control for known risk factors for poor outcome (i.e., age, prematurity, and congenital heart disease), and for days post symptom onset, linear regression analysis was performed with duration of any type of respiratory support in days.RESULTS: Ang-2 levels, Ang-2/Ang-1 ratios, sE-selectin levels, immature neutrophil count, and neutrophil/lymphocyte ratio (NLR) were higher in acute bronchiolitis versus controls. Ang-2, and NLR levels were significantly higher, and lymphocyte counts significantly lower, in infants that required respiratory support versus those that did not. Ang-2 levels (β: .32, 95% confidence interval [CI]: 0.19-1.19) and NLR (β: .68, 95% CI: 0.17-1.19) were positive predictors for the duration of respiratory support.CONCLUSIONS: Markers of endothelial and neutrophil activation are associated with respiratory support for acute bronchiolitis. Admission Ang-2 levels and NLR may be promising markers to determine requirement of respiratory support and deserve further study.

To determine the epidemiology and outcomes in critically ill children admitted with severe community acquired pneumonia (CAP) and to identify risk factors associated with mortality in a pediatric intensive care unit (PICU) METHODS: Retrospective review of medical records of all children (age 1 month to 18 years) admitted to PICU with CAP from January 2013 to March 2018 was done. Patients admitted in last 2 weeks before current illness and those with bronchiolitis (based on clinical diagnosis) were excluded. Data were collected on a structured proforma and included demographic, clinical data, comorbidities, therapeutic information, laboratory data, and outcome data. Results were presented as mean with SD and frequency with percentages. Factors associated with mortality were analyzed, using logistic regression for both univariate and multivariate analyses.A total of 187 children with severe CAP were identified, 53.5% (n = 100) were1 year of age and 65.2% (n = 122) were male, 32.6% (n = 61) were underweight, and 24.6% (n = 46) were stunted. A total of 94% (175) required mechanical ventilation. Mortality among the cohort was 20.3% (n = 38) with median length of mechanical ventilation 4 (2-8) days, and median length of PICU stay was 6 (4-12) days. PRISM score10 on admission, presence of systemic illness, empyema, and length of PICU stay 14 (±2) days were associated with increased mortality among critically ill children admitted with CAP (p .05).Severe illness on presentation, presence of systemic illness and empyema are associated with increased mortality in children admitted to the PICU with severe CAP.

International audience; Introduction: Bronchiolitis is the leading cause of hospitalization for infants but its economic burden is not well documented. Our objective was to describe the clinical evolution and to assess the 1-month cost of a first episode of acute bronchiolitis presenting to the emergency department (ED).Methods: Our study was an epidemiologic analysis and a cost study of the cohort drawn from the clinical trial GUERANDE, conducted in 24 French pediatric EDs. Infants of 6 weeks to 12 months of age presenting at pediatric EDs with a first episode of bronchiolitis were eligible. The costs considered were collected from a societal viewpoint, according to the recommendations of the French National Health Authority.Results: A total of 777 infants were included with a median age of 4 months. A total of 57% were hospitalized during the month following the first consultation in the ED, including 28 (3.6%) in an intensive care unit. The mean length of stay was 4.2 days (SD = 3.7). The average time to relief of all symptoms was 13 days (SD = 7). Average total cost per patient was €1919 (95% confidence interval: 1756-2138) from a societal perspective, mostly due to hospitalization cost. The estimated annual cost of bronchiolitis in infants was evaluated to be between €160 and €273 million in France.Discussion: Bronchiolitis represent a high cost for the health care system and broadly for society, with hospitalizations costs being the main cost driver. Thus significant investments should be made to develop innovative therapies, to reduce the number of hospitalizations and length of stay.

Introduction COVID‐19 pandemic and associated lockdown measures have deeply modified the natural course of seasonal viral infections, such as respiratory syncytial virus (RSV). Methods We analyzed French national data from three networks: emergency departments (ED) of French hospitals, general practitioners (GP), and hospital laboratories. We compared the number of ED or GP visits for bronchiolitis in children

Background Bronchiolitis is the leading cause of hospitalization for United States infants. Blood eosinophil and serum specific IgE (sIgE) levels are separately linked to clinical severity but few studies have examined these biomarkers together. Objective Among infants hospitalized for bronchiolitis, we investigated the association between (1) blood eosinophilia and severity, (2) sIgE sensitization and severity, and (3) interaction between the two biomarkers on severity. Methods We enrolled 1016 infants hospitalized for bronchiolitis between 2011 and 2014 across 17 U.S. hospitals into a prospective cohort study. Of those, 873 (86%) had eosinophils measured and all had sIgE levels from blood collected at hospitalization. We investigated higher bronchiolitis severity using intensive care therapy as the outcome (i.e., intensive care unit admission, intubation, and/or receipt of continuous positive pressure ventilation). Results Among 873 infants in the analytic cohort, 18% had blood eosinophilia of ≥3%, and 20% were positive for sIgE. With regard to bronchiolitis severity, 15% received intensive care therapy. In unadjusted analyses, eosinophils ≥3% was not associated with intensive care therapy, while sIgE was associated with a significantly higher risk (odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.08-1.92; p = .01). In a multivariable model for intensive care therapy, eosinophilia remained unassociated with severity, and sIgE remained associated (OR: 1.60, 95% CI: 1.05-2.45; p = .03). Also, sIgE did not modify the association between eosinophil level and intensive care therapy (pinteraction = .14). Conclusion Blood eosinophilia of ≥3% was not associated with bronchiolitis severity. By contrast, sIgE was independently associated with bronchiolitis severity and did not modify the association between eosinophil level and severity.

BACKGROUND Respiratory syncytial virus (RSV) bronchiolitis is the most common lower respiratory tract disorder causing hospitalization in infants. Due to decreased hospitalization rates of premature infants following Palivizumab immune prophylaxis, the proportion of infants with chronic diseases not eligible for Palivizumab has increased. AIM To characterize infants hospitalized during 2014-2018 with RSV bronchiolitis, to compare between those with and without chronic conditions, and to identify risk factors for severe disease. METHODS This retrospective study analyzed demographic and clinical data of patients younger than 2 years admitted with bronchiolitis during four consecutive RSV seasons. RESULTS Of 1124 hospitalizations due to RSV bronchiolitis, 244 (22%) were in infants with chronic diseases. Although 20/1124 qualified for RSV prophylaxis, only eight received immune prophylaxis. Compared to otherwise healthy infants, children with chronic diseases had longer hospitalizations, median 4.8 days (interquartile range [IQR]: 3.4-8.3) versus 3.7 days (IQR: 2.7-5.1), p

Background Child exposure to cigarette smoke is harmful. It should be reduced through parental smoking cessation interventions. The aim of our study was to determine the impact of simple advice provided by the pediatrician on the smoking habits of parents of children with cystic fibrosis (CF), diabetes mellitus (DM) and infants hospitalized for bronchiolitis. Methods Parents were interviewed on their smoking habits. Smoking cessation advice was provided by the pediatrician. A new smoking habits assessment was done at three months by phone interviews. Results Two hundred and sixty parents were interviewed (91 in the CF group, 136 in the DM group and 33 in the bronchiolitis group). Seventy parents were active smokers: 33% of parents of children with CF, 23.5% of parents of children with DM and 24.2 % for those with infants hospitalized for bronchiolitis (p = 0.42). In the CF group, smoking cessation had been significantly more frequently discussed with the medical team previously. Sixty-seven smoking parents (95.7%) answered the 3-month assessment: 29.8% reported having started a smoking cessation process; 10.4% had quit smoking. The quitting rate was significantly higher in the groups of patients followed for a respiratory disorder (37.5% for bronchiolitis, 15% for CF versus 0% for DM, p= 0.005). Conclusion This study shows the important role that information and simple advice from pediatricians can have in initiating smoking cessation in parents of patients followed in specialized clinics or who are hospitalized, with a greater efficiency in parents of patients suffering from lung disorders. This article is protected by copyright. All rights reserved.

Background: The aim of this study was to evaluate diaphragmatic parameters in bronchiolitis patients and identify correlations between clinical and sonographic severity scores and outcomes in order to develop a more objective and useful tool in the emergency department. Methods: Children aged between 1 and 24 months and diagnosed with acute bronchiolitis were included in the study. The Modified Respiratory Distress Assessment Instrument (mRDAI) score was used to quantify the clinical severity of the disease. Lung ultrasound was performed and a bronchiolitis ultrasound score (BUS) was calculated. Diaphragm ultrasound was then performed and diaphragm thickness at the end of inspiration and expiration, thickening fraction, diaphragm excursion (EXC), inspiratory slope (IS), expiratory slope (ES), and total duration time of the respiratory cycle were measured. Results: There were 104 patients evaluated in this study. The mRDAI score and BUS had a significant positive correlation. There was a positive correlation between IS and respiratory rate at admission. As the clinical score increased, IS, ES, and EXC measurements rose and they were positively correlated. Values of IS, ES, and EXC were higher in the moderate-severe group than the mild group for both mRDAI and BUS scores. Inspiratory slope values were correlated with the length of stay in the hospital. Conclusion: Values of IS and ES were correlated with clinical and sonographic severity scores. Moreover, IS was a good predictor of outcome. Diaphragm ultrasound appears to be an objective and useful tool to help the physician make decisions regarding the evaluation and management of bronchiolitis.

Introduction The prognosis of postinfectious bronchiolitis obliterans (PIBO) has many implications, ranging between reduced quality of life and life-threatening complications. We evaluated the prognostic factors for PIBO using the baseline clinical characteristics of patients and built a prediction model for determining the prognoses of PIBO patients using the identified parameters. Methods We included 47 PIBO patients who underwent spirometry and impulse oscillometry and followed them up for at least 1 year. A patient's prognosis was classified as poor if the patient experienced at least one of the following: persistent respiratory symptoms for more than 1 year, two or more instances of hospitalizations due to respiratory symptoms, or more than one intensive care unit admission. Results The prognoses of 32/47 (68.1%) patients was good, while that of 15/47 (31.9%) was poor. Spirometry results showed significantly lower forced vital capacity (FVC), forced expiratory volume in the first second (FEV1 ), forced expiratory flow at 25%-75% of FVC, and post-bronchodilator (BD) FEV1 values in the poor prognosis group; chest computed tomography (CT) demonstrated more inflammatory bronchiolitis findings. We created a nomogram for predicting prognoses using post-BD FEV1 and inflammatory bronchiolitis on chest CT. The area under the curve for the nomogram was 84.6% (95% confidence interval: 72.8%-96.4%). Conclusions PIBO patients with lower pulmonary function values and more findings of inflammatory bronchiolitis on initial examination have poor prognoses. The nomogram for predicting PIBO prognosis is easy to use and can be applied at the time of diagnosis.

OBJECTIVES: Although recent evidence suggests that management of viral bronchiolitis requires something other than guidelines-guided therapy, there is a lack of evidence supporting the economic benefits of phenotypic-guided bronchodilator therapy for treating this disease. The aim of the present study was to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. METHODS: A decision analysis model was developed to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. Phenotypic-guided bronchodilator therapy was defined as the administration of albuterol in infants exhibiting a profile of increased likelihood of response to bronchodilators. The effectiveness parameters and costs of the model were obtained from systematic reviews of the literature with meta-analyses and electronic medical records. The main outcome was the avoidance of hospital admission after initial care in the emergency department. RESULTS: Compared to guidelines-guided strategy, treating patients with viral bronchiolitis with the phenotypic-guided bronchodilator therapy strategy was associated with lower total costs (US$250.99; 95% uncertainty interval [UI]: US $184.37 to $336.51 vs. US$263.46; 95% UI: US$189.81 to $349.19 average cost per patient) and a higher probability of avoidance of hospital admission (0.7902; 95% UI: 0.7315–0.8356 vs. 0.7638; 95% UI: 0.7062–0.8201), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS: Compared to guidelines-guided strategy, treating infants with viral bronchiolitis using the phenotypic-guided bronchodilator therapy strategy is a more cost-effective strategy, because it involves a lower probability of hospital admission at lower total treatment costs.

Rational This study aims to describe the current weaning practices from any type of noninvasive support in infants with bronchiolitis, in terms of weaning procedures, weaning initiation and weaning failure criteria. Working hypothesis No information regarding the weaning practices is currently available and there may be a wide variability of strategies. Study design A cross-sectional electronic survey. Methodology The survey was distributed to physicians from five French-speaking countries with key roles in pediatric intensive care units (PICUs). Results Responses were obtained from 29 PICUs from five French-speaking countries. A written weaning protocol was available in three pediatric centers (10%) and nurses had a key role in the weaning process in 72% of centers. The sudden weaning was the most commonly used procedure, no matter the type of noninvasive ventilatory (NIV) support. The most commonly used criteria for weaning initiation and weaning failure were the degree of respiratory distress, the occurrence of apneas and the fraction of inspired oxygen (FiO2 ). The thresholds commonly used for weaning initiation criteria were (a) none or a slight use of accessory muscles; (b) FiO2 less than equal to 40%, (c) respiratory rate less than 60 per minute, (d) no apnea, (e) blood pH more than 7.30, and (f) partial pressure of venous carbon dioxide less than equal to 50 mm Hg. Conclusion In infants with bronchiolitis requiring NIV support, the sudden weaning procedure was the most commonly used strategy. We observed a certain consensus on criteria for weaning initiation. These findings should help in building nurse-driven weaning protocols, but prospective studies remain needed to assess the best weaning strategy in infants with bronchiolitis-related acute respiratory failure.

Introduction When children require supplemental oxygen due to acute hypoxemic respiratory distress (AHRD), manual control of the oxygen flow is often difficult and time-consuming, and carries the risk of unrecognized hypoxia and hyperoxia. To date, no automatic oxygen titration system has been developed and evaluated in spontaneously breathing children. Methods Children between 1 month and 15 years of age receiving supplemental oxygen due to AHRD were recruited within 24 hours following the onset of the O2 administration in a French University Department of Paediatrics. Patients were randomized to receive either automated oxygen administration using the FreeO2 device, or conventional manual oxygen administration over a maximum period of 6 hours. Stratification was performed to classify the patients into two age groups: 1 month to 2 years of age and 2 to 15 years of age. The primary outcome was % time spent within the SpO2 target range (92%-98%). Results 60 patients (30 infants, 30 children) were randomized and 55 could be analyzed for the primary outcome (28 automated, 27 manual). The automated O2 delivery using the FreeO2 device significantly increased the time spent within the predefined SpO2 range (94.6% ± 6% vs 76.3% ± 22%, difference [95% confidence interval {CI}] 18.4 [10.1; 26.7]) with less time spent with hypoxemia (1% ± 1.1% vs 15.1% ± 21.8%, difference [95% CI] -14.4 [-22.2; -6.7]). This difference was greater among (2-15 years of age) children, compared to (1 month-2 years of age) infants. Conclusions The present randomized controlled pilot study indicates that the tested automated closed-loop O2 titration technology was safe and yielded improved oxygen parameters among spontaneously breathing children. Based on our pilot data, a full randomized controlled trial will be required to verify the potential clinical benefits.

OBJECTIVE To assess whether increment of vitamin D daily intake results in improved serum25(OH) vitamin D levels and reduced respiratory morbidity in premature infants. METHODS A randomized double-blind clinical pilot trial, including preterm infants born at 32 + 6 to 36 + 6 weeks of gestation. The control group received 400 international units (IU) of cholecalciferol daily compared to 800 IU daily in the intervention group. Levels of 25(OH) vitamin D were measured at birth and 6 and 12 months of age. Respiratory morbidity was followed until 1 year of age. RESULTS Fifty subjects were recruited during the study period; the median measured 25(OH) vitamin D levels in the control vs intervention groups were: 26.5 vs 34 nmol/L (P = .271) at birth, 99 vs 75.5 nmol/L (P = .008) at 6 months and 72.5 vs 75 nmol/L (P = .95) at 12 months of age. Infants with insufficient vitamin D (

Respiratory syncytial virus (RSV) lower respiratory tract infection (LRTI) during early childhood may be associated with subsequent pulmonary sequelae, including recurrent wheezing and asthma. We undertook a systematic review to investigate the pulmonary function sequelae following RSV LRTI in the first 3 years of life. The systematic review protocol was registered on PROSPERO (CRD42018087168). PubMed, Scopus, Cochrane Library, and World Health Organization Global Index Medicus, as well as ClinicalTrials.gov and Cochrane Central Register of Controlled Trials, were searched up until 15 June 2019 for published and unpublished interventional and observational studies with the end-point outcome of pulmonary function testing (PFT) after a proven RSV LRTI in the first 3 years of life. Two independent reviewers screened all the titles, abstracts and full texts. Data were extracted using a standardized data extraction form. Corresponding authors were contacted for additional information if required. All studies were assessed for risk of bias using the Newcastle-Ottawa quality assessment scale. The final analysis included 31 studies. Thirteen studies using spirometry reported no association between RSV LRTI and pulmonary function sequelae. The remaining 16 reported abnormal spirometry; 12 obstructive airways disease, three restrictive lung disease, and one mixed lung disease. The heterogeneity in PFT techniques, different ages at testing, and methods used for reporting outcomes made direct comparisons or pooled effect estimates impossible. Children with confirmed RSV LRTI during the first 3 years of life often have abnormal PFTs, favoring obstructive airways disease. The evidence, however, is not overwhelming with conflicting results between studies.

OBJECTIVE To assess cardiac function in infants with bronchiolitis and the association with disease severity and outcomes. WORKING HYPOTHESIS Cardiac function may be impaired in bronchiolitis and represent an early predictor of disease severity. STUDY DESIGN A prospective cohort study. PATIENT SELECTION Infants with suspected bronchiolitis were included. METHODOLOGY All cases received antigen detection and viral genome detection from nasal lavage or swabs and echocardiography within 24 hours from admission. Systolic and diastolic function in left ventricle (LV) and right ventricle (RV) were assessed using longitudinal strain (LS), a measure of myocardial deformation. Pulmonary artery pressures were estimated using tricuspid regurgitation jet (TR), when present, and end-systolic eccentricity index (EI ES). Main outcomes (duration of respiratory support, length of stay [LOS], and type of respiratory support) were collected. Data were compared to normative existing data, and a group of healthy infants, matched in age. RESULTS Twenty-eight infants with bronchiolitis and 10 healthy comparators were included. Cases with bronchiolitis showed significantly lower values of RV LS and LV LS compared to healthy comparators (LV: p0.04 and RV: P