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Background: reports suggest that congenital esophageal atresia/tracheoesophageal fistula (EA/TEF) is associated with a number of upper airway anomalies [1,2]. Aims: it remains unclear whether vocal cord paresis or paralysis (VCP) is usually a primary anomaly, or is secondary to EA/TEF repair. Methods: a retrospective study was carried out in 105 patients with EA/TEF referred to the Department of Pediatric Medicine, Bambino Gesu Children’s Hospital (BGCH) for multidisciplinary follow-up following EA/TEF repair, between 2010 and 2015. Results: 64 of the 105 patients included in the study underwent EA/TEF repair and had pre-operative bronchoscopy in BGCH; the remaining patients had their initial surgery elsewhere. No patient included in the study had VCP detected pre-operatively. Six patients were diagnosed with VCP during the follow-up period (6/105, 5.7%), of whom 4 were surgically managed at the BGCH, and two were managed elsewhere. Four children with bilateral VCP initially required tracheostomy. The other two patients were treated with posterior cordotomy by CO2 laser, and one received a tracheostomy. Conclusion: we did not observe VCP in pre-operative bronchoscopy in patients undergoing EA/TEF repair, but observed VCP in 5.7% of patients during a post-operative re-evaluation, suggesting that VCP is an acquired lesion in TEF patients. Future studies are needed to determine whether VCP is present in some patients prior to EA/TEF repair, and if so, what the prevalence is. References: 1. Ann Otol Rhinol Laryngol. 2015; 124: 808-13. 2. Laryngoscope. 2015; 125: 469-74.

Canadian Inuit infants suffer the highest rate of lower respiratory tract infections (LRTI's) in the world. The causes of this are incompletely understood. The primary objective of this study was to determine whether there exists an association between respiratory morbidity and oral aspiration in Inuit children. A retrospective chart review was conducted including children from Nunavut who underwent Video Fluoroscopic Swallowing Study between the years of 2001 to 2015. The primary outcome was hospitalization for LRTI. We hypothesized that infants found to have aspiration would experience a higher rate of admissions for LRTI than those with normal swallowing studies. One-hundred and twenty-seven patients were identified, of whom 94 were included. Fifty-six percent of patients had an abnormal swallowing study. Compared with patients with normal swallowing, the incidence rate of LRTI was higher in patients with aspiration (incidence rate ratio [IRR] = 1.51; 95% confidence interval [CI] = 1.23-1.87) and in patients with penetration (IRR = 1.40; 95% CI = 1.11-1.76). Fourteen percent of patients had confirmed laryngeal cleft; patients with confirmed presence of this also had a higher incidence rate of LRTI (IRR = 1.66; 95% CI = 1.32-2.07). The incidence of abnormal swallowing study showed an 11-fold variation across the five regions in Nunavut, with the highest prevalence in west Qikiqtani Region (Baffin Island). We conclude that swallowing dysfunction is not only prevalent amongst Canadian Inuit but clinically significant. This is the first study to demonstrate an association between swallowing dysfunction and respiratory morbidity in this population. Geographic distribution patterns and high rates of laryngeal cleft may point to a potential genetic etiology for what remains at this point, idiopathic swallowing dysfunction.

Background Pediatrician and pediatric subspecialist density varies substantially among the various Canadian provinces, as well as among various states in the US. It is unknown whether this variability impacts health outcomes. To study this knowledge gap, we evaluated pediatric asthma admission rates within the 2 Canadian provinces of Manitoba and Saskatchewan, which have similarly sized pediatric populations and substantially different physician densities. Methods This was a retrospective cross-sectional cohort study. Health regions defined by the provincial governments, have, in turn, been classified into “peer groups” by Statistics Canada, on the basis of common socio-economic characteristics and socio-demographic determinants of health. To study the relationship between the distribution of the pediatric workforce and health outcomes in Canadian children, asthma admission rates within comparable peer group regions in both provinces were examined by combining multiple national and provincial health databases. We generated physician density maps for general practitioners, and general pediatricians practicing in Manitoba and Saskatchewan in 2011. Results At the provincial level, Manitoba had 48.6 pediatricians/100,000 child population, compared to 23.5/100,000 in Saskatchewan. There were 3.1 pediatric asthma specialists/100,000 child population in Manitoba and 1.4/100,000 in Saskatchewan. Among peer-group A, the differences were even more striking. A significantly higher number of patients were admitted in Saskatchewan (590.3/100,000 children) compared to Manitoba (309.3/100,000, p

Background . Food insecurity, vitamin D deficiency and lower respiratory tract infections are highly prevalent conditions among Inuit children. However, the relationship between these conditions has not been examined in this population. Objective . The objective of this study was to examine the relationship between food insecurity and severe respiratory infections before age 2 years and health centre visits for a respiratory problem in the past year. We also explored the relationship between serum vitamin D status and respiratory outcomes in this population. Design . We included children aged 3–5 years who participated in a cross-sectional survey of the health of preschool Inuit children in Nunavut, Canada, from 2007 to 2008 (n=388). Parental reports of severe respiratory infections in the first 2 years of life and health care visits in the past 12 months were assessed through a questionnaire. Child and adult food security were assessed separately and serum 25-hydroxyvitamin D3 levels were measured in a subgroup of participants (n=279). Multivariate logistic regression was performed to assess the association between food security, vitamin D and each of the 2 respiratory outcomes. Results . Child and adult food insecurity measures were not significantly associated with adverse respiratory outcomes. Household crowding [odds ratio (OR)=1.51, 95% confidence interval (CI) 1.09–2.09, p=0.01 for the child food security model] and higher birth weight (OR=1.21, 95% CI: 1.02–1.43, p=0.03) were associated with reported severe chest infections before age 2 years while increasing age was associated with decreased odds of reported health care visits for a respiratory problem (OR=0.66, 95% CI: 0.48–0.91, p=0.02). Neither vitamin D insufficiency nor deficiency was associated with these respiratory outcomes. Conclusions . Using a large cross-sectional survey of Inuit children, we found that household crowding, but not food security or vitamin D levels, was associated with adverse respiratory outcomes. Further studies are warranted to examine the impact of decreasing household crowding on the respiratory health of these children. Keywords: food security; vitamin D; Inuit; bronchiolitis; lower respiratory tract infections; crowding (Published: 15 February 2016) Citation: Int J Circumpolar Health 2016, 75: 29954 - http://dx.doi.org/10.3402/ijch.v75.29954

OBJECTIVE:To assess the effectiveness of nurse-initiated administration of oral corticosteroids before physician assessment in moderate to severe acute asthma exacerbations in the pediatric ED.METHODS:A time-series controlled trial evaluated nurse initiation of treatment with steroids before physician assessment in children with Pediatric Respiratory Assessment Measure score ≥4. One-to-one periods (physician-initiated and nurse-initiated) were analyzed from September 2009 through May 2010. In both phases, triage nurses initiated bronchodilator therapy before physician assessment, per Pediatric Respiratory Assessment Measure score. We reviewed charts of 644 consecutive children aged 2 to 17 years for the following outcomes: admission rate; times to clinical improvement, steroid receipt, mild status, and discharge; and rate of return ED visit and subsequent admission.RESULTS:Nurse-initiated phase children improved earlier compared to physician-initiated phase (median difference: 24 minutes; 95% confidence interval [CI]: 1–50; P = .04). Admission was less likely if children received steroids at triage (odds ratio = 0.56; 95% CI: 0.36–0.87). Efficiency gains were made in time to steroid receipt (median difference: 44 minutes; 95% CI: 39–50; P < .001), time to mild status (median difference: 51 minutes; 95% CI: 17–84; P = .04), and time to discharge (median difference: 44 minutes; 95% CI: 17–68; P = .02). No differences were found in return visit rate or subsequent admission.CONCLUSIONS:Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.

Inuit children in Nunavut, Canada, have high rates of lower respiratory tract infection (LRTI) early in life. Whether this commonly results in chronic respiratory symptoms later in life is unknown.A cross-sectional survey of 3- to 5-years-old Inuit children was conducted in all three regions of Nunavut, as part of the "Qanuippitali, what about us, how are we?" survey.Reported chronic cough and wheezing were common in preschool Inuit children, although reported asthma diagnosed by a healthcare professional was uncommon. The presence of smokers in the home tended to be associated with severe LRTI in the first 2 years of life. Reported wheezing as well as reported bronchitis or pneumonia in the previous 12 months was significantly associated with severe LRTI in the first 2 years of life. Reported wheezing was also strongly associated with reported bronchitis or pneumonia in the past 12 months. The prevalence of chronic moist cough could not be clearly assessed, due to limitations in the questionnaire.Severe LRTI in the first 2 years of life was associated with ongoing respiratory morbidity in preschool Inuit children, although symptoms appeared to lessen in severity over time.

The fractional concentration of exhaled nitric oxide (Feno) is a useful indicator of airway inflammation in children and adults with asthma.We determined the range of Feno concentrations and the factors affecting it in a large sample of healthy school children attending grades 4 through 6, in Windsor, ON, Canada.Feno was measured in 657 children between 9.1 and 12.9 years of age. The range of Feno concentrations in healthy school children was 12.7 parts per billion (ppb) [95% confidence interval (CI), 11.8 to 13.7 ppb] in whites and 22.8 ppb [95% CI, 17.9 to 27.7 ppb] in Asian-Canadian children (p0.001). Feno values also appeared to be higher in African-Canadian children than in whites, although the CI was wide because of the small number of African-Canadian children sampled. Feno rose slightly but significantly with age (p = 0.007) and with height (p = 0.023). Body mass index and gender did not significantly alter the measured Feno. FVC had a nonsignificant effect on Feno. Participation in physical activity during the same day had a borderline-significant effect on measured Feno, but a reported history of a respiratory tract infection in the preceding 2 weeks did not.Feno concentrations in healthy school-aged children appeared to be affected by race, and, to a lesser extent, by age and height. These factors should be taken into consideration when interpreting clinical results.

Background: Inuit infants have the highest reported rate of hospital admissions because of lower respiratory tract infections in the world. We evaluated the prevalence of reduced ventilation in houses in Nunavut, Canada, and whether this was associated with an increased risk of these infections among young Inuit children. Methods: We measured ventilation in 49 homes of Inuit children less than 5 years of age in Qikiqtaaluk (Baffin) Region, Nunavut. We identified the occurrence of lower respiratory tract infections using a standardized questionnaire. Associations between ventilation measures and lower respiratory tract infection were evaluated using multiple logistic regression models. Results: The mean number of occupants per house was 6.1 people. The mean ventilation rate per person was 5.6 L/s (standard deviation [SD] 3.7); 80% (37/46) of the houses had ventilation rates below the recommended rate of 7.5 L/s per person. The mean indoor carbon dioxide (CO 2 ) concentration of 1358 (SD 531) ppm was higher than the recommended target level of 1000 ppm. Smokers were present in 46 homes (94%). Of the 49 children, 27 (55%) had a reported history of lower respiratory tract infection. Reported respiratory infection was significantly associated with mean CO 2 levels (odds ratio [OR] 2.85 per 500-ppm increase in mean indoor CO 2 , 95% confidence interval [CI] 1.23–6.59) and occupancy (OR 1.81 for each additional occupant, 95% CI 1.14–2.86). Interpretation: Reduced ventilation and crowding may contribute to the observed excess of lower respiratory tract infection among young Inuit children. The benefits of measures to reduce indoor smoking and occupancy rates and to increase ventilation should be studied.

Infants with bronchopulmonary dysplasia (BPD) are at risk for numerous complications following discharge from the Neonatal Intensive Care Unit (NICU). Few studies have evaluated risk factors for adverse events (AE). This retrospective study provided an initial evaluation of the use of capillary carbon dioxide (PCO2) tension as a predictor of infants with BPD at increased risk for AE. PCO2 was compared in patients who suffered, or avoided, severe AE, defined as pulmonary hypertension, death, or subsequent reintubation or tracheostomy for respiratory illness. One hundred twelve consecutive patients followed at the BPD clinic were evaluated, and data from 104 subjects were suitable for analysis. Mean PCO2, obtained shortly before or after discharge from NICU, was 47.2 mmHg (range, 31-83). PCO2 was significantly higher in patients who required reintubation and ventilation (54.7 vs. 46.7, p < 0.04). No cutoff value of PCO2 clearly distinguished patients with subsequent AE. PCO2 was not significantly higher in the group of patients who had a severe AE than in the group of patients who did not have a severe AE, but logistic regression showed a significant association between PCO2 and risk of both severe AE (p = 0.018), and readmission to hospital (p = 0.038). An elevated PCO2 is associated with an increased risk of AE, including reintubation, and readmission to hospital, in infants with BPD. Patients with an elevated discharge PCO2 may require closer monitoring during followup. Prospective studies will be needed to confirm these observations.

The aim of this study was to describe the changes in respiratory system compliance and other measures of respiratory mechanics associated with peritoneal insufflation (12 mmHg pressure) with carbon dioxide (PNP12) and 20° Trendelenburg positioning (TDG20) in pediatric patients undergoing laparoscopic surgery for abdominal cryptorchidism. Twelve subjects with abdominal cryptorchidism undergoing orchiopexy were enrolled in the study. General anesthesia was conducted with sevoflurane/O2/air, fentanyl, and rocuronium. Pressure-controlled ventilation with a peak inspiratory pressure (PIP) of 10-15 cm H2O and a positive end-expiratory pressure of 5 cm H2O was titrated to achieve a tidal volume (VT/kg) of 6-10 mL·kg−1 and end-tidal carbon dioxide (EtCO2) of 35-40 mmHg. Adjustments of PIP and respiratory rate (RR) were made to maintain the initial VT/kg and EtCO2

Background. Adrenal suppression secondary to high-dose inhaled corticosteroid use has been reported in children. Methods. The authors report the use of ciclesonide to reverse adrenal suppression secondary to inhaled fluticasone use in four pediatric patients. Results. In these four children, hypothalamic-pituitary-adrenal axis function normalized after the patients were changed to ciclesonide, while good asthma control was maintained. Conclusions. Ciclesonide should be considered for the reversal of adrenal suppression secondary to the use of fluticasone, and perhaps other older inhaled corticosteroids as well.

A nine-year-old girl presented to the emergency department in the fall of 2009 with a one-week history of cough, neck swelling, sore throat and mild diarrhea, but no fever or vomiting. She had a history of asthma, which was treated with montelukast. Her physical examination showed subcutaneous

Billy, who is 2 years old, presents to the physician’s office with his fourth episode of wheezing in the past 18 months. He was admitted to hospital at 6 months of age with bronchiolitis caused by respiratory syncytial virus. At 9 months, he was seen in the local emergency department with a cold

BACKGROUND: The fractional concentration of exhaled nitric oxide (FeNO) appears to be a good marker for airway inflammation in children with asthma.OBJECTIVE: To evaluate the effect of environmental exposures on exhaled nitric oxide in a community sample of children.METHODS: The relationship among exhaled nitric oxide, underlying disease and home environmental exposures was examined using questionnaire data and measurement of exhaled nitric oxide in a cross-sectional study of 1135 children that included healthy children, and children with allergies and/or asthma who were attending grades 4 through 6 in Windsor, Ontario.RESULTS: Among healthy children, there was a positive association between FeNO and occupancy (PCONCLUSIONS: The type of heating system, but not previously reported environmental tobacco smoke or mold exposure appears to affect exhaled nitric oxide in children. Exposure to different types of pets may have disparate effects on airway inflammation.

Objective To test the association between reported allergy and allergic diseases, respiratory symptoms, and the fractional concentration of exhaled nitric oxide (FeNO), in a community sample of school aged children. Methodology We administered a respiratory questionnaire and measured FeNO in a cross-sectional study of 1,135 children. Results FeNO was significantly greater in children with reported asthma (20.3 (standard deviation (SD) 21.3) parts per billion (ppb)) or allergies (18.1 (SD 18.0) ppb) than in healthy children (14.0 (SD 13.4) ppb). It was greater in children with asthma and reported allergies (22.8 (SD 23.6) ppb), than in children with asthma but no allergies (15.8 (SD 15.6) ppb) (overall P-value between disease groups = 0.002). FeNO was not related to respiratory symptoms in healthy children. Eczema was associated with an elevated FeNO concentration, even in the absence of respiratory symptoms. Some children with reported allergies but not asthma who had respiratory symptoms suggestive of asthma had elevated FeNO concentrations, and the proportion of healthy children with reported bronchitis or pneumonia in the past year who had an abnormally high FeNO concentration was significantly elevated. Conclusions In a community sample of children, FeNO concentrations appear to reflect allergic conditions, including allergic asthma, reported allergies, and eczema, rather than just asthma, particularly since asthma in children may be non-allergic. FeNO is similarly elevated in school aged children with reported asthma or reported allergies. FeNO is higher in children with asthma and allergies than in children with asthma alone. However, an elevated FeNO may help alert the clinician to the possibility of undiagnosed asthma. Pediatr. Pulmonol. 2008; 43:1198–1205. © 2008 Wiley-Liss, Inc.

Inuit infants have extremely high rates of lower respiratory tract infection (LRTI), but the causes for this are unclear. The aims of this study were to assess, in young Inuit children in Baffin Region, Nunavut, the feasibility of an epidemiologic study of the association between indoor air quality (IAQ) and respiratory health; to obtain data on IAQ in their housing; and to identify and classify risk factors for LRTI. Twenty houses in Cape Dorset, Nunavut with children below 2 years of age, were evaluated using a structured housing inspection and measurement of IAQ parameters, and a respiratory health questionnaire was administered. Twenty-five percent of the children had, at some time, been hospitalized for chest illness. Houses were very small, and had a median of six occupants per house. Forty-one percent of the houses had a calculated natural air change rate0.35 air changes per hour. NO(2) concentrations were within the acceptable range. Smokers were present in at least 90% of the households, and nicotine concentrations exceeded 1.5 microg/m(3) in 25% of the dwellings. Particulates were found to be correlated closely with nicotine but not with NO(2) concentrations, suggesting that their main source was cigarette smoking rather than leakage from furnaces. Mattress fungal levels were markedly increased, although building fungal concentrations were low. Dust-mites were virtually non-existent. Potential risk factors related to IAQ for viral LRTI in Inuit infants were observed in this study, including reduced air exchange and environmental tobacco smoke exposure. Severe lower respiratory tract infection is common in Inuit infants. We found reduced air change rates and high occupancy levels in houses in Cape Dorset, which may increase the risk of respiratory infections. This suggests the measures to promote better ventilation or more housing may be beneficial. Further health benefits may be obtained by reducing bed sharing by infants and greater turnover of mattresses, which were found to have high levels of fungi.

Congenital esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) are common congenital anomalies. Respiratory and GI complications occur frequently, and may persist lifelong. Late complications of EA/TEF include tracheomalacia, a recurrence of the TEF, esophageal stricture, and gastroesophageal reflux. These complications may lead to a brassy or honking-type cough, dysphagia, recurrent pneumonia, obstructive and restrictive ventilatory defects, and airway hyperreactivity. Aspiration should be excluded in children and adults with a history of EA/TEF who present with respiratory symptoms and/or recurrent lower respiratory infections, to prevent chronic pulmonary disease.

vuz nwrv Objectif: Il n'est pas toujours facile d'obtenir un echantillon montrant clairement les cils vibratils necessaires au diagnostic de dyskinesie ciliaire. Le but de cette etude est de determiner la meilleure technique d'echantillonnage dans ce contexte. Devis: Etude prospective de quatre techniques d'echantillonnage: le brossage nasal, la biopsie nasale, le brossage bronchique, et la biopsie tracheale. Localisation: L'Hopital pour enfants de l'Est Ontarien, un hopital de soins pediatriques tertiaires. Methode: Nous avons evalue au microscope la qualite des quatre types d'echantillons preleves sur 10 patients consecutifs anesthesies pour bronchoscopie et biopsie tracheale. Resultats: Le brossage nasal et la biopsie tracheale fournissent des echantillons de meilleure qualite mais le brossage est plus efficient. Les biopsies nasales sont souvent metaplasiques et sont donc inferieures au brossage de la meme region (p = .02). Conclusion: Son efficaciate demontree, le cout faible et la morbidite limitee font du brossage nasal la technique initiale optimale dans le diagnostic de la dyskinesie cilaire primaire.

Plasma carnitine concentrations were measured in 43 children and adults with cystic fibrosis (CF), and values were compared with those from normal controls. Clinically significant abnormalities of plasma carnitine concentration were not found in CF patients. The concentration of free carnitine was slightly but significantly elevated in CF patients, and the acylcarnitine concentration and acylcarnitine/free-carnitine ratio were slightly but significantly lower. Total carnitine concentrations were similar to those of controls. The CF patients did not have abnormal urinary acylcarnitines. Altered concentrations of free and esterified carnitine were not associated with nutritional status or with liver or pulmonary function.

Twenty-eight children with high-risk acute lymphocytic leukemia underwent monthly serum lactate dehydrogenase (LDH) and LDH isoenzyme fraction determinations to examine whether LDH isoenzyme fractions change with an increase in the body burden of tumor cells. The 9 patients who relapsed and 5 patients who presented with leukemia during the study period had a slightly lower mean LDH-1 isoenzyme fraction. When the period from 3 months before to 3 months after relapse was examined, significant increases in the LDH-3 isoenzyme fraction and decreases in the LDH-1 and LDH-2 isoenzyme fractions were seen at the time of relapse. These results were highly significant when patients with non-T-cell and T-cell leukemia were combined and when bone marrow and central nervous system relapse was included. The changes at relapse appeared to revert with intensification of chemotherapy. The changes at relapse were not different in magnitude from random variation occurring in patients who remained in remission throughout the study. Although changes in LDH isoenzymes appeared to occur at the time of relapse compared with the periods immediately before and after relapse, these changes were not specific for relapse. LDH isoenzymes do not appear to be useful in predicting relapse in children with leukemia.

We present a child with Down's syndrome, bilateral lower lobe bronchiectasis, sinusitis, and severe ear disease who was found to have a novel ciliary defect, with a frequent, partial absence of the walls of the A subunits of some peripheral doublets. The defect caused the A subunits to be "U-shaped" rather than "O-shaped." A nuclear nasal mucociliary transport study confirmed that this defect was associated with abnormal mucociliary transport. The ciliary defect was not observed in a biopsy performed in a second patient who had Down's syndrome.