Actinomycosis is a rare, indolent and invasive infection caused by Actinomyces species. Pulmonary actinomycosis is very rarely seen in the paediatric population. The classic radiological presentation of thoracic involvement of actinomycosis includes lower lobe consolidation, empyema and periostitis of the ribs. We report a case of endobronchial pulmonary actinomycosis in a child diagnosed on endobronchial biopsy and broncho-alveolar lavage taken during bronchoscopy. Bronchoscopy can be dangerous when performed on these cases, as there is a risk of severe bleeding and large airway obstruction, as was the case with this patient.
Reintubation in the pediatric intensive care unit (PICU) increases morbidity, mortality, and the overall cost of care. Post-extubation airway obstruction (PEAO) is a potentially predictable cause of extubation failure and may be prevented by the use of corticosteroids. Defining which patients are most at risk for the development of POAE as well as the optimal dose and timing of corticosteroids for prevention is critical. We review the current literature regarding the use of corticosteroids surrounding extubation in the PICU and discuss the implications that a clear algorithm for identification and treatment of these patients would have in the care of critically ill children.
Silent RSV in infants with SARS‑CoV‑2 infection: a case seriesAntonietta Giannattasio, MD, PhD1, Marco Maglione, MD, PhD1, Carolina D’Anna, MD1, Stefania Muzzica, MD1,Francesca Angrisani, MD1, Sabrina Acierno, MD1, Alessandro Perrella2, MD, PhD2, Vincenzo Tipo, MD11Santobono-Pausilipon Children’s Hospital, Pediatric Emergency and Short Stay Unit, Naples, Italy2Cardarelli Hospital, Infectious Disease-Health Policy Direction, Naples, Italy
Objectives: Pneumothorax (PTX) in newborns is a life-threatening condition associated with high morbidity and mortality especially in premature infants. The frequency of PTX in neonates at different gestational ages (GA) and its impact on neonatal mortality have not been quantified. We aimed to determine: 1) the prevalence of PTX in neonates at different GA from ≤24 weeks to ≥37 weeks, 2) the impact of PTX on mortality per GA, and 3) the impact of PTX on the length of stay (LOS) per GA. Methods: The national Kids’ Inpatient Database (KID) for the years of 2006 to 2012 were used. We included all infants admitted to the hospital with a documented GA and ICD9 code of pneumothorax. Bivariate and multivariate analyses were conducted and odds ratios (OR) were calculated. Results: A total of 10 625 036 infants were included; of them 3665 infants (0.034 %) had a diagnosis of PTX, with highest prevalence at ≤24 weeks GA (0.67%), and lowest at term (0.02%). The overall mortality rate of patients with PTX was 8.8%, and greater in preterm (16.3%) vs. term infants (2.7%). The association of mortality with PTX was greatest at GA of 29−32 weeks (OR = 8.55 (95% CI: 6.56−11.13). Infants who survived until discharge had a median of 2–12 days longer length of stay depending on GA category. Conclusions: The prevalence of PTX peaks in infants <24 weeks, however its impact on mortality is greatest at 29-32 weeks. PTX is associated with longer length of stay in survivors.
CFTR (cystic fibrosis transmembrane conductance regulator) modulators are small molecules that directly change the CFTR protein, improving function of the CFTR chloride channel. Beginning in 2012 with the FDA approval of the first CFTR modulator, ivacaftor, this class of medication has had largely positive effects on many outcomes in people with cystic fibrosis (pwCF), including lung function, quality of life, and growth. There have been continued exciting developments in the current research on CFTR modulators, expanding beyond original studies. This first part of a three-part Cystic Fibrosis (CF) Year in Review 2020 will focus on research on CFTR modulators. Subsequent parts of the CF year in review will cover pulmonary and infectious inflammatory aspects, and the multisystem effects of CF in the 2020 literature. The review focuses on articles from Pediatric Pulmonology, but it includes articles from other journals that are of particular interest to clinicians. New developments in CF research continue to be brought forth to the CF community, deepening the understanding of this disease and improving clinical care.
Bullying-induced dyspnoea in children: a case seriesIan P. Sinha 1,2Claire Hepworth 1Sujata De 1Sunil D. Sharma 1Ian Street 1Philip J. Lawrence 1Thomas Hampton* 1,21 Alder Hey Children’s Hospital, Liverpool, UK2 Division of Child Health, University of Liverpool, UK*Corresponding author (Thomas.firstname.lastname@example.org)Dear EditorWe conduct a multidisciplinary complex breathlessness clinic for children1. We conduct spirometry before and after a treadmill exercise test (until the child is breathless), continuous nasal laryngoscopy, pulse oximetry, and calculation of maximal oxygen consumption (VO2max). Here we describe a series of children who presented with troublesome breathlessness that appeared to be caused, or exacerbated by, being bullied.Case 1 (14 year old white female): She was a highly competitive sportsperson, but was recently unable to train or compete. She described her breathlessness as ‘air getting stuck in her throat’, and had a non-specific cough. She had frequent admissions to hospital, treated as presumed asthma attacks. The referring clinician felt her asthma was of insufficient severity to cause her problems. She had no documented obstruction on spirometry in clinic, nor and Fractional Exhaled Nitric Oxide (FeNO) was normal. In clinic she managed a few minutes of running, before suddenly stopping. There was no evidence of exercise-induced bronchoconstriction or exercise-induced laryngeal obstruction (EILO), but she had features of dysfunctional breathing (DB). On questioning she described feeling bullied by parents of other children in her sports team, whom she described as overcritical and disparaging. She was taught breathing exercise and referred to psychological services. Her symptoms and asthma attacks improved, and she recommenced competitive sports.Case 2 (10 year old white female): She had a chronic wet cough since the age of six months. She underwent flexible bronchoscopy which identified mild tracheobronchomalacia. She recently described breathlessness on mild exertion that was disproportionate to the degree of tracheobronchomalacia. Physiological testing never demonstrated airways obstruction, or raised FeNO. In clinic she started running but stopped within minutes, with no physiological evidence of increased work of breathing or bronchoconstriction. Laryngoscopy was normal. On questioning she described that she was bullied at school. Specifically, she described that children would not sit near her because of her cough. She was followed up in respiratory physiotherapy clinic, and her symptoms and exercise tolerance improved.Case 3 (13 year old white female): She had no medical diagnoses at the time of testing, but previously had tonsillectomy because of recurrent tonsillitis. She described breathlessness on exertion. She stopped running very suddenly, as soon as she felt breathless on the treadmill. The breathlessness started as discomfort underneath her ribs and in her throat. Spirometry and laryngoscopy were normal before and after exercise. She had apical breathing and hyperventilation at rest, suggestive of dysfunctional breathing. She described being bullied at school. She did not attend follow up sessions with physiotherapy and was discharged from the service.Case 4 (9 year old black male): He was treated for mild asthma which had, until recently, been well controlled. He had become withdrawn, and was not enjoying playing sports despite previously being very athletic. On questioning he described suffering significant and long-standing racial bullying at school. He discussed this with the teachers but his symptoms seemed to develop after he felt like his complaints were not taken seriously. His breathlessness and exercise tolerance improved temporarily after enrolling in a community sports program for children with asthma 2, and he was much better after moving school.Across these cases, we identified common themes:The character and severity of the breathlessness was out of keeping with their underlying diagnoses, and was intensely unpleasant. All children described non-specific and variable symptoms of pain in their abdomen, joints, or chest.They appeared withdrawn, unhappy, and lacking in self-confidence. They had slouched posture, and spoke quietly.They had very sudden and surprising termination of exercise after starting to feel breathless, with no significant physiological evidence of increased work of breathing – we noticed a stark difference compared with other children who saw breathlessness as a challenge and would continue to run long after showing signs of tachypnoea and tachycardia.In all cases, it was the healthcare professionals who raised the subject of bullying. The children had felt that they had raised concerns about being bullied but felt these were dismissed.When children engaged with physiotherapy, we noticed improvements. The children were relieved when we did not find significant anatomical or physiological diagnoses, and all agreed their breathlessness was caused by bullying.We feel that these patterns relate to a phenotype of childhood dyspnoea specifically related to bullying. Anxiety is associated with tachypnoea, but in our experience the pattern of breathing in these children was different: their shallow, rapid breathing at rest was felt to be related to a slouched posture causing restriction, and all had a sudden cessation to exercise after very minimal exertion. We suggest these are manifestations, specifically, of low self-esteem. It was notable that they described the breathlessness as intensely uncomfortable. The neural pathways involved in driving respiration, and sensing breathlessness, are complex, and we postulate that they are affected by low self-esteem.This, to our knowledge, is the first description of bullying-induced dyspnoea in children, as a separate phenomenon to anxiety-related hyperventilation. There may be crossover with other psychological, physiological and anatomical problems, and further research is warranted. Having asthma is a risk factor for being bullied3, and bullying is associated with worse asthma control4. A recent review has also identified possible associations between bullying and the development of childhood asthma5. It is important ask about bullying when taking a history from a child with unexplained or disproportionate breathlessness.
Bronchopulmonary dysplasia is a relatively common and severe complication of prematurity, and its pathogenesis remains ambiguous. Revolutionary advances in microbiological analysis techniques, together with the growing sophistication of the gut-lung axis hypothesis, have resulted in more studies linking gut microbiota dysbiosis to the occurrence and development of bronchopulmonary dysplasia. The present article builds on current findings to examine the intrinsic associations between gut microbiota and bronchopulmonary dysplasia. The gut microbiota affects bronchopulmonary dysplasia via several potential mechanisms including alteration of the gut-lung axis, promotion of inflammation and the ensuing growth effects, therefore these are also investigated. By evaluating the potential mechanisms, new therapeutic targets and potential therapeutic modalities for BPD can be identified from a microecological perspective.
Introduction: With improving mortality rates in pediatric acute respiratory distress syndrome (PARDS), functional outcomes in survivors are increasingly important. We aim to describe the change in functional status score (FSS) from baseline to discharge and to identify risk factors associated with poor functional outcomes. Methods: We examined clinical records of patients with PARDS admitted to our pediatric intensive care unit (PICU) from 2009 to 2016. Our primary outcome was acquired morbidity at PICU and hospital discharge (defined by an increase in FSS ≥3 points above baseline). We included severity of illness scores and severity of PARDS in our bivariate analysis for risk factors for acquired morbidity. Results: There were 181 patients with PARDS, of which 90 (49.7%) survived. Median pediatric index of mortality 2 score was 4.05 (1.22, 8.70) and 21 (26.6%) patients had severe PARDS. 59 (65.6%) and 14 (15.6%) patients had acquired morbidity at PICU and hospital discharge, respectively. Median baseline FSS was 6.00 (6.00, 6.25), which increased to 11.00 (8.75, 12.00) at PICU discharge before decreasing to 7.50 (6.00, 9.25) at hospital discharge. All patients had significantly higher median FSS score at both PICU and hospital discharge compared to baseline. Feeding and respiratory were the most affected domains. After adjusting for severity of illness, severity categories of PARDS was not a risk factor for acquired morbidity. Conclusion: Acquired morbidity in respiratory and feeding domains was common in PARDS survivors. Specific attention should be given to these two domains of functional outcomes in these children.
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection usually causes no or mild coryzal symptoms in the paediatric population. In this letter, we describe a 21-month-old boy infected with SARS-CoV-2 who presented atypically with features compatible with croup. With the current Coronavirus Disease 2019 (COVID-19) pandemic, infection control measures need to be appropriately heightened and early diagnostic sampling for SARS-CoV-2 should be carried out even in symptomatology that is atypical of COVID-19.
Disseminated tuberculosis (TB) in the pediatric population is relatively rare in the United States with variable nonspecific presentations. In this letter we discuss the case of 2-year-old child with a lung mass and central neurogenic hyperventilation with primary respiratory alkalosis as a rare pediatric presentation of disseminated tuberculosis with TB meningitis and pulmonary tuberculosis.
Background: A crucial balance exists between oxidant and antioxidant mechanisms in the functional immune system. We aimed to evaluate the contributions of balance between these systems to coronavirus disease 2019 (COVID-19), a devastating pandemic caused by viral infection. Method: We analyzed serum oxidant and antioxidant stress parameters according to the clinical and demographic characteristics of children and adults with COVID-19 and compared them against the values of healthy controls. Serum native thiol (NT), total thiol (TT), disulfide, total antioxidant status, total oxidant status, and ischemia-modified albumin levels were evaluated and compared between groups. Results: A total of 79 children and 74 adults were evaluated in the present study, including 46 children and 40 adults with COVID-19, 33 healthy children, and 34 healthy adults. TT, NT, and disulfide levels were significantly lower in the adult COVID-19 group than in all other groups (p = 0.001, p = 0.001, and p = 0.005, respectively). Additionally, TT and NT levels were significantly lower in both pediatric and adult COVID-19 cases with severe disease course than mild/moderate course. TT and NT levels were identified as predictors for the diagnosis of the adult COVID-19 cases and as independent predictors for disease severity in both children and adults with COVID-19. Conclusion: Parameters that reveal the oxidant and antioxidant capacity, including TT and NT, appear to be good candidates for the accurate prediction of the clinical course among patients with COVID-19.
It was recently reported that due to the COVID-19 pandemic, in the European winter 2020-2021, bronchiolitis had practically disappeared. But early reports from the southern hemisphere (Australia) raised concerns about a late spring / summer peak. After a full winter season and now ending the summer, we report that there was no peak of common respiratory viruses in late spring / summer in South America.
Background: Effective yet safe treatment of latent tuberculosis is important for preventing the spread of tuberculosis and the progression to active disease in pediatric patients. As of 2017, the short course combination regimen of weekly isoniazid and rifapentine (3HP) administered by directly observed therapy (DOT) has replaced 9 months of isoniazid as the standard of treatment for latent tuberculosis in pediatric patients. The literature, limited in size, has established the 3HP regimen’s superior safety and adherence. Methods: We completed a retrospective chart review (n = 22) of pediatric patients at our institution receiving this regimen between 2017 and 2019. Frequencies of selected outcomes were compared to data collected in a literature review. Results: In this retrospective chart review, pediatric patients ages 2 to 20 years receiving 3HP with DOT for latent tuberculosis experienced higher adverse event rates, more severe adverse events, and higher treatment discontinuation than that which has been previously reported in the literature. A possible explanation for this finding is that our cohort’s race/ethnicity differed from the cohorts used in the literature. Conclusions: Our data suggests that the short course combination regimen for pediatric latent tuberculosis patients may have a higher adverse event rate than previously established. Although this sample size is small, this study urges further investigation of more diverse cohorts to better establish the regimen’s safety and tolerability.
Objective: Obstructive sleep apnea (OSA) is highly prevalent in children and requires an expensive and relatively unavailable sleep study for diagnosis. This study was undertaken to translate the previously validated OSA screening tool (POSAST) to the Thai language and assess its accuracy and test-retest reliability in at-risk symptomatic children. Study design: Prospective cross-sectional cohort study Methods: Pediatric patients clinically referred for suspected OSA who underwent overnight polysomnography (PSG) were recruited, and caregivers completed the Thai version of the POSAST. The same questionnaire was completed again after 2-4 weeks. Results: One hundred and ten subjects completed the study. The mean age was 8.4±2.9 years. The mean apnea-hypopnea index (AHI) was 10.9±11.9 events/hour. Test-retest reliability (Pearson correlation coefficient = 0.96, P<0.001) and internal consistency (Cronbach’s alpha coefficient = 0.82, P<0.001) between each question were excellent. A cumulative equation-derived score cut-off of 1.9 yielded 78.4% sensitivity and 50.0% specificity, while a numerical additive score cut-off of 8 corresponded to 81.1% sensitivity and 52.8% specificity for diagnosing moderate and severe OSA (AHI ≥5 events per hour) Conclusion: The internal consistency and reproducibility of the Thai version of the POSAST are satisfactory, display acceptable validity, and the instrument can be used for screening symptomatic Thai children for OSA.
Numerous studies in the past 10 years have reported on the neurocognitive sequalae of pediatric Sleep Disordered Breathing (SDB). Variations in criteria used to define SDB in conjunction with the wide variety of neuropsychological measures selected to evaluate cognitive consequences of SDB have resulted in discrepancies within the literature. This review summarizes the extant literature regarding cognitive effects of pediatric SDB across domains of global intelligence, attention, executive function, memory, language, and visuospatial ability. This review also addresses the proposed etiology underlying neurocognitive consequences of pediatric SDB. The differences in findings across the literature are highlighted and discussed throughout.
Abstract Background: The effects of minimally invasive surfactant administration (MISA) in preterm infants with neonatal respiratory distress syndrome (NRDS) are unclear. Methods: We searched randomized controlled trials (RCTs) and compared MISA techniques with intubation for surfactant delivery in preterm infants with NRDS in PubMed, Embase, Cochrane Library, and Web of Science. Results: Thirteen RCTs (1931 infants) were included in the meta-analysis. The use of MISA techniques decrease the incidence of bronchopulmonary dysplasia (BPD) at 36 weeks, pneumothorax, and hemodynamically significant patent ductus arteriosus (hsPDA) (Risk Ratio(RR) : 0.59, 95% confidence interval (CI) : 0.46 to 0.75, p < .0001; RR : 0.60, 95% CI : 0.39 to 0.93, p= .02 and RR : 0.88, 95% CI : 0.78 to 1.00, p= .04, respectively). In addition, infants in the MISA group required less mechanical ventilation within 72 h of life or during hospitalization (RR : 0.60, 95% CI : 0.48 to 0.75, p< .00001 and RR : 0.64, 95% CI : 0.49 to 0.82, p = .0005, respectively) compared with infants in the control group. However, the rate of surfactant reflux was higher in the MISA group than that in the control group (RR : 2.12, 95% CI : 1.37 to 3.29, p = .0008). There were no significant differences in mortality and other outcomes beteween the MISA group and the control group. Conclusions: The administration of surfactant with MISA techniques could lower the requirement for mechanical ventilation, and decrease the incidence of BPD at 36 weeks, pneumothorax, and hsPDA.