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This review highlights important advances in paediatric respiratory medicine since 2014, excluding cystic fibrosis. It focuses mainly on the more common conditions, bronchopulmonary dysplasia, bronchiolitis and preschool wheezing, asthma, pneumonia and sleep, and highlights some of the rarer conditions such as primary ciliary dyskinesia and interstitial lung disease (ILD). [ABSTRACT FROM AUTHOR]

Heated humidified high-flow nasal cannula therapy (HHHFNC) was originally described as a mode of respiratory support in premature neonates and is now increasingly used in the management of acute respiratory failure in older infants and children. Heating and humidification of gas mixtures allow comfortable delivery of flow rates that match or exceed the patient's inspiratory flow rate. Emerging evidence from observational studies suggests that the use of HHHFNC therapy may be associated with reduced work of breathing, improved ventilation efficiency and a decreased need for intubation in children with respiratory insufficiency. There are several proposed mechanisms of action, and the potential for provision of unpredictable positive distending pressure has caused concern. Randomised controlled trial evidence comparing clinical outcomes with those achieved using other forms of respiratory support is, however, awaited. We review the proposed mechanisms of actions, indications, advantages and complications of HHHFNC therapy in children and describe our approach to its use in the paediatric ward environment. [ABSTRACT FROM AUTHOR]

Aim: To determine whether a child with chronic wet cough and poor response to at least 4 weeks of oral antibiotics is more likely to have bronchiectasis. Methods: All chest multi-detector computerised tomography (MDCT) scans at a single paediatric tertiary hospital from April 2010 to August 2012 were reviewed retrospectively so as to identify those ordered by respiratory physicians for assessment of children with a chronic wet cough. Information regarding age, sex, ethnicity, indication for imaging and the response to at least 4 weeks of antibiotics before having the scan were recorded from their charts. The data were analysed using simple and multiple logistic regression. Results: Of the 144 (87 males) eligible children, 106 (65 males, 30 Indigenous) aged 10-199 months had MDCT scan evidence of bronchiectasis. Antibiotic data were available for 129 children. Among the 105 children with persistent cough despite at least 4 weeks of antibiotics, 88 (83.8%) had bronchiectasis, while of the 24 children whose cough resolved after antibiotics, only six (25.0%) received this diagnosis (adjusted OR 20.9; 95% CI 5.36 to 81.8). Being Indigenous was also independently associated with radiographic evidence of bronchiectasis (adjusted OR 5.86; 95% CI 1.20 to 28.5). Conclusions: Further investigations including a MDCT scan should be considered in a child with a chronic wet cough that persists following 4 weeks of oral antibiotics. However, while reducing the likelihood of underlying bronchiectasis, responding well to a single prolonged course of antibiotics does not exclude this diagnosis completely. [ABSTRACT FROM AUTHOR]

Background Identification of bacterial pathogens is paramount for prompt and effective treatment of respiratory exacerbations in children with cystic fibrosis (CF). This can be a challenge in non-expectorating patients as reliability of cough swabs (CS) is poor. More recently, cough plates (CP) have been reported to give high yields in some series. The aim of the study was to ascertain their effectiveness compared to CS and to assess the impact of cough strength on efficacy of CP. Method Non-expectorating children with CF aged 3-16 years were recruited. Baseline data was recorded and peak cough flow measured. Specimens were obtained with CP and a cough swab in a randomised order and repeated at up to four clinic visits to obtain multiple measurements. Subjects completed a short questionnaire. Results Number of subjects was 95, mean age 8.8 ±4.1 years, 45 males. Mean baseline % predicted FEV1 was 90.8±18. In total, 324 sets of specimens were collected. Pathogens were isolated in 18.2% of CS and 8% of CP. Agreement between the two specimens occurred in only 5.5% of cases. CP isolated pathogens on six occasions when the CS was negative while 40 CS were positive with a corresponding negative CP. Cough strength increased with age, and there was a trend towards older children isolating more pathogens on CP. However, this was not statistically significant. The majority of subjects preferred the CP. Conclusions CP are less effective than CS in identifying respiratory pathogens in children with CF. [ABSTRACT FROM AUTHOR]

Objectives To examine the association between longterm exposure to air pollution and lung function among Chinese schoolchildren in Southern China (Hong Kong). Methods We conducted a cross-sectional study among 3168 schoolchildren (aged 8-10 years) in 3 districts in Hong Kong. Annual means of ambient PM10 ( particulate matter <10 μm), SO2, NO2 and O3 from 1996 to 2003 were used to estimate the individual exposure of the subjects. Children's lung function was measured for forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), forced expiratory flow between 25% and 75% of FVC (FEF25-75) and forced expiratory flow at 75% of FVC (FEF75). Analysis of covariance was performed separately by gender to estimate the impact of air pollution on lung function, with adjustment for socioeconomic characteristics, respiratory morbidities, height and weight, physical activity level, indoor air contaminants and shortterm exposure to the air pollutants. Results After controlling for potential confounding factors, FEV1, FEF25-75 and FEF75 for boys in a highpollution district (HPD) were significantly lower than those in a low-pollution district (LPD) by 3.0%, 7.6% and 8.4%, respectively. No significant differences were found for girls. Results from the comparison between a moderate-pollution district (MPD) and the HPD were similar. There were no differences between children in the LPD and MPD, except that a higher FEF75 was found in boys in the MPD. PM10 is the primary pollutant responsible for the lung function deficit. Asthmatic children were more vulnerable to exposure to air pollution. Conclusions Long-term exposure to higher ambient air pollution levels was associated with lower lung function in Chinese schoolchildren, especially among boys. Adverse effects were observed on large and small airways, with a stronger effect on the latter. [ABSTRACT FROM AUTHOR]

Objective Acute severe asthma in children is a common cause of admission to intensive care units (ICU), but there are few reports on long-term outcomes. This study describes outcomes for children with asthma admitted to an ICU. Methods All children with asthma aged 2-18 years admitted to the ICU at the Royal Children's Hospital Melbourne between 1990 and 2004 were eligible for the study. Data were collected by reviewing medical records and through telephone interviews. Results Complete data were obtained for 410 (61%) of 684 eligible patients. The mean duration of follow-up was 10.3±4.6 years. After the index admission, 67% were readmitted to hospital for asthma and 17% to the ICU. Eighty-eight per cent continued to have asthma: 46% had episodic asthma and 42% persistent asthma. Twelve patients (1.8%) subsequently died from asthma. Five per cent of those who required ventilation at their index admission died within 10 years. Risk factors for ICU readmission were admission for asthma in the preceding year (AOR 4.7; 95% CI 2.4 to 9.3) and ventilation at admission (AOR 2.4; 95% CI 1.0 to 5.3). Risk factors for subsequent mortality were multiple ICU admissions (AOR 5.0; 95% CI 1.3 to 19), persistent asthma (AOR 5.8; 95% CI 1.2 to 28.5) and ventilation at admission (AOR 4.5; 95% CI 1.3 to 15.7). Conclusion Admission to the ICU for asthma is a predictor of hospital readmission. Those with persistent asthma or requiring ventilation are at significant risk of mortality in subsequent years and require close follow-up. [ABSTRACT FROM AUTHOR]

Background Bronchiolitis is a significant cause of acute morbidity in the first 12 months of life and some infants with bronchiolitis are admitted to hospital. No studies have yet devised a scoring system to predict admission for routine use in the emergency department. Aim To identify clinical predictors of hospital admission in infants with acute bronchiolitis and to devise a simple clinical risk scoring system which could be used to aid decision making in the emergency department. Methods All infants presenting with acute bronchiolitis to a dedicated paediatric emergency department from April 2009 to March 2010 were included in the study. Clinical predictors of admission were determined through case note review and logistic regression analysis. The strongest predictors of admission were assimilated into a simple clinical risk scoring system using widely accepted statistical methods. Results 449 infants presented with acute bronchiolitis during the study period (298 (66%) male, mean age 23±14.5 weeks). 163 (36%) infants were admitted to hospital. The five best predictors of admission (age, respiratory rate, heart rate, oxygen saturations and duration of symptoms) were incorporated into the bronchiolitis risk of admission scoring system. The area under the receiver operator characteristic curve was 0.81 (95% CI 0.77 to 0.85) at the optimal cut-off, demonstrating good diagnostic accuracy. Conclusions The authors have identifi ed important clinical predictors of admission in acute bronchiolitis. This information has been used to develop a simple clinical risk scoring system to aid decision making in the emergency department. [ABSTRACT FROM AUTHOR]

Introduction: Preterm infants have a substantially increased risk of developing respiratory illnesses. The goal of this study was to consider the impact of modifiable postnatal exposures on respiratory morbidity among a cohort of very low birth weight (VLBW) infants. Objectives: (1) Assess the rates of respiratory morbidity and exposure to indoor respiratory triggers in a population of VLBW infants at 1 year; (2) determine the association between exposures and respiratory morbidity. Methods: We enrolled 124 VLBW infants into a prospective cohort study. Parents were called at 1 year to assess respiratory outcomes and environmental exposures. We used bivariate and multivariate analyses to assess the relationship between environmental exposures and acute care for respiratory illnesses. Results: At 1 year, 9% of infants had physician- diagnosed asthma, 47% required ⩾1 acute visit and 11% required hospitalisation for respiratory illness. The majority of infants (82%) were exposed to at least one indoor respiratory trigger. Infants living with a smoker (61% vs 40%) and infants exposed to pests (62% vs 39%) were more likely than unexposed infants to require acute care for respiratory problems. In a multivariate regression controlling for demographics, birth weight, bronchopulmonary dysplasia, and family history of asthma or allergies, both living with a smoker (OR 2.62; Cl 1.09 to 6.29) and exposure to pests (OR 4.41; CI 1.22 to 15.94) were independently associated with the need for acute care for respiratory illnesses. Conclusions: In this sample, respiratory morbidity and exposure to triggers were common. VLBW infants may benefit from interventions that decrease exposure to respiratory triggers. [ABSTRACT FROM AUTHOR]

Bronchiolitis is the commonest reason for hospital admission in infancy and the most frequent cause of acute respiratory failure in children admitted to paediatric intensive care units in the UK and North America. The respiratory syncytial virus accounts for most cases of bronchiolitis, however, new virus isolation techniques have led to the discovery of previously unrecognised viruses, including the human metapneumovirus and bocavirus which also play a significant role. The main developments in bronchiolitis management in recent years relate to the use of immunoprophylaxis; a number of other therapies such as the use of heliox are currently being investigated. Supportive therapy remains the mainstay of management with limited or no evidence of benefit for most other pharmacological treatments. This article summarises the current understanding of the different bronchiolitis phenotypes, with a brief description of outcomes and a review of the evidence for the various therapeutic interventions. [ABSTRACT FROM AUTHOR]

Aims: We compared the radiological features and outcome of WHO defined severe pneumonia among HIV infected and exposed uninfected children randomised to receive penicillin or oral amoxicillin in Durban, South Africa. Methods: Of 425 children aged between 3 and 59 months with WHO defined severe pneumonia, 366 had anonymous HIV testing performed. Outcome was assessed by failure to improve at 48 h after enrolment or deterioration within 14 days. Chest radiographs were evaluated according to WHO defined radiological criteria for pneumonia and internationally standardised radiological criteria. Findings were stratified for HIV status. Results: 82 (22.4%) children were HIV infected, 40 (10.9%) were HIV exposed and 244 (66.7%) were HIV uninfected. The day 14 outcome in children <12 months of age was significantly worse in HIV-1 infected than HIV uninfected children (OR 2.8 (95% CI 1.35 to 3.5), p=0.002), while HIV-1 infected and uninfected children aged ⩾12 months had equivalent outcomes. Parental penicillin and oral amoxicillin had equivalent response rates in all HIV groups. According to the WHO radiological classification, children who failed WHO standard antimicrobial treatment had significantly higher "other consolidates/infiltrates" than "endpoints for consolidation" in the HIV infected group (OR 5.45 (95% CI 1.58 to 21.38), p<0.002), while the reverse was true for HIV exposed uninfected children (OR 4.13 (95% CI 0.88 to 20.57), p<:0.036). Conclusions: The WHO standard treatment guideline for severe pneumonia is inadequate for HIV-1 infected infants. The increased prevalence of "other consolidates/infiltrates" among HIV-1 infected children who failed standard treatment supports the addition of co-trimoxazole to WHO standard treatment. [ABSTRACT FROM AUTHOR]

Objective: To describe the spectrum of clinical features and management of community acquired pneumonia in the UK. Design: Prospectively recorded clinical details for all children with possible pneumonia and chest x ray (CXR) changes in 13 hospitals in the North of England between 2001 and 2002. Results: 89% of 711 children presenting to hospital with pneumonia were admitted; 96% received antibiotics, 70% intravenously. 20% had lobar CXR changes, 3% empyema and 4% required intensive care. Respiratory rate (RR), hypoxia and dyspnoea all correlated with each other and prompted appropriate interventions. Admission in children, not infants, was independently associated with RR, oxygen saturation, lobar CXR changes and pyrexia. Neither C-reactive protein, lobar CXR changes or pyrexia were associated with severity. Children over 1 year old with perihilar CXR changes more often had severe disease (p=0.001). Initial intravenous antibiotics were associated with lobar CXR changes in infants and children and with dyspnoea, pyrexia and pleural effusion in children. The presence of pleural effusion increased duration of antibiotic treatment (p<0.001). Cefuroxime was the most often used intravenous antibiotic in 61%. Oral antibiotics included a penicillin in 258 (46%), a macrolide in 192 (34%) and a cephalosporin in 117(21%). Infants stayed significantly longer (p<0.001) as did children with severe disease (p<0.01), effusions (p=0.005) or lobar CXR changes (p<0.001). Conclusions: There is a high rate of intravenous antibiotic administration in hospital admissions for pneumonia. Despite lobar CXR changes not being independently associated with severe disease, initial lobar CXR changes and clinical assessment in children independently influenced management decisions, including admission and route of antibiotics. [ABSTRACT FROM AUTHOR]

Children account for a major proportion of the global tuberculosis disease burden, especially in endemic areas. However, the accurate diagnosis of childhood tuberculosis remains a major challenge. This review provides an overview of the most important recent advances in the diagnosis of intrathoracic childhood tuberculosis: (1) symptom-based approaches, including symptom-based screening of exposed children and symptom-based diagnosis of active disease; (2) novel immune-based approaches, including T cell assays and novel antigen-based tests; and (3) bacteriological and molecular methods that are more rapid and/or less expensive than conventional culture techniques for tuberculosis diagnosis and/or drug-resistance testing. Recent advances have improved our ability to diagnose latent infection and active tuberculosis in children, but establishing a diagnosis of either latent infection or active disease in HIV-infected children remains a major challenge, particularly in high-burden settings. Although improved access to diagnosis and treatment is essential, ultimately the burden of childhood tuberculosis is determined by the level of epidemic control achieved in a particular community. Several recent initiatives, in particular the United Nations Millennium Developmental Goals, deal with the problem of poverty and disease in a holistic fashion, but global political commitment is required to support these key initiatives. [ABSTRACT FROM AUTHOR]

Background: In Germany, 2910 infants died in 2004; for many infants the reason was clear, especially prematurity or congenital abnormalities. However, 394 babies die every year suddenly and unexpectedly. The cause may be immediately clear, but is often not obvious. Aims: (1) To describe the causes of explained sudden unexpected death in infancy (SUDI) and (2) to compare risk factors for sudden infant death syndrome (SIDS) and explained SUDI. Methods: A 3-year population-based case-control study in Germany, 1998-2001. Results: 455 deaths, of which 51(11.2%) were explained. Most of these deaths were due to respiratory or generalised infections. The risk factors for SIDS and explained SUDI were remarkably similar except for sleep position and breast feeding. Prone sleeping position is a major risk factor for SIDS (adjusted odds ratio (OR) 7.16, 95% confidence interval (CI) 3.85 to 13.31) but not for explained SUDI (adjusted OR 1.71, 95% Cl 0.25 to 11.57). Not being breast fed in the first 2 weeks of life is a risk factor for SIDS (adjusted OR 2.37, 95% CI 1.46 to 3.84) but not for explained SUDI (adjusted OR 0.39, 95% CI 0.08 to 1.83). Conclusions: Prone sleeping position is a unique risk factor for SIDS. Socioeconomic disadvantage and maternal smoking are risk factors for both SIDS and explained SUDI, and provide an opportunity for targeted intervention. [ABSTRACT FROM AUTHOR]

The influence of physical housing quality on childhood asthma expression, especially the effect of exposure to moulds, allergens, and pollutants, is well documented. However, attempts to explain increasing rates and severity of childhood asthma solely through physical environmental factors have been unsuccessful, and additional exposures may be involved. Increasing evidence has linked psychological stress and negative affective states to asthma expression. At the same time, recent scholarship in the social sciences has focused on understanding how social environments, such as housing, "get under the skin" to influence health, and suggests that psychological factors play a key role. While there is relevant overlapping research in social science, psychology, economics, and health policy in this area, findings from these disciplines have not yet been conceptually integrated into ongoing asthma research. We propose to expand the dimensions of housing considered in future asthma research to include both physical and psychological aspects which may directly and indirectly influence onset and severity of disease expression. This synthesis of overlapping research from a number of disciplines argues for the systematic measure of psychological dimensions of housing and consideration of the interplay between housing stress and physical housing characteristics in relation to childhood asthma. [ABSTRACT FROM AUTHOR]

Background: Croup remains a common respiratory problem presenting to emergency departments. A single oral treatment of oral dexamethasone results in improved outcome. Prednisolone has similar pharmacokinetic properties and has a significant advantage in that it is commercially available in liquid preparations. Objective: To ascertain whether a single oral dose of prednisolone was equivalent to a single oral dose of dexamethasone (matched for potency) in children with mild to moderate croup. Design: A double blind, randomised, controlled equivalence trial Setting: Tertiary paediatric emergency department. Patients: 133 children aged 3 to 142 months presenting with mild to moderate croup. Interventions: Children received either a single oral dose of dexamethasone 0.15 mg/kg or single oral dose of prednisolone 1 mg/kg. Outcome: The main outcome measure was unscheduled re-presentation to medical care as determined by telephone follow up at 7 to 10 days. Croup score, adrenaline (epinephrine) use, time spent in the emergency department, and duration of croup and viral symptoms were secondary outcome measures. Results: Children treated with prednisolone were more likely to re-present: 19 of 65 children (29%) reattended medical care compared with 5 of 68 (7%) from the dexamethasone group. The confidence intervals around this 22% difference in outcome were 8% to 35%, outside the 0% to 7.5% range of equivalence. There were no significant differences in other outcome measures. Conclusion: A single oral dose of prednisolone is less effective than a single oral dose of dexamethasone in reducing unscheduled re-presentation to medical care in children with mild to moderate croup. [ABSTRACT FROM AUTHOR]

This article discusses community-acquired pneumonia in children (CAP). Pediatric respiratory disease remains an important cause of morbidity in both the developing and the developed world. In Great Britain respiratory illness is the most common reason parents cite for taking their children to see the general practitioner, and for attendance to the emergency department with a pediatric medical problem. CAP refers to an infection of the lung by a variety of microorganisms acquired outside the hospital setting, resulting in inflammation of the lung tissue. It is typically associated with fever and respiratory symptoms such as cough and tachypnoea, but symptoms may be non-specific in young children. Research is ongoing to identify the most sensitive and specific tools to identify the causative organism so that more directed could use treatment. International travel, the introduction of new vaccines, and the development of new treatments will all have an impact on the way this disease is managed in years to come.

Objective: To determine whether neonatal respiratory morbidity at term is associated with an increased risk of later asthma and whether this may explain previously described associations between caesarean delivery and asthma. Design: Retrospective cohort study using Scottish Morbidity Record (SMR) data of maternity (SMR02), neonatal (SMR11), and acute hospital (SMR01) discharges. Setting: Scotland. Participants: All singleton births at term between 1992-1995 in 23 Scottish maternity hospitals. Main outcome measures: Hospital admission with a diagnosis of asthma in the principal position between 1992 and 2000. Results: Children who had a diagnosis of transient tachypnoea of the newborn or respiratory distress syndrome were at increased risk of being admitted to hospital with a diagnosis of asthma (hazard ratio (HR) 1.7, 95% confidence interval (95% Cl) 1.4 to 2.2, p<0.001). This association was observed both among children delivered vaginally (HR 1.5, 95% Cl 1.1 to 2.0, p = 0.007) and among those delivered by caesarean section (HR 2.2, 95% Cl 1.6 to 3.0, p<0.001). In the absence of neonatal respiratory morbidity, delivery by caesarean section was weakly associated with the risk of asthma in childhood (HR 1.1, 95% Cl 1.0 to 1.2, p = 0.004). The strengths of the associations were similar whether the caesarean delivery was planned or emergency and were not significantly altered by adjustment for maternal, obstetric, and other neonatal characteristics. Conclusions: Neonatal respiratory morbidity at term is associated with an increased risk of asthma in childhood which may explain previously described associations between caesarean delivery and later asthma. [ABSTRACT FROM AUTHOR]

Aims: To examine the dose-response relation of inhaled fluticasone for both efficacy and adrenal function in children with asthma. Methods: Systematic review of double blind randomised dose-response studies of fluticasone in children of at least 4 weeks duration. Main outcome measures: FEV1, morning peak expiratory flow, night awakenings, β agonist use, major exacerbations, 12 or 24 hour urinary cortisol, peak plasma cortisol post-stimulation. Results: Seven studies of 1733 children with asthma met the inclusion criteria for efficacy. The dose-response curve for each efficacy outcome measure suggested that the response began to plateau between 100 and 200 μg per day with additional efficacy at the 400 μg per day dose shown in one study of severe asthmatics. Five studies of 1096 children with asthma met the inclusion criteria for assessment of adrenal function. The largest placebo controlled study of 437 children reported no difference in 24 hour urinary cortisol between placebo and fluticasone at doses of 100 and 200 μg per day. The non-placebo controlled study of 528 children reported significant suppression of overnight urinary cortisol levels with fluticasone at 400 compared with 200 μg per day. Conclusions: There is insufficient data to determine the dose-response of fluticasone in children at doses >400 μg per day. The dose-response curve for fluticasone appears to plateau between 100 and 200 μg per day for efficacy. There was additional efficacy at the 400 μg per day dose in children with severe asthma; however there was evidence of adrenal suppression at this dose. [ABSTRACT FROM AUTHOR]

Aims: To determine whether routine outpatient monitoring of growth predicts adrenal suppression in prepubertal children treated with high dose inhaled glucocorticoid. Methods: Observational study of 35 prepubertal children (aged 4-10 years) treated with at least 1000 pg/day of inhaled budesonide or equivalent potency glucocorticoid for at least six months. Main outcome measures were: changes in HtSDS over 6 and 12 month periods preceding adrenal function testing, and increment and peak cortisol after stimulation by iow dose tetracosactrin test. Adrenal suppression was defined as a peak cortisol &les; 500 nmol/l. Results: The areas under the receiver operator characteristic curves for a decrease in HtSDS as a predictor of adrenal insufficiency 6 and 12 months prior to adrenal testing were 0.50 (SE 0.10) and 0.59 (SE 0.10). Prediction values of an HtSDS change of -0.5 for adrenal insufficiency at 12 months prior to testing were: sensitivity 13%, specificity 95%, and positive likelihood ratio of 2.4. Peak cortisol reached correlated poorly with change in HtSDS (p=0.23, p=0.l9 at 6 months; p=0.33, p =0.06 at 12 months). Conclusions: Monitoring growth does not enable prediction of which children treated with high dose inhaled glucocorticoids are at risk of potentially serious adrenal suppression. Both growth and adrenal function should be monitored in patients on high dose inhaled glucocorticoids. Further research is required to determine the optimal frequency of monitoring adrenal function. [ABSTRACT FROM AUTHOR]

Assesses the effects of inhaled bronchodilator agonists on lung function in infants with malacia or recurrent wheeze. Negative effects of bronchodilators on forced expiratory flow in infants with airway malacia; Analysis of pertinent topics and relevant issues; Implications on studies of childhood diseases.

Aims:To ascertain whether the reduction in nasopharyngeal carriage of vaccine serotypes induced by pneumococcal conjugate vaccine (PnCV) administered to infants persists beyond the age of 2 years. Methods: Non-randomised, unblinded controlled study of 2-5 year old children who had received three doses of heptavalent PnCV (7VPnCV) in infancy and 23-valent pneumococcal polysaccharide vaccine at 13 months, and unimmunised controls. Nasopharyngeal swabs were taken in summer (150 vaccinated subjects, 126 controls) and winter (143 vaccinated subjects, 188 controls). The swabs were cultured and serotyped for Streptococcus pneumoniae. Results: Carriage rates (vaccinated subjects: 24.7% and 43.4%; controls: 27.0% and 41.0%, in summer and winter respectively) and carriage of vaccine serotypes (subjects: 10.0% and 30.0%; controls: 13.5% and 31.5%, in summer and winter respectively) were similar in the two groups. Conclusions: Effects of vaccination in infancy on rates of nasal carriage of pneumococcus and serotype replacement in children living in a largely unvaccinated population are no longer evident by 2-5 years of age. [ABSTRACT FROM AUTHOR]

Explores logical approach to the assessment and management of respiratory problems in neurological impaired children. Prevalence of respiratory disease in children with severe disabilities; Child nutrition; Stages of assessment and management; Respiratory support.

Discusses several ways in which physicians may be confronted with a spectrum of disorders representative of the adult outcome of congenital lower respiratory tract malformations. Tracheo-oesophageal fistula; Cystic malformations; Congenital diaphragmatic hernia.

Evaluates ethnic differences in the prevalence of respiratory and skin symptoms in the first two years of life. Effects of ethnic backgrounds and socioeconomic status on the prevalence of allergic diseases; Analysis of pertinent topics and relevant issues; Implications on studies of childhood diseases.

Aims: To assess the clinical effectiveness of a paediatric hospital at home service compared to conventional hospital care. Methods: A total of 399 children suffering from breathing difficulty (n = 202), diarrhoea and vomiting (n = 125), or fever (n = 72) were randomised to Hospital at Home or in-patient paediatric care. Main outcome measures were: comparative clinical effectiveness as measured by readmission rate within three months (used as a proxy for parental coping with illness); and length of stay/care and comparative satisfaction of both patients and corers. Results: Clinical effectiveness of both services was not significantly different. Length of care was one day longer in the Hospital at Home group; however, most parents and children preferred home care. Conclusions: Hospital at Home is a clinically acceptable form of care for these groups of acute paediatric illness. Readmission rates within three months failed to show any advantage in terms of parental coping. Parents and patients expressed a strong preference for hospital at home. [ABSTRACT FROM AUTHOR]

Background and Aims: The measurement of airway resistance using the interrupter technique (R[sub int]) is feasible in preschool children and other subjects unable to undertake spirometry. This makes it potentially useful for the measurement of lung function in these groups. Commercial devices use different algorithms to measure pressure and flow from which R[sub int] is derived. This study provides normative values for British children using devices from a single manufacturer. Methods: R[sub int] was measured in 236 healthy children of three ethnic groups (Afro-Caribbean and black African, Bangladeshi, and white British) aged 2-10 years using Micro Medical devices. Software in the devices calculated R[sub int] from pressure measured by the two point, back extrapolation method from the pressure transient during valve closure, with flow measured just before valve closure. Results: R[sub int] is related to both age and height, but when age is allowed for there is not a significant relation with height. Neither gender nor any of the ethnicities studied was significantly related to R[sub int]. Discussion: These measurements in healthy children using this technique may be used as reference data for similar populations. [ABSTRACT FROM AUTHOR]

Background: Following the emergence of penicillin and cephalosporin resistant pneumococcal meningitis in the United States, inclusion of vancomycin in empiric therapy for all suspected bacterial meningitis was recommended by the American Academy of Pediatrics. Few data are available to evaluate this policy. Aims: To examine the management and clinical course in relation to antibiotic therapy of a large unselected cohort of children with pneumococcal meningitis in a geographic area where antibiotic resistance has recently increased. Methods: Retrospective review of all cases of pneumococcal meningitis in a defined population (Sydney, Australia), 1994-99. Results: A total of 104 cases without predisposing illnesses were identified; timing of lumbar puncture (LP) was known in 103. Resistance to penicillin increased from 0 to 20% over the study period. Only 57 (55%) had an early LP (prior to parenteral antibiotics); 55 (96%) had organisms on Gram stain. Severe disease (intensive care admission or death) increased significantly from 57 cases with early LP (28%) to 33 with delayed LP (42%) to 13 with no LP (62%). Evidence of pneumococcal infection was available within 24 hours in 85% of those with delayed or no LP. Outcome was not related to empiric vancomycin use, which increased from 5% prior to 1998 to 48% in 1999. Conclusion: LP is frequently delayed in pneumococcal meningitis. Based on disease severity, empiric vancomycin is most justified when LP is deferred. If an early LP is done, vancomycin can be withheld if Gram positive diplococci are not seen. [ABSTRACT FROM AUTHOR]

Examines parents' accounts of how they recognize and judge respiratory symptoms in children. Parents' interpretations of respiratory survey questions about wheeze, shortness of breath and cough; Factors influencing parents' judgements; Distinctions between different types of cough.

Aims-To determine the respiratory health in adolescence of children of birth weight <1501 g, and to compare the results with normal birthweight controls. Methods-Prospective cohort study of children born in the Royal Women's Hospital, Melbourne. Two cohorts of preterm children (86 consecutive survivors 500-999 g birth weight, and 124 consecutive survivors 1000-1500 g birth weight) and a control group of 60 randomly selected children >2499 g birth weight were studied. Children were assessed at 14 years of age. A paediatrician determined the clinical respiratory status. Lung function was measured according to standard guidelines. Results-Of 180 preterm children seen at age 14, 42 (23%) had bronchopuhnonary dysplasia (BPD) in the newborn period. Readmission to hospital for respiratory ill health was infrequent in all groups and the rates of asthma were similar (15% in the 500-999 g birth weight group, 21% in the 1000-1500 g birth weight group, 21% in controls; 19% BPD, 18% no BPD). Overall, lung function was mostly within the normal range for all cohorts; few children had lung function abnormalities in clinically significant ranges. However, the preterm children had significantly lower values for variables reflecting flow. Lung function in children of 500-999 g birth weight was similar to children of 1000-1500 g birth weight. Preterm children with BPD had significantly lower values for variables reflecting flow than children without BPD. Conclusions-"The respiratory health of children of birth weight <1501 g at 14 years of age is comparable to that of term controls. [ABSTRACT FROM AUTHOR]

Background-Over the last decade there has been an apparent increase in childhood wheeze. We speculated that much of the reported increase may be attributed to the term wheeze being adopted by parents to describe a variety of other forms of noisy breathing. Aims-To investigate terminology used by parents to describe their children's breath sounds. Methods-An interview was carried out with the parents of 92 infants with noisy breathing, beginning with an open question and then directed towards a more detailed description. Finally, the parents were asked to choose from a wheeze, ruffle, and stridor on imitation by the investigator and video clips of children. Results-Wheeze was the most commonly chosen word on initial questioning (59%). Only 36% were still using this term at the end of the interview, representing a decrease of one third, whereas the use of the word ruffles doubled. Conclusions-Our results reflect the degree of inaccuracy involved in the use of the term wheeze in clinical practice, which may be leading to over diagnosis. Imprecise use of this term has potentially important implications for therapy and clinical trials. [ABSTRACT FROM AUTHOR]

Alms-To investigate how parents report children's respiratory sounds on video compared to a clinical "gold standard". Methods-Five clinicians agreed on 10 video clips of children with audible breathing. These responses were the "gold standard". The clips were shown to parents of children: (a) with asthma/wheeze; (b) with other respiratory complaints; (c) without respiratory complaints. Parents were asked what they called the sounds, where they originated, and whether their own child made similar sounds. Results-A total of 190 parents took part. The "correct" labelling of wheeze was 59% (95% confidence interval 52 to 66%) and 47% (95% confidence interval 40 to 54%) for other sounds (stridor, snoring, stertor). Parents were better at locating both sounds than labelling. There were no differences between subject groups. There were more false positive responses to labelling and locating other sounds than for wheeze (27% v 8% and 33% v 10%). Conclusion-Parents locate sounds better than describing them. At least 30% of all parents use other words for wheeze and 30% labelled other sounds as "wheeze". This could have important clinical implications. [ABSTRACT FROM AUTHOR]

A prospective randomised controlled pilot study was performed comparing home oxygen therapy with traditional inpatient hospitalisation for children with acute bronchiolitis. Children aged 3–24 months with acute bronchiolitis, still requiring oxygen supplementation 24 h after admission to hospital, were randomly assigned to receive oxygen supplementation at home with support from "hospital in the home" (HiTH) or to continue oxygen supplementation in hospital. 44 children (26 male, mean age 9.2 months) were recruited (HiTH n = 22) between 1 August and 30 November 2007. Only one child from each group was readmitted to hospital and there were no serious complications. Children in the HiTH group spent almost 2 days less in a hospital bed than those managed as traditional inpatients: HiTH 55.2 h (interquartile range (IQR) 40.3–88.9) versus in hospital 96.9 h (IQR 71.2–147.2) p = 0.001. Home oxygen therapy appears to be a feasible alternative to traditional hospital oxygen therapy in selected children with acute bronchiolitis. [ABSTRACT FROM AUTHOR]

Background: The incidence of childhood empyema, a complication of pneumonia, is increasing and the underlying mechanisms are not understood. Whether a rise in pneumonia incidence could account for the increase in empyema remains to be seen. Objective: To report trends for empyema admissions in the context of pneumonia and croup admissions in Scottish children over a 25-year period to 2005. Design: Whole-population study with retrospective analysis using diagnosis codes (International classification of diseases, 9th and 10th revisions). Setting: All non-obstetric and non-psychiatric hospitals in Scotland. Participants: Patients <15 years admitted with a diagnosis of empyema, pneumonia or croup (the latter included for reference) between 1 January 1981 and 31 December 2005. Results: There were 217 admissions for empyema in children (76 1-4 year olds). 24 312 admissions for pneumonia (11 299 l-4-year olds), and 31 120 (20 332 1-4 year age group, empyema admissions rose in the late 1990s and 2000s from an average of 6.5 per million per year between 1981 and 1898 to 66 per million in 2005. Overall annual admission rates for pneumonia remained unchanged in most age groups. However, among 1-4-year olds, admissions rose steadily by an average of 50 per million per year between 1981 and 2005. Admission rates for croup in Scottish children (<15 years) remained stable over the preceding 25 years. Conclusions: This whole-population study show that the incidence of childhood empyema has risen since 1998 and continues to rise independently of pneumonia. Croup admissions remained stable, suggesting that changes in coding or admission policies are not likely to explain the observed trends. The observations suggest that the rise in empyema is not related to an increase in pneumonia. Changes in bacterial pathogenicity and∕or host susceptibility may be important. [ABSTRACT FROM AUTHOR]

A cross-sectional study showed that 130 out of 1758 (8%) primary school children without a previous asthma diagnosis had undiagnosed asthma. Thirty-eight per cent of their parents refused to visit a general practitioner for this disorder. Factors associated with the refusal were high maternal education, mild symptoms and absence of airway reversibility. [ABSTRACT FROM AUTHOR]

Aims: To determine whether the monitoring of respiratory disease progression in children with cystic fibrosis (CF) can be made using six pre-selected computed tomography (CT) cuts in lieu of the conventional full study. Methods: Forty one lung CT scans from 21 paediatric patients with CF were analysed. The Bhalla and Nathanson scores of the total lung CT and the six pre-selected CT cuts were compared. Results: The Bhalla mean score of the total lung CT evaluated by two radiologists was 5.62. It was 5.36 when just the six pre-selected sections were evaluated. The difference between means was not statistically significant. The Nathanson mean score of the total lung CT evaluated by both radiologists was 66.11; it was 66.51 when just the six pre-selected sections were evaluated. The difference between means was not statistically significant. The mean total radiation dose from a single whole lung CT scan was 716.22 mGy·cm. A dose of 250.66 mGy·cm was estimated if only six sections were used, with a reduction in radiation of about 65%. Conclusion: It is possible to obtain the same radiological information from six pre-selected CT cuts as it is from a full pulmonary CT scan, thereby markedly reducing radiation exposure for children who will require repeat investigations in the future. [ABSTRACT FROM AUTHOR]

The article discusses the use of inhaled corticosteroid therapy (ICT) in the management of asthma during childhood. In recommended doses, ICT has had an excellent safety record, but encouraged by reports of the apparent safety of high dose ICT in adults, paediatricians became increasingly bold in ignoring the manufacturers' dosage recommendations. The author argues that patients on exceptionally high doses of ICT should have an adrenal function test performed. Loss of bone mineral density is a long established side effect of oral corticosteroid therapy for asthma.

This article presents abstracts related to respiratory diseases in children presented at the 8th Spring meeting of the Royal College of Paediatrics and Child Health, University of York in York, England during March 29 to April 1, 2004. Some children suffer from chronic severe asthma, despite maximal inhaled therapy. Children were treated with three or more monthly injections of intramuscular triamcinolone acetonide. It was reviewed whether any beneficial effect persisted after 4 weeks, a period beyond the expected duration of effect of intramuscular steroid. Recurrent cough and/or wheeze requiring treatment are frequently reported at follow up of very prematurely born infants.

Aims: (1) To determine the pattern of respiratory impairment in children with thalassaemia major (TM); (2) to assess the relation between the degree of respiratory impairment and total body iron content. Methods: Twenty nine TM patients were recruited. All underwent physical examination, standardised pulmonary function tests (spirometry, lung volume, and single breath diffusion capacity for carbon monoxide), and magnetic resonance imaging measurements of the liver. Serum ferritin was measured. The signal intensity ratio of liver to that of paraspinal muscle (T1 weighted sequence) and serum ferritin were used as surrogate index of body iron content. Results: Sixteen boys and 13 girls (median age 14.2 years) were studied. None had clinical evidence of congestive heart failure. Sixteen had normal lung function. Impairment of diffusion capacity (median DL[sub co] 83.5% predicted) was the most common abnormality, being observed in 34% of patients. Pure restrictive and obstructive ventilatory impairment was found in one and two patients respectively. Five patients had a combination of ventilation and diffusion defects. There was no correlation between the degree of impairment of each respiratory abnormality and body iron content. Conclusion: Diffusion impairment was the commonest abnormality found in our cohort of paediatric TM patients. Our data did not support the notion that respiratory function impairment was correlated with body iron content. [ABSTRACT FROM AUTHOR]

This article present several studies related to respiratory disease in children. There are common risk factors for having reduced maximal flow at functional residual capacity in infancy and also for wheeze that persists beyond three years. The mitochondrial proteins, uncoupling protein, located on the inner mitochondrial membrane, and voltage-dependent anion channel, located on the outer mitochondrium have been proposed to regulate both energy metabolism and apoptosis. The extent to which abundance of these primary mitochondrial proteins may be reprogrammed by maternal nutrient restriction is unknown.

The article reports that November 18, 2008 was marked by the European Center for Disease Prevention and Control (ECDC) as the first annual European Union (EU) Antibiotic Awareness Days. This movement is an effort to enhance the use of antibiotics. They are commonly used in children and each year there are 6 million children prescribed with antibiotics. However, most of the children were given antibiotic prescriptions to treat their viral upper respiratory tract infections. The government in Great Britain should have collaborated with other countries to improve in the identification of pediatric infections management.

Pneumothorax is a known complication in cystic fibrosis (CF), associated with poor outcome. Records of CF patients with pneumothorax at the Royal Children's Hospital, Melbourne between 1 990 and 2004 were reviewed, and the characteristics, sputum culture results, lung function, treatment, and outcome for the 11 patients who had pneumothoraces were described. [ABSTRACT FROM AUTHOR]

In children under 5 years of age, presenting to the paediatric emergency room with clinical and radiological findings of pneumonia, viridans streptococci were isolated in 10/33 positive haemocultures as the only microorganism. Viridans streptococci should therefore not be ruled out as a cause of pneumonia. [ABSTRACT FROM AUTHOR]

Presents the authors' reply to a critique of their research article on hypoxaemia in acute respiratory and non-respiratory illnesses in infants and children in developing countries published in the 'Archives of Disease in Childhood' journal in 2003. Key issues of interest; Analysis of pertinent topics and relevant issues; Implications on pediatrics.

Background: Parents often report that young children have "smelly urine" or a particular urinary odour. There is little evidence that these observations are relevant to the diagnosis of urinary tract infection (UTI). Aims: To determine whether parental reporting of smelly urine is of any relevance to the diagnosis of UTI in children less than 6 years of age. Methods: Parents whose children were having urine collected as part of their admission to a large district hospital were given a simple questionnaire to complete regarding the current smell of their child's urine. Parents were asked whether their child's urine smelled different from usual or had a particular smell. Microscopy and culture results of the child's urine were compared to their parent's questionnaire answers to see if there was a association between parental reporting of a different or particular urine smell and a diagnosis of UTI. Results: One hundred and ten questionnaires and urine samples were obtained. Fifty two per cent of parents thought that their child's urine smelled different from usual or had a particular smell. Only 6.4% of children were diagnosed as having a UTI. There was no statistically significant association between parental reporting of abnormal urine smell and diagnosis of UTI. Conclusion: In determining whether a young child has a UTI, asking parents about urine smell is unlikely to be of benefit. [ABSTRACT FROM AUTHOR]

Discusses the case of a pediatric patient with persistent hypothermia following recovery from respiratory syncytial viral (RSV) infection. Medical history of the patient; Neurological complications of RSV; Patient body temperature.

Investigates the association of the influenza virus and respiratory syncytial virus (RSV) with wheezing among children. Collection of baseline characteristics and wheezing severity from the control group; Determination of the odds ratio and the confidence interval for the two viruses; Absence of any association between the influenza virus and acute wheezing.

Reports on the effects of the HIV pandemic in South African children with largyngeal airway obstruction (LAO). Differences in disease presentation, age and etiology between HIV positive and non-HIV positive children with LAO; Similarity in short term outcomes, duration of hospital stay and need for mechanical ventilation for both groups; Reversibility of LAO among HIV positive children.

Examines the impact of HIV 1 on children with largyngeal airway obstruction (LAO). Analysis of mortality, need for supportive management and intensive care and hospitalization stay for children with LAO; Presence of HIV infection in admitted children; Justification for the admission of HIV positive children with LAO to the pediatric intensive care.

Acute respiratory infection (ARI) is the commonest cause of illness in children. With the development of rapid viral diagnostic technologies and the availability of effective antiviral therapy, community physicians will be able to make more accurate treatment decisions and reduce unnecessary antibiotic usage. The procedure commonly used for specimen collection in the diagnosis of viral ARI is a painful and unpleasant nasopharyngeal swab or aspirate, and a relatively painless alternative would certainly be desirable.

There is estimated to be over a million new cases of paediatric tuberculosis (TB) globally every year. Children usually acquire TB infection from smear positive adult family contacts, a high proportion going on to develop disease. Childhood disease reflects recent infection and therefore paediatric TB represents continuing transmission in the population. In England and Wales, TB notifications declined from 7406 cases in 1982 to 5085 in 1987, rising to 6087 cases in 1998. In London notifications increased from 1445 in 1987 to 2414 in 1998, representing 16% and 40% of the national total respectively in those years.