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Inhaled nitric oxide (iNO) has potential anti-inflammatory, anti-microbial, and anti-viral properties for patients with lower respiratory tract infections.We compared the safety and efficacy of iNO administered in two concentrations in addition to standard supportive treatment (SST) compared to SST alone with the aim to improve clinical outcomes of infants with bronchiolitis.In this prospective, multicenter, double-blind, randomized-controlled study, 89 infants hospitalized with moderate-severe bronchiolitis were randomly assigned to three treatment groups: 150 parts per million (ppm) NO+SST(1); 85 ppm NO+SST(2); and the control treatment O2/air+SST(3). Treatment was given for 40 minutes, 4 times/day for up to 5 days. The primary endpoint was time to reach "fit for discharge". This was a composite endpoint comprised of both reaching a sustained oxygen saturation (SpO2) ≥92% in room air, and reaching a clinical score ≤5. Secondary endpoints included time to reach sustained SpO2 ≥92% in room air, time to clinical score ≤5, and time to hospital discharge. Safety was assessed by the number of treatment-related adverse-events (AEs) or serious adverse-events (SAEs). Time-to-event efficacy outcomes were analyzed by Cox proportional-hazards regression-model. Hazard ratio (HR) describes how many times more likely an individual is to experience an event, if such an individual receives the NO rather than the control treatment during the observational period.Group 1 demonstrated significant efficacy for time to reach "fit to discharge" compared to Groups 2 (HR=2.11, p=0.041) and 3 (HR=2.32, p=0.049). Group 1 also demonstrated significant efficacy for time to hospital discharge compared to Groups 2 (HR=2.01, p=0.046) and 3 (HR=2.28, p=0.043). No significant differences were observed between Groups 2 and 3 for either endpoint. There were no differences between treatment groups in time to reach clinical score ≤5. The iNO therapy was well-tolerated with no treatment-related SAEs.Treatment with high dose intermittent iNO at 150 ppm showed reduced time to clinical improvement when compared to 85 ppm or control treatment of hospitalized infants with acute bronchiolitis. The 150 ppm iNO dose is well-tolerated, with significant benefit compared to both standard therapy and 85 ppm iNO, improving respiratory outcome and reducing length of stay.

High-flow nasal cannula (HFNC) therapy may be better tolerated than traditional noninvasive ventilation (NIV) and is rapidly gaining acceptance in pediatric acute care. In Israel, HFNC is approved for domestic use. We aim to describe its indications, efficacy, parental satisfaction, and safety.Retrospective study of children treated with home HFNC therapy in three pediatric centers. Data included demographic parameters, indication of use, weight and days of hospitalization before and after initiation. Safety, tolerability, and parental satisfaction were assessed via standardized telephone questionnaire.Median (interquartile range [IQR]) age of initiating home HFNC in 75 children was 8.3 (2.2, 29.6) months. Indications were obstructive sleep apnea (33; 44%), airway malacia (19; 25%), chronic lung disease (15; 20%), neuromuscular disease (4; 5%), and postextubation support (4; 5%). Weight standard deviation score rose from -2.3 pre-HFNC to -1.7 at 6.7 months post-HFNC initiation, p 0.001. Hospital admission days during the 2 months pre- versus post-HFNC initiation were 22 (5.5, 60) and 5 (0, 14.7) respectively, p 0.008. Median (IQR) parental satisfaction score was 5/5 (4, 5). Fifty of 60 (83%) respondents would recommend home HFNC to other families in a similar situation. There were no serious adverse events.In our population, domestic HFNC appeared safe and well tolerated for a variety of indications. Its introduction was associated with improved weight gain, fewer hospitalization days and high parental satisfaction. Further work is required to characterize groups of children most likely to benefit from HFNC, as opposed to traditional modes of NIV.

Introduction Vitiligo is a skin disorder characterized by defected melanocytes causing depigmented skin lesions. The role of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios as prognostic hematological markers has not yet been studied in a large population. We aimed to investigate these values in patients with mild and severe vitiligo compared to healthy controls. Methods This was a single-center retrospective cohort study that included patients of all ages diagnosed with vitiligo between 2005 and 2020. We compared patients with vitiligo to controls matched for age and gender. Results 8,398 adults and 1,428 children were included in this study. Patients had a lower NLR compared to their controls (2.04 vs 2.23, pConclusion Decreased NLR is associated with both severe and mild forms of vitiligo.

Background Spontaneous pneumomediastinum (SPM) occurs in cases of mediastinal leaks that are not caused by trauma, mechanical ventilation, or other surgical procedures. In most cases, in the pediatric population a trigger can be identified, most commonly asthma. SPM caused by foreign body aspiration is not a common entity. It is usually a benign condition that generally resolves without severe sequela, but in some cases, severe morbidity and mortality have been documented. Treatment is usually conservative and includes rest, analgesics, and treatment of any underlying pathologies. Case Report We report a case of a 19-month-old boy who presented to the emergency department with acute facial swelling and wheezing with no history of foreign body aspiration. This misleading presentation led the medical staff in the emergency department to initially treat the patient for anaphylaxis. The diagnosis was made only after imaging modalities demonstrated SPM with a suspected foreign body in the right main stem bronchus. Why Should an Emergency Physician Be Aware of This? Providers should consider SPM from an aspirated foreign body in young children with respiratory distress and acute facial swelling, especially when crepitus is present. © 2021 Elsevier Inc.

Septic pulmonary embolism (SPE) in children is a rare disease. Data are scarce regarding the clinical and laboratory manifestation of SPE compared with nonseptic pulmonary embolism (ns-PE). Furthermore, specific guidelines for the management of SPE in children are lacking.We compared the clinical course and outcome of children with SPE and ns-PE.A retrospective, cohort study of hospitalized children, 2005-2020, with documented pulmonary embolism imaging.Sixteen children (eight SPE, eight ns-PE) were identified. Episodes of SPE occurred secondary to endocarditis, musculoskeletal and soft tissue infections, with Staphylococcus aureus (n = 4) and streptococcus spp. (n = 2) as the most common pathogens. Radiographically, SPE presented as a microvascular disease with parenchymatic nodules/cavitations, whereas ns-PE presented as larger vessel disease with filling defects. Risk factors (including thrombophilia) were noted in 0% and 87.5% of SPE and ns-PE patients, respectively (p .01). Pulmonary embolism diagnosis was delayed in SPE compared with ns-PE (median: 8.5 days vs. 1 day). The SPE group had higher rates of fever (100% vs. 12.5%, p .01), C-reactive protein (CRP levels; 18.49 vs. 4.37 mg/dl, p = .02), and fibrinogen levels (880 vs. 467 mg/dl, p .001). Antithrombotic treatment for4 months was administrated to 14.3% and 87.5% of SPE and ns-PE patients, respectively (p .01). One ns-PE patient had a second thromboembolic event compared to none in the SPE group.SPE in children is a unique subgroup of PE with different clinical and laboratory findings that requires a different diagnostic approach and probably shorter duration of antithrombotic treatment.

Background: A 2017 meta-analysis of data from 25 randomised controlled trials (RCTs) of vitamin D supplementation for the prevention of acute respiratory infections (ARIs) revealed a protective effect of this intervention. We aimed to examine the link between vitamin D supplementation and prevention of ARIs in an updated meta-analysis. Methods: For this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and the ClinicalTrials.gov registry for studies listed from database inception to May 1, 2020. Double-blind RCTs of vitamin D3, vitamin D2, or 25-hydroxyvitamin D (25[OH]D) supplementation for any duration, with a placebo or low-dose vitamin D control, were eligible if they had been approved by a research ethics committee, and if ARI incidence was collected prospectively and prespecified as an efficacy outcome. Studies reporting results of long-term follow-up of primary RCTs were excluded. Aggregated study-level data, stratified by baseline 25(OH)D concentration and age, were obtained from study authors. Using the proportion of participants in each trial who had one or more ARIs, we did a random-effects meta-analysis to obtain pooled odds ratios (ORs) and 95% CIs to estimate the effect of vitamin D supplementation on the risk of having one or more ARIs (primary outcome) compared with placebo. Subgroup analyses were done to estimate whether the effects of vitamin D supplementation on the risk of ARI varied according to baseline 25(OH)D concentration (vs 25·0–49·9 nmol/L vs 50·0–74·9 nmol/L vs >75·0 nmol/L), vitamin D dose (daily equivalent of vs 400–1000 IU vs 1001–2000 IU vs >2000 IU), dosing frequency (daily vs weekly vs once per month to once every 3 months), trial duration (≤12 months vs >12 months), age at enrolment (vs 1·00–15·99 years vs 16·00–64·99 years vs ≥65·00 years), and presence versus absence of airway disease (ie, asthma only, COPD only, or unrestricted). Risk of bias was assessed with the Cochrane Collaboration Risk of Bias Tool. The study was registered with PROSPERO, CRD42020190633. Findings: We identified 1528 articles, of which 46 RCTs (75 541 participants) were eligible. Data for the primary outcome were obtained for 48 488 (98·1%) of 49 419 participants (aged 0–95 years) in 43 studies. A significantly lower proportion of participants in the vitamin D supplementation group had one or more ARIs (14 332 [61·3%] of 23 364 participants) than in the placebo group (14 217 [62·3%] of 22 802 participants), with an OR of 0·92 (95% CI 0·86–0·99; 37 studies; I2=35·6%, pheterogeneity=0·018). No significant effect of vitamin D supplementation on the risk of having one or more ARIs was observed for any of the subgroups defined by baseline 25(OH)D concentration. However, protective effects of supplementation were observed in trials in which vitamin D was given in a daily dosing regimen (OR 0·78 [95% CI 0·65–0·94]; 19 studies; I2=53·5%, pheterogeneity=0·003), at daily dose equivalents of 400–1000 IU (0·70 [0·55–0·89]; ten studies; I2=31·2%, pheterogeneity=0·16), for a duration of 12 months or less (0·82 [0·72–0·93]; 29 studies; I2=38·1%, pheterogeneity=0·021), and to participants aged 1·00–15·99 years at enrolment (0·71 [0·57–0·90]; 15 studies; I2=46·0%, pheterogeneity=0·027). No significant interaction between allocation to the vitamin D supplementation group versus the placebo group and dose, dose frequency, study duration, or age was observed. In addition, no significant difference in the proportion of participants who had at least one serious adverse event in the vitamin supplementation group compared with the placebo group was observed (0·97 [0·86–1·07]; 36 studies; I2=0·0%, pheterogeneity=0·99). Risk of bias within individual studies was assessed as being low for all but three trials. Interpretation: Despite evidence of significant heterogeneity across trials, vitamin D supplementation was safe and overall reduced the risk of ARI compared with placebo, although the risk reduction was small. Protection was associated with administration of daily doses of 400–1000 IU for up to 12 months, and age at enrolment of 1·00–15·99 years. The relevance of these findings to COVID-19 is not known and requires further investigation. Funding: None.

Background With increasing longevity and quality of life in adults with Cystic fibrosis (CF), growing maternity rates are reported. Women with severe CF are becoming pregnant, with unpredictable maternal and fetal outcomes. Aim To determine how baseline disease severity, pancreatic insufficiency (PI) and Pseudomonas aeruginosa (PA) infection affect fertility, the pregnancy course, delivery, neonatal outcome, and subsequent disease progression. Methods A multicenter-retrospective cohort study. Data on patients that had been pregnant between 1986-2018 was collected from ten CF centers worldwide. Disease severity [mild or moderate-severe (mod-sev)] was defined according to forced expiratory volume % predicted in 1 second (FEV1) and body mass index (BMI). Three time periods were compared, 12 months prior to conception, the pregnancy itself and the 12 months thereafter. Results Data was available on 171 pregnancies in 128 patients aged 18-45 years; 55.1% with mod-sev disease, 43.1% with PI and 40.3% with PA. Women with mod-sev disease had more CF-related complications during and after pregnancy and delivered more preterm newborns. However, FEV1 and BMI decline were no different between the mild and mod-sev groups. A more rapid decline in FEV1 was observed during pregnancy in PI and PA infected patients, though stabilizing thereafter. PI was associated with increased risk for small for gestational age infants. Conclusion Baseline disease severity, PA infection and PI have an adverse impact on infant outcomes, but do not impact significantly on disease progression during and after pregnancy. Consequently, pregnancies in severe CF patients can have a good prognosis.

Case Presentation A previously healthy, 9-year-old boy presented with five recurrent episodes of left-sided chest pain with low-grade fever over the last 18 months. The pain usually lasted for few hours, was severe and consistent, and resolved spontaneously. It worsened during inspiration, physical activity, and swallowing. He did not experience any cough, dyspnea, chills, cold sweats, or weight loss. His medical and family history was unremarkable.

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

Asthma is the most common chronic respiratory disease in children. The neutrophil-to-lymphocyte ratio (NLR) is a marker of a chronic inflammatory state; however, data on the association of NLR with acute asthma exacerbations in children is lacking. In this cross-sectional study, between 2016 and 2021, children aged 2–18 years who were referred to the emergency department (ED) due to asthma exacerbation, were included. NLR, calculated from complete blood count upon arrival, was assessed as a continuous variable and was classified into four groups according to quartiles. The association between severity parameters and NLR quartiles was examined. A total of 831 ED visits for asthma exacerbation were included in the study. The median NLR was 1.6, 3.8, 6.7, and 12.9 in quartiles 1–4, respectively (p < 0.001). Demographic parameters, background diseases, and chronic medications were similar between the quartiles. Higher heart rate, body temperature, systolic blood pressure, and respiratory rate were observed in the higher NLR quartiles, as well as lower oxygen saturation. Higher urgency scale and higher rates of intravenous magnesium sulfate were observed in the higher NLR quartiles, with higher admission rates and prolonged hospitalizations. In summary, NLR upon admission is associated with the severity of asthma exacerbation and higher chances of hospitalization among children in the ED.

Background: Since the outbreak of the Coronavirus disease 2019 (COVID-19) pandemic, there has been a decline in pediatric emergency department visits. Our aim was to assess the pattern of pediatric foreign body aspiration (FBA) during the first year of the COVID-19, in comparison to the prior years. Methods: In this retrospective multicenter study, we compared the number of children that presented with FBA during the COVID-19 year (March 1st, 2020 to February 28, 2021), to the annual average of the years 2016-2019. We also compared the lockdown periods to the post-lockdown periods and the percentage of missed FBA, proven FBA, and flexible bronchoscopy as the removal procedure. Results: 345 children with FBA from six centers were included, 276 in the pre-COVID-19 years (average 69 per year) and 69 in the COVID-19 year. There was no difference in the prevalence of FBA between the COVID-19 year and any of the prior four years. Examining the lockdown effect, the monthly incidence of FBA dropped from a pre-COVID-19 average of 5.75 cases to 5.1 cases during lockdown periods and increased to 6.3 cases in post-lockdown periods. No difference in the percentage of missed FB or proven FB was observed. There was a significant rise in the usage of flexible bronchoscopy as the removal procedure (Average of 15.4% vs 30.4%, p=0.001) Conclusion: There was no difference in the prevalence of FBA during the COVID-19 year. However, there were fewer cases during lockdown periods, compared to post-lockdown periods, presumably related to better parental supervision.

Mycobacterium abscessus is an emerging multidrug-resistant non-tuberculous mycobacterium (NTM) with high prevalence in patients with cystic fibrosis. However, studies on antimicrobial susceptibilities and effective treatments against M. abscessus are still limited. Nitric oxide (NO) is important in innate immune response to various infections, including mycobacterial infections. In this case study, we describe a compassionate treatment of inhaled NO (iNO) at 150–250 ppm for 4 weeks. The dosing strategy proposed for this treatment was selected to minimise the potential of adverse events, while maximising the antibacterial effectiveness of NO, and was found to be safe, well tolerated and resulted in positive clinical findings including improvement in patient well-being, CT scan values, quality of life and bacterial load. Taken together, these observations may indicate that iNO could play a crucial role and potentially serve as a reliable option in the treatment of patients with chronic refractory NTM lung infection.

Objective: Poor adherence to asthma therapy is a major problem in the management of asthma. We aimed to assess if a designed coaching program in children with asthma, coming from low socioeconomic ...

Background Acute asthma exacerbations are a common cause for emergency department (ED) visits and hospitalizations in children. Since the outbreak of coronavirus disease 2019 (COVID‐19) and the education system closure/total lockdown in Israel on March 2020, we have noticed a decrease in pediatric ED visits and an increase in hospitalizations of asthma exacerbations. Objective to examine the patterns of ED visits for asthma exacerbations during COVID‐19 outbreak, in comparison to the previous year. Methods A retrospective study comparing asthma related ED visits and hospitalizations among children aged 2–18 years at a tertiary center in southern Israel. Three time periods were selected: 2020 A (prelockdown, 2/1/20 to 3/14/20), 2020 B (lockdown, 3/15/20 to 5/15/20) and 2020 C (postlockdown, 5/16/20 to 6/30/20) and compared to the three parallel time periods in 2019. Data regarding demographics, number of ED visits and clinical severity parameters were collected and analyzed. Results Five hundred and twelve children visited the ED for asthma exacerbation: 273 children during 2019 and 239 children during 2020. Lockdown period in 2020 revealed significantly fewer ED visits per day compared to the parallel calendar period in 2019 (1.8 vs. 1.43, p

Background 25(OH) vitamin D levels are inversely associated with respiratory infections and childhood wheezing. Objective To evaluate serum 25(OH) vitamin D levels in infants and toddlers with acute bronchiolitis, compared to subjects with non-respiratory febrile illness. Methods A prospective cross-sectional case-control study which compared serum 25(OH) vitamin D levels between infants and toddlers diagnosed with acute bronchiolitis to subjects with non-respiratory febrile illness. Multivariate logistic regression, adjusted for age, sex, ethnicity and nutrition was performed. Correlation between serum vitamin D levels and bronchiolitis severity was assessed via Modified Tal Score and length of hospital stay (LOS). Results One hundred twenty-seven patients aged p = 0.002)). Serum 25(OH) vitamin D levels were significantly lower in the bronchiolitis group; median [IQR] 28[18–52] vs. 50[25–79] nmol/L, respectively, (p = 0.005). Deficient vitamin D levels (p = 0.028). Multivariate logistic regression showed vitamin D deficiency was more probable in bronchiolitis patients; OR [95% CI] 3.139[1.369–7.195]. No correlation was found between serum vitamin D levels and bronchiolitis severity, which was assessed via Modified Tal Score and by length of hospital stay. Conclusion Children with acute bronchiolitis displayed significantly lower vitamin D levels than children with non-respiratory acute febrile illnesses.

Rigid bronchoscopy is the procedure of choice for removal of inhaled foreign bodies. In this retrospective study, we assessed the safety and efficacy of flexible bronchoscopy use in the removal of inhaled foreign bodies in children. One hundred eighty-two patients (median age of 24 months, 58% males) underwent an interventional bronchoscopy for the removal of inhaled foreign body between 2009 and 2019, 40 (22%) by flexible, and 142 (78%) by rigid bronchoscopy. 88.73% of rigid and 95% of flexible bronchoscopies were successful in foreign bodies removal (p value = 0.24). Complication rate was higher among rigid bronchoscopy (9.2% vs. 0%, p = 0.047). From 2017 onwards, following the implementation of flexible bronchoscopy for foreign bodies removal, 64 procedures were performed, 33 (51.6%) flexible, and 31 (48.4%) rigid. Procedure length was shorter via flexible bronchoscopy (42 vs 58 min, p = 0.016). Length of hospital stay was similar.Conclusion: In our hands, flexible bronchoscopy is an efficient and safe method for removal of inhaled foreign bodies in children, with shorter procedure time and minimal complication rate. Flexible bronchoscopy could be considered as the procedure of choice for removal of inhaled foreign bodies in children, by an experienced multidisciplinary team. What is Known: • Rigid bronchoscopy is currently the gold standard for removal of inhaled foreign bodies in children. • Rigid bronchoscopy has a relatively high complication rate compared to flexible bronchoscopy. What is New: • Flexible bronchoscopy is a short, safe, and efficient procedure to remove inhaled foreign bodies in children, compared to rigid bronchoscopy. • Flexible bronchoscopy could be proposed as the procedure of choice for removal of inhaled foreign bodies in children, if an experienced operator is available.

Currently, there are no approved treatments for infants with acute bronchiolitis, the leading cause for hospitalization of infants worldwide, and thus the recommended approach is supportive. Inhaled Nitric oxide (iNO), possesses anti-viral properties, improves oxygenation, and was shown to be safe in infants with respiratory conditions. Hospitalized infants with acute bronchiolitis were therefore recruited to a prospective double-blinded, multi-center, randomized controlled pilot study. They received intermittent high dose iNO (160 ppm) plus oxygen/air for 30 min or oxygen/air alone (control), five times/day, up to 5 days. Sixty-nine infants were enrolled. No difference was observed in frequencies of subjects with at least one Adverse Event (AE) in iNO (44.1%) vs. control (55.9%); neither was Methemoglobin7% safety threshold. No drug-related serious AEs (SAEs) were reported. Analysis of Per-Protocol population revealed that length of stay (LOS), time to SpO

BackgroundA 2017 meta-analysis of data from 25 randomised controlled trials of vitamin D supplementation for the prevention of acute respiratory infections revealed a protective effect of the intervention. Since then, 20 new RCTs have been completed.MethodsSystematic review and meta-analysis of data from randomised controlled trials (RCTs) of vitamin D for ARI prevention using a random effects model. Pre-specified sub-group analyses were done to determine whether effects of vitamin D on risk of ARI varied according to baseline 25-hydroxyvitamin D (25[OH]D) concentration or dosing regimen. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and the ClinicalTrials.gov registry from inception to 1st May 2020. Double-blind RCTs of supplementation with vitamin D or calcidiol, of any duration, were eligible if they were approved by a Research Ethics Committee and if ARI incidence was collected prospectively and pre-specified as an efficacy outcome. Aggregate data, stratified by baseline 25(OH)D concentration, were obtained from study authors. The study was registered with PROSPERO (no. CRD42020190633).FindingsWe identified 45 eligible RCTs (total 73,384 participants). Data were obtained for 46,331 (98.0%) of 47,262 participants in 42 studies, aged 0 to 95 years. For the primary comparison of vitamin D supplementation vs. placebo, the intervention reduced risk of ARI overall (Odds Ratio [OR] 0.91, 95% CI 0.84 to 0.99; P for heterogeneity 0.01). No statistically significant effect of vitamin D was seen for any of the sub-groups defined by baseline 25(OH)D concentration. However, protective effects were seen for trials in which vitamin D was given using a daily dosing regimen (OR 0.75, 95% CI 0.61 to 0.93); at daily dose equivalents of 400-1000 IU (OR 0.70, 95% CI 0.55 to 0.89); and for a duration of ≤12 months (OR 0.82, 95% CI 0.72 to 0.93). No significant interaction was seen between allocation to vitamin D vs. placebo and dose frequency, dose size, or study duration. Vitamin D did not influence the proportion of participants experiencing at least one serious adverse event (OR 0.97, 95% CI 0.86 to 1.09). Risk of bias within individual studies was assessed as being low for all but three trials. A funnel plot showed left-sided asymmetry (P=0.008, Egger’s test).InterpretationVitamin D supplementation was safe and reduced risk of ARI, despite evidence of significant heterogeneity across trials. Protection was associated with administration of daily doses of 400-1000 IU vitamin D for up to 12 months. The relevance of these findings to COVID-19 is not known and requires investigation.FundingNone

STUDY OBJECTIVES: Rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare condition. Little is known about sleep/wake and slow-wave activity in this condition, although the central hypothalamic dysfunction associated with autonomic dysregulation would make the occurrence of SWA deregulation most likely. METHODS: Two children with clinical presentation of ROHHAD syndrome were evaluated, diagnosed, and treated. Their polysomnographic studies were compared with 4 matched children with obstructive sleep apnea and 6 controls. RESULTS: Children that were clinically diagnosed with ROHHAD exhibited significantly weaker slow-wave activity power and shallower slow-wave activity slopes during the first 2 sleep cycles compared with children with obstructive sleep apnea or controls. CONCLUSIONS: This study shows that children with ROHHAD have suppressed slow-wave activity, possibly because of hypothalamic dysregulation that may contribute to their rapid-onset obesity and excessive daytime sleepiness. CITATION: Goldbart AD, Arazi A, Golan-Tripto I, Levinsky Y, Scheuerman O, Tarasiuk A. Altered slow-wave sleep activity in children with rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation syndrome. J Clin Sleep Med. 2020;16(10):1731–1735.

Inhalations of hypertonic saline is a known therapy for infants diagnosed with acute bronchiolitis. Recent meta-analysis has shown that it can reduce the length of hospitalization and decrease the chances of admission.To assess the extent of use of hypertonic saline inhalations in the pediatric wards in Israel in 2018.During October 2018 a detailed questionnaire was emailed to all the managers of pediatric wards in Israel. The questions related to treatments given to infants with acute bronchiolitis in pediatric wards and emergency departments in 2018. All results underwent statistical analysis.A total of 22/28 (78%) of all pediatric wards managers completed the questionnaire; 17/22 (77%) routinely use hypertonic saline in their wards. In 15 out of the 17 wards the hypertonic saline is also provided at their emergency department. In 12 wards (70%) the saline is provided together with a bronchodilator, in 4 (24%) with inhaled steroids, and in 2 (12%) with adrenaline.In most pediatric wards and their emergency departments in Israel, hypertonic saline with bronchodilators is routinely used to treat infants with acute bronchiolitis.

OBJECTIVE To further validate the use of the Modified Tal Score (MTS), a clinical tool for assessing bronchiolitis severity, by physicians with varying experience and training levels, and to determine the ability of the MTS to predict bronchiolitis severity. METHODS This prospective cohort study included infants of

Acute viral bronchiolitis is the most common lower respiratory infection in early infancy and a leading cause of infant hospitalization. The treatment of bronchiolitis is largely supportive. Inhaled nitric oxide (NO) has pulmonary vasodilatory properties and has been approved for the treatment of persistent pulmonary hypertension of the newborn. Furthermore, preclinical studies show that high-dose NO possesses anti-bacterial and anti-viral properties. In a recent pilot study, we have shown safety and tolerability of high-dose NO (160 ppm) in infants with moderately severe bronchiolitis. In this study, we are conducting a randomized, multicenter, double-blind, controlled pivotal trial comparing the efficacy of intermittent 160 ppm NO (30min, 5 times/day, up to 5 days) with standard supportive care (O2/air) in 94 infants (0-12 months old, clinical score 7-10, requiring >24hr hospitalization) admitted to 10 hospitals across Israel. All subjects receive standard of care treatment. The primary outcome measure is the length of hospital stay (LOS). The secondary outcome measures are time to reach clinical score of 5 and below (Modified Tal score) and time to reach O2 saturation of 92% and above in room air. Adverse events (AE’s) and NO-related AE’s including methemoglobin and nitrogen dioxide levels are closely monitored. At the time of submission, the trial is ongoing with 46 out of 94 subjects enrolled at 5 sites. We anticipate demonstrating efficacy by reducing LOS and improving clinical symptoms in infants treated with NO. We predict completing the trial by April 30, 2018 and present final results at the next 2018 ERS International meeting, Paris.

AIM The aims of this pilot study were to determine safety, tolerability (primary outcome) and efficacy (secondary outcome) of high-dose inhaled nitric oxide for the treatment of infants with moderately severe bronchiolitis. METHODS This was a pilot, double-blinded, randomized controlled study (phase IIa). Intermittent inhalations of nitric oxide 160 ppm for 30 min or oxygen/air (control) were given 5 times/day to hospitalized infants (2-11 months) with acute bronchiolitis. Oxygen saturation, methemoglobin, and nitric dioxide (NO2 ) levels and vital signs were monitored. RESULTS Forty-three infants were enrolled. Baseline characteristics were comparable in both study groups. Mean clinical score, comprised of four components: respiratory rate, use of accessory muscles, wheezes and crackles, and % room-air oxygen saturation, was 7.86 (±1.1) and 8.09 (±1.2) in the NO and control groups, respectively, consistent with moderate severity. The overall frequency of adverse events was similar between the groups. Repeated nitric oxide inhalations did not result in increased inhaled NO2 levels or cumulative effect on methemoglobin levels. Secondary outcomes of efficacy were measured by length of hospitalization (LOS) in hours: LOS did not differ between groups. However, in a post-hoc analysis of a subgroup of infants hospitalized for >24 h (n = 24), the median LOS was shorter in the nitric oxide (41.9 h) than in the control group (62.5 h) (P = 0.014). CONCLUSION Our study was unable to detect a difference in side effects using intermittent high-dose nitric-oxide inhalation or supportive treatment alone, in infants with moderate bronchiolitis. Preliminary efficacy outcomes are encouraging.