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AIM: This study aimed to evaluate antibiotic prescriptions for children with otitis media (OM) in a large nationwide network of private clinics between 2014 and 2020. Special focus was paid to amoxicillin and amoxicillin-clavulanic acid prescriptions, which the national guidelines recommend for first-line drugs. We also focused on macrolides, which are commonly prescribed for respiratory tract infections in children but are not appropriate for OM cases. METHODS: The data were obtained from the electronic health records of about 250,000 annual visits in

Aim: We evaluated main trends in antibiotic prescriptions for children with lower respiratory tract infection (LRTI) by Terveystalo, Finland's largest private healthcare company. Methods: The study comprised of 89,359 children aged 0–17 years (57.2% boys) who visited Terveystalo primary care clinics from 2014 to 2020 with LRTI. The data were assessed by age, study year, location, the doctor's speciality and whether the diagnosis was bronchitis or community-acquired pneumonia (CAP). Results: There were gradual decreases in overall antibiotic prescription rates during the study period (37.0% in 2014 vs. 20.1% in 2020) and in prescribed macrolides (16.8% vs. 7.5%). Altogether, 31.3% of 72,737 children with bronchitis and 22.5% of those 16,622 with CAP-received antibiotics. Macrolides were the most frequently prescribed antibiotics for bronchitis, at more than 40%, without any substantial relative decrease during the study. Costs of antibiotics increased from 2014 to 2016 and then decreased in line with the reduction in prescriptions. However, there was still a marked overuse of antibiotics, especially macrolides, for children with bronchitis. The relative use of amoxicillin for CAP increased from 41.4% to 65.4% between 2016 and 2020, in line with current guidelines. Conclusion: Despite an overall reduction in prescribed antibiotics, some antibiotics were still overused, particularly macrolides for bronchitis. acceptedVersion

Aim: The aim of this cohort study was to evaluate doctor-diagnosed and self-reported asthma in young adults after early-childhood hospitalisation for wheezing. Methods: In this prospective-controlled follow-up, questionnaires were sent to 95 subjects aged 24–28 years, who had been hospitalised for their first episodes of wheezing under 24 months of age. Fifty-eight cases and 100 controls returned the questionnaires. Results: The risk of doctor-diagnosed asthma was 2.14-fold (95% confidence interval 0.61–7.41), and the risk of self-reported asthma 2.39-fold (1.14–4.99) in cases compared to controls. The increased risk of self-reported asthma remained as statistically significant in analyses adjusted for current smoking, overweight and allergic rhinitis. Study subjects presented with wheezing symptoms, use of bronchodilators and inhaled corticosteroids, and with seasonal symptoms presumptive for allergic rhinitis during the last 12 months, more often than controls. The identification of a respiratory syncytial virus or rhinovirus during hospitalisation in early childhood was not anymore associated with asthma risk in adulthood. As expected, previous asthma during early childhood was a strong risk factor for asthma in young adulthood. Conclusion: In this controlled questionnaire study, early-childhood hospitalisation for lower respiratory infection with wheezing was an independently significant risk factor of asthma in young adults. publishedVersion

Aim Our aim was to evaluate the impact of the 2014 Finnish Current Care Guidelines for paediatric lower respiratory tract infections (LRTIs), particularly on taking of chest radiographs. Methods This study used official national data and regional (Pirkanmaa) data on children aged 0-16 years who underwent chest radiographs in 2011 and 2015. We also collected data for LRTI diagnoses from local registers, including prescribed antibiotics and taking of chest radiographs. The local cohort comprised children aged 0-15 who presented to the primary care emergency room or to the hospital emergency department (Tampere university hospital) in November-December 2012-2015. Results Chest radiographs for Finnish children aged 0-16 fell from 2011 to 2015: by 15.9% nationally and by 16.9% in Pirkanmaa. When asylum seekers with chest radiographs for tuberculosis screening were excluded, the estimated national reduction was 29.9%. In the local cohort, chest radiographs increased from 82 to 139 (69.5%) between 2012/2013 and 2014/2015 as the occurrence of community-acquired pneumonia (CAP) increased. However, the proportion of patients with CAP who had chest radiograph taken tended to decrease from 84.6% to 71.3% (p = 0.078). Conclusion Decreases in national and regional chest imaging trends were observed after the 2014 guidance for children`s LRTI was introduced.

Background:Wheezing in early childhood has implications for respiratory morbidity in later life.Objectives:We evaluated respiratory health-related quality of life (HRQoL) in young adults ages 17‐20 years with a history of early childhood wheezing.Methods:Between 1992 and 1993, 100 children ages < 24 months were treated in the hospital for a lower respiratory tract infection with wheezing, and we followed up this cohort. In 2010, 49 of the patients (cases) and 60 population-based controls attended a clinical follow-up. St. George’s Respiratory Questionnaire (SGRQ) was used to evaluate respiratory HRQoL, expressed as symptom, activity, impact, and total scores.Results:The median (interquartile range) SGRQ symptom scores were higher (13.7 [3.8‐29.1]) in the 49 subjects (cases) with early childhood wheezing compared with the 60 population controls (7.8 [0.0‐18.3]; p = 0.019). However, there were no between-group differences in total scores or in other SGRQ domains. Current asthma was a major risk factor for reduced HRQoL. In univariate analyses, the median symptom scores were 20.2 in those with asthma and 7.8 in those without asthma (p Conclusion:Hospitalization for wheezing in early childhood mainly had indirect effects on HRQoL by increasing the risk of asthma.

Objective To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT). Methods A retrospective cohort (1990–2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland). Results The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4–6 weeks’ postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia. Conclusions Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990–2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.

Background: Bronchiolitis, a lower respiratory tract infection, causes a remarkable number of hospitalizations globally. The epidemiology follows the same pattern as respiratory syncytial virus (RSV), the most common pathogen in bronchiolitis. Epidemics have typically followed a biannual pattern in Nordic countries - first, a small epidemic during spring, followed by a higher peak the next autumn. The aim of this study was to evaluate whether the incidence of bronchiolitis hospitalization has changed during the last 2 decades in Tampere, Finland. Methods: In this retrospective register-based study, data on infants

Upper respiratory tract infection (URTI) is a self-limiting viral infection and should not be treated with antibiotics. The aim was to evaluate antibiotic prescriptions for children with uncomplicated URTI in a large nationwide private clinic network between 2014 and 2020. Special focus was given to macrolide prescriptions and costs. The data were obtained from the electronic health records (EHR) of the largest private healthcare company in Finland (with about 250,000 paediatric visits annually across the country). The collected variables included diagnoses, age, visit year, speciality of the doctor, and prescribed antibiotics. The number of uncomplicated URTIs in Conclusion: Antibiotic prescriptions for uncomplicated URTIs, especially macrolides, decreased substantially during the 7-year surveillance period; however, 8.8% of children still received unnecessary antibiotics. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system. What is Known:• Upper respiratory tract infection (URTI) is the most common infection in children. Uncomplicated URTI is a self-limiting viral infection, and antibiotic treatment is not warranted. What is New:• Almost 9% of children with uncomplicated URTIs still received unnecessary antibiotics. Paediatricians prescribed antibiotics less often than general practitioners or ear, nose, and throat specialists. To further reduce unwarranted antibiotic prescriptions, active interventions are needed that can be performed by applying the available EHR system.

Aim: We evaluated antibiotic prescriptions issued for Finnish children with acute sinusitis by a nationwide private outpatient clinic network from 2014–2020. Data were compared before and after updated guidelines in 2018. Methods: The study comprised data on 45 296 children aged 2–17 years with acute sinusitis, namely diagnoses, ages, dates, the doctor's specialty and any antibiotics. We measured compliance with the updated 2018 Finnish guidelines, which recommended amoxicillin or amoxicillin-clavulanic acid for children under 12 years old, with doxycycline as an alternative for 12 years plus. Results: There were 6621–7585 visits per year for acute sinusitis in 2014–2019 and 2954 in 2020. Antibiotics were prescribed for 37.9%–41.6% of patients during the study years. Amoxicillin, including penicillin, accounted for 35.9% of prescriptions, followed by amoxicillin-clavulanic acid (26.9%). Macrolides accounted for 20.6% and, encouragingly, decreased by 38% from 2014–2019. Doxycycline accounted for 5.3%. Paediatricians, general practitioners (GPs) and ear, nose and throat specialists followed the guidelines in 75.1%, 73.8% and 66.7% of cases, respectively. GPs prescribed antibiotics more often than other physicians. Conclusion: Antibiotics were prescribed for about 40% of acute sinusitis visits by Finnish children from 2014–2019. Specialities differed with regard to prescribing rates and whether they followed the guidelines. publishedVersion

Our aim was to construct and test an intervention programme to eradicate cough and cold medicine (CCM) prescriptions for children treated in a nationwide healthcare service company. The study was carried out in the largest private healthcare service company in Finland with a centralised electronic health record system allowing for real-time, doctor-specific practice monitoring. The step-by-step intervention consisted of company-level dissemination of educational materials to doctors and families, educational staff meetings, continuous monitoring of prescriptions, and targeted feedback. Outreach visits were held in noncompliant units. Finally, those physicians who most often prescribed CCM were directly contacted. During the intervention period (2017–2020), there were more than one million paediatric visits. Prescriptions of CCMs to children were completely eradicated in 41% of units and the total number of CCM prescriptions decreased from 6738 to 744 (89%). During the fourth intervention year, CCMs containing opioid derivatives were prescribed for only 0.2% of children aged Conclusion: The study showed that a nationwide systematic intervention to change cough medicine prescription practices is feasible and requires only modest financial investments. What is Known:• Cough and cold medicines (CCM) are not effective or safe, especially for children aged 6 years.• Although the use of CCMs has been declining, caregivers continue to administer CCMs to children, and some physicians still prescribe them even for preschool children. What is New:• A nationwide systematic intervention can significantly and cost effectively change CCM prescription habits of paediatricians, general practitioners, and other specialists.• Electronic health records provide additional tools for operative guideline implementation and real-time quality monitoring, including recommendations of useless or harmful treatments.

Background and aim: The burden of bronchiolitis is remarkable due to high morbidity in infants. The aim of this study was to evaluate bronchiolitis-associated costs for patients' families and the healthcare system. Methods: This retrospective, descriptive study included 136 infants under 12 months of age treated at Tampere University Hospital, Finland, between October 1, 2018 and March 31, 2020, with bronchiolitis as the main diagnosis. The data consists of patient background and medical information and of estimated costs for the families and for the healthcare system. The data were collected from the hospital's electronic patient files and registries and were analyzed with descriptive statistical analyzes using SPSS v. 26 software. Results: The total median costs associated with bronchiolitis from the perspective of families and healthcare were €16,205 per patient if intensive care was needed and €2266 per patient treated only on the ward. The median costs for the families were €461 and €244, respectively, and for the healthcare system, they were €15,644 and €2019. Conclusion: The majority of the total costs for treatment were due to healthcare costs and only 10% of costs were targeted at families. Bronchiolitis-associated total median costs were 7.2 times higher and the families' costs were 1.9 times higher if intensive care was needed instead of treatment on the ward only. publishedVersion

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Background: There is an increased risk of asthma after viral wheezing episodes in early childhood, but unfortunately, prospective longitudinal data are lacking. The aim of this cohort study was to evaluate the risk of asthma in young adulthood after hospitalization for viral wheezing episodes in early childhood. Methods: The original cohort comprised 100 individuals aged

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This study evaluated the cost-effectiveness of hypertonic saline (HS) inhalations for infant bronchiolitis, compared to normal saline inhalations or standard treatment without inhalations as controls. The decision tree in the decision analysis was used to calculate the expected costs. Actual cost data were obtained from our retrospective case-control study on bronchiolitis treatment. The effectiveness of treatment, based on the hospitalization rate of those admitted to the emergency department and the length of stay (LOS) of those who were hospitalized, was collected from previous studies. For the effectiveness estimations, we made a meta-analysis summarizing the results of the meta-analysis of the Cochrane review in 2013 and the results of 10 studies published after it. The mean hospitalization rate was 24.7% in the HS inhalation group and 32.6% in the control group [risk ratio: 0.80, 95% confidence interval (CI) 0.67–0.96] and the mean LOS was 3.736 (HS group) and 4.292 (controls) days (mean difference: − 0.55 days, 95% CI − 0.96 to − 0.15), respectively. The expected costs per patient, when both inpatients and outpatients were included, were €816 ($1111) in the HS inhalation group and €962 ($1310) in the control group. The expected costs per hospitalization, when only inpatients were included, were €2600 ($3540) in the HS inhalation group and €2890 ($3935) in the control group. HS inhalations slightly reduced the expected hospitalization costs of infant bronchiolitis. However, the low effectiveness, rather than the cost, is the factor that will limit the use of HS inhalations in infant bronchiolitis.

We undertook a cumulative meta-analysis for the efficacy of hypertonic saline (HS) compared to normal saline (NS) inhalations or no inhalations as controls in bronchiolitis. We performed literature searches from PubMed, Scopus, and by hand search until 20 June 2017. We accepted published randomized controlled trials of HS inhalations in children with bronchiolitis aged

AIM We retrospectively evaluated the hospital reimbursement rates for inpatient bronchiolitis treatment and then compared them to the RAFAELA® nursing intensity scores. METHODS We selected all 44 bronchiolitis patients treated in the paediatric intensive care unit (PICU) and then for each PICU-treated patient two patients treated on the ward (n = 88) under 12 months of age in 2010-2015. The data included medical histories, hospital reimbursement rates using the Nordic Diagnosis Related Groups (NordDRG) or expense categories and the RAFAELA® scores. RESULTS Reimbursement claims were mostly based on expense categories for PICU admissions and NordDRG categories for ward admissions. The median (range) was €6352 (€1330-30 554) and €2009 (€768-6027) per episode for the PICU and ward cases, respectively. The median lengths of hospital stay were 8.5 days (3-18) and 3 days (1-8), respectively. Higher RAFAELA® scores were associated with nasal continuous positive airway pressure therapy and mechanical ventilation in the PICU and oxygen supplementation and nasogastric tube feeding on the ward. The correlation coefficients between RAFAELA® scores and hospital reimbursement claims ranged from 0.121-0.450. CONCLUSION Hospital reimbursement claim for a PICU admission was three times as much as a ward admission and reimbursement claims for bronchiolitis did not match with nursing intensity scores.

We evaluated the cost-effectiveness of high-flow nasal cannula (HFNC) to provide additional oxygen for infants with bronchiolitis, compared to standard low-flow therapy. The cost-effectiveness was evaluated by decision analyses, using decision tree modeling, and was based on real costs from our recently published retrospective case-control study. The data on the effectiveness of HFNC treatment were collected from earlier published retrospective studies, using admission rates to pediatric intensive care units (PICU). The analyses in the study showed that the expected treatment costs of each episode of infant bronchiolitis varied between €1,312-2,644 ($1,786-3,600) in the HFNC group and €1,598-3,764 ($2,175-5,125) in the standard treatment group. The PICU admission rates and consequential costs were lower for HFNC than for standard treatment. HFNC treatment proved more cost-effective than standard treatment in all the baseline analyses and was also more cost-effective in the sensitivity analyses, except for in the worst-case scenario analysis. In conclusion, our modeling demonstrated that HFNC was strongly cost-effective for infant bronchiolitis, compared to standard treatment because it was both more effective and less expensive. Thus, if children hospitalized for bronchiolitis need oxygen, it should be delivered as HFNC treatment. Pediatr Pulmonol. 2016;51:1393-1402. © 2016 Wiley Periodicals, Inc.

Hypertonic saline (HS) inhalations in infants hospitalised for bronchiolitis are still under discussion, although 20 randomised controlled trials (RCTs) have evaluated the effectiveness.1–3 Two RCTs, one from Japan2 and another from Switzerland,3 were published until 31 January 2020 after our cumulative meta-analysis,1 which covered data until 30 June 2017. Morikawa et al randomised 63 Japanese children hospitalised for moderately severe bronchiolitis caused by respiratory syncytial virus at

Aim Meta-analyses of randomised controlled trials on infant bronchiolitis do not support medication. We summarised the current data and evaluated the real-life use of medication for infants treated for bronchiolitis in hospitals, including paediatric wards, emergency departments and paediatric intensive care units (PICU). Methods We searched PubMed for studies published from 2009 to 2018 that provided data on the real-life use of adrenaline, salbutamol, corticosteroids or antibiotics for infants hospitalised for bronchiolitis. Results The review identified 10 such studies and showed substantial variations in medication for infant bronchiolitis between different countries and even between different hospitals in the same country. A multi-centre study including 38 hospitals in eight countries reported that a mean of 29% infants admitted for bronchiolitis received drugs without any research-based evidence on their effectiveness, ranging from 9% in Australia and New Zealand to 58% in Spain and Portugal. In addition, an American prospective multi-centre study of 16 PICUs reported that bronchodilators were used by a mean of 60%, corticosteroids by 33% and antibiotics by 63%. Other studies reported that higher ages and a history of wheezing increased the use of medication. Conclusion There were substantial variations in bronchiolitis treatment between, and within, different countries.

Aim: Using a high‐flow nasal cannula (HFNC) for infant bronchiolitis is increasingly common, but insufficiently studied. In this retrospective study, we examined the outcomes of HFNC and compared infants who did and did not respond to this oxygen delivery method. Methods: This 2012–2015 study of six Finnish hospitals focused on 88 infants under 12 months who received HFNC: 53 on paediatric wards and 35 in paediatric intensive care units (PICUs). We reviewed patient files for underlying factors, clinical parameters and HFNC treatment. The treatment failed if the patient was transferred to another respiratory support. Results: We found HFNC treatment was successful in 76 (86%) infants, including all 53 on the paediatric wards and 23/35 PICU patients. The responders’ heart rates were significantly lower, and their oxygen saturation was significantly higher at 60 minutes after HFNC treatment started and then stayed relatively constant. Their respiratory rate was only significantly lower after 360 minutes. In non‐responders, the respiratory rate initially decreased but was higher at 180 and 360 minutes after the start of HFNC. Conclusion: We found preliminary evidence that oxygen support needs and heart rate were useful early predictors of HFNC therapy success in infants hospitalised with bronchiolitis, but respiratory rate was not.

Aim Inhaled racemic adrenaline was used for bronchiolitis in many hospitals in Finland prior to new national current care guidelines for bronchiolitis in 2014, which limited its recommendations to on-demand rescue therapy. We studied the drug's use before and after the new guidelines to gauge changes in prescribing habits. Methods This 2012-2016 study analysed how many 0.5 mL doses of racemic adrenaline were used for children by emergency rooms, paediatric wards and paediatric intensive care units at four university hospitals and estimated drug and staff costs. Results There were substantial differences in the yearly consumption of racemic adrenaline between the hospitals before and after the bronchiolitis guidelines were published, with reductions in drug costs and staff time. The overall use more than halved during the study period, particularly in two hospitals where baseline consumptions were highest, but not in a third where baseline consumption was already low. In the fourth, the baseline consumption was modest and there was a constant decrease during the study years. Conclusion The current care guidelines for bronchiolitis had some impact on clinical practice, as the overall use of racemic adrenaline more than halved, but considerable differences remained in the four study hospitals after their publication.

Aim Up to 3% of infants with bronchiolitis under 12 months of age are hospitalised, and up to 9% require intensive care. We evaluated the costs of bronchiolitis hospitalisation, with a special focus on whether infants needed intensive care. Methods Baseline and cost data were retrospectively collected, using electronic hospital files, for 80 infants under 12 months old who were treated in the paediatric intensive care unit (PICU) for bronchiolitis during a 13-year period. We calculated the daily costs for patients admitted to the PICU and compared them with 104 admitted to inpatient wards and 56 outpatients treated in the emergency department. Results The mean hospitalisation cost for PICU patients was €8061 (95% CI 6193–9929), compared to €1834 (1649–2020) for other inpatients and €359 (331–387) for the outpatients. The hospitalisation cost per patient was associated with length of hospital stay, but not gender, age on admission or gestational age. There was no constant increase or decrease in hospitalisation costs during the study period. Conclusion The hospitalisation costs of infants treated in the PICU for bronchiolitis at

Aim The ten-year Finnish national allergy programme was launched in 2008 to lessen the disease and psychological burden of allergy. This study assessed the prevalence of parent-reported food allergies requiring avoidance diets at primary school in children aged six and seven years. Methods The cohort comprised 1937 children (51% boys) who started primary school in Tampere, Finland, in August 2016. School health nurses charted parent-reported, doctor-diagnosed food allergies requiring avoidance diets as part of the routine health examination. Results We found that 127 (6.6%) children had parent-reported, doctor-diagnosed allergies to at least one food and 37 (1.9%) were allergic to basic foods, namely cows' milk, wheat and one other grain. All required an avoidance diet. The figure did not differ significantly from the 2.7% and 2.5% found by studies of this age group in 2009 and 2013, respectively. Allergies to fresh fruit and vegetables decreased from 5.8% in 2009 to 3.6% in 2016. Conclusion We studied the national allergy programme that started in 2008 and found that there was a nonsignificant overall decrease in the number of children aged six to seven years on avoidance diets for allergies between 2009 and 2016. The only allergies that showed significant decreases were fresh fruit and vegetables.

This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged 12 months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7 days (interquartile range 5-12), 5 days (4-8) and 8 days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.

Aim High-flow nasal cannula (HFNC) therapy provides non-invasive respiratory support for infant bronchiolitis and its use has increased following good clinical experiences. This national study describes HFNC use in Finland during a severe respiratory syncytial virus (RSV) epidemic. Methods A questionnaire on using HFNC for infant bronchiolitis during the 2015-2016 RSV epidemic was sent to the head physicians of 18 Finnish children's hospitals providing inpatient care for infants: 17 hospitals answered, covering 77.5% of the infants born in Finland in 2015. Results Most (85%) HFNC was given on paediatric wards. The mean incidence for bronchiolitis treated with HFNC in infants under the age of one in 15/17 hospitals was 3.8 per 1,000 per year (range 1.4-8.1): one hospital did not supply the relevant data and one supplied a figure of 34.1 due to a different treatment policy. Instructions on how to start and wean HFNC therapy were present in 71% and 61% of the hospitals, respectively, weighted to the population. Providing weaning instructions was associated with shorter weaning times. Conclusion HFNC was actively used for infants with bronchiolitis, with no substantial over-use. Randomised controlled studies are needed before any evidence-based guidelines can be constructed for using HFNC in infant bronchiolitis. This article is protected by copyright. All rights reserved.

High-flow (HF) oxygen therapy is a new promising way to treat infant bronchiolitis. Experimental studies have reported beneficial physiologic effects, and the clinical experience has been positive. The aim of this study was to compare the cost-effectiveness of HF oxygen therapy and standard low-flow (LF) oxygen therapy in infant bronchiolitis. The decision tree in the decision analysis was used to evaluate the cost-effectiveness. The actual cost data were obtained from our recently published case-control study. The data on the effectiveness of HF oxygen therapy were collected from earlier published studies, using the admission rate to pediatric intensive care unit (PICU) as the effectiveness measure. The expected hospitalization costs of each treatment episode of infant bronchiolitis varied between €1,312 to €2,644 in the HF group and €1,598 to €3,764 in the LF group. The incremental cost-effective ratios varied between €-65 to €-324 per 1% reduction in the PICU admission rate. The PICU admission rates and consequential costs were lower for HF than for LF oxygen therapy. HF oxygen therapy proved more cost-effective than standard treatment in all baseline analyses, and was also more cost-effective in the sensitivity analyses, except for in the worst-case scenario analysis. In conclusion, our modelling demonstrated that treating all infants, who need oxygen support during hospitalization for bronchiolitis, with HF instead of LF oxygen therapy is cost-effective. However, prospective randomized controlled trials are needed to provide evidence of the indications, benefits and cost-effectiveness of using HF oxygen therapy for infants with bronchiolitis.

The aim was to evaluate the risk factors for intensive care and for need of respiratory support in infants admitted for bronchiolitis at age less than 12 months. This is a retrospective descriptive case-control study on 80 bronchiolitis (age-specific population 1.4/1000/year) patients treated in pediatric intensive care unit (PICU) and 160 controls treated in the emergency department (ED) or at the ward in Tampere University Hospital, between 2000-2012. A structured form was used to collect medical data of cases and controls separately in the ED, at the ward and in the PICU. Statistically significant risk factors in non-adjusted analyses were included in the adjusted logistic regression. Age Less than 0.25% of infants needed intensive care for bronchiolitis at age less than 12 months. Half (49%) of those treated in the PICU were born prematurely. Low age, low birth weight and congenital heart disease were independently significant risk factors for both intensive care and respiratory support.

We evaluated the cost-effectiveness of high-flow nasal cannula (HFNC) to provide additional oxygen for infants with bronchiolitis, compared to standard low-flow therapy. The cost-effectiveness was evaluated by decision analyses, using decision tree modeling, and was based on real costs from our recently published retrospective case-control study. The data on the effectiveness of HFNC treatment were collected from earlier published retrospective studies, using admission rates to pediatric intensive care units (PICU). The analyses in the study showed that the expected treatment costs of each episode of infant bronchiolitis varied between €1,312-2,644 ($1,786-3,600) in the HFNC group and €1,598-3,764 ($2,175-5,125) in the standard treatment group. The PICU admission rates and consequential costs were lower for HFNC than for standard treatment. HFNC treatment proved more cost-effective than standard treatment in all the baseline analyses and was also more cost-effective in the sensitivity analyses, except for in the worst-case scenario analysis. In conclusion, our modeling demonstrated that HFNC was strongly cost-effective for infant bronchiolitis, compared to standard treatment because it was both more effective and less expensive. Thus, if children hospitalized for bronchiolitis need oxygen, it should be delivered as HFNC treatment. Pediatr Pulmonol. 2016;51:1393-1402. © 2016 Wiley Periodicals, Inc.

Tausta: Bronkioliitti eli ilmatiehyttulehdus on yleisin sairaalahoidon syy alle vuoden ikäisillä vauvoilla. Sairastuvuus bronkioliittiin on korkeaa ja 1-3 % tästä ikäryhmästä hoidetaankin vuosittain sairaalassa bronkioliitin vuoksi. Suomalaisissa tutkimuksissa on havaittu, että noin 6 % sairaalahoidetuista vauvoista päätyy tehohoitoon. Tutkimusten mukaan sairaalahoidon kustannukset ovat nousseet eri maissa. Bronkioliitin sairaalahoito perustuu oireiden helpottamiseen; hypertonisia keittosuolaliuosinhalaatioita on käytetty laajasti viime vuosina ja korkeavirtaushappihoito on uusi, lupaava hoitomuoto. Tämän väitöstutkimuksen tavoitteena on arvioida sairaalahoidon kustannuksia Suomessa. Lisäksi verrataan korkeavirtaushappihoidon ja perinteisen lisähappihoidon kustannusvaikuttavuutta, kuten myös hypertonisten ja normaalien keittosuolaliuosinhalaatioiden vaikuttavuutta ja kustannusvaikuttavuutta. Aineisto ja menetelmät: Kustannusanalyysi on tehty tapaus-verrokki asetelmasta. Potilasaineisto koostuu kaikista vauvoista (n=80), jotka ovat olleet tehohoidossa bronkioliitin takia vuosien 2000–2012 välillä Tampereen yliopistollisessa sairaalassa. Verrokkipotilaiksi (n=160) valittiin ne vauvat, jotka ovat saapuneet päivystyspoliklinikalle hoitoon bronkioliitin takia juuri ennen tehohoidettua vauvaa ja heti tämän jälkeen. Kustannustiedot koostuvat kuntalaskutustiedoista, joten työn näkökulma on rajattu terveydenhuollon palveluntarjoajan näkökulmaan. Kustannusvaikuttavuusanalyyseissä käytettiin omasta aineistosta saatavia kustannustietoja ja vaikuttavuustiedot koottiin aiemmin julkaistuista tutkimuksista. Kustannusvaikuttavuusanalyysit olivat mallintavia päätösanalyyseja, joissa käytettiin analyysimenetelminä päätöspuita ja näissä ensiommäisessä verrattiin korkeavirtaushappihoitoa perinteiseen lisähapenantoon ja toisessa hypertonisia keittosuolaliuosinhalaatioita normaaleihin keittosuolaliuosinhalaatioihin. Lisäksi keittosuolaliuosinhalaatioiden vaikuttavuutta arvioitiin meta-analyysin avulla. Tulokset: Bronkioliitin suorat, keskimääräiset sairaalahoidon kustannukset olivat 8 061€, kun hoitoon liittyi tehohoitojakso, 1 834€, kun hoito oli toteutettu vuodeosastolla ja 359€, kun hoitoa oli annettu vain sairaalan päivystyspoliklinikalla. Korkeammat kustannukset olivat voimakkaasti yhteydessä pidempään sairaalahoidon kestoon ja erityisesti pidempään tehohoidon kestoon. Heikompi yhteys havaittiin ennenaikaisuuden ja nuoremman iän suhteen. Muita korkeisiin kustannuksiin voimakkaasti yhteydessä olevia tekijöitä ei havaittu. Korkeavirtaushappihoito oli vaikuttavampaa ja edullisempaa perinteiseen lisähapen antoon verrattuna. Odotetut sairaalahoidon kustannukset vaihtelivat korkeavirtaushappihoidon ryhmässä 1 312€ ja 2 644€ välillä ja perinteisen lisähappihoidon ryhmässä 1 598€ ja 3 764€ välillä. Korkeavirtaushappihoito oli dominoiva hoitomuoto perinteiseen lisähapenantoon verrattuna huolimatta siitä, mitä mallia analyyseissa käytettiin. Hypertoniset keittosuolaliuosinhalaatiot olivat vain hieman edullisempia verrattuna kontrollihoitoon, mutta niiden vaikuttavuus oli matalaa ja tietyissä tilanteissa jopa olematonta. Uudemmat, vuoden 2012 jälkeen julkaistut tutkimukset eivät enää osoita vastaavaa vaikuttavuutta. Hypertonisia keittosuolaliuosinhalaatioita vuodeosastolla saaneilla keskimääräinen sairaalahoidon kesto oli liki 12 tuntia vähemmän kuin kontrollihoidetuilla. Poliklinikkahoidossa kumulatiivinen riskisuhde sairaalahoidolle oli 0.72 suosien hypertonisia keittosuolaliuosinhalaatioita. Johtopäätökset: Sairaalahoidon kustannukset ovat tehohoidetuilla neljä kertaa korkeammat kuin osastohoidetuilla ja jopa 20 kertaa korkeammat kuin polikliinisesti hoidetuilla. Korkeavirtaushappihoito näyttää vähentävän tehohoidon käyttöä ja sen myötä sairaalahoidon kustannuksia. Tämä tulos perustuu kuitenkin mallintavaan tutkimukseen ja se pitää varmistaa prospektiivisilla satunnaistetuilla ja kontrolloiduilla tutkimuksilla. Hypertoniset keittosuolaliuosinhalaatiot eivät puolestaan vaikuta olevan niin tehokkaita, että niiden käytöllä voisi syntyä todellista kustannusten säästöä sairaalahoidossa. Tämän takia niitä ei enää pitäisi käyttää rutiinisti bronkioliitin hoidossa. Background: Bronchiolitis is the most common infectious reason for hospitalisation in infancy. Morbidity is high, and approximately 1% to 3% of infants under 12 months of age are hospitalised annually. As demonstrated in two Finnish studies, 6% of those hospitalised are treated in the paediatric intensive care unit (PICU). The hospitalisation costs are high in all countries and are increasing. The treatment of bronchiolitis is supportive. Hypertonic saline (HS) inhalations have been widely used in recent years, and high flow oxygen therapy (HFOT) is a promising new treatment method. The aim of this thesis is to evaluate the hospitalisation costs of bronchiolitis in Finland. Additionally, the cost-effectiveness of HFOT compared to standard low flow oxygen therapy (LFOT) is evaluated, as well as the effectiveness and costeffectiveness of HS inhalations compared to normal saline (NS) inhalations, or to standard treatment without inhalations. Materials and methods: The cost analysis was done in form of a case-control study. We collected the medical data and hospitalisation costs for all infants with bronchiolitis treated in the PICU (n=80) of the Tampere University Hospital between the years 2000 and 2012. As controls (n=160), we collected the data of infants with bronchiolitis treated in the emergency department just before, and one just after, the index case. The hospitalisation costs were based on municipal billing, and the viewpoint was that of the health care providers. For evaluation of cost-effectiveness we used the cost data collected in this study, and the data for evaluating the effectiveness of HFOT and HS inhalations were obtained from previously published studies. The cost-effectiveness analyses were carried out by decision tree models that compared HFOT to LFOT, as well as HS to NS. Additionally, the effectiveness of HS inhalations was evaluated by meta-analysis. Results: The direct total mean hospitalisation costs of bronchiolitis were €8,061 for those who were treated in the PICU, €1,834 for those treated on the ward, and €359 for those treated in the emergency department only. The higher costs were correlated to a longer length of stay in the hospital, especially in the PICU. Additionally, lower gestational age and age on admission were weakly linked to the higher costs. Other factors strongly associated with higher costs were not found. HFOT was both more effective and less expensive when compared to LFOT. The expected hospitalisation costs were between €1,312 and €2,644 for HFOT, and between €1,598 and €3,764 for LFOT. HFOT was the dominant treatment in all models in comparison to LFOT. HS inhalations were slightly less expensive than control treatments, but the effectiveness was low and, in some situations, even absent. The effectiveness of HS inhalations compared to controls decreased by the publication time of this study. Cumulative mean difference of the length of stay in the hospital was nearly 12 hours, and the cumulative risk ratio for hospitalisation was 0.771, favouring HS inhalations. Conclusion: The hospitalisation costs of infant bronchiolitis are four times higher if intensive care is needed when compared to ward treatment, and over 20 times higher when compared to the treatment in the emergency department. HFOT seems to decrease the use of intensive care, and further to decrease, the hospitalisation costs. However, the results based on the theoretical model with historical controls used here need to be confirmed by prospective randomised controlled trials. On the other hand, HS inhalations are not effective enough for any real cost-saving to be gained, and such inhalations should not be routinely used in the treatment of infant bronchiolitis.