Risk factors for hyperinflation in young schoolchildren born prematurely

 Lung function abnormalities, including hyperinflation, are common in young children born prematurely. The aim of this study was, in such patients, to determine factors associated with hyperinflation, that is an elevated lung volume. Lung volume was estimated by measuring functional residual capacity (FRC) before and after bronchodilator therapy in 41 5-year-old children who had been born prematurely at a median of 30 weeks gestational age. Hyperinflation was defined as an FRC greater than 120% of that predicted for height and a positive bronchodilator response as a greater than or equal to 10% change in FRC. Twelve (29%) of the children were symptomatic at 5 years, their median FRC (132%) was significantly higher than that of the asymptomatic children (109%), P < 0.01. Twelve (29%) children were hyperinflated; a greater proportion of the hyperinflated compared to the non-hyperinflated patients were symptomatic at 5 years (7 or 58% versus 5 or 17%) (P < 0.05) and responded to bronchodilator therapy (9 or 75% versus 4 or 14%) (P < 0.01). Regression analysis demonstrated that hyperinflation related significantly only to current symptom status, but not perinatal variables. Conclusion Hyperinflation in young children born prematurely reflects current symptom status and not adverse neonatal events. Received: 19 January 1996 / Accepted: 1 July 1996     

Respiratory morbidity in preschool children born prematurely. Relationship to adverse neonatal events

Respiratory morbidity, recurrent cough and/or wheeze and lung function abnormalities are common even outside infancy in preschool children born prematurely. Throughout the first 5 years of life, adverse neonatal events such as immaturity at birth and a requirement for prolonged respiratory support are significantly associated with positive symptom status. In the older preschool child, however, there is some evidence to suggest that other factors, such as a family history of atopy, may be equally important. The development of recurrent symptoms even at 4 years of age can be predicted accurately from the results of lung function measurements made in infancy, and hopefully such data will facilitate the introduction of effective intervention strategies. Lung function abnormalities are more marked in symptomatic patients and, in older children, seem to reflect increased airway responsiveness rather than having a significant relationship to adverse neonatal events. The hospital readmission rate for respiratory disorders, however, is certainly adversely affected by extremely low birthweight and neonatal chronic lung disease, as well as current symptom status. These data highlight that strategies to reduce extremely premature delivery and its consequences should favourably influence respiratory morbidity in preschool children.     

Respiratory morbidity in young school children born prematurelychronic lung disease is not a risk factor?

Abstract Children born prematurely and recruited into a prospective follow up study were examined at 5 years of age. Our aim was to determine actiological associations of respiratory symptoms in such children and in particular, to determine the importance of severe chronic lung disease (CLD, oxygen dependence beyond 36 weeks post conceptional age). Respiratory status was documented from parental history in 103 children of median gestational age 29 weeks (range 23–35), 17 of whom had suffered from severe CLD. In 90 of the 103 children lung function had been assessed at 1 year of age. Regression analysis revealed that neither severe CLD nor other perinatal variables, but only a family history of atopy, significantly related to a positive symptom status. A high airways resistance at 1 year also significantly related to positive symptom status.Conclusion Reduction in severe CLD (oxygen dependence beyond 36 weeks postconceptional age) may make relatively little impact on respiratory morbidity in young school children born prematurely.     

Executive functions in school-age children born very prematurely

BACKGROUND: School-age preterm children are at risk for cognitive difficulties including Executive Dysfunction and low average IQ. AIM: The aim of this study was to determine the performance of very preterm, school-age children on three components of Executive Function (EF), two components of Executive Attention and a measure of IQ. STUDY DESIGN: Cross-sectional, independent samples comparison. METHODS: A UK sample of 40 very preterm (<32 weeks gestational age, Mean 28.43, SD 2.41) children and 41 term born control children aged between 6 and 12 years (mean ages 8 years 5 months in both groups) was assessed on IQ, EF (inhibition, working memory and set shifting) and attention (sustained and selective). Between group comparisons were made using multivariate analysis of variance and covariance. RESULTS: Multivariate analyses indicated that preterm children scored significantly lower than their term born peers across Executive Function and executive attention tasks. As expected, the preterm group achieved IQ scores at the low end of the average range. Univariate analyses indicated some difficulties with shifting and inhibition components of EF, although covariate analysis revealed that only shifting was independent of IQ. CONCLUSIONS: Preterm children showed mild executive function and executive attention difficulties in the context of average IQ scores. The findings highlight the benefit of using multivariate assessments of executive skills rather than general intellectual outcome alone, to obtain a better distinction of the specific cognitive weaknesses associated with preterm birth.     

Effect of topical cromoglycate solution on atopic dermatitis: Combined treatment of sodium cromoglycate solution with the oral anti-allergic medication,oxatomide

The effect of topically applied sodium cromoglycate solution in moderate to severe atopic dermatitis (AD) in children aged 4–14 years was studied in a double-blind, placebo-controlled, randomized group-comparative trial. One group of patients was treated with topical sodium cromoglycate solution and oral oxatomide whereas the other group was treated with topical placebo solution and oral oxatomide. After 4 weeks, AD improved significantly in the group treated with the sodium cromoglycate solution and oxatomide combination while marginal improvement was noted in the placebo. In addition, spontaneous IgE production from peripheral blood mononuclear cells decreased significantly in the sodium cromoglycate group but not in the placebo group. These results suggest that sodium cromoglycate solution may be very effective in combination with anti-allergic medication in the treatment of moderate to severe AD in children.     

Prediction of outcome from the chest radiograph appearance on day 7 of very prematurely born infants

Our aim was to determine whether the chest radiograph appearance at 7 days predicted chronic lung disease development (oxygen dependency at 36 weeks post-menstrual age) or death before discharge and if it was a better predictor than readily available clinical data. Two consecutive studies were performed. In both, chest radiographs taken at 7 days for clinical purposes were assessed using a scoring system for the presence of fibrosis/interstitial shadows, cystic elements and hyperinflation and data were collected regarding gestational age, birth weight, use of antenatal steroids and post-natal surfactant and requirement for ventilation at 7 days. Oxygenation indices were calculated in the first study (study A) at 120 h and in the second (study B) at 168 h. In study A, there were 59 infants with a median gestational age of 26 weeks (range 24 to 28 weeks) and in study B, 40 infants with a median gestational age of 27 weeks (range 25–31 weeks). In both studies, infants who developed chronic lung disease had a significantly higher total chest radiograph score, with a higher score for fibrosis/interstitial shadowing than the rest of the cohort. Infants who died before discharge differed significantly from the rest with regard to significantly higher scores for cysts. In both studies, the areas under the receiver operator characteristic curves with regard to prediction of chronic lung disease were higher for the total chest radiograph score compared to those for readily available clinical data. Conclusion:in infants who require a chest radiograph for clinical purposes at 7 days, the chest radiograph appearance can facilitate prediction of outcome of infants born very prematurely.Abbreviations CLD chronic lung disease - CXR chest radiograph - CMV conventional mechanical ventilation - HFO high frequency oscillation - KCH Kings College Hospital - OI oxygenation index - PIE pulmonary intestinal emphysema - PMA post-menstrual age - ROC receiver operator characteristic curves - UKOS United Kingdom Oscillation Study     

Neurodevelopmental screening of in utero growth-retarded prematurely born children before school age

As part of a prospective follow-up study of two premature cohorts (gestational age 36 weeks) born between 1976 and 1977, designed to evaluate the effects of IUGR on morbidity, mortality and neurological development in prematurely born children, 71 prematurely born children (48 AGA, 23 IUGR) without major neurological handicaps were subjected to detailed assessment of their neurological and psychological status at the age of 4 years. Thirty-six healthy full-term children formed a control group. The socioeconomic status of the families of the premature groups was similar to that of the families of the control group. The assessment consisted of a neurodevelopmental screening test and four psychological tests. Validation of the NDS test in relation to proven cognitive problems (sensitivity 96%, specificity 64%, relative risk 16.74) and determination of normal ranges were based on findings in the control group. There were significantly more children with moderate to high risk scores (10) among the IUGR group than among the AGA group. The neurodevelopmental profile of the preterm IUGR group was characterized by complex deviations of motor, visual and perceptual functions from normal. Preterm AGA children had only slightly higher risk scores in relation to fine motor, upper motor and perceptive functions than control children. Of the various perinatal factors studied, IUGR (especially in relation to boys who needed respirator therapy) was the most likely to be associated with abnormal NDS scores before school age.Abbreviations AGA adequate for gestational age - IUGR intrauterine growth retardation - IQ intelligence quotient - NDS neurodevelopmental screening - PI ponderal index     

Comparison of the effects of inhaled calcium antagonist verapamil,sodium cromoglycate and ipratropium bromide on exercise-induced bronchoconstriction in children with asthma

Fifteen children with exercise-induced asthma (EIA) participated in a double-blind trial comparing the protective effects of inhaled sodium cromoglycate (20 mg/2ml), ipratropium bromide (500 g/2ml) and verapamil (5 mg/2ml). Saline was used as control. There was no significant difference in base line pulmonary function before and after the administration of each agent. After exercise the maximal percentage fall in the forced expiratory volume in 1 s (FEV-1) (means and SD) were 40.9±17.2 after inhalation of saline, 15.3±11.7 after sodium cromoglycate, 36.2±21.4 after verapamil and 21.7±17.7 after ipratropium bromide. The inhibitory effects of sodium cromoglycate and ipratropium bromide were significant whereas verapamil failed to produce any effect. To see if a double dose of verapamil is more effective, nine different children with EIA were provoked by the same standardized treadmill running after giving a placebo (4 ml saline) and after verapamil (10 mg in 4 ml). Despite the double dose, again verapamil was ineffective even though the protection index doubled that obtained with the lower dose. The results suggest that the calcium antagonist (verapamil) had almost no effect on the prevention of EIA in the children studied.Abbreviations FEV-1 forced expiratory volume in 1 s - RAST radio allergo sorbent test - SCG sodium cromoglycate - IB ipratropium bromide - EIA exercise-induced asthma - SD standard deviation     

Net cost of palivizumab for respiratory syncytial virus prophylaxis during the 1998/99 season in northern Alberta

OBJECTIVE:

Palivizumab has been shown to decrease respiratory syncytial virus (RSV) hospitalization rates in preterm infants and infants with chronic lung disease. The objective of the present study was to determine whether the use of palivizumab during the 1998/99 RSV season would have resulted in a cost-saving in infants discharged from Edmonton hospitals.

DESIGN:

A retrospective study of RSV hospitalizations was performed by contacting parents and reviewing hospital lists. The net cost of using palivizumab was determined by comparing the cost of giving the drug from November 1, 1998 to April 1, 1999 with the cost of potentially averted medical transports and hospitalizations.

POPULATION:

One hundred fifty-nine infants discharged from Edmonton hospitals who met the Canadian Paediatric Society’s criteria for receiving palivizumab during the 1998/99 RSV season were studied.

RESULTS:

The cost of using palivizumab in these 159 study infants would have been $753,300. The infants had 21 RSV hospitalizations and required four medical transports. The estimated cost of RSV hospital-based care for these infants was $168,888. Assuming a drug efficacy of 39% in infants with chronic lung disease and 78% in infants born before 33 weeks’ gestation with no chronic lung disease, $121,147 of these costs could have been averted if palivizumab had been used.

CONCLUSIONS:

The net cost to the health care system of using palivizumab, as recommended in the Canadian Paediatric Society guidelines, in study infants in northern Alberta during the 1998/99 RSV season would have been $632,153.     

Supporting caregivers of children born prematurely in the development of language: A scoping review

BackgroundInfants born prematurely can display impairments that negatively impact the early years of their development. Compared to their peers born at term, preterm children have higher risks of cerebral palsy, sensory deficits, learning disabilities, cognitive and language deficits, as well as difficulties related to attention and behaviour. Following discharge, parents of preterm children are often supported through neonatal follow-up programs or by community health care practitioners. Through assessment and consultation, professionals foster parental resilience by teaching them about their child’s development. Research shows a large volume of literature on improving outcomes for preterm infants, but less attention has been given to the impact and potential importance of education of parents regarding the care they provide from the home.ObjectiveA scoping review was completed to determine the best practices for early intervention in premature children regarding the development of language skills during the preschool years.MethodsThe review followed the guidelines for the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).ResultsFour general themes emerged from the review and included the importance of providing (1) parental training in the care of an infant born prematurely during neonatal intensive care unit stay; (2) education on the development of language and the importance of parental responsiveness; (3) provision of activities to support child language learning; and (4) overall and ongoing monitoring and support by qualified health professionals.ConclusionsThe conclusions drawn will provide guidance to health care professionals regarding the education of parents on best practices for stimulating language development in their child.     

Inhaled versus systemic steroids in chronic oxygen dependency of preterm infants

The speed of action and side-effects of systemic versus inhaled steroids was compared in infants with mild-moderate oxygen dependency. Forty infants (median gestational age 27 weeks) were randomized to receive either 10 days of dexamethasone (systemic group) or budesonide (100 μg qds) (inhaled group). At randomization, there was no significant difference in the gestational or postnatal age, inspired oxygen requirements or compliance of the respiratory system of the two groups. After 36 h of treatment, there were significant changes (P < 0.01) in both the inspired oxygen concentration and compliance of the respiratory system in the systemic but not the inhaled group. Only after 1 week of inhaled therapy were improvements in respiratory status noted but, even at that time, the inspired oxygen requirement was significantly lower in the systemic versus the inhaled group. In the systemic group only, however, were there significant increases in blood pressure. Conclusion Systemically administered rather than inhaled steroids appear to have a faster onset of action. Received: 22 December 1995 / Accepted: 27 May 1996     

The efficiency of nebulization treatment with water compared to sodium cromoglycate in reducing upper respiratory infections in children

Twenty-two children aged 1 to 5 years with history of recurrent upper respiratory infections (URI) were investigated in a double blind cross over clinical study. After a three week observation period, patients received, at random, over two alternating periods of six weeks each, either 2 ml placebo (water) or 1% sodium cromoglycate (SC) solution t.i.d. by means of a home nebulizer. A significant decline in the number of illness days during both the nebulization periods as compared to the pretreatment period was observed (a mean percentage of days of 13.7 and 36.1 respectively, p less than 0.001). Both types of nebulization were equally efficient in reducing URI morbidity. The present study indicates that humidification may have some beneficial effect on reducing the recurrence rate of URI. Sodium cromoglycate was not superior to water for this purpose.     

Effect of chronic lung disease on blood pressure levels at follow up

Thirteen preterm infants (median gestational age 28 weeks) who had developed neonatal chronic lung disease (CLD) and 13 gender- and gestational agematched controls (without CLD) were prospectively followed. The infants were seen at monthly intervals for 6 months. At each attendance the infants were examined and their blood pressure (BP) measured using a noninvasive Doppler technique. No infant developed symptoms related to hypertension and there were no significant differences in their BP levels at follow up. Our results suggests significant BP elevation is uncommon following neonatal CLD.     

Diminished lung function, RSV infection, and respiratory morbidity in prematurely born infants

Background

Diminished lung function appears to be a risk factor for respiratory syncytial virus (RSV) infection/bronchiolitis in term born infants.

Aims

To determine if diminished lung function prior to neonatal unit discharge was associated with subsequent symptomatic RSV lower respiratory tract infection (LRTI) and respiratory morbidity in prematurely born infants.

Methods

Of 39 infants in a tertiary neonatal intensive care unit (median gestational age 28 weeks, range 23–31), 20 had bronchopulmonary dysplasia. Lung function (compliance and resistance of the respiratory system (C_rs and R_rs) and functional residual capacity (FRC)) was measured on the neonatal unit at 36 weeks postmenstrual age (PMA). Following neonatal unit discharge, nasopharyngeal aspirates were obtained on every occasion, at home or in hospital, an infant had an LRTI. RSV was identified by immunofluorescence and/or culture.

Results

The 15 infants who suffered a symptomatic RSV LRTI had a higher mean R_rs and suffered more wheeze at follow up than the rest of the cohort. Regression analysis showed that a high R_rs was significantly associated with a symptomatic RSV LRTI; significant factors for cough were a high R_rs and a symptomatic RSV LRTI, and for wheeze were a high R_rs.

Conclusion

Prematurely born infants, who had a symptomatic RSV LRTI and/or respiratory morbidity at follow up, had worse lung function prior to neonatal unit discharge.     

Survey of sleeping position recommendations for prematurely born infants on neonatal intensive care unit discharge

Introduction Prematurely born infants are at an increased risk of sudden infant death syndrome (SIDS), particularly when sleeping prone. Parents are strongly influenced in their choice of sleeping position for their infant by practitioners. The aim of this study was to determine the neonatal units’ recommendations regarding the sleeping position for premature infants prior to and after discharge and ascertain whether there had been changes from those recorded in a survey performed in 2001–2002. Materials and methods A questionnaire survey was sent to all 229 neonatal units in the United Kingdom; 80% responded. Results and discussion The majority (83%) of units utilized the supine sleep position for infants at least 1–2 weeks prior to discharge, but after discharge, only 38% of the units actively discouraged prone sleeping and 17% additionally recommended side sleeping. Compared to the previous survey, significantly more units started infants with supine sleeping 1–2 weeks prior to discharge (p < 0.0001) and fewer recommended side sleeping after discharge (p = 0.0015). However, disappointingly, less actively discouraged prone sleeping after discharge (p = 0.0001). Conclusion Recommendations regarding sleeping position for prematurely born infants after neonatal discharge by some practitioners remain inappropriate. Evidence-based guidelines are required as these would hopefully inform all neonatal units’ recommendations.     

The combination of nebulized sodium cromoglycate and salbutamol in the treatment of moderate‐to‐severe asthma in children

The aim of this multi‐centre prospective study was to evaluate the efficacy, tolerability, and safety of the combination of sodium cromoglycate (SCG) and salbutamol (administered as a nebulized solution), compared to SCG alone and salbutamol alone, in the management of severe, intractable asthma in childhood. The study was an open, randomized, cross‐over trial of 12 weeks' duration in children with moderate‐to‐severe intractable asthma. All treatments were administered twice daily by powered nebulizer. The primary outcome measure was the change in asthma severity, as measured by the mean asthma score during the last 2 weeks of a baseline period and the last 2 weeks of each treatment. Secondary outcome measure was the patient's opinion of the effectiveness of treatment. The change in asthma scores from baseline values were significantly greater with the combination treatment compared to each component administered separately. The mean difference in asthma score between the combination and salbutamol was: ?7.5; 95% CI, ?11.70 to ?3.29 (p < 0.0001). The mean difference between the combination and SCG was: ?8.53; 95% CI, ?14.03 to ?3.25 (p < 0.0001). Patients were also significantly in favor of combination treatment (p < 0.001 vs. salbutamol; p < 0.01 vs. SCG). Two patients reported adverse effects. We concluded that regular twice‐daily inhalation of a combination of SCG and salbutamol gave better control of symptoms than previous treatments in patients with severe, intractable asthma. Few adverse effects with this therapy suggest that it is extremely useful, safe, and effective.     

Preventing hospitalizations for respiratory syncytial virus infection

Respiratory syncytial virus infection is the leading cause of lower respiratory tract infections in young children. Palivizumab has minimal impact on RSV hospitilization rates as it is only practical to offer it to the highest risk groups. The present statement reviews the published literature and provides updated recommendations regarding palivizumab use in children in Canada.     

Lung volume measurements in infants with and without chronic lung disease

Infants born prematurely who develop chronic lung disease (CLD) have airways obstruction and hence may have low lung volume. The aim of this study was to test that hypothesis and ascertain whether the nature of the comparison control group influenced the results. Sixteen infants who were oxygen dependent for more than 28 days (CLD) and eight infants without CLD had measurements of functional residual capacity (FRC) at 14 and 28 days. The 16 CLD infants consisted of eight less than 27 weeks gestational age (group A) and eight greater than 26 weeks gestational age (group B). The eight infants without CLD (group C) were each matched for gestational age and gender to infants in group B. Group A compared to group C had lower FRCs both at 14 days (median 18 ml/kg vs 27 ml/kg, P<0.01) and 28 days (median 20 ml/kg vs 26 ml/kg, P<0.05), but group A differed from group C with respect to both gestational age (P<0.01) and birth weight (P<0.01). The FRC results of group B were lower than those of their matched controls (group C) only at 28 days (median 22 vs 26 ml/kg, P<0.05). Overall, the FRC results at 14 and 28 days correlated significantly with the duration of oxygen and ventilator dependence and weakly with gestational age. Conclusion These results support the hypothesis that FRC results are lower in infants with CLD compared to those without CLD when measured in the neonatal period and emphasize the importance of an appropriate control group. Measurement of lung volume may facilitate assessment of the response to therapies for CLD. Received: 5 May 1997 / Accepted in revised form: 29 September 1997     

Prediction of respiratory morbidity in the third year of life in children born prematurely

We have tested the hypothesis that recurrent respiratory symptoms in the third year of life in patients born prematurely were more likely to reflect a family history of atopy rather than adverse neonatal events. Comparison of 28 symptomatic and 72 asymptomatic children revealed that a family history of atopy ( p <0.01), prolonged dependencc on respiratory support in the neonatal period ( p <0.01) and extreme immaturity ( p <0.02) were significantly commoner in the symptomatic group. The relative risk of having symptoms was 2.27 for a family history of atopy, 2.48 for prolonged dependence on respiratory support and 1.7 for low gestational age. We conclude that respiratory morbidity in the third year of life following premature delivery has a multifactorial aetiology.