A.L.M. Boehmer

The effect of 3% and 6% hypertonic saline in viral bronchiolitis: a randomised controlled trial

Bronchiolitis is a common disorder in young children that often results in hospitalisation. Except for a possible effect of nebulised hypertonic saline (sodium chloride), no evidence-based therapy is available. This study investigated the efficacy of nebulised 3% and 6% hypertonic saline compared with 0.9% hypertonic saline in children hospitalised with viral bronchiolitis. In this multicentre, double-blind, randomised, controlled trial, children hospitalised with acute viral bronchiolitis were randomised to receive either nebulised 3%, 6% hypertonic saline or 0.9% normal saline during their entire hospital stay. Salbutamol was added to counteract possible bronchial constriction. The primary endpoint was the length of hospital stay. Secondary outcomes were need for supplemental oxygen and tube feeding. From the 292 children included in the study (median age 3.4 months), 247 completed the study. The median length of hospital stay did not differ between the groups: 69 h (interquartile range 57), 70 h (IQR 69) and 53 h (IQR 52), for 3% (n=84) and 6% (n=83) hypertonic saline and 0.9% (n=80) normal saline, respectively, (p=0.29). The need for supplemental oxygen or tube feeding did not differ significantly. Adverse effects were similar in the three groups. Nebulisation with hypertonic saline (3% or 6% sodium chloride) although safe, did not reduce the length of stay in hospital, duration of supplemental oxygen or tube feeding in children hospitalised with moderate-to-severe viral bronchiolitis. Hypertonic saline nebulisation did not reduce hospital stay for children with viral bronchiolitis http://ow.ly/xRVVx

Risk Factors for Pediatric Intensive Care Admission in Children With Acute Asthma

INTRODUCTION: Severe acute asthma in children is associated with substantial morbidity and may require pediatric ICU (PICU) admission. The aim of the study was to determine risk factors for PICU admission. METHODS: The study used a retrospective multicenter case-control design. The cases included children admitted to the PICU because of severe acute asthma and a history of out-patient treatment by pediatricians or pediatric pulmonologists. Controls were children with asthma without a PICU admission for severe acute asthma. The children were matched for sex, age, hospital, and time elapsed since the diagnosis of asthma. Fourteen possible risk factors were analyzed. RESULTS: Sixty-six cases were matched to 164 controls. In univariate analysis, all but one of the analyzed variables were significantly associated with PICU-hospitalization. After multivariate conditional logistic regression analysis, 4 risk factors remained significant. These included active or passive smoking, allergies, earlier hospitalization for asthma, and non-sanitized home. CONCLUSIONS: Physicians and parents should be aware of these risk factors, and efforts should be made to counteract them.

Asthma therapy for children under 5 years of age

Purpose of review The evidence for effectiveness of currently used asthma medication for wheeze in young children is reviewed. Recent findings The management of the infant and preschool child with wheezing is complicated by the uncertainty with respect to the aetiology. Difficulties in defining phenotypes and objective outcome parameters combined with the transient nature of symptoms which often resolve spontaneously have confounded many therapeutic studies. Recent studies on the effect of pharmacotherapy in wheezing infants have tried to define a more homogeneous phenotype as well as make a selection of patients that are likely to respond to the studied drug. In addition, these studies have used lung function parameters and nitric oxide as one of the outcome measurements. Studies on the nature of inflammation and the development of airway remodelling in infants and young children are done to further define phenotypes. Summary Currently, there are no evidence-based guidelines and not even consensus statements on the right approach in pharmacological treatment of wheezing in infants and preschool children. The main issue still is the difficulty in coming to a correct diagnosis. Further studies are needed on the nature and the diagnostics of phenotypes and on the effect of early intervention.

Moeilijk behandelbaar astma: diagnostiek en behandelopties

SamenvattingKinderen met moeilijk behandelbaar astma (MBA) zijn een heterogene groep voor wie met behulp van gestructureerde diagnostiek een individueel behandelplan opgesteld moet worden. In de literatuur worden diverse protocollen voor de diagnostiek en behandeling van MBA bij kinderen en volwassenen beschreven. Deze stellen alle een gestructureerde aanpak voor met als doel kwaliteitsverbetering in diagnostiek en behandeling van MBA. Recent is er een protocol uitgebracht door de Sectie Kinderlongziekten van de Nederlandse Vereniging voor Kindergeneeskunde voor de Nederlandse praktijk. Dit protocol is gebaseerd op de wetenschappelijke kennis van dit moment. In dit protocol wordt een systematische benadering van het kind met MBA voorgesteld. Het protocol bestaat uit twee fasen. In de eerste fase worden andere diagnosen dan astma aangetoond dan wel uitgesloten, wordt beoordeeld of de therapie adequaat is, de symptoomperceptie beoordeeld, worden factoren die het astma verergeren geïdentificeerd inclusief de comorbiditeit en wordt gepoogd het astma weer behandelbaar te maken. Nadat is vastgesteld dat het gaat om astma, waarbij alle astma verergerende factoren, inclusief de psychologische, bij het kind en zijn/haar omgeving zijn onderzocht en behandeld, blijft er een kleine groep kinderen met therapieresistent astma’ over. De tweede fase van het protocol, diagnostiek en behandeling van ‘therapieresistent astma’ volgt elders in dit tijdschrift. Op basis van de registratie van kinderen met MBA via het Nederlands Signaleringscentrum Kindergeneeskunde (www.pedianet.nl/nsck) wordt geëvalueerd of dit protocol aanpassing behoeft.SummaryChildren with MBA are a heterogeneous group of patients.With use of a structured diagnostic approach, an individual treatment plan for a child with MBA must be drawn. Some protocols for the diagnosis and treatment of difficult-to-treat asthma (DTA) in children and adults have been proposed. These protocols all use a structured approach for the diagnosis and treatment of MBA. Recently, a protocol by the Dutch Society for Paediatrics, based on the current best available evidence, was published. The protocol, a systematic approach to the child with MBA, comprises two phases. In the first phase alternative diagnoses are excluded, sufficiency of treatment is reviewed, symptom perception is assessed, factors aggravating asthma and co-morbidity are identified and treated. This includes co-morbidity such as psycho-social issues. After phase one, only a small minority of patients will still be uncontrolled. These children have what is called ‘severe, therapy resistant asthma’. See for the second phase of the protocol further on in this edition.

A virtual asthma clinic for children: Fewer routine outpatient visits, same asthma control

eHealth is an appealing medium to improve healthcare and its value (in addition to standard care) has been assessed in previous studies. We aimed to assess whether an eHealth intervention could improve asthma control while reducing 50% of routine outpatient visits. In a multicentre, randomised controlled trial with a 16-month follow-up, asthmatic children (6–16u2005years) treated in eight Dutch hospitals were randomised to usual care (4-monthly outpatient visits) and online care using a virtual asthma clinic (VAC) (8-monthly outpatient visits with monthly web-based monitoring). Outcome measures were the number of symptom-free days in the last 4u2005weeks of the study, asthma control, forced expiratory volume in 1u2005s, exhaled nitric oxide fraction, asthma exacerbations, unscheduled outpatient visits, hospital admissions, daily dose of inhaled corticosteroids and courses of systemic corticosteroids. We included 210 children. After follow-up, symptom-free days differed statistically between the usual care and VAC groups (difference of 1.23u2005days, 95% CI 0.42–2.04; p=0.003) in favour of the VAC. In terms of asthma control, the Childhood Asthma Control Test improved more in the VAC group (difference of 1.17u2005points, 95% CI 0.09–2.25; p=0.03). No differences were found for other outcome measures. Routine outpatient visits can partly be replaced by monitoring asthmatic children via eHealth. A virtual asthma clinic as an individualised online monitoring strategy can partly replace routine outpatient visits http://ow.ly/f9Vd30dqWvJ

Online asthma management for children is cost-effective

eHealth interventions have been proposed as an appealing method to improve health outcomes and reduce healthcare costs [1–3]. However, the development of an eHealth intervention is associated with high costs and this investment needs to be balanced by increased clinical effectiveness and related cost savings. Unfortunately, solid evidence for the effectiveness of eHealth with regard to health improvement is still limited [2–5], as is evidence regarding cost-effectiveness. This causes uncertainty about the effectiveness of eHealth and constitutes a barrier towards successful implementation in daily practice [6, 7]. Thus, it is necessary to assess both effectiveness and cost-effectiveness to convince colleagues and policymakers of its added value. Online asthma management in children can (partly) substitute routine outpatient visits and is cost-effective http://ow.ly/oabk30f7Sre

Children with severe acute asthma admitted to Dutch PICUs: A changing landscape

The number of children requiring pediatric intensive care unit (PICU) admission for severe acute asthma (SAA) around the world has increased.

Barriers and facilitators when implementing online monitoring and management as a substitution for traditional outpatient care in children with asthma (Preprint)

Background Despite their potential benefits, many electronic health (eHealth) innovations evaluated in major studies fail to integrate into organizational routines, and the implementation of these innovations remains problematic. Objective The purpose of this study was to describe health care professionals’ self-identified perceived barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient care. Also, we assessed patients’ (or their parents) satisfaction with this eHealth innovation. Methods Between April and November 2015, we recruited 76 health care professionals (from 14 hospitals). During a period of 6 months, participants received 3 questionnaires to identify factors that facilitated or impeded the use of this eHealth innovation. Questionnaires for patients (or parents) were completed after the 6-month virtual asthma clinic (VAC) implementation period. Results Major perceived barriers included concerns about the lack of structural financial reimbursement for Web-based monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of Web-based portal use on clinician workload, and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals toward eHealth, the possibility to tailor care to individual patients (“personalized eHealth”), easily deliverable care according to current guidelines using the VAC, and long-term profit and efficiency. Conclusions The implementation of Web-based disease monitoring and management in children is complex and dynamic and is influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context, and economic and political context. Understanding and defining the barriers and facilitators that influence the context is crucial for the successful implementation and sustainability of eHealth innovations.

Pathofysiologie, diagnostiek en behandeling van chronisch hoesten

SamenvattingHoesten is een veelvoorkomend symptoom op de kinderleeftijd. Voor de dagelijkse praktijk is het belangrijk om een onderscheid te maken in niet-specifieke hoest (een droge hoest zonder andere symptomen en zonder afwijkingen bij aanvullend onderzoek) en specifieke hoest (met een duidelijke oorzaak). Bij niet-specifieke hoest kan het beleid vaak expectatief zijn, bij specifieke hoest is behandeling doorgaans aangewezen.We stellen een systematische evaluatie voor bij de diagnostiek en behandeling om belangrijke diagnosen niet te missen.SummaryCough is a frequent symptom in childhood. For daily practice, it is important to distinguish between non-specific cough (dry cough without other symptoms and without abnormal investigations) and specific cough (resulting from underlying illness). Non-specific cough requires a different approach than specific cough.We propose a systematic approach for the investigation and treatment of cough to prevent missing important diagnoses.