Ingvild Bruun Mikalsen

Acute bronchiolitis in infants, a review

Acute viral bronchiolitis is one of the most common medical emergency situations in infancy, and physicians caring for acutely ill children will regularly be faced with this condition. In this article we present a summary of the epidemiology, pathophysiology and diagnosis, and focus on guidelines for the treatment of bronchiolitis in infants. The cornerstones of the management of viral bronchiolitis are the administration of oxygen and appropriate fluid therapy, and overall a “minimal handling approach” is recommended. Inhaled adrenaline is commonly used in some countries, but the evidences are sparse. Recently, inhalation with hypertonic saline has been suggested as an optional treatment. When medical treatment fails to stabilize the infants, non-invasive and invasive ventilation may be necessary to prevent and support respiratory failure. It is important that relevant treatment algorithms exist, applicable to all levels of the treatment chain and reflecting local considerations and circumstances.

The outcome after severe bronchiolitis is related to gender and virus.

To cite this article: Mikalsen IB, Halvorsen T, Øymar K. The outcome after severe bronchiolitis is related to gender and virus. Pediatric Allergy Immunology 2012: 23: 391–398.

Severe bronchiolitis in infancy: can asthma in adolescence be predicted?

Bronchiolitis in infancy is a risk factor for development of asthma in the first decades of life, although the majority may be asymptomatic at school age. Respiratory symptoms are common in early life, and prediction of later asthma may be challenging. We aimed to study if simple clinical variables assessed at 2 years of age could predict asthma at 11 years of age and thereby provide a basis for follow‐up and treatment after bronchiolitis in infancy. The study included 105 children hospitalized for bronchiolitis during their first year of life. Of these, 101 (96.2%) participated in the first follow‐up at 2 years of age and 93 (88.6%) in the second follow‐up at age 11. The overall prevalence of asthma at 11 years of age was 22.6%. Among the risk factors assessed at 2 years of age, recurrent wheeze appeared most important (odds ratio for later asthma: 7.2; 95% confidence interval: 1.3, 41.6; P = 0.015). Tested separately, recurrent wheeze had high sensitivity (90.5%), but low specificity (58.3%), low negative likelihood ratio (LR) (0.2) and low negative post‐test probability (4.5%); indicating that absence of recurrent wheeze was better suited to exclude than to predict asthma at 11 years of age. Combining recurrent wheeze with either parental atopy, parental asthma or atopic dermatitis improved the specificity (>80), positive LR (>3) and positive post‐test probability (∼50%), rendering the combinations more appropriate for the prediction of later asthma. In conclusion, after bronchiolitis in infancy, simple clinical non‐invasive variables assessed at 2 years of age could predict asthma at 11 years of age with reasonable accuracy. However, the data were better suited to exclude than to predict later asthma. Pediatr Pulmonol. 2013; 48:538–544.

Decline in admissions for childhood asthma, a 26-year period population-based study

The prevalence of childhood asthma has increased, although the rate of hospitalization for asthma seems to decrease. In Norway, the rate of hospital admission for childhood asthma from 1984 to 2000 increased. The aim of this study was to assess further trends in hospital admissions for childhood asthma up to 2010.

Blood eosinophil counts during bronchiolitis are related to bronchial hyper-responsiveness and lung function in early adolescence.

To assess whether inflammatory markers measured in urine and blood during acute bronchiolitis in infancy were associated with asthma, lung function, bronchial hyper‐responsiveness (BHR) and atopy at 11 years of age.

Prescription patterns of inhaled corticosteroids for preschool children – A Norwegian register study

Although guidelines for treatment of wheeze and asthma in preschool children are available, symptoms are overlapping and it may be difficult to decide which children should be given inhaled corticosteroids (ICS). Previous studies suggest an inappropriate prescription pattern of ICS in this age group. We studied time trends of ICS use in preschool children in Norway during 2004–2013 by age, gender and physician specialty, and the persistence of ICS use during preschool years.

Forskrivning av legemidler mot astma til barn i perioden 2004–15

BAKGRUNN Astma kan være vanskelig å diagnostisere hos barn. For barn under skolealder finnes det få tilgjengelige objektive diagnostiske undersøkelser, og retningslinjene for diagnose og behandling er basert på sykehistorie og klinisk undersøkelse. Dette kan gi rom for varierende behandlingspraksis. MATERIALE OG METODE Data fra Reseptregisteret ble brukt til å studere forskrivning av legemidler mot astma til barn i aldersgruppene 0-4 år og 5-9 år fordelt på fylker fra 2004-15. RESULTATER Det var stor variasjon mellom fylkene i andelen per 1 000 barn som fikk forskrevet legemidler mot astma i perioden 2012-14 (aldersgruppen 0-4 år: median: 104/1 000; ekstremverdier: 64-147, aldersgruppen 5-9 år: 68/1000; 46-86). Inhalasjonssteroider var hyppigst forskrevet, og det var her variasjonen mellom fylkene var størst i begge aldersgruppene (aldersgruppen 0-4 år: 85/1 000; 42-116, aldersgruppen 5-9 år: 51/1 000; 31-70). De fleste fikk kun en eller få forskrivninger med inhalasjonssteroider over en treårsperiode. Endring i forskrivningen av inhalasjonssteroider fra 2004 til 2015 varierte betydelig mellom fylkene, mest for aldersgruppen 0-4 år. FORTOLKNING Stor forskjell i forskrivning av legemidler mot astma fylkene imellom, høy andel sporadisk bruk og endring over tid, særlig i den yngste aldersgruppen, kan tyde på en unaturlig variasjon i behandlingen som ikke kan forklares av forskjeller i astmaforekomst. Uklare retningslinjer som ikke er tilstrekkelig innarbeidet i klinisk praksis kan være én årsak.

The optimal management for patients.

We appreciate the comments by Matti Korppi regarding our recent publication in Pediatric Pulmonology. We fully agree that age limits are important when defining bronchiolitis, particularly in follow-up studies looking at risk factors for asthma later in life. Children hospitalized for wheezing during the second year of life have a higher risk for subsequent asthma, particularly if wheezing episodes start during the second year. Diagnosing these children as bronchiolitis may therefore include more children with established asthma, with an obvious consequence for the occurrence of asthma in follow-up studies. This is important to consider when comparing the outcome from different studies. Further, as also stated by Korppi, predicting subsequent asthma already at the admission for wheezing during the first 12 months of age may be difficult, as no single or group of parameters may have sufficient sensitivity and specificity. In this age group, caution should be taken both to diagnose symptoms as being asthma and to initiate treatment on a regular basis. As suggested also by Korppi, these children should be reevaluated at the age of two, as asthma can be predicted with a better accuracy at that age. It is, however, important to remember that the children studied by us represent a different population than those hospitalized and diagnosed with bronchiolitis during their second year of life. Korppi suggests including more factors in the prediction algorithm, such as eosinophilia, non-clinical atopy and viral etiology, particularly rhinovirus. However, RSV negative bronchiolitis is a heterogeneous group, and rhinovirus is not the only agent of relevance in this context. Some prospective studies have addressed the issue of viral etiology during acute bronchiolitis in more detail, and the long term outcome of these studies may provide better insight in these questions. However, the aim of the present study was to assess if simple clinical and non-invasive risk factors available at 2 years of age could predict asthma in adolescents. Our conclusion was that these simple variables, easily accessible also in an out-patient setting, could predict asthma as good as more complex models. Finally, we agree with Matti Korppi that there is a need for large and sufficiently powered prospective follow-up studies, including children with bronchiolitis and control subjects from the start. Bronchiolitis is the most common reason for hospitalization during the first year of life, and both children and parents deserve a well-founded estimate of the predictive significance of this event. — INGVILD BRUUN MIKALSEN* Department of Pediatrics Stavanger University Hospital Stavanger, Norway

Protrahert bakteriell bronkitt hos barn

Barneavdeling for allergi og lungesykdommer Oslo universitetssykehus, Rikshospitalet Hun har bidratt med litteratursøk og revisjon av manuset og har godkjent innsendte manusversjon. Suzanne Crowley (f. 1956) er dr.med. og spesialist i pediatrisk pulmonologi fra England. Hun er overlege og leder for Den norske legeforenings barnelungeinteressegruppe. Forfatter har fylt ut ICMJE-skjemaet og oppgir ingen interessekonflikter.Protracted bacterial bronchitis is a common cause of persistent, wet cough in pre-school children. The condition has been described relatively recently, and knowledge of the diagnosis may be an aid to making the correct assessment of children with chronic cough, helping to ensure that the symptoms are not misinterpreted and treated as asthma.