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Air Quality Index and Childhood Asthma: A Pilot Randomized Clinical Trial Intervention

Author/s: 
Rosser, F. J., Rothenberger, S. D., Han, Y., Forno, E., Celedón, J. C.

Introduction: To reduce air pollution exposure, the U.S. asthma guidelines recommend that children check the Air Quality Index before outdoor activity. Whether adding the Air Quality Index and recommendations to asthma action plans reduces exacerbations and improves control and quality of life in children with asthma is unknown.

Methods: A pilot, unblinded, randomized clinical trial of 40 children with persistent asthma, stratified by age and randomized 1:1, recruited from the University of Pittsburgh Medical Center Children's Hospital of Pittsburgh (Pittsburgh, PA) was conducted. All participants received asthma action plans and Air Quality Index education. The intervention group received printed Air Quality Index information and showed the ability to use AirNow. Asthma exacerbations were assessed through a questionnaire, asthma control was assessed with the Asthma Control Test and Childhood Asthma Control Test, and quality of life was assessed with the Pediatric Asthma Quality of Life Questionnaire. After randomization (July-October 2020), participants were followed monthly for 6 months (exit January-March 2021). Outcome differences between groups were evaluated at the exit visit and over time (analysis was in 2021).

Results: At randomization, there were no significant differences in age, sex, race, or asthma severity. At exit, more intervention participants checked the Air Quality Index (63% vs 15%) with no differences in the proportion of asthma exacerbations or mean Childhood Asthma Control Test or Pediatric Asthma Quality of Life Questionnaire scores. The mean change in Asthma Control Test score was higher in the intervention group (change in Asthma Control Test=2.00 vs 0.15 for the control), which was modified by time (β=1.85, CI=0.09, 3.61). Physical activity was decreased overall and showed modification by treatment and time.

Conclusions: Addition of the Air Quality Index to asthma action plans led to improved asthma control by Asthma Control Test scores but may decrease outdoor activity.

Keywords 
children quality of life asthma air pollution United States

Acid Suppression and Antibiotics Administered During Infancy Are Associated with Celiac Disease

Author/s: 
Boechler, M., Susi, A., Hisle-Gorman, E., Rogers, P. L., Nylund, C. M.

Objective
To investigate why certain at-risk individuals develop celiac disease, we examined the association of proton pump inhibitors (PPI), histamine-2 receptor antagonist (H2RA), and antibiotic prescriptions in the first six months of life with an early childhood diagnosis of celiac disease.
Study design
A retrospective cohort study was performed using the Military Healthcare System (MHS) database. Children with a birth record from October 1, 2001- September 30, 2013, were identified. Outpatient prescription records were queried for antibiotic, PPI, and H2RA prescriptions in the first 6 months of life. Cox proportional hazards regression was used to calculate the hazard ratio (HR) of developing CD based on medication exposure. ICD-9 codes identified children with an outpatient visit for celiac disease.
Results
968,524 children met inclusion criteria with 1,704 cases of celiac in this group. Median follow up for the cohort was about 4.5 years. PPI’s (HR, 2.23; 95% CI, 1.76-2.83), H2RA’s (HR, 1.94 95% CI, 1.67-2.26) and antibiotics (HR 1.14 95%CI 1.02-1.28) were all associated with an increased hazard of celiac disease.
Conclusion
There is an increased risk of developing celiac disease if antibiotics, PPI’s and H2RA’s are prescribed in the first 6 months of life. Our study highlights modifiable factors such as medication stewardship that may change the childhood risk of CD.

Keywords 
Infancy Retrospective Studies children prescriptions celiac disease

The effect of lead exposure on IQ test scores in children under 12 years: a systematic review and meta-analysis of case-control studies

Author/s: 
Heidari, S., Mostafaei, S., Razazian, N., Rajati, M., Saeedi, A., Rajati, F.

An inevitable exposure to the toxic heavy metal such as lead in our environmental can have irreversible effects on children's mental performance.In this study, 3316 children in 8 case-control studies were selected for review. The case group was exposed to a concentration of lead above 10 μg/dL, and the control group was exposed to a concentration of less than 10 μg/dL, but the duration of exposure was different among studies, and the subgroup analysis was performed based on this variable.In the subgroup with duration of exposure less than the average of 4.5 years, the difference of IQ test score between two groups was significant (MD = -3.53) (P-value <0.05). Also, in the subgroup with more than 4.5 years of duration, the difference of IQ test score was significant (MD = -22.63) (P-value < 0.001).This study demonstrates that the concentration and duration of lead exposure have a large effect on mental function in children.

Keywords 
children Intelligence Tests Lead meta-analysis systematic review

Food Allergy Prevention: Early Versus Late Introduction of Food Allergens in Children

Author/s: 
Djossi, S. K., Khedr, A., Neupane, B., Proskuriakova, E., Jada, K., Mostafa, J. A.

The emergence of food allergies in children is crucial for various medical fields seeking a viable strategy for allergy prevention. The most well-recognized approach adopted by numerous health care and government institutions hinges on the delay in the introduction of food allergens, which supposedly protects infants from sensitization and decreases the possibility of allergy development. However, recent experimental findings indicate that the benefits of this approach might be overestimated, as early exposure to allergenic foods has been shown to yield more advantageous outcomes. Multiple investigations on the causes of allergic diseases report that avoiding food allergies might be related to early consumption of these allergens. Alternatively, delaying the contact with allergenic nourishments, explored in contemporary research, has been proven to result in a higher prevalence of allergies among children, originating such conditions as atopic diseases and extreme sensitization to foods. The current paper compares the two prominent strategies of allergenic food introduction, gathering the most pertinent modern evidence to distinguish whether exposure to food allergens should be delayed or advanced.

Keywords 
Food Allergy children Allergens Allergy Prevention

Screening and Interventions to Prevent Dental Caries in Children Younger Than 5 Years US Preventive Services Task Force Recommendation Statement

Author/s: 
US Preventative Services task Force

IMPORTANCE Dental caries is the most common chronic disease in children in the US.
According to the 2011-2016 National Health and Nutrition Examination Survey, approximately
23% of children aged 2 to 5 years had dental caries in their primary teeth. Prevalence is higher
in Mexican American children (33%) and non-Hispanic Black children (28%) than in
non-Hispanic White children (18%). Dental caries in early childhood is associated with pain,
loss of teeth, impaired growth, decreased weight gain, negative effects on quality of life, poor
school performance, and future dental caries.
OBJECTIVE To update its 2014 recommendation, the US Preventive Services Task Force
(USPSTF) commissioned a systematic review on screening and interventions to prevent
dental caries in children younger than 5 years.
POPULATION Asymptomatic children younger than 5 years.
EVIDENCE ASSESSMENT The USPSTF concludes with moderate certainty that there is a
moderate net benefit of preventing future dental caries with oral fluoride supplementation at
recommended doses in children 6 months or older whose water supply is deficient in
fluoride. The USPSTF concludes with moderate certainty that there is a moderate net benefit
of preventing future dental caries with fluoride varnish application in all children younger
than 5 years. The USPSTF concludes that the evidence is insufficient on performing routine
oral screening examinations for dental caries by primary care clinicians in children younger
than 5 years and that the balance of benefits and harms of screening cannot be determined.
RECOMMENDATION The USPSTF recommends that primary care clinicians prescribe oral fluoride
supplementation starting at age 6 months for children whose water supply is deficient in
fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply
fluoride varnish to the primary teeth of all infants and children starting at the age of primary
tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is
insufficient to assess the balance of benefits and harms of routine screening examinations for
dental caries performed by primary care clinicians in children younger than 5 years. (I statement)

Keywords 
Dental Caries screening Intervention children

A retrospective cohort study of 12,306 pediatric COVID‑19 patients in the United States

Author/s: 
Parcha, V., Booker, K.S., Kalra, R., Kuranz, S., Berra, L., Arora, G., Arora, P.

Children and adolescents account for ~ 13% of total COVID-19 cases in the United States. However, little is known about the nature of the illness in children. The reopening of schools underlines the importance of understanding the epidemiology of pediatric COVID-19 infections. We sought to assess the clinical characteristics and outcomes in pediatric COVID-19 patients. We conducted a retrospective cross-sectional analysis of pediatric patients diagnosed with COVID-19 from healthcare organizations in the United States. The study outcomes (hospitalization, mechanical ventilation, critical care) were assessed using logistic regression. The subgroups of sex and race were compared after propensity score matching. Among 12,306 children with lab-confirmed COVID-19, 16.5% presented with respiratory symptoms (cough, dyspnea), 13.9% had gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal pain), 8.1% had dermatological symptoms (rash), 4.8% had neurological (headache), and 18.8% had other non-specific symptoms (fever, malaise, myalgia, arthralgia and disturbances of smell or taste). In the study cohort, the hospitalization frequency was 5.3%, with 17.6% needing critical care services and 4.1% requiring mechanical ventilation. Following propensity score matching, the risk of all outcomes was similar between males and females. Following propensity score matching, the risk of hospitalization was greater in non-Hispanic Black (RR 1.97 [95% CI 1.49-2.61]) and Hispanic children (RR 1.31 [95% CI 1.03-1.78]) compared with non-Hispanic Whites. In the pediatric population infected with COVID-19, a substantial proportion were hospitalized due to the illness and developed adverse clinical outcomes.

Keywords 
COVID-19 pediatrics United States children 2019 novel coronavirus coronavirus

A national consensus management pathway for paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS): results of a national Delphi process

Author/s: 
Harwood, Rachel, Allin, Benjamin, Jones, Christine E., Whittaker, Elizabeth, Ramnarayan, Padmanabhan, Ramanan, Athimalaipet V., Kaleem, Musa, Tulloh, Robert, Peters, Mark J., Almond, Sarah, Davis, Peter J., Levin, Michael, Tometzki, Andrew, Faust, Saul N., Knight, Marian, Kenny, Simon

Paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) is a novel condition that was first reported in April, 2020. We aimed to develop a national consensus management pathway for the UK to provide guidance for clinicians caring for children with PIMS-TS. A three-phase online Delphi process and virtual consensus meeting sought consensus over the investigation, management, and research priorities from multidisciplinary clinicians caring for children with PIMS-TS. We used 140 consensus statements to derive a consensus management pathway that describes the initial investigation of children with suspected PIMS-TS, including blood markers to help determine the severity of disease, an echocardiogram, and a viral and septic screen to exclude other infectious causes of illness. The importance of a multidisciplinary team in decision making for children with PIMS-TS is highlighted throughout the guidance, along with the recommended treatment options, including supportive care, intravenous immunoglobulin, methylprednisolone, and biological therapies. These include IL-1 antagonists (eg, anakinra), IL-6 receptor blockers (eg, tocilizumab), and anti-TNF agents (eg, infliximab) for children with Kawasaki disease-like phenotype and non-specific presentations. Use of a rapid online Delphi process has made it possible to generate a national consensus pathway in a timely and cost-efficient manner in the middle of a global pandemic. The consensus statements represent the views of UK clinicians and are applicable to children in the UK suspected of having PIMS-TS. Future evidence will inform updates to this guidance, which in the interim provides a solid framework to support clinicians caring for children with PIMS-TS. This process has directly informed new PIMS-TS specific treatment groups as part of the adaptive UK RECOVERY trial protocol, which is the first formal randomised controlled trial of therapies for PIMS-TS globally.

Keywords 
COVID-19 SARS coronavirus SARS-CoV-2 coronavirus children

Mucocutaneous Manifestations of Multisystem Inflammatory Syndrome in Children During the COVID-19 Pandemic

Author/s: 
Young, Trevor K., Shaw, Katharina S., Shah, Jinal K., Noor, Asif, Alperin, Risa A., Ratner, Adam J., Orlow, Seth J., Betensky, Rebecca A., Shust, Gail F., Kahn, Philip J., Oza, Vikash S.

Importance: To date, no study has characterized the mucocutaneous features seen in hospitalized children with multisystem inflammatory syndrome in children (MIS-C) or the temporal association of these findings with the onset of systemic symptoms.

Objective: To describe the mucocutaneous findings seen in children with MIS-C during the height of the coronavirus disease 2019 (COVID-19) pandemic in New York City in 2020.

Design, setting, and participants: A retrospective case series was conducted of 35 children admitted to 2 hospitals in New York City between April 1 and July 14, 2020, who met Centers for Disease Control and Prevention and/or epidemiologic criteria for MIS-C.

Main outcomes and measures: Laboratory and clinical characteristics, with emphasis on mucocutaneous findings, of children who met criteria for MIS-C. The characterization of mucocutaneous features was verified by 2 board-certified pediatric dermatologists.

Results: Twenty-five children (11 girls [44%]; median age, 3 years [range, 0.7-17 years]) were identified who met definitional criteria for MIS-C; an additional 10 children (5 girls [50%]; median age, 1.7 years [range, 0.2-15 years]) were included as probable MIS-C cases (patients met all criteria with the exception of laboratory test evidence of severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection or known exposure). The results of polymerase chain reaction tests for SARS-CoV-2 were positive for 10 patients (29%), and the results of SARS-CoV-2 immunoglobulin G tests were positive for 19 patients (54%). Of the 35 patients, 29 (83%) exhibited mucocutaneous changes, with conjunctival injection (n = 21), palmoplantar erythema (n = 18), lip hyperemia (n = 17), periorbital erythema and edema (n = 7), strawberry tongue (n = 8), and malar erythema (n = 6) being the most common findings. Recognition of mucocutaneous findings occurred a mean of 2.7 days (range, 1-7 days) after the onset of fever. The duration of mucocutaneous findings varied from hours to days (median duration, 5 days [range, 0-11 days]). Neither the presence nor absence of mucocutaneous findings was significantly associated with overall disease severity.

Conclusions and relevance: In this case series of hospitalized children with suspected MIS-C during the COVID-19 pandemic, a wide spectrum of mucocutaneous findings was identified. Despite their protean and transient nature, these mucocutaneous features serve as important clues in the recognition of MIS-C.

Keywords 
COVID-19 coronavirus children Multisystem Inflammatory Syndrome

Managing nonspecific abdominal pain in children and young people

Author/s: 
Chanchlani, Neil, Walters, Thomas D., Russell, Richard K.

KEY POINTS

• Children present frequently to primary and emergency care with nonspecific abdominal pain.

• Only a few treatment options exist to manage colicky, undifferentiated pain; however, most children will not present more than once or twice to health services for this problem.

• Undifferentiated abdominal pain is poorly understood but likely multifactorial, arising from a combination of sensitizing medical events, psychosocial events and visceral hyperalgesia.

• Among children who seek health care for this problem, 20%–25% go on to be diagnosed with a disorder of the brain–gut axis, “a functional gastrointestinal disorder,” for which international guidelines exist to guide management.

• At first consultation, it is important to establish a positive therapeutic relationship between the clinician and the child and their parents, focusing on optimizing symptom control over unnecessary investigation and medicines.

Keywords 
children Emergency Care

A Randomized, Controlled Trial of Liraglutide for Adolescents With Obesity

Author/s: 
Kelly, AS, Auerbach, P, Barrientos-Perez, M, Gies, I, Hale, PM, Marcus, C, Mastrandrea, LD, Prabhu, N, Arslanian, S, NN8022-4180 Trial Investigators

Background: Obesity is a chronic disease with limited treatment options in pediatric patients. Liraglutide may be useful for weight management in adolescents with obesity.

Methods: In this randomized, double-blind trial, which consisted of a 56-week treatment period and a 26-week follow-up period, we enrolled adolescents (12 to <18 years of age) with obesity and a poor response to lifestyle therapy alone. Participants were randomly assigned (1:1) to receive either liraglutide (3.0 mg) or placebo subcutaneously once daily, in addition to lifestyle therapy. The primary end point was the change from baseline in the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) standard-deviation score at week 56.

Results: A total of 125 participants were assigned to the liraglutide group and 126 to the placebo group. Liraglutide was superior to placebo with regard to the change from baseline in the BMI standard-deviation score at week 56 (estimated difference, -0.22; 95% confidence interval [CI], -0.37 to -0.08; P = 0.002). A reduction in BMI of at least 5% was observed in 51 of 113 participants in the liraglutide group and in 20 of 105 participants in the placebo group (estimated percentage, 43.3% vs. 18.7%), and a reduction in BMI of at least 10% was observed in 33 and 9, respectively (estimated percentage, 26.1% vs. 8.1%). A greater reduction was observed with liraglutide than with placebo for BMI (estimated difference, -4.64 percentage points) and for body weight (estimated difference, -4.50 kg [for absolute change] and -5.01 percentage points [for relative change]). After discontinuation, a greater increase in the BMI standard-deviation score was observed with liraglutide than with placebo (estimated difference, 0.15; 95% CI, 0.07 to 0.23). More participants in the liraglutide group than in the placebo group had gastrointestinal adverse events (81 of 125 [64.8%] vs. 46 of 126 [36.5%]) and adverse events that led to discontinuation of the trial treatment (13 [10.4%] vs. 0). Few participants in either group had serious adverse events (3 [2.4%] vs. 5 [4.0%]). One suicide, which occurred in the liraglutide group, was assessed by the investigator as unlikely to be related to the trial treatment.

Conclusions: In adolescents with obesity, the use of liraglutide (3.0 mg) plus lifestyle therapy led to a significantly greater reduction in the BMI standard-deviation score than placebo plus lifestyle therapy. (Funded by Novo Nordisk; NN8022-4180 ClinicalTrials.gov number, NCT02918279.).

Keywords 
obesity children adolscent body mass index body weight weight loss
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