Preventing Exacerbations in Preschoolers With Recurrent Wheeze: A Meta-analysis

Kaiser, Sunitha V.; Huynh, Tram; Bacharier, Leonard B.; Rosenthal, Jennifer L.; Bakel, Leigh Anne; Parkin, Patricia C.; Cabana, Michael D.

doi:10.1542/peds.2015-4496

Cited by 110 publications

(116 citation statements)

References 45 publications

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“…A recent Cochrane review found that there was no evidence for maintenance or intermittent montelukast in pre‐school children with EVW. A recent meta‐analysis agreed with these findings, noting the positive effect of intermittent administration of ICS for these children. Previously, an Australian study found a reduction in acute unscheduled medical presentations for those randomised to montelukast compared to placebo …”

supporting

confidence: 55%

Role of montelukast in management of episodic viral wheeze

Harding

2017

J Paediatrics Child Health

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Egg allergy preventionThe mistaken belief that you could prevent peanut allergy by withholding peanuts from infants was turned on its head when studies showed the opposite. Now a Japanese group has shown that early introduction of egg is associated with far less egg allergy.1 Children aged 4-5 months with eczema, and consequent high risk of food allergy, who had never been given egg, were randomised to be given heated egg powder or placebo. The egg was started at age 6 months at a low dose (50 mg daily), increased to 250 mg daily from 9 to 12 months. At age 12 months, the incidence of egg allergy was assessed clinically through oral food challenge. The calculated sample size was 150, but the researchers stopped the study after 100 children had been challenged, because 9% of the eggs exposed but 38% of the placebo children had developed diagnosed egg allergy (risk ratio = 0.22, 95% confidence interval 0.08-0.60, P = 0.001). The only difference in adverse events between groups was that 6 of 60 children in the egg group but none of the placebo group were admitted to hospital; P = 0Á022). The novel aspects of this study are the use of heated egg in powder form and the gradual increase in dose. The proportion of all babies who survived without neurodevelopmental impairment increased from 16 to 20%. While these differences were statistically significant, for a parent deciding about resuscitation or intensive care, the message is that just over a third will survive and half the survivors will have major neuro-developmental impairment. The study could not examine lesser degrees of impairment in the 'normal' survivors. The mortality for 22-week gestation infants did not change across the three-time periods (98, 95 and 97%), and only 9 (1.2%) of 749 22-weekers survived without neuro-developmental impairment. Kaiser et al. also examined the use of ICS in pre-school children with EVW. Intermittent ICS -that is, high-dose ICS given at onset of viral upper respiratory tract infection symptoms for 7-10 days -is beneficial when compared to placebo (number needed to treat = 6), with one severe exacerbation (as defined by need for oral corticosteroids) prevented for every six children treated (Fig. 1), 1 and is equivalent to regular ICS in this subgroup. This approach is an attractive therapeutic option as it has the potential to reduce systemic steroid exposure as well as hospital presentations. At present, the optimal dose of intermittent ICS is unknown as the dose varied across the studies included in the meta-analysis and in most cases was greater than the licensed dose for this age group, if licensed at all. 4 We believe that this study has highlighted intermittent ICS as a potential therapeutic option in pre-school children with EVW, and anticipate that further studies will inform translation to clinical practice if a safe and effective dose can be identified. Reference Reference References

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supporting

confidence: 55%

Role of montelukast in management of episodic viral wheeze

Harding

2017

J Paediatrics Child Health

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“…Among medical treatments for control of recurrent preschool wheeze, which are reviewed in this issue by Avraham Beigelman, inhaled corticosteroid use has accrued the most evidence of effectiveness [18–21], with less evidence supporting use of leukotriene inhibitors [22]. A recent multicenter randomized crossover trial demonstrated heterogeneity in response to treatment: 74% of 230 children age 12–59 months who require a daily controller medication had a differential response to treatment with daily inhaled corticosteroids, intermittent inhaled corticosteroids, and leukotriene receptor antagonists.…”

Section: Medical Management In Early Childhoodmentioning

confidence: 99%

Strategies to alter the natural history of childhood asthma

Lee-Sarwar

Bacharier

Litonjua

2017

Current Opinion in Allergy &Amp; Clinical Immunology

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Purpose of review Asthma exhibits significant heterogeneity in occurrence and severity over the lifespan. Our goal is to discuss recent evidence regarding determinants of the natural history of asthma during childhood, and review the rationale behind and status of major efforts to alter its course. Recent findings Variations in microbial exposures are associated with risk of allergic disease, and the use of bacterial lysates may be a promising preventive strategy. Exposure to air pollution appears to be particularly damaging in prenatal and early life, and interventions to reduce pollution are feasible and result in clinical benefit. E-cigarette use may have a role in harm reduction for conventional cigarette smokers with asthma, but has undefined short- and long-term effects that must be clarified. Vitamin D insufficiency over the first several years of life is associated with risk of asthma, and vitamin D supplementation reduces the risk of severe exacerbations. Summary The identification of risk factors for asthma occurrence, persistence and severity will continue to guide efforts to alter the natural history of the disease. We have reviewed several promising strategies that are currently under investigation. Vitamin D supplementation and air pollution reduction have been shown to be effective strategies and warrant increased investigation and implementation.

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“…Evidence is accumulating to support the use of modest doses of maintenance inhaled corticosteroid 28. For those infants experiencing severe or frequent episodes, in particular for those requiring critical care, it would seem reasonable to consider an 8-week trial of low dose maintenance inhaled corticosteroids.…”

Section: Maintenance Treatmentmentioning

confidence: 99%

Fifteen-minute consultation: An evidence-based approach to the child with preschool wheeze

Khetan¹,

Hurley

Neduvamkunnil³

et al. 2017

Arch Dis Child Educ Pract Ed

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Preschool wheeze is very common and its prevalence is increasing. It consumes considerable healthcare resources and has a major impact on children and their families due to significant morbidity associated with acute episodes.History taking is the main diagnostic instrument in the assessment of preschool wheeze. Diagnosis and management is complicated by a broad differential and associations with many other diseases and conditions that give rise to noisy breathing, which could be misinterpreted as wheeze. Several clinical phenotypes have been described but they have limitations and do not clearly inform therapeutic decisions. New insights in aetiopathogenesis modify treatment options and lay foundation for further research. An understanding of the approach and available evidence to assess and manage wheeze informs best patient care and use of resources.Our objective is to demonstrate a focused history, examination and management options in a preschool child with wheeze.

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Preventing Exacerbations in Preschoolers With Recurrent Wheeze: A Meta-analysis

Cited by 110 publications

References 45 publications

Role of montelukast in management of episodic viral wheeze

Role of montelukast in management of episodic viral wheeze

Strategies to alter the natural history of childhood asthma

Fifteen-minute consultation: An evidence-based approach to the child with preschool wheeze

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