Pediatrics

Vitamin D supplementation for acute bronchiolitis: a double-blind randomized controlled trial Amr A Sarhan, Nancy M Saeed, Ahmed A Mostafa, Amal M Osman Alexandria Journal of Pediatrics 2019 32(2):61-67 Background Vitamin D deficiency has been declared as a risk factor for acute bronchiolitis. Objective The aim was to delineate the therapeutic effect of vitamin D supplementation on the clinical course of acute bronchiolitis and to investigate the relationship between vitamin D status and the severity of acute bronchiolitis. Materials and methods A randomized double-blind controlled trial was conducted including 60 infants who required hospital-based care for acute bronchiolitis. The included infants were randomly assigned to either vitamin D3 treatment (100 IU/kg/day) (vitamin D group) or placebo (placebo group) all through the period of admission. The primary outcome was the length of hospital stay in days, and the secondary outcome measures were as follows: time to resolution of tachypnea, chest retractions, hypoxia, inability to feed/lethargy, and any adverse events. Modified Tal score was used for severity assessment. Basal serum vitamin D level was evaluated in all patients before enrollment in the randomized trial. Results The vitamin D group had significantly shorter length of hospital stay, rapid resolution of signs of respiratory distress, and shorter need for oxygen therapy. Further, patients with severe disease showed significant low basal serum vitamin D level compared with milder cases. Moreover, patients with exclusive breastfeeding and those with daily outdoor exposure for less than 1 h were found to have significantly lower serum vitamin D. Conclusion Vitamin D supplementation at a dose of 100 IU/kg/day could have a significant beneficial effect in infants with acute bronchiolitis.

Ventilator-associated pneumonia: incidence and risk factors in the paediatric intensive care unit Dalia A Latef, Lamiaa M Kamel, Amany M AbdAllah Alexandria Journal of Pediatrics 2019 32(2):68-75 Background Ventilator-associated pneumonia (VAP) is one of the endless research topics that is always under focus, as it represents a major problem in the medical and surgical ICUs, especially with the growing problem of continuous settlement of resistant bacterial strains that influence all prevention bundles. Objective The aim of this study was to update the incidence, risk factors, and outcome of VAP in PICU. Patients and methods This prospective observational study was conducted on 300 cases admitted to the PICU in Zagazig University Hospitals, Egypt. All children were radiologically free means have no abnormal lung aeration findings. And connected to mechanical ventilation due to non-pulmonary cause. Follow-up of the cases was scheduled, and radiological, clinical and laboratory data were obtained throughout their ICU stay and according to their days of MV. Results The incidence of VAP was 37.56 per 1000 ventilation days of PICU patients. The commonest significant risk factors for VAP among the studied group were reintubation [relative risk (RR)=1.53; 95% confidence interval (CI): 1.01–32.24], exposure to sedation (RR=8.13; 95% CI: 2.05–32.24), rate of suction greater than or equal to 3 h interval (RR=2.72; 95% CI: 1.62–4.54), recumbent position (RR=2.69; 95% CI: 1.54–4.71), interval of oral hygiene (RR=1.84; 95% CI: 1.21–2.8), and ineffective hand hygiene (RR=1.51; 95% CI: 1.01–2.5). Multivariate regression analysis revealed that reintubation, rate of oral hygiene greater than 3 h, and duration of MV greater than 7 days are independent risk factors for VAP. Moreover, there was a nonsignificant relation between presence of VAP and mortality among studied patients. Conclusions The main risk factors for VAP are reintubation, longevity of MV, and the rate of oral hygiene. Close monitoring and training of all ICU staff is recommended.

The role of nebulized hypertonic saline in the management of acute bronchiolitis Dooa A.E Heiba Alexandria Journal of Pediatrics 2019 32(2):76-85 Background Acute bronchiolitis is the most frequent lower respiratory tract infection in infants and the most frequent cause of hospitalization in this age group. It places enormous strains on pediatric inpatient services and pediatric ICUs, and despite the growing understanding of its pathogenesis, currently available therapies have failed to show consistent benefit, and supportive care remains the mainstay of bronchiolitis therapy. It is suggested that hypertonic saline nebulization may be useful in making secretions less viscous and promoting their excretion, thereby resulting in clinical improvement, and over the past decade, a growing number of randomized trials have suggested that early and repeated doses of nebulized 3% hypertonic saline improve clinical outcomes in hospitalized children compared with 0.9% normal saline. Objectives The current study aimed to study the safety and efficacy of nebulized 3% hypertonic saline in hospitalized infants with a clinical diagnosis of bronchiolitis. Patients and methods This double-blind, randomized controlled trial was conducted on 110 infants who were admitted to Alexandria University Children’s Hospital with a clinical diagnosis of acute bronchiolitis. The diagnosis of bronchiolitis was based on clinical evaluation. Patients were randomly allocated into two groups: one group received nebulized 3% hypertonic saline with 2.5-mg salbutamol at intervals of 4 h, whereas the second group received nebulized 0.9% normal saline with 2.5-mg salbutamol at intervals of 4 h. Results There was no significant difference in the clinical severity score between the two studied groups in all days of admission, except for mild improvement on the second and third days of admission, yet it was not sufficient enough to make the patients eligible for discharge. Furthermore, there was no significant difference in length of hospital stay among infants who received hypertonic saline. Complications of nebulized hypertonic saline, namely, vomiting, agitation, exacerbation of cough, cyanosis, and apnea, were similar to normal saline. Conclusion The use of nebulized 3% hypertonic saline in hospitalized infants with bronchiolitis is considered safe, but when compared with 0.9% normal saline, it did not improve the clinical severity score nor shorten the length of hospital stay in hospitalized infants with bronchiolitis.

Evaluation of left ventricular diastolic and systolic function in children with type 1 diabetes mellitus using echocardiography and tissue Doppler imaging Magdy A Ramadan, Mamdouh A Elghandour, Hani M Adel, Shaimaa A.M Oraby Alexandria Journal of Pediatrics 2019 32(2):86-92 Background It has been shown that children with type 1 diabetes mellitus (T1DM) have high incidence of heart failure even in the absence of ischemic, hypertensive, or valvular heart disease. Most of these children have normal or even hyper-dynamic left ventricular (LV) systolic function at rest, whereas the diastolic function, particularly relaxation, is impaired. Tissue Doppler echocardiography measures myocardial motion and velocity, which provide a useful tool for defining subtle systolic and diastolic dysfunction. Objective To assess the LV systolic and diastolic functions in children with type 1 diabetes mellitus attending the Alexandria University Children’s Hospital and its relation to the glycemic control and duration of the disease. Patients and methods The study was conducted on 40 patients with T1DM who were followed up at the diabetes clinic of the Alexandria University Children’s Hospital and 20 apparently healthy control children of matched age and sex. Cardiac functions were assessed by conventional Doppler echocardiography and tissue Doppler imaging (TDI). Results The results showed early cardiomyopathic changes in the form of diastolic dysfunction and impaired relaxation by studying the E/A ratio using conventional Doppler mitral flow in 7.5% of the diabetic children, whereas by using pulsed TDI, we found diastolic dysfunction of the septal or medial segment of the LV in 52.5%, and of the lateral segment in 42.2% of the diabetic patients. Moreover, the mean peak pulsed Doppler Am velocity was significantly higher in diabetic patients than in controls. There was a significant negative correlation between the duration of diabetes and E/A ratio. A significant negative correlation was found also between the LV diastolic dysfunction and the duration of the diabetes, whereas no significant correlation was found with the glycated hemoglobin% or age of the patients. The systolic function was normal in our diabetic patients. Conclusion Our diabetic patients are in need of better glycemic control and periodic echocardiographic assessments, particularly by TDI to monitor the progression of subclinical ventricular dysfunction and to guard against the development of congestive heart failure.

Study of the effects of the use of sustained lung inflation in treatment of preterm infants with respiratory distress in the delivery room Hesham Ghazal, Hassan Heshmat, Khalid M Saad, Marwa Abdel Karim Alexandria Journal of Pediatrics 2019 32(2):93-100 Objective To assess the effect of sustained lung inflation (SLI) on the need for invasive mechanical ventilation (MV) within the first 72 h of age in preterm infants with respiratory distress. Study design In this controlled trial, we randomly assigned preterm infants 33 weeks of gestation or less to receive SLI (25 cmH2O) at birth, to be repeated if needed for a second time (30 cmH2O) followed by continuous positive airway pressure (CPAP), or assistance according to the recommendations of the American Academy of Pediatrics. The primary outcome was the need for invasive MV within the first 72 h of life. The secondary outcomes included development of bronchopulmonary dysplasia or death. The risk ratios (RRs) and 95% confidence intervals of the outcomes were calculated for the SLI group and compared with the control group. Results A total of 145 infants were enrolled: 71 in the SLI group and 74 in the control group. Less preterm infants needed invasive MV in the SLI of preterm group compared with the control group (19.72 vs. 29.73%; RR, 0.6633; 95% confidence interval, 0.2693–1.2517), with a number needed to treat of 10 patients; the difference was statistically significant by multivariate logistic regression (P=0.032). No statistically significant difference was detected between the studied groups regarding the occurrence of bronchopulmonary dysplasia, and also the median cumulative survival for the SLI of preterms group showed no statistically significant difference when compared with the median of the standard group. Conclusion A sustained inflation followed by early nasal CPAP, delivered through a nasopharyngeal tube, is a more efficient strategy than repeated manual inflations with a self-inflating bag and mask followed by nasal CPAP on admission to the neonatal intensive care unit.