In the modern United Kingdom, about 12 percent of all normal, healthy, full-term babies are hospitalized at least once in their first 8 months of life. Many of these hospitalizations are for pneumonia, bronchiolitis, or other chest infections; many are for diarrhea or other gastroenteritis.  How big a difference might breastfeeding make in preventing these kids from being hospitalized?

The results of a huge study of almost 16,000 babies were published in the April 2007 Pediatrics. Researchers from Oxford and University College London looked at the outcomes of babies who were exclusively breastfed for 8 month, those who were exclusively formula-fed for the same period, and those who received a combination. After accounting for other factors,* the investigators calculated that exclusive breastfeeding could prevent more than 50 percent of all diarrhea and gastroenteritis hospitalizations each month! Even breastfeeding just partially could prevent more than 30 percent of them. Similarly, exclusive breastfeeding could prevent 27 percent of pneumonia and chest infection hospitalizations each month; partial breastfeeding could prevent 25 percent of them. The effect disappeared soon after the child was weaned.

What a gift when babies can breastfeed at least some throughout their entire first year! Even if they can’t, I’m very happy for every month they get.

*The profound effect of breastfeeding held up after researchers accounted for many other variables including birth weight, gestation, mode of delivery, infant’s age in months, infant’s gender, maternal age, whether the infant was firstborn, maternal smoking, maternal socioeconomic class, maternal occupation, maternal education, maternal marital status, and whether the infant lives in a rented accommodation.

The percentage of people with asthma has doubled in the last decade, and quadrupled since 1973. Asthma has become the most common chronic medical condition in children. To help those with asthma, allergies, and other respiratory illnesses, a number of governmental agencies have teamed up to provide a free gift. This gift comes from the United States Environmental Protection Agency, the National Weather Service, NASA, the National Park Service, Environment Canada, and a coalition of tribal, state, and local governments.

Together this cross-agency team will deliver instant, customized air quality information to your cell phone, pager, and/or email – to allow people to adjust their activities or preventive medications to stay ahead of their condition. You might sign up to be alerted if the temperature is going to drop, if the mold in the air is especially high, if pollen are rising, or if ozone or particulate pollution are likely to trigger a problem. You can learn in advance which days are likely to be smog days. In the remaining days of 2004 this helpful service, called EnviroFlash, is available in Cincinnati, Detroit, Greensboro, High Point, Nashville, Oklahoma City, and Winston-Salem. They expect to expand it to many other locations by March 2005. In the meantime, much of the information is available online at the AIRNow, EnviroFlash website.

In just a few hours, I will be boarding another airplane. Typically, commercial airplanes fly at an altitude of about 38,000 feet. The cabin is pressurized to make it safe and comfortable at that extreme altitude – but this does not make breathing in an airplane the same as breathing on the ground. Most people are not surprised that the humidity and air pressure of airplane air decreases as the plane ascends. But that’s not all that changes.

At sea level, the air we breathe contains about 21 percent oxygen; on a typical commercial flight, the cabin air has only about 15 percent oxygen. The implications of decreasing the oxygen by one quarter are discussed in the November 2004 Thorax. Most people are unaware that the oxygen levels in their blood are lower when flying. Thankfully, most children have oxygen to spare and can tolerate this without trouble, but for some, the decrease is enough to cause significant problems. New recommendations for air travel were published by the British Thoracic Society in September 2004. When possible, healthy term babies should not fly in the first week of life. Premature babies who have had complications probably should not fly until 6 months after their due dates. Anyone who has been hospitalized within the last 6 weeks with respiratory problems should not fly without a pre-flight evaluation.

For children with specific conditions such as cystic fibrosis, sickle cell anemia, or Down syndrome, it’s important to at least talk with your doctor about the risks of flying. For children with any chronic lung disease, including asthma, this conversation is important. Most children should not fly if their asthma peak flow readings are in the red zone, if their oxygen saturation is not at least 95 percent, or if they can’t walk 150 yards comfortably. All those with asthma or respiratory illnesses should bring their inhalers or other medicines with them in their carry-on luggage. For most people, and especially for most children, flying is a very safe way to travel. More than one billion people travel by air each year.

What can take otherwise vibrant, healthy teens and permanently give them the lung capacities of 50-year-olds? Air pollution! Perhaps spare the air days should be called spare the children days. The air in some cities is so dirty that it hinders normal lung development.

A landmark study in the September 9, 2004 New England Journal of Medicine followed 1,759 children from twelve different California communities with widely different air pollution levels. Lung health and air pollution levels were followed from when the children were about age 10 to about 18. Air pollution, primarily from motor vehicle exhaust, proved extremely damaging. Children in the most polluted areas were three times more likely to develop asthma. Even if they didn’t have asthma, they had a five times greater chance of having severely diminished lung capacity — and the damaging effects of pollution were found to be irreversible. The damage is about the same as that from having a mother who smokes, but not as severe as from a teen smoking directly. Why is the damage irreversible? Lung capacity normally increases until the late teens or early twenties and then declines gradually as we age. Because this damage occurs during a critical window, these kids reach a smaller peak capacity. They will decline from there for the rest of their lives.

In the communities most polluted by exhaust, about 1 in 12 kids had peak lung capacities less than 80 percent of what they should be. In the least polluted communities, it was only 1 in 62 children. Our children deserve better. What cities have the dirtiest air? The cleanest? How polluted is your city? I wish more people drove hybrid cars and super-ultra-low-emission vehicles. What will you do?

We all want to help a coughing child. But a big difference looms between what should happen and what does happen when kids have bronchitis and other cough illnesses. Even though overall antibiotic use is dropping, there is a glaring exception. More than 60 percent of kids diagnosed with bronchitis leave the doctor’s office, clinic, or emergency room with a prescription for antibiotics, according to data published in the September 2003 Pediatrics.

This continues even though the CDC has stated that antibiotics often do more harm than good for bronchitis and other cough illnesses. Regardless of how long they last, bronchitis and nonspecific cough illnesses in children rarely warrant antibiotics.

Occasionally, if the cough has lasted for more than 10 days and specific bacteria are suspected, one round of antibiotics may be worthwhile. Children with underlying lung disease (not including asthma) might also benefit from antibiotics when their diseases flare up.

We’ve done a good job reducing unhelpful antibiotic use in many other areas, I hope this cough season we do it here as well.

There has never been a better time to be sure your asthma is under control. With a proper treatment plan, most asthma symptoms can be prevented or minimized. Uncontrolled, the linings of the airways in the lungs can remain inflamed. This is not healthy for the lungs. It can also mimic symptoms of SARS, or make actual SARS worse.

Rebecca Raleigh, an American citizen who was the first suspected SARS patient in India, turned out not to have SARS, but to have a fever from another cause during a flare-up of her asthma. The core symptoms of SARS are fever greater than 100.4 F (38.0 C) and cough (usually a dry cough), difficulty breathing, or other respiratory symptoms. The respiratory symptoms of SARS and asthma can be the same. Toss in a fever, and you either have anxiety – or a real case of SARS.

Keeping asthma inflammation under control can also make it easier for people with asthma to cope with SARS or other lung infections if they are really present.

Asthma is a lung condition where the airways are sometimes tight – a result of airway hyper-responsiveness. Our airways are designed to be responsive to harmful substances in the air. If we walk through clouds of smoke, our airways will shrink, protecting our delicate lung tissues from the noxious ingredients in the smoke. They should return to normal when we begin to breathe fresh air. People with asthma have an exaggerated tightening response.

Different people with asthma respond to different “triggers.” Viral infections are among the most common triggers, especially in young children. Other triggers include smoke, animal dander, pollens, molds, house dust mites, fumes and fragrances, or cold air.

When we exercise, we breathe rapidly and are unable to bring air temperature all the way up to 98.6 degrees — particularly if we breathe through the mouth. Thus, asthmatics who are sensitive to cold air will often wheeze with exercise. (Wheezing, the classic asthma symptom, is the noise made by air moving through these tight airways.) Because asthmatics respond differently to different triggers, their airways are tighter at some times than at others.

Hyper-responsive airways tighten in three ways in response to triggers. First and most immediately, smooth muscle surrounding the airways constricts, narrowing the caliber of the airways. Second, the airways are narrowed by inflammation and swelling of the airway lining. This leads to the third component of airway narrowing, which is the accumulation of mucus and other fluids, which can plug the airways.

The inflammation is the most important part of the disease. It perpetuates the cycle of airway narrowing. It can cause ongoing damage. It also is the slowest to respond to treatment.

Despite clear treatment guidelines, far too many people have uncontrolled asthma. Albuterol is very effective at helping people breath better for the moment, but does nothing to treat the inflammation.

People with asthma who have symptoms more than twice a week, or nighttime wheezing more than twice a month, benefit greatly from using a preventive, anti-inflammatory medicine rather than using albuterol alone.

Certainly, someone who uses albuterol daily should be on a preventive medicine instead or in addition to inhaled albuterol. Preventive and anti-inflammatory medicines are greatly underused for controlling asthma.

If you or your child has asthma, ask that the National Asthma Education and Prevention Program (NAEPP) guidelines be followed. Preventing inflammation prevents damage to the lungs and can greatly improve the long-term outcome.

More infomation on SARS:
SARS – A Worldwide Threat
SARS Update
SARS Hotel
SARS KidsS
top Respiratory Infections
SARS – School’s Out
Preventing SARS
SARS and Allergies
Disease – Severe Acute Respiratory Syndrome (SARS)
SARS Unmasked
Prepare for the Worst; Hope for the Best

Definition:
Severe Acute Respiratory Syndrome (SARS) is a serious form of pneumonia, resulting in acute respiratory distress and sometimes death. It is a dramatic example of how quickly world travel can spread a disease. It is also an example of how quickly a networked health system can respond to an emerging threat.

This contagious respiratory infection was first described on February 26, 2003. SARS was identified as a new disease by WHO physician Dr. Carlo Urbani. He diagnosed it in a 48-year-old businessman who had traveled from the Guangdong province of China, through Hong Kong, to Hanoi, Vietnam. The businessman died from the illness. Dr. Urbani subsequently died from SARS on March 29, 2003 at the age of 46. In the meantime, SARS was spreading, and within 6 weeks of its discovery, it had infected thousands of people around the world, including people in Asia, Australia, Europe, Africa, and North and South America. Schools had closed throughout Hong Kong and Singapore. National economies were affected. The WHO had identified SARS as a global health threat, and issued an unprecedented travel advisory. Daily WHO updates tracked the spread of SARS seven days a week. It wasn’t clear whether SARS would become a global pandemic, or would settle into a less aggressive pattern.

The rapid, global public health response helped to stem the spread of the virus, and by June 2003, the epidemic had subsided to the degree that on June 7 the WHO backed off from its daily reports. Nevertheless, even as the number of new cases dwindled, and travel advisories began to be lifted, the sober truth remained: every new case had the potential to spark another outbreak. SARS appears to be here to stay, and to have changed the way that the world responds to infectious diseases in the era of widespread international travel.

Causes And Risk Factors
SARS is caused by a new member of the coronavirus family (the same family that can cause the common cold). The discovery of these viral particles represents some of the fastest identification of a new organism in history.

SARS is clearly spread by droplet contact. When someone with SARS coughs or sneezes, infected droplets are sprayed into the air. Like other coronaviruses, the SARS virus may live on hands, tissues, and other surfaces for up to 6 hours in these droplets and up to 3 hours after the droplets have dried. While droplet transmission through close contact was responsible for most of the early cases of SARS, evidence began to mount that SARS might also spread by hands and other objects the droplets had touched. Airborne transmission was a real possibility in some cases. Live virus had even been found in the stool of people with SARS, where it has been shown to live for up to four days. And the virus may be able to live for months or years when the temperature is below freezing.

With other coronaviruses, re-infection is common. Preliminary reports suggest that this may also be the case with SARS.

Preliminary estimates are that the incubation period is usually between two and ten days, although there have been documented cases where the onset of illness was considerably faster or slower. People with active symptoms of illness are clearly contagious, but it is not known how long contagiousness may begin before symptoms appear or how long contagiousness might linger after the symptoms have disappeared.
Reports of possible relapse in patients who have been treated and released from the hospital raise concerns about the length of time individuals can harbor the virus.

Prevention
Minimizing contact with people with SARS minimizes the risk of the disease. This might include minimizing travel to locations where there is an uncontrolled outbreak. Where possible, direct contact with people with SARS should be avoided until at least 10 days after the fever and other symptoms are gone.

The CDC has identified hand hygiene as the cornerstone of SARS prevention. This might include hand washing or cleaning hands with an alcohol-based instant hand sanitizer.

People should be taught to cover the mouth and nose when sneezing or coughing. Respiratory secretions should be considered to be infectious, which means no sharing of food, drink, or utensils. Commonly touched surfaces can be cleaned with an EPA approved disinfectant.

In some situations, appropriate masks and goggles may be useful for preventing airborne or droplet spread. Gloves might be used in handling potentially infectious secretions.

Symptoms
The hallmark symptoms are fever greater than 100.4 F (38.0 C) and cough, difficulty breathing, or other respiratory symptoms. Symptoms found in more than half of the first 138 patients included (in the order of how commonly they appeared):

• fever
• chills and shaking
• muscle aches
• cough
• headache

Less common symptoms include (also in order):

• dizziness
• productive cough (sputum)
• sore throat
• runny nose
• nausea and vomiting
• diarrhea

These symptoms are generally accompanied by findings on the chest X-ray and on laboratory tests.

Signs And Tests:
Listening to the chest with a stethoscope (auscultation) may reveal abnormal lung sounds. In most people with SARS, progressive chest X-ray changes or chest CT changes demonstrate the presence of pneumonia or respiratory distress syndrome.

Much attention was given early in the outbreak to developing a quick, sensitive test for SARS.

Specific tests for the SARS virus include the PCR for SARS virus, antibody tests to SARS (such as ELISA or IFA), and direct SARS virus isolation. All current tests have some limitations. General tests used in the diagnosis of SARS might include:

• a chest X-ray or chest CT
• a CBC (people with SARS tend to have a low white blood cell count (leukopenia), a low lymphocyte count (lymphopenia), and/or a low platelet count (thrombocytopenia).
• clotting profiles (often prolonged clotting)
• blood chemistries (LDH levels are often elevated. ALT and CPK are sometimes elevated. Sodium and potassium are sometimes low).

Treatment:
People suspected of having SARS should be evaluated immediately by a physician and hospitalized under isolation if they meet the definition of a suspect or probable case. Antibiotics are sometimes given in an attempt to treat bacterial causes of atypical pneumonia. Antiviral medications have also been used. High doses of steroids have been employed to reduce lung inflammation. In some serious cases, serum from people who have already gotten well from SARS (convalescent serum) has been given. Evidence of general benefit of these treatments has been inconclusive.

Other supportive care such as supplemental oxygen, chest physiotherapy, or mechanical ventilation is sometimes needed.

Prognosis:
As the first wave of SARS began to subside, the death rate proved to have been about 14 or 15 percent of those diagnosed. In people over age 65 the death rate was higher than 50 percent. Many more were sick enough to require mechanical ventilation. And more still were sick enough to require ICU care.

Intensive public health policies are proving to be effective in controlling outbreaks.

Many nations have stopped the epidemic within their own countries. All nations must be vigilant, however, to keep this disease under control. Viruses in the coronavirus family are known for their ability to spawn new mutations in order to better spread among humans.

Complications:

• respiratory failure
• liver failure
• heart failure
• myelodysplastic syndromes

Call Health Care Provider:
Call your health care provider if you suspect you or someone you have had close contact with has SARS.

More infomation on SARS:
SARS – A Worldwide Threat
SARS Update
SARS Hotel
SARS Kids
Stop Respiratory Infections
SARS – School’s Out
Preventing SARS
SARS and Allergies
Asthma and SARS
SARS Unmasked
Prepare for the Worst; Hope for the Best

Review date: 6/7/2003
Reviewer: Alan Greene, MD, Chief Medical Officer, A.D.A.M.

Introduction to wheezing:

Our airways are designed to be responsive to harmful substances in the air. If we walk through clouds of smoke, our airways will shrink, protecting our delicate lung tissues from the noxious ingredients in the smoke. They should return to normal when we begin to breathe fresh air.
Some people – those with asthma – have an exaggerated tightening response.

What is wheezing?

Wheezing is the noise made by air moving through tight airways in the chest. Classically, wheezing is heard when children are breathing out, and these tiny airways collapse.
Wheezing does not necessarily mean asthma – and vice versa.
Wheezing can progress to respiratory distress.

Who gets wheezing?

Wheezing is the classic symptom of asthma, but it is also an important feature of other problems such as inhaled foreign bodies, RSV infections, other types of bronchiolitis, or cystic fibrosis. Wheezing might be a symptom of gastroesophageal reflux or of a food allergy. It can also be present during many common viral infections, especially during the first two years of life.
Not all children with asthma wheeze. Some cough instead, as a way to move air through the narrowed airways.

What are the symptoms of wheezing?

Tight, noisy breathing during expiration.

Is wheezing contagious?

No – although the causes of wheezing may be contagious.

How long does wheezing last?

Wheezing lasts as long as the airways are too tight. The duration depends on the underlying cause.

How is wheezing diagnosed?

The cause of wheezing should be carefully considered. Inhaled foreign objects should always be suspected – especially with the first episode of wheezing. They are most common at the age when the child is unlikely to be able to describe what happened.
Reflux should also be considered as a possible cause, as should other sources of airway obstruction.
Wheezing and asthma are so linked in many people’s minds that other causes are often missed.

How is wheezing treated?

Wheezing is treated by reversing the tightness of the small airways of the chest. This might be done with bronchodilator medicines to relax the smooth muscles around the airways. It might be done with anti-inflammatory medicines to reduce swelling within the airways. Or it might be done by removing an inhaled object.

How can wheezing be prevented?

Wheezing can often be prevented by taking steps to prevent the individual underlying causes. See separate articles

Related A-to-Z Information:

Adenovirus, Asthma, Bronchiolitis,Common Cold, Cough, Cystic Fibrosis, Food Allergies, Gastroesophageal Reflux, Peanut Allergy, Pneumonia, RSV (Respiratory syncytial virus)

Introduction to parvovirus:

If anything comes to mind when parents hear the word “parvovirus,” it’s usually something to do with dogs or cats. This makes sense. Parvoviruses have long been known to be significant causes of disease in animals. But animal strains of parvovirus do not cause infections in humans and human parvovirus does not cause infection in other animals.

What is parvovirus?

Parvovirus B19 is a very common virus that causes infections in humans. The infection can take many forms, but the most commonly recognized is an illness called “fifth disease” or “slap-cheek.” It can also cause serious infections in unborn children and children with sickle cell disease.

Who gets parvovirus?

This is a very common infection – about half of the people in the world have had it. The typical time to be infected with parvovirus B19 is during the elementary and middle school years.
Parvovirus B19 infections are most common during the late winter and early spring.

What are the symptoms of parvovirus?

Many children with parvovirus B19 have no symptoms at all. Of those who do, the most common appearance is the childhood illness called fifth disease. It may be confused with the other childhood exanthems (rash illnesses).
Some children with parvovirus B19 infections have arthritis or joint pain, either alone or along with fifth disease.
Some develop temporary, but significant, anemia from decreased production of red blood cells. For those children who are losing red blood cells for other reasons such as sickle cell anemia, this can cause an “aplastic crisis”, where there is a severe shortage in red blood cells.
Also, in children whose immune systems are not working well, such as those with HIV infection, parvovirus B19 can cause serious illness.
If mothers become infected with parvovirus B19 for the first time during pregnancy, most babies will be fine, but some will have serious illness or death.

Is parvovirus contagious?

Yes. Parvovirus B19 is spread by respiratory droplets. It can also be spread in blood and blood products, and from mother to unborn child.

How long does parvovirus last?

The length of infection varies, but may last for weeks or months.

How is parvovirus diagnosed?

Often the diagnosis is based on a typical pattern of symptoms. Lab tests are available to aid in diagnosis and to detect immunity or recent infection.

How is it treated?

Most children need no treatment. Those with anemia or other complications may need transfusions or other specific treatment. Since this is a virus and not a bacteria, antibiotics are not useful in treating parvovirus infections.

How can parvovirus be prevented?

Because children with the parvovirus B19 rash are no longer contagious, avoiding them will not prevent infections. Routine hand washing and avoiding contact with used facial tissues can decrease spread.
Pregnant women who have been exposed to parvovirus B19 should discuss this with their obstetricians. About half of adults tested have already had it and are thus immune. Even when women get fifth disease for the first time during pregnancy, most of the babies do well. Still, some babies do need treatment, and the pregnancy should be monitored closely.

Related A-to-Z Information:

Adenovirus, Anemia (Low hemoglobin), Arthritis (Juvenile rheumatoid arthritis, JRA), Body-Fluid Transmission, Common Cold, Cough, Droplet Transmission, Exanthems (Childhood rash), Fifth Disease, Fomites, Headache, HIV, Influenza (Flu), Lyme Disease, Roseola, Scarlet Fever

Introduction to bronchiolitis:

Worried parents stand over the crib, listening to their baby cough and struggle to breathe. He may have bronchiolitis. Most parents have heard of pneumonia or bronchitis, but what does bronchiolitis mean?

What is bronchiolitis?

Bronchitis is inflammation of the large airways in the chest and pneumonia is inflammation of the lung tissue. Bronchiolitis is inflammation of the smaller airways connecting the two.
Bronchiolitis is usually a viral infection. RSV is responsible for the illness in many children. Adenovirus, parainfluenza (croup), and other viruses can also cause bronchiolitis.
In adults and older children, RSV usually appears as a bad cold. However, in babies and toddlers whose bronchioles are smaller and easier to plug, these viruses often cause bronchiolitis when inhaled.

Who gets bronchiolitis?

Bronchiolitis is primarily a disease of young children before their second birthdays. The most common age for bronchiolitis is about 6 months.
Winter and early spring are bronchiolitis season. Children in day care are usually much more likely to get bronchiolitis. Kids who are exposed to cigarette smoke are at even higher risk. Babies who attend day care are less likely to get bronchiolitis than those who stay home with a parent who smokes.
Boys are more often affected, as are formula-fed infants. Those at high risk for asthma also appear to be prone to bronchiolitis.
Most kids who get bronchiolitis have been exposed to an adult or another child with a cold in the previous week.

What are the symptoms of bronchiolitis?

Bronchiolitis usually begins with cold symptoms such as a runny nose, sneezing, and perhaps a mild cough. The appetite is often decreased. The child may have a fever or might be a bit cooler than normal.
After a day or two, breathing becomes faster and the cough becomes more severe. It may be a deep or wheezy cough. The child may develop wheezing and respiratory distress.
Breathing difficulties can make it hard for babies to feed.

Is bronchiolitis contagious?

Bronchiolitis is very contagious. It spreads most commonly by contact transmission, droplet transmission, and fomites.

How long does bronchiolitis last?

Mild bronchiolitis may last only for a day or so. Often the disease lasts 5 to 12 days. The first 3 days are the most critical.

How is bronchiolitis diagnosed?

Diagnosis is often based on the history and physical exam. A chest x-ray can give additional information, as can a pulse oximeter to measure oxygen levels. A nasal swab for RSV and other viruses might be done to identify the specific cause of bronchiolitis.

How is bronchiolitis treated?

There are no specific medicines for treating bronchiolitis at home. It is important to give plenty of fluids to prevent dehydration. Also, a humidifier or saline nose drops might be recommended to thin the mucus.
Some children need supplemental oxygen or even mechanical help to breathe.  A powerful aerosol treatment specifically against RSV is sometimes used for hospitalized children.
Steroids and antibiotics are not usually helpful. It is unclear whether inhaled medications such as albuterol are helpful.

How can bronchiolitis be prevented?

If possible, protect your baby from exposure to sick individuals during the peak bronchiolitis season. In addition, good hand washing, particularly just before anyone handles susceptible infants, can decrease spread. Don’t forget to use a tissue when you cough or sneeze.
Two products are now available to prevent RSV infection in children at high risk for serious disease. RSV-IGIV (RespiGam) and palivizumab (Synagis) have been approved for high-risk children (such as premature babies and infants with severe heart or lung diseases).

Related A-to-Z Information:

Adenovirus, Asthma,Common Cold, Contact Transmission, Cough, Croup, Cystic Fibrosis, Dehydration, Droplet Transmission, Fomites, Pneumonia, Respiratory Distress, RSV (Respiratory syncytial virus, Sudden Infant Death Syndrome (SIDS), Wheezing