American Thoracic Society: Clinical Practice Guideline on ILD in infancy

The American Thoracic Society has released new clinical practice guidelines on the classification, evaluation and management of childhood interstitial lung disease (chILD) in infants.

Childhood ILD includes a diverse group of rare lung diseases found in infants, children and teens that involve the interstitial tissues of the lung, which surround the air sacs (alveoli) in the lung and airways (breathing tubes).

It is not known how many children have these disorders. Some types of chILD are caused by other diseases, while the cause is unclear in others, and prognosis varies by disease type.

The new guidelines appear in the August 1 American Journal of Respiratory and Critical Care Medicine.

"The characteristics and natural history of ILD differ in children and adults," said Geoffrey Kurland, MD, of the Division of Pediatric Pulmonology at the Children's Hospital of Pittsburgh and a member of the committee that drafted the guidelines.

"These new guidelines specifically address the diagnostic evaluation and management of chILD in neonates and infants, as most of the new diagnostic entities that have been recently described affect infants disproportionately."

The guidelines' recommendations include the following:

Diagnosis:

• Once other possible causes of lung disease symptoms have been eliminated, "chILD Syndrome" can be diagnosed if at least three of the following four criteria are present: (1) respiratory symptoms (cough, rapid and/or difficult breathing, or exercise intolerance), (2) respiratory signs (tachypnea, adventitious sounds, retractions, digital clubbing, failure to thrive, or respiratory failure), (3) hypoxemia, and (4) diffuse abnormalities on a chest radiograph or computed tomography (CT) scan. 
• In patients with chILD Syndrome, diagnostic testing should be performed to determine the exact chILD diagnosis and echocardiography should be performed as part of the initial evaluation to rule out structural cardiovascular disease and pulmonary hypertension.
• If thin section CT is performed, the lowest radiation dose that provides adequate diagnostic information should be used.
• For neonates and infants with chILD Syndrome in whom other diagnostic investigations have not identified the precise chILD disease, or in whom there is clinical urgency to identify the precise chILD disease, surgical lung biopsy should be performed, preferably using video-assisted thoracoscopy rather than open thoracotomy. 
• Appropriate genetic testing should be performed.

Management:

• As there have been no controlled trials of any therapeutic interventions in chILD Syndrome, management is based upon indirect evidence, case reports and clinical experience. 
• For infants with severe, life threatening chILD diseases, referral to a pediatric lung transplantation center after discussion with the family is recommended.
• Given the limited evidence of a beneficial effect on clinical outcomes and the well-known side effects of immunosuppressive medications, the decision about whether or not to initiate a trial of immunosuppressive therapy must be made on a case-by-case basis. Considerations include the severity of disease, rate of progression, prognosis without treatment, co-morbidities and family values and preferences. 
• All patients with chILD Syndrome should receive supportive and preventive care, including treatment of co-morbidities and prevention of infection. 
• Families of patients with chILD Syndrome should receive education and support from care providers.

Research priorities:

• Establish accurate incidence and prevalence rates of specific chILD diagnoses. 
• Determine the natural history and clinical phenotypes of specific chILD diagnoses and their relationships to adult pulmonary disease through international databases. 
• Further delineate the mechanisms underlying chILD diagnoses. 
• Conduct multicenter studies of protocol-driven diagnostic, therapeutic and quality approaches to chILD Syndrome to ascertain the optimal methods of clinical evaluation and management. 
• Create high-quality, accessible tissue repositories and biobanks to enhance research efforts 
• Promote common terminology for chILD diagnoses and their continued inclusion in future revisions of The International Classification of Diseases (ICD).

"As our understanding of the distinctions between adult and child ILD developed, the need for clinical practice guidelines on the diagnosis and management of chILD became clear," said Dr. Kurland.

"These guidelines should help clinicians navigate the evaluation and management of children with this complex constellation of diseases."

Obesity in Children: Overeating learned in infancy

In the long run, encouraging a baby to finish the last ounce in their bottle might be doing more harm than good. Though the calories soon burn off, a bad habit remains.

 Renata Forste

Brigham Young University sociology professors Ben Gibbs and Renata Forste found that clinical obesity at 24 months of age strongly traces back to infant feeding.

"If you are overweight at age two, it puts you on a trajectory where you are likely to be overweight into middle childhood and adolescence and as an adult," said Forste. "That's a big concern."

The BYU researchers analyzed data from more than 8,000 families and found that babies predominantly fed formula were 2.5 times more likely to become obese toddlers than babies who were breastfed for the first six months.

But, the study authors argue, this pattern is not just about breastfeeding.

Ben Gibbs

"There seems to be this cluster of infant feeding patterns that promote childhood obesity," said Gibbs, lead author of the study that appears in the journal Pediatric Obesity.

Putting babies to bed with a bottle increased the risk of childhood obesity by 36 percent. And introducing solid foods too soon -- before four months of age -- increased a child's risk of obesity by 40 percent.

"Developing this pattern of needing to eat before you go to sleep, those kinds of things discourage children from monitoring their own eating patterns so they can self-regulate," Forste said.

Forste said that the nature of breastfeeding lends itself to helping babies recognize when they feel full and should stop. But that same kind of skill can be developed by formula-fed infants.

"You can still do things even if you are bottle feeding to help your child learn to regulate their eating practices and develop healthy patterns," Forste said. "When a child is full and pushes away, stop! Don't encourage them to finish the whole bottle."

Sally Findley

Breastfeeding rates are lowest in poor and less educated families. Sally Findley, a public health professor at Columbia University, says the new BYU study shows that infant feeding practices are the primary reason that childhood obesity hits hardest below the poverty line.

"Bottle feeding somehow changes the feeding dynamic, and those who bottle feed, alone or mixed with some breastfeeding, are more likely to add cereal or sweeteners to their infant's bottle at an early age, even before feeding cereal with a spoon," said Findley.

The next project for Gibbs and Forste is to re-evaluate the link between breastfeeding and cognitive development in childhood.

Forste has previously published research about why women stop breastfeeding.

"The health community is looking to the origins of the obesity epidemic, and more and more, scholars are looking toward early childhood," Gibbs said.

"I don't think this is some nascent, unimportant time period. It's very critical."

Journal Reference:

1. B. G. Gibbs, R. Forste. Socioeconomic status, infant feeding practices and early childhood obesity†.Pediatric Obesity, 2013; DOI: 10.1111/j.2047-6310.2013.00155.x

The Autumn of your Life may mean Longevity

Autumn Colours

People born in autumn are more likely to live for 100 years compared to those born in summer, according to a report in the Journal of Aging Research.

Researchers from the University of Chicago have found that people, who are born in autumn, from September to November, are likely to live for 100 years compared to those who are born in March.

The discovery was made while analysing data from the Rootsweb ancestry website.

Researchers conducted a study on more than 1,500 centenarians born in the United States between 1880 and 1895. The data obtained from the study was compared with 10,855 shorter-lived siblings and 1,083 spouses.

"Centenarians (cases) were compared to their "normal" shorter-lived siblings (controls) or spouses using a within-family analysis.

This approach allows investigators to study the within-family differences, not being confounded by the between-family variation.

Long-lived persons born in 1880-1895 were used as cases," said Leonid A Gavrilov, researcher at the University of Chicago, in a statement.

The study found that people who are born in September, October and November have a longer life span compared to their siblings born in March, April, May, June, July and August.

"These results demonstrate that persons born in September-November have significantly higher chances of exceptional longevity than persons born in March.

This survival advantage of persons born in the fall months is consistent across different lifespan cut-offs suggesting long-lasting influence of season of birth on longevity," said Natalia S Gavrilova, researcher at the University of Chicago, in a statement.

Researchers are not sure as how month of the birth affects mortality and health in later life but they have suggested some theories.

One is that the nutritional status of mother during pregnancy might have a long lasting effect on the child in later life, which in turn can increase the mortality risk.

Another theory is that children born between March and August are likely to be affected by several infections and disease, which in turn increase their mortality rate.

According to the researchers, the human enterovirus and it's cousin, poliovirus have epidemic peaks, only in the months of July and August.

The effect of environmental temperature during the time of birth may be another possible explanation for low proportion of centenarians among individuals born during the summer and spring months.

For example, Britons, who had experienced higher summer temperatures during their first year of life, had severe diarrhea and dehydration in infancy and they had higher blood pressure at older ages, according to the Journal of Aging Research.