1. Pınar Köksal1, Umut Gök Balcı1, Didem Çekiç1, Serkan Günalay1,
Assessment of Risk Factors in Acute Bronchiolitis Patients Admitted to Emergency Department
Pınar Köksal, MD
İzmir Tepecik Training and Research Hospital, TURKEY
Pınar Köksal1, Umut Gök Balcı1, Didem Çekiç1, Serkan Günalay1,
Duygu Çam1, Hande Kutlu1, Murat Anıl1, Kurtulus Ongel2
1 İzmir Tepecik Educational and Research Hospital , Clinic of Family Medicine, İzmir, Türkiye
2 İzmir Katip Çelebi University, Faculty of Medicine, Department of Family Medicine, İzmir, Türkiye

2. Overview Mortality in Children
Respiratory Tract Infections and Acute Bronchiolitis
Risk Factors
Study
Conclusions

3. Mortality in children under 5 years of age
5.9 million children under the age of 5 died in 2015 worldwide
Pneumonia & respiratory diseases are the second most common cause of death under 5 year old according to UNICEF Report 2015
Acute respiratory disease was 6th most common cause of mortality in Turkey, ( %3)
Almost 6 million children under the age of 5 died in 2015 worldwide
This mortality may be caused by many factors
As you see in this chart from WHO Reports, Pneumonia and other LRTI are among the most common causes of mortality
In Turkey, most common cause of mortality is accidents (%34)
Ministry of Health, Infant Mortality Forms

4. Respiratory Tract Infections in Post-Neonathal Children
Cause of death
Risk factors
Prevention
Pneumonia, or other acute respiratory infections
Low birth weight Malnutrition Non-breastfed children Overcrowded conditions
Vaccination Adequate nutrition Exclusive breastfeeding Reduction of household air pollution
More than half of these early child deaths are due to conditions that could be prevented or treated with access to simple, affordable interventions
The same is true for Pneumonia and other LRTI
Risk factors include: Low birth weight, Malnutrition, Non-breastfed children, Overcrowded conditions
And these risk factors can be eliminated by: Vaccination, Adequate nutrition, Exclusive breastfeeding, Reduction of household air pollution which may include smoking
More than half of these early child deaths are due to conditions that could be prevented or treated with access to simple, affordable interventions

5. Acute Bronchiolitis Pathology; Signs and symptoms; Acute inflammation,
Edema,
Necrosis of epithelial cells lining small airways,
Increased mucus production
Signs and symptoms;
Begin with rhinitis, cough
May progress to tachypnea,
Wheezing, rales
Use of accessory muscles, nasal flaring
Bronchiolitis is a type of LRTI common in children
Most common etiology of bronchiolitis is respiratory syncytial virus (RSV)
Highest incidence of infection between December and March
Image: momjunction.com

6. Risk Factors of Bronchiolitis
Unpreventable
Age<12 weeks
A history of prematurity
Underlying cardiopulmonary disease
Immunodeficiency
Down Syndrome
Cystic fibrosis
Neuromuscular Disease and Pulmonary Abnormality
Preventable
Tobacco use
prenatal smoking
postnatal smoking
secondhand smoking
Heating source; wood stove & poor air quality
Household crowding
Lack of breastfeeding (> 6 mo)
Hand hygiene
Young, M, and Langley, J. Open Forum Infectious Diseases. Vol. 1. No. Suppl 1. Oxford University Press, 2014.

7. Smoking (A Preventable Risk Factor)
Tobacco smoke exposure
 risk and severity of bronchiolitis
 risk of hospitalization for bronchiolitis1
Maternal smoking
 incidence of wheezing illness up to 6 years of age2
Household smoking
2x risk of lower respiratory tract infection in children3
 Eliminate or reduce secondhand smoke exposure, including education of parents4
Therefore, AAP recommends eliminating reduce secondhand smoke exposure, including education of parents
1Strachan DP & Cook DG. Thorax 1997; 52(10): p905
2DiFranza JR, et al. Pediatrics 113. Supplement 3 (2004): p1007
3Li JSM, et al. Pediatr Pulmonol 1999;27: p5
4AAP Reports, 2009

8. Heating Source (A Preventable Risk Factor)
Bronchiolitis frequency
 in houses using coal stove for heating (but not statistically significant)
It causes indoor air pollution and predisposes to infection1
In infants and children in Nepal who reported more time spent next to stoves suffered more life threatening episodes of acute respiratory infections
Wood-burning stove use and respiratory illness exposure were independently associated with higher risk2
According to a study by Morris K, et al. "Wood-burning stoves and lower respiratory tract infection in American Indian children.”
1Morris K, et al. American Journal of Diseases of Children (1990): p105
2British Medical Bulletin, 2003

9. Crowded Household (A Preventable Risk Factor)
Frequency of bronchiolitis is proportional to the number of family members1
Insidance of acute bronchiolitis
 if more than 3 family member sleep in the same room2
baby only: %12
3 or more people: %22
According to a study by Morris K, et al. "Wood-burning stoves and lower respiratory tract infection in American Indian children.”
1Bosis S, et al, J Med Virol 2005;75(1): p101
2Etiler N & Aktekin MR, J Turgut Ozal Medical Center, 2000;7(3): p208

10. Study Patient Group Age 0 - 24 months, (total of 74 patient)
Admitted to emergency room
Period of one week in March 2015
Izmir Tepecik Training and Research Hospital
Wheezing complaints
Diagnosed with acute bronchiolitis
In this study, We questioned parents of children younger than 24 mo old admitted to ER with wheezing complaints and diagnosed with bronchiolitis

11. Material and Methods Parents were asked about Ages of children
Smoking history
during pregnancy
postpartum period
household smoking inside home
Previous bronchiolitis attacks
Heating source of residence
Sharing bedroom with the child
Parents were asked about...

12. Age Groups Largest age group: 6 - 12 Mo
Previous studies established that this is the age period in which bronchiolitis is mostly seen

13. Household Smoking
Smoking prevalence among women in our patient population (%31, %29 in another study) is significantly (almost 3 times) higher than women in Turkey (General: %27, Women: %13)
Household smoking in a study found to be 34% in Turkey

14. Household Smoking by Age-Groups
This is the graph that shows Household Smoking by Age-Groups
As you see, household do not pay attention to vulnerability of newborns or children to the effects of smoking
Actually, 2 of patient younger than 3 months had respiratory arrest and couldn’t be saved, unfortunately
As PCPs, we need to pay special attention to educating parents about this issue

15. Household Smoking vs Occurrence of Bronchiolitis Attacks
Household smoking prevalence is 70% among bronchiolitis patients in this study
Household smoking prevalence is 34% in a comparable general population in Turkey1
Parents were asked if the patient had previous bronchiolitis attacks
Among patients of month
Not statistically meaningful
Smoking vs Number of bronchiolitis attacks
Bronch <2
Bronch ≥ 2
Total
Smoking
n = 29 (44%)
n = 14 (22%)
n = 43 (66%)
Non-Smoking
n = 8 (12%)
n = 22 (34%)
n = 65
Household smoking prevalence is 70% among bronchiolitis patients in our study
However, this is significantly lower (34%) in a comparable general population in a study done in Turkey
Therefore, we wanted to look at the relationship between Household Smoking and occurrence of previous bronchiolitis attacks
The results were Not statistically meaningful, that is, household smoking does not seem to have any effect on number of bronchiolitis attacks.
It was shown that bronchiolitis attacks are not common under 3 months
1Kucuk O, et al. JOPP Dergisi, 2012;4(3): p124

16. Heating Source
In Turkey, choice of heating source is closely related to socioeconomic level
Sharing Bedroom with the Child
73 of 74 patients sharing the bedroom at least with parents
but some with also other siblings or grand parents
Socioeconomic level of the patient population in the vicinity of our hospital is lower than the average of Turkey.
As a result, households are more crowded and heating amenities of homes are of lower quality.
To conserve, they rely on a single heating source in a single sleeping room.
A study in a region with a contrasting socioeconomic level would be a good study to complement this one

17. Biases In the community near our hospital,
Socioeconomic level is lower
Smoking prevalence among women is higher
Many of the families are extended families
In Turkey,
Sleeping with baby during breastfeeding (commonly first 2 years) is traditional
So as you have seen in our data Socioeconomic level is lower
Smoking prevalence among women is higher
Many of the families are extended families
This is inevitably adds some bias to our study

18. Conclusion
Smoking in the family, maternal smoking during pregnancy, heating sources and sleeping in the crowded room are some environmental risk factors for acute bronchiolitis
Clinicians should counsel caregivers about exposing the infant or child to environmental tobacco smoke and about smoking cessation when assessing a child for bronchiolitis
This study shows that smoking prevalence is higher in household of bronchiolitis patients
However, this study needs to be expanded to include a more unbiased patient population
1Rosen LJ, et al. Pediatrics. 2012;129(1): p141

19. Thanks for your attention