Parental severity assessment predicts supportive care in infant bronchiolitis

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Supplementary Online Content to the manuscript:

Parental severity assessment predicts supportive care in infant bronchiolitis

Jon Olav Gjengstø Hunderi, MD^a,b,c, Karin C. Lødrup Carlsen, PhD^b,c, Leif Bjarte Rolfsjord, MD^c,d, Kai-Håkon Carlsen, PhD^b,c, Petter Mowinckel, MSc^b,c, Håvard Ove Skjerven, PhD^b,c

Affiliations: ^aDepartment of Pediatrics and Adolescent Medicine, Østfold Hospital Trust, Norway; ^bDivision of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; ^cInstitute of Clinical Medicine, University of Oslo, Oslo, Norway; ^dDepartment of Pediatrics, Innlandet Hospital Trust, Elverum, Norway

Address correspondence to: Jon Olav Gjengstø Hunderi, Department of Pediatrics and Adolescent Medicine, Østfold Hospital Trust, Postboks 300, 1714 Grålum, Norway, [jonhun@so-hf.no], 0047 91880816

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Methods

The parental VAS items are for the publication given in English, after translation from Norwegian and back-translation by persons independent of the study, showing full agreement in the text. The three questions are given in Figure 1S.

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Table S1 The Clinical Score used in the study (1), Kristjansson et.al.

Score 0 Score 1 Score 2

Respiratory rate (breaths/min) <40 40-60 >60 Respiratory Chest recessions none Moderate

Costodiaphragmatic

Severe. As 1+ rib and jugular retractions Auscultatory breath sounds Vesicular Wheeze,

rales/ronchi

Faint ± severe wheeze

± pronounced rales and rhonci

Skin colour Normal Pallor Cyanosis

General Condition Not affected Moderately affected Severely affected

The clinical score was completed by doctors at inclusion and daily during hospital stay. A clinical core ≥four of ten was required for study inclusion. The score is identical to that used in a study of acute bronchiolitis by Krisjansson et al (1).

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Table S2 Background characteristics of the 404 infants in the Bronchiolitis ALL SE-Norway study admitted to hospital due to acute bronchiolitis, shown for infants included in the present study based upon available parental assessments and infants who did not have parental visual analogue scale (VAS) assessments (not included in the present study).

Included (N-267)

Not included (N-137)

p

Male sex (%) 161/ 267 (60.3) 79/137 (57.7) 0.61

Age (mean (range)) in days 127.9 (7, 364) 123.9 (9,362) 0.66

Weight (mean (range)) in grams 6558 (2925, 11655) 6417 (3230, 10750) 0.48 Length (mean (range)) in centimetres 63.0 (48.0, 80.0) 62.5 (50, 80) 0.64 Infant medical history (%)

Reported atopic eczema 29/ 253 (11.5) 11/121 (9.1) 0.49 Reported allergies 4/ 252 (1.6) 3/121 (1.4) 0.55 Parental socio-demography

Mother Caucasian (%) 228/244 (93.4) 97/112 (86.6) 0.048 Father Caucasian (%) 225/239 (94.1) 97/112 (86.6) 0.15 Maternal education^a(mean (SD)) 3.9 (0.9) 3.7 (1.2) 0.026

Paternal education^a(mean (SD)) 3.8 (0.9) 3.7 (1.1) 0.52

Parental smoking (%) 34/233 (14.6) 24/108 (22.2) 0.08

Parental medical history (%)

Maternal Asthma 37/219 (16.9) 11/106 (10.4) 0.12 Paternal Asthma 27/219 (12.3) 16/106 (15.1) 0.49 Maternal rhinitis/ rhinoconjunctivitis 42/244 (17.4) 20/112 (17.9) 0.88 Paternal rhinitis/ rhinoconjunctivitis 48/244 (19.7) 22/112 (19.6) 1.00 Clinical characteristics at inclusion

SpO2 (SD)^b 96 (4) 96 (3) 0.56

Respiratory rate- breaths/min (SD) 54 (11) 53 (11) 0.56

Heart rate- beats/min (SD) 153 (18) 155 (19) 0.48

a Education was given in 5 categories, from 1 (no school completed) to 5 (higher education, more than three years).

b SpO2: peripheral capillary oxygen saturation measured by pulse oximetry.

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Table S3 Background characteristics of infants scored in lower quartile (least severe), middle quartiles and upper quartile (most severe), for each of the three parental visual analogue scale (VAS) items recorded at study inclusion.

A- VAS Activity

Lower quartile

≤25% Middle quartiles

>25%- ≤75% Upper quartile

>75%

N(total) 66 132 66

Male sex (%) 38/66 (57.6) 80/132 (60.6) 41/66 (62.1)

Age (mean (range)) in days 124 (14, 347) 124 (7, 364) 139 (19, 334) Weight (mean (range)) in grams 6791

(3475, 11400) 6406

(2925, 10870) 6647 (3588, 11655) Length (mean (range)) in centimetres 63 (50, 78) 63 (48, 80) 64 (50, 80) Infant medical history (%)

Reported atopic eczema* 6/61 (9.8) 20/126 (15.9) 3/63 (4.8)

Reported allergies 1/60 (1.7) 3/126 (2.4) 1/63 (0.0)

Parental socio-demography

Mother Caucasian (%) 54/58 (93.1) 112/120 (93.3) 59/63 (93.7) Father Caucasian (%) 53/56 (94.6) 111/ 118 (94.1) 59/61 (95.2) Maternal education^a(mean (SD))** 3.8 (0.9) 3.9 (0.9) 4.2 (0.8) Paternal education^a(mean (SD)) 3.7 (0.9) 3.8 (0.9) 3.9 (0.9) Parental smoking (%) 11/57 (19.3) 17/ 115 (14.8) 5/58 (8.6) Parental medical history (%)

Maternal Asthma 10/50 (20.0) 20/106 (18.9) 7/60 (11.7)

Paternal Asthma 7/50 (14.0) 15/106 (14.2) 5/60 (8.3)

Maternal rhinitis/ rhinoconjunctivitis 13/59 (22.0) 19/120 (15.8) 10/62 (16.1) Paternal rhinitis/ rhinoconjunctivitis 15/59 (25.4) 21/120 (17.5) 11/62 (17.7)

*Middle quartiles vs upper quartile p= 0.028

**Lower quartile vs upper quartile p= 0.012, Middle quartiles vs upper quartile p= 0.02

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B- VAS Feeding

Lower quartile

>25%- ≤75% Upper quartile

>75%

N(total) 66 131 66

Male sex (%) 42/66 (63.6) 74/131 (56.5) 41/66 (62.1)

Age (mean (range)) in days* 105 (13, 347) 123 (7, 364) 158 (22, 345) Weight (mean (range)) in grams 6443

(2925, 10350) 6423

Reported atopic eczema 5/61 (8.2) 16/ 126 (12.7) 8/62 (12.9)

Mother Caucasian (%) 52/57 (91.2) 116/ 121 (95.9) 57/62 (91.9) Father Caucasian (%) 52/55 (94.5) 112/ 118 (94.9) 58/62 (93.5) Maternal education^a(mean (SD))** 3.7 (0.9) 4.0 (0.9) 4.1 (0.8) Paternal education^a(mean (SD)) 3.7 (1.0) 3.8 (0.9) 3.9 (0.9)

Parental smoking (%) 11/55 (20) 16/119 (13.4) 7/55 (12.7)

Parental medical history (%)

Maternal Asthma 8/56 (14.3) 17/101 (16.8) 11/58 (19.0)

Paternal Asthma 11/56 (19.6) 11/101 (10.9) 5/53 (8.6)

Maternal rhinitis/ rhinoconjunctivitis 11/59 (18.6) 24/120 (20%) 7/61 (11.5) Paternal rhinitis/ rhinoconjunctivitis 12/59 (20.3) 23/120 (19.2) 11/61 (18.0)

*Lower quartile vs upper quartile p<0.001, Middle quartiles vs upper quartile p= 0.008

**Lower quartile vs upper quartile p= 0.005, Lower quartile vs middle quartiles p= 0.032

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C- VAS Illness

Lower quartile

>25%- ≤75% Upper quartile

>75%

N(total) 67 133 67

Male sex (%) 38/67 (56.7) 85/133 (63.9) 38/67 (56.7)

Age (mean (range)) in days 133 (14, 364) 125 (7, 347) 129 (14, 334) Weight (mean (range)) in grams 6776

(3475, 11400) 6543

Reported atopic eczema 9/65 (13.8) 15/125 (12.0) 5/63 (7.9)

Mother Caucasian (%)* 58/62 (93.5) 117/121 (96.7) 53/61 (86.9) Father Caucasian (%)** 60/61 (98.4) 114/ 120 (95.0) 51/58 (87.9) Maternal education^a(mean (SD)) 3.8 (1.0) 4.0 (0.9) 3.9 (0.9) Paternal education^a(mean (SD)) 3.8 (0.9) 3.8 (1.0) 3.8 (0.9) Parental smoking (%) 13/58 (22.4) 14/ 115 (12.2) 7/60 (11.7) Parental medical history (%)

Maternal Asthma 9/55 (16.4) 18/ 106 (17.0) 10/58 (17.2)

Paternal Asthma 7/55 (12.7) 16/ 106 (15.1) 4/58 (6.9)

Maternal rhinitis/ rhinoconjunctivitis 11/63 (17.5) 24/ 120 (20) 7/61 (11.5) Paternal rhinitis/ rhinoconjunctivitis 13/63 (20.6) 25/ 120 (20.8) 10/61 (16.4)

*Middle quartiles vs upper quartile p= 0.009

** Lower quartile vs upper quartile p= 0.032

a Education was given in 5 categories, from 1 (no school completed) to 5 (higher education, more than three years), with an overall mean parental education of 3.9 (1.0) for mothers and 3.8 (1.0) for fathers.

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Table S4 Area under the receiver operating characteristic curve^a for the three visual analogue scale (VAS) items; Activity, Feeding and Illness, predicting supportive care

aDisplayed in figure S2. P<0.05 for all Oxygen supplement

Nasogastric tube feeding

Ventilatory support

Any supportive treatment VAS Activity%

(95% CI)

0.65 (0.57, 0.71)

0.68 (0.60, 0.75)

0.64 (0.47, 0.76)

0.67 (0.60, 0.73) VAS Feeding%

(95% CI)

0.60 (0.52, 0.66)

0.71 (0.63, 0.77)

0.65 (0.49, 0.76)

0.66 (0.59, 0.72) VAS Illness %

(95% CI)

0.65 (0.57, 0.71)

0.67 (0.58,0.73)

0.62 (0.44, 0.75)

0.66 (0.59, 0.72)

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Table S5 Sensitivity, specificity, positive

likelihood ratio

and negative predictive value for the clinical score, the three visual analogue scale (VAS) items; Activity , Feeding, Illness, respiratory rate and SpO

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predicting supportive care

Cutoff Value^a

Sensitivity%

(95% CI)

Specificity

% (95% CI)

Pos. Likelihood Ratio

Neg Likelihood Ratio

Clinical Score

Supportive treatment 5.0 59 (50, 68) 45 (37, 54) 1.07 0.91

Oxygen supplement 5.0 58 (48, 68) 44 (36, 52) 1.04 0.95

Nasogastric tube feeding 5.0 67 (54, 78) 47 (39, 54) 1.52 0.86 Ventilatory support 5.0 63 (38,84) 44 (37, 50) 1.33 0.98

VAS Activity

Supportive treatment 5.0 67 (58, 75) 57 (48, 66) 1.67 0.63

Nasogastric tube feeding 6.2 58 (45, 70) 72 (65, 79) 2.07 0.58 Ventilatory support 7.2 53 (29, 76) 77 (71, 83) 2.3 0.61

VAS Feeding

Supportive treatment 5.8 58 (48, 66) 70 (62, 78) 1.93 0.6

Nasogastric tubefeeding 5.8 68 (56, 79) 66 (58, 73) 2.0 0.48 Ventilatory support 7.6 63 (38, 84) 73 (66, 78) 2.33 0.51

VAS Illness

Supportive treatment 6.2 61 (52, 69) 71 (61, 79) 2.1 0.55

Nasogastric tube feeding 6.2 68 (56, 79) 64 (57, 71) 1.89 0.5 Ventilatory support 6.0 68 (43, 87) 53 (46, 59) 1.45 0.6 Respiratory Rate

Supportive treatment 51 64 (55, 72) 46 (37, 55) 1.19 0.78

Oxygen supplement 57 47 (40, 57) 60 (52, 68) 1.17 0.88

Nasogastric tubefeeding 55 67 (54, 78) 52 (45, 60) 1.4 0.63 Ventilatory support 56 42 (20, 67) 53 (46, 59) 0.89 1.09 SpO2

Supportive treatment 96 63 (54, 72) 63 (54, 71) 1.7 0.59

Oxygen supplement 96 67 (57, 76) 61 (53, 69) 1.72 0.54

Nasogastric tubefeeding 95 54 (41, 66) 72 (65, 79) 1.93 0.64 Ventilatory support 93 58 (34, 80) 88 (83, 92) 4.83 0.48

a The cutoff values were stablished by receiver operating characteristic analyses (Online Figure 2)

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Figure S1

The parental assessment consisted of a three-item smiley VAS on a 10-centimeter single horizontal line where 10 indicates most severe. The three categories concerned the activity level termed Activity, the interest in food, termed Feeding and finally the question “How ill is the child?” termed Illness.

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Figure S2

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Figure S2 Associations between parental Visual Analogue Scale (VAS) score at inclusion and need of supportive care (Figure 1) during hospital stay in 267 infants with parental VAS score. Each of the three VAS items; Activity, Feeding and Illness

are presented with mean scores in lower quartile (least severe), middle quartiles

and upper quartile (most severe), all with the 95% upper Confidence Interval. The level of significance is presented comparing upper to lower quartile.

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Figure S3

a) Any supportive care

b) Oxygen Supplement

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c) Nasogastric tube feeding

d) Ventilatory support

Figure S3 Receiver operating characteristic curves for parental VAS- items at inclusion

The figures show receiver operating characteristic curves for the three visual

analogue scale (VAS) items; Activity, Feeding and Illness at inclusion, predicting any supportive care (a), oxygen supplement (b), nasogastric tube feeding (c) and ventilatory support (d) in infants with bronchiolitis. Optimal cut off for each curve is marked. Area under the curve varied between 0.60 and 0.71 (Table S4)

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REFERENSES

Parental severity assessment predicts supportive care in infant bronchiolitis

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Table S5 Sensitivity, specificity, positive

and negative predictive value for the clinical score, the three visual analogue scale (VAS) items; Activity , Feeding, Illness, respiratory rate and SpO

predicting supportive care

VAS Activity

VAS Feeding

VAS Illness

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