Effect of Buteyko breathing technique on clinical and functional parameters in adult patients with asthma: a randomized, controlled study.

BACKGROUND: The established therapy of asthma might be supported by additional non-pharmaceutical measures, such as the Buteyko breathing technique (BBT); however, the available data are mixed. To clarify the effects of BBT in patients with asthma, we investigated whether it led to clinical improvements with correlation to functional parameters. METHODS: Using a randomized, controlled design, we studied two groups (n = 30 each) of patients with asthma under either BBT or usual therapy (UT) w/o BBT over a period of 3 months. The primary outcome comprised the voluntary control pause (CP) after 3 months, secondary outcomes an additional breathhold parameter, forced expiratory volume in 1 s (FEV1), capnovolumetry, exhaled nitric oxide (FeNO), Asthma Control Questionnaire (ACQ) and Nijmegen Questionnaire (NQ), and the use of medication (ß2-agonists; inhaled corticosteroids, ICS). RESULTS: CP showed significant time-by-group interaction [F(1,58.09) = 28.70, p < 0.001] as well as main effects for study group [F(1,58.27) = 5.91, p = 0.018] and time [F(1,58.36) = 17.67, p < 0.001]. ACQ and NQ scores were significantly (p < 0.05 each) improved with BBT. This was associated with reductions in the use of ß2-agonists and ICS (p < 0.05 each) by about 20% each. None of these effects occurred in the UT group. While FEV1 and the slopes of the capnovolumetric expiratory phases 2 and 3 did not significantly change, the capnovolumetric threshold volume at tidal breathing increased (p < 0.05) with BBT by about 10 mL or 10%, compared to baseline, suggesting a larger volume of the central airways. No significant changes were seen for FeNO. CONCLUSIONS: BBT was clinically effective, as indicated by the fact that the improvement in symptom scores and the small increase in bronchial volume occurred despite the significant reduction of respiratory pharmacotherapy. As the self-controlled Buteyko breathing therapy was well-accepted by the participants, it could be considered as supporting tool in asthma therapy being worth of wider attention in clinical practice. Trial registration Retrospectively registered on 10 March 2017 at ClinicalTrials.gov (NCT03098849).

Why are children with asthma bullied? A risk factor analysis.

The links between bullying and asthma have not been explored in children. We wanted to determine the child/parent factors and attitudes associated with asthma-related bullying. Individual child/parent responses of children with asthma (N=943) from the Room to Breathe survey were analysed. 1 in 10 children reported asthma-related bullying/teasing (n=93). Children with well-controlled asthma were less likely to report being a victim of asthma-related bullying/teasing (OR 0.51, 95% CI 0.23 to 0.84, p=0.006). Being a victim of bullying/teasing was more common in children reporting activity restriction (OR 1.74, 95% CI 1.11 to 2.75, p=0.010), who described their asthma as 'bad' (OR 3.02, 95% CI 1.86 to 4.85, p<0.001) and those whose parents reported ongoing asthma-related health worries (OR 1.64, 95% CI 1.04 to 2.58, p=0.024). Asthma consultations should incorporate specific questions about bullying and be child-focused in order to gain a representative appreciation of asthma control and its impact on the child's life.

Physicians' Speech Complexity and Interrupting Behavior in Pediatric Consultations.

Pediatricians' communication behavior affects a variety of outcomes in both children and their parents. This study analyzes how speech complexity and interruptions as indicators of accommodative behaviors relate to parental recall of medical information and to their satisfaction with the medical encounter. We recruited 19 pediatricians and 68 parents at pediatric inpatient and outpatient consultations in two Swiss clinics. All medical interactions were videotaped and transcripts were analyzed to assess pediatricians' speech complexity and interrupting behavior was coded from the videos. At the end of the encounter, parents rated their satisfaction with the medical encounter and were probed regarding their recall of medical information. Our results show recall of medical information to be unrelated to pediatricians' speech complexity and negatively associated with their interrupting behavior for parents who report low positive mood. We also found less educated parents to report lower satisfaction when pediatricians employed more complex language. Furthermore, parental satisfaction was negatively associated with pediatricians' interrupting behavior, especially when displayed by male pediatricians. Overall, these findings suggest that pediatricians' speech complexity and interruptions indicate a nonaccommodative stance reducing advantageous parent outcomes.

The Buteyko breathing technique in children with asthma: a randomized controlled pilot study.

BACKGROUND: Evidence supports the Buteyko breathing technique (BBT) as reducing medication and improving control and quality of life in adults with asthma, but having minimal impact on spirometry. For children with asthma, evidence addressing the utility of BBT is sparse. We evaluated the effectiveness of BBT in managing various aspects of asthma in children. METHODS: Thirty-two children with partly controlled asthma (age 6-15 years, 66% male) were randomized to either Treatment as Usual (TAU) or TAU combined with Buteyko training (Buteyko group, BG). Children in the BG received an intensive five-day training followed by three months of home practice. Primary outcome was bronchodilator reduction. Secondary outcomes were changes in physiological parameters FEV1_AR (at rest), FEV1_ER (after ergometry), FEV1_BR (after bronchospasmolysis), corticosteroid use, FeNO, SpO2, breath-hold test and questionnaire data [Asthma Control Questionnaire and Pediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ)]. All measures were collected at Baseline and a three-month follow-up. RESULTS: For the primary outcome, no significant between-group difference was found. Regarding the secondary outcomes, children receiving treatment augmented with BBT revealed significantly greater improvement at the follow-up than those receiving TAU for FEV1_AR (p = .04, d=-0.50), FEV1_ER (p = .02, d=-0.52), and the emotional function subscale of the PACQLQ (p < .01, d = 1.03). No between-group differences were found for the remaining secondary measures of outcome. CONCLUSIONS: Our preliminary findings suggest that the addition of BBT to treatment as usual for children with asthma enhances outcomes with respect to spirometry and parental emotional function but does not lead to reductions in medication, at least over the short term.

[Pediatric integrative medicine is an integral part of child health care in Switzerland]. / La pédiatrie intégrative fait partie intégrante des soins pédiatriques en Suisse.

Based on evidence and experience, pediatric integrative medicine uses conventional and complementary therapies in an interprofessional approach to optimally support health and development of children and adolescents. Switzerland has a high standard of child health care including complementary medicine. Many pediatricians and family physicians offer an integrative approach to their patients based on additional trainings in complementary medicine, which ensures a full and competent medical care. The Swiss Interest Group for Integrative Pediatrics of the Swiss Society of Pediatrics deals with all questions relating to complementary and integrative medicine in pediatrics including the organization of training events and the coordination of research projects.

Basée sur l'évidence et l'expérience, la pédiatrie intégrative utilise des thérapies conventionnelles et complémentaires dans une approche interprofessionnelle, pour promouvoir de manière optimale le développement et la santé des enfants et adolescents. La Suisse dispose d'un niveau élevé de soins pédiatriques incluant la médecine complémentaire. De nombreux pédiatres et médecins de famille offrent une approche intégrative aux patients, basée sur des formations supplémentaires en médecine complémentaire, ce qui garantit une prise en charge large et compétente. Le Groupe d'intérêt suisse pour la pédiatrie intégrative de la Société suisse de pédiatrie traite de toutes les questions relatives à la médecine complémentaire et l'approche intégrative en pédiatrie, y compris l'organisation des formations et la coordination de la recherche.

[Strategies to reduce antibiotic use with the help of complementary and integrative medicine]. / Stratégies de réduction de l'usage d'antibiotiques à l'aide de la médecine complémentaire et intégrative.

Limiting antibiotic use is urgent due to increasing antibiotic resistance and the long-term implications of a disturbed microbiome. Data on antibiotic use of physicians integrating conventional and complementary medicine show that a significant reduction of antibiotic use in primary care is possible. In the setting of non-complicated infections in out-patient medicine, open dialogue with the patient, recognizing the importance of fever and reducing antipyretic use are general measures that can help reduce patients' concerns, and increase their trust in a well-functioning immune system and a treatment approach without antibiotics. Accumulating evidence suggests that complementary medicine strategies are useful in the management of common infections without antibiotics.

Vu l'augmentation de la résistance aux antibiotiques et les conséquences qu'implique, à long terme, un microbiote perturbé, il est urgent de limiter leur consommation. Les données obtenues chez les médecins intégrant médecines conventionnelle et complémentaire montrent un recours aux antibiotiques diminué dans les soins primaires. Une communication adaptée, la compréhension de l'importance de la fièvre et la diminution de la prise d'antipyrétiques sont autant d'étapes clés pouvant aider les patients à surmonter leurs craintes, à renforcer leur confiance en leur système immunitaire et en un traitement sans antibiotiques en cas d'infections simples. Un nombre croissant d'études démontre ainsi que les outils de la médecine complémentaire peuvent contribuer à la gestion des infections courantes sans antibiotiques.

Study protocol for the ABERRANT study: antibiotic-induced disruption of the maternal and infant microbiome and adverse health outcomes - a prospective cohort study among children born at term.

INTRODUCTION: There is compositional overlap between the maternal intestinal microbiome, the breast milk microbiome and the infant oral and intestinal microbiome. Antibiotics cause profound changes in the microbiome. However, the effect of intrapartum and early-life antibiotics on the maternal intestinal and breast milk microbiome, and the infant oral and intestinal microbiome, and whether effects are only short term or persist long term remain uncertain. METHODS AND ANALYSES: In this prospective cohort study, we will use metagenomic sequencing to determine: (1) the effect of intrapartum antibiotics on the composition of the breast milk, and the infant oral and intestinal microbiome, including the development and persistence of antibiotic resistance; (2) the effect of antibiotic exposure in the first year of life on the composition of the infant oral and intestinal microbiome, including the development and persistence of antibiotic resistance; (3) the effect of disruption of the infant oral and intestinal microbiome on health outcomes and (4) the compositional overlap between the maternal intestinal microbiome, the breast milk microbiome and the infant oral and intestinal microbiome. ETHICS AND DISSEMINATION: The ABERRANT study has been approved by the commission cantonale d'éthique de la recherche sur l'être humain (CER-VD) du Canton de Vaud (#2019-01567). Outcomes will be disseminated through publication and will be presented at scientific conferences. TRIAL REGISTRATION NUMBER: NCT04091282.

Swiss paediatrician survey on complementary medicine.

BACKGROUND: In Switzerland, complementary medicine (CM) is officially recognised within the healthcare system and mainly practised in an integrative manner, in conjunction with conventional medicine. As in other countries, there is high demand for and use of CM with children. However, there has so far been no research into the attitude towards, training in and offer of CM among paediatricians in Switzerland. Our study addresses this gap by investigating these topics with an online survey of paediatricians in Switzerland. METHODS: We conducted a national online survey using a 19-item, self-reporting questionnaire among all ordinary and junior members of the Swiss Society of Paediatrics (SSP). A comparison of the study sample with the population of all paediatricians registered with the Swiss Medical Association (FMH) allowed an assessment of the survey’s representativeness. The data analysis was performed on the overall group level as well as for predefined subgroups (e.g. sex, age, language, workplace and professional experience). RESULTS: 1890 paediatricians were approached and 640, from all parts of Switzerland, responded to the survey (response rate 34%). Two thirds of respondents were female, were aged between 35 and 55 years, trained as paediatric generalist and worked in a practice. Apart from young paediatricians in training, the study sample was representative of all Swiss paediatricians. 23% had attended training in CM, most frequently in phytotherapy, homeopathy, acupuncture/traditional Chinese medicine (TCM) and anthroposophic medicine. 65% were interested in CM courses and training. 16% provide CM services to their patients and almost all paediatricians (97%) are asked by patients/parents about CM therapies. More than half of the responding paediatricians use CM for themselves or their families. 42% were willing to contribute to paediatric CM research. CONCLUSIONS: In a representative sample of paediatricians in Switzerland, their personal attitude towards CM is positive, emphasised by great interest in CM training, a willingness to contribute to CM research and a high rate of paediatricians who use CM for themselves and their families. In contrast, the percentage of paediatricians offering CM is currently rather low despite strong demand for CM for children. This study provides key pointers for the future development of complementary and integrative medicine for children in Switzerland.

Acceptance, satisfaction and cost of an integrative anthroposophic program for pediatric respiratory diseases in a Swiss teaching hospital: An implementation report.

BACKGROUND: For the pilot phase of an integrative pediatric program, we defined inpatient treatment algorithms for bronchiolitis, asthma and pneumonia, using medications and nursing techniques from anthroposophic medicine (AM). Parents could choose AM treatment as add-on to conventional care. MATERIAL AND METHODS: To evaluate the 18-month pilot phase, parents of AM users were asked to complete the Client Satisfaction Questionnaire (CSQ-8) and a questionnaire on the AM treatment. Staff feedback was obtained through an open-ended questionnaire. Economic data for project set-up, medications and insurance reimbursements were collected. RESULTS: A total of 351 children with bronchiolitis, asthma and pneumonia were hospitalized. Of these, 137 children (39%) received AM treatment, with use increasing over time. 52 parents completed the questionnaire. Mean CSQ-8 score was 29.77 (95% CI 29.04-30.5) which is high in literature comparison. 96% of parents were mostly or very satisfied with AM; 96% considered AM as somewhat or very helpful for their child; 94% considered they learnt skills to better care for their child. The staff questionnaire revealed positive points about enlarged care offer, closer contact with the child, more relaxed children and greater role for parents; weak points included insufficient knowledge of AM and additional nursing time needed. Cost for staff training and medications were nearly compensated by AM related insurance reimbursements. CONCLUSIONS: Introduction of anthroposophic treatments were well-accepted and led to high parent satisfaction. Additional insurance reimbursements outweighed costs. The program has now been expanded into a center for integrative pediatrics.

Pediatric Consultations: Negative-Word Use and Parent Satisfaction.

Objective: This study investigates the impact of pediatricians' negative-word use on parents' affective quality and satisfaction judgements during the medical encounter. Methods: In total, 68 medical consultations were videotaped and pediatricians' communication transcribed for analysis. We used the Linguistic Inquiry and Word Count application to measure the amount of negative words used by the pediatrician. Parents rated their momentary mood as well as their satisfaction at the end of the encounter. Results: Pediatricians' negative-word use was negatively linked to parents' affect quality, but not with the satisfaction ratings after the medical visit. Although there was no direct effect, our results revealed an indirect effect of pediatricians' negative-word use on parents' satisfaction via parents' mood. Conclusions: The results point to the negative impact that words used during the medical encounter can have on individuals in need of care. Consequently, this is relevant for clinical training and practice.

Reported Exercise-Related Respiratory Symptoms and Exercise-Induced Bronchoconstriction in Asthmatic Children.

BACKGROUND: Unlimited physical activity is one of the key issues of asthma control and management. We investigated how reliable reported exercise-related respiratory symptoms (ERRS) are in predicting exercise-induced bronchoconstriction (EIB) in asthmatic children. METHODS: In this prospective study, 179 asthmatic children aged 7 - 15 years were asked for specific questions on respiratory symptoms related to exercise and allocated into two groups according to whether they complained about symptoms. Group I (n = 134) consisted of children answering "yes" to one or more of the questions and group II (n = 45) consisted of children answering "no" to all of the questions. RESULTS: Sixty-four of 179 children showed a positive exercise challenge test (ECT). There was no difference in the frequency of a positive test between children in group I (n = 48) and group II (n = 12) (P = 0.47). The sensitivity of a positive report for ERRS to predict a positive ECT was only 37%, with a specificity of 0.72. CONCLUSION: According to current guidelines, the report or lack of ERRS has direct consequences on treatment decisions. However, the history of ERRS did not predict EIB and one-third of asthmatic children without complaints of ERRS developed EIB during the ECT. This raises the question of the need for objective measures of bronchial hyperresponsiveness (BHR) in pediatric asthma management.

Pediatricians' affective communication behavior attenuates parents' stress response during the medical interview.

OBJECTIVE: To investigate whether the medical interview in the pediatric context generates a stressful response in parents in form of heightened cortisol activity, and whether pediatricians' empathetic communication is able to attenuate this stress response. METHODS: 68 parents were recruited at pediatric out-patient and in-patient consultations. Salivary samples were collected between 60 and 30min prior to the consultation, shortly before the consultation, 20min as well as 45min after the consultation. 19 pediatricians participated in the study and effectuated the medical visit as usual. We videotaped the consultations and coded pediatricians' affective communication using the RIAS and the Four Habits Coding Scheme. RESULTS: Parents' cortisol increased during the medical visit with a peak at 20min after the medical encounter. Furthermore, multilevel analysis revealed a lesser increase in parents' cortisol response associated with pediatricians' levels in supportive communication behaviors. CONCLUSION: As indicated by their humoral stress responses, the medical encounter was stressful for the parents. Pediatricians' affective communication modulated this stress response in that more supportive communication was related to smaller cortisol increases. PRACTICE IMPLICATION: Pediatricians' affective communication behavior during the medical visit can alleviate parents' distress and anxiety, representing a source of social and emotional support.

Spirometry reference equations for central European populations from school age to old age.

BACKGROUND: Spirometry reference values are important for the interpretation of spirometry results. Reference values should be updated regularly, derived from a population as similar to the population for which they are to be used and span across all ages. Such spirometry reference equations are currently lacking for central European populations. OBJECTIVE: To develop spirometry reference equations for central European populations between 8 and 90 years of age. MATERIALS: We used data collected between January 1993 and December 2010 from a central European population. The data was modelled using "Generalized Additive Models for Location, Scale and Shape" (GAMLSS). RESULTS: The spirometry reference equations were derived from 118'891 individuals consisting of 60'624 (51%) females and 58'267 (49%) males. Altogether, there were 18'211 (15.3%) children under the age of 18 years. CONCLUSION: We developed spirometry reference equations for a central European population between 8 and 90 years of age that can be implemented in a wide range of clinical settings.

Global impact of asthma on children and adolescents' daily lives: the room to breathe survey.

OBJECTIVE: To establish children and adolescents' perspectives regarding their asthma and its impact upon their daily lives. DESIGN: A 14-item questionnaire. SETTING: Canada, Greece, Hungary, The Netherlands, the United Kingdom, and South Africa. PARTICIPANTS: Children/adolescents (aged 8-15 years) with physician-diagnosed asthma. INTERVENTION: Interviews were conducted by telephone (Canada, Greece, Hungary, The Netherlands, and the United Kingdom) or face-to-face (South Africa). OUTCOME MEASURES: Asthma symptoms, impact on activities, and quality of life. RESULTS: Of the 943 children/adolescents interviewed, 60% were male. Most (81%) described their asthma as "not too bad" or "I only get it every now and then," with only 4% reporting their asthma as being "very bad"; however, 92% experienced asthma-related coughing and 59% reported nocturnal awakening. Over half (57%) of children/adolescents believed they could predict when their asthma would make them ill; the most common initial symptoms being breathlessness (41%) and bad cough (33%). They considered the worst things about having asthma to be the symptoms of an asthma attack (32%) and not being able to play sport (25%). Almost half (47%) of children/adolescents felt that their asthma affected their ability to play sport or engage in physical activity. One in ten reported they had suffered asthma-related bullying. CONCLUSIONS: Children/adolescents underestimate the severity of their asthma, and overestimate its control, indicating that they expect their illness to be symptomatic. Asthma has a substantial impact on their daily lives, particularly on physical activity and social functioning. Efforts are required to improve asthma control and expectations of health in children/adolescents.

Baseline leptin and leptin reduction predict improvements in metabolic variables and long-term fat loss in obese children and adolescents: a prospective study of an inpatient weight-loss program.

BACKGROUND: It is unclear whether high plasma leptin in obese individuals represents leptin resistance or whether individuals with marked reductions in leptin concentrations in response to weight loss may be at greater risk of regaining weight. Moreover, whether changes in leptin predict metabolic improvements during weight loss is uncertain. OBJECTIVE: The objective was to prospectively examine associations between plasma leptin, body fat, and weight and metabolic risk factors in obese children during weight loss. DESIGN: In obese children and adolescents [n = 203; mean age: 14.1 y, >98th body mass index (BMI) percentile for age and sex] participating in a 2-mo inpatient weight-loss program, we measured changes in body composition (by dual-energy X-ray absorptiometry), plasma leptin, insulin, and lipids. After discharge, anthropometric measures and plasma leptin were remeasured at 6 (n = 139) and 12 (n = 100) mo. RESULTS: During the 2-mo program, mean (±SD) weight and fat loss were 13.9 ± 4.0 kg and 9.2 ± 2.5 kg, respectively; and mean plasma leptin decreased by 76%. Weight and fat loss were sustained, and no significant differences in BMI-SD score (SDS) or body composition were found between 12 and 2 mo. Baseline leptin was a negative predictor for percentage fat loss at 2, 6, and 12 mo (P < 0.05). The percentage change in leptin during the 2-mo intervention positively correlated with the relative change in fasting insulin, the relative change in LDL cholesterol at 2 mo, percentage fat loss, and change in BMI-SDS at 2 and 6 mo (P < 0.02). CONCLUSIONS: Even in obese children with strongly elevated baseline leptin, large leptin reductions that predict short- and long-term loss of body fat and improvements in lipids and insulin sensitivity can be achieved. Thus, increased plasma leptin in obese children may not necessarily reflect leptin resistance; many children appear to remain leptin sensitive at this age.

During rapid weight loss in obese children, reductions in TSH predict improvements in insulin sensitivity independent of changes in body weight or fat.

BACKGROUND: Although serum TSH is often elevated in obesity and may be linked to disorders of lipid and glucose metabolism, the clinical relevance of these relationships remains unclear. SUBJECTS: Subjects were obese children and adolescents (n=206; mean age 14 yr) undergoing rapid weight and fat loss in a standardized, multidisciplinary, 2-month, in-patient weight loss program. DESIGN: This was a prospective study that determined thyroid function, glucose and lipid parameters, leptin, anthropometric measures, and body composition measured by dual-energy x-ray absorption at baseline and at the end of the intervention. RESULTS: At baseline, 52% of children had TSH concentrations in the high normal range (>2.5 mU/liter), but TSH was not correlated with body weight, body mass index sd scores, lean body mass, or body fat percentage. At baseline, independent of adiposity, TSH significantly correlated with total cholesterol (P=0.008), low-density lipoprotein cholesterol (P=0.013), fasting insulin (P=0.010), homeostatic model assessment (HOMA) (P=0.004), and leptin (P=0.006). During the intervention, mean body fat, TSH, HOMA, and fasting insulin decreased by 21, 11, 53, and 54%, respectively. Change (Δ) in TSH did not correlate with Δbody weight or Δbody composition, but ΔTSH significantly correlated with, Δfasting insulin and ΔHOMA, independent of Δbody weight or Δbody composition (P<0.05). CONCLUSION: TSH concentrations are elevated in obese children but are not correlated with the amount of excess body weight or fat. During weight loss, independent of changes in body weight or composition, decreases in elevated serum TSH predict decreases in fasting insulin and HOMA. These findings suggest interventions that target high TSH concentrations during weight loss in obese subjects may improve insulin sensitivity.

Effects of a short-term rehabilitation program on airway inflammation in children with cystic fibrosis.

BACKGROUND: Respiratory therapy in cystic fibrosis (CF) consists of airway clearance, infection control, and reduction of airway inflammation. It is well recognized that physical activity as well as daily chest physiotherapy, enhance airway clearance. We investigated the effects of pulmonary rehabilitation, including physical activity and chest physiotherapy, on airway inflammation in children with CF. METHODS: Eighteen children with stable CF (six females), aged 8.2-16.2 years, participating in a 3-week multidisciplinary inpatient rehabilitation program were recruited. Assessment at the beginning and the end of the program included clinical score, pulmonary function test, exhaled breath condensate (EBC) and sputum analysis. Sputum supernatant and EBC were analyzed for interleukin (IL)-1b, 6, 8, 10, 12, tumor necrosis factor-alpha (TNF-alpha) and LTB4. RESULTS: Median (IQR) symptom scores decreased from 19 [23] to 16 [21], P = 0.005. Vital capacity and FVC increased significantly (P < 0.05). However no difference was found for the total sputum cells and sputum as well as EBC cytokines between the two visits. Significant correlations were found for sputum IL-1 (+), IL-6 (-), and IL-8 (+) to total sputum cell count and neutrophils and for IL-8 to TNF-alpha. CONCLUSIONS: We have shown that a short-term inpatient rehabilitation for children with stable CF with intensive physical activity mainly improve subjective clinical symptoms and measures of lung function such as VC and FVC but does not influence airflow obstruction and airway inflammation as assessed by sputum and EBC analysis.

Aerosol delivery of nebulised budesonide in young children with asthma.

BACKGROUND: Lung deposition of inhaled steroids, likely to be of benefit in the anti-inflammatory treatment of asthma in young children, is low. This is explained by age specific anatomical and physiological characteristics as well as poor cooperation with aerosol therapy. However, total lung deposition and the ratio of lung deposition to oropharyngeal deposition are key determinants of clinical efficacy and of systemic side effects of aerosolized drugs. OBJECTIVES: The aim of this study was to determine lung deposition and ratio of lung deposition to oropharyngeal deposition using a modified vibrating membrane nebuliser to deliver budesonide with a small particle size, taking into account the needs of young children. PATIENTS AND METHODS: Ten asthmatic children (5 males), mean age 20.3 months (range 6-41 months) inhaled radiolabelled budesonide (MMD 2.6microm) through a modified vibrating membrane nebuliser (modified PARI e-Flow). Lung deposition expressed as a percentage of the emitted dose was measured using scintigraphy and the ratio of lung deposition to oropharyngeal deposition was calculated. RESULTS: Mean lung deposition (SD) expressed as percentage of emitted dose and mean lung to oropharyngeal deposition ratio (SD) in quietly breathing children (n=5) and in children crying during inhalation were 48.6% (10.5) versus 20.0% (10.9), and 1.0 (0.3) versus 0.3 (0.2), respectively. CONCLUSIONS: We have shown that by using an improved age-adjusted complementary combination of delivery device and drug formulation to deliver small particles, lung deposition and ratio of lung deposition to oropharyngeal deposition in young asthmatic children is highly improved. But the main factor limiting aerosol delivery in this age group remains cooperation.