Respiratory tract infections in children - our paediatrician's insight and bold vision for the future

Clare Taylor: 0:16

Welcome to all of our listeners. Today's episode on ESWI Airborne, the podcast series of the European Scientific Working Group on Influenza, otherwise known as ESWI. I'm your host, Clare Taylor speaking, and this is the place to be to stay up to date with all things viral hearing directly from ESWI members. These are the people that know the most about viruses, pandemics, vaccines and more. Today's episode is all about insights into the burden of disease from RSV in children. And here to tell us all about it, I am delighted to welcome to the studio ESWI member Dr Paula Tähtinen, clinical lecturer, paediatrics and adolescent medicine, adjunct professor in the Department of Clinical Medicine at the University of Turku and yes, you guessed right also an ESWI board member. Paula, welcome to ESWI Airborne.

Paula Tähtinen: 1:19

Thank you, it's a pleasure to be here.

Our listeners may remember the ESWI Airborne episode where we heard from Terho Heikkinen, professor of paediatrics at the University of Turku, and Terho shared with us his insights into the importance of flu vaccinations for children in reducing the burden of disease. Paula, I imagine you and Terho probably know each other, is that right?

Yes, I do. We both work at the Department of Pediatrics in Turku University Hospital and University of Turku in Finland.

Okay, great, and I think we'll hear a bit more about the kind of work you do together. I would also note note in a more recent episode of ESWI Airborne, we had a very good discussion with Dr Stefania Maggi from the Neuroscience Institute in Padova in Italy, about respiratory syncytial virus, or RSV, and the burden of disease in older adults. So, Paula, I'm really looking forward to what we're going to learn from you today about the burden of disease in children as, shall we say, kind of filling in the gaps or mapping the territory around these topics. But first I really want to know how you got started. You qualified as a doctor in 2004 and you went to work as a GP. What was it that made you want to work with children in particular?

Well, I have always loved children and paediatrics was my number one option already in medical school. Working as a GP for at least nine months is part of our specialisation in Finland. I worked a lot in a well-baby clinics where I saw children from one week to seven years of age. It was very interesting to getting to know the families and get to see the children grow. Children are usually very honest and they don't pretend. So when they are sick you can see that from their face, but they also heal very fast. So working as a pediatrician is very rewarding.

And what did you feel you really learned from these early days? When did you decide that you were going to go for PhD studies and take it further?

Well, I learned a lot from those years. Working as a GP in a small rural health care center was my first job as a real doctor, so I still had to spend a lot of time studying because, of course, I couldn't know everything at that time and I still don't know everything. But I think it's very important for every young doctor to work as a GP. It's good to have a wider perspective of healthcare system and to know how things work in a primary care. I learned how to treat acute heart attack or how to apply a cast on a broken bone or how to talk to person with mental issues. But, most importantly, I learned that I love my job. People trust me and it makes me feel good to be able to help them. The reason why I moved back to Turku was that we were about to start our randomised clinical trial on treatment of acute otitis media, together with my supervisor, Dr Aino Ruohola, and this was something that we had planned already when I was still in medical school, when I first met Aino.

And I guess this is where you first encountered Terho, is that right?

Yes, so actually I first met Terho when I was still a medical student. Professor Heikkinen gave us lectures about pediatric infectious diseases and he taught us how to use the otoscope and tympanometry and these are the devices that are used to examine ears. And he also told us about his own research and I remember thinking already back then that otitis media research sounds very interesting and clinically relevant.

And Terho's postdoc was more than 10 years earlier than yours and he focused in on acute otitis media in children and this, as you're telling us, also took up your interest. And could you, what were the synergies? I mean, could you see how the research field has developed in that time, in that 10-year interval?

Well, talking about synergies. So my PhD thesis was about treatment of acute otitis media and the supervisor of my PhD thesis, a young professor Aino Ruohola, she actually did her thesis under the supervision of Terho. So Terho has actually been like a role model for me for almost 20 years. And back in 1970s and 80s, for example, all ear infections were treated by puncturing the tympanic membrane, which is the eardrum, and sucking the pus from the middle ear. And this procedure is not very pleasant and it can actually cause pain if the local anesthetic drops do not work properly. So thanks to several studies that show that antibiotic treatment is as effective as the puncture itself, we rarely do these procedures anymore. Nowadays many children are treated without antibiotics and the use of pain medication is emphasised. So treatment guidelines have changed a lot based on research. What has not changed is the fact that the acute vital infection, that is a common cold, precedes the ear infection and these viruses play a great role in the development of acute otitis media.

That's very interesting what you have to say about treatment, and I would like us to come back to that later in the conversation, because I think it's a very important issue for parents everywhere. So, but when you were kind of carrying out your postdoctoral studies, you defended your thesis in 2012, right? So that brings us up to 10 years ago and it seems to me, looking at your bio, this was a big year for you. You got this wonderful title, Young Investigator Award. This is a great title, I think, in any field from the European Society for Pediatric Infectious Diseases, and in that same year, you got Researcher of the Year from the National Graduate School of Clinical Investigation. So was this a big year for you? Like, how did this recognition affect you personally and professionally?

Well, naturally, I was very touched by these recognitions. It's a great honor to be chosen among many smart and talented researchers to receive an award. Research work is a team effort, so I think that these awards show that we as a group have done a good job and are on a right path to fight pediatric infectious diseases.

Well, it certainly sounds like with Terho at the helm, he has been an inspiring figure for many. And I see that just after you received these awards, you made this big jump and went stateside. You went to the US and studied and worked at Harvard. So this was going up in the elevator for sure. What was it like for you in the States?

The years in Boston they were very memorable for me and our whole family. Boston is a very international city with many prestigious universities, so it was very exciting to see how innovative and productive the research groups there were. In Boston I had the privilege to work together with Professor Stephen Pelton, who has a long history of pediatric infectious diseases research and he's also a highly respected clinician. During my years in Boston I did translational research, which means that I used our clinical samples collected from the nature farms of children who had acute respiratory tract infection and I studied the bacteria and viruses in this sample in the laboratory. So I learned new laboratory and statistical skills. However, I think the most important part was to get to know new people and make contacts and friendships that have lasted for years.

And this is an interesting kind of transatlantic community of interest and community of practice, great cooperation. I see that the European Society for Paediatric Infectious Diseases that gave you this marvelous Young Investigator Award also gave you a fellowship award and supported your work in the States.

Yes, the SBIT Fellowship Award was another recognition that gave me courage to continue my research work, and the fellowship actually allowed me to continue my postdoc project when I returned to Finland.

So when and why did you decide to return to Finland?

We moved back to Finland in 2015 after spending two years in the United States. The main reason we moved back to Finland was that my husband had a job in Finland and my children started school here. I also wanted to continue my specialisation in paediatrics. Our hearts still stayed in Boston, and it's funny how it always feels like coming back to home when we visit Boston.

Isn't that great to have that home, away from home experience as well as returning to your homeland. And since you've been in Finland, your research work continues. You teach, you work as a paediatrician. How do you manage your time among these different professional activities?

Well, that's a good question. I wish I had more hours in my day, but to be honest, I think these three roles support each other. As a clinical lecturer, it's good to have both scientific and clinical background and for a clinical researcher, it's also good to work at the front line and see which diseases cause a lot of burden for children and which questions still remain unanswered.

This is great. So you feel that they really feed each other, that you're a busy woman, but these are mutually supporting activities. And now let's dive a bit deeper into the topic of the burden of disease from RSV in children. In a nutshell, Paula, I know this is difficult to say in a nutshell, but what would you see as the leading issues here?

Well, RSV is a common virus that usually causes acute respiratory symptoms such as runny nose, cough or fever. So for older children and adults, RSV usually causes mild common cold-like symptoms. But for younger children, especially for infants, RSV may cause severe infections and lead to hospitalisation. It's the most common cause of lower respiratory tract infection in children less than one year of age. So infants with RSV often have difficulties of breathing. They may have a wheezing sound, especially when they are breathing out. And infants have small and narrow airways and the inflammation process that is caused by the virus that usually makes the airways even more narrow. During RSV infection, children usually produce a lot of mucus, which makes the breathing and eating even more difficult. Some children may have pneumonia, which is a lung infection, and two to three percent of children with RSV may end up in a hospital. We know that RSV typically causes seasonal winter epidemics throughout the world. In Finland we used to have a big epidemic every other year and a smaller one every other year. Every winter we treat these babies at the hospital and try to do our best to help their breathing and eating.

So would you see the burden of disease in children as much more acute than for healthy adults. You see you're talking about two to three percent will be hospitalised.

Yes, the burden is higher among children, RSV causes a significant burden, especially for young children. It's a common cause for outpatient visits, especially for children less than two years of age. According to some studies, in the United States, the annual incidence of RSV is approximately 200 cases per 1,000 children. Virtually all children have RSV by the age of two years. Unfortunately, previous infection does not protect them from getting a new infection, and some children may even have several RSV infections during the same year. And this virus is also an important cause of death in infants, especially in research limited setting. The risk factors for severe infection are young age, prematurity, which means that the child was born several weeks before the due date, and underlying chronic diseases such as heart or lung diseases. Immunocompromised children are also at risk for severe infection. So healthy adults, they usually have very mild cold-like symptoms, but we know that older adults and immunocompromised adults may also have severe diseases. This is something that we are learning a lot every year. Several studies have shown that RSV may cause significant burden for the older adults as well.

For sure, and we heard from Stefania about that. I think what I'm picking up from you is that, especially for younger children under two years of age, less than a year old infants and with pre-existing health conditions or immunocompromised in some way, that the common cold is not something to be taken lightly. Now, Paula, something you said there a child can get RSV over and over again. Is this because the virus mutates?

Yes, RSV, as most of the respiratory tract viruses, do mutate quite easily. I think the main issue also is that there are several types of RSV circulating in the community at the moment. So you might get infected with one type and within a couple of months you might get the other type and you don't have enough antibodies to protect from that different type of RSV.

Do you feel that healthcare professionals are sufficiently aware of these issues?

I think that the healthcare professionals are well aware of the burden of RSV among young children. They are taught to evaluate the overall condition and the breathing of children. If they suspect that the child might need hospitalisation, they send the child to a specialist. I think that all pediatricians are aware of the seasonality of RSV infections and they follow the epidemiological data to see if there are any signs of new RSV outbreak.

Okay, good, so you think awareness is at a sufficiently high level among practitioners, and what is the recommended approach to treatment for RSV in children?

Unfortunately there are no specific treatments for RSV. The treatments that we use are mainly symptomatic treatments. We help the breeding by giving warm, humidified air through the nose to the lungs and, if necessary, we give extra oxygen for the child. We suck the mucus from the nose and the other airways. And if the baby has difficulties of eating, we might give intravenous fluids to keep him or her hydrated.

Staying with the topic of treatment, now there's something I'm curious about. I suppose all parents, myself included, have witnessed just how painful acute otitis media or ear infections are in children, and usually treated with antibiotics. But these infections often also clear up on their own. So it's very difficult for a parent to choose. You know, you see your child in pain, you want to do something, and then at the same time we all know know about the fairly dreadful prospect of antibiotic resistance which is building, and so there may be a reluctance to prescribe antibiotics in certain cases. How does this affect your choices as a pediatrician and indeed your advice to our listeners on when it's appropriate to prescribe a course of antibiotics?

Well, yes, of course we think about antibiotic resistance every day in clinical practice. It's a huge problem worldwide. The treatment guidelines for ear infections as I already said earlier, they have changed a lot over the past 20-30 years. We know that antibiotics are effective for the treatment of acute otitis media, but we also know that some children may recover well without antibiotics. RSV, for example, causes acute otitis media quite often, but it's a virus that doesn't need antibiotics to be treated. So one of the aims of our research group is to determine which children need antibiotics and which don't. Studies have shown that children less than two years of age, children who have the infection in both ears and children who have very bulging eardrum, meaning that there's a lot of pus in the middle ear, they seem to benefit most from antimicrobial treatment. In my clinical practice I make treatment decisions case by case and I discuss the options with parents.

So we've come quite a long way from puncturing eardrums, into a more kind of holistic care, I would say? And yet prevention remains better than cure, usually always. What can we say about prevention? What advice can we give to parents, especially parents of very young children, about prevention of RSV in children?

well, we can give the same advices that everybody already know, based on COVID-19 pandemic. Wash your hands with soap, cover your mouth when coughing, keep distance and stay at home when sick. It's especially important to protect young infants, children less than one year of age, from getting sick. That's why young children should be kept away from covered places such as malls during winter time. Especially those infants who are born at the beginning of the RSV epidemic should be kept at home for the first few months. So the past two years have shown that we can limit the spread of viruses by modifying our behavior. During the COVID pandemic, school closures, social distancing and mask wearing actually resulted in marked reductions in all respiratory tract infections, including RSV. Naturally, we can't continue those strict restrictions forever, but I think that we should learn and take what we learned from the COVID-19 pandemic and use that knowledge to prevent other viral infections as well.

For sure. It no longer seems strange to choose to wear a mask in a crowded public space, or I think we've all become more accustomed to non-pharmaceutical interventions.

Exactly. Unfortunately, we do not have any vaccine against RSV yet, but several research groups around the world are working on developing such a vaccine. We do have a specific antibody against RSV virus available, but that's very rarely used. Its use is actually restricted to children who are at risk of severe infections. And this antibody that can help prevent severe RSV disease, but unfortunately it cannot prevent the infection itself or cure an infection if the child has already been sick.

Paula, I feel that in the future years, we're going to hear from you much more about this because, as I understand it, you're in the middle of setting up your own research group with the main focus on prevention and treatment of respiratory tract infections. How many people are going to be in this group?

Hopefully many. At the moment, I have two PhD students and several medical students to supervise, but I really hope that someday I will have a big group of researchers who are as excited about infectious diseases as I am.

And what's your vision for what this future research supergroup could achieve?

Well, currently I'm applying for funding to start new projects within the next few years. I really hope that we could find a way to modify the microbiome in the child's nose, meaning all the bacteria and viruses that are there, so that they do not get respiratory tract infections, especially ear infections, as often as they used to. By reducing the burden of respiratory tract infections, we could also reduce the use of antibiotics, and by this we could decrease antimicrobial resistance worldwide.

Paula, that was really interesting. I want to say thank you so much for being with us in the studio today. This is obviously a really, this is your life's work. I feel that you're engaged in here and I feel confident that we're going to hear a lot more from the research group that you're leading in the future.

Thank you for inviting me. It's been a pleasure.

And also thanks to all of our listeners. Please, folks, keep on tuning in to ESWI Airborne, the viral podcast series, where you can hear all about the latest on pandemics, vaccination, influenza, visualising viruses and a whole lot more directly from the expert group of virologists and members of ESWI, the European Scientific Working Group on Influenza. Until next time, dear listeners, stay safe.

Aida Bakri: 27:12

ESWI Airborne is brought to you by ESWI, the European scientific working group on influenza and other acute respiratory viruses. These episodes would not be possible without the team's efforts and we would like to extend special thanks to our ESWI secretariat, our technical and IT teams, our arts team and our host, Clare Taylor. The podcasts are recorded virtually and we thank our guests for their participation in this inspiring series. Talks are adapted to a global audience and are intended to be educational. For any specific medical questions you may have, these should be addressed to your local general practitioner. Many thanks to our sponsoring partners and thank you for listening.

Respiratory tract infections in children - our paediatrician's insight and bold vision for the future

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