Highlights
- Device Choice Matters: High-delivery valved holding chambers (VHCs) significantly improve clinical scores (RDAI) and reduce hospitalization rates (NNT 3.3) in children with acute wheezing compared to low-delivery alternatives.
- Neonatal Oxygenation: Automated FiO2 control is safe and reduces caregiver workload but does not significantly improve a composite outcome of death or major morbidity in extremely preterm infants.
- Therapeutic Safety: Large-scale RCT evidence (PIPPA Tamariki) confirms that paracetamol use in the first year of life does not increase the risk of eczema or bronchiolitis compared to ibuprofen.
- Metabolic Innovation: Inclisiran (siRNA) demonstrates sustained efficacy and safety in adolescents with heterozygous familial hypercholesterolemia, offering a simplified dosing regimen.
Background
Pediatric medicine is currently navigating a transition from generalized treatment protocols to evidence-based precision, where the nuances of drug delivery, therapeutic safety, and longitudinal monitoring dictate clinical success. Acute wheezing remains one of the primary drivers of pediatric emergency department (ED) visits, yet the clinical impact of varying medical devices—specifically valved holding chambers (VHCs)—has long been debated based primarily on in vitro data. Simultaneously, neonatology and pediatric psychiatry are grappling with systemic challenges: the management of oxygen in preterm infants and the rising incidence of first-episode psychosis linked to substance use. This review synthesizes high-impact clinical trials and observational studies to provide a roadmap for optimized pediatric care.
Key Content
Respiratory Interventions: The Clinical Impact of VHC Performance
While clinicians have recognized that VHCs differ in their in vitro drug delivery profiles, the 2026 randomized clinical trial by Csonka et al. (NCT03900494) provides definitive evidence that these differences translate into significant clinical outcomes for children aged 6 to 48 months with acute wheezing.
In this multicenter study conducted across four Finnish pediatric EDs, 80 children with moderate-to-severe respiratory distress (RDAI score ≥6) were randomized to receive salbutamol via either a high-delivery VHC (VHC-1) or a low-delivery VHC (VHC-2). The results were stark: posttreatment RDAI scores were significantly lower in the VHC-1 group (mean 2.7) compared to the VHC-2 group (mean 6.8), with a mean difference of -4.1 (95% CI, -5.4 to -2.7; P < .001).
Beyond symptomatic relief, the choice of device impacted resource utilization. The hospitalization rate was 20% for the high-delivery group versus 50% for the low-delivery group, resulting in a Number Needed to Treat (NNT) of only 3.3 to prevent one hospitalization. Furthermore, children using the high-performance chamber were less likely to require a fourth dose of salbutamol (RR 0.72) and exhibited superior oxygen saturation and lower respiratory rates post-treatment. These findings suggest that current guidelines, which often treat VHCs as interchangeable, should be updated to provide device-specific recommendations.
Neonatal and Early Childhood Refinements
In the domain of neonatal care, the management of supplemental oxygen in extremely preterm infants (23 to 27 weeks) remains critical. A large multicenter trial (Lancet Child Adolesc Health, 2026) compared closed-loop automated control of FiO2 (FiO2-C) against routine manual control. While FiO2-C is known to improve the time spent within target SpO2 ranges, the study found no significant difference in the composite primary endpoint of death, necrotizing enterocolitis, or bronchopulmonary dysplasia (OR 0.90, 97.5% CI 0.65-1.24). However, the intervention was deemed safe and effective in reducing caregiver burden, supporting its role as a supportive technology rather than a primary clinical outcome modifier.
Regarding early childhood medication safety, the PIPPA Tamariki trial addressed the long-standing concern that early paracetamol exposure might predispose infants to atopy. Comparing paracetamol and ibuprofen for fever or pain in 3,908 infants, researchers found no significant difference in the risk of eczema (OR 1.10) or bronchiolitis (OR 1.23) at age one year. This provides robust reassurance to parents and clinicians regarding the safety of both common antipyretics.
Precision Therapeutics and Emerging Genomic Challenges
Advancements in biotechnology are introducing new modalities for chronic pediatric conditions. The ORION-16 study evaluated inclisiran, a small interfering RNA (siRNA) targeting PCSK9, in adolescents with heterozygous familial hypercholesterolemia (HeFH). Inclisiran achieved a 28.5% greater reduction in LDL cholesterol compared to placebo at day 330, with a safety profile comparable to adults. The infrequent dosing (twice yearly after initial doses) represents a significant advancement for adherence in the adolescent population.
Conversely, the CIFFREO study on gene therapy for Duchenne muscular dystrophy (fordadistrogene movaparvovec) serves as a cautionary tale. Despite the promise of rAAV9-based mini-dystrophin delivery, the Phase 3 trial failed to meet its primary efficacy endpoint (change in NSAA score), highlighting the complexities of gene transfer in neuromuscular diseases and leading to the discontinuation of its development.
Mental Health and Global Suffering
Longitudinal population data from Canada (2006–2023) indicate a disturbing trend: the incidence of first-episode psychosis is rising, particularly among younger cohorts, with a quadrupling of the cumulative incidence of substance-induced psychosis by age 30 for those born in the 1990s compared to the 1980s. This is mirrored by findings in adolescent suicidal ideation, where high cumulative exposure to ‘ordinary’ life events (family distress, sexuality, autonomy) significantly predicts ideation, often independent of major childhood trauma.
On a global scale, the burden of serious health-related suffering (SHS) in children is evolving. While the absolute number of children requiring palliative care remained near 10.6 million in 2023, there is a distinct shift from decedent to non-decedent suffering, with 81% of children now living with chronic, progressive suffering rather than terminal illness. This necessitates a massive realignment of palliative care resources toward LMICs.
Expert Commentary
The pediatric landscape is increasingly defined by the intersection of high-quality delivery systems and precision molecular therapy. The VHC trial is a watershed moment for emergency pediatrics; it proves that the physics of aerosol delivery is not just a laboratory concern but a life-saving clinical variable. Clinicians should prioritize chambers with proven high-delivery profiles in the ED to reduce admissions.
In the broader context, while we celebrate the success of siRNA in HeFH, the failure of gene therapy in DMD and the escalating mental health crisis highlight where research must pivot. The lack of efficacy in the DMD trial suggests that even biologically sound ‘cures’ face immense barriers in the complex environment of human physiology. Meanwhile, the data on substance-induced psychosis suggests that public health policy is trailing behind pharmacological trends in substance use.
Conclusion
Significant progress has been made in optimizing existing pediatric therapies, particularly in respiratory delivery and neonatal monitoring. However, as clinicians move toward more specialized interventions like gene therapy and digital mental health tools (such as the ICTI for traumatic intrusive memories), the need for rigorous, large-scale RCTs remains paramount. Future research must address the geographic and socioeconomic gaps in pediatric palliative care and the rising tide of substance-related mental health disorders in the young.
References
- Csonka P, et al. Valved Holding Chambers in Young Children With Acute Wheezing: A Randomized Clinical Trial. JAMA Pediatr. 2026;e256479. PMID: 41729513.
- Pfizer. Safety and efficacy of fordadistrogene movaparvovec in Duchenne muscular dystrophy (CIFFREO). Lancet Neurol. 2026;25(3):245-255. PMID: 41722591.
- ORION-16 Study Group. Efficacy and safety of inclisiran in adolescents with HeFH. Lancet Diabetes Endocrinol. 2026;14(3):233-242. PMID: 41616799.
- PIPPA Tamariki Investigators. Paracetamol versus ibuprofen and the risk of eczema and bronchiolitis. Lancet Child Adolesc Health. 2026;10(3):156-166. PMID: 41616793.
- Lancet Commission Update. The global need for paediatric palliative care 1990-2023. Lancet Child Adolesc Health. 2026;10(3):167-178. PMID: 41679887.
