PRISMA 2020 Checklist
Section and Ite
Checklist item
Topic m#
TITLE
Title 1 Identify the report as a systematic review.
ABSTRACT
Abstract 2 See the PRISMA 2020 for Abstracts
checklist.
INTRODUCTION
Rationale 3 Describe the rationale for the review in the
context of existing knowledge.
Objectives 4 Provide an explicit statement of the
objective(s) or question(s) the review
addresses.
METHODS
Eligibility criteria 5 Specify the inclusion and exclusion criteria
for the review and how studies were
grouped for the syntheses.
Information 6 Specify all databases, registers, websites,
sources organisations, reference lists and other
sources searched or consulted to identify
studies. Specify the date when each source
was last searched or consulted.
Search strategy 7 Present the full search strategies for all
databases, registers and websites, including
any filters and limits used.
Selection process 8 Specify the methods used to decide whether
a study met the inclusion criteria of the
review, including how many reviewers
screened each record and each report
retrieved, whether they worked
independently, and if applicable, details of
automation tools used in the process.
Data collection 9 Specify the methods used to collect data
process from reports, including how many reviewers
Location where item is reported
A systematic review and meta-analysis on the effectiveness of swimming on lung function and asthma control in
children with asthma
OK
Given the unpredictability with which this pandemic evolves, and the fact that persistent childhood asthma is
associated with poorer lung functions in adulthood ( Bui et al., 2018 ), an updated review on the role of swimming
in asthma control in children is timely to control the burden of asthma in the coming years.
To determine the effectiveness of swimming as an intervention on lung function and asthma control in children
below the age of 18 years. Any adverse effects from swimming on asthma were also examined.
Study Selection
Inclusion criteria were included in this study: (a) study participants were aged 18 years and below with a
diagnosis of asthma; (b) studies presented swimming as an intervention with at least one session per week, with
each session lasting a mini- mum of 30 min for at least 4 weeks; (c) studies compared swim- ming with a control
group receiving no intervention, usual care or with a comparator group receiving aerobic exercises other than
swimming; (d) studies examined at least one outcome of interest (i.e. lung function –specifically FEV1, FVC, PEF;
asthma symptom control and adverse events related to swimming); (e) studies pub- lished in English.
excluded studies: (a) with mixed interventions (e.g. swim- ming and other exercises as an intervention) and other
exercise in- terventions where swimming was a subcomponent, and (b) were qualitative studies, book chapter
reviews, abstracts-only journals, editorials, discussion papers, conference proceedings and letters.
PubMed, CINAHL, Embase, CENTRAL, Scopus, and PsycINFO. A search on The United States (US) Na- tional
Library of Medicine Clinical Trials ( www.ClinicalTrials.gov ) and World Health Organization International Clinical
Trials Reg- istry Platform was done for relevant ongoing unpublished trials, and Google Scholar to identify grey
literature and unpublished tri- als.
To achieve sensitivity within concepts, each concept involved a set of medical subject headings (MeSH) and
keywords (in title or abstract) combined with the Boolean operator “OR”. To ensure reasonable precision,
Boolean operator “AND”was used to combine the two different concepts
The retrieved study records from the six databases were im- ported into the EndNote X9 Software to aid in
managing refer- ences, removing duplicates and storing and organizing of studies ( Clarivate Analytics, 2019 ).
After the removal of duplicate refer- ences, the titles and abstracts of the study records were then inde- pendently
assessed against the eligibility criteria by two indepen- dent reviewers (HJR & JY) to minimize the possibility of
excluding relevant studies. Studies with irrelevant titles and abstracts were excluded. Full-text copies of the
eligible studies were retrieved and further evaluated and analysed by HJR and JY independently to determine
compliance with eligibility criteria and study inclusion. Disagreements between the two reviewers were resolved
through discussion and then consultation with a third experienced reviewer (WW).
The retrieved study records from the six databases were im- ported into the EndNote X9 Software to aid in
managing refer- ences, removing duplicates and storing and organizing of studies ( Clarivate Analytics, 2019 ).
 PRISMA 2020 Checklist

Section and Ite

Checklist item Location where item is reported
Topic m#
collected data from each report, whether After the removal of duplicate refer- ences, the titles and abstracts of the study records were then inde- pendently
they worked independently, any processes assessed against the eligibility criteria by two indepen- dent reviewers (HJR & JY) to minimize the possibility of
for obtaining or confirming data from study excluding relevant studies. Studies with irrelevant titles and abstracts were excluded. Full-text copies of the
investigators, and if applicable, details of eligible studies were retrieved and further evaluated and analysed by HJR and JY independently to determine
automation tools used in the process. compliance with eligibility criteria and study inclusion. Disagreements between the two reviewers were resolved
through discussion and then consultation with a third experienced reviewer (WW).
Data items 10a List and define all outcomes for which data outcome was re- ported via the same measurement scale, and through the standard- ized mean difference (SMD)
were sought. Specify whether all results that when outcomes were reported using different measurement scales.
were compatible with each outcome domain
in each study were sought (e.g. for all
measures, time points, analyses), and if not,
the methods used to decide which results to
collect.
10b List and define all other variables for which outcome was re- ported via the same measurement scale, and through the standard- ized mean difference (SMD)
data were sought (e.g. participant and when outcomes were reported using different measurement scales.
intervention characteristics, funding
sources). Describe any assumptions made
about any missing or unclear information.
Study risk of bias 11 Specify the methods used to assess risk of The Cochrane ‘Risk of Bias’ assessment tool found in the Cochrane Handbook of Systematic reviews of
assessment bias in the included studies, including details Interventions was used to guide the assessment of possible risk of bias for each in- cluded study and consists of
of the tool(s) used, how many reviewers the following six domains –random sequence generation (selection bias), allocation concealment (se- lection
assessed each study and whether they bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias),
worked independently, and if applicable, incomplete outcome data (attrition bias), and selective reporting (reporting bias)
details of automation tools used in the
process.
Effect measures 12 Specify for each outcome the effect outcome was re- ported via the same measurement scale, and through the standard- ized mean difference (SMD)
measure(s) (e.g. risk ratio, mean difference) when outcomes were reported using different measurement scales.
used in the synthesis or presentation of
results.
Synthesis 13a Describe the processes used to decide OK
methods which studies were eligible for each
synthesis (e.g. tabulating the study
intervention characteristics and comparing
against the planned groups for each
synthesis (item #5)).
13b Describe any methods required to prepare OK
the data for presentation or synthesis, such
as handling of missing summary statistics, or
data conversions.
13c Describe any methods used to tabulate or OK
visually display results of individual studies
and syntheses.
13d Describe any methods used to synthesize The I -squared ( I 2 ) statistic and chi-squared test (Chi 2 ) were used to determine the heterogeneity of the
results and provide a rationale for the studies, considering di- rection and effect magnitude. Study heterogeneity was indicated if the Chi 2 or Cochrane
 PRISMA 2020 Checklist

Section and Ite

Checklist item Location where item is reported
Topic m#
choice(s). If meta-analysis was performed, Q Test had a p -value is < 0.10. The ex- tent of heterogeneity was assessed using the I 2 overlapping inter- vals
describe the model(s), method(s) to identify as low ( I 2 = 0 −40%), moderate ( I 2 = 30 −60%), substantial ( I 2 = 50 −90%) and considerable ( I 2 = 75
the presence and extent of statistical −100%) (
heterogeneity, and software package(s)
used.
13e Describe any methods used to explore NO
possible causes of heterogeneity among
study results (e.g. subgroup analysis, meta-
regression).
13f Describe any sensitivity analyses conducted NO
to assess robustness of the synthesized
results.
Reporting bias 14 Describe any methods used to assess risk of NO
assessment bias due to missing results in a synthesis
(arising from reporting biases).
Certainty 15 Describe any methods used to assess
assessment certainty (or confidence) in the body of
evidence for an outcome.
RESULTS
Study selection 16a Describe the results of the search and OK
selection process, from the number of
records identified in the search to the
number of studies included in the review,
ideally using a flow diagram.
16b Cite studies that might appear to meet the OK
inclusion criteria, but which were excluded,
and explain why they were excluded.
Study 17 Cite each included study and present its OK
characteristics characteristics.
Risk of bias in 18 Present assessments of risk of bias for each OK
studies included study.
Results of 19 For all outcomes, present, for each study: OK
individual studies (a) summary statistics for each group (where
appropriate) and (b) an effect estimate and
its precision (e.g. confidence/credible
interval), ideally using structured tables or
plots.
Results of 20a For each synthesis, briefly summarise the OK
syntheses characteristics and risk of bias among
contributing studies.
20b Present results of all statistical syntheses NO
conducted. If meta-analysis was done,
 PRISMA 2020 Checklist

Section and Ite

Checklist item Location where item is reported
Topic m#
present for each the summary estimate and
its precision (e.g. confidence/credible
interval) and measures of statistical
heterogeneity. If comparing groups, describe
the direction of the effect.
20c Present results of all investigations of NO
possible causes of heterogeneity among
study results.
20d Present results of all sensitivity analyses NO.
conducted to assess the robustness of the
synthesized results.
Reporting biases 21 Present assessments of risk of bias due to YES
missing results (arising from reporting
biases) for each synthesis assessed.
Certainty of 22 Present assessments of certainty (or YES
evidence confidence) in the body of evidence for each
outcome assessed.
 PRISMA 2020 Checklist

DISCUSSION
Discussion 23a Provide a general interpretation of the This review evaluated the effectiveness of nine studies using swimming as an intervention on three asthma
results in the context of other evidence. outcomes: improved lung function, medication use and symptom control in asthma, and any adverse effects among
asthmatic children. The studies in- volved 387 participants across 8 different countries. The swim- ming
intervention spanned across 6 weeks to 12 months with varying program outlines, frequencies and duration of
each swim session.

23b Discuss any limitations of the evidence This review has several limitations. Firstly, as most of the in- cluded studies had insufficient information
included in the review. regarding the measures undertaken to prevent bias, the findings in this review are to be in- terpreted with caution as
the quality of the included studies are uncertain. Secondly, the small sample sizes of included studies, coupled
with the fact that most of the studies in this review failed to provide sufficient data to be included into the meta-
analysis, caused limitations in statistical power analysis in most studies and reduces generalizability of results
(Guyatt et al., 2011). Thirdly, the variability in swimming programme outline, duration and fre- quency of sessions
makes it challenging to accurately compare the effect of swimming across studies. Furthermore, ambiguity in base- line
asthma severity amongst participants, swimming environment and provider details in some of the included studies is
problematic in making meaningful conclusions on the efficacy of swimming in- terventions on pulmonary function and
symptom control in asth- matics. Lastly, as inclusion in this review was limited to studies published in English,
potentially eligible studies in other languages were omitted and may have hindered the comprehensiveness of the
findings in the review.

23c Discuss any limitations of the review ADA

processes used.
23d Discuss implications of the results for Swimming is an inexpensive exercise that does not require any special equipment, although availability and
practice, policy, and future research. accessibility varies between countries. It benefits physiologic functioning (Lazovic- Popovic et al., 2016) and
support psychosocial well-being of the asthmatic child through improved self-esteem, self-confidence and
reduced stigma (Beggs et al., 2013). This review showed that swim- ming has the potential to improve lung
function, asthma control and does not result in any adverse effect, specifically BHR and EIB. Whether
swimming is superior to other forms of aerobic ac- tivity cannot be determined from this review. Nevertheless,
while healthcare professionals may still recommend swimming as a form of physical exercise and as an
adjunct to pharmacotherapy in the treatment of asthma, the importance of pool maintenance in mini- mizing the
exposure to chlorine irritants and by-products in swim- ming pools cannot be overstated. Future studies that (1)
are ade- quately powered to assess the effectiveness and potential adverse effects of swimming in asthmatic
children should (2) design swim- ming interventions of sufficient intensity, frequency and duration, (3) examine
accurate cumulative exposures to chlorine-by products and (4) account for and control potential cofounders are
certainly warranted. Of particular interest is whether long-term exposures to a physical activity like swimming
can offset the rate of decline in lung function seen in asthmatics, especially in a time when the COVID-19
pandemic has brought into focus the magnitude of good respiratory health.
OTHER INFORMATION
Registration and 24a Provide registration information for the This Review was no registered
protocol review, including register name and
registration number, or state that the review
was not registered.
24b Indicate where the review protocol can be To improve the transparency, accuracy and completeness, this systematic review and meta-analysis is written and
accessed, or state that a protocol was not structured in accordance with the guidelines from the Preferred Reporting Items for Systematic review and Meta-
prepared. Analysis (PRISMA)

24c Describe and explain any amendments to No Information

 PRISMA 2020 Checklist

information provided at registration or in the

protocol.
Support 25 Describe sources of financial or non- No external funding.
financial support for the review, and the role
of the funders or sponsors in the review.
Competing 26 Declare any competing interests of review There is no conflict of interest declared by the authors.
interests authors.
Availability of 27 Report which of the following are publicly Index terms and keywords for searching in seven databases
data, code and available and where they can be found: . Table of excluded studies
other materials template data collection forms; data
Summary of Included Studies (n = 9)
extracted from included studies; data used
for all analyses; analytic code; any other
materials used in the review.

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi:
10.1136/bmj.n71
For more information, visit: http://www.prisma-statement.org/

From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi:
10.1136/bmj.n71
For more information, visit: http://www.prisma-statement.org/