[Atopic dermatitis and allergy]. / Dermatite atopique et allergie : quels liens ?

Atopic dermatitis (AD) is a very common chronic inflammatory skin disease in childhood, often the first step in the atopic march. It seems justified to look for a food or a respiratory allergy, being worsening or responsible for the AD. At infant age, some clinical features are consistent with a food allergy: a severe AD, with an early onset, uncontrolled by topical corticosteroids, and a history of immediate-type reactions. As sensitization to food allergens is very common (positive skin prick-test, atopy patch-test or specific IgE), the role of food allergens in worsening AD is difficult to affirm. So, it could be necessary to ask the advice of an allergist, to avoid unnecessary elimination diets. At older age, exposure to aeroallergens cans worsen AD. Looking for an aeroallergen allergy can help to choose the specific immunotherapy, which clinical efficacy on AD seems interesting.

[Allergic march in children, from rhinitis to asthma: management, indication of immunotherapy]. / Marche allergique chez l'enfant, de la rhinite à l'asthme : prise en charge, place de la désensibilisation.

Allergic rhinitis (AR) is a common IgE dependent disorder. AR is maybe one of the steps of the allergic march, which starts with atopic dermatitis and food allergy and includes atopic asthma. AR and asthma are frequently associated. AR is frequently under-diagnosed and undertreated although it affects quality of life and school performance. Management of AR depends on its severity and will associate environmental control (best guided by environmental investigation and skin testing of specific IgE antibodies), pharmacotherapy (with antihistamines and intranasal corticosteroids as first line drugs). At present allergen immunotherapy is considered in patients with severe AR, insufficiently controlled by pharmacotherapy and who demonstrate specific IgE antibodies to relevant allergens. Sublingual immunotherapy is well tolerated. Only immunotherapy with the right allergens has the potential to alter the natural history of the allergic march, by preventing the development of new allergen sensitizations and reducing the risk for the subsequent development of asthma. This fact might extend the indications of specific allergen immunotherapy. Patients (and parents) education is of utmost importance in the management of allergic disorders.

Allergy to betalactam antibiotics in children: results of a 20-year study based on clinical history, skin and challenge tests.

Studies based on skin and challenge tests have shown that 12-60% of children with suspected betalactam hypersensitivity were allergic to betalactams. Responses in skin and challenge tests were studied in 1865 children with suspected betalactam allergy (i) to confirm or rule out the suspected diagnosis; (ii) to evaluate diagnostic value of immediate and non-immediate responses in skin and challenge tests; (iii) to determine frequency of betalactam allergy in those children, and (iv) to determine potential risk factors for betalactam allergy. The work-up was completed in 1431 children, of whom 227 (15.9%) were diagnosed allergic to betalactams. Betalactam hypersensitivity was diagnosed in 50 of the 162 (30.9%) children reporting immediate reactions and in 177 of the 1087 (16.7%) children reporting non-immediate reactions (p<0.001). The likelihood of betalactam hypersensitivity was also significantly higher in children reporting anaphylaxis, serum sickness-like reactions, and (potentially) severe skin reactions such as acute generalized exanthematic pustulosis, Stevens-Johnson syndrome, and drug reaction with systemic symptoms than in other children (p<0.001). Skin tests diagnosed 86% of immediate and 31.6% of non-immediate sensitizations. Cross-reactivity and/or cosensitization among betalactams was diagnosed in 76% and 14.7% of the children with immediate and non-immediate hypersensitivity, respectively. The number of children diagnosed allergic to betalactams decreased with time between the reaction and the work-up, probably because the majority of children with severe and worrying reactions were referred for allergological work-up more promptly than the other children. Sex, age, and atopy were not risk factors for betalactam hypersensitivity. In conclusion, we confirm in numerous children that (i) only a few children with suspected betalactam hypersensitivity are allergic to betalactams; (ii) the likelihood of betalactam allergy increases with earliness and/or severity of the reactions; (iii) although non-immediate-reading skin tests (intradermal and patch tests) may diagnose non-immediate sensitizations in children with non-immediate reactions to betalactams (maculopapular rashes and potentially severe skin reactions especially), the diagnostic value of non-immediate-reading skin tests is far lower than the diagnostic value of immediate-reading skin tests, most non-immediate sensitizations to betalactams being diagnosed by means of challenge tests; (iv) cross-reactivity and/or cosensitizations among betalactams are much more frequent in children reporting immediate and/or anaphylactic reactions than in the other children; (v) age, sex and personal atopy are not significant risk factors for betalactam hypersensitivity; and (vi) the number of children with diagnosed allergy to betalactams (of the immediate-type hypersensitivity especially) decreases with time between the reaction and allergological work-up. Finally, based on our experience, we also propose a practical diagnostic approach in children with suspected betalactam hypersensitivity.

[Physical activity and exercise training for patients with cystic fibrosis]. / Activité physique et réentraînement à l'effort du patient atteint de mucoviscidose.

In France patients with cystic fibrosis benefit from a multidisciplinary follow-up in Cystic Fibrosis Centres. In this follow-up, despite the numerous therapeutic benefits of exercise in this disease, little emphasis is placed on the promotion of physical activity. The aim of this article is to improve this aspect of management, giving advice from a working group of experts, based on the medical literature and clinical experience. These proposals include quantification of physical activity, evaluation of exercise, training and rehabilitation programs and finally, modification of behaviour to include physical activity in the overall cystic fibrosis treatment strategy. It is intended to set up multicentre studies to evaluate the impact of these proposals.

[Exercise alveolar hypoventilation in long-term survivors of bronchopulmonary dysplasia]. / Hypoventilation alvéolaire à l'exercice chez des enfants avec dysplasie bronchopulmonaire.

BACKGROUND: We aimed to confirm that children who have survived bronchopulmonary dysplasia (BPD) display lower ventilation during exercise than healthy children, and to determine whether alveolar hypoventilation associated with exercise-induced hypoxemia occurred in these children. METHODS: Twenty children with BPD (birth weight 1441+/-523 g [mean +/- SD], gestational age 31+2.3 weeks), aged 7 to 14 years, and 18 matched healthy children, born at term, performed resting pulmonary function and cardiopulmonary incremental exercise tests. Arterialized capillary blood gases were measured at rest and at maximal exercise in the BPD group. RESULTS: The BPD group showed moderate expiratory airflow limitation and hyperinflation. Maximal oxygen uptake and ventilatory threshold were similar in the two groups. The BPD group displayed ventilatory limitation on exercise, with greater use of the ventilatory reserve (p<0.01), lower maximal ventilation (p<0.01), tidal volume (p=0.01). Changes in ventilation (p<0.0001) and tidal volume (p=0.003) during exercise were significantly smaller in the BPD group than in controls, at similar submaximal workloads. At peak exercise, we observed hypoxemia in 12 BPD children (60%). In the subgroup with hypoxemia, a significant increase in PaCO2 (p=0.01) was measured at peak exercise, showing alveolar hypoventilation sustained by the lower tidal volume. CONCLUSIONS: Despite normal maximal aerobic performance, BPD children showed ventilatory limitation on exercise, frequently with hypoxemia and alveolar hypoventilation. Despite an improvement in their pulmonary condition, continued follow-up by cardiopulmonary exercise testing, is strongly recommended.

Allergic rhinitis in children with asthma: a questionnaire-based study.

BACKGROUND: Allergic rhinitis (AR) and asthma frequently coexist but has rarely been evaluated in children. OBJECTIVE: This prospective study aimed to estimate the prevalence of AR in asthmatic children, and ascertain whether AR is a risk factor for the severity of asthma. METHODS: The questionnaire, modified from the adult form of the score for allergic rhinitis (SFAR), was completed by 404 asthmatic children aged 3-18 years seen in the outpatient clinic between June 2005 and July 2007. Each item was assigned a number of points with a final score ranging from 0 to 17. AR and asthma were classified according to ARIA and GINA 2004 recommendations, respectively. RESULTS: AR was diagnosed in 237 patients (58.7%). It was intermittent in 57.8% of the patients and persistent in 42.2%. A total score >or=9 was discriminant for AR (sensitivity=91.1%, specificity=95.2%, positive predictive value=96.4%, negative predictive value=88.3%, Youden's Index=0.86). The proportion of children having mild or moderate-to-severe asthma was independent of the presence of AR, 61.6% of moderate-to-severe asthmatic children and 55.4% of intermittent and mild asthmatic children having AR. CONCLUSION: AR and asthma are frequently associated (58.7%). The SFAR adapted for children seems to be a simple and a reliable tool to detect AR in asthmatic children.

[Cystic fibrosis: how to use pulmonary function tests]. / Mucoviscidose: du bon usage des explorations fonctionnelles respiratoires.

INTRODUCTION: Neonatal screening for cystic fibrosis (CF) leads to early dedicated specialist care for all patients. BACKGROUND: Pulmonary function tests (PFT) are mandatory for routine monitoring of CF patients. The aim of this article is to review the current guidelines for PFTs in CF, particularly the type of test, the age and the clinical status of the patient. VIEWPOINT: The regular use of spirometry is generally accepted. Many other tests are used but their clinical value in the routine follow-up of CF patients remains to be established. CONCLUSION: Further efforts should be made to evaluate the value of PFTs in CF, particularly in very young children.

[Exercise test for asthmatic children. For whom? What indications?]. / Epreuve d'effort chez l'asthmatique. Pour qui ? Pour quoi ?

Asthma in children is not the most important indication for an exercise test. However, one might recommend a cardiopulmonary exercise test systematically in the follow-up of patients with severe asthma when there is persistent bronchial obstruction, when an asthmatic child complains of dyspnoea on exertion, or when the child's physical activity is limited. This test could be used to assess exercise tolerance, ventilatory adaptations, and the need for exercise training. Follow-up and evaluation of this training could be through a field exercise test (shuttle test or walk test). Moreover, the diagnosis of childhood asthma is frequently based only on symptoms suggestive of exercise-induced asthma. When the clinical features or a bronchodilatator test are not diagnostic, analysis of symptoms occurring during an exercise test can establish the diagnosis. The exercise test is thus a method that provides the time and intensity necessary to trigger exercise-induced bronchospasm.

[From walk test to cardiopulmonary exercise test]. / Du test de marche à l'épreuve d'effort cardio-pulmonaire.

Cardiopulmonary exercise test is a new respiratory functional test used for sick children. It demonstrates the integrated response of all the systems involved in exercise (especially cardiac and respiratory ones) and consequently evaluates exercise adaptations during chronic disease. This dynamic test assesses exercise tolerance, and so quality of life more objectively than a resting test. Values measured (especially oxygen uptake and ventilatory threshold) are quantifiable and reproducible, allowing the follow-up of a disease and the initiation and individualization of exercise training. Moreover, it is also useful for diagnosis and assessment of abnormal symptoms during exercise (as dyspnea), especially abnormalities that are undetectable during rest. The six-minute walk test, the step test and the shuttle test are rapid, simple and low-cost field tests that give adequate information on the daily physical performance (walking, climbing stairs, or running) of the sick child. They allow a closed follow-up, especially during an exercise training period. However, only the cardio-pulmonary exercise test can allow the physical practise in sick children, eliminating the contra-indications.

Hypersensitivity reactions to paracetamol in children: a study of 25 cases.

BACKGROUND: Allergic-like reactions to paracetamol (acetaminophen) are rare. Paracetamol allergic and nonallergic hypersensitivity (HS) has been diagnosed in a few patients with skin and/or respiratory symptoms, immediate and accelerated urticaria, and angioedema especially. Most patients with HS to paracetamol were also hypersensitive to anti-inflammatory drugs (i.e. acetylsalicylic acid, ASA), suggesting that their reactions resulted from a nonallergic HS. However, anaphylactic reactions, and potentially harmful toxidermias, such as acute generalized exanthematic pustulosis and toxic epidermal necrolysis, have been related to specific paracetamol allergic HS, with tolerance to anti-inflammatory drugs. PATIENTS AND METHODS: We report the results of a study performed in 25 children with suspected paracetamol HS. Diagnosis of paracetamol HS was based on a suggestive clinical history and a positive response in an oral challenge (OC) test. RESULTS: Paracetamol HS was diagnosed in only one child (4%). In this child, a positive response to an OC with ASA diagnosed HS to anti-inflammatory drugs. CONCLUSIONS: Our results in children agree with those of the literature, showing that paracetamol HS is rare, and is associated with HS to anti-inflammatory drugs in most patients.

Anaphylaxis during anesthesia: results of a 12-year survey at a French pediatric center.

BACKGROUND: Following adverse reactions to anesthesia, tests are carried out to determine the mechanism of the reaction and to identify the agent responsible. No specific data are available in France concerning such skin tests in children. METHODS: Between 1989 and 2001, we assessed hypersensitivity reactions to general anesthesia in 68 children. Thirty underwent more than one operation, for congenital malformations. Immunoglobulin (Ig)E-mediated anaphylaxis was diagnosed on skin tests combined with the clinical history. RESULTS: Grade I, II and III reactions were observed in 20, 27 and 21 children, respectively. IgE-mediated anaphylaxis was diagnosed in 51 children: 31 (60.8%) for neuromuscular blocking agents (NMBA), 14 (27%) for latex, seven (14%) for colloids, five (9%) for opioids and six (12%) for hypnotics. Vecuronium was the NMBA causing the largest number of reactions. Cross reactivity to NMBA available in France was observed in 23 of 30 children (76%), particularly for vecuronium and atracurium or pancuronium. The estimated frequency of IgE mediated anaphylactic reactions was one in 2100 operations. Based on our results, 25 children subsequently received a different anesthetic with no adverse reaction. CONCLUSIONS: As in adults, NMBA, then latex were responsible for most anaphylactic reactions during anesthesia. Our results confirm that skin tests with anesthetic agents are feasible and safe in children and improve the safety of subsequent anesthetic procedures.

[Latex-induced anaphylactic shock following graft reperfusion during renal transplantation]. / Réaction anaphylactique liée au latex probablement transmis par le greffon au cours d'une transplantation rénale.

We report a case of a young man with an allergy to latex who developed anaphylactic shock during anaesthesia for renal transplantation. All anaesthetic agents used before the episode were tested as potential allergens and only latex was shown to be positive. It appears that latex contamination in the graft was the cause since no materials containing latex were used during the operation. We feel it essential that donor organs should be removed in a totally latex-free environment. Such conditions will remove the risk of anaphylactic shock at the point of reperfusion of the transplant.

[Practical advice for exercise-induced asthma in children: experience of the exercise training centre of Necker-Enfants malades hospital]. / Conseils pratiques pour l'asthme de l'enfant déclenché par l'exercice physique: expérience du centre de réentraînement à l'effort de l'hôpital Necker-Enfants-malades .

Now, to care exercise-induced asthma is not only to prescribe drugs. It is a global and interdisciplinary approach: the pulmonary rehabilitation, matching a therapeutic education and a physical training, with the goal of promoting a regular physical activity in the asthmatic child, achieving physiological benefits and improvement of quality of life. Getting from the experience of Necker-Enfants Malades Hospital's Training Centre, a few advises encourage the physical practice of the asthmatic child, and decrease risks of exercise-induced asthma: optimisation of treatments;progressive beginning and end of exercises; use of the diaphragmatic breathing, keeping up with the exercise; use of the ventilatory threshold (or dysponea threshold) as intensity of the aerobic training; practice of different activities promoting play and conviviality in sports and allowing the integration of sports in the daily life of the asthmatic child.

[The asthmatic child at school: difficulties encountered and proposed solutions]. / L' enfant asthmatique en milieu scolaire: difficultés rencontrées, solutions envisagées...

Among a child out of ten is asthmatic. School absenteeism is frequent, due to an insufficient control of asthma. This insufficient control is especially evident at school where the usual risk factors of asthma are present. Allergenic risk with animals danders carried by other children, or regular practice of sports, are difficult situations for the asthmatic child. Controlling asthma, informing school and communicating with teachers, using the individualized care project, should avoid this absenteeism, which is responsible of school backwardness and difficulties in choosing careers.

[Allergen skin tests. Asthmatic infants and young children]. / Tests cutanés allergologiques. Nourrisson et jeune enfant asthmatiques.

Skin tests represent a major tool in the diagnosis of IgE mediated-allergy. The main indication is the measure of atopy during infancy and early childhood, as a predictive factor of the development of asthma. When atopic eczema is present, skin testing can provide a diagnosis of food allergy. Skin tests are easily done, without absolute contraindications. The epidemiological knowledge helps to choose the allergens to test. The skin-prick test method is well standardized and must be rigorous because of the hyporeactivity of the infant skin. Results are always confounded with positive and negative control solutions. The interpretation of pricks tests must be careful, standing out a clinical allergy (when clinical allergic symptoms are presents) from a sensitization (atopy). The predictive value of a positive skin test is discussed: predisposition to asthma, association with severe asthma, predisposition to acute bronchiolitis during an epidemic of respiratory virus. A positive skin test to food allergen would predict a later pneumallergen sensitization.