["NPAs": a new allergic risk?]. / Les << NAC >> : un risque allergique nouveau ?

In recent years, to the list of classic pet animals (dogs and cats) as allergens we must now add the "new pet animals" (NPAs). This group of animals, referred to by the Anglo-Saxons as "pets", includes both those previously recognized (rabbit, guinea pig, hamster, birds) and the "truly new NPAs"; by general agreement "NPA" will include all animals other than cats and dogs. Some rather rare animals are regularly added to this list. The emergence of "NPAs" can be related to a social phenomenon, in particular, to the fashion and need for the exotic (http://www.aquadesign.be). They are a very diverse group: warm-blooded animals, spiders, batrachia (frogs, toads, salamanders, etc.) and reptiles. Besides the physical risks from their natural aggressive behaviour, the "NPAs" can be an allergic risk factor and this risk has a tendency to increase. Allergists and paediatricians have a role to play in the diagnosis and prevention of these allergies by giving advice on the choice of pet animals. This review concerns allergies to rodents, reptiles, batrachians, spiders, etc.

[The history of tuberculosis]. / Petite histoire illustrée de la tuberculose.

The history of tuberculosis has given rise to a great number of publications. The aim of this review is to describe the main steps of this history from Antiquity to our time. The permanent fight against tuberculosis has eventually been won, even though the disease remains worrying in many countries of the world affected by serious economical difficulties. This fight has served as a model for the present management of chronic diseases like diabetes mellitus, asthma or allergies.

Long-term outcome of idiopathic pulmonary hemosiderosis in children.

We retrospectively analyzed the long-term outcome of idiopathic pulmonary hemosiderosis (IPH) in 15 children. IPH started at a mean age of 5 years, and the mean duration of follow-up was 17.2 years (range, 10-36 yr). Four patients developed immune disorders, 3 cases of rheumatoid polyarthritis or rheumatoid polyarthritis-like diseases and 1 case of celiac disease. Respiratory outcome showed that 3 patients had severe symptoms: 2 patients developed severe pulmonary fibrosis resulting in major chronic respiratory insufficiency, and 1 patient had severe asthma. Twelve patients (80%) had mild or no respiratory problems and were able to lead a normal life. According to chest X-ray and pulmonary function test data, 4 patients had normal chest X-ray and no evidence of restrictive syndrome, 6 patients had an interstitial pattern on chest X-ray and evidence of restrictive pattern, 1 patient had an interstitial pattern but normal lung function, and 1 patient had a normal chest X-ray but evidence of mixed obstructive and restrictive pattern. Our results show that long-term survival is possible in patients with IPH. Factors of poor prognosis seem to be the presence of antineutrophil cytoplasm antibodies (ANCA) or other autoantibodies. No other clinical or biological predictive factors for prolonged survival were found.

High-dose albuterol by metered-dose inhaler plus a spacer device versus nebulization in preschool children with recurrent wheezing: A double-blind, randomized equivalence trial.

UNLABELLED: Inhaled albuterol is the most frequently used bronchodilator for acute wheezing, and nebulization is the standard mode of delivery in hospital setting. However, recent guidelines consider spacer devices as an easier to use, and cost-saving alternative and recommend the high-dose metered-dose inhaler bronchodilator. OBJECTIVE: To demonstrate clinical equivalence between a spacer device and a nebulizer for albuterol administration. DESIGN: Randomized, double-blind, parallel group equivalence trial. SETTING: Pediatric emergency wards at 2 tertiary teaching hospitals. PATIENTS: Sixty-four 12- to 60-month-old children with acute recurrent wheezing (32 per group). INTERVENTIONS: Albuterol was administered through the spacer device (50 microg/kg) or through the nebulizer (150 microg/kg) and repeated 3 times at 20-minute intervals. Parents completed a questionnaire. OUTCOME MEASURES: Pulmonary index, hospitalization, ease of use, acceptability, and pulse oximetry saturation. RESULTS: The 90% confidence interval of the difference between treatment groups for the median absolute changes in pulmonary index values between T0 and T60 was [-1; +1] and was included in the equivalence interval [-1.5; +1.5]. Clinical improvement increased with time. Less than 10% of the children (3 in each group) required hospitalization (2 in each group attributable to treatment failure). Parents considered administration of albuterol using the spacer device easier (94%) and better accepted by their children (62%). CONCLUSIONS: The efficacy of albuterol administered using the spacer device was equivalent to that of the nebulizer. Given its high tolerance, repeated 50-microg/kg doses of albuterol administered through the spacer device should be considered in hospital emergency departments as first-line therapy for wheezing.

Continuous subcutaneous infusion of beta 2-agonists in infantile asthma.

Eleven infants presenting with an asthmatic syndrome were treated with subcutaneous infusions of a beta 2-agonist (beta 2A) during an acute episode. This treatment was used after difficulties with or failure of beta 2A infusions and IV nebulizations. No local or general adverse reactions were observed. The serum concentrations of salbutamol obtained at a dose of 0.1 micrograms/kg/min were measured in six infants and found to be within the generally accepted therapeutic range. This mode of administration proved extremely useful, both by itself and as part of a therapeutic protocol, combined with an antibiotic, a corticosteroid, and theophylline. It avoids the difficulties of administering beta 2A intravenously or by nebulization, while preserving some degree of freedom and better general care for the child. The preferred indication is in treatment of severe acute asthmatic episodes after failure of nebulizations. The exact place in the therapeutic arsenal of infantile asthma remains to be defined.

Respiratory function in children undergoing bone marrow transplantation.

We conducted a prospective study of respiratory function in children undergoing bone marrow transplantation (BMT) for onco-hematological disorders. Each child was evaluated before and 100 days after BMT. The investigations included clinical examination, chest X-ray, and pulmonary function tests (PFT) to determine: slow vital capacity (VC), functional residual capacity (FRC), total lung capacity (TLC), forced expiratory volume in 1 s (FEV1), carbon monoxide diffusing capacity (DLCO), ratio of residual volume (RV) to TLC, and FEV1/VC. The values obtained before and after BMT were compared to predicted values, and the post-BMT values were compared to the pre-BMT values (Student's t-test). From 1986 to 1995, 77 children underwent BMT, of whom 39 were available for testing. The pre-BMT VC (P = 0.0234) and DLCO (P < 0.0001) were lower and FRC higher (P < 0.0001) than predicted values. After BMT, the VC (P = 0.004), TLC (P = 0.044), and FEV1 (P = 0.012) were lower, and the RV/TLC ratio was higher (P = 0.043), compared with pre-BMT data. The observed respiratory abnormalities were not clinically relevant. The only identifiable risk factor for a decrease in lung function was age at BMT. This study shows that some lung dysfunction may be present before BMT and be further altered by BMT. This stresses the need for longitudinal respiratory monitoring and follow up to detect such dysfunctions and to insure an optimal treatment program for these children.

Comparison of the efficacy and safety of nebulized beclometasone dipropionate and budesonide in severe persistent childhood asthma.

Inhaled steroids are recommended for long-term control of asthma, but their use may be limited in young children because of difficulties in using the associated inhaler device. The use of nebulizers may help to overcome this issue, without compromising therapeutic efficacy or safety. This 14-week, multicentre, randomized, controlled, open-label, parallel-group study compared the efficacy and safety of nebulized corticosteroids in paediatric patients (aged 6 months to 6 years) with severe persistent asthma. Beclometasone dipropionate (BDP) 800 microgday(-1) suspension for nebulization and budesonide (BUD) 750 microg day(-1) given by nebulization in a twice-daily regimen, and when used in addition to the usual maintenance therapy, resulted in comparable clinical efficacy across all parameters. The primary efficacy endpoint was the number of patients who did not experience any major exacerbation, this being 40.4% and 51.7% in the BDP and BUD groups respectively in the ITT population (P = 0.28), and the mean number of global exacerbations (major plus minor) decreased respectively by -37.5% in the BDP group and -23.3% in the BUD group. Both treatments were also associated with marked reductions in the number of nights with wheezing and the number of days of oral steroid use. Moreover, the two treatment groups had a similar adverse-event incidence and profile. Only 11 adverse events were reported, and no serious adverse events were related to treatment. Urinary cortisol and the time course of height and weight were unaffected by both treatments, and BDP was confirmed to have a neutral effect on bone metabolism. In conclusion, this study demonstrates that both BDP 800 microg day(-1) suspension for nebulization and BUD 750 microgday(-1) administered by nebulization are effective, with an acceptable safety profile, for treatment of severe persistent asthma in infants and young children.

Peanut hypersensitivity in children.

Peanut is the major allergen in the United States. It is increasing in importance in Europe and has become the principal food allergen affecting children over the age of three years, once hypersensitivity to eggs has resolved. We report 132 pediatric cases of peanut hypersensitivity, confirmed by food challenge. The study group included 86 boys and 46 girls aged between 6 months and 15 years. More than half the children with peanut hypersensitivity were diagnosed before the age of three. The most common symptom was atopic dermatitis (43.1% of cases). The other symptoms observed were hoarseness (34.8%), asthma attacks (13.6%), anaphylaxis (6%), gastrointestinal symptoms (1.5%) and oral syndrome (0.7%). All patients had positive skin prick tests, with a mean wheal diameter of 8 mm (range: 2 to 25 mm). Wheal diameter was significantly smaller in the youngest children (mean 4.5 mm for children under the age of 1 year, p < 0.01). Specific IgE concentration was below 0.75 IU/ml in 16 cases (14.3%), the mean for the entire group being 30.9 IU/ml (range: 0.75 to 100 IU/ml). Food challenges were not performed in three of the eight children with a history of anaphylaxis. Labial food challenge (LFC) was positive in 85 cases (64.8%). An oral food challenge (OFC) was carried out for 45 children (34.3%) and the mean reactive dose was 850 mg (range: 1 mg to 7g). LFC with peanut oil was positive in 2 cases of 50 tested (4%) and 17 of 63 children (29.9%) tested by OFC were also found to be sensitized to peanut oil. Half the children were also hypersensitive to other foods, as demonstrated by oral challenge (53.7%) or sensitized to airborne allergens (62.8%). Hypersensitivity in the very youngest children raises questions about how sensitization occurs. Diagnosis was confirmed by food challenge. Peanut products are very difficult to eliminate from the diet because of inadequate labeling of food products. An ELISA test, available in a number of countries, can be used to detect the allergen.

[Asthma in infants and young children: definitions and epidemiology]. / Asthme du nourrisson et du jeune enfant: définitions et épidémiologie.

Asthma of infants and young children (under school age) is a syndrome and not a disease. While the definitions given in 1981 by Tabachnik an Levision and by Geubelle still hold good, recent epidemiological findings show that several situations exist. Less than 20% of asthmatic infants in fact have allergic asthma that will persist after the age of 10. Bronchiolitis due to respiratory syncytial virus leads to a common variety of asthma. But pre-existing abnormalities of the small airways which create favorable conditions for bronchiolitis may also lead us to overestimate the sequelae. Prospective follow-up of cohorts of newborns is thus very important, and all wheezy children should undergo careful examination to exclude "false asthma" and identify "true asthma".

[The pediatrician and the telephone]. / Le pédiatre et le téléphone.

Approximately half of the phone calls received in the pediatrician's office are telephone consultations or advice requests concerning pathologies. In those cases the pediatrician has to know that his responsibility is involved. Among the rules to be applied in this telephone practice, he must always require that the child be examined when parents call for the second time. In some chronic pathologies permanent phone services with the participation of trained practitioners might be useful in order to properly answer parent's advice requests.

[Asthma and food allergy: report of 163 pediatric cases]. / Asthme et allergies alimentaires: à propos de 163 observations pédiatriques.

The prevalence of food as a cause for asthma is not well known. The aim of this study was to define with standardized tests the incidence of food-induced asthma, the distribution of foods allergens in asthmatic children with food allergy. The study was carried on 163 asthmatic children with food allergy followed during average of 5.5 years. Asthma has been identified with pulmonary function tests (reversibility of FEV1 to bronchodilators) and food allergy has been documented by double-blind placebo-controlled food challenge (DBPCFC). Familial atopic disease was found in 148 children (90.7%). Inhalant sensitization was documented in 132 children (81%). Positive DBPCFC were observed in 250 of 385 challenges (65%) carried on these 163 children. The most frequent offending foods were, sometimes in association, peanut (30.6%), egg (23.1%), cow's milk (9.3%), mustard (6.9%), codfish (6%), shrimp (4.5%), kiwi fruit (3.6%), hazelnut (2.7%), cashew nut (2.1%), almond (1.5%), garlic (1.2%). Symptoms occurring during DBPCFC were cutaneous (143 cases, 59%), respiratory symptoms (58 cases, 23.9%), gastrointestinal symptoms (28 cases, 11.5%) and 15 anaphylactic shock (6.1%). Respiratory symptoms were oral allergy syndrome in 13 cases (5.3%), rhinoconjunctivitis in 15 cases (6.1%), asthma in 23 cases (9.5%). Only seven of these children had asthma only (2.8% of cases). The prevalence of asthma induced by food allergy is low. In our study, asthma induced by food allergy concerned 9.5% of cases and asthma alone was identified in only 2.8% of cases. We observed new food allergens associated with respiratory symptoms such as kiwi fruit, tree-nuts (hazelnut, cashew) and spices. Diagnosis relied upon data obtained from history, skin prick-tests and specific IgE. Oral food challenge is the corner stone of the diagnosis. Asthma induced by food allergens is potentially severe leading to prescribe to these patients a first aid kit with bronchodilators and epinephrine auto-injectors.

[Allergy to hymenoptera venoms in children]. / Allergie aux venins d'hyménoptères chez l'enfant.

Incidence of hymenoptera venom allergy in children is about 0.4 to 0.8%. Clinical features usually range from urticaria to anaphylaxis. Fatal reactions can occur but with less frequency than in adults. Allergologic investigations must be performed in children with systemic or generalized reactions after hymenoptera stings, which may lead to venom immunotherapy. Venom immunotherapy is well reported, but protocols differ according to the authors: ultra-rush in 3 h, accelerated in 3 to 5 days and semi-rush in 2 to 8 weeks. Results are always excellent (90 to 100%). We report our experience with 91 children receiving venom immunotherapy. Clinical history and positivity of skin tests indicated immunotherapy. Clinical symptoms were anaphylaxis (15.3%), serious reaction (37.3%) strong reaction (34%), and mild reaction (7.6%). Changes in immunological parameters revealed wide individual variations, not differing from data in the literature, with no correlation with evolution of immunotherapy. Venom immunotherapy appeared with good tolerability in children, whatever the protocol used.

[The consequences of parental smoking in children: pediatricians must act]. / Les méfaits du tabagisme chez l'enfant: les pédiatres doivent agir.

Prenatal and childhood passive tobacco smoke exposure resulting from parental smoking may have severe side effects, such as low birth weight, prematurity, sudden infant death syndrome, upper and lower respiratory tract infections and asthma. By giving information to parents, and particularly by emphasizing the dangers of passive smoke exposure for their children, pediatricians have a critical role to play in their prevention. This may also be helpful for adolescents who are starting to smoke actively by trying to understand the needs that they express by this behavior, and encouraging them to go to a stop smoking counseling center.

[Treatment of asthma crisis in children]. / Traitement de la crise d'asthme chez l'enfant.

The occurrence of an acute exacerbation of asthma frequently reflects failure of a first line treatment that has to be reconsidered. Severe episodes of acute asthma are often related to non-recognition of signs of gravity, inadequate treatment and/or delayed access to an emergency department. Several consensus conferences have established guidelines for management of asthma attacks in the patient's home, and have defined the symptoms which should lead the physician to refer the patient to an emergency department and the criteria of hospitalization when the patient does not respond properly to the treatment. Guidelines for management of acute asthma based on the currently recommended therapeutic schedules are presented.

[Food allergens in children]. / Allergènes alimentaires de l'enfant.

Food hypersensitivity is increasing, with clinical indications and allergens multiplying and evolving. We report our experience with clinical indications and distribution of allergens in children with food hypersensitivity. Data were established in a prospective study at medical centres in Nancy and Toulouse (France). We studied 378 children with food hypersensitivity indicated by food challenge, which account for 74.2% of food hypersensitivity. Clinical features were: atopic dermatitis (46.5%), urticaria (17.9%), oedema (14.2%), asthma (8.4%), anaphylaxis (5.2%), gastro-intestinal symptoms (2.1%), oral syndrome (1.8%) and rhino-conjunctivitis (0.5%). Five allergens accounted for 82% of confirmed food hypersensitivity: egg (51.8%), peanut (34.3%), milk (11.6%), mustard (8.9%) and codfish (7.1%). Allergens according to the symptoms showed that peanut allergies were more serious than other food allergy. Allergens according to age showed that peanut allergy is the first food allergy occurring after the age of three. There exists a modification in children's allergen distribution. Peanut allergy is increasing seriously, and diagnosis with food challenge is a necessity.

[Chronic cough in children: etiology and decision trees]. / La toux chronique de l'enfant: grandes étiologies et arbre décisionnel.

Recurrent or chronic cough can be the symptom of a worrying condition which must be diagnosed without delay (cystic fibrosis, asthma, bronchial foreign body, bronchiectasis). Investigation of recurrent or chronic cough is based on simple principles: careful history-taking concerning the characteristics of the cough, full clinical examination to look for any associated symptoms, and auxological assessment to detect any interruption in weight increase. Only when this initial evaluation has been carried out can complementary investigations be sought. Ordinary respiratory infections that are part of the building up of immunity are predominant in coughs of children aged under 6 years and are aggravated by deleterious factors such as passive exposure to tobacco, early introduction to communal life, and urban pollution. We describe the most frequent causes of cough and their frequency according to the age of the child.

[Chronic cough and gastroesophageal reflux in children]. / Toux chronique et reflux gastro-oesophagien chez l'enfant.

Gastroesophageal reflux (GER) is one of the three most common causes of chronic cough in children, along with postnasal drip syndrome and asthma. There may be no gastrointestinal symptoms up to 50-75% of the time. GER plays a causative role in chronic cough, asthma without allergy and posterior laryngitis. GER most commonly provokes coughing by stimulating an esophageal-bronchial reflex and by irritating the lower respiratory tract by microaspiration. Twenty-four-hour pH monitoring of the distal esophagus is the most accurate diagnostic method for children with suspected GER and it helps to establish a temporal correlation between cough and GER. The first step of the treatment is the association of postural and dietetic measures and medications (prokinetics and antacids). The length of the treatment is a minimum of 3 months up to the age of walking. Surgical treatment must be reserved for the failure of medical treatment. The benefits of minimally invasive surgery are evident in children with chronic cough, who have a faster recovery with fewer complication than after open surgery.

[Method for using inhalation chambers with facial masks in asthma. Evaluation in 60 children below four years of age]. / Technique d'utilisation de la chambre d'inhalation avec masque facial dans l'asthme. Evaluation chez 60 enfants âgés de moins de quatre ans.

UNLABELLED: Spacers with face masks are widely used for the treatment of asthma in young children. A poor inhalation technique may compromise the treatments efficiency. METHODS: The inhalation technique of spacers with face masks was evaluated in a prospective study of 60 children below four years of age. A checklist of 12 items was used, each one being coded by zero or one, and a total score < or = 12 points was calculated. RESULTS: Mean total score was 8.93 +/- 1.84 (extremes: 6-12). The canister was shaken before use in 48.3% of cases, one puff delivered when the child was breathing in 71.7% and the valve's mobility checked in 85%. The canister was shaken before the second puff in 13.3% of cases and two consecutive puffs individualized in 28%. DISCUSSION: The usual mistakes are lacking to shake the canister and consecutive puffs' individualization. Medical partners and families education should be reinforced.