[Diagnostic utility of nocturnal in-home respiratory polygraphy]. / Rentabilidad de la poligrafía respiratoria del sueño realizada en el domicilio.

INTRODUCTION: Sleep apnea-hypopnea syndrome (SAHS) is relatively frequent in children. The gold standard for diagnosis is polysomnography. However, because of technical difficulties and the cost of this method, new alternatives have become available, such as respiratory polygraphy (RP) performed at home or in hospital, which have provided satisfactory results in children with clinical suspicion of SAHS. OBJECTIVE: The aim of this study was to analyze the diagnostic utility of in-home RP in the diagnosis of SAHS in a sample of boys and girls referred to the pediatric respiratory care department for suspected sleep apnea, snoring, or both. MATERIAL AND METHODS: In all patients, a history and physical examination were performed; X-ray of the chest and cavum and RP were carried out. The following qualitative variables were analyzed: place where RP was performed, the result, sex, the reason for consulting, place of residence, results of otorhinolaryngological examination, and treatment. The quantitative variables analyzed were age, total number of apneas, total number of hypopneas, apnea index/hour, hypopnea index/hour, mean and minimum SpxO2, number of snores per hour and the snore index/hour. Statistical analysis was performed using Pearson's chi-square test and Student's t-test. RESULTS: A total of 132 patients were studied, 44 (33.3 %) through in-home RP (group 1) and 88 (66.6 %) through in-hospital RP (group 2). In group 1, two recordings (4.5 %) were considered nonvalid. The mean age of the patients was 8.3 years (SD 3.02). The results [means (standard deviation)] of in-home RP were as follows: apnea-hypopnea index (AHI)/h: 3.4 (4.3); mean SpxO2: 97.3 (1.8); minimum SpxO2: 87.7 (10.3). In group 2, four recordings (4.5 %) were nonvalid. The mean age of the patients was 7.4 years (SD 3). The results of in-hospital RP were as follows: AHI/h: 4.45 (5.4); mean SpxO2: 96.8 (1.8); minimum SpxO2: 87 (11). No significant differences were found between the validity of in-home and in-hospital RP. Likewise, no significant differences were found between AHI/h, SpxO2 and in-home and in-hospital RP. CONCLUSION: In conclusion, in our sample, the diagnostic utility of in-home RP was equal to that of in-hospital RP. In-home RP allows the possibility of performing a more physiological sleep study and, by eliminating the cost of hospitalization, is more cost-efficient. Therefore, in-home RP is a valid and reliable technique for the diagnosis of childhood SAHS.

[Obstructive sleep apnea-hypopnea syndrome]. / Síndrome de apneas-hipopneas obstructivas del sueño.

We analyzed a cohort of 400 patients referred from the otorhinolaryngology department (40.05 %), primary care (PC) (36.52 %), and the pediatric pulmonary unit (17.63 %). The children were referred for clinical suspicion of apneas in 191 (47.87 %), snoring and apneas in 101 (25 %), and snoring in 87 (21.80 %). Adenotonsillar hypertrophy was found in 211 patients (52.75 %), tonsillar hypertrophy in 87 (21.75 %), and adenoid hypertrophy in 73 (18.25 %). All patients underwent respiratory polygraphy (RP) during sleep. Obstructive sleep apnea-hypopnea syndrome (OSAHS) was diagnosed in 298 patients (74.5 %). OSAHS was mild in 96 patients (24 %), moderate in 148 (37 %), and severe in 54 (13.5 %). The results of RP expressed in means plus standard deviation were as follows: number of apneas 21.38 (24.47), number of hypopneas 19.81 (20.74), apnea-hypopnea index per hour (AHI/h) 5.29 (7.10), mean oxygen saturation 94.60 (11.80), minimal saturation 83.14 (13.45), number of snores 98.27 (254.55), and snoring index per hour 5.68 (6.5). Significant differences were found between oxygen saturation and AHI/h per hour. No differences were found among age, mean oxygen saturation, area of residence, reason for consulting, and AHI/h. Adenotonsillectomy was performed in 289 patients (72.25 %) of the initial cohort. In conclusion, OSAHS in childhood is frequent. RP during sleep aids diagnosis. The main cause of OSAHS in children is adenotonsillar hypertrophy.

[Effects of inhaled glucocorticoids effects on the body composition in children with moderate asthma]. / Efecto de los glucocorticoides inhalados en la composición corporal del niño con asma moderada.

BACKGROUND: To assess anthropometric variables and body composition in children with moderate asthma. SUBJECTS AND METHOD: Cross-sectional study of two homogeneous cohorts. Group 1 (study group): 84 children with moderate asthma treated with inhaled budesonide for al least 12 months; group 2 (control group): 89 healthy children. Body measurements were studied by bioelectrical impedance. RESULTS: Males with moderate asthma showed lower values for fat-free mass and total body water. Data corrected for weight rendered no statistically significant differences. CONCLUSIONS: Male children with moderate asthma show a lower fast-free mass.

[Pediatric palliative care: a comprehensive model of care for children with life-threatening conditions and their families]. / Los cuidados paliativos: un modelo de atención integral al niño gravemente enfermo y a su familia.

The present article reviews aspects unique to pediatric palliative care: the attitudes of medical staff toward pediatric death and life-threatening conditions, distinct patterns of pediatric deaths, the causes of suffering in children with life-threatening conditions and their families, and the features that make palliative care a challenge for children, families, medical staff and society. Concepts of pediatric palliative care and various approaches are described. In addition, Universal Principles of Pediatric Palliative Care are presented. Special attention is paid to approaches that start palliative care at diagnosis of a life-threatening conditions, do not require a short-term life prognosis and do not exclude curative or life-prolonging therapies since these approaches can benefit both children who survive life-threatening conditions and those who die, as well as their families. The need for certain changes through education and research is proposed to improve the quality of life of children and families who currently suffer, satisfaction and cohesion among medical staff, and healthcare quality.

[Acute bronchiolitis: fundamentals of a rational protocol]. / Bronquiolitis aguda: bases para un protocolo racional.

Bronchiolitis is the most frequent respiratory tract disease in the first 2 years of life. It occurs in epidemics in winter and spring. Etiology is viral and the most frequent causative agent is respiratory syncytial virus. In most patients the disease is benign and self-limiting and only occasionally requires hospitalization. In daily clinical practice, one of the problems most frequently faced by the pediatrician is the lack of agreement on the correct pharmacological treatment of bronchiolitis, as well as the absence of simple, or standardized, clinical scores with which to diagnose severity. The present study provides a review of the medical literature on the most commonly used clinical scores and the therapeutic efficacy of the different drugs employed. A protocol for the practical management of bronchiolitis is provided. The use of inhaled adrenaline in the treatment of moderate-to-severe bronchiolitis in hospitalized infants, as well as oxygen and fluid therapy as support measures, are recommended.

[Gallstones in infancy (author's transl)]. / Litiasis biliar en la primera infancia.

Authors present a 22 month old female, suffering from biliary lithiasis, diagnosted before surgery by endovenous cholangiography, associated to cataracts and neurological impairment. Current etiopathogenic views are briefly exposed, pointing out that incidence of gallstones has ceased to be exceptional.

[Analysis of the impact of Anales Españoles de Pediatría through the Science Citation Index from 1997-2000]. / Análisis de la repercusión de Anales Españoles de Pediatría a través del Science Citation Index durante el período 1997-2001.

OBJECTIVES: To quantify the impact factor of Anales Españoles de Pediatría from 1997 until 2000 and to identify the journal's citation patterns and the topics with the greatest impact. METHODS: SCISEARCH was used to locate citations of articles published in Anales Españoles de Pediatría between 1995 and 1999. The following data were collected for each article: year of publication, authors, journal, country of publication, language, specialty or specialties, institution(s), residence of the first author and topic. The impact factor was calculated as the ratio between citations received over 1 year by articles published in Anales Españoles de Pediatría in the two previous years and the total number of articles published by Anales Españoles de Pediatría over the 2 years under study. RESULTS: The impact factor of Anales Españoles de Pediatría was 0.052 in 1997, 0.080 in 1998, 0.101 in 1999, 0.089 in 2000 and 0.064 in 2001. Citations were found in a wide range of source journals. The greatest proportion (35.6 %) were found in Spanish medical journals. Citations were made mainly by Spanish authors (62.8 %) and self-citation was moderate (14.3 %). Topics related to neurology (16.9 % of the citations received), infectious diseases (16.2 %) and neonatology (14.8 %) had the greatest impact. CONCLUSION: The impact factor of Anales Españoles de Pediatria is modest, although higher than that of some other biomedical publications included in Journal Citation Reports.

[Effect of passive smoking on pulmonary function in the asthmatic child]. / Efecto del tabaquismo pasivo sobre la función pulmonar del niño asmático.

OBJECTIVE: Few studies refer to pulmonary function in asthmatic children exposed to environmental tobacco smoke (ETS). Some authors have found lower FEV1 and FEF25-75 values in asthmatic children exposed to ETS. The objective of this study was to evaluate pulmonary function parameters between asthmatic children exposed and not exposed to ETS. PATIENTS AND METHODS: A case-control study in children between 3 and 19 years of age, with a ratio of 1:1 of cases versus control, was carried out. Cases were defined as asthmatic children with at least one of the following criteria: FVC < 85%, FEV1 < 85%, PEF < 85% or FEF25-75 < 60%. Controls were asthmatic children with none of the above mentioned criteria. Measurement of exposure was carried out both directly by assessment of capillary blood COHb in both parents and the child and indirectly through a questionnaire about smoking habits. Measurement of effect was by pulmonary function (forced spirometry) and a scale of clinical symptoms. The statistics used included descriptive statistics, Chi square test, Student's-t and ANOVA. RESULTS: Three hundred and twelve children were studied (mean age 9.01 +/- 3.45 years). Parental CoHb results correlated with the number of cigarettes smoked (p < 0.01). ETS exposure correlated with the children's COHb values (p < 0.01). ETS exposed children had lower pulmonary function values, OR for exposure was 1.84 (1.12-3.03). CONCLUSIONS: 1) We have validated a questionnaire about smoking habits. Smokers have higher COHb values. 2) We found a weak correlation between exposure to ETS (number of cigarettes and maternal COHb) and the child's COHb. 3) Pulmonary function in asthmatic children is influenced by parental smoking habits.

[The excretion of free cortisol in the urine in healthy children and in asthmatics treated with long-term inhaled glucocorticoids]. / Excreción de cortisol libre en orina en niños sanos y en asmáticos tratados con glucocorticoides inhalados a largo plazo.

OBJECTIVE: To assess urinary free cortisol (UFC) excretion in 24 hour urine samples collected from asthmatic children treated with inhaled glucocorticoids (IGC). PATIENTS AND METHODS: A retrospective cohort study was performed on a group of 358 children between the ages of 3 and 14 years. The children were divided into two groups, a normal population (n = 108) and an asthma group (n = 250). These children were treated uninterruptedly with IGC (mean dose 676 micrograms/day) during 17 +/- 8 months with budesonide (n = 221) or beclomethasone (n = 29) in dry powder (n = 167) or MDI with spacer chamber (n = 83). We considered the 24 hour urine sample valid when creatinine levels in blood and urine, as well as creatinine clearance, were normal. We determined UFC with a specific direct radioimmunoassay after cortisol extraction with dichloromethane. We performed a short ACTH test to assess the subnormal adrenocortical function when UC excretion in AG was less than -1SD. RESULTS: UFC excretion was 81.98 +/- 32.12 nmol/m2/day in the asthma group. There was no correlation between UFC and the mean dose of IGC, total dose given, device used for inhalation, time of treatment or oral glucocorticoid series. The subgroup treated with beclomethasone presented UF rates lower than the subgroup treated with budesonide. Except for two cases, the ACTH test performed in the AG had normal adrenocortical responses. CONCLUSION: 1) We established the normal values for UFC excretion in our pediatric population. 2) The long term asthma treatment with glucocorticoids at mean doses of 650 micrograms l/m2/day decrease physiologically the UFC excretion since the adrenocortical response remains within the normal range.

[Cut-off point for a positive bronchodilation test]. / Cuándo se considera positivo el test de broncodilatación.

OBJECTIVE: To determine bronchodilation in healthy children aged 7-14 years in order to establish the value defining a positive bronchodilation test. PATIENTS AND METHODS: We performed a cross-sectional study in healthy, nonsmoking schoolchildren aged 7-14 years in the city of Huesca (Spain). The sample (n 145) was representative of the pediatric population aged 7-14 years (N 4,272). Health was determined through a validated questionnaire. Expired carbon monoxide was measured with a Micro III Smokerlyzer EC50(R). Forced basal and post-bronchodilation spirometry (0.2 mg of inhaled salbutamol with a Babyhaler(R) chamber) was performed with a Vitalograph spirometer mod. 2120(R). Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC, forced expiratory flow at 24-25 % of forced vital capacity (FEF25-75 %) and peak expiratory flow (PEF) were measured. To establish whether increments in the variables followed normal distribution, the Kolmogorov-Smirnov test (Lilliefors modification) and histograms were used. The relationship between increases in FEV1 and the variables in the questionnaire was analyzed using Student's t-test (qualitative variables) and Pearson's correlation (quantitative variables). To evaluate the reliability of the test, Spearman's non-parametric correlation coefficient and dispersion graphs were used. RESULTS: The percentage increase in FEV1 compared with the theoretical value was: mean (SD), 3.97 (2.65); 95 % percentile, 8.87 %; and 97.5 percentile, 10.25 %. The percentage increase in FEV1 compared with the previous value was: mean: 3.99 (2.63), 95-percentile: 8.43 %; and 97.5 percentile: 10.14 %. CONCLUSIONS: In children aged 7-14 years, increases of greater than 9 % above the theoretical or previous FEV1 value define the bronchodilation test as positive.

[Risk factors for asthma, allergy and bronchial hyperresponsiveness in children aged 6-8 years old]. / Factores de riesgo de asma, alergia e hiperreactividad bronquial en niños de 6 a 8 años.

OBJECTIVE: To determine risk factors for asthma, allergy and bronchial hyperresponsiveness in children aged 6-8 years old from Huesca (Spain). PATIENTS AND METHODS: Cross-sectional study of asthma, rhinitis and atopic dermatitis, using the prick test and bronchial hyperresponsiveness (free-running test, forced expiratory volume in 1 sec) in a random sample (n = 309) of children aged 6-8 years oldfrom an urban area (n = 1,051). To evaluate differences in the study variables between asthmatics and non-asthmatics, allergic and non-allergic children and BHR-positive and BHR-negative children, a bivariate analysis was performed using the Chi-squared test and Fisher's exact test. Multiple regression analysis was used to study the association between asthma, allergy and BHR and the study variables. Beta-coefficients and their corresponding standard deviations were calculated according to the maximum verisimilitude method using the SPSS program. RESULTS: The theoretical sample included 305 children and informed consent was requested from 357 parents or guardians. The participation rate was 86.55 % (n = 309). The results of the multivariate analysis were as follows: (1) risk factors for asthma were a history of asthma in the immediate family (OR: 5.17; 95 % CI: 21.82-1.23), cutaneous sensitization to aeroallergens (OR: 8.49; 95 % CI: 30.52-2.37) and recurrent bronchitis during the first 2 years of life (OR: 4.68; 95 % CI: 17.76-1.24); (2) risk factors for allergy were symptoms of atopic dermatitis (OR: 10.87; 95 % CI: 38.63-3.06), a history of asthma in the immediate family (OR: 6.11; 95 % CI: 27.68-1.38) and male sex (OR: 4.53; 95 % CI: 19.55-1.05); (3) risk factors for BHR were recurrent bronchitis during the first 2 years of life (OR: 4.56; 95 % CI: 20.24-1.02), symptoms of atopic dermatitis (OR: 4.15; 95 % CI: 16.28-1.06) and cutaneous sensitization to aeroallergens (OR: 3.43; 95 % CI: 10.91-1.08). CONCLUSIONS: The risk factors for asthma, allergy and BHR have been determined in children aged 6-8 years old from Huesca.

[Agreement between tracheal auscultation and pulmonary function in methacholine bronchial inhalation challenge in asthmatic children]. / Medida de la respuesta bronquial a la metacolina en niños asmáticos mediante la auscultación traqueal.

BACKGROUND: PC wheezing (PCw) is defined as the concentration of methacholine at which wheeze is detected on auscultation of the trachea. PCw has been suggested as a measure of bronchial hyperresponsiveness in methacholine challenge testing (MCT). OBJECTIVE: The aim of this study was to determine the agreement between the concentration of methacholine that produces a 20 % decrease in forced expiratory volume in 1 second (FEV1) (PC20) and PCw in MCT in asthmatic children. PATIENTS AND METHODS: Eighteen asthmatic children with a mean age of 11.5 years (range: 6-16 years) were studied. Fifteen of the children were under treatment with inhaled glucocorticoids. MCT was performed according to the guidelines of the American Thoracic Society (1999) using a Hudson nebulizer calibrated to obtain a mean output of 0.14 ml/min. After each nebulization, two independent observers registered FEV1 and tracheal auscultation. FEV1 was determined by forced spirometry 30 and 90 seconds after the end of nebulization and PC20 was registered (exponential model). Respiratory rate and transcutaneous oxygen saturation were continuously monitored. Tracheal auscultation was performed at 0, 60 and 120 seconds after the end of nebulization. The end point was defined as the appearance of wheezing over the trachea. The values of PC20 and PCw, as well as the concentration of methacholine corresponding to a decrease in FEV1 equal to or higher than 20 %, were compared using Student's matched pairs-test and Wilcoxon's test. The degree of agreement between variables was compared by using Bland-Altman's test. RESULTS: MCT was positive in 17 of 18 patients. No differences were found between PC20 and PCw (p 0.15). Both variables showed agreement in 12 of 17. A clear association was found between both measures (log PCw, log PC20): R: 0.92; p < 0.001. The mean decrease in FEV1 on reaching PCw was 24.8 % (range: 10-41). No adverse effects were observed. CONCLUSION: The agreement between PC20 and PCw in MCT in asthmatic children is excellent. PCw could be helpful in determining bronchial hyperresponsiveness in young asthmatic children in whom spirometry is not feasible.

[Spirometric values in healthy children of the urban area of the Basque Autonomic Community]. / Valores espirométricos en niños sanos de un área urbana de la Comunidad Autónoma Vasca.

OBJECTIVE: Our objective was to obtain spirometric reference values for children. PATIENTS AND METHODS: We performed a transversal study in schools in Bilbao of children of both sexes that were between 7 and 14 years of age, non-smokers and healthy (according to a questionnaire and physical examination). A sample of 657 subjects was calculated based on the standard deviations of height for each sex and age group. The sample units were the schools and they were selected randomly. The following data were collected: age, sex, weight, height, FVC, FEV1, FEV1/FEC, PEF, FEF25, FEF50, FEF75 and FEF25-75. Forced spirometry was carried out according to the ATS guidelines by using a MasterScreen model 4.10.b (Jaeger, Germany). A descriptive statistical study was performed, as well as a normality test and linear regression. RESULTS: We studied 765 subjects (415 boys and 350 girls). The natural logarithm of the spirometric variables was taken to obtain a Gaussian distribution. These variables were related to age, weight and height. The relationship improved when associated with sex, with the best association being between height and sex. The equations obtained were only valid for FVC and FEV1, and were as follows: in boys FVC(L) = -1.968 + 0.020 height and FEV1(L) = -1.831 + 0.018 height and for girls FVC(L) = -1.879 + 0.019 height and FEV1(L) = -1.809 + 0.018 height [R2 = 0.893, 0.891, 0.868 and 0.871, respectively]. CONCLUSIONS: The pediatric reference values for forced spirometry were established for our population, complying with the current applicable guidelines.

[Current prevalence of asthma, allergy and bronchial hyperresponsiveness in children aged 6 to 8 years old]. / Prevalencia actual de asma, alergia e hiperrespuesta bronquial en niños de 6-8 años.

OBJECTIVE: To determine the current prevalence of asthma, allergy and bronchial hyperresponsiveness in children aged 6to 8years old from Huesca (Spain). PATIENTS AND METHODS: We carried out a cross-sectional study to determine the prevalence of asthma, rhinitis and dermatitis by questionnaire (ISAAC), skin test and bronchial hyperresponsiveness (exercise challenge, forced expiratory volume1) in all children aged 6 to 8 years old living in an urban area (n=1051) and in a representative sample from the same area (n=309). RESULTS: The questionnaire response rate was 88.01% (n=925). Current prevalence rates were 7.4% for wheezing, 10.5% for rhinitis and 8.5% for dermatitis. Participation rate in the skin test and bronchial hyperresponsiveness study was 86.55% (n=309): bronchial hyperresponsiveness was found in 5.3% and skin test was positive in 21.8% while sensitization against grass pollen was found in 45.5%, against olives in 34.8% and against house dust mite in 10.6%. Rhinitis and/or dermatitis symptoms and positive skin test were found in 7.92%. Asthma related symptoms and bronchial hyperresponsiveness were found in 5.5%. CONCLUSIONS: This study reports the current prevalence of asthma (5.5%), allergy (7.92%) and bronchial hyperresponsiveness (7.92) in children aged 6 to 8 years old from Huesca.

[Idiopathic purpura fulminans with transient protein S deficiency]. / Púrpura fulminante idiopática con déficit transitorio de proteína S.

Idiopathic purpura fulminans produces rapidly progressive hemorrhagic necrosis of the skin with disseminated intravascular coagulation in individuals without known abnormalities of the protein C pathway or acute infections. The disease mainly affects children and in 90 % of cases is preceded by a benign infection. Its pathogenesis involves a temporary autoimmune protein S deficiency that provokes a state of hypercoagulability. We present the case of a previously healthy 2-year-old boy with hemorrhagic skin lesions characteristic of purpura fulminans and disseminated intravascular coagulation without sepsis. Severe, temporary protein S deficiency was confirmed. The patient received daily replacement therapy with fresh frozen plasma for 12 days and anticoagulation with heparin for 3 months. Evolution was favorable. Although the other parameters returned to normal, protein S remained low for 50 days despite treatment. The patient has made a complete recovery.