[Fluticasone propionate in children and infants with asthma]. / Propionate de fluticasone dans l'asthme de l'enfant et du nourrisson.

The known efficacy of fluticasone propionate in adults, comparable at half-dosage of corticosteroids has been validated by the market authorization (MA) and by the national and international guidelines for beclomethasone. This could be partly explained by its pharmacological properties, affinity for glucocorticosteroid receptors, lung deposition and lipophilicity. The limited systemic adverse events is due to its low bioavailability, optimal hepatic clearance, high plasma protein binding. The efficacy in asthmatic children has been confirmed in clinical studies showing a "plateau" efficacy between 100 and 200 microg/d for the majority of children. Most children are controlled by such dosages: the added value of increasing posology on asthma control exists but is small. A high off-label posology does not allow more quickly asthma control and therefore is not justified. A twice daily dosing is more efficient, particularly for initiation of maintenance therapy, than a once daily dosing. A literature survey confirms that, at MA recommended daily doses in children (100-200 microg), fluticasone propionate has no clinically significant effect either on hypothalamic-pituitary-adrenal (HPA) axis (basal function or stimulation tests), bone or growth velocity. However, high daily doses (higher to 500 microg/day) for long periods expose to systemic adverse effects with measurable consequences on growth rate, bone density (decreasing biochemical makers of bone formation) and HPA function. Several cases of adrenal insufficiency that may have led to acute adrenal crisis have been reported in 4- to 10-year-old children receiving fluticasone propionate in doses between 500 to 2000 microg daily. In case of surgery or infection, a preventive treatment of adrenal insufficiency with hydrocortisone should be proposed for children treated for more than 6 months with such high daily doses. Such children need definitely an advice from paediatricians specialized in chest diseases as well as in endocrinology. It is important to recall that the clinical benefit of daily doses of inhaled corticosteroids higher than recommended is low and that the good use of inhaled corticosteroids particularly in children lays on the careful search of the minimal efficient daily doses.

[Different diagnosis of children with viral or bacterial bronchopneumonia infection]. / Différence de diagnostic des infections broncho-pulmonaires virales ou bactériennes chez l'enfant.

Community-acquired bronchopneumonia is very common in children and responsible for a great morbidity. It can be revealed by bronchiolitis, due to viral infection, bronchitis (80% due to viruses), and pneumonia potentially much more severe due to bacteria (60%), viruses (40%) or both causes (20%). Being unable to exclude a bacterial origin in pneumonia leads physicians to prescribe systematically antibiotics.

[Severe asthma in children: identification and investigation]. / Asthme difficile à traiter de l'enfant, identification et explorations.

Severe asthma in children is characterized by the persistence of symptoms or bronchial obstruction in spite of adequate treatment. Side effects of high dose inhaled or repeated courses of systemic corticosteroids must be considered. Therefore, an exact assessment is necessary. First, the observation of the child has to be secured and risk factors eliminated by interrogation and examination (smoking, ENT affection, allergy with persistence of high exposure, gastro-esophageal reflux). An initial thorax-X-ray is essential. After exclusion of differential diagnoses and confirmation of severe asthma, the child must be referred to a specialized department for a diagnostic work-up including a thoracic CT and bronchoscopy. Patient education including treatment can be realized in asthma schools and consultation intervals must be shortened.

Case-control study of Stenotrophomonas maltophilia acquisition in cystic fibrosis patients.

The aims of this case-control study were to describe the characteristics of cystic fibrosis (CF) patients who isolated Stenotrophomonas maltophilia in sputum, to determine risk factors for acquisition, to assess persistence of the organism and clinical outcomes postacquisition. Data were collected from 1991-1999. CF patients and controls (who had never isolated S. maltophilia) were matched for age (+/- 1 yr), sex and forced expiratory volume in one second (+/- 10%). Data were collected from the year prior and for 2 yrs postacquisition of S. maltophilia. The prevalence of S. maltophilia increased from 3.3% to 15%. Factors associated with S. maltophilia acquisition were more than two courses of intravenous antibiotics, isolation of Aspergillus fumigatus in sputum and oral steroid use. The effect of A. fumigatus was independent of steroid use. Clinical status did not change postacquisition. The majority of patients cleared the organism from the sputum. Long-term infection or an accelerated deterioration in lung function or nutrition is not likely post-Stenotrophomonas maltophilia acquisition in cystic fibrosis. This is the first documentation of an association between Aspergillus fumigatus isolation and Stenotrophomonas maltophilia acquisition in cystic fibrosis, independently of steroid therapy.

[Streptococcus pneumoniae purulent pleurisy and hemolytic uremic syndrome. A case report]. / Pleurésie purulente à Streptococcus pneumoniae et syndrome hémolytique et urémique. A propos d'un cas.

A 22-month-old infant developed purulent pleurisy caused by Streptococcus pneumoniae and a hemolytic uremic syndrome. The diagnosis was suggested by the classical triad: hemolytic anemia, renal failure and thrombocytemia confirmed by renal biopsy which demonstrated extensive cortical necrosis. Renal involvement was severe, justifying an indication for renal transplantation.

[Food allergy and asthma in children]. / Allergie alimentaire et asthme chez l'enfant.

The links between food allergy and asthma are becoming more clear. The association of food allergy and asthma in the same child is unusual (less than 10% in atopic subjects). This association is however a sign of gravity leading to more severe manifestations of food allergy in asthmatic children. Compared with the non-asthmatic child, the asthmatic child has a 14-fold higher risk of developing a severe allergic reaction to the ingestion of food. The most commonly cited foods are fruits with a rind, cow's milk and, of course, nuts. Epidemiological data established from methodologically sound studies should enable a definition of the current allergic environment. Formal diagnosis is established with standardized tests. Treatment is oriented towards prevention associating a restricted diet, asthma control, patient education, and prescription of an emergency first aid kit with epinephrine. Supplementary inquiries are needed to determine the outcome in children with food allergy and respiratory symptoms.

Vascular ring abnormalities: a retrospective study of 62 cases.

BACKGROUND: The authors analyzed clinical signs of vascular ring anomalies together with appropriate complementary examinations and factors predictive of outcome after surgical treatment. METHODS: The authors reviewed the files of 62 patients with vascular ring abnormalities treated at Necker-Enfants Malades Hospital between January 1990 and January 2000, to analyze age at symptom onset, results of paraclinical examinations, the type of vascular ring abnormality, the surgical indications and type of surgery, and postoperative outcome. Outcomes were divided into 3 categories: cure, partial improvement, and no improvement. The chi2 test corrected with Fischer's Exact test was used for statistical analysis. RESULTS: Vascular ring abnormalities were diagnosed at birth in 28% of cases and during the first year of life in 68%. Sixteen percent of patients had associated abnormalities. Recurrent pulmonary and bronchial infections occurred after one year of age. An esophagogram was done in 76% of cases and showed impression images. Endoscopy was done in 63% of cases and showed malacia in 41% of patients and stenosis in 51%. Fifty-eight children were treated surgically. The average hospital stay was 7.4 days. The average follow-up was 37.4 months (12 to 159 months). Complete improvement was obtained in 68% of cases, partial improvement in 17%, and no improvement in 15%. Preoperative malacia was more frequent in patients with partial improvement or no improvement. CONCLUSIONS: Surgical treatment of congenital vascular ring abnormalities is effective and safe. Complications are rare. Prognostic factors include the quality of preoperative preparation of respiratory function, the type of abnormality, and the degree of malacia.

Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures.

Complications of flexible bronchoscopy (FB) were prospectively evaluated during 1,328 diagnostic procedures in children, not in intensive care units. A total 92.8% of the procedures were performed in conscious patients under sedation and 7.2% under deep sedation. Supplementary oxygen was provided in approximately 80% of cases via endoscopic face mask (n=783) or nasal prongs (n=290). At least one complication was recorded in 91 cases (6.9%). Minor complications (n=69; 5.2%) included moderate and transient episodes of desaturation (n=15), isolated excessive coughing (n=22), excessive nausea reflex with coughing (n=20), transient laryngospasm (n=6) and epistaxis (n=6). Major complications (n=22; 1.7%) included oxygen desaturation to <90%, either isolated (n=10) or associated with laryngospasm (n=6), coughing (n=4), bronchospasm (n=1), and pneumothorax (n=1). Major complications involving oxygen desaturation were associated with age <2 yrs (13 of 529 versus 8 of 778) and laryngotracheal abnormalities (7 of 85 versus 14 of 1,222). The overall frequency of complications was similar in conscious (6.7%) but sedated patients and patients under deep (7.3%) sedation. However, the frequency of transient desaturation was significantly higher in children undergoing FB under deep sedation. Transient fever after bronchoalveolar lavage was observed in 52 of 277 cases (18.8%). Flexible bronchoscopy is a safe procedure with <2% major complications. Careful analysis of indications and clinical status for each patient, and proper anaesthesia and monitoring during the examination ensure that the procedure is successful, with a minimum of complications.