Impact of house dust mite-driven asthma on children's school performance and activity.

Evidence regarding asthma's impact on children's daily lives is limited. This prospective and cross-sectional, observational, multicenter study assessed school/work and activity impairment in children and adolescents with allergic asthma and their caregivers and allergen immunotherapy (AIT) effects. Included patients were schooled children and adolescents (5 to 17 years) with allergic asthma due to house dust mites (HDM). Impairment of school/work (i.e., absenteeism and presenteeism) and activity was measured in patients and their caregivers using the Work Productivity Impairment Questionnaire plus Classroom Impairment Questions: Allergy Specific (WPAI + CIQ:AS). HDM allergic patients with school impairment received subcutaneous AIT with a MicroCrystalline Tyrosine-associated allergoid. WPAI + CIQ:AS and effectiveness variables were compared between baseline and 1-year post-AIT. Of the 113 patients included, 59 (52.2%) and 51 (45.1%) showed school and activity impairment, respectively, missing a mean (SD) of 37.6 (24.4) % and 42.6 (25.6) % of school and activity time, respectively. Twenty-six (23%) caregivers reported activity impairment and, of the 79 (69.9%) employed, 30 (38%) reported work impairment. Of the 65 patients with school/activities impairment, 41 (63.1%) received AIT, of which 21 (51.2%) completed 1 year of treatment. Effectiveness variables and WPAI + CIQ:AS significantly improved: Mean (SD) school impairment decreased from 39.7 (26.7) to 2.1 (7.1) % (p < 0.001) and activity impairment from 46.2 (34.6) to 1.4 (3.6) % (p < 0.001). CONCLUSION: Allergic asthma due to HDMs results in school/work and activity impairment in children and adolescents and their caregivers. One year of AIT provided clinical benefits and reduced school and activity impairment. WHAT IS KNOWN: • Allergic asthma impairs children's school performance and daily activities. • Allergen immunotherapy modifies allergic disease course and ameliorates its symptoms. WHAT IS NEW: • Asthma symptoms due to allergy to house dust mites impair children's school attendance and productivity and daily activity and their caregivers' work performance and daily lives. • Allergen immunotherapy with a house dust mite MicroCrystalline Tyrosine (MCT)-associated allergoid seems to provide clinical benefits, associated with decreased school and activity impairment, supporting it as an effective treatment option.

Egg OIT in clinical practice (SEICAP II): Maintenance patterns and desensitization state after normalizing the diet.

BACKGROUND: It is unknown which are the most suitable maintenance pattern and egg consumption to maintain the desensitization state after ending the oral immunotherapy (OIT). This multicenter, randomized, controlled trial compared two OIT maintenance patterns with pasteurized egg white (PEW), evaluating the egg consumption effect on the desensitization state after ending the OIT. METHODS: One hundred and one children with confirmed egg allergy were randomized: 25 to an egg-free diet (CG) and 76 to an OIT year with PEW and two maintenance patterns, 38 patients to daily 3.3 g proteins (AG) and 38 to every two days (BG). PEW challenge (DBPCFC), adverse reactions, and immune markers were assessed at baseline, at the end of the OIT, and at 6 and 12 months later on ad libitum egg consumption (T0, T12, T18, and T24). A questionnaire evaluated the egg consumption at T18. RESULTS: At T12, 64 of 76 (84.21%) OIT patients had reached total desensitization (32 AG and 32 BG) vs 4 of 25 (16.00%) CG who passed the PEW DBPCFC. Thirty (93.75%) AG vs 25 (78.12%) BG patients completed an OIT year. At T18, 27 of 29 (93.1%) AG vs 20 of 24 (83.3%) BG passed the PEW DBPCFC, 96% consuming at least two egg servings/week. At T24, 97.43% OIT patients passed the challenge. Most patients had adverse reactions, more frequent in the BG patients; frequency and severity of reactions decreased through the study. PEW skin prick test wheal and sIgE antibody serum levels similarly decreased in AG or BG, but AG patients had greater increase in PEW sIgG4 (P < 0.05). CONCLUSIONS: Daily OIT maintenance achieves better adherence, effectiveness, and safety. Two egg servings/week ensure maintained desensitization after the end of an OIT year.

Egg oral immunotherapy in children (SEICAP I): Daily or weekly desensitization pattern.

BACKGROUND: Studies are required before incorporating egg oral immunotherapy (OIT) into clinical practice. The Spanish Society of Pediatric Allergy, Asthma and Clinical Immunology (SEICAP) conducted a multicenter, randomized controlled study assessing the effectiveness and safety of the OIT using pasteurized egg white (PEW) in egg-allergic children. METHODS: One hundred and one egg-allergic children (6-9 years) were randomized for 1 year: 25 to an egg-free-diet (CG) and 76 to OIT (target dose 3.3 g PEW proteins), PI (30% weekly plus 5% daily increments) or PII (only 30% weekly increments) buildup patterns. Egg skin prick test, sIgE and sIgG4 serum levels, PEW double-blind placebo-controlled food challenge (DBPCFC), and dosing adverse reactions (DARs) were evaluated in all patients from inclusion (T0) until completing 1 year of follow-up (T12). At T12, egg-allergic control patients could start OIT. The effectiveness and safety of OIT and the effect of the buildup pattern were analyzed. RESULTS: At T12, 4/25 (16.0%) CG patients passed the PEW DBPCFC vs 64/76 (84.2%) OIT that reached total desensitization (P = 0.000); 12 egg-allergic control patients started OIT. Finally, 72/88 (81.81%) patients reached total desensitization, 96.15% PI vs 75.80% on PII (P = 0.01). Induction period (121.12 ± 91.43, median 98.00 days) was longer in patients on PII buildup pattern, and those with allergic asthma, minor threshold dose, or higher egg sIgE (P < 0.05). Most patients (89.06%) developed DARs: 74.53% were mild; 21.90% moderate; and 3.5% requiring adrenaline-treatment. Moderate reactions and those requiring adrenaline were more frequent in patients with allergic asthma, PII pattern, or higher egg sIgE serum antibody levels (P < 0.05). CONCLUSIONS: PEW OIT is an effective treatment for children with persistent egg allergy. A 30% weekly plus 5% daily increment pattern could be more effective and safer than one with only 30% weekly increments.

Pediatric allergy and immunology in Spain.

The data of the ISAAC project in Spain show a prevalence of childhood asthma ranging from 7.1% to 15.3%, with regional differences; a higher prevalence, 22.6% to 35.8%, is described for rhinitis, and atopic dermatitis is found in 4.1% to 7.6% of children. The prevalence of food allergy is 3%. All children in Spain have the right to be visited in the National Health System. The medical care at the primary level is provided by pediatricians, who have obtained their titles through a 4-yr medical residency training program. The education on pediatric allergy during that period is not compulsory and thus very variable. There are currently 112 certified European pediatric allergists in Spain, who have obtained the accreditation of the European Union of Medical Specialist for proven skills and experience in pediatric allergy. Future specialists in pediatric allergy should obtain their titles through a specific education program to be developed in one of the four accredited training units on pediatric allergy, after obtaining the title on pediatrics. The Spanish Society of Pediatric Allergy and Clinical Immunology (SEICAP) gathers over 350 pediatric allergists and pediatricians working in this field. SEICAP has a growing activity including yearly congresses, continued education courses, elaboration of technical clinical documents and protocols, education of patients, and collaboration with other scientific societies and associations of patients. The official journal of SEICAP is Allergologia et Immunophatologia, published every 2 months since 1972. The web site of SEICAP, http://www.seicap.es, open since 2004, offers information for professionals and extensive information on pediatric allergic and immunologic disorders for the lay public; the web site is receiving 750 daily visits during 2011. The pediatric allergy units are very active in clinical work, procedures as immunotherapy or induction of oral tolerance in food allergy, contribution to scientific literature, and collaboration in international projects.

Cow's milk protein allergy. A multi-centre study: clinical and epidemiological aspects.

BACKGROUND: Due to the age when it becomes apparent and the treatment needed, cow's milk proteins (CMP) allergy requires an accurate diagnosis to avoid labelling infants falsely as allergic and subjecting them to unnecessary diets. The objective of this multi-centre study carried out at the Allergy Units of 14 Children's Hospitals was to discover the epidemiological, clinical and evolutionary characteristics of cow's milk protein allergy (CMPA). METHODS AND RESULTS: Infants suspected of CMPA who attended allergy clinics at the hospitals taking part during the study period were studied and a detailed clinical history was collected on all of them. Prick tests were done with cow's milk and its proteins and specific IgE anti-bodies were determined by means of CAP with the same allergens as the Prick test. The challenge test with cow's milk was carried out unless contraindicated by the diagnostic protocol. Two different challenge regimens were used: one of them carried out in 3 days and the other in one day. 409 infants with suspected CMPA were included and the diagnostic challenge test was performed on 286 patients (70 %) and not carried out on 123, as it was not indicated according to the protocol. IgE-mediated allergy was confirmed in 234 infants (58 %) and in 15 (4 %) non-IgE-mediated hypersensitivity was diagnosed. The two challenge regimens were equally secure. The average age when the reaction to cow's milk formula took place was 3.5 months (10 days-10 months). The symptoms appeared in the first week of introduction in 95 % of cases and appeared in 60 % with the first feeding with the formula. The most frequent clinical signs were cutaneous in 94 % of cases and the majority of cases appeared within 30 minutes of the feed. 99 % had been breast fed and 44 % had received some cow's milk supplement during the lactation period. Sensitization to egg not given in the feed was noted in 30 % and to beef in 29 %, being well tolerated in all of these. CONCLUSIONS: Carrying out an appropriate diagnostic protocol in infants attending for suspected CMPA allows allergy to be ruled out in a high percentage of cases.

Pneumopatía raquítica: el retorno de una entidad clínica del pasado / Rickets pneumopathy: the return of a clinical entity of the past

Introducción. El raquitismo era una enfermedad poco frecuente en los países desarrollados; no obstante, debido a los cambios culturales y los episodios migratorios, vuelve a ser una patología emergente. La neumopatía raquítica se basa en el compromiso de la función respiratoria por una parrilla costal flexible y débil secundaria a una mineralización deficiente de los huesos en crecimiento. Se añade una mayor susceptibilidad a las infecciones y cambios del parénquima pulmonar. Caso clínico. Se presenta el caso de una lactante de 7 meses de padres subsaharianos que consulta por fiebre y dificultad respiratoria. En la inspección destaca un tórax delgado y acampanado, con una depresión transversal en la unión tóraco-abdominal (surco de Harrison), y se palpa craneotabes, por lo que se realiza un estudio que muestra: parathormona y fosfatasa alcalina elevadas, vitamina 25-(OH)-D3 baja, calcio, fósforo y función renal normales. La radiografía de muñeca izquierda muestra ensanchamiento de metáfisis y edad ósea retrasada. Comentarios. Hay descritos casos con presentaciones atípicas, como convulsiones hipocalcémicas, tetania o fractura patológicas, pero hay que remontarse a publicaciones de hace cuatro décadas para encontrar en la literatura artículos sobre patología respiratoria asociada a raquitismo. Cabe resaltar la importancia de la detección precoz de los síntomas y signos en la población de riesgo para disminuir la incidencia de raquitismo mediante una profilaxis adecuada (AU)

Introduction. Rickets is an extremely rare disease in high-income countries; however, cultural changes and migratory phenomena have led to a resurgence of this condition. Patients with rickets pneumopathy have impaired respiratory function resulting from dysfunctional rib cage due to insufficient bone mineralization during growth. In addition, patients have an increased susceptibility to infections and alterations in the lung parenchyma. Case Report. A 7-month-old infant born to Sub-Saharan parents presented with fever and respiratory distress. Physical examination revealed a bell-shaped, narrow thorax, with a horizontal groove along the lower border of the chest (Harrison groove) and palpable craniotabes. Additional evaluation showed elevated levels of parathyroid hormone and alkaline phosphatase, vitamin 25-(OH)-D3 deficiency, and normal calcium, phosphorus, and renal function. Wrist X-ray revealed widening of the metaphysis and delayed bone age. Comments. Several atypical presentations of rickets have been reported, such as hypocalcemic seizures, tetany, or pathological fractures, and yet rickets-associated respiratory diseases have seldom been reported in the last four decades. Early detection of symptoms and signs in populations at risk is paramount to reduce the incidence and severity of rickets and to provide adequate prevention and treatment (AU)

Intoxicació accidental per ferro a l’edat pediàtrica. Revisió d’un cas / No disponible

Introducció. La ingesta accidental de ferro representauna de les primeres causes de mort per intoxicació en infants menors de 6 anys en països com els Estats Units, amb una taxa de mortalitat entre els casos d'intoxicació greu superior al 10%, i una incidència mitjana de 3.000 casos l'any en el període comprès entre 1986 i 1997, any en què la US Food and Drug Administration (FDA) va publicar noves normes d'empaquetament monodosi per a aquests productes. Tot i així, és una intoxicació poc freqüent al nostre medi, cosa que fa important aprofundir en el coneixement d'aquesta intoxicació potencialment letal per assegurar un maneig correcte que permeti reduir-ne la morbimortalitat.Observació clínica. Presentem el cas d'una nena de 21mesos amb sospita d'intoxicació aguda per ferro, desprésd'ingerir 73 comprimits d'una presentació de parafarmàcia(dosi tòxica ingerida de ferro element: 21 mg/kg). Es va fer un rentat gàstric, i la pacient es va mantenir asimptomàtica durant les 12 hores d'observació.Comentaris. Només els valors de siderèmia obtingutsentre les quatre i sis hores postingesta es correlacionenamb el grau de toxicitat. En absència de valors de siderèmia és necessari calcular la dosi tòxica ingerida per kg de pes, per valorar la gravetat de la intoxicació i iniciar mesures destinades a evitar l'absorció del ferro: rentat gàstric, irrigació intestinal i tractament quelant amb deferoxamina. És important evitar l'alta precoç d'aquests pacients, ja que la toxicitat sistèmica no apareix fins les 12-24 hores postingesta

No disponible

Allergologia a l’atenció primària / Allergology in primary care

Fonament. Actualment, els especialistes en al·lergologiaduen a terme l’assistència en l’àmbit hospitalari. Entrediferents models d’assistència proposats, la incorporacióparcial de l’al·lergòleg a primària és l’aplicada en aquestestudi.Objectiu. Reduir el temps d’espera per a la primeravisita al servei d’al·lèrgia. Quantificar el nombre i tipus depatologia derivada per estudi. Avaluar el grau de resoluciódel pla i de satisfacció dels usuaris.Mètode. L’estudi s’ha dut a terme des del setembre del2004 fins al juliol del 2005. L’al·lergòleg s’ha desplaçat auna àrea bàsica de Manresa (ABS-M3) per fer la primeravisita, les exploracions complementàries (proves cutànies,funcionalisme pulmonar) i una enquesta sobre el grau desatisfacció dels usuaris atesos. Es van incloure infants de0-14 anys remesos per a estudi al·lergològic.Resultats. Es van fer 46 primeres visites ambulatòries.La patologia respiratòria fou el motiu de consulta més freqüent(31/46; 67.4%) seguit d’al·lèrgia alimentària (14/46;30.4%), urticària i angioedema (12/46; 26.1%) i estudi defàrmacs (3/46; 6.5%). El 39.1% (18/46) dels pacients forendonats d’alta des de primària sense que calgués desplaçarsea l’hospital, mentre que el 60.9% (28/46) es derivaren al’hospital per completar l’estudi o fer seguiment clínic. Elgrau d’absentisme fou inferior a l’hospitalari (2.2%).Conclusions. El desplaçament de l’al·lergòleg a primàriaredueix el temps d’espera dels infants remesos a la consultaespecialitzada. La patologia més freqüentment derivadafou la respiratòria. L’absentisme fou inferior a l’hospitalarii el grau de satisfacció dels pacients elevat. Probablement,un model mixt que inclogui l’assistència hospitalària i ambulatòriaseria l’adequat per millorar l’assistència

Background. Currently, allergy specialists are hospitalbased.Among the different future models of primary care,some proposals include the presence of an allergy specialistin primary care centers. This is the approach that wasevaluated in this pilot study.Objective. To reduce the delay to the first visit by theallergologist. To determine the number of patients andthe type of clinical problems referred for evaluation. Toevaluate the satisfaction level of the patients.Method. This study was performed between September2004 and July 2005. An allergologist moved to one ofManresa's primary health care centers (ABS-M3) to performthe first visits, prick tests, pulmonary function tests,and a survey about the patients' satisfaction.Results. Forty-six new patients were evaluated. Themost common reason for referral was respiratory symptomatology(67.4%), followed by food allergy (30.4%),urticaria/angioedema (26.15), and drug allergy (6.5%).Twenty-eight patients (60.9%) were subsequently referredto the hospital in order to complete the evaluation. Theno-show rate decreased significantly to 2.2% when comparedto hospital visits. Conclusions. The transfer of an allergologist to primaryhealth care centers reduces the time to the first visit.Respiratory symptoms were the most common reason forreferral. No-show rates were lower, and the level of satisfactionwas high. A hybrid model including hospital andprimary health care centers would improve access to specializedcare in allergology

Cow's milk protein allergy. A multi-centre study: clinical and epidemiological aspects / Alergia a las proteínas de la leche de vaca. Estudio multicéntrico : aspectos clínicos y epidemiológicos

Background: Due to the age when it becomes apparent and the treatment needed, cow's milk proteins (CMP) allergy requires an accurate diagnosis to avoid labelling infants falsely as allergic and subjecting them to unnecessary diets. The objective of this multi-centre study carried out at the Allergy Units of 14 Children's Hospitals was to discover the epidemiological, clinical and evolutionary characteristics of cow's milk protein allergy (CMPA). Methods and results: Infants suspected of CMPA who attended allergy clinics at the hospitals taking part during the study period were studied and a detailed clinical history was collected on all of them. Prick tests were done with cow's milk and its proteins and specific IgE anti-bodies were determined by means of CAP with the same allergens as the Prick test. The challenge test with cow's milk was carried out unless contraindicated by the diagnostic protocol. Two different challenge regimens were used: one of them carried out in 3 days and the other in one day. 409 infants with suspected CMPA were included and the diagnostic challenge test was performed on 286 patients (70 %) and not carried out on 123, as it was not indicated according to the protocol. IgE-mediated allergy was confirmed in 234 infants (58 %) and in 15 (4 %) non-IgE-mediated hypersensitivity was diagnosed. The two challenge regimens were equally secure. The average age when the reaction to cow's milk formula took place was 3.5 months (10 days-10 months). The symptoms appeared in the first week of introduction in 95 % of cases and appeared in 60 % with the first feeding with the formula. The most frequent clinical signs were cutaneous in 94 % of cases and the majority of cases appeared within 30 minutes of the feed. 99 % had been breast fed and 44 % had received some cow's milk supplement during the lactation period. Sensitization to egg not given in the feed was noted in 30 % and to beef in 29 %, being well tolerated in all of these. Conclusions: Carrying out an appropriate diagnostic protocol in infants attending for suspected CMPA allows allergy to be ruled out in a high percentage of cases

Objetivos: La alergia a proteínas de leche de vaca (PLV)por la edad en la que se presenta y el tratamiento que requiere exige un diagnóstico de certeza para evitar etiquetar al lactante de falsamente alérgico sometiéndolo a dietas innecesarias. Se trata de un estudio multicéntrico realizado en las unidades de alergia de 14 Hospitales infantiles para conocer las características epidemiológicas, clínicas y evolutivas de la alergia a proteínas de leche de vaca (APLV). Material y métodos: Se estudiaron a los niños con sospecha de APLV que acudieron a las consultas de alergia de los hospitales participantes, en el periodo del estudio, realizándoles a todos ellos una detallada historia clínica, Prick-test con leche de vaca y sus proteínas y determinación de anticuerpos IgE específicos mediante CAP para los mismos alergenos del Prick. Se llevó a cabo la prueba de provocación con leche de vaca de no estar contraindicada según el protocolo diagnóstico. Se utilizaron dos pautas de provocación distintas una de ellas llevada a cabo en 3 días y la otra en un día. Resultados: Se incluyeron 409 niños con sospecha de APLV realizándose prueba de provocación diagnóstica en 286 pacientes (70%), no llevándose a cabo en 123 por no estar indicada según el protocolo. Se confirmó alergia IgE mediada en 234 lactantes (58%) y en 15 (4%) se diagnosticó de Hipersensibilidad no IgE mediada. Las dos pautas de provocación utilizadas fueron igualmente seguras. La edad media de la reacción con formula de leche de vaca tuvo lugar a los 3.5 meses (10 días-10 meses). Los síntomas aparecieron en la primera semana de su introducción en el 95% y en el 60% aparecieron con la primera toma de fórmula. Las manifestaciones clínicas más frecuentes fueron las cutáneas en el 94% y se presentaron en la mayoría de los casos en los primeros 30 minutos tras la toma del alimento. El 99% había recibido lactancia materna y el 44% había recibido algún suplemento de leche de vaca durante la lactancia. Se observó sensibilización a huevo no introducido en la alimentación en el 30% y sensibilización a carne de ternera en el 29% siendo bien tolerada en todos ellos. Conclusiones: El realizar un protocolo diagnóstico adecuado en los niños que consultan por sospecha de CMPA permite descartar la alergia en un alto porcentaje de casos

Neonato con anemia crónica / Newborn chronic anemia

Introducción. la transfusión feto-materna (TFM) o hemorragia feto-materna (HFM) es una causa infrecuente de anemia en recién nacidos que puede presentarse desde formas asintomáticas hasta otras con importante patología dependiendo del tiempo de instauración. Observación clínica. Recién nacido de minutos de vida, asintomático, que presenta intensa palidez cutánea. En el análisis inicial destacan valores de hemoglobina de 4.9 gr/dL y hematocrito de 16.3%. El test de Kleihauer materno confirman la sospecha diagnóstica de transfusión feto-materna. La terapia transfusional resulta clave para la resolución de la anemia. Comentarios. La TFM es una enfermedad de etiología poco clara que implica el paso de sangre fetal a la madre durante la gestación o en el momento del parto. La presentación clínica es muy diversa y variará según la severidad y rapidez de instauración de la hemorragia. La evolución y el pronóstico dependerán de un buen diagnóstico precoz y de la respuesta al tratamiento con transfusión de concentrado de hematíes. En nuestro caso, la cronicidad del cuadro y el tratamiento con la transfusión han proporcionado una buena evolución (AU)

Introduction. Fetomaternal transfusion (FMT) or fetomaternal hemorrhage (FMH) is a rare cause of neonatal anemia with a wide spectrum of clinical presentations, ranging from no symptoms to severe clinical deterioration, depending on the time of its occurrence. Clinical observation. Newborn with pallor and no other abnormal findings. Laboratory evaluation revealed hemoglobin of 4.9 g/dL and hematocrit of 16.3%. The Kleihauer test performed in the mother confirmed the diagnosis of FMT. Comments. FMT is a phenomenon of unclear etiology that results from the transfer of fetal blood into the mother during the pregnancy or at the time of delivery. The type and severity of the clinical presentation correlates with the amount and timing of the transfusion. An early diagnosis, a judicious use of transfusions of packed red blood cells, and the clinical response to replacement therapy are important prognostic factors. In the case presented here, the chronic nature of the condition and the early diagnosis and treatment resulted in a good outcome (AU)