Drug-induced enterocolitis syndrome (DIES) in a 10-year-old girl.

We report the case of a child presenting with an adverse drug reaction highly suggestive of drug-induced enterocolitis syndrome (DIES) to amoxicillin (AMX). A 10-year-old girl developed repetitive vomiting and pallor without cutaneous or respiratory symptoms 2h after AMX intake. DIES is not a well-described entity, and very few data are available in the literature. In the absence of an existing definition, the diagnosis of DIES can only be suspected and is based on its homology with food protein-induced enterocolitis (FPIES). The major criterion is the recurrence of repetitive and often incoercible vomiting occurring within 1-4h of ingestion of the culprit food in the absence of IgE-mediated allergic classic skin and respiratory symptoms. Once the diagnosis of DIES to AMX is suspected, an open challenge with AMX should be undertaken with caution, under medical supervision in a day hospital unit because of the risk of severe recurrence. Once the diagnosis is confirmed, AMX should be contraindicated to avoid severe reactions.

[Persistent coughs in children and adolescents]. / Toux traînantes chez l'enfant et l'adolescent.

A persistent cough lasting more than 4-8weeks should lead to a diagnostic workup. A detailed history and a full clinical examination, with a chest X-ray, are essential for initial assessment. Most reported causes of chronic cough in children are post-nasal drip syndrome, cough variant asthma (a spirometry with test of bronchodilator responsiveness should be attempted in children old enough to perform the manoeuvres). GERD is often suspected but a causal relationship is difficult to establish. Protracted bacterial bronchitis, post-infectious cough (B. pertussis, Mycoplasma) and somatoform respiratory disorders (including hyperventilation syndrome) are also common. Signs which are pointers suggesting an underlying respiratory or systemic disease require further investigation: inhaled foreign bodies, cystic fibrosis and chronic lung diseases with bronchiectasis, airway abnormalities, interstitial lung diseases need to be considered. Recent reports of refractory coughs have identified features of a sensory neuropathy disorder, and might explain persistent cough triggers.

[Solid food introduction and allergic risk]. / Diversification alimentaire et risque allergique.

Solid food introduction in childhood suffered in recent decades many changes due to findings of increased allergies with a likely mismatch schemes and a recent reversal of recommendations for delaying the introduction of foods. The advice may still change due to the latest findings on the mechanisms of sensitization. There is little or no certainty on the date and to provide food at the right time. It seems that the introduction of solid foods may be favorable age between 4 and 6 months. Delaying the introduction of allergenic potential has not yet demonstrated a preventive effect. It could be preferable to induce an early oral tolerance that cause allergy with transcutaneous sensitization by ingesting any new dietary protein introduced in the environment of the infant.

[Apparent life-threatening events due to cow's milk allergy in infants]. / Malaises graves d'origine allergique chez le nourrisson.

The analysis of an apparent life-threatening event is mainly based on the clinical approach. When the event occurs after a meal, the diagnosis of acid gastroesophageal reflux complicated by esophagitis is suspected first. Cow's milk protein allergy is suspected when the event occurs during weaning from breastfeeding or when it is accompanied by urticaria or relapses when cow's milk is reintroduced. We report on two cases of an apparent life-threatening event associated with cow's milk protein allergy, whose symptoms and first diagnostic approach initially delayed diagnosis. Clinical manifestations of food allergy need to be known in order to avoid errors in diagnostic orientation and therapy, which may be responsible for more severe recurrences.

Goat's milk allergy without cow's milk allergy: suppression of non-cross-reactive epitopes on caprine ß-casein.

BACKGROUND AND OBJECTIVE: Goat's milk (GM) allergy associated with tolerance to cow's milk (CM) has been reported in patients without history of CM allergy and in CM-allergic children successfully treated with oral immunotherapy. The IgE antibodies from GM-allergic/CM-tolerant patients recognize caprine ß-casein (ßcap) without cross-reacting with bovine ß-casein (ßbov) despite a sequence identity of 91%. In this study, we investigated the non-cross-reactive IgE-binding epitopes of ßcap. METHODS: Recombinant ßcap was genetically modified by substituting caprine domains with the bovine counterparts and by performing site-directed mutagenesis. We then evaluated the recognition of modified ßcap by IgE antibodies from 11 GM-allergic/CM-tolerant patients and 11 CM-allergic patients or by monoclonal antibodies (mAb) raised against caprine caseins. The allergenic potency of modified ßcap was finally assessed by degranulation tests of humanized rat basophil leukaemia (RBL)-SX38 cells. RESULTS: Non-cross-reactive epitopes of ßcap were found in domains 44-88 and 130-178. The substitutions A55T/T63P/L75P and P148H/S152P induced the greatest decrease in IgE reactivity of GM-allergic/CM-tolerant patients towards ßcap. The pivotal role of threonine 63 was particularly revealed as its substitution also impaired the recognition of ßcap by specific mAb, which could discriminate between ßcap and ßbov. The modified ßcap containing the five substitutions was then unable to trigger the degranulation of RBL-SX38 cells passively sensitized with IgE antibodies from GM-allergic/CM-tolerant patients. CONCLUSIONS: Although IgE-binding epitopes are spread all over ßcap, a non-cross-linking version of ßcap was generated with only five amino acid substitutions and could thus provide new insight for the design of hypoallergenic variants.

[Prevalence of chronic hyperventilation syndrome in children and teenagers]. / Prévalence du syndrome d'hyperventilation chronique chez les enfants et les adolescents.

OBJECTIVE: The aim of this study was to investigate the prevalence of hyperventilation syndrome in the general population of children and teenagers from the Île-de-France region (France). METHODS: Three hundred children and teenagers (170 girls and 130 boys, aged 1 to17 years) were included in the study. To evaluate the probability of hyperventilation syndrome, we asked the children and teenagers to complete the Hyperventilation Syndrome Ambroise-Paré Enfant (SHAPE) questionnaire. The frequency of occurrence of the signs was evaluated by the child himself or herself with or without parental help. Children and teenagers with a score of 25 or over were considered to have hyperventilation syndrome. RESULTS: Sixty-three out of 300 questionnaires with a score of 25 or over revealed the presence of hyperventilation syndrome: 21% of the population evaluated. Among those surveyed, 42 were girls and 21 boys: 24.7 and 16.2%, respectively. The 280 questionnaires filled out among the non-asthmatics showed that 52 were positive (18.6%), while the positivity rate in the asthma group amounted to 55%. CONCLUSION: Although the diagnostic criteria for hyperventilation syndrome remains contested, this study shows that the disorder is real and frequent.

[Secondary and tertiary prevention of allergic asthma in children]. / Prévention secondaire et tertiaire de l'asthme allergique de l'enfant.

Asthma is a disease of the lung epithelial barrier, most often associated with allergy in children. Asthma and allergy are two distinct diseases, but the phenotypic expression of asthma depends on atopic status. A better definition of phenotypes of asthma would result in better targeting of prevention and treatment modalities. Secondary prevention aims to prevent the onset of asthma and the acquisition of new sensitizations in sensitized children. Studies concerning allergen avoidance are insufficient to reach a definitive conclusion and antihistamines have not been shown to be effective. The results for specific immunotherapy suggest a benefit to prevent transition from allergic rhinitis to asthma and the onset of new sensitizations. Tertiary prevention aims to reduce symptoms in children with an existing allergic asthma diagnosis. The avoidance of known respiratory allergens will only be effective in combination with management of the whole environment. Specific immunotherapy has a real place, in combination with background therapy. It should be used according to guidelines in appropriately treated patients.

[A new case of food protein-induced enterocolitis syndrome]. / Syndrome d'entérocolite induit par les protéines alimentaires, à propos d'une observation.

We report a case of food protein-induced enterocolitis syndrome (FPIES) with milk whose signs of milk intolerance began in the 1st days of life, consisting in minor and nonspecific symptoms. The 3 foods in question were cow's milk, soja, and wheat. The diagnosis of FPIES was suspected at the age of 9 months, after 3 hospitalizations for vomiting, sometimes associated with lethargy and hypotension, which occurred around 2h after cow's milk ingestion. Symptoms were not associated with positive specific IgE and cutaneous tests. Signs then occurred with soja and wheat. Because of the late diagnosis, 3 anaphylactic shock episodes occurred. FPIES is an uncommon cell-mediated food allergy reaction. This syndrome is characterized by gastrointestinal symptoms, especially severe vomiting, sometimes associated with anaphylactic shock. Usually signs occur 2h after ingestion. These reactions begin early, in the 1st months of life, and regress by the age of 3 years in 38-100% of cases depending on the responsible food. They are usually induced by cow's milk and soy proteins. Diagnosis is difficult and delayed because of nonspecific symptoms. Oral food challenge is the only examination that confirms the diagnosis. Treatment involves the exclusion of the specific food involved. Severe reactions require treatment of shock and adjunction of corticosteroids.

Oral food challenge in children: an expert review.

Oral food challenges are indicated for the diagnosis of food allergy and the double-blind, placebo-controlled oral food challenge is considered the gold standard diagnostic method in children with suspected food allergy. This practice parameter for oral food challenges in children was prepared by a workgroup at the request of the French Society for Allergology and Clinical Immunology (SFAIC) and the French Paediatric Society for Allergology and Pulmonology (SP2A). We aimed to develop practical guidelines for oral food challenges in children for the diagnosis of suspected food allergy or the evaluation of food tolerance. We also considered the safety measures to be implemented during testing and management of the potentially serious allergic reactions that may arise during the test. The strength of the recommendations was established, using the GRADE evidence-based approach. We considered four issues: (1) the selection of children for oral food challenges (indications and contraindications); (2) the procedure used (material, where the test should be carried out, technique and management of reactions); (3) interpretation of the test and (4) consequences of the test.

[Diagnostic value of the SHAPE questionnaire in recognition of the hyperventilation syndrome in children: a pilot study]. / Valeur diagnostique du questionnaire SHAPE pour le syndrome d'hyperventilation de l'enfant : étude pilote.

OBJECTIVE: Determination of a diagnostic scoring method for hyperventilation syndrome (HVS) in children and proposal of a simplified questionnaire. METHOD: We used the main clinical signs of HVS in children and adolescents identified in a previous study and classified them according to their odds ratios (OR). The intensity of each sign, measured using a visual analogic scale in the previous study, led us to analyze several scoring methods, with a breakdown between major and minor signs according to their OR. Building receiver operating characteristics (ROC) curves allowed us to choose the best diagnostic combination. RESULTS: A sample of 85 children and adolescents aged from 7 to 20 years (mean age, 11.9 years) was tested. This sample comprised 45 children with isolated HVS or HVS associated with asthma and 40 controls, with asthma but without HVS or attending our emergency unit after trauma. Seven respiratory signs and 10 nonrespiratory signs were selected. For each scoring method, a significant difference was observed between HVS and non-HVS patients. The most suitable area under the curve (0.934) and the best combination between specificity and sensitivity (Sp=0.90 and Se=0.82) were obtained when the scoring method was 0,3,6 for major signs, and 0,1,2 for minor signs, according to perceived intensity of each sign ("never or almost never", "sometimes" or "often or very often"). CONCLUSION: Since no gold standard is available to confirm the diagnosis of HVS in children, we propose using a simplified questionnaire composed of 17 items to compute a diagnostic score. The questionnaire will be validated shortly in a new prospective study.

[Diagnosing and food allergy in children]. / Bilan allergologique d'allergie alimentaire.

Values of allergic tests in childhood food allergies are discussed. Diagnosis procedures are then proposed depending of clinical pictures.

[A diagnostic questionnaire for the hyperventilation syndrome in children]. / Elaboration d'un questionnaire diagnostique du syndrome d'hyperventilation chez l'enfant.

INTRODUCTION: Intensive efforts should be made to diagnose the hyperventilation syndrome (HVS) at an early stage as this will prevent stigmatisation and reinforcement of symptoms. It will also prevent children from undergoing unnecessary medical examinations and treatment. A diagnostic questionnaire should be useful for this purpose. METHODS: We administered a questionnaire with 16 respiratory symptoms and 23 non respiratory symptoms to 25 children with HVS alone, 20 with asthma and HVS, and two control groups: 20 children with asthma without HVS and 20 presenting with trauma. For each symptom a visual analogue scale (VAS) was completed. The symptoms for which the mean VAS values were significantly different between the children with HVS and the controls were subject to principal component analysis after varimax rotation with Kaiser normalisation. RESULTS: There was no significant difference in symptoms between HVS children with or without asthma. The five major respiratory symptoms were: throat-clearing, sniffing, difficulty in breathing in, sighing and yawning. The combined sensitivity of those symptoms was 99%, the combined specificity 24%. The five major non-respiratory symptoms were: anxiety, difficulty in going to sleep, general fatigue, abdominal pain, and joint pains. The combined sensitivity of those symptoms was 99%, the combined specificity 36%. CONCLUSIONS: We performed a simplified diagnostic questionnaire for HVS in healthy and asthmatic children and found 5 respiratory and 5 non-respiratory symptoms of significance.

[Food hypersensibility: inhalation reactions are different from ingestion reactions]. / Allergie alimentaire : les réactions à l'inhalation sont différentes des réactions à l'ingestion.

Eight children, aged from 3 to 9 years, presented to inhaled peanut an immediate allergic reaction. All were sensitized to peanut but none had already ingested it overtly. A strict avoidance diet was prescribed concerning this food allergen. An oral provocation challenge was realized to determine the eliciting dose (ED) to ingestion. The ED was high enough to allow all the children a less restrictive diet. Inhaled allergic reaction to peanut does not always justify a strict avoidance diet.

Allergy to goat and sheep milk without allergy to cow's milk.

BACKGROUND: Cow's milk (CM) allergy is the most frequent cause of food allergy in infants. Most children who are allergic to CM are also sensitized to whey proteins and/or to the casein fraction and many of them cannot tolerate goat's or sheep's milk (GSM) either. Conversely, the GSM allergies that are not associated with allergic cross-reactivity to CM are rare. METHODS: Twenty-eight children who had severe allergic reactions, including anaphylaxis, after consumption of GSM products but tolerated CM products were recruited in a retrospective study. Whole casein and whey proteins were fractionated from CM and GSM. beta-Lactoglobulin and the different caseins were isolated, purified and used to perform enzyme allergosorbent tests (EAST) and EAST inhibition studies with the sera of the allergic children. RESULTS: Clinical observations, skin prick testing and immunoglobulin (Ig)E-binding studies confirmed the diagnosis of GSM allergy without associated CM allergy. EAST determinations demonstrated that GSM allergy involves the casein fraction and not whey proteins. Cow's milk caseins were not at all or poorly recognized by the patient's IgE, while alphaS(1)-, alphaS(2)- and beta-caseins from GSM were recognized with a high specificity and affinity. In all cases, increasing concentrations of CM caseins failed to inhibit the binding of patient's IgE to sheep or goat milk caseins, whereas this binding was completely inhibited by GSM caseins. CONCLUSIONS: The characteristics of GSM allergy differ from those of the CM allergy because it affects older children and appears later. CM products do not elicit any clinical manifestation in GSM allergic patients, whereas CM allergic patients, usually cross-react to GSM. In all the GSM allergic children, the IgE antibodies recognized the caseins but not the whey proteins. Moreover, IgE specificity and affinity was high to GSM and lower to CM caseins despite their marked sequence homology. Doctors and allergic individuals should be aware that GSM allergy requires a strict avoidance of GSM and milk-derived products because reactions could be severe after ingestion of minimal doses of the offending food.

[Food allergy in children]. / Allergie alimentaire de l'enfant.

Food allergy is an adverse reaction to food protein by an immunological mechanism (IgE or non IgE-mediated). Signs can involve all organs, but atopic dermatitis remains the main manifestation. In children, only few allergens are involved. In France, it is cow milk, hen eggs, kiwi, peanut, fish, nuts, shrimp. Diagnosis is based on clinical history, skin tests, specific IgE and, sometimes, food challenge. Treatment is based on specific eviction. Regime can be total or sometimes limited to large among of the specific food, or only raw food. Food allergy disappears sometimes. Tolerance or food desensitization is in progress.

[What type of avoidance for peanut allergic children?]. / Le régime d'éviction chez les allergique à l'arachide.

We analyzed, from the literature, the balance benefit/risk of a strict avoidance of peanut in children with peanut allergy. The benefits of a strict avoidance diet seem limited: reactions to the low doses and to the peanut oil refined are rare and most often slight. It is not proven that a strict avoidance facilitates the cure of allergy. On the other hand, strict avoidance could induce a worsening of allergy, with deterioration of quality of life, creation of food neophobia. In case of cure of allergy, it is difficult to normalize the diet after a strict avoidance. Outside of the rare sensitive patients to a very low dose of peanut, for which a strict avoidance is counseled, the report benefits risk is in favor of the prescription of adapted avoidance to the eliciting dose. For the majority of the peanut allergic children, it seems to us that the avoidance can and must be limited to the non hidden peanut.

[Mosquito bites allergy, which prevention?]. / Réactions allergiques aux piqûres de moustiques, quelle prévention?

Mosquito bites may induce allergic reactions in children. Usually underestimated, these reactions are often cutaneous and difficult to distinguish from non-specific histaminic phenomena. Recently, the identification of major allergens in mosquito saliva has allowed the achievement of recombinant allergens, which should facilitate the diagnosis and treatment of allergic reactions. Preventive cares must be performed in all children with large reactions, allergic or even non-allergic. Prevention consists in cutaneous protection, the use of repellents (with special attention to their toxicity), and antihistamines. A practical sheet for patient is provided.

[Hyperventilation syndrome in children]. / Le syndrome d'hyperventilation pulmonaire chez l'enfant, revue de la litterature.

Hyperventilation syndrome is frequent in adults. There are only very few and very ancient publications in children. Diagnosis is sometimes difficult, because the symptoms often mimic those of organic diseases. Hyperventilation syndrome and organic diseases, especially asthma, often coincide. Intensive efforts should be made to diagnose hyperventilation syndrome at an early stage because this will prevent stigmatization and fixation of symptoms and disease, and also prevent children from undergoing unnecessary medical examinations and therapies. The authors review the literature about hyperventilation syndrome in children.

[Compliance with and acceptability of a new electronic peak flow meter, the PiKo-1]. / Observance et acceptabilité d'un nouveau débitmètre de pointe electronique, le PiKo-1.

BACKGROUND: Monitoring airflow obstruction is an essential component of asthma management. We examined home recording of PEFR using a new electronic peak flow meter in terms of compliance and acceptability in a group of children with asthma. METHODS: Twenty three children (3 with intermittent asthma and 20 with persistent asthma) (average age 10.9 +/- 3.8 [5-18] yrs) were asked to assess their PEFR every day during a period of 5.8 +/- 1.2 [4-8] weeks and record it in a diary card. Patients were not aware that their data was also being stored on the PiKo-1. At the end of the study, the written data were compared to the stored data. A multiple choice questionnaire was given to each subjectto check the acceptability of the PiKo-1. RESULTS: 2 patients were lost to follow up. The compliance (expressed as a percent of the number of recordings that should have been made) was more that 80% for 14/21(67%) patients and less than 45% for 3/21 (14%). Compliance decreased during the study (96% in the first week, 68% during the fifth). 12% of the values were falsified. The PiKo-1 was considered to be small, attractive and useful. Some children found the mouthpiece too small. CONCLUSION: The good results for compliance that we observed might have been due to the short duration of the study. PiKo-1 was well accepted by the subjects. It will be possible to monitor PEFR and forced expiratory volume in the first second of expiration at home using this new device.