Consenso para el abordaje del asma grave pediátrica en la práctica clínica habitual / Consensus-based approach for severe paediatric asthma in routine clinical practice

INTRODUCCIÓN: La identificación adecuada del paciente pediátrico con asma grave es esencial para su correcto manejo. Sin embargo, los criterios para definir el asma grave y las recomendaciones para su control varían mucho entre las distintas guías. MATERIAL Y MÉTODOS: Se elaboró una encuesta telemática para analizar las opiniones relativas a la definición y control del asma grave pediátrica. Para lograr un consenso se siguió una metodología Delphi modificada. Con los resultados se elaboraron recomendaciones prácticas. RESULTADOS: El cuestionario fue respondido por 11 neumólogos y alergólogos pediátricos expertos en asma grave. Hubo consenso en 50 de los 65 ítems planteados (76,92%). Se consideró que un paciente tiene asma grave si en el último año ha requerido 2 o más ciclos de corticoides orales, si requiere tratamiento diario con corticoides inhalados a dosis medias (con otra medicación controladora) o dosis altas (con o sin otra medicación controladora), si no responde a un tratamiento convencional optimizado, o si la enfermedad pone en riesgo su vida o deteriora gravemente su calidad de vida. La definición de asma grave también podría incluir a los pacientes que consumen recursos sanitarios de manera regular y justificada, o tienen factores psicosociales o ambientales que impiden su control. Para la monitorización, se recomienda usar cuestionarios específicos de población pediátrica (CAN o ACT). Respecto al tratamiento, se debería considerar el uso de omalizumab en un escalón anterior al de los corticoides orales. CONCLUSIONES: El presente trabajo ofrece recomendaciones consensuadas que pueden ser de utilidad en el manejo del asma grave pediátrica

INTRODUCTION: Accurate identification of paediatric patients with severe asthma is essential for an adequate management of the disease. However, criteria for defining severe asthma and recommendations for control vary among different guidelines. MATERIAL AND METHODS: An online survey was conducted to explore expert opinions about the definition and management of severe paediatric asthma. To reach a consensus agreement, a modified Delphi technique was used, and practice guidelines were prepared after the analysis of the results. RESULTS: Eleven paediatric chest disease physicians and allergy specialists with wide expertise in severe asthma responded to the survey. Consensus was reached in 50 out of 65 questions (76.92%). It was considered that a patient has severe asthma if during the previous year they have required 2 or more cycles of oral steroids, required daily treatment with medium doses of inhaled corticosteroids (with other controller medication) or high doses (with or without other controller medication), did not respond to optimised conventional treatment, or if the disease threatened the life of the patient or seriously impairs their quality of life. The definition of severe asthma may also include patients who justifiably use health resources on a regular basis, or have psychosocial or environmental factors impeding control. For monitoring, the use of questionnaires designed specifically for paediatric population, such as CAN or ACT, is recommended. As regards treatment, the use of omalizumab should be considered prior to the use of oral corticosteroids. CONCLUSIONS: This paper provides consensus recommendations that may be useful in the management of severe paediatric asthma

Protocolo de seguimiento de los pacientes con displasia broncopulmonar / Guidelines for the follow up of patients with bronchopulmonary dysplasia

La displasia broncopulmonar (DBP) es la secuela más prevalente del recién nacido pretérmino, y sigue suponiendo un motivo frecuente de consulta en las unidades de Neumología Pediátrica. La decisión del alta de la unidad neonatal debe apoyarse en una valoración exhaustiva de la situación clínica del paciente y en el cumplimiento de unos requisitos, que incluyen la estabilidad respiratoria y nutricional, y la instrucción a los cuidadores en el manejo domiciliario. Para un control adecuado de la enfermedad, es necesario que quede establecido, previamente al alta, un calendario de visitas y de exploraciones complementarias, y deben aplicarse las pautas de prevención de exacerbaciones y el tratamiento apropiados. El concepto de DBP como enfermedad multisistémica es fundamental en el seguimiento de los pacientes y debe ser tenido en cuenta para un buen control de la enfermedad. En este documento, el Grupo de Trabajo de Patología Respiratoria Perinatal de la Sociedad Española de Neumología Pediátrica propone un protocolo que sirva como referencia para unificar el seguimiento de los pacientes con DBP entre los diferentes centros y ámbitos asistenciales. Se revisan los aspectos a tener en cuenta en la evaluación previa al alta de la Unidad Neonatal y las principales complicaciones durante el seguimiento. Seguidamente, se detallan las recomendaciones en materia de tratamiento de la enfermedad y prevención de complicaciones, los controles tras el alta y su cronología

Bronchopulmonary dysplasia (BPD) is the most common complication of preterm birth, and remains a major problem in pediatric pulmonology units. The decision of discharging from the Neonatal Unit should be based on a thorough assessment of the condition of the patient and compliance with certain requirements, including respiratory and nutritional stability, and caregiver education on disease management. For proper control of the disease, a schedule of visits and complementary tests should be established prior to discharge, and guidelines for prevention of exacerbations and appropriate treatment should be applied. In this paper, the Working Group in Perinatal Respiratory Diseases of the Spanish Society of Pediatric Pulmonology proposes a protocol to serve as a reference for the follow up of patients with BPD among different centers and health care settings. Key factors to consider when planning discharge from the Neonatal Unit and during follow up are reviewed. Recommendations on treatment and prevention of complications are then discussed. The final section of this guide aims to provide a specific schedule for follow-up and diagnostic interventions to be performed in patients with BPD

[Guidelines for the follow up of patients with bronchopulmonary dysplasia]. / Protocolo de seguimiento de los pacientes con displasia broncopulmonar.

Bronchopulmonary dysplasia (BPD) is the most common complication of preterm birth, and remains a major problem in pediatric pulmonology units. The decision of discharging from the Neonatal Unit should be based on a thorough assessment of the condition of the patient and compliance with certain requirements, including respiratory and nutritional stability, and caregiver education on disease management. For proper control of the disease, a schedule of visits and complementary tests should be established prior to discharge, and guidelines for prevention of exacerbations and appropriate treatment should be applied. In this paper, the Working Group in Perinatal Respiratory Diseases of the Spanish Society of Pediatric Pulmonology proposes a protocol to serve as a reference for the follow up of patients with BPD among different centers and health care settings. Key factors to consider when planning discharge from the Neonatal Unit and during follow up are reviewed. Recommendations on treatment and prevention of complications are then discussed. The final section of this guide aims to provide a specific schedule for follow-up and diagnostic interventions to be performed in patients with BPD.

[Consensus-based approach for severe paediatric asthma in routine clinical practice]. / Consenso para el abordaje del asma grave pediátrica en la práctica clínica habitual.

INTRODUCTION: Accurate identification of paediatric patients with severe asthma is essential for an adequate management of the disease. However, criteria for defining severe asthma and recommendations for control vary among different guidelines. MATERIAL AND METHODS: An online survey was conducted to explore expert opinions about the definition and management of severe paediatric asthma. To reach a consensus agreement, a modified Delphi technique was used, and practice guidelines were prepared after the analysis of the results. RESULTS: Eleven paediatric chest disease physicians and allergy specialists with wide expertise in severe asthma responded to the survey. Consensus was reached in 50 out of 65 questions (76.92%). It was considered that a patient has severe asthma if during the previous year they have required 2 or more cycles of oral steroids, required daily treatment with medium doses of inhaled corticosteroids (with other controller medication) or high doses (with or without other controller medication), did not respond to optimised conventional treatment, or if the disease threatened the life of the patient or seriously impairs their quality of life. The definition of severe asthma may also include patients who justifiably use health resources on a regular basis, or have psychosocial or environmental factors impeding control. For monitoring, the use of questionnaires designed specifically for paediatric population, such as CAN or ACT, is recommended. As regards treatment, the use of omalizumab should be considered prior to the use of oral corticosteroids. CONCLUSIONS: This paper provides consensus recommendations that may be useful in the management of severe paediatric asthma.

Profilaxis frente al virus respiratorio sincitial en el periodo 2011-2012 en el servicio de neumología pediátrica de tres hospitales terciarios españoles / Prophylaxis against respiratory syncytial virus in the 2011-2012 season in the Paediatric Neumology departments of three Spanish tertiary hospitals

Introducción: Los niños con neumopatías crónicas presentan más morbilidad que los pretérmino si se sobreinfectan por el virus respiratorio sincitial (VRS) y, en algunas ocasiones, podrían beneficiarse de la profilaxis, incluso más que los niños con cardiopatías. El objetivo de este estudio era describir las características y la tasa de hospitalización por VRS en pacientes pediátricos con neumopatía crónica que habían recibido profilaxis con palivizumab (PVZ). Material y métodos: Se realizó un estudio retrospectivo en pacientes con neumopatía de base que habían recibido profilaxis con PVZ en el periodo 2011-2012. Resultados: De los 74 pacientes incluidos, el 55% eran niños. La edad media al inicio de la profilaxis en esta estación fue de 15,7 ± 13,8 meses. El 69% (51/74) recibieron profilaxis completa y el 31% (23/74) incompleta. Ningún paciente interrumpió la profilaxis por presentar reacciones adversas. La media de dosis administradas fue de 4,7 ± 0,8. El 27% (20/74) presentó, como mínimo, una reagudización respiratoria aguda y el 6,7% (5/74) un segundo episodio. En 2 pacientes el agente infeccioso responsable fue el VRS, y en 18 otros agentes. Los 2 pacientes con infección por el VRS requirieron ingreso hospitalario, y el 45,5% (8/18) de los pacientes del grupo afectado por otros agentes. La tasa global de hospitalización por infección por el VRS en la muestra de estudio fue del 2,7%. Conclusiones: La tasa de hospitalización en nuestro estudio fue similar a la obtenida en otros realizados en pacientes con otras patologías de base a los que se les había administrado profilaxis con PVZ, lo que puede sugerir un efecto beneficioso en pacientes con neumopatías de base (AU)

Purpose: Children with chronic lung disease have more morbidity than preterm children with respiratory syncytial virus (RSV) overinfection and even compared to heart disease, and could benefit from this prophylaxis. The aim of this study is to describe the clinical and epidemiological characteristics and the RSV hospitalization rate in pediatric patients with chronic lung disease who received prophylaxis with palivizumab (PVZ) in the 2011-2012 RSV outbreak. Patients and methods: Retrospective study was designed and patients with chronic lung disease who have received prophylaxis with PVZ in the previous RSV season were included. Results: Of 74 patients included, 55% were males. Mean age at the beginning of prophylaxis in the season 2011-2012 was 15.7 ± 13.8 months. Sixty-nine percent (51/74) of them received complete prophylaxis with PVZ and 31% (23/74) received incomplete prophylaxis. None of the patients withdrew prophylaxis due to an adverse reaction. Mean administrated doses were 4.7 ± 0.8. From all, 27% (20/74) suffered at least one respiratory relapse, with or without hospitalization, and 6.7% (5/74) a second relapse. In only 2/20 of those with any relapse the responsible infectious agent was RSV. Both patients (100%) with RSV infection required hospitalization, while 45.5% (8/18) of the patients in the other group. Hospitalization rate due to RSV infection for our study sample was 2.7. Conclusions: Hospitalization rate obtained in our study was within the range found in previous reports in patients with other chronic conditions who have received prophylaxis with PVZ which may suggest a health benefit in patients with chronic lung diseases (AU)

Aerosolterapia / No disponible

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Asthma phenotypes identified by latent class analysis in the ISAAC phase II Spain study.

BACKGROUND: Classification of respiratory symptoms may help to identify different underlying asthma phenotypes reflecting differences in aetiology and prognosis of wheezing disease among children. OBJECTIVE: To determine childhood asthma phenotypes based on respiratory symptoms from a widely used questionnaire to further classify phenotypes in international settings. METHODS: Between 2000 and 2002 cross-sectional studies were performed in four centres in Spain. Parental questionnaires were used to collect information on allergic diseases in more than 4000 children aged 8-12 years. In addition, objective markers for allergic sensitization and bronchial hyperresponsiveness (BHR) were measured. Latent class analyses (LCA) were applied to identify subgroups of children according to respiratory symptoms, and then the association of these groups with relevant clinical features such as concomitant allergic disease symptoms, atopy and BHR was studied. RESULTS: We found seven classes, one corresponding to healthy children, three classes related to wheeze and three other classes mainly related to congestion and coughed-up phlegm. These tentative phenotypes differed in severity of symptoms and also in clinical correlates such as BHR and allergic sensitization. Atopy was more predominant in the 'wheeze phenotypes' whereas concomitant 'allergic' symptoms were most frequent in two of the 'wheeze phenotypes' and one of the 'cough phenotypes'. CONCLUSIONS: LCA on reported symptoms in a cross-sectional survey allowed different subgroups with meaningful clinical correlates to be defined. It remains to be investigated to what extent these groups also have different aetiologies, prognoses and therapeutic needs.

Asma en el niño escolar / Asthma in chool child

El asma es la enfermedad crónica más frecuente en la infancia. Es una enfermedad inflamatoria crónica de las vías aéreas cuya prevalencia ha aumentado en todo el mundo, aunque no de igual manera en todos los países. Existe un componente genético que predispone a padecer la enfermedad, habiéndose descrito hasta ahora más de 100 genes relacionados con el asma y la alergia. Además, existirían factores ambientales (exposición a neumoalergenos, infecciones respiratorias, contaminación atmosférica) que determinarían la aparición de síntomas. Estos se deben a la obstrucción del flujo aéreo ocasionado por el estrechamiento de la vía aérea y consisten en episodios de tos, sibilancias y dificultad respiratoria, reversibles de forma espontánea o tras tratamiento con broncodilatadores. Una espirometría con patrón obstructivo y un test de broncodilatación positivo apoyarían firmemente el diagnóstico. La historia clínica detallada permite establecer la relación con factores desencadenantes, clasificar la gravedad del asma y decidir el tratamiento de fondo cuando sea necesario (corticoides inhalados, antileucotienos, beta-adrenérgicos de acción larga), reservando los beta-adrenérgicos de acción corta y los corticoides sistémicos para la crisis de asma. La inmunoterapia con alérgenos puede estar indicada en algunos pacientes alérgicos, y otros con asma grave pueden beneficiarse del tratamiento con omalizumab (AU)

Asthma is the most frequent chronic condition in child-hood. It is chronic inflammatory disorder of the airways, which frequency has increased in the whole world, but not in the same way. There is a genetic predisposition to suffer the disease, and the moment, more than of 100 genes have been described related to asthma and allergy. In addition, environmental factors would exist that determine the appearance of symptoms (pneumoallergen exposition, respiratory infection, air pollution). These are due to air flow obstruction caused by the narrowing of the airway and they consist of episodes of cough, wheeze and difficulty breathing, reversible on spontaneous was or after treatment with bronchodilators. A spirometry with airway obstruction and positive bronchodilator response would firmly support the diagnosis. A clinical detailed history allows to establish the relationship with trigger factors, to classify the severity of the disease and decide treatment, that whould be necessary (inhaled corticosteroids, leukotriene-receptor agonists, long-acting beta2-agonists), keeping the short acting beta2-agonists and systemic corticoids for asthmatic exacerbations. Immunotherapy can be indicated in some allergic patients, and other with severe asthma could benefit of treatment with omalizumab (AU)

Patología traqueal. Tratamiento médico y manejo clínico / No disponible

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Protocolo de diagnóstico y seguimiento de los pacientes con fibrosis quística / Protocol for the diagnosis and follow up of patients with cystic fibrosis

La fibrosis quística (FQ) es la enfermedad autosómica recesiva grave más frecuente de la raza caucásica. El aumento tan importante de la supervivencia de los pacientes con FQ en los últimos años se debe en gran parte a la disponibilidad de nuevos tratamientos de la enfermedad pulmonar, en especial de las infecciones respiratorias. Este protocolo revisa y actualiza los aspectos del diagnóstico y el manejo de la enfermedad respiratoria de la FQ. La prueba del sudor continúa siendo el estándar del diagnóstico de la FQ aunque, pese a realizarse de la forma adecuada, no siempre es concluyente. Se debe controlar a los pacientes con FQ en unidades especializadas por un equipo multidisciplinario y experto, mediante protocolos específicos de seguimiento clínico, estudios por imagen y pruebas funcionales respiratorias y microbiológicas que se actualizan en esta revisión. Se incluyen las recomendaciones sobre el tratamiento precoz y agresivo de la primoinfección y de la infección crónica por Pseudomonas aeruginosa, Staphylococcus aureus y otros microorganismos no habituales. Asimismo se describen los tratamientos de los diferentes aspectos de la enfermedad pulmonar y sus complicaciones y se revisan las indicaciones y el estado actual del trasplante pulmonar. Este documento de consenso ha sido elaborado por los miembros del Grupo de Trabajo de Fibrosis Quística de la Sociedad Española de Neumología Pediátrica con el objetivo de actualizar el previo, publicado en esta Revista en 1999 (AU)

Cystic fibrosis (CF) is the most common severe recessive genetic disease in Caucasians. During the last years, new therapies and aggressive management of the lung disease have contributed significantly to the increased life expectancy in CF patients. A review and update of CF diagnosis and management of lung disease are included. The sweat chloride test (SCT) remains the gold standard for CF diagnosis and should be performed properly. However, in a few patients SCT results may not be conclusive to clarify the CF diagnosis. Patients with CF should be followed up in specialist Units by an expert multidisciplinary expert applying standard clinical protocols and using lung function tests, and microbiological and imaging studies. An overview with the recommendations for treatment of early onset and chronic infections due to Pseudomonas aeruginosa, Staphylococcus aureus and other uncommon pathogens is included. Furthermore, the management of other aspects of CF lung disease and complications is provided, as well as the indications for lung transplantation. This document has been prepared by the members of the CF working group of the Spanish Paediatrics Pulmonary Society to provide an update to the earlier documents published in this Journal in 1999 (AU)

[Protocol for the diagnosis and follow up of patients with cystic fibrosis]. / Protocolo de diagnóstico y seguimiento de los pacientes con fibrosis quística.

Cystic fibrosis (CF) is the most common severe recessive genetic disease in Caucasians. During the last years, new therapies and aggressive management of the lung disease have contributed significantly to the increased life expectancy in CF patients. A review and update of CF diagnosis and management of lung disease are included. The sweat chloride test (SCT) remains the gold standard for CF diagnosis and should be performed properly. However, in a few patients SCT results may not be conclusive to clarify the CF diagnosis. Patients with CF should be followed up in specialist Units by an expert multidisciplinary expert applying standard clinical protocols and using lung function tests, and microbiological and imaging studies. An overview with the recommendations for treatment of early onset and chronic infections due to Pseudomonas aeruginosa, Staphylococcus aureus and other uncommon pathogens is included. Furthermore, the management of other aspects of CF lung disease and complications is provided, as well as the indications for lung transplantation. This document has been prepared by the members of the CF working group of the Spanish Paediatrics Pulmonary Society to provide an update to the earlier documents published in this Journal in 1999.

The management of tracheobronchial obstruction in children.

Tracheobronchial obstruction is very uncommon in children and small infants. Stenosis and malacia, either congenital or acquired, are probably the most frequent diagnosis in this setting. Clinical symptoms are common to both airway anomalies and bronchoscopy plays a crucial role in the diagnostic work-up. Management is complex and surgeons involved in it should be familiar with multiple surgical and endoscopical techniques. Symptomatic short tracheal stenosis are best treated by means of resection and reconstruction, although endoscopic dilation or laser resection can be tried first in selected cases. In long tracheal stenosis, slide tracheoplasty is the surgical procedure of choice. Tracheobronchial malacia is usually self-limiting by the age of 3 years and most cases show mild symptoms that can be treated conservatively. In a small group of patients airway compromise is severe enough to require surgical or endoscopical treatment. Aortopexy or tracheostomy are the classic treatments for congenital tracheomalacia, but increasing experience with endoscopic airway stent placement in children is making this technique more attractive and popular. Acquired tracheomalacia is usually caused by a long-standing tracheostomy and if decannulation is impaired surgical treatment is mandatory.

Effect of breastfeeding on asthma, lung function and bronchial hyperreactivity in ISAAC Phase II.

The association between breastfeeding and wheezing, lung function and atopy was evaluated in the International Study of Asthma and Allergy in Childhood (ISAAC) Phase II. Cross-sectional studies were performed in 27 centres in 20 countries. Information on disease and exposure factors was collected by parental questionnaires. Data from 54,000 randomly selected school children (aged 8-12 yrs, 31,759 with skin prick testing) and a stratified subsample (n = 4,888) were used for testing the correlation of breastfeeding with bronchial hyperreactivity and lung function. Random effect models for meta-analysis were applied to calculate combined odds ratios (ORs). Any breastfeeding was associated with less wheeze both in affluent (adjusted OR (OR(adj)) 0.87, 95% confidence interval (CI) 0.78-0.97) and nonaffluent countries (OR(adj) 0.80, 95% CI 0.68-0.94). Further analyses revealed that this was true only for nonatopic wheeze in nonaffluent countries (OR(adj) 0.69, 95% CI 0.53-0.90). Breastfeeding was not associated with atopic wheeze and objective measures of allergy in both affluent and nonaffluent countries. In contrast, breastfeeding was associated with higher predicted forced expiratory volume in one second in affluent countries only (mean ratio 1.11, 95% CI 1.02-1.20). Breastfeeding is associated with protection against nonatopic wheeze, which becomes particularly evident in nonaffluent countries. Overall, breastfeeding was not related to any measure of allergy. These findings may explain some of the controversy regarding breastfeeding, since the direction of the association with breastfeeding depends on the predominating wheeze phenotype (e.g. atopic, nonatopic).

A multi-centre study of candidate genes for wheeze and allergy: the International Study of Asthma and Allergies in Childhood Phase 2.

BACKGROUND: Common polymorphisms have been identified in genes suspected to play a role in asthma. We investigated their associations with wheeze and allergy in a case-control sample from Phase 2 of the International Study of Asthma and Allergies in Childhood. METHODS: We compared 1105 wheezing and 3137 non-wheezing children aged 8-12 years from 17 study centres in 13 countries. Genotyping of 55 candidate single nucleotide polymorphisms (SNPs) in 14 genes was performed using the Sequenom System. Logistic regression models were fitted separately for each centre and each SNP. A combined per allele odds ratio and measures of heterogeneity between centres were derived by random effects meta-analysis. RESULTS: Significant associations with wheeze in the past year were detected in only four genes (IL4R, TLR4, MS4A2, TLR9, P<0.05), with per allele odds ratios generally <1.3. Variants in IL4R and TLR4 were also related to allergen-specific IgE, while polymorphisms in FCER1B (MS4A2) and TLR9 were not. There were also highly significant associations (P<0.001) between SPINK5 variants and visible eczema (but not IgE levels) and between IL13 variants and total IgE. Heterogeneity of effects across centres was rare, despite differences in allele frequencies. CONCLUSIONS: Despite the biological plausibility of IgE-related mechanisms in asthma, very few of the tested candidates showed evidence of association with both wheeze and increased IgE levels. We were unable to confirm associations of the positional candidates DPP10 and PHF11 with wheeze, although our study had ample power to detect the expected associations of IL13 variants with IgE and SPINK5 variants with eczema.

How the presence of rhinoconjunctivitis and the severity of asthma modify the relationship between obesity and asthma in children 6-7 years old.

BACKGROUND: The association between asthma and obesity in children, and the effect modification of allergy on this association have not been fully established. Aims The objective of the study was to know the effect modification of the severity of asthma and of the coexistence of rhinoconjunctivitis (RC) in the relationship between obesity and asthma. METHODS: A cross-sectional study of 17 145 schoolchildren 6-7 years old from eight Spanish cities who had completed information on height and weight of the ISAAC phase III questionnaire, which also included questions about asthma and RC symptoms and on various risk factors. Body mass index (BMI) was used to define obesity according to international standards. Two different logistic regressions, using current occasional asthma (COA) and current severe asthma (CSA) as dependent variables, were made stratifying for gender and for the coexistence of RC and controlling for age, older and younger siblings, exercise, mother's education, truck traffic, cat/dog during the first year of life and smoking father or mother. RESULTS: Obesity was a risk factor of CSA without RC, both for boys (1.92, CI 95% 1.13-3.25) and for girls (2.99, CI 95% 1.68-5.32). Every BMI unit increment increased by 6.7% the risk of CSA without RC in boys and by 12.4% in girls. Obesity was not a risk factor for CSA with RC. The association between COA and obesity was weaker and the coexistence of RC did not modify it greatly. CONCLUSIONS: Obese schoolchildren are more at risk of suffering from non-allergic asthma than the non-obese subjects.

Effect of extensively hydrolyzed milk formula on growth and resistance to bronchitis and atopic dermatitis in infants and toddlers.

OBJECTIVE: This study aimed to evaluate the adverse effects of extensively hydrolyzed milk formula on growth in infants and toddlers. METHODS: Prospectively, 45 infants and toddlers with a positive history of cow's milk allergy confirmed by positive skin prick test and high IgE levels for either alpha-lactalbumin, beta-lactoglobulin, or casein and positive single-blind food challenge received extensively hydrolyzed milk formulas for 1 year. Sex-normalized percentiles of heights and weights of infants and toddlers before their enrollment in the study were compared to those at the end of the study. The contribution of breastfeeding, early use of bottle feeding and intake of adapted or special milk formulas, and history of bronchitis and atopic dermatitis on toddlers' growth were also evaluated by multivariate analysis. RESULTS: Similar percentiles of the children's weight and height were observed at the beginning of the study and 1 year later. According to the multivariate analysis, sex, breastfeeding, early bottle feeding, ingestion of adapted or special milk formulas, atopic dermatitis, and bronchitis were not correlated with either the children's weight or height at diagnosis of the allergy or at 1 year of follow-up (P > .10). Weights and heights were not different between toddlers who had atopic dermatitis or bronchitis during the study period and those who did not. CONCLUSIONS: Growth of infants and toddlers with cow's milk allergy was not affected by the intake of extensively hydrolyzed milk for 1 year. Atopic dermatitis and bronchitis did not appear to have any deleterious effect on these children's growth.

[Growth in infants with cow's milk allergy]. / Cómo crecen los lactantes diagnosticados de alergia a proteínas de leche de vaca?

INTRODUCTION: Approximately 2-3 % of infants develop cow's milk allergy (CMA). Treatment consists of eliminating milk from the diet. Some studies have shown growth failure in children with CMA and a milk-free diet. OBJECTIVES: To evaluate growth status at 1 and 2 years of age in infants diagnosed with CMA. MATERIAL AND METHODS: An observational, longitudinal, retrospective study of all infants diagnosed with CMA from 2000-2001 was performed. The following data were analyzed: chronology and type of feeding, the presence of allergy to other foods, atopic dermatitis or other symptoms of allergy, duration of CMA, and anthropometric data (weight and height) at diagnosis, and at 1 and 2 years of age. Anthropometric data were expressed as Z-scores. RESULTS: A total of 141 infants (71 boys and 70 girls) were studied. Atopic dermatitis was found in 67 infants (47.5%) and wheezing in 36 (25.5%). Allergy to foods other than milk was found in 27%. Only 21.3% of the infants grew out of CMA at the age of 2 years, of which 37% did so in the first year of life. Z-scores for weight were -0.5 at birth, -0.25 at the first follow-up visit, -0.25 at 1 year, and -0.19 at 2 years. Z-scores for height were 10.26 at the first follow-up visit, 10.64 at 1 year, and 10.35 at 2 years. A significant difference in Z scores for weight was found in infants with allergies to other foods, atopic dermatitis or wheezing compared with those with CMA only. CONCLUSIONS: Infants with CMA receiving a substitute formula (hydrolyzed or soy formulae) showed normal weight and height at 2 years, although the percentile for height tended to be better than that for weight. The presence of other food allergies, atopic dermatitis or wheezing seems to affect the nutritional status of infants with CMA.

¿Cómo crecen los lactantes diagnosticados de alergia a proteínas de leche de vaca? / A follow-up study of growth in infants with cow’s milk allergy

Introducción: Aproximadamente el 2-3 % de los lactantes sufren alergia a proteínas de leche de vaca (APLV). El tratamiento consiste en su eliminación de la dieta. Algunos estudios han demostrado una disminución del crecimiento en aquellos niños con APLV y dieta exenta en lácteos. Objetivos: Evaluación del crecimiento al año y a los 2 años de edad de una cohorte amplia de lactantes diagnosticados de APLV. Material y métodos: Estudio observacional, longitudinal y retrospectivo de todos los lactantes diagnosticados de APLV en el período 2000-2001. Se recogieron datos relativos a la cronología y tipo de alimentación, presencia de alergia a otros alimentos, dermatitis atópica u otros síntomas de alergia, duración de la APLV y datos antropométricos (peso y talla) en el momento del diagnóstico, al año y 2 años de edad. Los datos antropométricos se expresan como puntuación Z. Resultados: Fueron diagnosticados de APLV 141 niños (71 niños y 70 niñas). Un total de 67 niños (47,5 %) presentaron dermatitis atópica y 36 (25,5 %) sibilancias. El 27 % tuvo alergia a otros alimentos además de la leche. Sólo el 21,3 % de los niños habían superado la APLV a los 2 años de edad, de los que el 37 % lo hicieron en el primer año. La puntuación Z para el peso fue ­0,5 al nacimiento, ­0,25 en la primera visita; ­0,25 al año y ­0,19 a los 2 años. La puntuación Z para la talla fue de 10,26, 10,64 y 10,35 en el momento del diagnóstico, al año y a los 2 años de edad, respectivamente. La alergia a otros alimentos, la presencia de dermatitis atópica o de sibilancias resultaron en una diferencia significativa de la puntuación Z del peso con respecto a los que sólo presentaron alergia a APLV. Conclusiones: Los niños con APLV que toman una fórmula de sustitución (hidrolizado o preparado de soja) tienen, a los 2 años de edad, un desarrollo ponderoestatural similar al de la población sana, aunque se apreció una tendencia a mejor percentil de talla que de peso. La multialergia alimentaria, así como la presencia de dermatitis o sibilancias, parecen ser factores que afecten al estado nutricional del niño con APLV

Introduction: Approximately 2-3 % of infants develop cow's milk allergy (CMA). Treatment consists of eliminating milk from the diet. Some studies have shown growth failure in children with CMA and a milk-free diet. Objectives: To evaluate growth status at 1 and 2 years of age in infants diagnosed with CMA. Material and methods: An observational, longitudinal, retrospective study of all infants diagnosed with CMA from 2000-2001 was performed. The following data were analyzed: chronology and type of feeding, the presence of allergy to other foods, atopic dermatitis or other symptoms of allergy, duration of CMA, and anthropometric data (weight and height) at diagnosis, and at 1 and 2 years of age. Anthropometric data were expressed as z-scores. Results: A total of 141 infants (71 boys and 70 girls) were studied. Atopic dermatitis was found in 67 infants (47.5 %) and wheezing in 36 (25.5 %). Allergy to foods other than milk was found in 27 %. Only 21.3 % of the infants grew out of CMA at the age of 2 years, of which 37 % did so in the first year of life. Z-scores for weight were ­0.5 at birth, ­0.25 at the first follow-up visit, ­0.25 at 1 year, and ­0.19 at 2 years. Z-scores for height were 10.26 at the first follow-up visit, 10.64 at 1 year, and 10.35 at 2 years. A significant difference in Z scores for weight was found in infants with allergies to other foods, atopic dermatitis or wheezing compared with those with CMA only. Conclusions: Infants with CMA receiving a substitute formula (hydrolyzed or soy formulae) showed normal weight and height at 2 years, although the percentile for height tended to be better than that for weight. The presence of other food allergies, atopic dermatitis or wheezing seems to affect the nutritional status of infants with CMA

[Geographic variation in the prevalence of asthma symptoms in Spanish children and adolescents. International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3, Spain]. / Variaciones geograficas en la prevalencia de sintomas de asma en los ninos y adolescentes espanoles. International Study of Asthma and Allergies in Childhood (ISAAC) fase III Espana.

OBJECTIVE: To analyze geographic variations in the prevalence of symptoms related to asthma in Spanish children and adolescents. POPULATION AND METHODS: In 2001 and 2002, the Spanish arm of the International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3 collected information on 28 445 children in the age bracket of 6-7 years in 10 metropolitan areas (A Coruña, Asturias, Barcelona, Bilbao, Cartagena, Castellón, Madrid, Pamplona, San Sebastián, and Valencia) and on 31 257 adolescents in the bracket 13-14 years in 11 areas (the previously named areas plus Valladolid). An asthma symptom questionnaire was filled in by parents or the adolescents themselves. Differences in symptoms between geographic areas were analyzed by fitting a logistic regression model. The relationship between symptoms and age was analyzed by linear correlation. RESULTS: The prevalence of recent wheezing (last 12 months) ranged from 7.1% to 12.9% among 6-7-year-olds and from 7.1% to 15.3% among the 13-14-year-olds. The greatest risk of recent wheezing was observed for children in A Coruña (odds ratio [OR] =1.96 in comparison with the area of lowest prevalence; 95% confidence interval [CI], 1.65-2.33) and Bilbao (OR=1.83; 95% CI, 1.54-2.18) and for adolescents in A Coruña (OR=2.38; 95% CI, 2.04-2.79) and Asturias (OR=2.37; 95% CI, 2.03-2.77). A strong correlation (r=0.72) was observed between the prevalence of recent wheezing and age in each of the geographic areas. CONCLUSIONS: Considerable geographic variation in the prevalence of asthma symptoms can be seen in Spain even among young children. Symptoms are more frequent in children and adolescents who live on the Spain s northern Atlantic coast.

Variaciones geográficas en la prevalencia de síntomas de asma en los niños y adolescentes españoles. International Study of Asthma and Allergies in Childhood (ISAAC) fase III España / Geographic variation in the prevalence of asthma symptoms in Spanish children and adolecents. International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3, Spain

Objetivo: Analizar las variaciones geográficas en la prevalencia de síntomas relacionados con el asma en niños y adolescentes españoles. Población y métodos: Durante los años 2001 y 2002, el International Study of Asthma and Allergies in Childhood (ISAAC) fase III estudió a 28.445 niños de 6-7 años de 10 áreas (A Coruña, Asturias, Barcelona, Bilbao, Cartagena, Castellón, Madrid, Pamplona, San Sebastián y Valencia) y 31.257 adolescentes de 13-14 años de 11 áreas (las anteriores más Valladolid) españolas. Los síntomas de asma se recogieron en un cuestionario escrito completado por los padres de los niños o por los propios adolescentes. Las variaciones geográficas de las prevalencias de los síntomas se analizaron con un modelo de regresión logística y su correspondencia por edad mediante correlación lineal. Resultados: La prevalencia de sibilancias recientes (últimos 12 meses) varió entre el 7,1 y el 12,9% a los 6-7 años, y entre el 7,1 y el 15,3% a los 13-14 años. El riesgo más elevado (odds ratio [OR] respecto al área de menor prevalencia) de presentar sibilancias recientes correspondió a los niños de A Coruña (OR = 1,96; intervalo de confianza [IC] del 95%, 1,65-2,33) y Bilbao (OR = 1,83; IC del 95%, 1,54-2,18) y los adolescentes de A Coruña (OR = 2,38; IC del 95%, 2,04-2,79) y Asturias (OR = 2,37; IC del 95%, 2,03-2,77). Se comprobó una fuerte correlación por edad en las prevalencias de sibilancias recientes de cada área geográfica (r = 0,72). Conclusiones: En España existen, desde edades tempranas, variaciones geográficas notables en la prevalencia de síntomas de asma. Éstos son más frecuentes en los niños y adolescentes que habitan en la fachada atlántica del país

Objective: To analyze geographic variations in the prevalence of symptoms related to asthma in Spanish children and adolescents. Population and Methods: In 2001 and 2002, the Spanish arm of the International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3 collected information on 28 445 children in the age bracket of 6-7 years in 10 metropolitan areas (A Coruña, Asturias, Barcelona, Bilbao, Cartagena, Castellón, Madrid, Pamplona, San Sebastián, and Valencia) and on 31 257 adolescents in the bracket 13-14 years in 11 areas (the previously named areas plus Valladolid). An asthma symptom questionnaire was filled in by parents or the adolescents themselves. Differences in symptoms between geographic areas were analyzed by fitting a logistic regression model. The relationship between symptoms and age was analyzed by linear correlation. Results: The prevalence of recent wheezing (last 12 months) ranged from 7.1% to 12.9% among 6-7-year-olds and from 7.1% to 15.3% among the 13-14-year-olds. The greatest risk of recent wheezing was observed for children in A Coruña (odds ratio [OR] =1.96 in comparison with the area of lowest prevalence; 95% confidence interval [CI], 1.65-2.33) and Bilbao (OR=1.83; 95% CI, 1.54-2.18) and for adolescents in A Coruña (OR=2.38; 95% CI, 2.04-2.79) and Asturias (OR=2.37; 95% CI, 2.03-2.77). A strong correlation (r=0.72) was observed between the prevalence of recent wheezing and age in each of the geographic areas. Conclusions: Considerable geographic variation in the prevalence of asthma symptoms can be seen in Spain even among young children. Symptoms are more frequent in children and adolescents who live on the Spain´s northern Atlantic coast