IgE antibody responses in young children with atopic dermatitis.

In 2184 young children aged 13-24 months with atopic dermatitis (SCORAD 5-59) serum IgE antibodies to a standard panel of food and inhalant allergens were assayed. The frequency of positive IgE responses (>0.35 kU/l) increased with greater severity of skin disease. A significant minority of infants had levels of IgE antibody to foods to suggest they were at risk of acute reaction to those foods (7% to hen's egg, 3% to cow's milk, 4% to peanut). Our findings indicate that the frequency of positive IgE responses is related to disease severity and suggest that differences in the time course of the development of IgE responses to food, which are at maximum prevalence within the first year of life, while inhalant allergies, are still developing between 1 and 2 yr and beyond.

Corticosteroids (inhaled and/or intranasal) in the treatment of respiratory allergy in children: safety vs. efficacy.

BACKGROUND: Topical administration of Corticosteroids (CS) can reduce the total dose of CS required to treat the patient and minimize side effects. Topical CS is extremely effective and has an excellent safety profile. Nonetheless, care must be taken when multiple sites such as lungs, nose and skin are being treated. CS mechanisms of action on the inflammatory process are complex. The aim of this study is to review such mechanisms and the adverse events secondary to it. METHODS: Review English database (Embase, PubMed, Scielo) searching words: CS, adverse events, inhaled CS, intranasal CS, and children. RESULTS: There is a classic mechanism involving a genomic effect of CS and a non-genomic effect, independently of gene transcription process. This mechanism acts by reducing mucosal blood flow in the asthmatic airways. Second-generation topical CS is the treatment of choice in allergic diseases control because of their good anti-inflammatory activity, poor absorption and first-pass hepatic metabolism. When comparing different CS, it is important to compare therapeutically equivalent doses. Although topical CS reduces systemic side effects, local and even systemic side effects can occur. Many factors affect the amount of drug that reaches the lung, including inhaler technique and inhaler type, fine particle dose and particle distribution. CONCLUSION: Most patients with allergic diseases respond to CS treatment, but there is a small subset of them whose response is unsatisfactory even with high doses of CS. They are classified as corticosteroid-resistant asthmatics. Pro-inflammatory cytokines appear to up regulate the expression of GRb that has been associated with CS resistance.

Prevalence of symptoms of asthma, rhinitis, and atopic eczema in Brazilian adolescents related to exposure to gaseous air pollutants and socioeconomic status.

OBJECTIVES: To evaluate the relationship between exposure to gaseous air pollutants (ozone [O3], carbon monoxide [CO], nitrogen dioxide [NO2], and sulfur dioxide [SO2]) socioeconomic status and the prevalence of symptoms of asthma, rhinitis and atopic eczema in adolescents. SUBJECTS AND METHODS: A sample of 16 209 adolescents from São Paulo West (SPW), São Paulo South (SPS), Santo André (SA), Curitiba (CR), and Porto Alegre (PoA) were enrolled. Data on air pollutants and socioeconomic status were compared to prevalence of symptoms with the Spearman correlation coefficient. RESULTS: Socioeconomic status was quite similar in all cities. The levels of O3 in SPW, SPS, and SA, and of CO in SA were higher than the acceptable ones. In relation to O3 and CO exposures, adolescents from SPW and SA had a significant risk of current wheezing, whereas living in SPW was associated with a high risk of rhinoconjunctivitis, eczema, and flexural eczema and living in CR to rhinitis. Exposure to NO2 was associated with a high risk of current wheezing in SPW and SA, and of severe asthma in SPW and PoA. Exposure to SO2 was associated with a high risk of current wheezing in SPW and SA, severe asthma in SPW and PoA, and nighttime cough, eczema, flexural eczema and severe eczema in SPW. Living in SPW, CR, or PoA was associated with a high risk of rhinitis, rhinoconjunctivitis, and severe rhinitis. CONCLUSIONS: Although we did not detect a characteristic pattern for all symptoms evaluated or a specific air pollutant, our data suggest a relationship between higher exposure to photochemical pollutants and high prevalence or risk of symptoms of asthma, rhinitis, and atopic eczema.

Changes in the prevalence of asthma and allergic diseases among Brazilian schoolchildren (13-14 years old): comparison between ISAAC Phases One and Three.

The present study is aimed to describe the changes in the prevalence of symptoms of asthma, rhinitis and eczema among Brazilian adolescents (AD, 13-14 years old) between Phases 1 and 3 of the International Study of Asthma and Allergies in Childhood (ISAAC). The prevalence of self-reported symptoms of asthma, rhinitis and eczema in AD from five Brazilian cities (Curitiba, Porto Alegre, Recife, Salvador and São Paulo), obtained during ISAAC Phase 1 (n = 15 419) and Phase 3 (n = 15 684), was compared to determine the trend of prevalence in a 7-year interval. There was a trend to reduction in the current prevalence of wheezing and increasing of nocturnal cough when averaging figures from the five cities. The prevalence of wheezing in the last 12 months was 27.7 vs. 19.9% (p < 0.01); asthma ever 14.9 vs. 14.7% (p > 0.05); severe episode of wheezing 5.2 vs. 5.2%; nocturnal cough 32.6 vs. 34.9% (p < 0.01); exercise wheezing 23.6 vs. 23.0% (p > 0.05) and awake with wheezing 11.8 vs. 11.2% (p > 0.05). Similar things were observed with the prevalence of current symptoms of rhinitis and eczema. In Brazil, there was a small but significant mean decrease in the prevalence of two asthma-related symptoms, wheezing and nocturnal cough, though this trend was not consistent in the surveyed cities. The prevalence of asthma symptoms in Brazil, despite its mean trend to a decrease, is still one of the highest in Latin America.

Antibody response to pneumococcal capsular polysaccharide vaccine in Down syndrome patients.

The majority of children with Down syndrome (DS) tend to have frequent bacterial infections including recurrent respiratory infections. Our objective was to evaluate the production of antibodies to pneumococcal polysaccharide antigens after active immunization in DS subjects. IgG antibodies to pneumococcal serotypes (1, 3, 6B, 9V, and 14) were measured before and 6 weeks after immunization with a 23-valent pneumococcal vaccine (Pneumo23, Pasteur-Merrieux) in 6- to 13-year-old DS children (N = 17) and in aged-matched normal controls (N = 30). An adequate response was defined as a 4-fold increase over baseline or a post-immunization level of specific pneumococcal serotype antibody > or = 1.3 microg/mL. After immunization, all DS children had an increase in post-immunization levels against all serotypes analyzed. A 4-fold or more increase was observed in all DS children concerning serotypes 1 and 14, in 90% of subjects for serotypes 3 and 9V, and in 65% for serotype 6B. Regarding this increase, 8 of the 17 DS children had an adequate response to all serotypes analyzed, 8/17 patients to 4 serotypes and 1/17 to 3 serotypes. However, when we compared post-immunization levels between DS children and controls, we observed lower levels in the former group (P < 0.05) for all serotypes except serotype 3. We conclude that pneumococcal polysaccharide immunization could be beneficial for these DS children.

Childhood tuberculosis diagnosed and managed as asthma: case report.

The worldwide incidence of tuberculosis (TB) has been increasing. Although its diagnosis is well established in adults, in children it is difficult due to its particular aspects. We report a 3 years and 8 month-old infant who experienced chronic wheezing, classified as moderate-to-severe asthma, had recurrent pneumonia, and was not responsive to management with beta adrenergic agents. Chest X-rays (CXR) showed heterogeneous condensation in medium lobe and the chest computerized-tomography scan (CCT) a heterogeneous increase in pulmonary transparency, like condensation in the same lobe. After four months of treatment with anti tuberculosis agents, a significant improvement in symptoms, normal CXR, absence of pulmonary medium lobe condensation, and persistence fibro-atelectatic band in lingula were observed.

Antibody response to pneumococcal capsular polysaccharide vaccine in Down syndrome patients

The majority of children with Down syndrome (DS) tend to have frequent bacterial infections including recurrent respiratory infections. Our objective was to evaluate the production of antibodies to pneumococcal polysaccharide antigens after active immunization in DS subjects. IgG antibodies to pneumococcal serotypes (1, 3, 6B, 9V, and 14) were measured before and 6 weeks after immunization with a 23-valent pneumococcal vaccine (Pneumo23®, Pasteur-Merrieux) in 6- to 13-year-old DS children (N = 17) and in aged-matched normal controls (N = 30). An adequate response was defined as a 4-fold increase over baseline or a post-immunization level of specific pneumococcal serotype antibody > or = 1.3 æg/mL. After immunization, all DS children had an increase in post-immunization levels against all serotypes analyzed. A 4-fold or more increase was observed in all DS children concerning serotypes 1 and 14, in 90 percent of subjects for serotypes 3 and 9V, and in 65 percent for serotype 6B. Regarding this increase, 8 of the 17 DS children had an adequate response to all serotypes analyzed, 8/17 patients to 4 serotypes and 1/17 to 3 serotypes. However, when we compared post-immunization levels between DS children and controls, we observed lower levels in the former group (P < 0.05) for all serotypes except serotype 3. We conclude that pneumococcal polysaccharide immunization could be beneficial for these DS children.

Avaliação espirométrica de crianças e adolescentes asmáticos acompanhados em ambulatório especializado / Spirometric evaluation of asthmatic children and adolescents followed in specialized out-patient clinic

Objetivo: descrever características espirométricas de crianças e adolescentes asmáticos acompanhados em ambulatório especializado. Métodos: cem asmáticos maiores de seis anos foram aleatoriamente convidados para o estudo. Sete recusaram-se a participar. Testes de função pulmonar (FP) foram realizados pela manhã (espirômetro Vitalograph®), quando os pacientes estavam livres de infecções respiratórias há pelo menos duas semanas e após suspensão de broncodilatadores de curta elonga ação. Foram obtidas curvas de fluxo-volume antes e 15 minutos após inalação de 400g de salbutamol. Doze pacientes não foram capazes de realizar curvas reprodutíveis. Resultados: a mediana de idade, foi 11,5 anos. Dezenove pacientes apresentavam asma intermitente (AI), 24 asma persistente leve (APL), 22 asma persistente moderada (APM) e 16 asma persistente grave (APG). As medianas dos valores basais de FP para AI, APL, APM e APG foram respectivamente: capacidadevital forçada (CVF): 96 per cent, 88 per cent, 84 per cent e 90 per cent; volume expiratório forçado no primeiro segundo (VEF1): 84 per cent, 82 per cent, 73 per cent e 65 per cent; fluxo expiratório forçado entre 25 per cent e 75 per cent da CVF (FEF25-75 per cent): 78 per cent, 66 per cent, 60 per cent e 43 per cent. Houve aumento significante nos valores de FP após salbutamol para todos os parâmetros avaliados. Não houve correlação entre a gravidade da asma e o incremento de FP após salbutamol. O FEF25-75 per cent foi o parâmetro que melhor discriminou a gravidade da asma e que indicou alterações funcionais em maior número de casos. Nãohouve correlação entre o tempo de doença e os valores de FP. Conclusões: a espirometria é útil na avaliação de crianças e adolescentes asmáticos. O FEF25-75 per cent é o parâmetro mais sensível para a avaliação da gravidade da doença.

Nasal provocation test (NPT) with isolated and associated dermatophagoides pteronyssinus (Dp) and endotoxin lipopolysaccharide (LPS) in children with allergic rhinitis (AR) and nonallergic controls.

BACKGROUND: Inhalation of endotoxin may enhance inflammatory airway response in sensitized asthmatics persons after allergen(s) inhalation. OBJECTIVE: To evaluate nasal response to intranasal instillation of Dermatophagoides pteronyssinus (Dp), endotoxin (LPS), and to Dp+LPS in children with perennial allergic rhinitis (PAR). METHODS: 10 PAR children (positive skin prick test to Dp) and 10 nonallergic controls (C) undergoing nasal provocation test (NPT), who were quantified by active anterior rhinomanometry and measurement of Total Nasal Resistance (TNR). The NPTs were initially performed with histamine (H; 0.03 to 16.0 mg/mL), and then, at least at weekly intervals, the NPTs were done with Dp (1/100,000 to 1/2.5), LPS (1 to 500 mg/mL) and to Dp+LPS. During NPT with Dp+LPS, Dp concentration was kept constant (1/100,000; 1/10,000; 1/1,000) and was combined with different concentrations of LPS (1, 5, 10, 20 mg/mL). The NPT was considered positive when TNR reached twice the basal TNR. RESULTS: H and Dp NPTs were positive in all AR children. In group C, H NPT was positive in 60% and Dp NPT was negative in all children. NPT with LPS was positive only in 30% of the AR children. NPT with Dp+LPS was positive in 90% of the AR patients in Dp concentration of 1/1,000 and in LPS concentrations of 5, 10, and 20 mcg/ mL. This positive association was observed with Dp concentrations lower than those obtained during NPT with Dp in 60% of AR patients. There were no changes in pulmonary function tests in all children after NPT. CONCLUSIONS: This study suggests that LPS enhances the effects of allergen challenges on nasal airflow. The daily inhalation of allergens plus endotoxin in AR patients does increase the nasal responsiveness.

Prevalence of rhinitis and related-symptoms in schoolchildren from different cities in Brazil.

By using the standard written questionnaire (WQ), designed for the International Study of Asthma and Allergies in Childhood (ISAAC) we determined the prevalence of rhinitis and its related-symptoms, in Brazilian children and adolescents, living in different cities of the country. The WQ was answered by the parents of 11,403 children aged 6-7 years from five Brazilian cities: Porto Alegre (South, N = 2,846), São Paulo (Southeast, N = 3,005) Uberlândia (Southeast, N = 2,991), Itabira (Southeast, N = 1,151) and Recife (Northeast, N = 1,410). The WQ was also applied to 20,587 adolescents (13-14 years old) living in: Porto Alegre (South, N = 3,195), Curitiba (South, N = 3,004), São Paulo (Southeast, N = 3,008), Uberlândia (Southeast, N = 2,998), Itabira (Southeast, N = 2,134), Salvador (Northeast, N = 3,162) and Recife (Northeast, N = 3,086). The mean response rates were 75% and 95%, for the 6-7 year-old children and for the adolescents, respectively. The data was transcribed to a database (Epi-Info) and analyzed regarding the answers to questions of rhinitis module. The mean prevalence of rhinitis (affirmative response to question 2) was 26.6% and 34.2% in the groups of 6-7 and 13-14 year-old, respectively. Applying the criteria that evaluate the association between nasal and ocular symptoms (affirmative response to question 3) the mean prevalence of allergic rhinitis were 12.8% for the 6-7 year-old children and 18.0% for the adolescents. In conclusion, the prevalence of rhinitis and its related symptoms among children and adolescents living in different Brazilian cities was as high as the prevalence observed in other areas of the world.

IGF-I, IGF-BP3, and GH serum levels after stimulation tests in prepubertal allergic boys.

The prevalence of short stature (SS, < 3rd percentile NCHS) among children with respiratory allergy (asthma and/or rhinitis) varies from 2% to 10%. In spite of several studies, the etiology of SS in those patients remains unknown. We evaluated growth hormone (GH) serum levels in response to two stimulating tests (standardized exercise and clonidine) in prepubertal boys (G1P1, Tanner; 8 years and 5 months to 14 years) with SS, 14 of them with respiratory allergy (A, positive skin prick test to D. pteronyssinus) and 5 nonallergic children (NA). Other causes of SS were excluded in both groups. Patients had mild asthma and/or rhinitis, and they had never received inhaled or systemic corticosteroid at any time. Tests were performed on different days, at least 1 week apart. [To prevent exercise-induced asthma, 30 min before the exercise test, allergic children inhaled disodium cromoglycate (2 mg)]. GH serum levels (Immunoassay, AIA-PACK HGH, Tosoh Co, Japan) were determined at the following times: exercise (E)--basal, 5, 15, and 30 min after exercising for 6 min; clonidine (C)--basal, 30, 60, and 90 min after clonidine (0.15 mg/m2 body surface) ingestion. A response was considered positive when GH serum levels reached the minimum of 10 ng/ml. Among (the allergic) A patients, four responded to both tests, five to C (clonidine) alone, four to E (exercise) alone and one had no response. Among NA, four had a positive response to both tests and one to C (clonidine) alone. The serum levels of insulin-like growth factor I (IGF-I) (DSL-5600 Active TM IGF-I Coated-Tube IRMA [DSL Lab Inc, USA]) and its binding protein (IGF-BP3) (DSL-6600 Active TM IGF-BP3 Coated-Tube IRMA [DSL Lab Inc, USA]) were within the normal range except for one A child. Bone age was delayed in relation to chronological age in all children, but adequate for height age. All children had delayed skeletal age in relation to chronological age, but bone age was normal for height. We concluded that in the children studied a deficiency of GH does not seem to be responsible for SS.

Asthma and respiratory disease mortality rates in the state of Sao Paulo, Brazil: 1970-1996.

BACKGROUND: Asthma morbidity and mortality have been increasing. Data of asthma and respiratory mortality rates in Brazil are scarse. METHODS: We studied asthma and respiratory disease mortality rates in the state of So Paulo (capital and country side) from 1970 to 1996, as its relation with sales of drugs usually used in asthma treatment. RESULTS: Asthma mortality in the 5-34-year age group has doubled in the state of So Paulo (0.2 deaths/100,000 inhabitants in 1970 to 0.4 in 1996), mainly by its increase in the capital. The greatest increase was observed in the population of up to 15 years of age. The sales of inhaled anti-inflammatory drugs are proportionally very low and reflect a greater concern about the treatment of acute exacerbations. CONCLUSION: We believe that the institution of a public health supply to the whole population could provide better conditions for the control of those indexes.

Barriers to measuring and achieving optimal outcomes in pediatric asthma.

To measure the effectiveness of any therapeutic endeavor, a set of defined outcome measurements must be performed, or the task of determining the effectiveness of any therapeutic step becomes difficult. With asthma, however, in which case it is difficult to establish the initial diagnosis, beginning a program of outcome measurements regarding any therapeutic interaction is nearly impossible. Conventional means are thwarted at the outset. One way of approaching the problem of obtaining reproducible outcomes data is to examine those areas in which measurements can be made and determine the barriers to obtaining the data. Establishing a good medical history is a critical step that, in general, is especially difficult with very young children, and tools that provide objective measurements that are used in the normal evaluation of older children are of little use in the very young child with asthma. Parts of the physical examination are difficult to perform in very young children, and findings associated with asthma can be found in other clinical states. In this age group, diary keeping suffers from the same problems and issues that are related to obtaining an accurate medical history. Barriers also exist to obtaining the best outcomes. The choice of medications for the very young child is limited; there are several typical adherence problems, and information about adverse effects is limited.

International Study of Asthma and Allergies in Childhood: validation of the rhinitis symptom questionnaire and prevalence of rhinitis in schoolchildren in São Paulo, Brazil.

Written questionnaires (WQ) have been widely used in epidemiologic studies. In order to yield comparable results, they must be validated after translation to another language. The International Study of Asthma and Allergies in Childhood (ISAAC) WQ has been previously validated by a comprehensive study, but its validation in Brazil has not been performed. Our objectives were to validate the rhinitis component of the ISAAC's self-applicable WQ following its translation to Portuguese, and to determine the prevalence of rhinitis and related symptoms among Brazilian children living in the city of São Paulo. A group of 10 pediatricians and 10 pediatric allergists graded the questions from 0 to 2 and established a maximum score for each question. The WQ was answered by parents or guardians of children 6-7 years of age with rhinitis (R) (n = 27) and of control children of the same age without rhinitis (C) (n = 27). The WQ was also completed by adolescents 13-14 years of age with rhinitis (R) (n = 32) and without rhinitis (C) (n = 32). Half of these individuals answered the same WQ after 2-4 weeks, to ensure reproducibility. Cut-off scores of 4 and 3 were identified for the 6-7- and 13-14-year-old groups, respectively, as scores predictive of rhinitis. The prevalence of rhinitis was 28.8% in the group of 3005 children 6-7 years of age and 31.7% in the group of 3008 children 13-14 years of age, respectively. Using the global cut-off score, these prevalences were even higher, in the order of 34.7% and 40.7%, respectively. In conclusion, the rhinitis component of the ISAAC WQ was proven to be reproducible, adequate and able to discriminate children and adolescents with and without rhinitis, and revealed that the prevalence of rhinitis among Brazilian children living in the city of São Paulo was as high as the prevalence of rhinitis in other areas of the world.

Specific and non-specific nasal provocation tests in children with perennial allergic rhinitis.

BACKGROUND: nasal provocation tests (NPT) have been extensively used in clinical practice to evaluate chronic rhinopathies, mainly allergic rhinitis (AR). METHODS: we submitted 10 perennial AR children (aged from six to 15 years) to histamine (H), Dermatophagoides pteronyssinus (Dp) and Blomia tropicalis (Bt) NPT. All children were sensitized (positive skin prick test, mean wheal > 3 mm) to both mites. Dp and Bt specific NPT were realized in two occasions, apart one week, always preceeded 24 hours by H challenge. Increased concentrations were applied to the nasal mucosa during each NPT: H (0,03 to 16 mg/ml), Dp (1/100,000 to 1 /2.5) and Bt (1/125,000 to 1/10). NPT were evaluated by clinical and rhinomanometric parameters (total score, TS), and by lung function tests. NPT was considered positive, when total nasal resistance (TNR) doubled in relation to basal value. RESULTS: H NPT was positive twice in 8/10 patients. Concordance between H concentration that induces a positive NPT measured by TNR or TS was observed. Regarding to specific NPT, 90 % of patients were positive to Dp and 60 % to Bt. There was no concordance between the allergen concentration that induces a positive SPT and a positive NPT, considering the different concentrations. There were no modification in lung function tests during both specific and non-specific provocation tests. CONCLUSIONS: NPT with H is an objective and reproducible method which allow evaluate nasal reactivity. Specific NPT have restricted indications, mainly when there where doubts about AR's etiology.

Cow's milk protein intolerance and chronic constipation in children.

Cow's milk protein (CMP) allergy was investigated in 25 children (age-range 3 months to 11 years) with chronic constipation. A diagnosis of constipation was made on the basis of a history of painful elimination of hard stools for at least 1 month, whether or not associated with a reduced frequency of stools or soiling. The children were evaluated using clinical parameters and the following laboratory tests: total serum immunoglobulin E (IgE); specific IgE (radioallergosorbent test [RAST]) for whole cow's milk, alpha-lactoalbumin, beta-lactoglobulin, and a food group; and skin-prick tests with whole milk, alpha-lactoalbumin, beta-lactoglobulin, and casein. Following the evaluation, the children were submitted to a CMP-free diet for a period of 4 weeks. In seven patients (28%), constipation disappeared during the CMP-free diet and reappeared within 48-72 h following challenge with cow's milk. In two infants a rectal biopsy revealed allergic colitis and they therefore did not undergo the challenge. High serum levels of total IgE were observed in five of the children who showed a clinical improvement (71%), a positive skin-test in two (29%), and detectable specific IgE in two (29%). These results suggest that CMP allergy or intolerance should be considered as a cause of chronic refractory constipation in children, although the underlying mechanism still require further investigation.

Inhaled budesonide for the treatment of acute wheezing and dyspnea in children up to 24 months old receiving intravenous hydrocortisone.

BACKGROUND: Inhaled corticosteroids are highly effective in the treatment of asthma at all ages, and their use in younger children is increasing. There are no data currently available on the treatment of infants with acute wheeze and dyspnea with nebulized budesonide. OBJECTIVE: Our purpose was to assess the clinical effect of nebulized budesonide in infants with acute wheeze and dyspnea. METHODS: A prospective study was performed comparing the addition of nebulized budesonide 0.25 mg every 6 hours (group A, n = 32) and nebulized ipratropium bromide 0.1 mg every 6 hours (group B, n = 39) with the normal treatment regimen with intravenous fluid, hydrocortisone, and nebulized fenoterol. A clinical score was made at admission and every 12 hours. The score included wheezing and costal retraction (0-6) and respiratory rate (counts per minute). RESULTS: Seventy-one infants aged 3 to 24 months were studied (42 boys). A statistically significant reduction was seen in clinical score and respiratory rate in both groups 12 hours after admission. The children who received budesonide improved significantly faster than the children who received ipratropium bromide, and the hospitalization period was significantly lower in the budesonide group (66.4 hours) compared with the ipratropium bromide group (93 hours) (P <.01). Three patients from the budesonide group and 2 from the ipratropium bromide group were readmitted within the first 4 weeks. CONCLUSION: Treatment of infants with acute wheeze with nebulized budesonide is associated with faster clinical improvement and reduction in hospital stay period.