Nutritional risks in children with food allergy.

BACKGROUND: Food allergies (FA) are a growing problem in the pediatric population and clinical features differ according to the underlying immunological mechanisms. While the primary management strategy is to eliminate the culprit food from the diet, assessment of the potential nutritional risks of elimination is also an integral part of management. In cases that do not improve over time; if you have basic food allergies and multiple food allergies, this can also lead to negative nutritional consequences. The contribution of basic nutrients, economical and easily accessible foods to the diet, is critical and has an important place in meeting the daily adequate intake of many nutrients. In the presence of food allergy, it is necessary to meet the vitamins and minerals that cannot be obtained from allergic foods, with alternative sources or supplements. For example, insufficient calcium intake in cow's milk allergy (CMA), the most common FA in early childhood, is very likely if an alternative supplement has not been introduced. In the management of CMA, choosing the appropriate formula and/or supplement for the clinical characteristics of children, when necessary, has an important place. In conclusion, nutritional risk assessment of children with FA requires a comprehensive, detailed, and multidisciplinary approach.

Oral health status of asthmatic children using inhaled corticosteroids.

BACKGROUND: Due to the increase in the prevalence of asthma, especially in childhood, oral health problems arising from the use of asthma medications have become a major health concern. Inhaled corticosteroids are widely used since they are the cornerstone of asthma management. This study aimed to investigate the effects of inhaled corticosteroids on oral health and various factors regarding active ingredients in inhalers, inhaler-spacer device use, rinsing the mouth after administration of inhaler, oral hygiene practices and parents` education on dental caries susceptibility in young children with asthma. METHODS: Children with asthma who were treated with inhaled corticosteroids for at least 6 months were included in the study. A questionnaire related to demographic characteristics and oral health practices of children was conducted with parents and the children were examined using a dental mirror and probe under dental unit lighting after air-drying the teeth. RESULTS: Oral health status was evaluated in 115 children, 54 (42-66) months old, 61% male and 39% female with determination of dmft-dmfs, DMFT-DMFS, ICDAS II, plaque index and gingival index. No statistically significant difference was found between sugar-containing and sugar-free inhalers, duration of inhaled corticosteroid use, inhaler-spacer device use, rinsing the mouth after administration of inhaler and dmft-dmfs, DMFT-DMFS, plaque and gingival index (p > 0.05). Long-term inhaled corticosteroid use was significantly associated with oral candidiasis (p=0.029). Also, the results showed that mothers` educational level had a significant effect on children`s oral health (p < sub > dmft/dmfs < /sub > < 0.001; p < sub > gingival index < /sub > =0.049; p < sub > plaque index < /sub > =0.005). CONCLUSION: Due to the effect of immunosuppression, long-term use of inhaled corticosteroids enhances the risk of development of the opportunistic pathogen candida. Regular dental visits and preventive dental treatments are needed in these patients for healthy oral status.

The relationship between oxidative stress markers in exhaled breath condensate and respiratory problems in patients with repaired esophageal atresia.

AIM: To evaluate the relationship between respiratory problems and oxidative stress markers in exhaled breath condensate (EBC) of patients with esophageal atresia (EA). METHODS: EA cases with respiratory problems were evaluated retrospectively for age, gender, the type of atresia, surgical treatment, outcome and respiratory symptoms. The results of gastroesophageal reflux (GER) treatment including the use of proton pump inhibitor (PPI) and fundoplication were also documented. EBC samples of 500-1000 µl were obtained by Ecoscreen machine in all cases. The levels of Glutathione (Glut), 8-isoprostane (8-iso), cysteinyl-leukotriene (Cys-LT) were measured with ELISA. Results were compared with healthy control subjects (CG, n = 26) and the relationship between oxidative stress markers and respiratory symptoms was evaluated. The results of GER treatment and oxidative stress markers in EBC were also correlated. RESULTS: Twenty-nine patients with a mean age of 8.8 years (3-14 years) were included. The male/female ratio was 16:13. The EA presented with distal fistula in 27 cases. While no fistula was observed in 1 case, both proximal and distal fistulae were present in another single case. Associated anomalies, most of which were cardiovascular anomalies, were observed in 65.5% (n = 19) of cases. The median Glut level was 1.03 mM/ml (0.93-1.15), iso-8 was 38.8 pg/mL (32.03-76.2) and Cys-LT was 0.44 pg/mL (20.17-61.3) in patients with EA. The median levels of oxidative markers in CG were 1.23 mM/mL (1.13-1.36), 66.3 pg/mL (33.5-106.7), and 56.9 pg/mL (27.4-80.1), respectively. Glut levels were significantly lower in EA cases compared to CG (p = 0.01). There was no significant difference between the groups regarding 8-iso and CYS-LT levels (p = 0.9, p = 1.0). Cys-LT levels were significantly lower in patients with PPI treatment [21.7 pg/mL (18.6-48.1)], when compared to patients without PPI treatment [41.1 pg/mL (22.5-83.1)] (p = 0.04) and healthy subjects [56.9 pg/mL (27.4-80.1)] (p = 0.017). The 8-iso levels were significantly decreased in cases with fundoplication compared to the patients without fundoplication (p = 0.02). CONCLUSION: Glut - an antioxidant agent - levels were significantly lower in EBC of EA cases. The decrease in Cys-LT levels in cases with PPI treatment and in 8-iso levels in patients with fundoplication suggests that the oxidative damage in EBC of EA cases may be correlated with GER and its management. TYPE OF STUDY: Case control study LEVEL OF EVIDENCE: Level III.

A Rare Case of Pediatric Bullous Spontaneous Acute Urticaria.

OBJECTIVE: Acute spontaneous bullous urticaria is an extremely rare entity, and there are few reports with blister formation in acute urticaria patients. CLINICAL PRESENTATION AND INTERVENTION: We present a 2-year-old girl who was admitted for bullous spontaneous acute urticaria; the underlying reason for this was not detected. Nikolsky's sign and Darier's sign were negative. Lesions were not compatible with erythema multiforme. However, biopsy was not allowed to be performed. Because of this, the underlying pathogenesis could not be clarified. The patient recovered by a short course of antihistamine and systemic steroid treatment, and the lesions did not recur during a 2-year follow-up. CONCLUSION: Short-term systemic steroid in addition to oral antihistamines resulted in prompt recovery in a patient with acute urticaria complicated by bullae.

What a pandemic teaches us about vaccination attitudes of parents of children with asthma.

BACKGROUND: During the recent pandemic, Influenza A/H1N1 vaccine uptake remained far below the targeted rates. Associated factors regarding vaccine refusal in the general population have been reported in many studies, however the reasons behind refusals for asthmatic children have not yet been identified. We aimed to investigate Influenza A/H1N1 virus vaccine acceptance for children with asthma, to determine the attitudes and beliefs of parents concerning Influenza A/H1N1 disease and vaccine and to identify the association of asthma control parameters with vaccination. METHODS: The parents of asthmatic children aged 6-18 years participated in a cross-sectional survey study in three pediatric allergy outpatient clinics. The survey measured demographic factors, asthma control parameters, vaccination rates, and beliefs and attitudes regarding Influenza A/H1N1 vaccine. RESULTS: Of the 625 asthmatic children, 16.8% (n=105) were immunized with Influenza A/H1N1 and 45.7% (n=286) with seasonal influenza vaccine. Educational background of parents (p<0.001 and p=0.002, for father's and mother's educational level, respectively), previous vaccination with seasonal influenza (p<0.001), and having a family member vaccinated against Influenza A/H1N1 (p<0.001) had a significant influence on vaccine acceptance, while fear of side effects (88.6%) was the major parental reason for refusing the vaccine. Asthma control parameters had no influence on uptake of the vaccine. Physician recommendation (84.8%) was important in the decision-making process for immunization. The statement "Children with asthma should receive swine flu vaccine" increased the likelihood of being vaccinated [OR: 2.160, (95%CI 1.135-4.111), p=0.019]. CONCLUSION: Although asthmatic children are considered to be a high-priority group for Influenza A/H1N1 vaccination, we found low uptake of vaccine among our patients. Beliefs and attitudes rather than asthma control parameters influenced parental decisions for immunization. Understanding the underlying determinants for refusing the vaccine will help to improve vaccine campaigns in advance of a future outbreak.

Pepsin levels and oxidative stress markers in exhaled breath condensate of patients with gastroesophageal reflux disease.

AIM: To evaluate the pepsin and oxidative stress markers in exhaled breath condensate (EBC) in patients with gastroesophageal reflux disease (GERD). PATIENTS AND METHOD: Patients with a presumptive diagnosis of GERD with recurrent respiratory and gastrointestinal problems aged between 2 and 14 years were included in the study. All patients underwent pH monitoring. Patients with a reflux index (RI) ≥4 were assessed as the reflux group, and those with an RO <4 were assessed as the non-reflux group. Pepsin levels and oxidative stress markers [NO metabolites (NOX) and total sulphydrile (TSH) levels] were measured in the EBC. RESULTS: There were 24 patients in the reflux group [RI 17.6 (6.6-46.4)] [median, interquartile range] and 23 in the non-reflux group [RI 0.8 (0.5-1.9) (p<0.001). Pepsin levels in the EBC were below the level of detection. The median levels of NOx in the EBC of children with reflux [13.7 µmol/L (7.3-24.5)] were lower in than non-reflux group [21.0 µmol/L (14.0-25.2)] (p=0.034). There was a negative correlation between reflux index and NOX levels in EBC (rs: -0.331, p=0.023). In contrast, there was no difference in TSH levels between the reflux and non-reflux groups [37.4 µmol/L (30.2-44.6) vs 40.1 µmol/L (37.4-44.9), respectively, (p>0.05)]. CONCLUSION: Decreased levels of NOX in patients with GER disease suggest increased oxidative stress in airways of these patients.

Dysfunctional voiding in children with asthma.

A prospective study was performed to evaluate the prevalence of suspected dysfunctional voiding (DV) and associated risk factors in children with asthma. The DV is defined as any voiding symptoms and/or urinary incontinence. Children (4-10-year-old) with asthma (n=178) and healthy subjects (n=197) were enrolled. DV and Incontinence Scoring System were administrated. Demographic features and asthma related characteristics were recorded. Suspected DV was noted in 19 (27.9%) of patients with asthma and 5 (6.6%) of healthy subjects in children younger than 6 years of age (p=0.001). In this patient group, asthma increased the risk of suspected DV (OR=5.7 (95% CI 1.988 to 16.344)). Children with asthma older than 6 years of age had similar prevalence of suspected DV but they had higher frequency of voiding and urgency. Asthma is associated with higher DV symptom scores in younger children who have already completed toilet training and with some of DV symptoms such as frequency and urgency in older children.

Perceptions of parents and physicians concerning the Childhood Asthma Control Test.

BACKGROUND: The Childhood Asthma Control Test (C-ACT) has been proposed to be a simple, patient-based test that is able to reflect the multidimensional nature of asthma control. In this analysis, the aim was to evaluate the perceptions of physicians and caregivers concerning C-ACT and its predictive value for future asthma-related events. METHOD: In a multicenter prospective design, 368 children aged 4-11 years with asthma who were either well- or not well-controlled were included in the study. The study participants were evaluated during three visits made at 2-month intervals and the Turkish version of C-ACT was completed each month. Parents completed questionnaires concerning their perception of asthma (before and after the study) and the C-ACT (after the study). Physicians completed a survey about their perception of a control-based approach and the C-ACT. RESULTS: The C-ACT scores increased from visit 1 to visit 3, with improvement seen in all domains of the test. At the end of the study period, the parents more strongly agreed that asthma could be controlled completely and that asthma attacks and nocturnal awakenings due to asthma were preventable (p < .05). Most of the parents reported that the C-ACT helped them to determine asthma treatment goals for their children and also that the C-ACT improved communication with their physicians. The physicians indicated that a control-centered approach was more convenient (95%) and simpler (94.5%) than a severity-centered approach and provided better disease control (93.4%). A higher C-ACT score was associated with a decreased risk of asthma attack and emergency department admittance in the 2 months following the administration of C-ACT. Conclusion. Our findings indicated that the C-ACT improved both parental outlook on asthma control and the communication between the physician and parents. There was a good correlation between the C-ACT score and the level of asthma control achieved, as described by the physician. Additionally the C-ACT score was predictive of future asthma-related events. These findings suggest that the C-ACT may have an important role in asthma management in the future.

Alternative algorithm for L-asparaginase allergy in children with acute lymphoblastic leukemia.

BACKGROUND: L-asparaginase is a crucial chemotherapeutic agent for the treatment of acute lymphoblastic leukemia. The alternatives to L-asparaginase are not available in many parts of the world, including Turkey. OBJECTIVE: We sought to evaluate the utility of premedication with or without a desensitization protocol in children with acute lymphoblastic leukemia and systemic hypersensitivity reactions to Escherichia coli-asparaginase. METHODS: In this prospective study patients with systemic hypersensitivity reactions to E coli-asparaginase for whom we were unable to ascertain/provide other alternatives to asparaginase were either premedicated, desensitized, or both to receive their chemotherapy as E coli-asparaginase according to the severity of the hypersensitivity reaction. RESULTS: Nineteen patients (13 male patients) with a mean age of 7.4 +/- 4.7 years experienced a systemic hypersensitivity reaction to E coli-asparaginase during a 4-year period. Polyethylene glycol-asparaginase could be used for 3 patients. Eight of the remaining 16 children, who had experienced anaphylaxis, were premedicated and desensitized with E coli-asparaginase, and in 7 patients treatment was tolerated. The other 8 patients, with acute allergic reactions to E coli-asparaginase, were premedicated first, and 5 of them showed no reaction subsequently. Three of them demonstrated systemic hypersensitivity reactions again (anaphylaxis, n = 3), and premedication and desensitization with E coli-asparaginase resulted in anaphylaxis. Polyethylene glycol-asparaginase was administered uneventfully to the patients who could be provided it. CONCLUSION: E coli-asparaginase could be administered to more than half of the patients who had a hypersensitivity reaction, and all of these patients were able to receive their planned doses of asparaginase. In countries with shortages of alternative asparaginase preparations, our approach might be a suitable option.

Physicians' perception of childhood asthma in Turkey: more appropriate practice among female physicians.

BACKGROUND: Low levels of asthma control worldwide point to the possibility of sub-optimal management; therefore, documentation of physicians' perception is critical for future interventions. Our aim was to examine self-reported management abilities of Turkish physicians dealing with children with asthma, document the factors affecting appropriate decisions and compare the results with those of a previous survey. METHODS: Physicians were surveyed via a questionnaire aimed to document self-perceived asthma knowledge and attitudes in asthma management. RESULTS: The majority of physicians were male (63%) and examined 234 +/- 9 patients per week. Infrequent use of objective parameters in asthma diagnosis and attack severity assessment was reported and most preferred nebulized corticosteroids to the systemic form in acute asthma. Even though self-perceived overall asthma knowledge did not differ between genders (p = 0.098), male physicians scored higher than females for inhaled steroids for acute asthma (2.8 +/- 0.12 vs 2.17 +/- 0.2, respectively, p = 0.007), while female physicians recorded more frequent use of inhaled steroids for chronic asthma (3.72 +/- 0.08 vs 3.43 +/- 0.07, respectively, p = 0.006). Female physicians' scoring for "symptom control" as the main aim of asthma management was higher than that of their male counterparts (3.88 +/- 0.04 vs 3.65 +/- 0.06, respectively, p = 0.002). CONCLUSION: Although there were some discrepancies between guidelines and clinical practice, most applications of Turkish physicians dealing with children with asthma were appropriate. Interestingly, when scores of female versus male physicians were compared, it can be suggested that female physicians have a more appropriate perception of asthma, indicating a significant contribution of gender-related factors in clinical attitudes and beliefs.

The triad of nesidioblastosis, congenital neuroblastoma and glomerulocystic disease of the newborn: a case report.

Neuroblastoma is the most common malignant tumor of the newborn, comprising 20% of all malignancies encountered during the neonatal period. We herein report a newborn who was born after 29 weeks' gestation and died unexpectedly at the 12th hour of life with no response to vigorous cardiopulmonary resuscitation. Autopsy findings revealed a right pararenal mass; microscopic examination showed neuroblastoma. Although the pancreas was grossly normal, its microscopic sections revealed a reduced number of islets of Langerhans and dispersion of the islet cells throughout the exocrine cells of the pancreas, and immunocytochemistry for the pancreatic hormones confirmed the dispersion of the islet cells. Final pathologic interpretation thus concluded the presence of nesidioblastosis. Furthermore, microscopic examination of the kidney showed glomerulocystic disease. Although the association of congenital neuroblastoma and nesidioblastosis has recently been defined as a new complex, neurocristopathy, the triad of congenital neuroblastoma, nesidioblastosis and glomerulocystic disease of the newborn has not been reported previously. To our knowledge, our case is the first reported newborn presenting with this triad. In conclusion, the association of nesidioblastosis and/or renal glomerulocystic disease should be kept in mind when encountering a case of congenital neuroblastoma. However, whether the presence of glomerulocystic disease in association with those other neurocristopathic pathologies is a coincidental finding or shares a common pathophysiological mechanism remains to be determined.