Local allergic rhinitis in children: identification and characterization in a specialty outpatient clinic.

Summary: Background. Local Allergic Rhinitis (LAR) is a phenotype defined by rhinitis symptoms with negative responses to systemic sensitization tests but with an exclusively nasal allergic inflammatory response. Data on the pediatric age group is scarce, and no Latin American data has been published so far. Methods. Nasal Allergen Challenge (NAC) was performed with Dermatophagoides pteronyssinus and Blomia tropicalis in six- to 18-year-old patients diagnosed with rhinitis and no systemic sensitization. NAC was monitored using subjective parameters and acoustic rhinometry. The study aimed to identify LAR in child and adolescent subjects previously diagnosed with non-allergic rhinitis (NAR) in a Brazilian specialty outpatient clinic (Allergy and Immunology). Results. During the study period, we analyzed 758 skin prick tests (SPT). Of those, 517 (68.2%) were diagnosed with rhinitis. Among those, 18.4% (95/517) had a negative SPT, meeting the criteria for inclusion in the study. Twenty-five patients underwent NAC, and 40% (10/25) of them, previously considered to have NAR, had a positive test and were reclassified as having LAR. Based on the analyzed characteristics, clinically differentiating LAR from NAR was impossible. Conclusions. This study represents the first investigation of LAR in child and adolescent subjects in Latin America, contributing significantly to the understanding of its prevalence and characteristics in this geographic area. Among a subgroup of patients lacking systemic sensitization submitted to NAC, 40% (10/25) demonstrated a positive NAC with Dermatophagoides pteronyssinus and Blomia tropicalis, warranting their reclassification to LAR. NAC with multiple allergens has been proven safe and viable in pediatric populations, affirming its critical role in the accurate diagnosis of LAR.

Impulse oscillometry in the assessment of children's lung function.

PURPOSE: To review available evidence in the literature on impulse oscillometry in the assessment of lung function in children with respiratory diseases, especially asthma. DATA COLLECTION: Research in the Medline, PubMed, and Lilacs databases, with the keywords forced oscillation, impulse oscillometry, asthma and impulse oscillometry. RESULTS: The Impulse Oscillometry System (IOS) allows the measurement of resistance and reactance of airways and is used as a diagnostic resource. A significant association between the findings of the IOS and those of spirometry is observed. In asthma, the IOS has already been used to assess the bronchodilator response and the therapeutic response to different drugs and has shown to be a sensitive technique to evaluate disease control. There are limitations to this assessment, such as children with attention deficit and in some cases it is difficult to interpret the results from a clinical point of view. CONCLUSION: The IOS is a useful tool for the measurement of the lung function of children. It is an easy test, although its interpretation is not straightforward.

Acoustic Rhinometry in Nasal Provocation Tests in Children and Adolescents.

OBJECTIVES: To standardize acoustic rhinometry (AR) in nasal provocation tests (NPTs) with histamine in children and adolescents. PATIENTS AND METHODS: We performed a cross-sectional validation to compare AR with anterior active rhinomanometry (AAR) during histamine NPT in 20 children and adolescents with persistent allergic rhinitis and 20 controls. Changes in total nasal resistance (AAR) were compared with changes in nasal volume in the first 5 cm (V5). RESULTS: Compared with controls, patients with rhinitis had significantly higher mean total nasal resistance (0.34 Pa/cm3/s vs 0.21 Pa/cm3/s; P=.01) and lower mean V5 values (8.20 cm3 vs 9.24 cm3; P=.04) at baseline. The mean histamine concentration necessary to increase total nasal resistance by at least 100% was significantly lower in the rhinitis group than in the control group (0.72 mg/mL vs 2.4 mg/mL; P<.001). At the end of the NPT a mean increase of 126% in total nasal resistance and a mean decrease of 24.3% in V5 were observed in the rhinitis group. When compared with the AAR criteria, the highest sensitivity and specificity values were observed for a cutoff represented by a 19%-21% drop in V5. CONCLUSIONS: We found AR to be a feasible and sensitive tool for monitoring nasal response in children and adolescents undergoing histamine NPT. The best AR cutoff for ending the NPT was a 19%-21% drop in V5.

Gender differences in the relationship between body mass index (BMI) changes and the prevalence and severity of wheezing and asthma in the first year of life.

BACKGROUND: Rapid weight gain has been recently associated with asthma at school age, but its influence in respiratory symptoms during infancy is still unknown. METHODS: Answers from 6541 parents living in six different cities of Brazil to the International Study of Wheezing in Infants (EISL) questionnaire were analysed. Data from reported weight and height at birth and at one year were used to calculate BMI. Rapid body mass index (BMI) gain was defined by the difference in BMI superior to 1.0z and excessive by the difference superior to 2.0z. RESULTS: Rapid BMI gain was found in 45.8% infants and excessive in 24.4%. Boys showed a significantly higher BMI gain than girls. Girls with rapid BMI gain showed a significantly higher prevalence of hospitalisation for wheezing (8.8% vs. 6.4%; aOR: 1.4, 95%CI: 1.1-1.8), severe wheezing (18.1% vs. 15.0%; aOR: 1.3, 95%CI: 1.0-1.5) and medical diagnosis of asthma (7.5% vs. 5.7%; aOR: 1.3, 95%CI: 1.0-1.7). Girls with excessive BMI gain also had a significantly higher prevalence of hospitalisation for wheezing (9.8% vs. 6.7%; aOR: 1.5, 95%CI: 1.1-2.0) and severe wheezing (18.9% vs. 15.5%; aOR: 1.3, 95%CI: 1.0-1.6). No significant association was found among boys. CONCLUSIONS: The majority of the evaluated infants showed BMI gain above expected in the first year of life. Although more commonly found in boys, rapid and excessive BMI gain in the first year of life was significantly related to more severe patterns of wheezing in infancy among girls.

Prevalence of symptoms of eczema in Latin America: results of the International Study of Asthma and Allergies in Childhood (ISAAC) Phase 3.

BACKGROUND: The aim of the International Study of Asthma and Allergies in Childhood (ISAAC) was to evaluate the prevalence of symptoms of eczema among children living in different parts of Latin America. Data were from centers that participated in ISAAC Phase 3. METHODS: This was a cross-sectional questionnaire survey of 93,851 schoolchildren (6 to 7 years old) from 35 centers in 14 Latin American countries and 165,917 adolescents (13 to 14 years old) from 56 centers in 17 Latin American countries. RESULTS: The mean prevalence of current flexural eczema in schoolchildren was 11.3%, ranging from 3.2% in Ciudad Victoria (Mexico) to 25.0% in Barranquilla (Colombia). For adolescents, the prevalence varied from 3.4% in Santo André (Brazil) to 30.2% in Barranquilla (mean prevalence, 10.6%). The mean prevalence of current symptoms of severe eczema among schoolchildren was 1.5%, ranging from 0.3% in Ciudad Victoria, Toluca, and Cuernavaca (Mexico) to 4.9% in La Habana (Cuba). For adolescents, the mean prevalence was 1.4%, ranging from 0.1% in Mexicali Valley (Mexico) to 4.2% in Santa Cruz (Bolivia). These prevalence values are among the highest observed during ISAAC Phase 3. In general, the prevalence of current symptoms of eczema was higher among the Spanish-speaking centers for both schoolchildren and adolescents. CONCLUSION: Environmental risk factors must be evaluated in order to identify potential causes for the differences observed, even in centers from the same country.

International Study of Wheezing in Infants (EISL): validation of written questionnaire for children aged below 3 years.

BACKGROUND: The multicenter International Study of Wheezing in Infants (EISL) was developed to study the prevalence of recurrent wheezing and related risk factors in infants during the first year of life using a written questionnaire (EISL-WQ). OBJECTIVES: To constructively validate a modified, shortened version of the EISL-WQ in children up to 36 months of age in São Paulo, Brazil, and to verify its usefulness in diagnosing probable asthma in these children. METHODS: The parents of 170 infants aged 12 to 36 months answered the shortened EISL-WQ in an emergency room and were asked if their child was currently wheezing before a diagnosis was made by a physician. The consistency between parent perception and the physician's diagnosis was then evaluated. A second group (n = 55) participated in the validation of the short-term repeatability of the shortened questionnaire by completing it twice (mean interval, 23 days). RESULTS: There was good agreement between parent perception of wheezing and the physician's diagnosis following auscultation (Kappa statistic = 0.7; odds ratio = 38.33; 95% confidence interval, 15.8 to 92.8; P < .001); sensitivity (82.8%), specificity (85.0%), positive predictive value (81.5%), and negative predictive value (86.0%) were all high.The short-term repeatability of the shortened version of the EISL-WQ was also high (kappa > 0.75). Questions added to the shortened EISL-WQ improved the internal consistency of the original questionnaire (Cronbach alpha = 0.823, P < .001) and a high Youden index was found for patients defined as probable asthmatics. CONCLUSIONS: The shortened version of the EISL-WQ translated into Portuguese has high internal consistency, and is a valid, reliable, and reproducible instrument for obtaining data on wheezing in children below 36 months of age and for identifying those with probable asthma.

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.

Prevalence of atopic eczema and related symptoms in Brazilian schoolchildren: results from the International Study of Asthma and Allergies in Childhood (ISAAC) phase 3.

BACKGROUND: International comparisons of the prevalence of atopic eczema and related symptoms are scarce. The standardized protocol of the International Study of Asthma and Allergies in Childhood (ISAAC) facilitates investigation of prevalence all over the world. OBJECTIVE: To apply the ISAAC written questionnaire to evaluate the prevalence of atopic eczema and related symptoms among 6-7 year-old children and 13-14 year-old adolescents living in 20 Brazilian cities. METHODS: The ISAAC written questionnaire was filled in by 23,422 children aged 6-7 years and 58,144 adolescents aged 13-14 years living in 2 population centers in the north, 8 in the northeast, 1 in the midwest, 5 in the southeast, and 5 in the south. RESULTS: The prevalence of flexural eczema (itchy rash ever in characteristic places in the last 12 months) ranged from 5.3% to 13.0% for children and was lower among the adolescents (range, 3.4%-7.9%). Among children, the highest rates were observed in population centers in the northeast, mainly along the coast. Among adolescents the highest rates were observed in the north and northeast, mainly in Natal, Aracaju, and Vitória da Conquista. The northeastern countryside had higher prevalence rates of severe eczema (kept awake at night by this itchy rash in the last 12 months) in comparison to northeastern coastal centers. There was a significant correlation between the prevalence of flexural eczema and severe eczema for both age groups, separately (6-7 year-olds, prho= 0.756, P<.004; 13-14 year-olds, rho=0.874, P<.0001) or grouped (6-7 plus 13-14 years-olds, rho=0.696, P<.0001). CONCLUSION: The prevalence of eczema and related symptoms is variable in Brazil, where the highest prevalence is found in the north and northeast; on the other hand, a higher prevalence of severe eczema was observed in Brazilian centers in the south.

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.

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.