Prevalence and characteristics of children with mild intellectual disability in a French county.

BACKGROUND: Studies conducted on mild intellectual disability (MID) in children are infrequent and the prevalence rates vary widely. This study aimed to estimate the prevalence of MID in children in a French county (Isère), to describe the clinical signs and associated comorbidities, and to specify the aetiologies of this disability. METHODS: The target population was comprised of the 15 100 children born in 1997 residing in Isère County, France, in 2008. Our goal was to find the children in this group with MID diagnosed between 9 and 13 years of age. MID was defined as an overall IQ score of between 50 and 69 [International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)]; this definition was adjusted for the study by integrating confidence intervals so that the risk of IQ measurement relativity and possible discrepancy of scores could be taken into account. Children were identified through an administrative data source designed to assist disabled persons that contains health information, and an educational data source. Parents who agreed to let their children participate responded to an in-depth questionnaire on their child's medical and academic history. A genetic investigation was proposed for those children whose MID had an unknown aetiology. RESULTS: The preliminary selection included 267 children, resulting in a prevalence rate of 18 per 1000 (CI [15.6; 19.9]), within the expected mean. Of these 267 cases, 181 families agreed to participate in the study (68%). MID more often affected boys [male gender ratio = 1.4 (CI [1.2; 1.6])], low socioeconomic groups, and families with a history of intellectual disability. The clinical signs and comorbidities associated with MID were very frequent, with 54% spoken language disorders and 10% pervasive developmental disorder. Only 9% of the children had undergone a genetic investigation before the study. The known aetiology rate for MID was 19% among all the children who had had genetic tests performed. CONCLUSION: MID is an important public health issue based on its prevalence. The associated clinical signs and comorbidities may be warning signs of MID in case of learning difficulties. This study may help decision-makers to develop and organise screening and care for MID.

[Epidemiology and clinical characteristics of childhood parapneumonic empyemas]. / Epidémiologie et caractéristiques cliniques des complications suppuratives des pneumonies de l'enfant.

UNLABELLED: Several studies have reported an increasing incidence of childhood parapneumonic empyemas in various countries. AIM OF THE STUDY: The aim of our study was to estimate the annual incidence of complicated community-acquired pneumonias in children during a 9-year period in a French area and to describe the epidemiological and clinical characteristics of these complications. POPULATION AND METHODS: We have listed the children from 28 days to 15 years old, hospitalized in the 2 children hospitals of the Isere district for a community-acquired pneumonia complicated with a pleural empyema or a pulmonary abscess from 1995 to 2003. RESULTS: During the study period, 90 children were hospitalized for a complicated pneumonia including 83 pleural empyemas and 7 isolated lung abscess. The average number of cases was 4 per year from 1995 to 1998 then increased since 1999 to reach 34 cases in 2003, according to a linear model (P<0,001). The incidence of the complicated pneumonia, plotted to the paediatric population of the area has gone up from 0.5 per 100000 to 13 per 100000 children between 1995 and 2003. CONCLUSION: The incidence of the complicated pneumonias in children increased since 1999 in a French area. Additional investigations are necessary to identify the causes of this increase.

Alternative splicing of the human CDC25B tyrosine phosphatase. Possible implications for growth control?

CDC25B2, a protein tyrosine phosphatase closely related to the putative CDC25B oncogene, was identified in a Burkitt lymphoma cDNA library. CDC25B2 differs from CDC25B by a 14 residue insertion and a 41 residue deletion, which are both located in the amino-terminal region of the protein, upstream of the catalytic domain. Examination of the genomic sequence revealed that CDC25B1 (formerly B) and CDC25B2 are splice variants of the same gene. A third variant, CDC25B3, that carries both the 14 and the 41 residue sequences was also identified in the same cDNA library. All three variants were detected in a panel of human primary culture and cell lines, although at different levels. In primary fibroblasts and in HeLa cells the CDC25B expression is cell cycle regulated, reaching a maximum in G2-phase. In vitro, CDC25B1 phosphatase is slightly more active than CDC25B2 and B3. However, episomal overexpression of the three CDC25B variants in fission yeast reveals that in vivo, CDC25B2 is largely more active than either B1 or B3 (B2>B3>B1) both to complement a thermosensitive S pombe CDC25 activity and to act as a mitotic inducer. Alternative splicing of CDC25B may therefore contribute to the control of cell proliferation.

The bacterial cytolethal distending toxin (CDT) triggers a G2 cell cycle checkpoint in mammalian cells without preliminary induction of DNA strand breaks.

The bacterial cytolethal distending toxin (CDT) was previously shown to arrest the tumor-derived HeLa cell line in the G2-phase of the cell cycle through inactivation of CDK1, a cyclin-dependent kinase whose state of activation determines entry into mitosis. We have analysed the effects induced in HeLa cells by CDT, in comparison to those induced by etoposide, a prototype anti-tumoral agent that triggers a G2 cell cycle checkpoint by inducing DNA damage. Both CDT and etoposide inhibit cell proliferation and induces the formation of enlarged mononucleated cells blocked in G2. In both cases, CDK1 from arrested cells could be reactivated both in vitro by dephosphorylation by recombinant Cdc25B phosphatase and in vivo by caffeine. However, the cell cycle arrest triggered by CDT, unlike etoposide, did not originate from DNA strand breaks as demonstrated in the single cell gel electrophoresis assay and by the absence of slowing down of S phase in synchronized cells. Together with additional observations on synchronized HeLa cells, our results suggest that CDT triggers a G2 cell cycle checkpoint that is initiated during DNA replication and that is independent of DNA damage.

[Role of "subtle" ultrasonographic signs during antenatal screening for trisomy 21 during the second trimester of pregnancy: meta-analysis and CPDPN protocol of the Grenoble University Hospital]. / Quelle est la place des signes d'appels échographiques dits "mineurs" dans le dépistage prénatal de la trisomie 21 au 2e trimestre de la grossesse? Méta-analyse de la littérature et protocole du Centre pluridisciplinaire de Dignostic Prénatal (CPDPN) du CHU de Grenoble.

OBJECTIVE: A meta-analysis about subtle ultrasonographic signs in second trimester of pregnancy. MATERIALS AND METHODS: 196 articles dealing with the subject--from 1985 to July 2002--were studied. Data on the 11 reported signs were collected from 92 theoretically and/or statistically valid studies. Then, the studies were selected according to several criteria: isolated characteristic, defined thresholds, calculable sensitivity and specificity. After checking for homogeneity, a likelihood ratio was calculated for some of the signs. RESULTS: This meta-analysis of the second trimester ultrasonographic signs of Down's syndrome enabled us to estimate the likelihood ratio (LHR) of six signs. At 22 weeks'gestation (WG) these signs are: pyelectasis equal to or greater than 5 mm; nuchal fold thickness equal to or greater than 6 mm; persistence of choroid plexus cysts; shortness of the femur and humerus below the tenth percentile; hyperechogenic bowe; and nasal bone length less than 2.5 mm. CONCLUSION: These validated ultrasonographic signs are independent of nuchal translucency thickness at 12 WG and of maternal serum biochemistry. This allows to calculate a combinate risk for nuchal translucency, maternal serum biochemistry and second trimester ultrasonographic signs when they are validated.

[Can caesarean delivery prevent cerebral palsy? Medico-legal implications of a French ecological study]. / La césarienne peut-elle prévenir la paralysie cérébrale ? Implications médico-légales d'une étude écologique française.

OBJECTIVE: For a long time, the benefit of a caesarean delivery in the prevention of cerebral palsy (CP) has been put forward, which was based on the assumption that CP is due to asphyxia in more than 50 % of the cases. However, from register-based data, this rate has been estimated less than 4 %. The aim of this study was to evaluate whether the rate of caesarean sections for fetal indication was correlated with the prevalence rate of CP in a French county. PATIENTS AND METHODS: This was an ecological study of register-based prevalence estimates of children with CP (postnatal cases excluded) born between 1997 and 2003 in a French county compared with the rates of caesarean section for fetal distress obtained from the maternal and infant protection service of the county. RESULTS: Whilst the rate of caesarean section for fetal indication increased by 44% during the period studied, the prevalence of CP remained nearly stable around 1.5 per 1000 live births. There was no correlation between caesarean section and CP prevalence (r'=-0.36, P=0.43). DISCUSSION AND CONCLUSION: The present study was in accordance with the results of a recent meta-analysis which concluded that emergency and prophylactic caesarean deliveries were not efficient in the prevention of CP. Indication of caesarean delivery for foetal heart rhythm anomaly, which is the most relevant cause for the growing rate of caesarean sections, should be justified by additional examinations in ambivalent cases, in order not to consider it as defensive medicine, which is ethically and therefore juridically blameworthy.

[Schooling and care of mild intellectual disability children]. / Parcours scolaire et prise en charge médico-éducative des enfants avec déficience intellectuelle légère.

Studies on mild intellectual disability (MID) are scarce. The aim of this study was to describe the educational and medical care trajectories and their determinants in children with MID. The study population concerned children born in 1997 and resident in a French county (Isère) in 2008. MID was defined as an overall IQ score between 50 and 69. For the present study, this definition was adjusted by integrating the IQ confidence intervals so that the risk of IQ measurement relativity and possible score discrepancy could be taken into account. Of the 267 children included, 180 (67%) were identified through an institute that decides upon special education and allowances (MDPH) and 87 (33%) through the educational system. The parents of 181 children (68%) accepted to answer a telephone questionnaire, describing their child's educational and medical history. Children with MID frequently presented clinical signs and comorbidities. Educational trajectories were quite varied: a majority of the children (52.9%) were oriented toward sections with adapted general and professional education (SEGPA) after finishing primary school, a minority (41.3%) were oriented towards specialized schools, such as medical-educational institutions, and a small proportion of children (5.8%) stayed in ordinary school. Children followed the SEGPA orientation more frequently when a relative written language disorder was present, and autism-spectrum disorders or other clinical signs were absent. Concerning follow-up care and rehabilitation, children mostly took part in speech therapy (76.2%) and psychotherapy (55.8%). The French law dating from 2005, ensuring equal opportunity for people with disabilities, has borne fruit in the diversification of educational trajectories.

Nuclear tyrosine phosphorylation: the beginning of a map.

Tyrosine phosphorylation is usually associated with cytoplasmic events. Yet, over the years, many reports have accumulated on tyrosine phosphorylation of individual molecules in the nucleus, and several tyrosine kinases and phosphatases have been found to be at least partially nuclear. The question arises as to whether nuclear tyrosine phosphorylation represents a collection of loose ends of events originating in the cytoplasm or if there may be intranuclear signaling circuits relying on tyrosine phosphorylation to regulate specific processes. The recent discovery of a mechanism causing nuclear tyrosine phosphorylation has prompted us to review the cumulative evidence for nuclear tyrosine phosphorylation pathways and their possible role. While we found that no complex nuclear function has yet been shown to rely upon intranuclear tyrosine phosphorylation in an unambiguous fashion, we found a very high number of compelling observations on individual molecules that suggest underlying networks linking individual events. A systematic proteomics approach to nuclear tyrosine phosphorylation should help chart possible interaction pathways.

Prevalence and time trends of disabilities in school-age children.

BACKGROUND: Although the evolution of the prevalence of cerebral palsy is now well documented, much less is known about the evolution of the prevalence of other disabilities such as mental retardation, sensorial defects, autism and psychosis. The aim of this paper is to determine those trends. METHODS: A population-based survey was carried out in 1992-1993 in three French 'départments'. All disabled children born between 1976 and 1985 and receiving a special education and/or financial assistance were systematically registered. RESULTS: The comparison of three cohorts of children born in 1976-1978, 1979-1981 and 1982-1984 using the test for trend in proportion showed a significant decrease (P = 0.03) in the prevalence of severe mental retardation, after exclusion of Down syndrome. This decrease was significant for severe mental retardation associated with psychosis. The time trend prevalence for cerebral palsy increased (P = 0.03) but was irregular. The time trend prevalence of other disabilities (other motor defects, severe sensorial disabilities, autism and psychosis) did not change significantly. A detailed analysis of severe mental retardation and cerebral palsy was performed by geographical area, age at first registration and type of disability. CONCLUSION: The increase in prevalence of cerebral palsy is possibly due to earlier registration of disabled children. The decrease in prevalence of severe mental retardation does not seem to be due to recruitment bias, but there is a possibility of classification bias.

Autism and associated medical disorders in a French epidemiological survey.

OBJECTIVE: To estimate the prevalence of autism, to assess the strength of its association with specific medical disorders, and to test for a secular increase in its incidence. METHOD: An epidemiological survey was conducted among 325,347 French children born between 1976 and 1985 and living in three different French départements. Diagnosis, educational level, and associated medical conditions were abstracted from the records of children known to local educational authorities. Data were also pooled with those from another similar survey. RESULTS: One hundred seventy-four children (mean age: 11.6 years) with autism were identified. The prevalence rate was 5.35/10,000 (16.3/10,000 if other pervasive developmental disorders are included), with no difference according to geographical area or social class. Rates of medical conditions were as follows: 1.1% for tuberous sclerosis, 2.9% for chromosomal abnormalities including fragile X, 2.9% for cerebral palsy, 4.6% for sensory impairments, 0.6% for neurofibromatosis, 0.6% for congenital rubella, and 1.7% for Down syndrome. In the combined sample of 328 children with autism, the level and pattern of medical correlates were comparable, with tuberous sclerosis having a consistently strong association with autism. Prevalence rates were similar in successive birth cohorts. CONCLUSION: Medical disorders (excluding epilepsy and sensory impairments) accounted for fewer than 10% of the cases of autism. No secular increase in the prevalence of autism was found.

Use of CDC2 from etoposide-treated cells as substrate to assay CDC25 phosphatase activity.

Cyclin-dependent kinases (CDKs) regulate the key transition of the cell cycle in all organisms. In response to Etoposide (VP-16) induced DNA damage, cells undergo a G2-phase arrest resulting in the accumulation of inactive CDK1 (CDC2) kinase complexes. Here we report that upon Etoposide treatment CDC2 is phosphorylated on tyrosine 15 and is dephosphorylated and activated in vitro by recombinant CDC25 phosphatase. We also show that inactive CDC2 kinase from Etoposide-treated cells can be used as a substrate in a sensitive two-step assay of CDC25 phosphatase. This assay, which is very simple to set-up, is based on the monitoring of CDC2 kinase activity after CDC25-dependent dephosphorylation. It provides the possibility to use a highly physiological substrate in antimitotic drugs screening.

[An epidemic of cholera in the city of Pemba (Mozambique) in 1983]. / A propos d'une épidémie de choléra dans la ville de Pemba (Mozambique) en 1983.

The purpose of the epidemiological study about 205 suspected hospitalized cases of cholera was to determinate which model of transmission was the most important. From the results, we noticed that direct non-waterborne has been more frequent than waterborne transmission (mainly in the infection of family contacts of index cases). We also found that virulence of the Vibrio cholerae El Tor responsible was quite close of virulence of the Vibrio cholerae classical.

[Consumption of psychotropic drugs in the general population in the Isère district]. / La consommation de psychotropes en population générale dans le département de l'Isère.

At the request of social insurance system, we implement a Public Health research on psychotherapeutic drug use in a French county. By telephone interviews we carried out a retrospective random survey. 1,330 answers out of 2,000 telephone numbers were obtained. 14% of the adults of this county recognize psychotherapeutic drug use during the last three months. Those older than 65 years are three times more user than those less than 65 years, and only loneliness has been noticed as other risk factor. Characteristics of use are very different between elderly people and young people, and risks of tolerance are prevailing in the first group. So we suggest that more research, especially on risks of regular use in people older than 45 years, should been conducted.

[How to calculate the completeness of ascertainment of a morbidity register? Example of the Isere childhood handicap register in Grenoble, France]. / Comment calculer l'exhaustivité d'un registre de morbidité? L'exemple du registre des handicaps de l'enfant et observatoire périnatal de l'Isère.

BACKGROUND: It should no longer be necessary to demonstrate the importance of knowing the completeness of ascertainment for a morbidity register, particularly with respect to the interpretation of prevalence rates and their trends, but also when using register data for etiological studies. METHOD: The study covered 9 generations of children born between 1980 and 1988. All of these children lived in the Isère department in SouthEast France, and each of them had at least one major deficiency, according to the inclusion criteria laid down by the RHEOP ("Registre des Handicaps de l'Enfant et Observatoire Périnatal", in French, or Childhood Handicap Register and Perinatal Observatory). These children were recruited from four different data sources. The completeness of ascertainment of the register was estimated first by means of the capturerecapture method, based on two sources that were shown to be independent by the Wittes method. Following this, loglinear models were used. The advantage of this was the absence of restrictions involved in adhering to the necessary validity conditions before applying the capture-recapture method, and the possibility of introducing heterogeneity variables, such as the number of deficiencies per child, for example. RESULTS: The applied capturerecapture method, with two main sources that have been found to be independent, gives an overall completeness of ascertainment of 86% CI(95%)[8291], with a variation of between 76% CI(95%)[6787] and 97% CI(95%)[93100] when the number of deficiencies per child is taken into account. After application of the loglinear models, the results obtained are very close to those obtained with the capture-recapture method, both in the case of estimation of the overall completeness of ascertainment and in the case of the completeness of ascertainment that is estimated according to the number of deficiencies variable. The similarity of the results obtained by the two methods appears to support our empirical study, but is only possible because of the validity of certain conditions (the interactions of the order of three were not significant) which can only be verified using statistical tests in the linear log models. CONCLUSION: If the application conditions of the capture-recapture method are carefully adhered to, it becomes possible, without the help of software, to produce a correct estimate of the number of missing cases. Nevertheless, it would be unreasonable to continue using this method alone since log linear models have been found to be independent of these validity conditions.

[Infant mortality trends compared with trends in handicapped children in Isere, 1976-1985]. / Comparaison de l'évolution de la mortalité infantile et de l'évolution des handicaps de l'enfant en Isère, 1976-1985.

Since 1960 progress in obstetric and neonatology modified the survival chance of babies and the pattern of mortality causes. With the information available in the death certificates the aim was to analyse the trends in infant mortality for all 0-1 year children deaths occurring from 1976 to 1991, and to look at its influence on disabled children prevalence rates. The study was conducted in Isere (France) and include 1702 infant deaths. A part from death groups with perinatal disease and/or with congenital defects, a group of deaths with risk factor of disability was identified. This group represented 43% of all the infantile deaths and showed a significant decreasing trend, very similar to the decrease of the early neonatal mortality component (until 1983). However, during the same period, for the disabled children prevalence and for the other infant mortality components, no significant variation was found. The decrease of the deaths with risk factor of disability suggests some influence on the disabled children prevalence.

[How to measure disability in children? Different methodologies, values and applications]. / Comment enregistrer les déficiences de l'enfant? Différentes méthodologies, intérêts et applications.

Infantile mortality data are insufficient for perinatal care evaluation. Long-term morbidity, particularly child impairment prevalence, needs to be assessed regularly. In this paper different surveys on child impairment registration published in the literature are examined: cohort studies, follow-up studies on "at risk" children, cross sectional surveys and morbidity registers. Study designs and case ascertainment are analysed as well as case validation and reference population. The consistency of the results is discussed. In France, most of the studies on childhood impairment are follow-up studies of at risk children, not concerning a geographically defined population, and there is a need for larger epidemiological studies in order to better assess perinatal morbidity and the quality of perinatal cares.

[Epidemiology of respiratory allergy in children]. / Epidémiologie de l'allergie respiratoire de l'enfant.

Epidemiology of paediatric respiratory allergic disorders allows the approach to causal and preventive risk factors by studying groups or sub groups of children in different locations and under different conditions. This is, however, complicated by the lack of consensus on disease definitions, which renders comparisons between studies difficult. Atopy is usually defined by the presence of positive skin tests (wheal size of at least a mean diameter > or = 3 mm), by the presence of specific IgE, or by the presence of increased total IgE (> or = 100 UI/mL). Infantile asthma is not well defined, complicated by the high prevalence of bronchiolitis; one thus questions between wheezing or wheezy bronchitis. Prevalence is high: among early wheezers, two populations will be defined by the medium term evolution: transient wheezers and persistent wheezers. Risk factors for these two conditions are different. Childhood asthma may be defined by the diagnosis of asthma (specific but fairly non-sensitive), by asthmatic symptoms (wheezing, waking by an attack of shortness of breath) (sensitive but not very specific), or by the combination of symptoms and airway hyperresponsiveness. The ISAAC study has standardised a questionnaire to assess the prevalence of asthma. The preliminary results show that there are wide variations across the world. The prevalence is low in Africa and Asia, intermediate in Europe, and high in Anglo-Saxon countries. The prevalence of asthma has gradually increased over the past 20 years in developed countries. Asthma and atopy are closely associated in children. Risk factors are genetic, associated with sex and environmental factors. Among these, allergic sensitisation is associated with the degree of exposure to allergens. Westernization of way of life is associated with increased prevalence of atopy, allergic rhinitis and asthma. Atopy seems inversely correlated to certain infections. Passive smoking is clearly associated with early wheezing. This and atmospheric pollution aggravate childhood asthma. However, the inducing role of pollution on asthma is still controversial.

[Definition and prevalence of school-age multi-handicaps]. / Définition et prévalence des polyhandicaps à l'âge scolaire.

BACKGROUND: Regulations concerning services for handicapped children in France have defined the notion of multi-handicap. There are, however, divergences in the procedures for applying this definition, and differences in the prevalence in different areas. This study is aimed at clarifying these two points. POPULATION AND METHODS: A survey in three French departments provided data about disabled children born between 1975 and 1985 who received services from the departmental committee for special education or from day hospitals. The data was systematically collected by a physician using medical files. RESULTS: The results showed that the group of multi-handicapped children was heterogeneous. The most restrictive definition (motor disability with profound mental retardation, bed-ridden or restricted to a chair) resulted in a prevalence of 0.73%. A broader definition based on the concept of zero autonomy, but excluding mild or moderate mental retardation, resulted in a prevalence of 1.28%. CONCLUSION: The importance of specifying the objectives of a definition selected for operational reasons is stressed in order to improve the estimation of specific needs.

[Motor deficiencies in children: for a nosologic clarification in epidemiological studies]. / Les déficiences motrices de l'enfant: pour une clarification nosologique dans les études épidémiologiques.

In order to clarify the epidemiological research on childhood motor deficiency in France there is a need to better differenciate the two terms used to define this pathology: the French term "infirmité motrice cérébrale" (IMC) and the English term "cerebral palsy" (CP). The distinction between IMC and CP is highlighted on the basis of clinical examples. IMC recovers motor deficiencies which are quite similar, however, it can be very difficult to control the variations in its use. CP has the advantage of a greater exhaustivity as well as a greater reproductibility for epidemiological records. Recently a study was conducted for measuring the prevalence of childhood deficiencies in France, and the results were expressed either as IMC or as CP. When using the CP definition the prevalence rate in France was found to be close to that of foreign studies (1.9 per thousand). In studies with etiological purposes involving several countries, a preliminary agreement on the definition of the clinical groups is absolutely necessary.

[Cross-sectional study of school integration of asthmatic children in a general population sample]. / Etude transversale de l'intégration scolaire des enfants asthmatiques issus d'un échantillon de la population générale.

AIMS: Asthma is one of the most frequently encountered chronic illnesses in children. The aim of the present study was to investigate the problem of integration of asthmatic subjects at school by assessing the reactions of parents and teachers, and also by considering the medical aspects. POPULATION AND METHODS: A cross-sectional random study was carried out during autumn 1994 including 4,251 primary school children aged between five and 14 years, and including teachers from 188 classes and 26 schools in Grenoble and its inner suburbs. The first screening questionnaire was completed by the parents, and data on 3,799 children were obtained; from this, 191 currently asthmatic children were identified. One hundred and forty-six parents of the identified asthmatics subsequently answered a second questionnaire on the severity of the illness and its effects on school attendance and educational activities. The 186 teachers from the schools involved were interviewed about their knowledge of the disorder, and about what they knew of the treatment and management of asthmatic children in school. RESULTS: It was found that the cumulative prevalence of asthma amounted to 7.6%, and that the prevalence over the previous 12-month period was 4.3%. Sixteen percent of the asthmatic children reported an asthma-associated school absence of more than six days during the six preceding months. In 45.2% of cases, physical exercise was responsible for an asthmatic attack, but premedication was used in only 21% of cases. Nine percent of the children had obtained a medical certificate which exempted them from participating in sports activities and physical exercise. Seventy-three percent of the parents had informed the teachers of their child's illness, but the information communicated was incomplete. It was found that the teachers did not have a thorough knowledge of the disorder, but that many of them (92.7%) would appreciate further information on the subject and on its management. Eighty-three percent of the teaching staff were unaware that the ministerial circular No. 93-248 of 22 July 1993 had been issued on the proposed management of chronic disorders at school, advocating a combined effort on the part of the parents, the child's physician, the school doctors and the teachers in setting up a concerted plan of action. CONCLUSIONS: This study has demonstrated that the school integration of asthmatic children remains problematical both as regards treatment and the pursuit of indoor and outdoor school activities. Integration could be improved by using parent-doctor-teacher liaison forms, thereby maintaining closer communication regarding the child's needs. When this is not sufficient, an individualized asthma management plan could be introduced in collaboration with the parents, doctors and teachers, which might result in improved treatment and integration of asthmatic children in school.