Reduced acute phase response to differentiate between viral and bacterial infections in children

The objective of this study was to document the reduced acute phase response that appears in children with viral as opposed to bacterial infections. The white blood cell count (WBCC), the erythrocyte sedimentation rate (ESR), and leukocyte and erythrocyte adhesiveness/aggregation were determined in 36 children with acute bacterial infection, 29 children with viral infection, and 19 controls. A significant reduced WBCC, ESR, and leukocyte and erythrocyte adhesiveness/aggregation was noted in the children with acute viral infection as opposed to those with bacterial infection: 10,800 +/- 3600 and 20,000 +/- 10,000 cells/cm2, 29 +/- 21 and 53 +/- 35 mm Hg, 23 +/- 9 and 41 +/- 15%, and 3.4 +/- 5.1 and 9.8 +/- 13.6 microns, respectively. The results indicate that a reduced acute phase response can be observed in children with an acute viral infection. This can have diagnostic implications and pathophysiological consequences in terms of less flow impairment in the microcirculation due to less red and white blood cell aggregation.

Evaluation of oral budesonide for treatment of mild and moderate exacerbations of Crohn's disease in children

OBJECTIVES

Oral budesonide has been found to be efficacious for mild to moderate Crohn's disease in adults, with equal improvement rates for budesonide and prednisone. We report the results of a retrospective study of budesonide treatment in mild to moderate Crohn's disease in children.

STUDY DESIGN

Charts of patients treated with budesonide (n = 62) with a pediatric Crohn's Disease Activity Index of 12.5 to 40 were compared with a cohort of 58 age-matched patients treated with prednisone.

RESULTS

Among children treated with budesonide, 48% had remission compared with 77% of the children treated with prednisone (P =.001). Among patients who had failed previous medical therapy with mesalamine, 59% had remission with budesonide (9 mg/day). Remission with prednisone occurred in 73% of children who failed to achieve remission with budesonide. Patients responding to budesonide had significantly milder disease compared with nonresponders who had remission while taking prednisone.

CONCLUSIONS

Budesonide is useful in mild to moderate Crohn's disease in children. It is more effective than mesalamine and antibiotics but less effective than prednisone. Budesonide should be considered for first-line therapy in mild to moderate Crohn's disease.

A randomized, controlled clinical trial of the homeopathic medication TRAUMEEL S in the treatment of chemotherapy-induced stomatitis in children undergoing stem cell transplantation

BACKGROUND

Stomatitis is a common consequence of chemotherapy and a condition for which there is little effective treatment. Although the management of patients with other chemotherapy-related toxicities has improved in recent years, the incidence of stomatitis is increasing because of more intensive treatment and is often a dose limiting factor in chemotherapy. The authors assessed the efficacy of a homeopathic remedy, TRAUMEEL S(R), in the management of chemotherapy-induced stomatitis in children undergoing bone marrow transplantation.

METHODS

A randomized, placebo-controlled, double-blind clinical trial was conducted in 32 patients ages 3-25 years who had undergone allogeneic (16 patients) or autologous (16 patients) stem cell transplantation. Of the 30 evaluable patients, 15 were assigned placebo, and 15 were assigned TRAUMEEL S both as a mouth rinse, administered five times daily from 2 days after transplantation for a minimum of 14 days, or until at least 2 days after all signs of stomatitis were absent. Stomatitis scores were evaluated according to the World Health Organization grading system for mucositis.

RESULTS

A total of five patients (33%) in the TRAUMEEL S treatment group did not develop stomatitis compared with only one patient (7%) in the placebo group. Stomatitis worsened in only 7 patients (47%) in the TRAUMEEL S treatment group compared with 14 patients (93%) in the placebo group. The mean area under the curve stomatitis scores were 10.4 in the TRAUMEEL S treatment group and 24.3 in the placebo group. This difference was statistically significant (P < 0.01).

CONCLUSIONS

This study indicates that TRAUMEEL S may reduce significantly the severity and duration of chemotherapy-induced stomatitis in children undergoing bone marrow transplantation.

Ethnic differences in cigarette smoking among adolescents: a comparison of Jews and Arabs in Jerusalem

BACKGROUND

Prevention of cigarette smoking is an important issue in public health policy. Since most adult smokers began smoking in childhood, understanding behavorial factors associated with smoking initiation would contribute to smoking initiation programs. Health-related behavior may vary between different ethnic groups.

OBJECTIVES

To determine the prevalence of smoking among Jewish and Arab adolescents in Jerusalem, and whether there are differences in smoking initiation between the two ethnic groups.

METHODS

We carried out a cross-sectional survey of all students in the 6th to 11th grades (age range 11-17 years) of a Jewish school and an Arab school in the Jerusalem area, using an anonymous self-completion questionnaire. A total of 791 questionnaires was analyzed, 479 from the Jewish students and 312 from the Arab students.

RESULTS

The lowest prevalence of smoking was found among Arab female students and the highest among Jewish female students (9% vs. 41%, P < 0.001). The prevalence of smoking among Jewish and Arab males was similar. More Arab female students smoked than their mothers. Peer pressure seemed to be a more important factor among Jewish students.

CONCLUSIONS

This study demonstrated the presence of ethnic differences in smoking prevalence and the reasons for smoking among adolescents in Israel. These results suggest the need for specific smoking prevention policies for different ethnic groups.

Leukocyte adhesiveness/aggregation test (LAAT) to discriminate between viral and bacterial infections in children

OBJECTIVES

We previously noted that white blood cells (WBC) have increased adhesive properties during bacterial infections. Here, we aim to explore the possibility of using the different adhesive properties of WBC as a means of differentiating between viral and bacterial infections, a common problem in paediatrics.

METHODS

The adhesive properties of WBC in the peripheral blood of 25 children with documented bacterial infections, 15 with documented viral infections and 36 with probable viral infections, were studied by means of a leukocyte adhesiveness/aggregation slide test (LAAT). The results of the LAAT were compared with those of the other acute phase reactants, namely WBC, differential count and erythrocyte sedimentation rate (ESR), which were taken in the same blood sample in each patient.

RESULTS

The sensitivity, specificity and positive predictive value were 92%, 96%, and 92%, respectively for the LAAT; 83%, 87% and 80% for the ESR; 56%, 78% and 56% for the white blood cell count; and 54%, 74% and 50% for the differential count.

CONCLUSIONS

The presence of bacterial infections in children can be tested using a simple slide test to reveal the increased state of leukocyte adhesiveness/aggregation in the peripheral blood. The LAAT is a reliable, rapid and inexpensive test, and it can be a useful laboratory tool for the paediatrician treating a child with acute febrile illness.

The role of scientific and expert advisory committees in food product research and approval

Scientific and expert advisory committees responsible for food products often have the advantage of being relatively unhindered by rigid regulations and the simultaneous disadvantage of having few guidelines to clarify their role in directing the research and approval process. Committees can thus miss opportunities to function in a proactive advisory capacity, and to assist in predetermining what research and documentation are necessary for regulatory approval of a particular food product. This paper examines the ways scientific and expert committees for nutritional products can contribute to formulation of procedures for effective hypothesis and study design development, preparation of well-structured, complete dossiers for product approval, and transparent interactions with petitioners.

Amelioration of ischemia-reperfusion injury in rat intestine by pentoxifylline-mediated inhibition of xanthine oxidase

BACKGROUND

Intestinal ischemia-reperfusion (IR) injury results in cell destruction, which may be mediated by the generation of reactive oxygen species, potentially toxic metabolites of xanthine oxidase. Pentoxifylline (PTX) possesses a variety of biochemical and antioxidant properties that can improve capillary flow and tissue oxygenation. Because of these combined effects, it has been hypothesized that pentoxifylline would protect against intestinal IR.

METHODS

Young adult rats were randomly assigned to one of four experimental groups: IR/Placebo (n = 12) in which superior and inferior mesenteric arteries were clamped for 45 minutes and then reopened; IR/PTX (n = 11) in which IR was induced as in the Placebo group, but with 25 mg/kg PTX at 0, 30, and 60 minutes; No IR/Placebo (n = 12); and No IR/PTX (n = 6) in which placebo and PTX were applied with no IR. Blood and intestinal samples were taken for serial thiobarbituric acid-reducing substances (TBARS; index of lipid peroxidation), for xanthine oxidase-xanthine dehydrogenase ratios, glutathione, myeloperoxidase, and histopathology.

RESULTS

Animals in the IR/PTX group had lower TBARS and the least severe histopathologic injury. Xanthine oxidasexanthine dehydrogenase ratios were elevated only in IR/ Placebo (0.67+/-0.22 vs. 0.45+/-0.14 in IR/PTX; 0.42+/-0.22 in No IR/Placebo; and 0.40+/-0.11 in No IR/PTX; p = 0.0009). Reduced glutathione was diminished in IR/PTX animals (38.9 +/-1.35 vs. 46.1+/-7.0 in IR/Placebo; 41.1+/-2.5 in No IR/ Placebo; 43.6+/-1.0 in No IR/PTX; p = 0.048). No differences were recorded in myeloperoxidase levels among groups.

CONCLUSIONS

Pentoxifylline ameliorates histopathologic signs of injury and decreases lipid peroxidation (TBARS). Normal xanthine oxidase-xanthine dehydrogenase ratios in the treated compared with IR-only animals imply that the protective effect of PTX is at least partially mediated through inhibition of xanthine oxidase.

Clinical manifestations of Bordetella pertussis infection in immunized children and young adults

STUDY OBJECTIVES

The incidence and prevalence of pertussis in adults have increased in recent years. It has been shown that previously immunized adults and adolescents are the main sources of transmission of Bordetella pertussis. The aim of this study was to describe the clinical presentation and the clinical course of pertussis in children and young adults who were immunized previously against B pertussis.

DESIGN

Retrospective study.

SUBJECTS

Children and young adults who were reported by local physicians to the Department of Epidemiology in the Israeli Ministry of Health with serologically confirmed pertussis and who were immunized previously were included. Information sought included personal data, epidemiologic data, signs and symptoms, laboratory results, initial diagnosis, and treatment.

RESULTS

In the 95 previously immunized patients with serologically confirmed pertussis (mean age [+/- SD], 8.9 +/- 4.4 years old; range, 5 to 30 years old), the mean duration from onset of symptoms until the final diagnosis of pertussis was 23 +/- 15 days. The disease was usually atypical and generally mild. All the described patients had cough, usually prolonged, lasting 4 +/- 3.6 weeks. Only 6% had the classic whoop. The mean WBC count was 8.7 +/- 2.6 cells/mm6, and the lymphocyte count was 40 +/- 12%. Two patients were admitted to the hospital for severe pneumonia. Among the reported cases, the proportion of patients between the ages of 10 and 45 years increased from 6.5% during the period from 1971 to 1980, to 26% during the period from 1980 to 1990, and to 38% during a 1989 outbreak.

CONCLUSIONS

Pertussis in previously immunized individuals is usually characterized by an atypical and relatively mild clinical course. Patients suffer mainly from a prolonged and persistent cough. Early diagnosis may lead to prompt administration of therapy. Prophylaxis of exposed persons might be effective in decreasing both severity and transmission of the disease.

Findings on routine abdominal ultrasonography in cystic fibrosis patients

BACKGROUND

Right lower quadrant abdominal pain may pose a diagnostic problem in patients with cystic fibrosis. Abdominal ultrasound examination, used commonly in the diagnostic work-up, may reveal abnormalities of the appendix. However, interpretation of such findings is problematic, because the appearance of the gastrointestinal system during routine examination has not been documented in patients with cystic fibrosis. The purpose of this study was to investigate the findings during routine abdominal ultrasound scans in our cohort of patients with cystic fibrosis and in control subjects.

METHODS

Abdominal ultrasound scans were performed prospectively during routine clinic visits in a cohort of patients with cystic fibrosis.

RESULTS

Fifty patients aged 10+/-6 years, (range, 0.5-28 years) were examined; 45 had pancreatic insufficiency. Four patients (3 with pancreatic insufficiency) reported right lower quadrant pain at the time of the scan. According to standard ultrasound criteria, the appearance of the appendix was abnormal in 8 patients (16%), 6 had a mucoid appendix, and 2 had a pathologically thickened appendiceal wall. Only 1 of these 8 patients mentioned abdominal pain at the time of the study. Other incidental findings included gallstones (3 patients), intussusception (2 patients), and pancreatic cyst (1 patient).

CONCLUSIONS

Abnormalities can be observed during routine abdominal ultrasonographic studies in cystic fibrosis. These findings may not be associated with abdominal pain; their clinical relevance needs further investigation.

Clinical and genetic risk factors for cystic fibrosis-related liver disease

OBJECTIVE

The aim of this study was to define the role of possible risk factors for the development of cystic fibrosis (CF)-related liver disease and to analyze the association between liver disease and the different genotypes present in the Israeli CF patient population.

PATIENTS AND METHODS

All patients followed at the seven CF centers in Israel were included in this study. Liver disease was determined by persistently elevated serum liver enzymes and/or bilirubin, and/or significant ultrasonographic changes suggestive of chronic liver disease. The following clinical parameters were evaluated: ethnic origin, age at assessment of liver function, sex, history of meconium ileus, pancreatic function, history of distal intestinal obstruction syndrome, pulmonary function, and cystic fibrosis transmembrane conductance regulator mutation analysis.

RESULTS

Of the 288 patients screened, 80 (28%) had liver disease. Of the 256 patients with pancreatic insufficiency, 80 (31%) had liver disease compared with none of the 32 patients with pancreatic sufficiency. Genotype-phenotype correlation was performed on 207 patients carrying identified mutations that were previously classified according to phenotype severity. Liver disease was found in 56 (32%) of 173 patients carrying mutations associated with a severe phenotype and in 6 (38%) of 16 patients carrying at least one mutation associated with a variable genotype (G85E and/or 5T allele). None of the 18 patients carrying the 3849+10kb C->T mutation had liver disease. Prevalence of liver disease increased with age. No correlation was found between liver disease and severity of lung disease, nutritional status, history of meconium ileus, or distal intestinal obstruction syndrome.

CONCLUSION

CF patients who have pancreatic insufficiency and carry mutations associated with a severe or a variable genotype are at increased risk to develop liver disease.

Are intraepithelial lymphocytes in celiac mucosa responsible for inducing programmed cell death (apoptosis) in enterocytes? Histochemical demonstration of perforins in cytoplasmic granules of intraepithelial lymphocytes

BACKGROUND

Programmed cell death refers to the genetically determined processes by which cells die in response to physiologic extracellular and intracellular signals, morphologically described as apoptosis. In physiologic and pathologic circumstances this process may involve effector and target cells.

METHODS

To identify serine esterase granules in intraepithelial lymphocytes, fresh-frozen human small intestine mucosal sections from normal and celiac-affected mucosa were incubated with substrate-specific N-alpha-benzyloxy-carbonyl-L-lysine thiobenzyl (BLT) and a chromogen (4 Benzoylamino-2,5-diethoxybenzene-dazonium chloride hemi [zinc chloride] salt as capture agent and were examined by light microscopy.

RESULTS

Normal mucosa showed an occasional intraepithelial lymphocyte with BLT-positive intracytoplasmic granules. Some large mononuclear cells of the lamina propria were similarly stained. Many more intraepithelial lymphocytes were BLT-positive among the surface enterocytes of untreated celiac mucosa. Lamina propria mononuclear cells close to the basal layer of crypt cells also appeared to be increased.

CONCLUSIONS

The histochemical identification of BLT-positive esters within intraepithelial lymphocytes suggests their involvement in enterocyte death under physiologic conditions. The increased BLT-positive intraepithelial lymphocytes found in the celiac mucosa may be related to the known increase in cytotoxic intraepithelial lymphocytes in untreated celiac disease.

Efficacy of corticosteroids in acute bronchiolitis: short-term and long-term follow-up

Corticosteroids continue to be used by many physicians to treat infants with bronchiolitis. The aim of this study was to examine the short-term and long-term efficacy of oral corticosteroid therapy when added to beta2-agonists in infants with mild to moderate bronchiolitis (defined as the first episode of wheezing associated with low grade fever, rhinitis, tachypnea, and increased respiratory effort in a previously healthy infant during the winter months). Infants with mild to moderate bronchiolitis, were randomly assigned to receive either oral prednisone (2 mg/kg/day) or placebo for 3 days. All patients received nebulized albuterol q.i.d. during this period. Upon admission and after 3 days of therapy, a clinical score was assigned based on respiratory rate, use of accessory muscle, and the presence of wheeze. Oxygen saturation (SaO2) was also measured. On day 7, we inquired as to the well-being of each child. Two years later, the development of chronic respiratory symptoms was assessed. Thirty-eight infants were enrolled in the study; 20 received prednisone and 18 received placebo. Both groups were similar in terms of age, duration of illness prior to enrollment, pretrial medication use, clinical severity of bronchiolitis, history of atopy, and family history of atopy. After 3 and 7 days of treatment, both groups showed similar clinical improvement and there were no statistically significant differences between the two groups in the clinical score or in the SaO2. No major side effects were observed. Two years later, 32% of the infants continued to suffer from chronic respiratory symptoms, with a similar prevalence in both groups. We conclude that a 3-day course of oral corticosteroids is of no benefit to infants with mild to moderate bronchiolitis who are also treated with an inhaled beta2-agonist.

Gallbladder and pancreatic involvement in hepatitis A

Gallbladder (GB) abnormalities are rarely reported in children, but involvement of the GB has been demonstrated in various inflammatory disorders. Thirty-nine children hospitalized with hepatitis A virus infection were evaluated by ultrasound. Pseudosurgical gallbladder wall of 10 mm or more with striation was found in 10. Pathological echographic findings were found in the pancreas of three patients, one with frank pancreatitis. Ascitic fluid was noted in eight. Pediatricians and pediatric surgeons alike should be familiar with this gallbladder and pancreatic involvement, which might avoid unnecessary procedures or surgery.

Celiac disease: a reappraisal

During the last decade significant changes have occurred in our concepts of celiac disease. As a result of the implementation of sensitive and specific serologic tests, the epidemiology and clinical presentation of affected patients have been radically reconsidered. Extraintestinal manifestations of celiac disease have been radically reconsidered. Extraintestinal manifestations of celiac disease have been increasingly recognized, and the strict association with diseases recognized as autoimmune disorders is well established; celiac disease itself has many aspects of an autoimmune condition. Celiac disease is of interest to clinicians and scientists because it represents a valuable model for the comprehension of diseases in which environmental, genetic, and immunologic factors interplay.

Histologic evaluation of endoscopic versus suction biopsies of small intestinal mucosae in children with and without celiac disease

BACKGROUND

Concern over the adequacy of histologic diagnosis of endoscopic duodenal biopsies in children prompted this comparative study on the histologic quality of endoscopic versus capsule biopsies. We found this problem addressed in only six previous reports.

METHODS

Blind examinations of the histologic sections of 48 duodenal biopsies obtained by gastrointestinal endoscopy in children aged 2-18 years were compared to 52 biopsies obtained by the small bowel suction method (from children aged 1-16 years).

RESULTS

Although 87.5% of endoscopic biopsies and 94.2% of capsule biopsies were adequate for histologic diagnosis, fragmentation or squashing was seen in 83.3% of endoscopic biopsies and only in 25% of capsule biopsies.

CONCLUSIONS

Biopsies obtained by suction are of better quality than those obtained by endoscopy. If endoscopy is preferred for technical reasons, the following conditions should be observed: the patients should be aged over 2 years, and a minimum of four biopsies should be obtained with forceps of a diameter greater than 2 mm. Adequate histologic criteria for diagnosis should include at least one full-thickness mucosal specimen more than 3 mm in length, vertically oriented, and not fragmented. In children under age 2, duodenal or jejunal capsule biopsies are preferred, since the specimens are usually larger and less fragmented. Endoscopy is technically more difficult in the very young patient.

Kingella kingae endocarditis in a child with hair-cartilage hypoplasia

Abstract. Kingella kingae is a fastidious Gram-negative rod that since the 1980s has been appreciated as a cause of a variety of human infections, including bone and joint infections, bacteremia, and rarely endocarditis [2, 6, 7, 9]. K. kingae endocarditis is rare, and only a few cases occur in normal, native valves. We report a case of K. kingae endocarditis in a patient with hair-cartilage hypoplasia who had previously undergone bone marrow transplantation. The combination of these rare conditions is discussed.

A missense cystic fibrosis transmembrane conductance regulator mutation with variable phenotype

OBJECTIVE

Cystic fibrosis (CF) has variable clinical presentation. Disease severity is partially associated with the type of mutation. The aim of this study was to report genotype-phenotype analysis of the G85E mutation.

PATIENTS

The phenotype of 12 patients (8 were from the same extended family, and 5 of them were siblings from 2 families) carrying at least one copy of the G85E mutation was evaluated and compared with the phenotype of 40 patients carrying the two severe mutations, W1282X and/or DeltaF508 (group 1), and with 20 patients carrying the splicing mutation, 3849+10kb C->T, which was found to be associated with milder disease (group 2).

RESULTS

A high phenotypic variability was found among the patients carrying the G85E mutation. This high variability was found among patients carrying the same genotype and among siblings. All the studied chromosomes carrying the G85E mutation had the 7T variant in the polythymidine tract at the branch/acceptor site in intron 8. Of the G85E patients, 25% had pancreatic sufficiency and none had meconium ileus, compared with 0% and 32%, respectively, of patients from group 1, and 80% and 0%, respectively, from group 2. Two patients carrying the G85E mutation had sweat chloride levels <60 mmol/L whereas all the others had typically elevated levels >80 mmol/L. Compared with group 2, patients carrying the G85E mutation were diagnosed at an earlier age and had higher sweat chloride levels, with mean values similar to group 1 but significantly more variable. Forced expiratory volume in 1 second (FEV1) was similar in the three groups, with no differences in the slope or in age-adjusted mean values of FEV1. The levels of transcripts lacking exon 9 transcribed from the G85E allele measured in 3 patients were 55%, 49%, and 35% and their FEV1 values were 82%, 83%, and 50% predicated, respectively.

CONCLUSIONS

The G85E mutation shows variable clinical presentation in all clinical parameters. This variability could be seen among patients carrying on the other chromosome the same CFTR mutation, and also among siblings. This variability is not associated with the level of exon 9 skipping. Thus, the G85E mutation cannot be classified either as a severe or as a mild mutation.

A cystic fibrosis transmembrane conductance regulator splice variant with partial penetrance associated with variable cystic fibrosis presentations

Some patients express various features of cystic fibrosis (CF) even though essential characteristics of the disease might be absent. Such patients may suffer from respiratory disease without pancreatic insufficiency and normal sweat chloride levels. Others may present as male infertility because of congenital bilateral aplasia of the vas deferens (CBAVD) with no other signs of CF. The 5T allele, a DNA variant in a noncoding region of the cystic fibrosis transmembrane conductance regulator (CFTR) gene that reduces the level of the normal CFTR transcripts, was found in increased frequency among male patients with CBAVD. The purpose of this study was to investigate the possibility that the 5T allele is associated with dysfunction of organs other than the male reproductive system, leading to CF or atypical CF. Analysis of the 5T allele was performed on 148 subjects (29 with CF, 61 with atypical CF, and 58 with CBAVD) carrying 232 chromosomes with unidentified CFTR mutations, and on 142 non-CF chromosomes from healthy subjects of Ashkenazi origin. The frequency of the 5T allele among chromosomes from patients of Jewish Ashkenazi origin with CF and atypical CF (six of 33; 18%) was significantly higher than the frequency in the normal Ashkenazi population (eight of 142; 6%; p = 0.03). Analysis of the clinical presentation of the five patients with CF and the 12 patients with atypical CF carrying the 5T allele indicated that most patients suffered from respiratory disease presenting as asthma like symptoms, nasal polyposis, chronic sinusitis, chronic bronchitis, or bronchiectasis. Six patients had pancreatic insufficiency, two with meconium ileus. Sweat Cl- levels ranged from normal to elevated. Of the six male patients with respiratory disease who were old enough to be evaluated for fertility status, five were fertile and one had pancreatic insufficiency. Among male patients with CBAVD, 41% suffered from respiratory symptoms. Thus, the 5T allele is a variant with partial penetrance causing disease with an extreme variability of clinical presentation: from normal healthy fertile subjects or male patients with CBAVD to those with atypical or typical clinical phenotype of CF.

Cigarette smoking habits among schoolchildren

STUDY OBJECTIVE

Cigarette smoking is a major preventable cause of morbidity and mortality worldwide. Most adult smokers start smoking regularly some time before 18 years of age. The aim of this study was to determine the age at which children begin cigarette smoking, to study the environmental factors that influence children to smoke, and to understand the reasons why children smoke. The results of this study may help lead to the development of more effective smoking prevention programs.

METHODS

We carried out a cross-sectional survey of all students in grades 6 to 11 (ages: 11 to 17 years) in two high schools in the Jerusalem area, using an anonymous self-completion questionnaire. The students were asked questions regarding the age at which they began smoking, initiation, their smoking habits, their reasons for smoking, and their views on children who smoke. In addition, they were asked about the smoking status of their parents, siblings, and friends. Finally they were asked about the health hazards of smoking.

RESULTS

Of the 847 students who answered the questionnaire, 35% stated that they had smoked at least once and 14% stated that they were currently smoking. The percentage of students who were currently smoking increased gradually with age to 36%. There was a sharp increase in experimental smoking after seventh grade (ages 12 to 13 years). Having a friend who smoked substantially increased the likelihood of smoking, whereas parental smoking or having a sibling who smoked did not increase the likelihood of smoking. The most common reason for starting to smoke was "to try something new" (55%). There was a significant difference between the views of students with different smoking statuses regarding children who smoke: nonsmoking children associated more negative characteristics to smoking. All of the children studied were well aware of the health hazards of cigarette smoking.

CONCLUSIONS

Smoking is highly prevalent among schoolchildren in Jerusalem. The increase in the rate of smoking at the age of 12 years indicates that smoking prevention programs need to be started at an earlier age. Peer pressure is a very strong stimulus for smoking in children. Since children are aware of the health hazards of smoking, prevention policy should be aimed more at associating smoking with negative images and addressing peer pressure.