[Prospective comparison of child asthma education in the emergency department and at scheduled follow-up consultation]

OBJECTIVES

To assess asthma control in asthmatic children attending the emergency department and to compare it with that for children with scheduled specialist follow-up.

POPULATION AND METHODS

Between September 2002 and September 2003, we included asthmatic children aged 6 to 16 years, attending the emergency department (group U) or pulmonology follow-up appointments (group C) at Necker Hospital, Paris, France. We used the Asthma Therapy Assessment Questionnaire (ATAQ), completed by the parents and children aged 10 years and over.

RESULTS

We interviewed 156 families and included 144 (92%) in the final analysis (77 in group U). The 2 groups did not differ in age, sex ratio, age at onset and asthma diagnosis and the frequency of asthma attacks. Children in group U received less daily maintenance treatment (P<0.01) but reported more severe asthma (P<0.05). They had also experienced fewer investigations for their asthma (fewer lung function tests P=0.01 and allergy tests P=0.001). The children in group C had better controlled asthma, as assessed by both the children themselves and their parents. They also had fewer problems relating to the behavior, communication and treatment control domains. The assessment of children and parents were similar in all areas except communication. The children considered their communication problems to be more serious than their parents did. Age-related differences were observed, with older children's parents having more difficulties in all domains investigated.

CONCLUSION

Clinicians should consider assessing asthma control in children attending the emergency department. There is clearly an opportunity to improve the quality of asthma education for these children. Clinicians could provide children with a written plan of action for asthma attacks and information about daily self-management. Improving communication between children, their parents and doctors should be considered a key educational project.

Hypersensitivity reactions to paracetamol in children: a study of 25 cases

BACKGROUND

Allergic-like reactions to paracetamol (acetaminophen) are rare. Paracetamol allergic and nonallergic hypersensitivity (HS) has been diagnosed in a few patients with skin and/or respiratory symptoms, immediate and accelerated urticaria, and angioedema especially. Most patients with HS to paracetamol were also hypersensitive to anti-inflammatory drugs (i.e. acetylsalicylic acid, ASA), suggesting that their reactions resulted from a nonallergic HS. However, anaphylactic reactions, and potentially harmful toxidermias, such as acute generalized exanthematic pustulosis and toxic epidermal necrolysis, have been related to specific paracetamol allergic HS, with tolerance to anti-inflammatory drugs.

PATIENTS AND METHODS

We report the results of a study performed in 25 children with suspected paracetamol HS. Diagnosis of paracetamol HS was based on a suggestive clinical history and a positive response in an oral challenge (OC) test.

RESULTS

Paracetamol HS was diagnosed in only one child (4%). In this child, a positive response to an OC with ASA diagnosed HS to anti-inflammatory drugs.

CONCLUSIONS

Our results in children agree with those of the literature, showing that paracetamol HS is rare, and is associated with HS to anti-inflammatory drugs in most patients.

Influence of thermal processing on the allergenicity of peanut proteins

Peanuts are one of the most common and severe food allergens. Nevertheless, the occurrence of peanut allergy varies between countries and depends on both the exposure and the way peanuts are consumed. Processing is known to influence the allergenicity of peanut proteins. The aim of this study was to assess the effect of thermal processing on the IgE-binding capacity of whole peanut protein extracts and of the major peanut allergens Ara h 1 and Ara h 2. Whole proteins, Ara h 1, and Ara h 2 were extracted and purified from raw, roasted and boiled peanuts using selective precipitation and multiple chromatographic steps, and were then characterized by electrophoresis and mass spectrometry. The immunoreactivity of whole peanut extracts and purified proteins was analyzed by the enzyme allergosorbent test (EAST) and EAST inhibition using the sera of 37 peanut-allergic patients. The composition of the whole protein extracts was modified after heat processing, especially after boiling. The electrophoretic pattern showed protein bands of low molecular weight that were less marked in boiled than in raw and roasted peanuts. The same low-molecular-weight proteins were found in the cooking water of peanuts. Whole peanut protein extracts obtained after the different processes were all recognized by the IgE of the 37 patients. The IgE-binding capacity of the whole peanut protein extracts prepared from boiled peanuts was 2-fold lower than that of the extracts prepared from raw and roasted peanuts. No significant difference was observed between protein extracts from raw and roasted peanuts. It is noteworthy that the proteins present in the cooking water were also recognized by the IgE of peanut-allergic patients. IgE immunoreactivity of purified Ara h 1 and Ara h 2 prepared from roasted peanuts was higher than that of their counterparts prepared from raw and boiled peanuts. The IgE-binding capacity of purified Ara h 1 and Ara h 2 was altered by heat treatment and in particular was increased by roasting. However, no significant difference in IgE immunoreactivity was observed between whole protein extracts from raw and roasted peanuts. The decrease in allergenicity of boiled peanuts results mainly from a transfer of low-molecular-weight allergens into the water during cooking.

Anaphylaxis during anesthesia: results of a 12-year survey at a French pediatric center

BACKGROUND

Following adverse reactions to anesthesia, tests are carried out to determine the mechanism of the reaction and to identify the agent responsible. No specific data are available in France concerning such skin tests in children.

METHODS

Between 1989 and 2001, we assessed hypersensitivity reactions to general anesthesia in 68 children. Thirty underwent more than one operation, for congenital malformations. Immunoglobulin (Ig)E-mediated anaphylaxis was diagnosed on skin tests combined with the clinical history.

RESULTS

Grade I, II and III reactions were observed in 20, 27 and 21 children, respectively. IgE-mediated anaphylaxis was diagnosed in 51 children: 31 (60.8%) for neuromuscular blocking agents (NMBA), 14 (27%) for latex, seven (14%) for colloids, five (9%) for opioids and six (12%) for hypnotics. Vecuronium was the NMBA causing the largest number of reactions. Cross reactivity to NMBA available in France was observed in 23 of 30 children (76%), particularly for vecuronium and atracurium or pancuronium. The estimated frequency of IgE mediated anaphylactic reactions was one in 2100 operations. Based on our results, 25 children subsequently received a different anesthetic with no adverse reaction.

CONCLUSIONS

As in adults, NMBA, then latex were responsible for most anaphylactic reactions during anesthesia. Our results confirm that skin tests with anesthetic agents are feasible and safe in children and improve the safety of subsequent anesthetic procedures.

[Practical advice for exercise-induced asthma in children: experience of the exercise training centre of Necker-Enfants malades hospital]

Now, to care exercise-induced asthma is not only to prescribe drugs. It is a global and interdisciplinary approach: the pulmonary rehabilitation, matching a therapeutic education and a physical training, with the goal of promoting a regular physical activity in the asthmatic child, achieving physiological benefits and improvement of quality of life. Getting from the experience of Necker-Enfants Malades Hospital's Training Centre, a few advises encourage the physical practice of the asthmatic child, and decrease risks of exercise-induced asthma: optimisation of treatments;progressive beginning and end of exercises; use of the diaphragmatic breathing, keeping up with the exercise; use of the ventilatory threshold (or dysponea threshold) as intensity of the aerobic training; practice of different activities promoting play and conviviality in sports and allowing the integration of sports in the daily life of the asthmatic child.

[Acute viral respiratory tract infections and childhood asthma]

Les infections virales respiratoires sont de très importants facteurs déclenchants des crises d'asthme. Chez l'enfant les études épidémiologiques les plus récentes, utilisant la PCR, leur attribuent le déclenchement de 80 à 85 % des crises, aussi bien pour les crises modérées que les crises nécessitant une hospitalisation. Le virus respiratoire syncytial et les virus parainfluenzae prédominent chez le nourrisson, les rhinovirus et le mycoplasme chez l'enfant plus grand. Les mécanismes précis de l'induction des crises d'asthme par les virus restent mal compris, toutefois de récentes études montrent une augmentation de l'activation des cellules inflammatoires dans le lavage alvéolaire. Les sujets atopiques, en dehors des périodes d'allergie, ne semblent pas avoir plus de manifestations respiratoires viro-induites que les non-atopiques. En revanche, chez le sujet asthmatique, l'infection virale aggrave les réactions immédiate et retardée de l'hypersensibilité immédiate après test de provocation allergénique, en augmentant la libération des médiateurs mastocytaires et le recrutement des éosinophiles dans les voies aériennes inférieures. Les études chez l'homme et l'animal suggèrent que la production locale de cytokines (IL4, IL8, RANTES, MIP-1a...) et l'expression accrue chez l'asthmatique de la molécule d'adhésion ICAM1 aient un rôle important pour le recrutement et l'activation des cellules de l'inflammation dans les voies aériennes. Une hypothèse, qui reste à démontrer serait que dans des situations où, comme dans l'asthme, les lymphocytes Th2 prédominent, un excès d'Il4 pourrait inhiber les CD8 cytotoxiques, les cellules NK et les Th1 et ainsi entraîner une diminution des défenses antivirales et une réaction inflammatoire broncho-pulmonaire plus sévère que chez le non-asthmatique.

[An unusual foreign body. Report of a case of subcutaneous emphysema during an asthma attack]

Pneumomediastinum is an uncommon complication after an asthma attack. The essential clinical sign is the presence of subcutaneous emphysema. In the great majority of cases, the treatment of pneumomediastinum corresponds to that of asthma, with resorption over several days. The situation is very different when the development of pneumomediastinum and subcutaneous emphysema is secondary to an aspiration syndrome.

[Inhaled treatment for asthma in practice]

The modalities of an inhaled treatment depends on the characteristics of the aerosol, on the age of the child, and mainly on the inhalatory system. Before the age of 8 years, the pressurised metered dose inhaler must be used together with a spacer device. Above this age, the use of a breath-actuated inhaler or of a dry powder inhaler can be proposed. Demonstration and educational instructions will increase the probability of compliance and efficiency of the treatment.

[What environmental measures should be taken for the treatment of atopic dermatitis in children and the prevention of other atopic manifestations?]

The association of atopic dermatitis, asthma and allergy is frequent. Hence, it is logical to imagine that eviction of the main indoor allergens (dust mites, animal danders) would have a preventive effect on the onset and progression of atopic dermatitis and the risk of asthma. Recent epidemiological studies are generally negative with regard to primary and also secondary and tertiary prevention. Only one study appeared positive; it combined eviction of food allergens and of indoor allergens during the first year of life. Other studies are warranted to assess the interest and efficacy of eviction of inhalant allergens in atopic dermatitis.

Knowledge, attitudes, and behavior of the parents of asthmatic children in Maputo

Asthma is increasing in frequency worldwide. The education of affected children and their parents is fundamental for the management of the disease. The aim of our study was to describe the knowledge, attitudes, and behavior of the parents of asthmatic children. We studied 152 adults accompanying asthmatic children to consultations in the pediatrics department of Maputo Central Hospital (Mozambique). In general, knowledge about asthma was poor: 11% of the adults thought that asthma was contagious and transmitted from person to person, and 4% thought that it was transmitted by contaminated food. More than half the parents thought that the child could not lead a normal life even during the periods between attacks. A large proportion of the parents thought that asthma could be cured by medical treatment in 7% of cases and by alternative treatment in 43% of cases. The precipitating factors were well identified by the adults, but they had an inaccurate perception of the symptoms of an asthma attack. The actions of the various classes of drugs used were poorly understood. Education programs for both the children and their parents should be developed to improve the management of asthmatic children. Surveys of this type facilitate the targeting of such programs.

Risk factors for asthma among children in Maputo (Mozambique)

BACKGROUND

Few studies have looked at risk factors for asthma in African children. We aimed to identify the risk factors associated with childhood asthma in Maputo (Mozambique).

METHODS

This case-control study included 199 age-matched children (100 asthmatic and 99 nonasthmatic) who attended Maputo Central Hospital between January 1999 and July 2000. We collected information concerning their familial history of atopy, birth weight, environment and breast-feeding. Detailed information about morbidity and treatment was obtained for each asthmatic child.

RESULTS

The children were aged between 18 months and 8 years; 60% were male. The asthmatic children were hospitalized more frequently than the nonasthmatic children (P < 0.0001). Most of the asthmatic children lived in the urban area of Maputo [odd ratio (OR) = 6.73, CI = 3.1-14.0, P < 0.0001], had a parental history of asthma (OR = 26.8, CI = 10.8-68.2, P < 0.0001) or rhinitis (OR = 4, CI = 1.2-13.3, P = 0.005), had at least parent who smoked and were weaned earlier than the nonasthmatic children (OR = 2.4, CI = 1.3-4.4, P < 0.001).

CONCLUSION

Childhood asthma was strongly associated with a family history of asthma and rhinitis, the place of residence, having smokers as parents and early weaning from maternal breast milk. These results highlight the need to reassess the management of asthmatic children in Maputo.

Serological characteristics of peanut allergy in children

BACKGROUND

Food challenge is considered an excellent clinical tool for the diagnosis of specific food allergy. However in the case of peanut allergy it may be difficult to perform because of the severity of the reactions. The quantitation of a specific immunoglobulin E (IgE) response to different peanut allergens could also contribute to the improvement of the diagnosis. We characterized the IgE response to a whole peanut protein extract and to Ara h 1 and Ara h 2 in different groups of patients classified according to the severity of their allergic reactions.

METHODS

Specific serum IgE were analyzed in 96 children by enzyme-linked immunosorbent assay tests using a whole protein extract or purified peanut proteins and anti-human IgE monoclonal antibodies labeled with acetylcholinesterase.

RESULTS

A parallel was observed between levels of peanut-specific IgE and the classification in five groups and subgroups of patients upon increasing severity of symptoms, especially within the group of highest severity. Moreover, the highest frequency of positive response and the highest levels of specific IgE were observed with whole peanut protein extract.

CONCLUSION

In a retrospective evaluation of peanut allergy in children, we have shown that quantitation of peanut-specific IgE could be used to avoid a food challenge particularly in the case of severe reactions. When compared to Ara h 1 and Ara h 2, whole peanut protein extract appeared to be the most appropriate allergen to perform the test.

[Streptococcus pneumoniae purulent pleurisy and hemolytic uremic syndrome. A case report]

A 22-month-old infant developed purulent pleurisy caused by Streptococcus pneumoniae and a hemolytic uremic syndrome. The diagnosis was suggested by the classical triad: hemolytic anemia, renal failure and thrombocytemia confirmed by renal biopsy which demonstrated extensive cortical necrosis. Renal involvement was severe, justifying an indication for renal transplantation.

[Latex allergy in children]

The aim of our study was to determine the prevalence of latex allergy and the clinical features of children with latex allergy.

PATIENTS AND METHODS

We prospectively investigated 243 children consulting in our allergy out-patients unit during 1 year. Parents answered a questionnaire, and children underwent skin prick tests with common allergens and latex. Latex-specific serum immunoglobulin E was determined by CAP test in children with latex sensitization. The results were compared in children with and without latex allergy.

RESULTS

The prevalence of latex allergy was 1.3%. A family history of atopy (75%) and a personal history of previous surgery was associated with latex allergy (P < 0.0001). In children with latex allergy, the frequency of sensitization to inhaled and food allergens, atopic dermatitis, rhinitis and conjunctivitis was higher than in children without latex allergy (P < 0.05). Avocado allergy was the food allergy most commonly associated with clinical symptoms. Balloon was the most common latex product causing symptoms (60%).

CONCLUSIONS

Due to its potential severe consequences, latex allergy should be investigated in children who had undergone multiple surgical procedures and in the children with pollen-food allergy syndrome. Avoidance of latex is an important preventive measure.

[Food allergy and asthma in children]

The links between food allergy and asthma are becoming more clear. The association of food allergy and asthma in the same child is unusual (less than 10% in atopic subjects). This association is however a sign of gravity leading to more severe manifestations of food allergy in asthmatic children. Compared with the non-asthmatic child, the asthmatic child has a 14-fold higher risk of developing a severe allergic reaction to the ingestion of food. The most commonly cited foods are fruits with a rind, cow's milk and, of course, nuts. Epidemiological data established from methodologically sound studies should enable a definition of the current allergic environment. Formal diagnosis is established with standardized tests. Treatment is oriented towards prevention associating a restricted diet, asthma control, patient education, and prescription of an emergency first aid kit with epinephrine. Supplementary inquiries are needed to determine the outcome in children with food allergy and respiratory symptoms.