Complications of flexible bronchoscopy in children: prospective study of 1,328 procedures

Complications of flexible bronchoscopy (FB) were prospectively evaluated during 1,328 diagnostic procedures in children, not in intensive care units. A total 92.8% of the procedures were performed in conscious patients under sedation and 7.2% under deep sedation. Supplementary oxygen was provided in approximately 80% of cases via endoscopic face mask (n=783) or nasal prongs (n=290). At least one complication was recorded in 91 cases (6.9%). Minor complications (n=69; 5.2%) included moderate and transient episodes of desaturation (n=15), isolated excessive coughing (n=22), excessive nausea reflex with coughing (n=20), transient laryngospasm (n=6) and epistaxis (n=6). Major complications (n=22; 1.7%) included oxygen desaturation to <90%, either isolated (n=10) or associated with laryngospasm (n=6), coughing (n=4), bronchospasm (n=1), and pneumothorax (n=1). Major complications involving oxygen desaturation were associated with age <2 yrs (13 of 529 versus 8 of 778) and laryngotracheal abnormalities (7 of 85 versus 14 of 1,222). The overall frequency of complications was similar in conscious (6.7%) but sedated patients and patients under deep (7.3%) sedation. However, the frequency of transient desaturation was significantly higher in children undergoing FB under deep sedation. Transient fever after bronchoalveolar lavage was observed in 52 of 277 cases (18.8%). Flexible bronchoscopy is a safe procedure with <2% major complications. Careful analysis of indications and clinical status for each patient, and proper anaesthesia and monitoring during the examination ensure that the procedure is successful, with a minimum of complications.

Safety of various dosage regimens during induction of sublingual immunotherapy. A preliminary study

BACKGROUND

Sublingual immunotherapy (SLIT) has been demonstrated to be a viable alternative to injection immunotherapy. Administration of high doses of allergens to ensure efficacy has been shown to be well tolerated. The aim of the present study was the first step to address the issue of fast-induction regimens using various induction SLIT regimens in paediatric and adult patients.

METHODS

Sixty-four patients (age range 5-46 years) with grass pollen rhinoconjunctivitis were enrolled in an 8-month double-blind, placebo-controlled trial of SLIT. Sixty-three patients were randomized to four groups and evaluated at the end of the study. One group received placebo (n = 16) and the other three groups (n = 47) received five grass pollen extracts according to three different induction regimens: regimen 1 starting with 3 IR tablets (n = 15), regimen 2 starting with 10 IR (n = 16) and regimen 3 starting with 30 IR (n = 16). The maintenance phase was made with sublingual-swallow drops at the same concentration of 300 IR/ml for all the patients. Adverse events were recorded on diary cards.

RESULTS

During induction phase, 25/47 patients in the SLIT groups had adverse reactions in comparison to 2/16 patients in the placebo group (p < 0.05). The rate of adverse reactions was 33.3% (11.8-61.6) (95% CI) for regimen 1, 31.3% (11.0-58.7) for regimen 2, 43.8% (19.8-70.1) for regimen 3 and 12.5% (1.6-38.3) for placebo. Fifty-seven reactions were local reactions involving the oral region (54 SLIT, 3 placebo) and 13 were systemic reactions (all in the SLIT groups). 11/13 reactions were mild (gastrointestinal disorders, rhinoconjunctivitis), 1/13 consisted of moderate asthma and 1/13 consisted of severe abdominal pain. No urticaria, angioedema or life-threatening events were observed.

CONCLUSIONS

These preliminary data showed that various induction regimens for SLIT are generally well tolerated and could allow a fast build-up phase of SLIT.

[The AIRE Study: data analysis of 753 European children with asthma]

PROBLEM

To analyse the paediatric data from the AIRE study (Asthma insights and reality in Europe) describing the standard of asthma control in Europe.

MATERIAL AND METHODS

Among the 73,880 households contacted by telephone in 7 countries 753 children under the age of 16 were identified. An interview was conducted with a close relative to determine the frequency and severity of symptoms during the recent month, visits to casualty and hospital admissions during the past year, the medications used, the effects on the lives of the children, the opinions of the parents on the level of control of asthma and the monitoring methods used.

RESULTS

38.2% of children reported diurnal symptoms and 28% disturbance of sleep at least once a week. The consequences were important: limitation of sporting activities (29.5%) and absence from school (42.7% in the past year). Treatment was inadequate: 26% of children used inhaled steroids yet 45.9% had persistent asthma. The level of control was overestimated: 61% of parents of children with severe persistent asthma considered the asthma to be well controlled.

CONCLUSION

European asthmatic children are poorly controlled, under-treated and rarely followed up. The consequences, particularly absence from school, should stimulate an improvement in their therapeutic and educational management.

Relationship between bronchial responsiveness and clinical evolution in infants who wheeze: a four-year prospective study

Recurrent illness involving wheezing during the first years of life is transient in most children. The role of bronchial hyperresponsiveness as a factor influencing the persistence of wheezing from infancy to school age remains unknown. In a prospective study we investigated whether infants who wheezed and subsequently developed persistent asthma differed from infants who wheezed and later became asymptomatic either in the initial degree of bronchial hyperresponsiveness or in the persistence of bronchial hyperresponsiveness with age. One hundred and twenty-nine infants with three or more wheezing episodes before 2 yr of age were followed during 4 yr with a clinical evaluation and a methacholine challenge performed every 6 mo until the child was 4 yr old and once per year thereafter. The clinical score significantly improved with time in most children. The proportion of children with persistent wheezing after 2 and 4 yr of follow-up was only 31% and 20%, respectively. Persistent wheezers had significantly lower VmaxFRC values at initial evaluation and higher SRaw values at the end of follow-up than infants who became asymptomatic. We used transcutaneous oxygen tension (PtcO(2)) to measure the response to methacholine. No significant difference in PD(15) PtcO(2) between groups with subsequently different clinical progression was observed at initial evaluation. Bronchial hyperresponsiveness persisted 4 yr later in all children but children with persistent wheezing showed significantly lower PD(15) PtcO(2) values than children who became asymptomatic, as early as 30 mo of age. However, an acceptable early PD(15) PtcO(2) cut-off point predictive for subsequent clinical progression could not be identified. The level of bronchial hyperresponsiveness in infants who wheezed was not predictive of the persistence of asthma 4 yr later.

Anaphylaxis to the 23-valent pneumococcal vaccine in child: a case-control study based on immediate responses in skin tests and specific IgE determination

Injections of the 23-valent pneumococcal vaccine are usually well tolerated. Skin tests (prick and intradermal) and a self-made RAST with pneumococcal vaccine and phenol were performed in a child reporting a severe anaphylactic reaction induced by a 23-valent pneumococcal vaccine, and in ten control children, including one child with a well-tolerated vaccination, and nine non-vaccinated children. Skin tests and RAST with the vaccine were positive in the child reporting anaphylaxis, and negative in nine of the control children. Intradermal test with the vaccine was slightly positive in a non-vaccinated child with negative RAST. Skin tests and RAST with phenol were negative in all the children. These results suggest that immediate responses in skin tests and specific IgE determination have a good diagnostic value in children reporting severe reactions suggestive of IgE-dependent hypersensitivity to pneumococcal vaccine.

[Epidemiological study of genetic and environmental factors in asthma, bronchial hyperresponsiveness and atopy. Protocol and potential selection bias]

BACKGROUND

The EGEA study combines a case-control study and a family study to assess genetic and environmental risk factors and their interactions for asthma, bronchial hyperresponsiveness and atopy. Information is scanty regarding potential selection biases, in particular regarding familial ressemblance in epidemiological surveys of this kind.

METHODS

Asthmatic probands (adult and paediatric) were recruited in chest clinics of six clinical centres. Controls were mostly population-based (electoral rolls) for adults and recruited in surgery departments for children.

RESULTS

The population examined includes 348 nuclear families ascertained by one asthmatic and 416 controls, totalling 1847 subjects (EGEA I) and an additional sample of 40 families ascertained by two asthmatic siblings (EGEA II). Potential biases for the various types of analyses have been studied. Quantification of the consequences of the greater participation of probands with a parental history of asthma shows it does not introduce a major bias in the estimates of familial resemblance. Cases and controls showed a good comparability regarding sex, age, area of residence and familial geographical origin, allowing proper associations studies for environmental and candidate genetic factors.

CONCLUSIONS

The case-control component of the study will allow to perform studies on environmental factors and association studies for various genetic polymorphisms. Using the family base collected, segregation and genetic linkage/association analyses with DNA markers may be performed.

Kinetics of plasma cytokine levels in children hyposensitized with wasp venom

Specific immunotherapy shifts immune responses towards a Th0/Th1 response. Production of chemokines is also decreased early after the initiation of rush venom immunotherapy. We aimed to investigate in vivo whether cytokine plasma levels reflect the shift towards a Th0-Th1 pattern of immune response as seen in vitro in lymphocytes from patients undergoing venom immunotherapy. Therefore, we studied plasma levels of various cytokines before (day 1), during (day 2), and after (day 4) rush immunotherapy in nine wasp-allergic children. The levels of interleukin-5 and IFN-gamma were below the detection threshold. No variations were observed in levels of interleukin-4, interleukin-10, and TNF-alpha. In contrast, mean levels of RANTES transiently increased at day 2, and decreased below the pretreatment levels at day 4. Those alterations were significant in five children with high levels of RANTES at day 1, and reporting severe anaphylaxis. In the four other children, the levels of RANTES were not significantly increased at day 4. These results suggest that RANTES plasma levels are positively correlated with the severity of the reaction to hymenoptera venom, and that a significant decrease in the levels of RANTES occurs only in children with high pretreatment levels. However, the kinetics of RANTES plasma levels correlated neither with the results of allergological tests, nor with the outcome of venom immunotherapy.

Increased bronchoalveolar lavage CD8 lymphocyte subset population in wheezy infants

Episodes of wheezing are very common in infancy but, despite their high prevalence, their mechanism is still poorly understood. To better understand the airway inflammation of wheezing infants, we examined cells of the bronchoalveolar lavage (BAL), focusing on the phenotype of lymphocytes and macrophages by using cytofluorimetry. Twenty-one wheezers (mean age 15.4 months) and seven non-wheezers (mean age 24.1 months) were studied. BAL was collected at fiberoptic bronchoscopy. Total and differential cell counts were similar in both populations. Eosinophils were not detected in the BAL fluid. The cell-surface markers CD2, CD3, CD4, CD7, CD8, CD19, and CD45 were studied for the lymphocyte sub-population analysis. The cell-surface markers CD14, CD54, CD62L, and human leucocyte antigen (HLA)-DR were studied for the macrophage sub-population analysis. A significant increase in the CD8(+) lymphocyte population (p = 0.03) was observed in wheezers (median 43.1%, 25-75% percentile: 30.1-54.9%), as compared to non-wheezers (median 29.3%, 25-75% percentile: 13.5-34.7%). A significantly (p = 0.04) decreased expression of HLA-DR (mean fluorescence intensity [MFI]) was detected in the macrophage population of the wheezers (median MFI, 7,016; range 2135-7986), as compared to non-wheezers (median MFI, 8,369; range: 6478-8860). The results of the present study suggest that viral infection may have induced a CD8(+) response in BAL cells.

Cardiopulmonary exercise testing in children: an individualized protocol for workload increase

OBJECTIVES

To investigate the feasibility of individualized workload increments, as used in adults, for exercise testing in children; and to investigate whether this individualized protocol makes it possible to satisfy the usual criteria for maximal exercise (clinical exhaustion, predicted maximum heart rate [HRmax], oxygen uptake [O(2)] plateau, maximal respiratory exchange ratio > 1.1).

DESIGN

Prospective clinical study.

SETTING

Pediatric exercise testing laboratory.

SUBJECTS

Ninety-two children aged 5 to 17 years with various cardiac and respiratory diseases (33 with asthma, 11 with bronchopulmonary dysplasia, 6 with cystic fibrosis, 10 with congenital heart disease, and 32 miscellaneous).

INTERVENTIONS

Individualized maximal incremental exercise testing. The increase in workload was adapted to the individual and was calculated from predicted maximal oxygen uptake (O(2)max) for each child. The test lasted 10 to 12 min.

RESULTS

The exercise test was well tolerated by all children and was maximal in all but seven patients. A total of 65.7% of children reached the predicted O(2)max and 68.4% satisfied the criteria for a O(2) plateau at peak exercise. The predicted HRmax was achieved in all but two children. The mean maximal respiratory exchange ratio was 1.06.

CONCLUSION

The individualized protocol for increasing workload, based on O(2) rather than power, was well tolerated by children. In our view, the best two criteria for assessing the maximality of the tests were clinical exhaustion and HRmax, especially if the O(2) plateau was not reached. These results suggest that individualized protocols could be used instead of standardized tests for exercise testing in children.

Increased eosinophil cationic protein levels in bronchoalveolar lavage from wheezy infants

Although studies examining the serum suggest a role for eosinophils in wheezing episodes in infants and toddlers, the presence of a chronic eosinophilic inflammation within their airways remains to be demonstrated. In this study we investigated whether eosinophil cationic protein (ECP) levels are increased in BAL fluid (BALF) from infants and toddlers with recurrent wheezing episodes, during an asymptomatic period. The levels of ECP in BALF were quantitated by radioimmunoassay in 61 children (36 with severe recurrent episodes of wheezing and 25 who were non-wheezy), aged 6-36 months, in whom flexible bronchoscopy was clinically indicated. BALF eosinophil counts were < or = 1% in all patients and did not differ in wheezers, compared to non-wheezers. In contrast, ECP levels in BALF were > or = 2.2 micrograms/l in 18 of 36 (50%) wheezy infants but in only three of 25 (12%) control infants (p < 0.01). Neutrophil counts were significantly higher in the wheezer group than in the non-wheezer group (8.1 x 10(3) cells/ml vs. 3.0 x 10(3) cells/ml). ECP levels in the BALF were not correlated with the absolute number of eosinophils (r = 0.03; p = 0.8) but were correlated with the absolute number of neutrophils (r = 0.54; p = 0.001). There was no association between high ECP levels in BALF and the atopic status of the wheezers. In conclusion, ECP levels are increased in BALF from young children with recurrent wheezing episodes, even during relatively quiescent periods, suggesting a chronic increased cell activation in the lower airways.

Blood histamine levels (BHL) in infants and children with respiratory and non-respiratory diseases

BACKGROUND

Blood histamine levels are decreased after severe allergic reactions and in various chronic diseases.

AIMS

To study blood histamine levels in infants and children with acute infectious and non-infectious, non-allergic, disease.

METHODS

Blood histamine levels were investigated by a fluorometric method in infants and children admitted to hospital with bronchiolitis, non-wheezing bronchitis, acute infections of the urinary tract, skin and ear-nose-throat, gastroenteritis, or hyperthermia of unknown aetiology. Results of blood histamine levels and white blood cell counts were compared with those obtained for children recovering from benign non-infectious, non-allergic illnesses.

RESULTS

As compared with control children, white blood cell numbers were significantly increased in children with acute infections of the urinary tract, skin and ear-nose-throat, and were significantly decreased in children with gastroenteritis. Blood histamine levels were significantly lower in children with gastroenteritis and hyperthermia than in children with other diseases and control children. It was not possible to correlate blood histamine levels and the number of blood basophils.

CONCLUSIONS

BHL are significantly decreased in infants and children with acute gastroenteritis and hyperthermia of unknown aetiology. The mechanisms responsible for the decrease in blood histamine levels in children with gastroenteritis and hyperthermia are discussed.

Spontaneous pneumomediastinum in children

SUMMARY. Spontaneous pneumomediastinum (SPM) is rare in children, mainly affecting male adolescents. It is usually secondary to alveolar rupture in the pulmonary interstitium, followed by dissection of gas towards the hilum and mediastinum. Many pathological and physiological events can lead to alveolar rupture, but the most common cause in children is asthma. The clinical diagnosis is based on the symptom triad of chest pain, dyspnea, and subcutaneous emphysema, and is also based on Hamman's sign. The diagnosis is confirmed by chest radiography. The main differential diagnosis is esophageal perforation, which requires an esophagogram with contrast when there is the slightest doubt in the diagnosis. Spontaneous pneumomediastinum generally resolves spontaneously within a few days, meaning that ambulatory treatment is usually appropriate. Management consists of treating the underlying cause (if identified), rest, analgesics, and simple clinical monitoring. Predisposing factors should be identified and controlled to prevent recurrence. Cases of idiopathic SPM necessitate diagnostic pulmonary function tests after the acute episode, to establish whether the child has asthma.

Early use of inhaled corticosteroids in infancy

The inability to accurately predict the outcome of infants with recurrent wheezy bronchitis makes the early use of inhaled corticosteroids (ICS) controversial. Data from bronchoalveolar lavages and epidemiological surveys suggest a persistent inflammation of the airways in the more severe cases. Prospective studies, mostly with nebulized corticosteroids, have demonstrated clinical efficacy on daytime and nightime symptoms, reduced requirements for rescue bronchodilators and a real steroid sparing effect. In infants with episodic viral-associated wheeze with or without interval symptoms, ICS use carries the risk of overtreatment and of adverse effects. Long-term prospective studies are urgently required to assess the efficacy and safety of ICS and their possible effects on the natural history of infantile asthma.

Genome screen for asthma and related phenotypes in the French EGEA study

A genome-wide search was conducted in 107 nuclear families with at least two siblings with asthma, as part of the French EGEA study. A two-stage analysis strategy was applied to the 107 families divided into two independent subsets of 46 and 61 families, where all regions detected in the first set of families were tested for replication in the second set. In addition, all regions reported by published genome scans in different populations were examined in the total sample. A total of 254 markers were typed in the first set of families and 70% of them in the second set. Linkage was investigated by model-free methods for asthma and four asthma-related phenotypes: bronchial responsiveness (BR), skin test response, total immunoglobulin E (IgE) levels, and eosinophil count. The two-stage analysis led to the detection of three regions: 11p13 for IgE, 12q24 for eosinophils, and 17q12-21 for asthma and skin tests. Among the regions reported by published genome screens, seven were found in the 107 French EGEA families: three being already detected by the two-stage analysis, 11p13 (p = 0.005), 12q24 (p = 0.0008), and 17q12-21 (p = 0.001), and four additional ones, 1p31 (p = 0.005) for asthma, 11q13 (p = 0.006) for IgE, 13q31 (p = 0.001) for eosinophils, and 19q13 (p = 0.02) for BR.

Usefulness of sniff nasal pressure in patients with neuromuscular or skeletal disorders

Inspiratory muscle strength is an important variable in patients with neuromuscular or skeletal disorders. It is usually assessed by measuring maximal inspiratory pressure (PI(max)), but this test may prove difficult for some patients, and low values may originate from incomplete effort or air leaks. We assessed the usefulness of the novel sniff nasal pressure (Pn(sn)) test in 126 patients with a neuromuscular or a skeletal disorder, aged 5 to 49 yr. Pn(sn) was measured in an occluded nostril during maximal sniffs performed through the contralateral nostril. All patients performed the Pn(sn) maneuver easily, whereas 10 young and weak patients with neuromuscular disorders could not perform the PI(max) maneuver. Data were analyzed for the 116 patients who could perform both tests (92 patients with neuromuscular and 24 with skeletal disorders). When expressed as percents of the predicted values, Pn(sn) was similar to PI(max) in patients with neuromuscular disorders (54 +/- 25% predicted [mean +/- SD] versus 52 +/- 24% predicted), and was higher than PI(max) in patients with skeletal disorders (70 +/- 25% predicted versus 61 +/- 27% predicted, p < 0.05). Pn(sn) appeared to be the main determinant of VC in patients with neuromuscular disorders, whereas the Cobb angle and PI(max) were the main determinants of VC in patients with skeletal disorders. We conclude that inspiratory muscle strength can be easily assessed with Pn(sn) in children and adults with various neuromuscular and skeletal disorders. This new muscular parameter appears particularly useful in neuromuscular disorders, in which it represents a major determinant of VC.

Long-term outcome of idiopathic pulmonary hemosiderosis in children

We retrospectively analyzed the long-term outcome of idiopathic pulmonary hemosiderosis (IPH) in 15 children. IPH started at a mean age of 5 years, and the mean duration of follow-up was 17.2 years (range, 10-36 yr). Four patients developed immune disorders, 3 cases of rheumatoid polyarthritis or rheumatoid polyarthritis-like diseases and 1 case of celiac disease. Respiratory outcome showed that 3 patients had severe symptoms: 2 patients developed severe pulmonary fibrosis resulting in major chronic respiratory insufficiency, and 1 patient had severe asthma. Twelve patients (80%) had mild or no respiratory problems and were able to lead a normal life. According to chest X-ray and pulmonary function test data, 4 patients had normal chest X-ray and no evidence of restrictive syndrome, 6 patients had an interstitial pattern on chest X-ray and evidence of restrictive pattern, 1 patient had an interstitial pattern but normal lung function, and 1 patient had a normal chest X-ray but evidence of mixed obstructive and restrictive pattern. Our results show that long-term survival is possible in patients with IPH. Factors of poor prognosis seem to be the presence of antineutrophil cytoplasm antibodies (ANCA) or other autoantibodies. No other clinical or biological predictive factors for prolonged survival were found.

Value of open lung biopsy in immunocompromised children

OBJECTIVES

To determine the value of open lung biopsy (OLB) in terms of diagnosis, morbidity, mortality, and benefits in immunocompromised children with pulmonary involvement.

STUDY DESIGN

We retrospectively reviewed 36 OLBs performed in 32 immunocompromised children between 1985 and 1998. Seventeen biopsies were performed in patients with primary immunodeficiency syndromes and 19 in patients with secondary immunodeficiency syndromes. Twenty-eight biopsies were performed because of a lack of response to ongoing antimicrobial treatments with negative or positive findings on bronchoalveolar lavage (BAL) and a deteriorating clinical or radiologic course, and 8 biopsies were performed because of persistent chest x-ray infiltrates.

RESULTS

Diffuse pulmonary infiltrates were observed on chest x-ray in 28 cases, hyperinflation in 3 cases, and nodular infiltrates in 5 cases. A histopathologic diagnosis was possible for all 36 OLBs. Specific diagnosis was obtained in 22 (61%) (12 infectious agents, 6 tumors, 4 bronchiolitis obliterans) and non-specific diagnosis in 14 (39%). Fungi were the main infectious agents (8 of 12). For the diagnosed infections, BAL provided 4 true-positive, 3 false-positive, and 6 false-negative results. Specific treatment was changed in 77% of cases, providing real benefits in 12 (33%) cases. The morbidity and overall mortality rates were 31% and 33%, respectively. The mortality rate was significantly higher in the first 30 days after OLB in patients receiving ventilatory assistance (58%).

CONCLUSIONS

OLB in immunocompromised children with deteriorating clinical or radiologic course is a sensitive diagnostic tool.

Prevalence of DSM IV anxiety and affective disorders in a pediatric population of asthmatic children and adolescents

A series of 82 children and adolescents with moderate and severe persistent asthma was studied. Their psychopathological problems were compared to those of 82 healthy subjects, matched for age, sex and socio-economic status. The patients completed the Child Depression Inventory, an inventory of fears and anxiety (ECAP) and the Coopersmith Self Esteem Inventory. Parents of asthmatic children filled in the Child Behavior Check List to assess their social competence. The patients were examined with the revised Kiddie Schedule for Affective Disorders and Schizophrenia. There were more anxiety symptoms in the asthmatic group than in the control group. Asthmatics were not significantly more depressed than controls and their self-esteem was as good. We found 29 anxiety disorders, four affective disorders and four disruptive behavior disorders. Generalized anxiety disorder was the main diagnosis (n=24). The asthmatic subgroup presenting anxiety and affective disorders had poorer self esteem, fewer activities and worse social competence than other asthmatics and controls. Adolescents did not seem to have more emotional disturbances than younger patients. Girls did not have more DSM IV anxiety or affective disorders than boys.

The role of inflammation in childhood asthma

The role of inflammation in adult asthma is well known, involving a cascade of immunological stimulation in which mast cells and eosinophils play pivotal roles. However, the assessment of airway inflammation in children is more difficult as the invasive methods used in adults cannot ethically be used for this purpose alone. Nevertheless, limited data from studies using invasive methodology, and studies using novel non-invasive techniques such as sputum induction and nitrous oxide exhalation, are improving knowledge. The immunopathology in childhood asthma appears to mirror that in adult sufferers. The inflammatory processes are evident at an early age in wheezing infants who later develop asthma, and there are different "wheezing phenotypes" in children with atopic asthma or viral associated wheeze. The mechanisms underlying childhood asthma are dependent not only on increased numbers of inflammatory cells in the airways, but also increased activation of these cells. In vitro data have shown that corticosteroids can inhibit the secretion of proinflammatory compounds from alveolar macrophages, suggesting a potential important role for these agents in halting the development of asthma. Techniques for measuring inflammation in infants need to be refined, in order to provide increased knowledge and accurate monitoring of the disease. It is hoped that this will enable the development of early interventions to minimise the impact of asthma in infants who are identified as being susceptible.

[Asthma and the child below 5 years of age: diagnosis and treatment]

Asthma is the most frequent chronic disease in pediatrics and the increase in its prevalence is a major public health problem. Diagnosis may be difficult in the young child, symptomatology most often occurring following a viral infection. It is important not to ignore a foreign body in the airways or fibrocystic disease and asthma remains, particularly in infants, a diagnosis of elimination. Misdiagnosis or insufficient treatment of asthma may risk the development of irreversible histological lesions and also could compromise pulmonary growth and the child's lung reserve. Spacer devices and nebulisers enable inhaled therapy to be administered to very young children. The value of early diagnosis is to institute appropriate treatment notably in severe asthma with inhaled corticosteroid therapy, the aim being to reduce remodelling lesions of the airways. The minimal effective dose should be defined to minimalise side-effects. The treatment of asthma is not restricted to pharmacotherapy: attempts should be made to reduce intercurrent viral infections, domestic pollution (including smoking) and allergenic concentrations. However, as for all chronic diseases, the clinician will encounter poor compliance. The work of education and support of health professionals is fundamental to the management of asthma.