[Value of ipratropium bromide in asthma crisis in children]

Ipratropium bromide is a synthetic derivative of atropine with little absorption when used in inhalation, and therefore little secondary effects. The authors review its pharmacological properties and therapeutic efficacy in the treatment of asthma in children. Combined nebulized inhalation of ipratropium bromide and beta 2 sympathomimetic results in a more efficient and more sustained bronchodilatation than beta 2 sympathicomimetic alone in the treatment of acute asthma in children. Ipratropium bromide should be usefully introduced in the therapeutic scheme of acute asthma in children. Further studies will be necessary in order to determine its efficacy and tolerance in infants.

Bronchiectasis in a child after acrolein inhalation

Acrolein is an unsaturated aldehyde produced by combustion of many organic compounds. Massive exposure may lead to severe pulmonary disease and possibly death. We report a case of intoxication in a 2-year-old boy; an 18-month follow-up showed development of obstructive bronchiolar disease with diffuse bronchiectasis.

Computed tomography with normal chest radiograph in tuberculous infection

Children with primary tuberculosis infection without disease must be identified and treated preventively to avoid an increase in the incidence of tuberculosis in children. However, the recognition of infected cases without disease is often difficult. In particular, minimal active disease may be present in many cases but unrecognised on chest radiography. Computed tomography was therefore performed in 15 children with tuberculous infection and a normal chest radiograph to measure the size of their mediastinal lymph nodes. Ten control children without tuberculosis were also evaluated. When compared with controls it was found that nine of 15 (60%) infected children had enlarged lymph nodes. Adenopathies were more frequent in infected children less than 4 years old than in those over 8 years old. The demonstration of unrecognised active disease in many infected children raises the question of the adequate treatment for these children. It is proposed that a two drug regimen would be more appropriate than isoniazid alone in these cases.

Value of ELISA using antigen 60 for the diagnosis of tuberculosis in children

We evaluated the possible value of enzyme-linked immunosorbent assay (ELISA) using antigen 60 (A60) for improved diagnosis of tuberculosis in children. Results obtained in 31 children with active tuberculosis and in 16 patients with tuberculous infection without disease were compared with the results of 198 control subjects with no mycobacterial disease. In control children, anti-A60 IgG increased with age and the optical density (OD) in ELISA assays rose from .079 +/- .053 (OD +/- SD) in children younger than 5 years old to 0.146 +/- 0.082 OD in children older than 5 years. In control subjects younger than 2 years old, IgG OD values were significantly higher in BCG-vaccinated children than in nonvaccinated children. At a chosen specificity of 98 percent, a positive serodiagnosis was observed in 68 percent of children with clinically active tuberculosis. In these children with active disease, smears were positive in only 26 percent of cases and mycobacterial cultures yielded the organism in 45 percent of cases. None of the infected children without disease had high IgG OD values. IgM measurements were also evaluated. Mean values from control and diseased children overlapped, leading to a low sensitivity (19 percent) in children with clinically tuberculosis active. We conclude that anti-A60 IgG measurement is a rapid and low-cost technique that enhances the diagnosis of clinically active tuberculosis in children and may distinguish recent infection without disease from infection with disease.

[Vaccinations of children allergic to eggs with vaccine prepared with egg]

BACKGROUND

The mumps, influenza, yellow fever and measles vaccines are grown in chick-embryos. Because allergic reactions to these vaccines have occasionally been reported in children who have suffered anaphylaxis from egg ingestion, it has been claimed that these children should not receive such vaccines.

PATIENTS AND METHODS

17 egg-allergic children aged 1 year 1 month to 7 years 10 months (mean 2 years 4 months) were studied. All had developed an allergic reaction less than one hour after egg ingestion. Allergy was confirmed by skin testing (prick skin test) and detection of IgE antibodies to egg (RAST).

RESULTS

Seven children were immunized normally by their general practitioner, who was not aware of their allergy; 8 children having negative prick skin and intradermal tests with the vaccine were also immunized normally while 2 children who had positive intradermal test with the vaccine received divided doses following a protocol established for this study. None of these 17 egg-allergic children developed local and/or general reactions. Reintroduction of egg (yolk then white) was tested on the day of immunization in 4 children: only one developed facial edema.

CONCLUSION

This protocol permits these vaccines to be safely given to egg-allergic children.

Serum bactericidal test as a prognostic indicator in acute pulmonary exacerbations of cystic fibrosis

The serum bactericidal test has been used for many years for optimal assessment of the efficacy of antibiotic therapy in patients with infective endocarditis and other bacterial infections. Its capacity to predict the bacteriological outcome of acute pulmonary exacerbations in patients with cystic fibrosis was evaluated. A total of 54 courses of intravenous antibiotic therapy were analyzed in 22 patients, whose ages ranged from 4 months to 24 years (mean age: 10 years). The serum bactericidal activity of blood samples, taken at expected peak and trough antibiotic levels on day 4 of therapy, were determined against the potentially pathogenic strains isolated in sputum at the time of admission. For 104 isolates (64 Pseudomonas aeruginosa, 28 Staphylococcus aureus, and 12 Haemophilus influenzae strains), the peak and trough bactericidal titers were compared to bacteriological outcome. Bacteriological success was defined as a decrease of 2 log10 units or more in the bacterial density in sputum between days 0 and 7 of therapy. At peak antibiotic levels, serum bactericidal titers of 1:128 or more were 96% (all isolates) and 89% (P aeruginosa isolates), predictive of cure, whereas serum bactericidal titers of less than 1:16 were 100% predictive of failure for all infecting bacteria. In patients aged less than 18 years, the best peak titer for predicting success was 1:64, with a predictive value of 96% for titers of 1:64 or greater. The peak titer that best predicted success in patients aged 18 years or more was 1:128, with a predictive value of only 83% for titers of 1:128 or greater.(ABSTRACT TRUNCATED AT 250 WORDS)

[Toxicity of fire smoke. Apropos of 2 pediatric cases]

BACKGROUND

Smoke inhalation is one of the main cause of respiratory problems in fire-related accidents.

CASE REPORTS

Case 1. A girl, aged 11 months, was found in her apartment 15 minutes after the start of accidental fire. She was in a stage I coma with cyanosis and covered with soot. She was placed on oxygen and given hydroxocobalamin. Aggravation of respiratory problems led to mechanical ventilation. Tracheobronchoscopy showed deposits of soots with moderate burnt lesions. Intubation was discontinued 12 hours later, but the child remained oxygen-dependent, with persistent tracheobronchitis, despite steroid therapy for 2 weeks. Case 2. Another girl, aged 4 1/2 years, was found in the same room as the preceding patient. She was also covered with soot, and in a coma (Glascow score = 11). She was intubated, placed on mechanical ventilation, and given hydroxocobalamin. Tracheobronchoscopy revealed similar changes to those seen in the preceding patient. Despite repeated tracheobronchial washings and steroid therapy, respiratory problems persisted with thoracic distension and pneumothorax. Mechanical ventilation was discontinued 16 days later but at 5 1/2 years, this child still has dyspnea and has developed bronchiectasis.

CONCLUSION

Bronchopulmonary changes can be a severe complication of smoke inhalation during fires, and require early mechanical ventilation and repeated tracheobronchoscopy.

[The asthmatic child]

Asthma is the most frequent chronic pediatric disease. Management is based on assessment of severity and should normalize lifestyle as well as pulmonary function. Mild asthma is treated with intermittent beta-2-agonists. Moderate asthma should receive non-steroids prophylactic anti-inflammatory drugs. Immunotherapy should be considered. Severe asthma requires inhaled steroids. At each stage inhaled medications should be preferred. Therefore inhalation delivery system must be adapted for children of different ages and degree of dyspnea. The importance of environment control is well recognized. Establishing a partnership with the child and its family and with the medical staff and with the child's school is always necessary.

Rejection in lung transplantation--an immunohistochemical study of transbronchial biopsies

The number, distribution, and phenotype of mononuclear cells infiltrating the allograft lung transplant were determined immunohistochemically with monoclonal antibodies directed against cellular antigens (CD3, CD4, CD8, CD22, CD25, CD16, CD56, CD68, HLA-DR) on frozen sections of transbronchial biopsies. Seventy-two transbronchial biopsies from 21 patients undergoing lung or heart-lung transplantation were evaluated histologically and immunohistologically in a prospective study. Four major results were obtained in the graft lung parenchyma: (1) whatever the histological grading of rejection, T lymphocytes expressing CD3 were present and in a significantly higher number than in control subjects (P < 0.0005); (2) there was a positive correlation between histological rejection and the number of CD3+, CD8+, CD25+, CD16+ cells (P < 0.01); (3) the CD4/CD8 ratio was inverted (0.52 +/- 0.04), with no correlation with the histological rejection; and (4) the number and location of CD3+, CD25+ cells did not correlate with CMV identification in bronchoalveolar lavage. Immunohistochemical criteria could be used for diagnosis of rejection in the management of heart-lung transplantation.

Could saliva stand for plasma in theophylline monitoring in asthmatic children? Still a controversial problem

Theophylline determination in saliva was proposed several years ago as a convenient and non-invasive alternative to monitoring plasma in children and adults. Published data demonstrated that theophylline saliva concentration linearly correlates plasma concentration. However, the variability found in interindividual serum/saliva ratios and the wide scattering among the data points precluded the clinical use of saliva for theophylline monitoring. The purpose of this study was to compare different standardized methods for obtaining stimulated saliva intending to reduce the variability in plasma/saliva ratios and to determine the most reliable one. A group of 150 ambulatory chronic asthmatic 4.5 to 20.83 (10 +/- 3.7; M +/- SD) year-old patients receiving theophylline 6.85 +/- 1.88 mg/kg every 12 h as slow release preparations for 4 to 100 days was studied. One ml venous blood and salivary specimens were simultaneously collected 5.15 +/- 0.36 h after the morning maintenance dose. In a subgroup of 75 patients, saliva was collected using first a new device called salivette, immediately followed by the collection of an expectorated sample 30 s after citric acid crystals stimulation. In the other patients saliva was collected using citric acid containing salivette. Theophylline concentration was determined using HPLC. For all types of saliva collection, salivary and plasma theophylline concentrations correlated significantly. However whichever method was used, based on the -2 to +2 SD interval, a large range of plasma theophylline was predicted from a single salivary theophylline concentration. Despite a further standardization of the sampling of saliva, saliva theophylline could not accurately predict plasma concentration.

Dissociation of symptom scores and bronchial hyperreactivity: study in asthmatic children on long-term treatment with inhaled beclomethasone dipropionate

The aim of the study was to evaluate the effects of inhaled steroids (IS) on the improvement of clinical asthma symptoms and on the decrease in bronchial hyperreactivity (BHR). Twenty-four children with severe asthma were given 1,000 micrograms beclomethasone dipropionate (BDP) daily and compared with ten asthmatic control children. The study included the evaluation of daily clinical score, of exercise induced asthma, of bronchial obstruction (forced expiratory volume in 1 sec, FEV1), and of BHR at months 0, 1, 2-3, and 4-5 (M0, M1, M2-3, and M4-5). BHR was assessed by standardized inhaled carbachol provocation measuring plethysmographic specific airway resistance (SRaw). The carbachol dose causing a 40% decrease in specific conductance (SGaw) was determined (PD40 SGaw). Clinical scores decreased at M1 (P less than 0.01) and throughout the study. FEV1 increased at M1 (P less than 0.05), M2-3 (P less than 0.01), and M4-5 (P less than 0.05) compared to M0. PD40 SGaw only increased significantly at M1 and M2-3. No individual correlation was found between clinical scores and PD40 SGaw at any testing, or between the decrease of clinical scores and the decrease of BHR. We conclude that bronchoconstrictive challenge tests do not adequately assess the clinical efficacy of IS. In clinical practice non-specific BHR should be preferentially measured for diagnosing atypical forms of asthma.

Partial and massive lung lavages in an infant with severe pulmonary alveolar proteinosis

Pulmonary alveolar proteinosis is a rare disease of unknown etiology, characterized by progressive respiratory failure. Lung lavage has only been applied in a few children. A 6 month old boy suffering from severe pulmonary alveolar proteinosis was treated with three lung lavages. The first two were partial (or unilateral) lavages; a 3.5 mm flexible bronchoscope was introduced adjacent to a no. 3 cuffed endotracheal tube. This procedure allowed selective ventilation of one lung, and contralateral lung lavage. Respiratory improvement was observed during 1 week after the two procedures. At the third lavage we used partial veno-venous extracorporeal circulation because of severe respiratory failure. A significant improvement during the 5 following months was achieved. These results suggest that both partial and total lung lavage can be performed even in young infants and they may control the declining respiratory status in severe pulmonary alveolar proteinosis.

[Mucoviscidosis and allergic bronchopulmonary aspergillosis]

Allergic bronchopulmonary aspergillosis (ABPA) is a severe disease inducing bronchopulmonary anatomic lesions which complicate those already present in patients with cystic fibrosis. The frequency of this association is estimated between 0.6 and 10% according to American studies. Diagnosis of ABPA is difficult, as findings such as sibilant rales, pulmonary infiltrates, bronchiectasies, anti-aspergillus precipitins may be present as single features in patients with cystic fibrosis. Thus it is important to ascertain the diagnosis as oral corticosteroid treatment is the only one able to prevent evolution towards bronchiectasies and pulmonary fibrosis.

Ultrathin flexible bronchoscopy in neonatal intensive care units

Thirty seven flexible bronchoscopies were performed in 33 infants in a neonatal intensive care unit, using a 2.2 mm flexible ultrathin bronchoscope. Twenty eight procedures were performed via an endotracheal tube or tracheostomy and nine in spontaneously breathing infants. Indications for endoscopy included persistent atelectasis and/or emphysema (n = 21), unexplained acute respiratory distress (n = 10), stridor (n = 3), assessment of congenital abnormalities of the tracheobronchial tree (n = 2), and follow up of an endobronchial granuloma during the course of corticosteroid treatment (n = 1). Abnormal airway dynamics and/or abnormal structure were seen in 23 of 37 cases. In 54% of the procedures, the results of bronchoscopy had a direct effect on further management. The procedure was well tolerated and completed in less than two minutes. Our results suggest that the ultrathin flexible bronchoscope improves airway exploration and the understanding of respiratory disorders during the first months of life, particularly in ventilated infants.

The value of flexible bronchoscopy in childhood pulmonary tuberculosis

The value of 121 flexible bronchoscopy (FB) procedures was evaluated in 54 children, aged three months to 14 years, suspected of having pulmonary tuberculosis. Specimens from FB were culture-positive for Mycobacterium tuberculosis in seven of the 13 bacteriologically confirmed cases. Bronchial abnormalities consistent with the diagnosis were found in 31 of 54 cases. Separate or coexistent findings at initial FB included airway compression (20 cases), granulation tissue (ten cases), and obstructive caseum (four cases). Chest roentgenograms underestimated bronchial involvement in 14 children. Further FB monitoring documented disease evolution. The FB was important in the management of patients, as it (1) guided the use of prednisone therapy, especially in the children with a chest roentgenogram not suggestive of bronchial involvement; (2) indicated a need for resection of granulation tissue by rigid bronchoscopy (three cases); and (3) guided the surgical decision (two children with persistent bronchial obstruction). Thus, FB is a safe and valuable procedure in the management of childhood pulmonary tuberculosis.

Treatment of asthma with tulobuterol or albuterol in school-age children

The subjects were 40 children aged 6 to 16 years with stable chronic asthma; 20 were randomly assigned to receive 40 micrograms/kg of tulobuterol twice daily and 20 received 100 micrograms/kg of albuterol three times daily for three months. Patients were assessed by spirometry after the morning dose of medication at 0, 2, 4, 8, and 12 weeks of treatment. After initial dosing, the mean percentage increases in forced expiratory volume in one second (FEV1) were significantly higher in the tulobuterol-treated patients than in the albuterol-treated patients: at 30 minutes after dosing, the mean increase was 17.2% in the tulobuterol group and 5% in the albuterol group; at one hour, 20.3% and 6.8%. Similar results were found at 12 weeks. Mean changes in forced vital capacity and peak expiratory flow rate were similar to the changes in FEV1. Treatment side effects were reported by seven tulobuterol-treated patients and by four albuterol-treated patients. Tulobuterol treatment was withdrawn in one patient because of severe vomiting and headache of unknown cause. No changes in cardiovascular function were found in any patient. It is concluded that tulobuterol taken twice daily was more effective than albuterol taken three times daily in the treatment of asthma in children.

Bronchoalveolar lavage in HIV infected patients with interstitial pneumonitis

The value of taking microbiological and cytological specimens by flexible bronchoscopy and bronchoalveolar lavage under local anaesthesia was assessed on 43 occasions in 35 HIV infected children, aged 3 months to 16 years, with interstitial pneumonitis. In acute interstitial pneumonitis (n = 22, 26 specimens from bronchoalveolar lavages) the microbiological yield was 73%, Pneumocystis carinii being the commonest infective agent (n = 14). P carinii pneumonia was found only in children with deficient antigen induced lymphocyte proliferative responses who had not been treated with long term prophylactic co-trimoxazole. In contrast, in 13 children with chronic interstitial pneumonitis that was consistent with a diagnosis of pulmonary lymphoid hyperplasia who underwent bronchoalveolar lavage on 17 occasions, there were two isolates of cytomegalovirus and one of adenovirus, but P carinii was not found. Ten of the 13 children had normal antigen induced lymphocyte proliferative responses. Useful cytological data were also gleaned from bronchoalveolar lavage specimens. Lymphocytosis was significantly higher in pulmonary lymphoid hyperplasia (36(SD 11)%) than in P carinii pneumonia (24(19)%) whereas the percentage of polymorphonuclear neutrophils was significantly lower (3(2)% compared with 12(13)%). Flexible bronchoscopy with bronchoalveolar lavage is safe even in young infants and should reduce the necessity for open lung biopsy in the management of HIV infected children with interstitial pneumonitis.

Congenital ciliary aplasia in two siblings. A primitive disregulation of ciliogenesis?

Congenital ciliary aplasia was demonstrated in two siblings with clinical history of primary ciliary dyskinesia. Ultrastructural histochemistry of successive bronchial biopsies revealed the predominance of immature mucous cells and the total absence of ciliated or preciliated cells in the respiratory epithelium. This original disorder may represent a unique variant of primary ciliary dyskinesia with primitive disregulation of ciliogenesis.

[The Pierre-Robin syndrome. Classification and new therapeutic approach]

Rhombencephalic failure of the suction-swallowing, excess of central and obstructive ventilatory arrests with hypoxia and hypercapnia, vagal hypertonia and esophagogastric motor abnormalities are the new clinical signs observed in children presenting with the Pierre Robin's syndrome. A therapeutic management adapted to each of the types I, II, III of the syndrome were defined and a good nursery-nursing allowed a reduction in the mortality-rate from 27 to 5%. Still considered by some as a malformative and glossoptosing disorder whose etiology is only bucco-pharyngeal in origin, this syndrome, common to numerous embryopathies, is a precocious embryonal abnormality of the brain stem neurogenesis, expressed by the dramatic failure of the physiological oro-ventilation system. This syndrome appears to be a peculiar form of dysautonomia of the brain stem development with an uncertain future, often transitory, isolated or associated but in the heart of pediatric internal medicine and its multi-disciplinarity.

Value of bronchoalveolar lavage in the management of severe acute pneumonia and interstitial pneumonitis in the immunocompromised child

The diagnostic value of 73 bronchoalveolar lavages was assessed in 67 immunocompromised children (aged 3 months to 16 years) with pulmonary infiltrates. Thirty one children had primary and 19 secondary immune deficiency, 14 acquired immunodeficiency syndrome (AIDS), and three AIDS related complex. Bronchoalveolar lavage was performed during fibreoptic bronchoscopy, under local anaesthesia in all but two. One or more infective agents was found in eight of 11 patients with severe acute pneumonia and in 26 of 62 patients with interstitial pneumonitis. In interstitial pneumonitis, the most frequently encountered agents were Pneumocystis carinii (12), cytomegalovirus (8), and Aspergillus fumigatus (3). The yield was related to the severity of interstitial pneumonitis. The mean cellular count and cytological profile in lavage returns from patients with varying infective agents or underlying pathological conditions showed no significant difference, except in those children with AIDS and AIDS related complex who had appreciable lymphocytosis (mean percentage of lymphocytes 28 (SD 17]. In children with AIDS and chronic interstitial pneumonitis lymphocytosis without pneumocystis infection was observed in eight of nine bronchoalveolar lavage returns and was suggestive of pulmonary lymphoid hyperplasia. Finally, bronchoalveolar lavage produced a specific diagnosis from the microbiological or cytological findings in 44 instances (60%). Transient exacerbation of tachypnoea was observed in the most severely ill children but there was no case of respiratory decompensation attributable to the bronchoscopy. Bronchoalveolar lavage is a safe and rapid examination for the investigation of pulmonary infiltrates in immunocompromised children. It should be performed as a first line investigation and should reduce the use of open lung biopsy techniques.

[Diffuse mediastinal, retroperitoneal and hepatic neurofibromatosis in 4-year-old child. Value of puncture biopsy guided by computerized tomography]

A case of neurofibromatosis in a 4 year-old girl is reported. Extensive localization to mediastinum, retroperitoneal space and liver is particularly infrequent. Histological diagnosis was obtained through a needle biopsy of the retroperitoneal space and the liver under the control of CT scan X-ray. Prognosis seems to be related to the tracheal compression.

[Viruses and asthma]

More than one-third of infants with respiratory syncytial virus (RSV) bronchiolitis subsequently experience recurrent episodes of wheezing. In asthmatic children, viral infections frequently trigger asthmatic attacks. Indeed, viruses induce immunological and respiratory functional disorders. As compared with non-wheezing RSV infected infants, wheezing infants with bronchiolitis or asthma due to RSV have: a) increased T-lymphocyte responsiveness to RSV antigen; b) more persistent IgE bound to nasopharyngeal epithelial cells; c) higher titers of RSV-specific IgE and higher histamine concentrations in nasopharyngeal secretions. In children with an atopic constitution, virus infections may trigger allergic sensitization. Furthermore, some viruses enhance the immunologic and non-immunologic human basophil histamine release. Non-specific bronchial hyperreactivity, which is a fundamental feature of asthma, can also be observed to a variable degree in viral respiratory infections. Pulmonary function testing allows in vivo determination of bronchial sensitivity and bronchial reactivity (respectively threshold dose and dose-response curves). Four factors may be involved in bronchoconstriction: a pre-existing diminution of bronchial diameter (which is lacking in many studies); hyperplasia or hypertrophy of bronchial muscles (which is to be excluded in recent viral infections); a non-specific decrease in the threshold for stimulation of irritant receptors due to airway epithelial injury; a partial beta blockade. Further studies are needed to ascertain whether this bronchial hyperreactivity is congenital or acquired.

[Bronchopulmonary dysplasia]

A retrospective study of 2 125 preterm infants, who were ventilated at the Institut de Puériculture in Paris over 9 years (1974-1982) for respiratory distress at birth, showed that 45 (2%) developed clinical and radiological bronchopulmonary dysplasia (BPD): 8 minimal forms, 23 moderate forms and 14 severe forms, 30 of these patients survived (66%). The pathogenesis of this chronic respiratory disease is multifactorial: oxygen + pressure + duration + endotracheal intubation. Efforts should be made to limit the damaging effect of each of these factors, which should be kept down to the minimum values compatible with adequate oxygenation. The presence of emphysema and of a patent ductus arteriosus has also been incriminated, but they may reflect the severity of the initial lung lesion. Rickets, whose incidence was found to be 27%, majors respiratory distress. In the ensuing months, babies with BPD are susceptible to recurrent viral or bacterial respiratory tract infection, failure to thrive and cor pulmonale. The presence of the mother and the care of a psychomotor development specialist are needed for these infants who will be confined for months in conditions which are unsuited to their sensory, physical, emotional and cognitive development.

[Bronchiolitis obliterans: technics of exploration and diagnosis]

Bronchiolitis obliterans is an anatomo-clinical entity which may, in young pediatric patients, follow severe viral infections, especially due to measles virus and adenoviruses. After a transient remission, the disease progresses to chronic respiratory failure with dyspneic paroxysms. Diagnosis is based on different investigations which confirm the absence of proximal bronchiolar obstruction and the presence of bronchiolar obliteration. Deficient pulmonary perfusion due to ventilatory defects are demonstrated by pulmonary scintigraphy and even better by digital subtraction pulmonary angiography. Obliteration of non-cartilaginous bronchioli by granulation tissue produces bronchiolar destruction and explains the permenence of alterations. Dissimilarity of the responses of children to acute respiratory viral infection remains unexplained. The degree of the viral load and of the initial immune deficiency as well as the persistence of the virus within the pulmonary tissue probably account for the chronic pulmonary damage.

[Continuous treatment of asthma in children with theophylline retard]

Continuous sustained-release theophylline therapy was used in 61 children with severe asthma, aged 5 to 16 years. Mean treatment duration was 5 months 8 days (range: 8 days-16 months). The necessary dosage to obtain correct blood theophylline levels was 18 +/- 3.6 mg/kg/day (range: 10-31 mg/kg/day). The adaptation of the doses to blood theophylline levels and regular check-ups confirmed intrapatient variability and the dose-dependent disposition of theophylline. In 35 of the 42 children (82%) who were observed for more than 3 months, theophylline induced a decrease of the frequency of the attacks and a better attendance to school. Nine times out of 30, oral steroid administration or sustained-release cosyntropin injections could be stopped and in 15, the dosages could be decreased by at least 50%. Evaluations of pulmonary function, performed several times in 12 children, showed that theophylline induces significant bronchodilatation, mostly of the large bronchi.

[Measurement of blood theophylline levels in the child: will this affect methods of prescription? (author's transl)]

Twelve children aged between 2 and 13 years received an oral dose of 5 mg/kg of pure theophylline, and 28 children aged between 2 and 15 years were given 10 mg/kg/day of the same drug in 3 or 4 divided doses for 3 days. In the first group blood theophylline levels were higher than 10 microgram/ml, after 1 or 3 hours, in only 3 children, two of whom were receiving erythromycin at the same time. Six hours and 12 hours later, none of the serum levels were higher than 10 microgram/ml. In the second group, estimations were performed on the 4th day. At 8 a.m., when the last dose had been given 12 hours previously, blood theophylline levels were all less than 10 microgram/ml (mean: 4.03 +/- 0,88 microgram/ml). Two hours and four hours after the usual morning dose, serum levels of greater than 10 microgram/ml were found in respectively 35 and 25% of the children only. Since the bronchodilator effect of theophylline is optimal for serum levels of greater than 10 microgram/ml, the dose currently recommended in France (10 mg/kg/day) would thus appear to be insufficient in most instances. However, increase in individual doses must be guided by serum estimations, which make it possible to avoid complications related to overdosage.