A minimally invasive tool to study immune response and skin barrier in children with atopic dermatitis

BACKGROUND

Atopic dermatitis (AD) affects children of all skin types. Most research has focused on light skin types. Studies investigating biomarkers in people with AD with dark skin types are lacking.

OBJECTIVES

To explore skin barrier and immune response biomarkers in stratum corneum (SC) tape strips from children with AD with different skin types.

METHODS

Tape strips were collected from lesional and nonlesional forearm skin of 53 children with AD and 50 controls. We analysed 28 immunomodulatory mediators, and natural moisturizing factors (NMF) and corneocyte morphology.

RESULTS

Interleukin (IL)-1β, IL-18, C-X-C motif chemokine (CXCL) 8 (CXCL8), C-C motif chemokine ligand (CCL) 22 (CCL22), CCL17, CXCL10 and CCL2 were significantly higher (P < 0·05) in lesional AD skin compared with nonlesional AD skin; the opposite trend was seen for IL-1α. CXCL8, CCL2 and CCL17 showed an association with objective SCORing Atopic Dermatitis score. NMF levels showed a gradual decrease from healthy skin to nonlesional and lesional AD skin. This gradual decreasing pattern was observed in skin type II but not in skin type VI. Skin type VI showed higher NMF levels in both nonlesional and lesional AD skin than skin type II. Corneocyte morphology was significantly different in lesional AD skin compared with nonlesional AD and healthy skin.

CONCLUSIONS

Minimally invasive tape-stripping is suitable for the determination of many inflammatory mediators and skin barrier biomarkers in children with AD. This study shows differences between children with AD with skin type II and skin type VI in NMF levels, suggesting that some aspects of pathophysiological mechanisms may differ in AD children with light versus dark skin types.

Stability and predictiveness of multiple trigger and episodic viral wheeze in preschoolers

BACKGROUND

In 2008, the European Respiratory Society Task Force proposed the terms multiple-trigger wheeze (MTW) and episodic (viral) wheeze (EVW) for children with wheezing episodes. We determined MTW and EVW prevalence, their 24-month stability and predictiveness for asthma.

METHODS

In total, 565 preschoolers (1-, 2- and 3-year-olds) in primary care with respiratory symptoms were followed until the age of 6 years when asthma was diagnosed. MTW status and EVW status were determined using questionnaire data collected at baseline and after one and 2 years. We distinguished 3 phenotypes and determined their 24-month stability, also accounting for treatment with inhaled corticosteroids (ICS). Logistic regression was used to analyse the phenotypes' associations with asthma.

RESULTS

Two hundred and eighty-one children had complete information. MTW and EVW were stable in 10 of 281 (3.6%) and 24 of 281 (8.5%), respectively. The odds of developing asthma for children with stable MTW and stable EVW were 14.4 (1.7-119) and 3.6 (1.2-11.3) times greater than those for children free of wheeze (for at least 1 year). ICS was associated with increased stability of MTW and EVW.

CONCLUSIONS

Stable multiple-trigger and stable episodic viral wheeze are relatively uncommon. However, 1- to 3-year-olds with stable MTW are at much increased risk of asthma.

Exclusively breastfed infants at risk for false negative double blind placebo controlled milk challenge

The double blind placebo controlled food challenge (DBPCFC) is the gold standard for diagnosing cow's milk allergy (CMA). However, false-negative DBPCFC have been reported. We present 2 cases with a false negative DBPCFC in exclusively breastfed infants suspected of CMA. These cases highlight the occurrence of severe allergic reactions of infants who were exclusively breastfed. Several reported causes of a false negative DBPCFC will be discussed. However, there is currently no clear understanding of the cause of a false negative DBPCFC. This paper highlights that a negative outcome of a DBFCFC must be interpreted with caution, because a severe allergic reaction might occur upon re-introduction of cow's milk. Therefore, an additional open food challenge under medical supervision is recommended in exclusively breastfed infants with a negative DBPCFC.

Gain in lung function after weight reduction in severely obese children

AIM

The primary objective of this prospective cohort study was to determine the effect of weight loss on pulmonary function values in extremely obese children.

METHODS

Obese children participated in a 26-week in-hospital or outpatient multidisciplinary treatment programme. Waist circumference was measured and pulmonary function tests were performed at enrolment and after 6 months.

RESULTS

The data of 112 children were analysed. The children had a mean age of 14.4 (range 8.5-18.9) years and 62.5% were girls. The mean SD score-body mass index (SDS-BMI) was +3.38 at baseline and +2.91 after the intervention. Lung function improved significantly: functional vital capacity increased by 3.08% (95% CI 1.16% to 5.00%) of the predicted value, forced expiratory volume in 1 s (FEV(1)) by 2.91% (95% CI 1.11% to 4.71%) of the predicted value, total lung capacity by 2.27% (95% CI 1.16% to 5.00%) of the predicted value, and expiratory reserve volume (ERV) by 14.8% (95% CI 8.66% to 20.88%) of the predicted value. The increase in ERV correlated with the reduction in SDS-BMI and with the reduction in waist circumference. FEV(1) did not correlate with the reduction in either SDS-BMI or waist circumference.

CONCLUSIONS

Weight loss in severely obese children correlated with an improvement in lung function, especially ERV. The improvement in ERV correlated with the decrease in SDS-BMI and waist circumference.

Assessing quality of care in pediatric asthma: applicability of a revised version of the QUOTE-CNSLD questionnaire

AIM

To establish the validity and applicability of a revised version of the QUality Of care Through the patient's Eyes-Chronic Non Specific Lung Disease (QUOTE-CNSLD) instrument in a population of children with controlled and partly controlled asthma.

METHODS

Randomized controlled trial evaluating quality of care in three follow-up settings: follow-up by the general practitioner, the pediatrician, and the specialized asthma nurse, for a period of 2 years.

RESULTS

One hundred and seven children were recruited, 45 from general practice and 62 from hospital practice. The revised QUOTE-CNSLD instrument completed by parents at baseline (T0), after 1 year (T1) and after 2 years (T2) showed that a process-, a structure-, and an asthma-specific domain could be deduced (Cronbach's α of 0.81, 0.82, and 0.62). A separate five-item "child-specific" questionnaire about their caregiver, completed by children, has a Cronbach's α of 0.88. The revised instrument could discriminate between quality of care in different follow-up settings for children with stable asthma, and the asthma-specific domain showed particularly discriminative properties. Quality aspects with potential for improvement could be derived from the scores in all three study groups.

CONCLUSION

The revised QUOTE-CNSLD instrument is applicable in a pediatric population with stable asthma and it has discriminative value between different follow-up settings.

Cost-effectiveness model for a specific mixture of prebiotics in The Netherlands

The objective of this study was to assess the cost-effectiveness of the use of prebiotics for the primary prevention of atopic dermatitis in The Netherlands. A model was constructed using decision analytical techniques. The model was developed to estimate the health economic impact of prebiotic preventive disease management of atopic dermatitis. Data sources used include published literature, clinical trials and official price/tariff lists and national population statistics. The comparator was no supplementation with prebiotics. The primary perspective for conducting the economic evaluation was based on the situation in The Netherlands in 2009. The results show that the use of prebiotics infant formula (IMMUNOFORTIS(®)) leads to an additional cost of € 51 and an increase in Quality Adjusted Life Years (QALY) of 0.108, when compared with no prebiotics. Consequently, the use of infant formula with a specific mixture of prebiotics results in an incremental cost-effectiveness ratio (ICER) of € 472. The sensitivity analyses show that the ICER remains in all analyses far below the threshold of € 20,000/QALY.

CONCLUSION

This study shows that the favourable health benefit of the use of a specific mixture of prebiotics results in positive short- and long-term health economic benefits. In addition, this study demonstrates that the use of infant formula with a specific mixture of prebiotics is a highly cost-effective way of preventing atopic dermatitis in The Netherlands.

No detectable beneficial systemic immunomodulatory effects of a specific synbiotic mixture in infants with atopic dermatitis

BACKGROUND

In a murine model of allergic inflammation, Bifidobacterium breve M-16V has been shown to reduce IL-4 and IgE by inducing IL-10 and IFN-γ. However, it remains unknown whether this strain has the same effect in humans with allergic disease.

OBJECTIVE

To determine the effects of Bifidobacterium breve M-16V combined with a prebiotic oligosaccharide mixture (synbiotic) on atopic markers, ex vivo cytokine production by peripheral blood mononuclear cells (PBMCs) and circulating regulatory T cell percentage in infants with atopic dermatitis.

METHODS

In a double-blind, placebo-controlled multi-centre trial, 90 infants with atopic dermatitis, age <7 months, were randomized to receive an infant formula with Bifidobacterium breve M-16V and a mixture of short chain galactooligosaccharides and long chain fructooligosaccharides (Immunofortis(®) ), or the same formula without synbiotics during 12 weeks. At week 0 and 12, plasma levels of IL-5, IgG1, IgG4, CTACK and TARC, ex vivo cytokine responses by PBMCs and percentage of regulatory T cells, were determined.

RESULTS

There were no significant differences between the synbiotic and the placebo group in IL-5, IgG1, IgG4, CTACK and TARC levels and ex vivo cytokine production by anti-CD3/anti-CD28-stimulated PBMCs. With allergen-specific stimuli, we found a decreased IL-12p40/70 and IL-12p70 production in response to egg allergen (P = 0.04 and P = 0.01, respectively) and decreased IL-12p70 production in response to peanut allergen (P = 0.003) in the synbiotic compared with the placebo group. Circulating regulatory T cell percentage did not significantly differ between the groups.

CONCLUSIONS AND CLINICAL RELEVANCE

This synbiotic mixture has no detectable effect on plasma levels of the analysed atopic disease markers, ex vivo cytokine production and circulating regulatory T cell percentage in infants with atopic dermatitis, besides down-regulation of IL-12 production in egg- and peanut-stimulated PBMCs. These results do not support the use of this synbiotic in clinical practice.

Effects of a single dose inhaled corticosteroid on the dynamics of airway obstruction after exercise

RATIONALE

Exercise-induced bronchoconstriction (EIB) is defined as a transient narrowing of the airways induced by exercise. Repetitive measurements of spirometric parameters, such as FEV(1) and expiratory flows, and forced oscillation technique (FOT) measurements can be used to analyze the dynamics of EIB. A single high dose of fluticasone propionate (FP) protects against EIB. The aim of the study was to analyze the effect of FP on the dynamics of exercise-induced airway narrowing as measured with FOT and spirometry.

METHODS

Twelve children performed an exercise challenge on 2 separate days, 4 hr after inhalation of 1 mg FP (pressurized metered dose inhaler) or a placebo. Before and after the exercise flow-volume loops as well as the FOT (frequency range: 4-32 Hz) were measured.

RESULTS

The FEV(1) , and FEF(50) fell significantly after exercise within groups; the peak fall in FEV(1) after FP was significantly smaller than after placebo (respectively, 19.3 ± 14.6% and 29.2 ± 14.8%, P = 0.03, 95% CI: 0.9-18.8%). The fall in FEV(1) and FEF(50) peaked 3 min after exercise and showed a subsequent partial recovery. The fall in the FEV(1) /FVC ratio showed a later peak fall (12 min after exercise). The resistance increased while the reactance decreased significantly after exercise. FP significantly decreased the maximal increase in Rrs(6) when compared to the placebo (respectively 176.5 ± 59.1% and 201.0 ± 63.8%, P = 0.05, 95% CI: 0.5-48.7%). The maximal decrease in Xrs(6) was not significantly affected by FP (P = 0.06).

CONCLUSION

Repetitive spirometric and FOT measurements after exercise show a rapid narrowing and steady recovery of the patency of the conducting airways, and indicate a delayed and prolonged recovery of the smaller airways. A single high dose of inhaled FP seems to employ its effect mainly in the conducting airways.

Synbiotics prevent asthma-like symptoms in infants with atopic dermatitis

BACKGROUND

  Infants with atopic dermatitis (AD) have a high risk of developing asthma. We investigated the effect of early intervention with synbiotics, a combination of probiotics and prebiotics, on the prevalence of asthma-like symptoms in infants with AD.

METHODS

  In a double-blind, placebo-controlled multicentre trial, ninety infants with AD, age <7\ months, were randomized to receive an extensively hydrolyzed formula with Bifidobacterium breve M-16V and a galacto/fructooligosaccharide mixture (Immunofortis(®) ), or the same formula without synbiotics during 12 weeks. After 1 year, the prevalence of respiratory symptoms and asthma medication use was evaluated, using a validated questionnaire. Also, total serum IgE and specific IgE against aeroallergens were determined.

FINDINGS

  Seventy-five children (70.7% male, mean age 17.3 months) completed the 1-year follow-up evaluation. The prevalence of 'frequent wheezing' and 'wheezing and/or noisy breathing apart from colds' was significantly lower in the synbiotic than in the placebo group (13.9%vs 34.2%, absolute risk reduction (ARR) -20.3%, 95% CI -39.2% to -1.5%, and 2.8%vs 30.8%, ARR -28.0%, 95% CI -43.3% to -12.5%, respectively). Significantly less children in the synbiotic than in the placebo group had started to use asthma medication after baseline (5.6%vs 25.6%, ARR -20.1%, 95% CI -35.7% to -4.5%). Total IgE levels did not differ between the two groups. No children in the synbiotic and five children (15.2%) in the placebo group developed elevated IgE levels against cat (ARR -15.2%, 95% CI -27.4% to -2.9%).

CONCLUSION

  These results suggest that this synbiotic mixture prevents asthma-like symptoms in infants with AD.

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

There is poor agreement on definitions of different phenotypes of preschool wheezing disorders. The present Task Force proposes to use the terms episodic (viral) wheeze to describe children who wheeze intermittently and are well between episodes, and multiple-trigger wheeze for children who wheeze both during and outside discrete episodes. Investigations are only needed when in doubt about the diagnosis. Based on the limited evidence available, inhaled short-acting beta(2)-agonists by metered-dose inhaler/spacer combination are recommended for symptomatic relief. Educating parents regarding causative factors and treatment is useful. Exposure to tobacco smoke should be avoided; allergen avoidance may be considered when sensitisation has been established. Maintenance treatment with inhaled corticosteroids is recommended for multiple-trigger wheeze; benefits are often small. Montelukast is recommended for the treatment of episodic (viral) wheeze and can be started when symptoms of a viral cold develop. Given the large overlap in phenotypes, and the fact that patients can move from one phenotype to another, inhaled corticosteroids and montelukast may be considered on a trial basis in almost any preschool child with recurrent wheeze, but should be discontinued if there is no clear clinical benefit. Large well-designed randomised controlled trials with clear descriptions of patients are needed to improve the present recommendations on the treatment of these common syndromes.

Asthma beliefs among mothers and children from different ethnic origins living in Amsterdam, the Netherlands

Background

Doctors and patients hold varying beliefs concerning illness and treatment. Patients' and families' explanatory models (EMs) vary according to personality and sociocultural factors. In a multi-ethnic society, it is becoming increasingly significant that doctors understand the different beliefs of their patients in order to improve patient/doctor communication as well as patient adherence to treatment.

Methods

Twelve focus groups were formed, consisting of 40 children diagnosed with asthma, as well as 28 mothers of these children. These groups included mothers and children of different ethnicities who were living in Amsterdam, the Netherlands. In order to understand the beliefs that both mothers and children hold regarding asthma and its treatment, the explanatory models were analysed and compared.

Results

Study findings show that mothers and children, regardless of ethnicity and age, have their own EMs. Overall, there is a great deal of uncertainty related to the causes, consequences, problems, and symptoms of asthma and its treatment. It also seems that many concerns and feelings of discomfort are the result of lack of knowledge. For instance, the fact that asthma is not seen as a chronic disease requiring daily intake of an inhaled corticosteroid, but rather as an acute phenomenon triggered by various factors, may be very relevant for clinical practice. This particular belief might suggest an explanation for non-adherent behaviour.

Conclusion

A thorough understanding of the mothers' and children's beliefs regarding the illness and its treatment is an important aspect in the management of asthma. Gaining an understanding of these beliefs will provide a foundation for a solid clinician-patient/family partnership in asthma care. Although ethnic differences were observed, the similarities between the mothers' and children's beliefs in this multi-ethnic population were striking. In particular, a common belief is that asthma is considered an acute rather than a chronic condition. In addition, there is a lack of knowledge about the course and the self-management of asthma. Health care providers should be aware of these commonly held beliefs, and this information could be shared in educational programs.

Assessment of current serum levels of PCDD/Fs, dl-PCBs and PBDEs in a Dutch cohort with known perinatal PCDD/F exposure

As part of a longitudinal cohort study, now in its second decade, we determined PCDDs/Fs dl-PCBs and PBDEs in serum of adolescents with known perinatal PCDD/F exposure. Of the original cohort, 33 adolescents aged 14-19 years, who had been studied previously during their neonatal (n=60), toddler and pre-pubertal period (n=41) agreed to participate in the current follow-up. PCDD/F-, dl-PCB- and PBDE congeners were measured using GC/MS. Current serum levels of PCDD/Fs determined in our cohort were relatively low (mean of 2.2 pg/g) compared to the perinatal exposure. No correlation between perinatal exposure and current serum PCDD/F was found. Planar PCB TEQ levels were 2.2 pg/g. Current summation operatorPBDE levels were 8.7 ng/g lipid. There was one outlier with a summation operatorPBDE of 74 ng/g lipid. The presence of this high value indicates that the exposure pathway is different from PCDD/F and PCB, most likely by dust and food contaminated with dust. Concluding we can say that current PCDD/F levels are quite low compared to the perinatal PCDD/F exposure of the cohort. PBDE levels however are relatively high compared to other European countries, more research on possible health effects of these levels, especially for subjects with outlier concentrations, should be performed.

Bacille-Calmette-Guerin vaccination and the development of allergic disease in children: a randomized, prospective, single-blind study

BACKGROUND

The increase in the prevalence of allergic diseases in countries with a so-called western lifestyle may be due to a decrease in exposure to infectious agents in early life.

OBJECTIVE

To establish the effect of Bacille-Calmette-Guerin (BCG) vaccination in 6-week-old high-risk infants in a prospective single-blind, randomized, placebo-controlled trial on the prevalence of allergic disease at the age of 4 and 18 months.

METHODS

Subjects were 121 predominantly Caucasian high-risk newborns, having either a mother, or both a father and at least one sibling with past or present allergic disease. BCG or placebo was administered at the age of 6 weeks, and repeated once when both a post-vaccination scar and a positive TB skin test were absent at the age of 4 months.

RESULTS

At the age of 18 months, the prevalence of allergic disease was not significantly different between the two groups. A trend towards less eczema (P=0.07) and significantly less use of medication for eczema was shown in the BCG group compared with the placebo group (P=0.04).

CONCLUSION

A single (or once repeated) BCG vaccination in 6-week-old high-risk Caucasian infants was not associated with a 50% reduction in the prevalence of allergic disease. However, there could be a smaller beneficial effect of BCG, especially because a trend towards less eczema and significantly less use of medication for eczema was shown. For definite proof, a larger study should be carried out.

Residential exposure to mould and dampness is associated with adverse respiratory health

BACKGROUND

Indoor exposure to mould and dampness is frequently associated with asthma symptoms with and without lung function changes. However, the mechanisms contributing to this threat to respiratory health are only partly understood.

OBJECTIVE

To investigate the contribution of recent exposure to mould and dampness in the living room or bedroom to respiratory health in a general practice-based cohort of 526 asthmatic children.

METHODS

Parents were questioned about home characteristics, including moulds and dampness. The level of asthma control was evaluated in their participating children by means of asthma symptoms, peak expiratory flow (PEF) variability, severity of airway hyperresponsiveness (AHR), and medication usage.

RESULTS

Children exposed to indoor moulds and dampness more often had severe AHR compared with non-exposed (42% vs. 16%; P< or =0.001). They also showed an increased PEF variability (11.3% vs. 8.4%; P=0.03) and, however, not significant, more frequent asthma symptoms. The use of controller medication was not significantly different between exposed and non-exposed children. After adjustment for gender, age, smoking, exposure to parental smoking, parental education, pet ownership, presence of inhalant allergy, use of controller medication, health care center, and season of study assessment, the odds ratio for severe AHR in exposed children was 3.95 [95% confidence interval (CI): 1.82-8.57].

CONCLUSION

We found a consistent association between reported moulds and dampness in the living room or the child's bedroom and an increased risk for severe AHR in a general practice-based cohort of asthmatic children, even after adjustment for gender, presence of inhalant allergy, and use of controller medication.

Severe airway hyperresponsiveness was not predictable with the use of current tools in asthmatic children in general practice

OBJECTIVE

To evaluate whether moderate to severe airway hyperresponsiveness (AHR) could be suspected with the use of routinely available clinical and environmental information.

STUDY DESIGN AND SETTING

Cross-sectional study of asthma in 526 asthmatics aged 7-17 years and treated in general practice.

RESULTS

Moderate to severe AHR was present in 48% (n=253) of the participants. The presence of inhalation allergy, nocturnal symptoms, and usage of beta2-mimetics were significantly associated with moderate to severe AHR. If all three factors were present, the probability of the presence of moderate to severe and severe AHR was 76% and 36%, respectively. If all three were absent, the probability decreased to 11% and 5%, respectively. In 319 subjects (64%) AHR could not be adequately predicted with routinely available information.

CONCLUSION

Moderate and severe AHR could not be suspected with the use of routinely available clinical and environmental information in the majority of children. Except for a subgroup of children, our models were not helpful in deciding in which child an inhaled corticosteroid should be started or whether the dose should be increased or decreased. We recommend measuring the severity of AHR in these children by means of an inhalation challenge test.

QUOTAC: QUestionnaire On day and night Time respiratory symptoms in Asthmatic Children -- a validity study

The aim of this study was to validate the QUOTAC, a questionnaire on day and night time respiratory symptoms in asthmatic children. Validity was examined by measuring agreement between the QUOTAC and a self-report diary in children aged 6 to 16 years, divided in an asthma group and a control group. As an extra interest in our study a sum score was computed as a measure of the severity of asthma. This study shows that the QUOTAC is discriminative between asthmatic and healthy children and is a reliable and sensitive scale for measuring the severity of asthma. However, cut-off scores for mild, moderate, or severe asthma should be investigated in further research.

Beclometasone dipropionate extrafine aerosol versus fluticasone propionate in children with asthma

Beclometasone dipropionate (BDP) extrafine is a hydrofluoroalkane-based, chlorofluorocarbon (CFC)-free inhalation aerosol. This study was conducted to determine whether BDP extrafine and CFC-fluticasone proprionate (FP) aerosols were equivalent in terms of efficacy and tolerability in children with symptomatic mild-to-moderate asthma. Male and female patients (aged 5-12 yr) with an asthma diagnosis for > or =3 months, peak expiratory flow (PEF) > or =60% of predicted normal and suboptimal asthma control were randomised to double-blind treatment with BDP extrafine 200 microg day(-1) (n=139) or CFC-FP 200 microg day(-1) (n=141) for up to 18 weeks. After 6 and 12 weeks, study medication was 'stepped down' to 100 and 50 microg day(-1), respectively, if patients had achieved good asthma control. Patients with poor asthma control discontinued from the study and those with intermediate control continued in the study but did not undergo a dose reduction. The estimated treatment difference in morning PEF% predicted at 6 weeks was -1.9% (90% CI -4.9, 1.0). There was a trend towards a greater increase in forced vital capacity (% predicted) in the BDP extrafine group (5.3 versus 0.4%; p=0.084). A 'step-down' in therapy to 100 microg day(-1) was possible in 36% and 42% of patients in the BDP extrafine and CFC-FP groups, respectively, at 6 weeks. Both drugs were well tolerated. BDP extrafine and CFC-FP aerosols were equally effective at improving asthma control in children with mild-to-moderate asthma at the same daily dose.

Inhaled corticosteroids during acute bronchiolitis in the prevention of post-bronchiolitic wheezing

BACKGROUND

Acute bronchiolitis in infants and young children is associated with long-term airway disease also known as post-bronchiolitic wheezing. Two major hypotheses have been proposed to explain the association between bronchiolitis and PBW. The first hypothesis considers bronchiolitis to be the first manifestation of recurrent wheezing in infants and children who are susceptible to obstructive airway disease. The second hypothesis suggests that the infection and concomitant inflammatory reaction in the acute phase leads to airway epithelium injury resulting in long-term obstructive airway disease. In line with the latter hypothesis, corticosteroids may have a beneficial effect on the prevention of post-bronchiolitic wheezing.

OBJECTIVES

The objective of this review was to evaluate the effect of inhaled corticosteroids, started during the acute phase of bronchiolitis, on the prevention of post-bronchiolitic wheezing.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2006) which contains the Cochrane Acute Respiratory Infections Group's trials register, MEDLINE (1966 to September 2006), EMBASE (1980 to September 2006) and Current Contents (September 2006). Abstracts and reports of congresses (ERS 1999 to September 2005, ATS 1999 to September 2005) were obtained. We contacted experts in the field and pharmaceutical companies for ongoing or unpublished studies.

SELECTION CRITERIA

Randomised placebo-controlled trials studying the effect of inhaled corticosteroids in children younger than two years of age with the clinical diagnosis of acute bronchiolitis were included.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed trial quality using the Jadad 5-point scale.

MAIN RESULTS

Five studies matched the inclusion criteria, with a median Jadad score of 4 (Inter Quartile Range 3 to 4), involving 374 infants. Pooling of the data was limited, due to the clinical diversity of the studies. However, no effect of inhaled corticosteroids in the prevention of wheezing (diary records or GP diagnosed), hospital re-admissions or use of corticosteroids or bronchodilators could be demonstrated. Duration of therapy, length of follow up or causative agent (respiratory syncytial virus or not) did not influence the pooled effect. In the three studies that also evaluated the adverse events, none were reported.

AUTHORS' CONCLUSIONS

This review does not demonstrate an effect of inhaled corticosteroids given during the acute phase of bronchiolitis in the prevention of post-bronchiolitic wheezing. The small number of included participants and the inability to pool all clinical outcomes precludes us from making strong recommendations.

Predictors of asthma control in children from different ethnic origins living in Amsterdam

To identify factors associated with asthma control in a multi-ethnic paediatric population. We interviewed 278 children with paediatrician diagnosed asthma (aged 7-17 years) and one of their parents. Asthma control was assessed with the Asthma Control Questionnaire (ACQ). Detailed information about sociodemographic variables, asthma medication, knowledge of asthma, inhalation technique and environmental factors were collected. Turkish and Moroccan parents were interviewed in their language of choice. Logistic regression analyses were used to identify correlates of asthma control. Of the 278 children, 85 (30.6%) were Dutch, 84 (30.2%) were Moroccan, 58 (20.9%) were Turkish and 51 (18.3%) were Surinamese. Overall, almost 60% had a status of well-controlled asthma, as indicated by the ACQ. Only 51 of the 142 (35.9%) Moroccan and Turkish parents had a good comprehension of the Dutch language. In logistic regression analyses the risk of having uncontrolled asthma was significantly higher among Surinamese children (OR 2.3; 95% CI 1.06-4.83), respondents with insufficient comprehension of the Dutch language (OR 2.3; 95% CI 1.08-4.78), children using woollen blankets (OR 9.8; 95% CI 1.52-63.42), and significantly lower among male (OR 0.5; 95% CI 0.31-0.91) and non-daily users of inhaled corticosteroids (OR 0.6; 95% CI 0.38-1.07). In conclusion, ethnicity as well as insufficient comprehension of the Dutch language appeared to be independent risk factors for uncontrolled asthma. Special attention should be given to children from immigrants groups for example by calling in an interpreter by physicians when comprehension is insufficient.

[The treatment of asthma: indications for a change in approach]

In both children and adults with persistent asthma, treatment with an inhaled corticosteroid (ICS) is recommended. Moreover, inhaled bronchodilating agents have a clear role to play. The minimum effective dose of an ICS in the individual patient can be determined either by starting with a low dosage of ICS and increasing the dosage gradually on the basis of the symptoms (the 'step-up' approach), or by starting with a high dosage and, if the results are good, decreasing it to the pointwhere adequate control is maintained (the 'step-down' approach). In a study of the step-up approach with the ICS fluticasone, with or without salmeterol as a long-acting beta2-agonist (LABA) in adult patients with asthma, the approach with salmeterol produced the best results, namely, good asthma control in 71% of the patients and total control in 41%. In a study involving both children and adults with asthma, good results were obtained from treatment with a relatively low maintenance dose of ICS (budesonide) combined with a LABA (formoterol), whereby patients were permitted to use additional inhalations of the combination ICS and LABA. How the different therapeutic concepts result in long-term control, what the side effects are in the long term, and whether, in addition to the clinical symptoms, laboratory findings are also important as a therapeutic criterion are all unknown.

Validation of a single concentration methacholine inhalation provocation test (SCIPT) in children

A new method to assess bronchial hyperresponsiveness (BHR) using a single concentration methacholine has already been validated in adults with asthma. Because the geometrical dimensions of the airways in children are different, the results from studies in adults cannot be extrapolated to children. In this study, we validated the single concentration methacholine inhalation provocation test (SCIPT) in children. Twenty-two children performed three methacholine inhalation challenge tests in random order. Two challenges were performed according to the SCIPT: doubling doses (0.03-1.8 mg; maximal cumulated dose 3.6 mg) were administered with an Aerosol Provocation System (Masterscope, Jaeger). The third challenge was performed according to a standard dosimeter method (SDM): doubling doses (0.002-1.8 mg; maximal cumulative dose 3.5 mg) were administered with a DeVillbiss 646 nebulizer. The degree of BHR is expressed as a PD20. A difference of < 1.5 dose step was assumed to be due to intraindividual variation. We found an intraclass correlation of 0.91 between both tests according to the SCIPT and of 0.80 between the SCIPT and SDM. We found, according to the method of Bland and Altman, good agreement when comparing these two challenge tests. The single concentration inhalation provocation test is reproducible and shows good agreement with a standard dosimeter method to test bronchial responsiveness in children.

Different breathing patterns in healthy and asthmatic children: responses to an arithmetic task

Asthma patients have been reported to be sensitive to breathlessness, independent of the degree of airway obstruction. Paying attention and task performance may induce changes in breathing pattern and these in turn may mediate such a feeling. The present experiment investigates whether strained breathing induced by an arithmetic task was different in children with asthma compared to healthy children.

METHODS

Seven healthy and eight asthmatic but symptom-free school children were equipped with electrodes for surface electromyographic (EMG) measurements of diaphragm, abdominal and intercostal (IC) muscles and with a strain gauge to monitor the pattern of breathing at rest and during an arithmetic task. The relative duration of exhalation and the relative speed of exhalation are used as measures of straining. The phase angle of maximal respiratory muscle activities relative to the maximal chest extension (MCE) are additional discriminating parameters.

RESULTS

Asthmatic children breathed more slowly and already at rest the phase of their respiratory muscle activity appears to be different. While in healthy children the maximal activity of the (left)abdominal muscles occurred 5+/-29% later than the MCE, in children with asthma the maximal activity occurred 26+/-30% of the cycle earlier than MCE. In children with asthma the activity of the IC muscles starts weaning already at 10+/-30% before MCE, in contrast to the healthy children in which intercostal muscle weaning starts only at 1+/-24% after MCE. During arithmetic, the significant difference between the groups in this respect disappeared.

CONCLUSION

Children with asthma show, even at rest, signs of respiratory muscle straining, probably in order to keep close control over the airflow in a similar way as healthy children during mental tasks. Such a 'careful' breathing pattern may work to prevent airway irritation also when they are free of symptoms.

Incidence and short-term outcome of acute lung injury in mechanically ventilated children

The aim of this study was to determine the incidence and short-term outcome of mechanically ventilated children suffering from acute lung injury (ALI) on a paediatric intensive care unit (PICU). Between January 1 1998 and January 1 2000, all mechanically ventilated children were evaluated using the criteria of an American-European Consensus Conference. Of the 443 children eligible for analysis, 44 (9.9%) were diagnosed as suffering from ALI. Of these, 79.5% developed the acute respiratory distress syndrome (ARDS); 54.5% (24 of 44) fulfilled the ARDS criteria at inclusion and 25% (11 of 44) later. PICU mortality for ALI was 27.3% (12 of 44) and within the ARDS subgroup 31.4% (11 of 35). Of the 12 children who died, 11 had ARDS; the main cause of death was cerebral damage (seven of 12). Acute lung injury and acute respiratory distress syndrome are rare diseases on a paediatric intensive care unit with a high mortality. Most of the children with acute lung injury develop acute respiratory distress syndrome. In the acute respiratory distress syndrome subgroup, mortality is higher than in the acute lung injury nonacute respiratory distress syndrome subgroup. Further investigations should confirm prognostic factors (e.g. respiratory parameters) for prediction of outcome.

Dexamethasone for treatment of patients mechanically ventilated for lower respiratory tract infection caused by respiratory syncytial virus

BACKGROUND

A study was undertaken to evaluate the efficacy of dexamethasone in patients mechanically ventilated for lower respiratory infection caused by respiratory syncytial virus (RSV-LRTI).

METHODS

In a multicentre randomised controlled trial patients were randomised to receive either intravenous dexamethasone (0.15 mg/kg 6 hourly for 48 hours) or placebo. End points were the duration of mechanical ventilation, length of stay (LOS) in the pediatric intensive care unit (PICU) and in hospital, and the duration of supplemental oxygen administration.

RESULTS

Thirty seven patients received dexamethasone and 45 received placebo. There was no significant difference in any of the end points between the two groups. In a post hoc analysis patients were stratified into those with mild gas exchange anomalies (PaO(2)/FiO(2) >200 mm Hg and/or mean airway pressure </= 10 cm H(2)O, bronchiolitis group) and those with severe gas exchange anomalies (PaO(2)/FiO(2) </=200 mm Hg and mean airway pressure >10 cm H(2)O, pneumonia group). In the 39 patients with bronchiolitis the duration of mechanical ventilation was 4.3 days shorter in the dexamethasone group than in the placebo group (4.9 v 9.2 days, 95% CI -7.8 to -0.8, p=0.02) and the duration of supplemental oxygen was 3.6 days shorter (7.7 v 11.3 days, 95% CI -8.0 to -0.1, p=0.048). No differences in end points were found in the pneumonia group.

CONCLUSIONS

Dexamethasone had no beneficial effect in patients mechanically ventilated for RSV-LRTI but was found to have a beneficial effect in patients with bronchiolitis.

Effect of intravenous hydrocortisone on nocturnal airflow limitation in childhood asthma

Low endogenous cortisol levels appear to contribute to the pathophysiology of nocturnal asthma. Lower cortisol levels are associated with lower forced expiratory volume in one second (FEV1) levels in children with asthma. The aim of the present study was to identify whether substitution of low serum cortisol with intravenous hydrocortisone decreases 24-h FEV1 variation and/or indirect measures of airway inflammation. Hydrocortisone was given over 24 h in a double-blind randomised crossover design to 26 subjects. FEV1 was measured every 4 h during 24 h; blood eosinophils and airway responsiveness to methacholine and adenosine 5'-monophosphate (AMP) were measured at 04:00 h and 16:00 h. Cortisol levels increased during the night and morning hours. FEV1 values were higher at all time points in children with nocturnal asthma (n=10; 24-h FEV1 variation > or = 15%) which was significant at 08:00 h, unlike in the non-nocturnal asthma (NA-) group (n=16). Numbers of eosinophils (10(9) x L(-1)) at 04:00 h decreased in the asthma group (median 0.61 (range 0.05-1.42) versus 0.52 (0.05-1.79)). Provocative dose causing a 20% fall in FEV1 (PD20) methacholine did not change, whereas PD20 AMP improved only at 16:00 h in the NA- group (72.0 (0.13-144.0) versus 144.0 (2.25-144.0) mg x mL(-1)). These results show that substitution of lower endogenous 24-h values of cortisol contribute to higher forced expiratory volume in one second values and a decrease of blood eosinophils as an inflammatory marker in more severe airway obstruction.

Pharmacokinetics of a single oral dose of baclofen in pediatric patients with gastroesophageal reflux disease

Transient relaxation of the lower esophageal sphincter (TLESR) is the predominant mechanism of gastroesophageal reflux (GER) in adults and children. Baclofen [4-amino-3-(p-chlorophenyl)-butanoic acid], a gamma-aminobutyric acid (GABA)-B receptor agonist used for the management of spasticity, has been recently shown to significantly inhibit GER in healthy adults without any relevant side effects. The objective of this study was to evaluate the pharmacokinetics of baclofen in a pediatric population with GER disease. In an open-label single-dose pharmacokinetic study, eight children with the diagnosis of GER made on clinical grounds received an oral dose of baclofen, 2.5 mg. Blood samples were drawn from an indwelling venous catheter, and urine was collected during a postdose period of 8 hours. The concentration of baclofen in these body fluids was determined using a validated high-performance liquid chromatography (HPLC) method with electrochemical detection after OPA-sulfite derivatization. Pharmacokinetic data were analyzed using the nonlinear regression program Scientist. Serum concentration-time curves could be best described using a two-compartment open model with a lag time. Mean plasma clearance (Cl) was 315.9 mL/h/kg; volume of distribution (Vd) was 2.58 L/kg; and half-life (T(1/2)beta) was 5.10 hours. No side effects were noted. As half-lives were comparable with those found in adult studies, the risk for accumulation seems not greater in children than in adults. Body composition can have a strong influence on the Vd of baclofen and, therefore, on the dose needed to obtain therapeutic plasma levels. Dosing according to clearly defined age groups with the help of therapeutic drug monitoring seems preferable. In view of the negative correlation between body weight and Vd, dosing according to body weight using adult pharmacokinetic data does not seem an effective way for using baclofen in children.

Clinical and immunologic factors associated with the presence or absence of airways hyper-responsiveness in childhood asthma

BACKGROUND

During the baseline period of a clinical trial comparing different dosage schedules of inhaled steroids, asthmatic children (aged 6-10 years) were expected to meet the inclusion criterion of airways hyper-responsiveness (PD(20) methacholine < 80 micro g) after withdrawal of inhaled corticosteroids for 2-8 weeks. However, many children failed to do so.

OBJECTIVE

It has been shown that young wheezing children may outgrow their symptoms. We investigated if differences between children with and without airways hyper-responsiveness after withdrawal of inhaled corticosteroids were compatible with differences between transient and persistent wheezers found in other studies.

METHODS

Seventy-eight children entered the study, of which 41 developed airways hyper- responsiveness after withdrawal of inhaled corticosteroids, and 37 did not. These two groups of children were compared with respect to differences in demographic, clinical, and immunological features (IL-4, IL-5, IL-10, and IFN-gamma produced by Con A stimulated peripheral mononuclear cells (PBMCs) and serum IL-4, IL-5 and soluble intercellular adhesion molecule-1 (sICAM-1)).

RESULTS

Hyper-responsive children had more atopic features (positive RAST, high IgE, eczema), lower levels of FEV1 and lower concentrations of sICAM-1 than non-hyper-responsive children. Apart from a borderline significantly higher IL-4 production in the hyper-responsive group, other immunologic parameters were comparable. Multivariate logistic regression analysis showed that high serum IgE, low FEV1, and low sICAM-1 levels were independently associated with the presence of airways hyper-responsiveness after stopping inhaled corticosteroids. Atopy was associated with higher concentrations of IL-4 in the hyper-responsive group.

CONCLUSION

After withdrawal of inhaled corticosteroids many children previously diagnosed with asthma did not develop airways hyper-responsiveness. We conclude that hyper-responsive children share features with persistent wheezers as found in previous studies, whereas the non-hyper- responsive children may represent transient wheezers.

Perinatal predictors of respiratory symptoms and lung function at a young adult age

A longitudinal cohort of 2,957 babies, born in 1975-1978, was used to investigate whether perinatal factors predict respiratory morbidity at a young adult age. In 1997, the presence of asthmatic (wheeze, nocturnal dyspnoea) and bronchitic (cough, phlegm, dyspnoea grade 3) symptoms and the level of lung function was determined in this cohort. The independent association between smoking during pregnancy, being first-born, birth weight and respiratory symptoms and lung function at young adult age was investigated using multiple regression models, taking other potential risk factors into account. Of 1,568 responders, 608 (39%, aged 18-22 yrs) had at least one respiratory symptom. The young adults who had a mother that smoked during pregnancy had a significantly lower level of lung function than their nonintra-uterine exposed peers (regression coefficient (B) (standard error): peak expiratory flow (PEF) -0.257 (0.131) L x s(-1); forced expiratory flow when 25% of the forced vital capacity has been exhaled (FEF25) -0.290 (0.129) L x s(-1)), although they were not at increased risk of having respiratory symptoms. Young adults who were first-born had better levels of lung function (B (SE): forced expiratory volume in one second (FEV1) 0.090 (0.042) L) and were less likely to have asthmatic symptoms (odds ratio (95%, confidence interval): 0.58 (0.35-0.95)) than those not first-born. Low birth weight (FEV1 -0.013 (0.004) L for a reduction of 100 g) was also predictive of reduced achieved levels of lung function at young adult age, independent of other potential risk factors, e.g. current smoking habits or familial predisposition. This study adds to the knowledge of the role of perinatal factors, such as smoking during pregnancy, as important predictors of respiratory morbidity.

Bronchiolitis hospitalisations in the Netherlands from 1991 to 1999

In order to analyse trends in the bronchiolitis hospitalisations in the Netherlands from 1991 to 1999 for children aged 0-4 years, the national number of bronchiolitis hospitalisations were compared with those of asthma and pneumonia hospitalisations of the same age group. The number of bronchiolitis hospitalisations significantly increased, whereas the number of asthma and pneumonia hospitalisations remained unchanged.