Evaluation of Cross-Reactivity Between Penicillins and Cephalosporins in Children with a History of Cephalosporin Allergy.

Objectives: The cross-reactivity problem between cephalosporins and penicillins has mainly been evaluated in the context of patients allergic to penicillins. However, we have little data regarding the opposite aspect of the problem, i.e. the cross-reactivity in subjects primarily sensitized to cephalosporins. This prospective study aims to evaluate the cross-reactivity to penicillins and some other cephalosporins in patients with immediate allergic reactions to cephalosporins. Methods: The study included 21 children with immediate allergic reactions to at least one cephalosporin. Skin testing was performed with a panel of minor and major determinant mixtures of penicillins and three commonly used cephalosporins (cephazoline, cefuroxime and ceftriaxone). Results: The children had used 5.14±4.91 (1-15) times any beta-lactam antibiotic in the previous year and the most common cephalosporins accused were ceftriaxone (42.92%), and cefuroxime, cefazolin, cefixime, cefprozil and cefotaxime (9.5% each). Skin tests were positive for any cephalosporin in 14 (66.7%) subjects and penicillin allergens in 15 (71.4%) subjects. Totally, 85.7% of children with a positive allergy history to cephalosporins were found to be sensitive to either penicillin or any one of three cephalosporins. Conclusion: There seems to be a high risk of adverse reactions to penicillins and other cephalosporins in children with a history of type I hypersensitivity reaction to cephalosporins. Therefore, skin testing with both cephalosporins and penicillins should be performed in patients with a history of cephalosporin allergy.

Effects of wheezing in early childhood in the development of allergic rhinitis in later years.

BACKGROUND: Studies on the long-term effects of wheezing in infancy have particularly focused on asthma. There isn't adequate information about the effects of wheezing in the development of allergic rhinitis in later years. OBJECTIVE: In this study, children with wheezing in the first year of life were investigated in terms of allergic rhinitis after five years of age. METHODS: The study consisted of children with early-transient wheezing or persistent wheezing. The study groups were evaluated in terms of allergic rhinitis with physical examination and a questionnaire translated from International Study of Asthma and Allergies in Children (ISAAC) questionnaire after five years of age. RESULTS: The study included 50 children; 23 (46%) had early-transient wheezing and 27 (54%) had persistent wheezing. The symptoms of allergic rhinitis were reported in 13 (48%) of children with persistent wheezing but in none of children with early-transient wheezing (p < 0.05). Skin prick tests showed positive results in 4.3% of children with early-transient wheezing and in 48.1% of children with persistent wheezing (p < 0.05). CONCLUSION: Persistent wheezing, but not early transient wheezing seems to be a risk factor in the development of allergic rhinitis in children after five years of age.

Niemann - Pick disease associated with hemophagocytic syndrome.

Hemophagocytic lymphohistiocytosis (HLH) is a disease characterized by phagocytosis of blood cells by macrophages within the lymphoreticular tissue. It can develop secondary to some diseases or be familial as a result of genetic mutations. Niemann-Pick disease (NPD) is a very rare lipid storage disease. A three-month-old girl presented with high fever (39°C), abdominal distension and paleness. The parents were consanguineous. The liver and spleen were palpable 10 cm and 11 cm below the costal margins, respectively. Bicytopenia (Hb: 5.5 g/dl, platelet: 77000/mm3), hypertriglyceridemia (351 mg/dl), hyperferritinemia (>1500 ng/dl) and hypofibrinogenemia (120 mg/dl) were detected. Bone marrow aspiration demonstrated foam cells and hemophagocytosis by macrophages and Niemann-Pick cells. Lysosomal sphingomyelinase activity was 0.24 nmol/h/mg/protein (normal: 0.86-2.8). Due to the parents' refusal of further evaluation, the nature of HLH as primary or secondary could not be determined. To the best of our knowledge, this is the first case of NPD associated with HLH and the first demonstration of hemophagocytosis by Niemann-Pick cells.

Etiology of upper gastrointestinal bleeding in young children.

OBJECTIVE: Evaluation of children younger than two years old admitted to a pediatric emergency department with upper gastrointestinal bleeding. METHODS: Thirty four (34) children aged < 2 years with upper gastrointestinal bleeding were studied. The demographic features, etiologies, laboratory and endoscopic findings and treatment procedures were evaluated retrospectively. RESULTS: The study consisted of 34 patients (73.5 % male, 26.5 % female) with a median age 12.3 months (1.5-24 months). 30 patients (88 %) had an underlying disease. 21 patients (56 %) had a history of aspirin or nonsteroidal anti-inflammatory drugs intake. Endoscopic findings were pathological in 85% of patients. CONCLUSION: The incidence of upper gastrointestinal bleeding in children aged < 2 years due to antipyretics must be taken into consideration although most of them may also have an underlying disease.

Pediatricians' knowledge about recent advances in anaphylaxis treatment in Istanbul, Turkey.

Severe anaphylactic reactions are medical emergencies in children and require immediate recognition and treatment. Many advances have been reported recently in the treatment of anaphylaxis. Despite this, little is known about whether or not these advances are known by all pediatricians. To evaluate the knowledge of pediatricians on the recent advances in the treatment of anaphylaxis, some pediatricians from istanbul were asked to complete an anonymous questionnaire. A total of 124 pediatricians agreed to participate in the study. Most attendants (92%) knew epinephrine as the first drug in the treatment of anaphylaxis, but more pediatricians (65%) also preferred subcutaneous route as the most effective route for injection. In addition, more than 80% did not know the trademarks of epinephrine autoinjectors or the amount of the drug in the autoinjectors. Our data show that the level of pediatricians' knowledge about recent advances in the management of anaphylaxis is unsatisfactory. Pediatricians' failure to know recent advances in the management of anaphylaxis may endanger children when assistance is required. Educational programs aimed at improving the general knowledge of pediatricians on recent advances in anaphylaxis are urgently needed.

Comparison of idiopathic thrombocytopenic purpura in children between 3 months and 2 years versus 2-5 years.

It has been reported that infantile idiopathic thrombocytopenic purpura (ITP) has different clinical features than ITP seen in older ages and classification of bleeding sites and grading of bleeding severity can be used in determining the risk of bleeding. In this study, patients with ITP were divided into two groups according to age (<2 years and 2-5 years). The clinical features, laboratory findings, treatment modalities, rate of response and chronicity, bleeding sites, grades of bleeding were compared between each group. No significant differences were established.

Etiologies of seizures in young children admitted to an inner city hospital in a developing country.

OBJECTIVES: In this study, we aimed to document the etiologies of seizures in young children in an urban reference hospital in a developing county. METHODS: One hundred fifty-six children (aged 1 to 24 months) hospitalized in an inner city hospital between 2000 and 2004 with seizures were evaluated retrospectively in terms of etiologies and some risk factors. RESULTS: The seizures were cryptogenic (presumed symptomatic) in 9 (5%) patients, symptomatic in 29 (18.6%) patients, and situation-related (febrile, hypocalcemic, hyponatremic, and hypoglycemic) in 118 (75.6%) patients. Hypocalcemia due to rickets was the leading cause (25.6%) of afebrile seizures in this population. CONCLUSIONS: Hypocalcemia has an important place in the etiology of afebrile seizures among our patients unlike in many developed countries. So, nutritional status should be kept in mind while evaluating the etiologies of seizures in young children in developing countries.

Effects of nebulized corticosteroids therapy on hypothalamic-pituitary-adrenal axis in young children with recurrent or persistent wheeze.

Inhaled corticosteroids (ICS) are preferred drugs for the long-term treatment of all severities of asthma in children. However, data about the safety of ICS in infants is lacking. So, it is essential to do further clinical studies to examine the safety and efficacy of ICS in this population. In this study, the effects of nebulized budesonide and nebulized fluticasone propionate suspensions on hypothalamic-pituitary-adrenal axis is examined in infants with recurrent or persistent wheeze. Thirty-one children aged 6-24 months admitted to our hospital between January and December 2005 with symptoms of recurrent or persistent wheeze were included in the study. The patients were randomly allocated to receive 0.25 mg BUD or 0.25 mg fluticasone propionate twice daily for 6 wk and half dose for another 6 wk with a jet nebulizer at home. Blood samples for basal cortisol concentration, adrenocarticotropic hormone, glucose, HbA1c and electrolytes were obtained at the beginning and at the end of the study. Adrenal function assessment was based on changes in cosyntropin-stimulated plasma cortisol levels. The study was completed with 31 patients, 16 of whom received BUD and 15 FP. All patients except one had plasma cortisol concentrations above 500 nmol/l (18 microg/dl) or had an incremental rise in cortisol of >200 nmol/l after stimulation. Although nebulized steroids seem to be safe in infancy, we recommend that adrenal functions should be tested periodically during long-term treatment with nebulized steroids.

Two children with invasive gastrointestinal aspergillosis.

We report two immunocompromised infants aged six and four months with invasive gastrointestinal aspergillosis. Both patients presented with weight loss and diarrhea. The underlying disorders were combined immunodeficiency and transient hypogammaglobulinemia of infancy. The diagnosis of gastrointestinal aspergillosis was established by gastrointestinal endoscopy and histopathological examination of the tissue specimens. Both children responded well to Amphotericin B.

Penicillin sensitivity among hospital nurses without a history of penicillin allergy.

AIM: This paper reports a study to document the prevalence of penicillin sensitivity among nurses who had no previous history of sensitivity and worked in an inner city hospital in Turkey. BACKGROUND: Frequent and prolonged exposure to any drug including penicillin may increase the risk of hypersensitivity to these drugs. Local administration of drugs increases the likelihood of sensitization. Nurses are the main group of healthcare workers who prepare and administer antibiotics to patients, so they may be at highest risk for sensitization. Skin testing with major and minor determinants of penicillin has proved useful for identifying penicillin-specific IgE antibodies in sensitized individuals. METHOD: Skin prick tests were performed with benzyl penicilloyl polylysine (PPL) and a mixture of minor antigenic determinants (MDM) solution with 83 nurses who had been handling beta-lactam antibiotics. The study was conducted in 2004. FINDINGS: Ten nurses (12%) had positive skin reactions to penicillin antigens. Six were sensitive to PPL (7 x 2%) and four were sensitive to MDM (4 x 8%). CONCLUSION: Occult sensitization to beta-lactam antibiotics, without symptoms, may develop in hospital nurses. It is possible that these healthcare workers might be at increased risk of hypersensitivity reactions should they be exposed to beta-lactams, administered for therapeutic purposes. Further research is needed to explore this important issue.

Effect of neonatal sepsis on the development of allergies and asthma in later childhood.

BACKGROUND: Exposure to large amounts of endotoxins and other bacterial products in early childhood may protect against the development of allergic diseases later in childhood. The aim of this study was to investigate the effects of neonatal sepsis on subsequent development of asthma, allergic rhinitis, and atopic dermatitis in children. METHODS: We recruited 85 children (mean age 48.67 +/- 12.88 months) who had been hospitalized for sepsis in their neonatal period and their siblings (n = 85) as controls (mean age 61.81 +/- 21.34 months) to investigate the prevalences of asthma, atopic dermatitis and allergic rhinitis. After asking the questions in the International Study of Asthma and Allergies in Children (ISAAC) questionnaires to the parents, total IgE levels in sera were measured and skin prick tests were performed. RESULTS: Children with neonatal sepsis had lower total IgE levels and less sensitivity to Dermatophagoides pteronyssinus than controls (25.9 vs. 9.4%, p = 0.003). In addition, wheeze ever, wheeze in the last 12 months, physician-diagnosed asthma, and use of asthma drugs were less common in these subjects. Prevalences of allergic rhinitis and atopic dermatitis were equal in both groups. CONCLUSION: Exposure to severe infections such as sepsis in the neonatal period may decrease sensitization to environmental allergens and prevalence of asthma in later childhood.

Nutritional vitamin B12 deficiency in hospitalized young children.

The authors sought to determine prevalence, social, economic, and dietary patterns of young children (n = 20) identified as having vitamin B12 deficiency anemia after admission to their hospital in the last 3 years. The diagnosis of vitamin B12 deficiency was based on symptoms and clinical findings, findings on peripheral blood films and bone marrow aspirates, and serum levels of vitamin B12. The children had been exclusively breast-fed without any animal food supplementation. Serum vitamin B12 levels were also measured in the sera of mothers and found to be low. The authors concluded that vitamin B12 deficiency might be an important health problem among children of mothers who do not consume animal foods adequately.

Reasons for discontinuation of antiasthma drugs in children with asthma coming from lower socioeconomic classes in a developing country.

Although asthma guidelines recommend regular use of controller therapies in both adults and children with moderate to severe asthma, most of the patients with asthma discontinue antiasthma drugs for various reasons. This study was performed to evaluate the reasons for discontinuation of antiasthma drugs in children with asthma in a developing country and to draw attention to these reasons to increase the adherence of the patients. The study was comprised of 118 children with asthma from lower-income groups who stopped using antiasthma drugs for various reasons. When they visited the hospital for routine or emergency room visits, they were asked for reasons for discontinuing the drugs. The average period for usage of antiasthma drugs ranged between 3 and 16 months (mean, 11.5 months). The most important cause for discontinuation of the drugs was disappearance of the symptoms. The other reasons were as follows: concerns of the parents about the side effects of antiasthma drugs, reluctance of the children to use the drugs, and replacement or discontinuation of the drugs by another physician. Expensiveness of the drugs was another important reason for the lower-income group. These findings suggest that children with asthma may easily discontinue the antiasthma drugs for various reasons. Because of this, both the parents and the children should be educated about long-term use and side effects of antiasthma drugs and warned about the problems of stopping treatment without physician approval.

Neutrophil hypersegmentation and thrombocytosis in children with iron deficiency anemia.

Neutrophil hypersegmentation is an expected peripheral blood smear finding in megaloblastic anemias. But some clinical reports suggest that neutrophil hypersegmentation may also occur in patients with iron deficiency anemia. In this study we searched the presence of neutrophil hypersegmentation and thrombocytosis in patients with iron deficiency anemia but who had normal serum vitamin B12 and folic acid levels. The study comprised 102 patients with iron deficiency anemia and 21 age-matched healthy controls. All routine tests for iron deficiency anemia were done, serum folate and cobalamin levels were measured, and platelets were counted in all patients and controls. Peripheral blood smears were examined for neutrophil hypersegmentation. Hypersegmentation was found in 30.4% of anemic patients and in 9.5% of controls (p < 0.05). The number of platelets was also significantly higher in anemic children (p < 0.05). These results show that neutrophil hypersegmentation may also be seen in patients with iron deficiency anemia, and thrombocytosis is a common laboratory finding in this disorder.

Serum ECP and total IgE levels in children with acute laryngotracheobronchitis.

OBJECTIVE: Eosinophilic cationic protein (ECP) and immunoglobulin E (IgE) are important mediators of allergic inflammation and they are commonly used in the diagnosis and follow-up of allergic diseases. But serum levels of these molecules can also be elevated by some other diseases including viral infections. Acute laryngotracheobronchitis (ALTB) is an important viral infection of upper airway and serum levels of ECP and IgE may increase in patients with ALTB. METHODS: In the present study serum ECP and IgE levels were measured before treatment and on the third day and third week after treatment in 27 patients with ALTB aged 10 months to 5 years and were compared with a age matched healthy controls. All patients were treated with nebulized budesonide. RESULTS: We found that pre-treatment ECP levels were significantly higher than post-treatment third days and third weeks (28.3+/-2.3 ng/ml versus 20.2+/-3.2 ng/ml and 11.4+/-1.1 ng/ml, respectively). Similarly, the mean pre-treatment serum IgE values were significantly higher than post-treatment values (131.6+/-17.5 IU/ml versus 83.6+/-12.4 IU/ml and 68.2+/-6.7 IU/ml). A positive correlation was found between serum ECP and IgE values for pre-treatment and post-treatment third week values (r=062, p=0.01 and r=0.64, p=0.01, respectively). The pre-treatment serum ECP and IgE levels were significantly higher than those of controls (10.8+/-1.5 ng/ml and 43.8+/-6.6 IU/ml, respectively p<0.05). CONCLUSION: In this study it was shown that, serum ECP and IgE levels increase in the acute phase of infection and return to normal after treatment in patients with ALTB such as in allergic patients. This effect of ALTB on serum ECP and total IgE levels should be kept in mind and these parameters should not be used in the diagnosis and follow-up of allergic diseases in children who had had ALTB in recent weeks.

Severe iron-deficiency anemia among hospitalized young children in an urban hospital.

The aim of this study was to investigate the prevalence and some characteristics of young children with severe iron-deficiency anemia hospitalized in an urban hospital. All of the young children (aged 7-24 months) hospitalized in a city hospital during the last 3 years were searched for iron-deficiency anemia and those with severe anemia were retrospectively evaluated. During this period, 3117 young children were hospitalized and 61.6% of them had a hemoglobin value of less than 11 g/dL and 52 children (2.7%) had severe iron-deficiency anemia (hemoglobin < 6 g/dL). It was concluded that iron-deficiency anemia is still an important health problem among young children in our society.

Comparison of two antibiotic regimens in the empirical treatment of severe childhood pneumonia.

OBJECTIVE: The diagnosis and the treatment of community-acquired severe pneumonia is still a serious child health problem in developing countries. The aim of this study is to evaluate the effectiveness of two different antibiotic regimens in the empirical treatment of severe childhood pneumonia. METHODOLOGY: We enrolled 97 infants (aged 2-24 months) with severe community-acquired pneumonia in a randomized-controlled trial of 10 days of treatment with penicillin G+chloramphenicol (n:46) or ceftriaxone (n:51). We evaluated the effectiveness of treatments with symptoms and some laboratory tests during and at the end of the study. RESULTS: The cure rates were similar in both groups and the antibiotic regimens in all patients were found effective (P< 0.001). The number of nurse rounds was much more in penicillin plus chloramphenicol group than ceftriaxone group. CONCLUSION: Both penicillin G plus chloramphenicol and ceftriaxone are effective in the empirical treatment of severe community pneumonia of young children. In spite of more nurse visits for antibiotic treatment, penicillin G+ chloramphenicol combination may be a cheaper alternative to ceftriaxone in the treatment of childhood pneumonia.

Penicillin sensitivity among children without a positive history for penicillin allergy.

To establish the prevalence of positive penicillin skin tests among outpatients without any drug reaction history. Skin testing was performed in 147 children (aged 6-13 years) who had had received a penicillin preparation at least three times in the last 12 months without any allergic reaction. Before testing, detailed pediatric and allergy history were learned and then all children were tested with benzyl penicilloyl polylysin (PPL) and mixture of minor antigenic determinants. The test procedures were made epidermally and intradermally subsequently in every subject. The overall frequency of positive skin reactions to penicillin antigens was 10.2%. A mild systemic reaction was observed in one of the children during testing with PPL. We concluded that frequent use of penicillin and other beta-lactam antibiotics leads to sensitization of children in our study population despite these children seem to be asymptomatic during testing time.

A comparison of nebulized budesonide, and intramuscular, and oral dexamethasone for treatment of croup.

OBJECTIVES: Croup or acute laryngotracheobronchitis is the most common cause of the upper airway obstruction. Cool mist, nebulized racemic epinephrine and steroids are commonly used for therapy. Although steroid treatment can be applied orally, in nebulized form, or parenterally, no study has compared these three regimens yet. In this study, the efficacy of nebulized budesonide, and oral and intramuscular dexamethasone are compared for treatment of croup. STUDY DESIGN: Sixty children aged 6-36 months were randomly allocated into four groups. The first three study groups (15 children in each) took nebulized budesonide, oral dexamethasone and intramuscular dexamethasone, respectively, in addition to salbutamol and other supportive measures and these were compared with the placebo group. All patients were evaluated with "Westley Croup Score" on admission to pediatric emergency department (0h) and at 24, 48 and 72h. RESULTS: At the end of the study, the croup scores of all steroid treatment groups were significantly lower than the placebo group, but there was no statistical difference among them. CONCLUSIONS: Nebulized budesonide, oral and parenteral dexamethasone have the same effectiveness for treatment of croup and the choice depends on conditions of the patient and the physician.