Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy.

OBJECTIVE: To measure functional gait improvements of robotic-assisted locomotion training in children with cerebral palsy (CP). DESIGN: Single-case experimental A-B design. SETTINGS: Rehabilitation Centre Affoltern am Albis, Children's University Hospital Zurich, Switzerland (inpatient group) and Neurology Department of the Dr von Haunersches Children's Hospital Munich, Germany (outpatient group). PARTICIPANTS: 22 children (mean age 8.6 years, range 4.6-11.7) with CP and a Gross Motor Function Classification System level II to IV. INTERVENTIONS: 3 to 5 sessions of 45-60 minutes/week during a 3-5-week period of driven gait orthosis training. MAIN OUTCOME MEASURES: 10-metre walk test (10MWT), 6-minute walk test (6MinWT), Gross Motor Function Measure (GMFM-66) dimension D (standing) and dimension E (walking), and Functional Ambulation Categories (FAC). RESULTS: The mean (SD) maximum gait speed (0.78 (0.57) to 0.91 (0.61) m/s; p<0.01) as well as the mean (SD) dimension D of the GMFM-66 (40.3% (31.3%) to 46.6% (28.7%); p<0.05) improved significantly after the intervention period. The mean (SD) 6MinWT (176.3 (141.8) to 199.5 (157.7) m), the mean FAC (2.6 (1.7) to 3.0 (1.6)) and the mean (SD) dimension E of the GMFM-66 (29.5% (30.3%) to 31.6% (29.2%)) also showed an increase, but did not reach a statistically significant level. CONCLUSION: These results suggest that children with CP benefit from robotic-assisted gait training in improving functional gait parameters.

Feasibility of robotic-assisted locomotor training in children with central gait impairment.

Intensive, task-specific training enabled by a driven gait orthosis (DGO) may be a cost-effective means of improving walking performance in children. A paediatric DGO has recently been developed. This study was the first paediatric trial aimed to determine the feasibility of robotic-assisted treadmill training in children with central gait impairment (n=26; 11 females, 15 males; mean age 10 y 1 mo [SD 4 y]; range 5 y 2 mo-19 y 5 mo). Diagnoses of the study group included cerebral palsy (n=19; Gross Motor Function Classification System Levels I-IV), traumatic brain injury (n=1), Guillain-Barré syndrome (n=2), incomplete paraplegia (n=2), and haemorrhagic shock (n=1), and encephalopathy (n=1). Sixteen children were in-patients and 10 were outpatients. Twenty-four of the 26 patients completed the training which consisted of a mean of 19 sessions (SD 2.2; range 13-21) in the in-patient group and 12 sessions (SD 1.0; range 10-13) in the outpatient group. Gait speed and 6-Minute Walking Test increased significantly (p<0.01). Functional Ambulation Categories and Standing dimension (in-patient group p<0.01; outpatient group p<0.05) of the Gross Motor Function Measure improved significantly. DGO training was successfully integrated into the rehabilitation programme and findings suggest an improvement of locomotor performance.

Is there a benefit from routine voiding cystourethrography after ureterocystoneostomy?

Surgical repair such as ureterocystoneostomy (UCN) for vesicoureteral reflux (VUR) or primary obstructive megaureter (POM) is the treatment of choice after the failure of conservative therapy. To document the postoperative outcome, a voiding cystourethrography is routinely performed to exclude persisting reflux. Our aim was to evaluate the benefit of voiding cystoureterography (VCUG) in our patients with respect to radiation, discomfort to the child and costs. The medical records of all patients who underwent an ureterocystoneostomy at the Department of Paediatric Surgery in St. Gallen, Switzerland, between January 1, 1995 and December 31, 2000 were reviewed in terms of the pre- and postoperative clinical course, type of surgical procedure and radiographic examinations performed. During this period, 126 renal units were operated in 81 patients. The surgical technique employed was Cohen's procedure in 121 (96 %) renal units and a Leadbetter-Politano procedure in 5 (4 %) renal units. Mean postoperative follow-up was 42 months (6 - 84). All patients had an ultrasonographic follow-up. 77 (95 %) patients underwent a VCUG with normal results one year postoperatively. VUR was found in 4 patients, 3 of them were asymptomatic one year postoperatively, one had a complication of a fistula with reflux and required reoperation 2 months after operation. The VCUG was performed earlier because of clinical und ultrasonographic findings. None of the routinely performed VCUGs led to a change of procedure. All pathologies had already been detected by clinical or ultrasonographic findings. We recommend clinical and ultrasonographic follow-up after an UCN and performance of a VCUG only when problems appear to be present.

Trends in prevalence of asthma, allergic rhinitis and atopic dermatitis in 5-7-year old Swiss children from 1992 to 2001.

BACKGROUND: Changing occurrence rates of asthma, allergic rhinitis and atopic dermatitis are of public health concern and require surveillance. Changes in prevalence rates of these atopic diseases were monitored during 10 years and their trend with time was determined taking into account the influence of personal and environmental risk factors. METHODS: Four cross-sectional surveys in 5-7-year old children were performed in seven different communities in Switzerland between 1992 and 2001. Prevalence of respiratory and allergic symptoms and of affecting risk factors including parental environmental concern were assessed using a standardized parental questionnaire. RESULTS: A total of 988 (74.1%), 1778 (79.0%), 1406 (82.6%) and 1274 (78.9%) children participated, respectively, in the 1992, 1995, 1998 and 2001 surveys. Prevalence rates of asthma and hay fever symptoms remained quite stable over time (wheeze/past year: 8.8%, 7.8%, 6.4% and 7.4%, sneezing attack during pollen season: 5.0%, 5.6%, 5.4% and 4.6%). Rates of reported atopic dermatitis symptoms (specific skin rash/past year: 4.6%, 6.5%,7.4% and 7.6%) showed an increase over time, but those of diagnosis of eczema did not show a clear pattern (18.4%, 15.7%, 14.0% and 15.2%). Stratified analysis by parental environmental concern and by parental atopy showed similar trends. Rates of atopic dermatitis symptoms showed significant increase in girls but stayed stable in boys. CONCLUSION: Results of these four consecutive surveys suggest that the increase in prevalence of asthma and hay fever in 5-7-year old children living in Switzerland may have ceased. However, symptoms of atopic dermatitis may still be on the rise, especially among girls.

Mastitis in early infancy.

AIM: To evaluate the clinical features and microbiological findings in young infants with mastitis. METHODS: Retrospective review of medical records of 18 infants with breast inflammation during the first 3 mo of life seen in the paediatric emergency department between 1992 and 2002. RESULTS: All were full-term infants with female-male ratio of 3.5:1. The age ranged from 12 to 45 d, with a peak in the 4th and 5th weeks of life. Only five patients had systemic manifestations, and five were pretreated with oral antibiotics (amoxicillin-clavulanic acid). The latter as well as seven additional cases required incision and drainage due to abscess formation. Bacterial cultures grew Staphylococcus aureus in 10 cases including all pretreated infants. In four of these cases, Gram stain showed the pathogen. After antimicrobial treatment, no recurrence was observed in any of the patients. CONCLUSIONS: These findings suggest that mastitis in early infancy should be treated with parenteral antibiotics guided by Gram stain when available and informative. Otherwise, beta-lactamase-resistant antibiotics are a reasonable empirical initial treatment pending culture results. Optimizing the management of infants with mastitis is important especially since abscess formation requiring incision may be detrimental for later breast development.

The effect of montelukast on lung function and exhaled nitric oxide in infants with early childhood asthma.

Effective treatment of respiratory symptoms, airway inflammation and impairment of lung function is the goal of any asthma therapy. Although montelukast has been shown to be a possible add-on therapy for anti-inflammatory treatment in older children, its efficacy in infants and young children is not well known. The aim of this study was to investigate its effect in infants and young children with early childhood asthma. In a prospective randomised double-blind placebo-controlled study, 24 young children (10-26 months) with wheeze, allergy and a positive family history of asthma consistent with the diagnosis of early childhood asthma were randomised to receive montelukast 4 mg or placebo. The forced expiratory volume in 0.5 seconds (FEV0.5) was measured using the raised volume rapid thoracic compression technique, and fractional exhaled nitric oxide (FeNO) and symptom scores were determined. No change was noted in FEV0.5, FeNO or symptom score in the placebo group following the treatment period. In contrast, significant improvements in mean+/-SD FEV0.5 (189.0+/-37.8 and 214.4+/-44.9 mL before and after treatment, respectively), FeNO (29.8+/-10.0 and 19.0+/-8.5 ppb) and median symptom score (5.5 and 1.5) were noted following treatment with montelukast. In conclusion, montelukast has a positive effect on lung function, airway inflammation and symptom scores in very young children with early childhood asthma.

Influence of MMR-vaccinations and diseases on atopic sensitization and allergic symptoms in Swiss schoolchildren.

The prevalence of asthma and allergic disease has increased in many countries. It has been proposed that vaccinations may contribute to the development of allergic disease by reducing clinical infections in infancy or through the direct IgE-inducing effects of the vaccines. Evidence for a potential role of immunizations in the development of allergic disease is scarce. Therefore the objective was to study the associations between vaccinations against measles, mumps and rubella (MMR), natural infections of these diseases and atopic sensitization to indoor and outdoor allergens and allergic symptoms in schoolchildren. The cross-sectional study including 1537 8(th) grade school children aged 13-15 years living in 10 communities across Switzerland was organized in the framework of an environmental health surveillance program within the School Health Services (Swiss Surveillance Program of Childhood Asthma and Allergies with respect to Air Pollution and Climate, SCARPOL). Main outcome measures were asthma and sneezing during pollen season assessed by parental questionnaires and atopic sensitization determined by IgE concentrations to various allergens. It was found that parents' reported history of measles or mumps was associated with a stronger immune response than two or more vaccinations against the respective infection (measles: geometric mean IgG titers (GMT) lU/ml (95% Cl) 2.8 (2.0-3.9) vs. 1.2 (1.0-1.4), mumps: GMT PE/ml (95% Cl) 16.3 (13.9-19.1) vs. 8.5 (6.1-11.7). With respect to atopic sensitization similar associations for exposure by natural MMR-infections or MMR-vaccinations were found: measles: OR (95% Cl) 1.02 (0.53-1.96) vs. 1.22 (0.69-2.16), mumps: 0.59 (0.38-0.93) vs. 0.79 (0.49-1.27), rubella: 0.93 (0.61-1.43) vs. 0.95 (0.66-1.37), respectively. Inverse relationships were found between the risk of asthma and a positive disease history or vaccination of measles 0.36 (0.14-0.91) vs. 0.45 (0.21-0.98) or a positive serum titer against measles 0.65 (0.35-1.20). From the present study can be concluded that exposure by MMR-vaccinations or natural MMR-infections in childhood does not increase the risk of sensitization to common allergens as well as to allergic respiratory diseases. MMR-vaccinations or natural MMR-infections are therefore an unlikely factor contributing to the increase in atopic disease in developed countries.

No further increase in asthma, hay fever and atopic sensitisation in adolescents living in Switzerland.

Prevalence rates of childhood asthma and allergy have been on the increase for several decades. The present study investigated whether this trend continued during the 1990s in adolescents living in Switzerland. Between 1992 and 2000, the change in prevalence of specific immunoglobulin E to aeroallergens, asthma symptoms and hay fever symptoms assessed by parents' and students' answers to the International Study of Asthma and Allergies in Childhood questions was investigated using three cross-sectional surveys. In total 1,324 (74.9%), 1,668 (80.6%) and 1,250 (73.9%) adolescents participated. Prevalence rates of asthma and current asthmatic symptoms remained constant, irrespective of whether the assessment was based on parental questionnaires or the student's self-completed written or video questionnaires (students' report of current wheeze 8.8, 7.3, and 8.3%). Similarly, no further increase was observed for reported hay fever rates and allergic sensitisation rates (positive multiscreen allergy test, SX1-test: 34.6, 38.9, and 35.6%, respectively). Although time trends in the occurrence of a series of known risk factors were recorded, none of these factors had a significant impact on asthma and allergy prevalence over time. No further increase in asthma and allergy rates occurred during the 1990s in adolescents living in Switzerland. However, to adequately assess the trend a longer period of observation is needed.

Vaginal foreign bodies.

OBJECTIVE: To evaluate the clinical features and outcome in girls with a vaginal foreign body. METHODS: Retrospective review of medical records of 35 girls with a vaginal foreign body seen in an outpatient clinic for paediatric and adolescent gynaecology between 1980 and 2000. RESULTS: The ages ranged from 2.6 to 9.2 years. The most common symptom was blood-stained vaginal discharge/vaginal bleeding (49%). Duration of symptoms varied from 1 day to 2 years. Fifty-four percent of the patients recalled insertion of the foreign object, usually by the girl herself. All but three patients (91%) either recalled insertion of the foreign object and/or had vaginal bleeding or blood-stained or foul-smelling vaginal discharge, and/or visualization or palpation of the foreign body in physical examination. Symptoms resolved after removal of the foreign body followed by a single irrigation with Providon-Iod (Betadine). CONCLUSION: In the majority of patients a carefully obtained history and physical examination suggest the diagnosis of a vaginal foreign object. The leading symptoms are vaginal bleeding and blood-stained or foul smelling vaginal discharge. Removal of the foreign object followed by a single irrigation with Providon-Iod is the definitive treatment and does not require additional measures.

Consultations with adolescents: the gap between their expectations and their experiences.

AIM: To study the expectations and experiences of adolescents when in consultation with doctors, particularly with regard to issues of confidentiality. METHODS: In a cross-sectional study, 613 seventh- and ninth-grade students (347 students aged 13 y and 266 students aged 15 y) completed a 40-item questionnaire specifically developed for this study. Students anonymously completed the self-administered questionnaire at school. RESULTS: Of these adolescents, 89% aged 13 y and 57% aged 15 y were accompanied by one of their parents to appointments with private practitioners. Of the respondents, 33%/52% (13-y-olds/15-y-olds) said that seeing the doctor alone for some time was important but only 18%/20% were given the opportunity to do so. Although 79%/90% of respondents stated that it was important for the doctor to keep information confidential, on request, only 37%/40% of private practitioners had spoken about confidentiality; 64%/78% of adolescents said that doctors should give assurance of confidentiality even with regard to their parents. However, only 26%/27% of private practitioners explicitly assured confidentiality with regard to parents. Acceptance of conditional confidentiality was high in all subpopulations. Short waiting times and the opportunity to talk about topics such as nutrition, drugs and sexuality were rated as important. CONCLUSION: Physicians should adapt their consultation style to the needs of adolescents by seeing the adolescent patient alone for some time and by assuring them of conditional confidentiality. Furthermore, they should provide opportunities to talk specifically about issues of potential concern to adolescents such as nutrition, drugs and sexuality. To accomplish these tasks, educational curricula in adolescent healthcare are required for physicians.

Fosfomycin for the initial treatment of acute haematogenous osteomyelitis.

BACKGROUND AND AIMS: At our institution there has been a dichotomous antimicrobial treatment behaviour for acute haematogenous osteomyelitis (AHOM) since 1984. The surgical department favoured fosfomycin as initial choice and the medical department beta lactams. We aimed to compare the performance of both strategies. METHODS: Data from patients discharged with the diagnosis of AHOM between January 1984 and January 1998 were gathered from the charts by means of a questionnaire. Patients receiving fosfomycin treatment (FT) were compared with those receiving fosfomycin plus other antimicrobials (FT+) and those receiving no fosfomycin treatment (NFT). RESULTS: A total of 103 patients aged 0.1-15.5 years (mean 6.5, median 6.9) with AHOM received no surgical treatment initially. In 23 (22.3%) FT was instilled initially, in 47 (45.6%) FT+, and in 33 (32.0%) NFT. The pathogen was established in 30%, 36%, and 42% of FT, FT+, and NFT patients, respectively, Staphylococcus aureus being the predominant isolate. Mean C reactive protein levels and erythrocyte sedimentation rates normalised in all treatment groups after two and four weeks, respectively. The mean duration of intravenous antimicrobial treatment in FT patients was 2.5 weeks, in FT+ patients 3.1 weeks, and in NFT patients 3.8 weeks (p < 0.05), whereas the mean duration of intravenous plus oral treatment was comparable (7.1 v 6.8 v 6.5 weeks). CONCLUSIONS: The leucocyte penetrating fosfomycin performed similarly to extracellular beta lactams in the treatment of AHOM. Intravenous treatment for longer than 2.5 weeks offered no advantage.

Vulvovaginitis in prepubertal girls.

This retrospective study evaluated the clinical features and findings in bacterial cultures and in microscopic examination of vaginal secretions in 80 prepubertal girls, aged 2-12 years, with vulvovaginitis. Vaginal secretions were obtained directly from the vagina with a sterile catheter carefully inserted into the vagina. Pathogenic bacteria were isolated in 36% of cases. In 59% of these cases the isolated pathogen was group A beta-haemolytic streptococcus. Candida was not found in any of the patients. The finding of leucocytes in vaginal secretions as an indicator for growth of pathogenic bacteria had a sensitivity of 83% and a specificity of 59%. Antimicrobial treatment should therefore be based on bacteriological findings of vaginal secretions and not on the presence of leucocytes alone.

Oral bleeding: Child abuse alert.

Physicians must be aware of histories, behaviours and physical findings of maltreated children. We report two cases of physical child abuse in which the initial symptom was oral bleeding. In both cases, the diagnosis was delayed and was made only after severe injuries were inflicted. Injuries to the oral cavity and oral bleeding of uncertain origin in infants should be considered seriously and should be carefully assessed in relation to adequacy of history to explain the mechanism of injury. When an infant has been injured and no adequate explanation is available to account for the mechanism, inflicted injury must be suspected and evaluated, so that in cases of child maltreatment, diagnosis and protection of the child from further injury can take place as early as possible.

Dosage regimens for inhaled therapy in children should be reconsidered.

In current asthma guidelines, dosage regimens for inhalation therapy in children are based on adult doses and are generally titrated per kilogram of bodyweight or per square metre of body surface area. However, these recommendations do not correspond well with current knowledge of aerosol therapy in childhood. Lung deposition of the aerosolised drug is the key determinant for clinical efficacy and for systemic side effects of inhalation therapy. Lung deposition increases with age, whereas lung deposition expressed as a percentage per kilogram bodyweight is age-independent. This finding is explained by the self-regulating effect of age-dependent airway anatomy on lung deposition. Therefore, it is more likely that adult doses translate into paediatric doses only by virtue of the differences in self-limiting pulmonary deposition when using the same absolute nominal doses of the medication. Adapting the adult dose to a paediatric dose calculated on body size might be unnecessary and could lead to insufficient pulmonary deposition of medication. These findings suggest that dosage regimens for inhalation therapy for children may have to be reconsidered, and should be determined from dose-ranging studies rather than calculated from adult doses based on body size.

Wearing a noseclip improves nebulised aerosol delivery.

OBJECTIVE: The efficiency of nebulised aerosol delivery is limited due to drug retained within the nebuliser, and due to a poor ratio between inspiratory drug delivery and expiratory drug loss. Several technical approaches have improved the ratio between inspiratory aerosol delivery and expiratory aerosol loss. In our pilot study we aimed to investigate if wearing a noseclip during inhalation therapy improves the inspiratory versus expiratory ratio and hence, improves nebulised aerosol delivery. METHODS: Drug delivery was measured in thirteen subjects (7 males; age range 23-36 years) inhaling in random order nebulised aerosol through a mouthpiece once while wearing a noseclip and once without. RESULTS: Wearing a noseclip leads to an increase of 113% (SEM 23.5) in drug delivery and improves the inspiratory versus expiratory ratio (ratio 2.07 versus 0.75). CONCLUSIONS: We have shown that aerosol delivery is increased due to an improved inspiratory versus expiratory ratio when wearing a noseclip.

Factors affecting the efficiency of aerosol therapy with pressurised metered-dose inhalers through plastic spacers.

AIM: The main objective of this study was to compare the in vitro delivery of salbutamol from a chlorofluorocarbon(CFC)-propelled pressurised metered-dose inhaler (pMDI) versus a newly developed hydrofluoroalkane(HFA)-propelled pMDI through various spacers. In addition, we aimed to study the effect on bronchodilator response when using an optimal pMDI/spacer combination for aerosol delivery compared to a suboptimal combination. METHODS: Particle size distribution and output from salbutamol pMDIs containing either CFC propellants (Ventolin) or HFA propellants (Airomir) were measured using a multistage liquid impinger (MSLI) and compared to that through both detergent-coated (non-static) or untreated (static) large volume (Nebuhaler, Volumatic) and small volume (Aerochamber) plastic spacers. Flow-volume curves (FEV1) were obtained from twelve asthmatic children with known significant bronchodilator response (8 males), aged 13-17 years, randomly inhaling salbutamol from a CFC-pMDI through a static spacer (Nebuhaler) and from an HFA-pMDI through a non-static spacer (Nebuhaler). RESULTS: In vitro output of particles in the respirable range (< 6.8 microns) from HFA-pMDIs was significantly higher than that from CFC-pMDIs using various spacers. Removal of electrostatic charge increased output from CFC- and HFA-pMDIs through all spacers by 17-82%. The mean (SD) bronchodilator response after inhalation of salbutamol from a CFC-pMDI through a static spacer was 7.1% (6.3%) compared to 17.5% (7.9%) after inhalation from an HFA-pMDI through a non-static spacer (p = 0.002). CONCLUSIONS: Use of a newly developed HFA-propelled pMDI greatly improves drug delivery through spacers compared to a CFC-propelled pMDI. However, electrostatic charge in plastic spacers remains the key determinant limiting delivery of salbutamol from a pMDI through spacers, and can be reduced by soaking the spacer in a household detergent. Using an optimal pMDI/spacer combination leads to a significantly improved bronchodilator response.

Family history of atopy and clinical course of RSV infection in ambulatory and hospitalized infants.

Respiratory syncytial virus (RSV) infection can be severe in pediatric patients. Risk factors for severe disease include age less than 6 months, prematurity, preexisting heart or lung disease or malformations, gastroesophageal reflux, and immunodeficiency. The aim of the present study was to investigate the influence of family history of allergy on the clinical course of RSV infection in ambulatory and hospitalized infants. In a retrospective study, 172 patients younger than 12 months of age (99 inpatients and 73 outpatients) were enrolled. Information was obtained from hospital charts and from questionnaires sent to pediatricians. Inpatients had a significantly higher rate of atopy in their family history than outpatients, 62% and 29%, respectively (P < 0.001). Bronchiolitis was diagnosed more frequently in patients with an atopic burden than those without, 89% versus 74%, respectively (P < 0.02). Inpatients with an atopic family history had a significantly longer hospital stay than those without such a history, 7.4 +/- 3.7 days and 6.1 +/- 2.3 days, respectively (P < 0.04). Factors other than age that are considered a risk for severe infection with RSV (prematurity, preexisting heart or lung disease or malformation, and gastroesophageal reflux) were not confirmed in the present study. We conclude that infants with a family history of atopy are at increased risk for severe RSV infection as indicated by higher rates of hospitalization, longer hospital stay, and more frequent occurrence of bronchiolitis.

Evaluation of a clinical algorithm involving serum eosinophil cationic protein for guiding the anti-inflammatory treatment of bronchial asthma in childhood.

A pilot study was performed to investigate a clinical algorithm using serum-eosinophil cationic protein level (S-ECP) as an objective parameter for tapering the anti-inflammatory treatment in chronic childhood asthma. We studied 21 outpatient asthmatic children (6 girls and 15 boys, mean age 9 yr, range 3-12 yr, all with initial S-ECP > or = 15 microg/l) over a period of 12 months at monthly intervals. At each visit a short history, clinical examination, blood sample for S-ECP and eosinophil count, lung function tests and drug compliance were assessed. According to the initial S-ECP, patients were allocated to two anti-inflammatory treatment groups: patients with S-ECP between 15 microg/l and 30 microg/l were treated with Budesonide 200 microg twice daily, while patients with S-ECP of 30 microg/l and above received Budesonide 400 microg twice daily. After this induction treatment the anti-inflammatory medication was tapered at monthly intervals according to actually measured S-ECP: patients with S-ECP < 15 microg/l received sodium cromoglycate (SCG) 10 mg twice daily per inhalation via spacer, patients with S-ECP > or = 15 microg/l and < 30 microg/l received Budesonide 200 microg twice daily via spacer, and patients with S-ECP > or = 30 microg/l received Budesonide 400 microg twice daily. Prior to inhalation of topical steroids or SCG all patients had to inhale 500 microg Terbutaline twice daily for optimal bronchodilatation. The use of medication was assessed by weighing the metered dose inhaler containers each month. Our results showed a decrease in symptoms (p = 0.0001) and in S-ECP (p= 0.02) and MEF50% predicted (p= 0.02) after the initial month of Budesonide treatment. During a total of 246 months of investigation there was no need for emergency room treatment or hospital admission, and no need for oral steroids. During the whole study period there was a tendency for inhaled steroids to be more effective than SCG in reduction of markers of airway inflammation, improvement of symptoms and lung function. Inadequate use of medication was related to an increase in S-ECP in all treatment groups. From this open pilot study it is concluded that a clinical algorithm including S-ECP for tapering the anti-inflammatory treatment may be helpful in childhood asthma. These first observations should be confirmed by a controlled long-term study.