COmparisoN of TastES of Available NutriTional integrated or non-integrated formulas for infants older than 1 year of age with cow's milk allergy: A multicenter, prospective, single blind, cross-sectional observational clinical study (CONTEST Study).

Palatability of the infant formulas lacking cow milk protein formulas is reported by parents to be an important drawback. The purpose of this study is to examine decisions made by mothers of infants having cow milk protein allergy, and physicians concerning the palatability of unflavored extensively hydrolyzed formulas and amino acid-based formulas. We conducted a multi-center, randomized, single-blinded, observational taste study involving 149 pediatricians from gastroenterology and allergy subspecialties at 14 tertiary healthcare units from different regions of Turkey and involving 94 mothers of infants with cow milk protein allergy. Blinding was performed for seven formulas available in the market, which were the most commonly prescribed for feeding: four AAFs (Neocate-Numil®, Aptamil Pregomin AS-Numil®, Alfamino-Nestle®, Comidagen-Mamma®), one AAF specifically designed to address the growing nutritional and lifestyle needs of children >1 year (Neocate Junior-Numil®), 2 eHFs (Bebelac Pepti Junior-Numil®, Similac Alimentum-Abott®). Considering all three formula characteristics, Neocate junior-Numil® ranked as the number 1 product among seven products by mothers (63.8%) and physicians (69.8%). The ratings of mothers were significantly higher than the physicians (8.1 points and 6.1 points, respectively; p < 0.001). No difference was found in terms of taste, smell, and appearance for Neocate junior-Numil® between the mothers' and physicians' ratings. Since caregivers have responsibility for careful selection of replacement products for infants with cow milk protein allergy, it is noteworthy that increased awareness and confidence in the palatability characteristics of these products should motivate mothers and physicians to comply with replacement treatment in the long term.

Prospective evaluation of tolerance to unheated milk-boiled egg after baked milk-egg tolerance under 2 years.

BACKGROUND: The time to acquisition of tolerance to unheated milk and regular egg after achievement of tolerance to baked goods is not known. OBJECTIVE: To determine the time to acquisition of unheated-milk-regular-egg tolerance, after the tolerance of the baked forms, in children younger than 2 years. METHODS: An initial oral food challenge with baked milk (BM) and baked egg (BE) was performed on patients who were reactive to unheated milk-regular egg, respectively. Patients who were BM-BE tolerant were offered unheated-milk-regular-egg challenges, and patients who were BM-BE reactive were offered BM-BE challenges at an average of 3-month intervals. Food-induced atopic dermatitis was included. RESULTS: Thirty-six children with unheated-milk allergy (median age, 7.3 months [interquartile range (IQR), 6.0-13.5]) and 65 with regular-egg allergy (median age, 7 months [IQR, 5.8-11.0]) were included. Seven of 13 children who were BM tolerant acquired unheated-milk tolerance after a median 4.0 months (IQR, 2.0-7.0). Twelve of 23 children who were BM reactive acquired unheated-milk tolerance after a median 5.0 months (IQR, 3.0-8.0) after BM tolerance. Twenty-one of 29 children who were BE tolerant acquired regular-egg tolerance after a median 3.0 months (IQR, 1.0-6.0). Sixteen of 36 children who were BE reactive acquired regular-egg tolerance after a median 4.0 months (IQR, 2.0-6.8) after BE tolerance. CONCLUSION: Different tolerance rates were determined for baked products at different time points in the first 2 years of life. Unheated-milk-regular-egg allergy resolved in up to 65.5% and 75.5% of cases, respectively, in an average 4 to 5 months after acquisition of BM-BE tolerance. Baked-milk-baked-egg tolerance may be regarded as a precursor of tolerance.

A Prospective Assessment of Clinical Characteristics and Responses to Dietary Elimination in Food Protein-Induced Allergic Proctocolitis.

BACKGROUND: Some aspects of diagnostic elimination/challenge diets in food protein-induced allergic proctocolitis (FPIAP) are still poorly defined. OBJECTIVE: This study investigated the symptom spectrum, time required for resolution of each symptom, triggering foods, and risk factors for multiple food allergies (MFA) in FPIAP. METHODS: Infants referred with visible blood in stool were enrolled after etiologies other than FPIAP had been excluded. Laboratory evaluation, clinical features, and elimination/challenge steps were performed prospectively during diagnostic management. RESULTS: Ninety-one of 102 infants (53 boys) were diagnosed with FPIAP. Eleven children did not bleed during challenges. Visible blood in stool began before 2 months of age in 63.6% of the infants not diagnosed with FPIAP, compared with 18.9% of the patients with FPIAP (P = .003). Offending foods were identified as cow's milk (94.5%), egg (37.4%), beef (10.9%), wheat (5.5%), and nuts (3.3%). MFA was determined in 42.9% of patients. Multivariate logistic regression analysis identified atopic dermatitis (AD) (odds ratio [OR]: 2.98, 95% confidence interval [CI]: 1.18-7.55, P = .021) and an eosinophil count ≥300 cells/µL (OR: 2.72, 95% CI: 1.09-6.80, P = .032) as independent risk factors for MFA. Blood and mucus in stool disappeared in a median 3 days (interquartile range [IQR]: 1-14.5 days) and 30 days (IQR: 8-75 days), respectively. CONCLUSIONS: A tendency to transient bleeding occurs in infants who present with bloody stool before 2 months of age. A 2-week duration of elimination for blood in stool is sufficient to reach a judgment of suspected foods for FPIAP. Mucus in stool is the last symptom to disappear. Concurrent AD suggests a high probability of MFA in FPIAP.

Are large local reactions a marker for systemic reactions to subcutaneous immunotherapy in children?

BACKGROUND: Previous studies involving predominantly adults concluded that the patients developing frequent large local reactions (LLRs) might be at greater risk for systemic reactions (SRs) during subcutaneous allergen immunotherapy (SCIT). OBJECTIVE: To determine the rate of side effects to SCIT and evaluate frequency of LLR among pediatric patients with SRs. METHODS: The retrospective study included pediatric patients receiving SCIT. Data on the demographic features, season at onset of SCIT, the indication for treatment, additional allergic diseases, laboratory results, the allergens applied, side effects after injection, grade of SRs, and the total number of injections for each patient were collected retrospectively from the medical records and injection charts. RESULTS: A total of 19,562 injections were administered to 261 patients with conventional SCIT. The incidence LLRs was 0.2% per injection; 1.15% of all patients (n = 3) experienced LLRs on at least two consecutive visits. Systemic side effects were seen in 1% of all SCIT injections. No grade 3 or grade 4 SRs were observed. Logistic regression analysis showed that having an LLR was 3.32 times (95% CI, 1.313-8. 440; P = 0.011) and initiation of SCIT in summer and spring was 4.309 and 3.056 times than autumn (95% CI, 1.527-12.157, P = 0.006; 95% CI, 1.358-6.849, P = 0.007), respectively, increased risk for an SR. CONCLUSIONS: Having LLRs might predict the risk of SRs at any time during immunotherapy in also pediatric patients. Knowing the risk factors is important for developing a personalized protocol in these patients.

Food-induced anaphylaxis in early childhood and factors associated with its severity.

Background: Several factors that increase the risk of severe food-induced anaphylaxis have been identified. Objective: We aimed to determine the demographic, etiologic, and clinical features of food-induced anaphylaxis in early childhood and also any other factors associated with severe anaphylaxis. Methods: We carried out a medical chart review of anaphylaxis cases from 16 pediatric allergy and immunology centers in Turkey. Results: The data of 227 patients with 266 food-induced anaphylaxis episodes were included in the study. The median (interquartile range) age of the first anaphylaxis episode was 9 months (6-18 months); 160 of these patients were boys (70.5%). The anaphylaxis episodes were mild in 75 cases (28.2%), moderate in 154 cases (57.9%), and severe in 37 cases (13.9%). The most frequent food allergens involved were cow's milk (47.4%), nuts (16.7%), and hen's egg (15.8%). Epinephrine was administered in only 98 (36.8%) of these anaphylaxis episodes. A logistic regression analysis revealed two statistically significant factors that were independently associated with severe anaphylaxis: the presence of angioedema and hoarseness during the anaphylactic episode. Urticaria was observed less frequently in patients who developed hypotension. In addition, confusion and syncope were associated with 25.9- and 44.6-fold increases, respectively, in the risk of concomitant hypotension. Conclusion: Cow's milk, nuts, and hen's egg caused the majority of mild and moderate-to-severe anaphylaxis episodes. The presence of angioedema and hoarseness in any patient who presents with a history of food-induced anaphylaxis should alert clinicians that the reaction may be severe. In addition, the presence of confusion, syncope, or stridor probably indicates concomitant hypotension.

Proven Food-Induced Acute Urticaria and Predictive Factors for Definitive Diagnosis in Childhood.

BACKGROUND: Urticaria can be the only sign of a food allergy or can be seen together with other signs and symptoms of a food allergy. OBJECTIVE: To determine the demographic, etiologic, and clinical features of food-induced acute urticaria in childhood. METHODS: Patients suspected of food-induced acute urticaria were included in this prospective cross-sectional multicenter study. RESULTS: Two hundred twenty-nine urticaria cases were included in this study. Seventeen patients who did not meet the inclusion criteria of the study were excluded. Of the 212 included cases, 179 (84.4%) were diagnosed with definitive food-induced acute urticaria. The most common foods causing acute urticaria were cow's milk, hen's eggs, and nuts in 56.4, 35.2, and 19% of cases, respectively. The positive predictive value of a history of milk-induced acute urticaria together with a milk-specific IgE >5 kU/L for cow's milk-induced acute urticaria was 92% (95% CI: 81-96%). A history of cow's milk-induced and/or hen's egg-induced acute urticaria was consistent with a definitive diagnosis of food-induced urticaria (Chen's kappa: 0.664 and 0.627 for milk and eggs, respectively). Urticaria activity scores were higher in patients with food-induced acute urticaria (p = 0.002). CONCLUSION: Cow's milk, hen's eggs, and nuts were the most common allergens in the etiology of childhood food-induced acute urticaria. Although the urticaria activity score provides guidance for diagnosis, an oral food challenge is often essential for the definitive diagnosis of a patient with a history of food-induced acute urticaria.

Utility of fresh egg skin prick test and egg yolk specific immunoglobulin E for outgrowth.

BACKGROUND: In children younger than 2 years, studies evaluating the value of skin prick tests (SPTs) and specific immunoglobulin E (sIgE) results to predict persistence or resolution of egg allergy (EA) are limited. In addition, the value of egg yolk (EY) sIgE and fresh egg (FE) SPTs has not been well characterized. OBJECTIVE: To investigate the optimal decision points (ODPs) for outgrowing allergy with SPTs and sIgE tests for egg allergen preparations. METHODS: SPTs for FE, egg white (EW), and EY, sIgE tests for EW and EY, and oral food challenges (OFCs) were performed in children with suspected EA. Reactive patients strictly avoided all dietary egg. After 1 year, EA was reevaluated with addition OFCs, SPTs, and sIgE tests. RESULTS: A total of 81 children (median age, 7 months; age range, 2-24 months) were enrolled. Notably, 4 children with a history of anaphylaxis and 60 of 77 children with a positive challenge result underwent egg elimination. The 1-year follow-up OFC test was performed on 59 children. A total of 27 reacted to egg. No persistent patient had a follow-up SPT result for FE of 4 mm or less (positive predictive values of 100% and negative predictive value of 56% for outgrowth). The diameters of the initial SPT for FE decreased 50% or more in half of the patients who outgrew EA. The ODPs for outgrowing allergy for follow-up sIgE tests for EY and EW were 2.1 kU/L or less (positive predictive value of 86.2%) and 4.0 kU/L or less (positive predictive value of 84.6%), respectively. CONCLUSION: A SPT diameter for FE of 4 mm or less and sIgE values of 2.1 kU/L or less for EY and 4.0 kU/L or less for EW have a good positive predictive value for outgrowth of EA in children younger than 2 years.

Two approaches for diagnosis of nonsteroidal anti-inflammatory drug hypersensitivity in children.

BACKGROUND: The oral provocation test (OPT) with culprit drug is the gold standard in the diagnosis of nonsteroidal anti-inflammatory drug hypersensitivity (NSAID-H). Some authors have proposed that the total number of OPTs required to diagnose NSAID-H is much lower with acetyl salicylic acid (ASA) provocations, regardless of patients' reaction history, and less time consuming. OBJECTIVE: This study aims to evaluate the total number of OPTs required to confirm NSAID-H according to the drugs (ASA or culprit NSAID) used in the initial OPT. METHODS: The study included patients with a history of NSAID-H. Data on the demographic and clinical features, coexisting chronic or allergic disease, and laboratory results were collected from medical records. The drug used for the initial OPT (ASA or culprit NSAID), results of the OPT, and the total number of OPTs were reviewed. RESULTS: We included 56 children with suspected hypersensitivity reaction to NSAIDs. NSAID-H was confirmed in 21 children (37.5%). We calculated that if all OPTs were performed with culprit drugs as an initial choice, the number of OPTs required for diagnosis would be 3 or more in 85.7% of positive cases. The number of episodes was an independent risk factor for NSAID-H by multiple logistic regression analysis (odds ratio, 4.3; 95% confidence interval, 1.48-12.24; P = .007). CONCLUSION: Performing an initial OPT with ASA regardless of patients' reaction history can result in much lower numbers of OPT to diagnose NSAID-H and can improve patient compliance.

Abatacept as a Long-Term Targeted Therapy for LRBA Deficiency.

BACKGROUND: LPS-responsive beige-like anchor (LRBA) deficiency presents with susceptibility to infections, autoimmunity, and lymphoproliferation. The long-term efficacy of cytotoxic T-lymphocyte-associated antigen 4-immunoglobulin (abatacept) as targeted therapy for its immune dysregulatory features remains to be established. OBJECTIVE: To determine the clinical and immunologic features of LRBA deficiency and long-term efficacy of abatacept treatment in controlling the different disease manifestations. METHODS: Twenty-two LRBA-deficient patients were recruited from different immunology centers and followed prospectively. Eighteen patients on abatacept were evaluated every 3 months for long-term clinical and immunologic responses. LRBA expression, lymphocyte subpopulations, and circulating T follicular helper cells were determined by flow cytometry. RESULTS: The mean age of the patients was 13.4 ± 7.9 years, and the follow-up period was 3.4 ± 2.3 years. Recurrent infections (n = 19 [86.4%]), immune dysregulation (n = 18 [81.8%]), and lymphoproliferation (n = 16 [72.7%]) were common clinical features. The long-term benefits of abatacept in 16 patients were demonstrated by complete control of lymphoproliferation and chronic diarrhea followed by immune dysregulation, most notably autoimmune cytopenias. Weekly or every other week administration of abatacept gave better disease control compared with every 4 weeks. There were no serious side effects related to the abatacept therapy. Circulating T follicular helper cell frequencies were found to be a reliable biomarker of disease activity, which decreased on abatacept therapy in most subjects. However, high circulating T follicular helper cell frequencies persisted in 2 patients who had a more severe disease phenotype that was relatively resistant to abatacept therapy. CONCLUSIONS: Long-term abatacept therapy is effective in most patients with LRBA deficiency.

Suspected Reaction with Cephalosporin May Be a Predictive Factor for ß-Lactam Allergy in Children.

BACKGROUND: Most children diagnosed with ß-lactam allergy based only on history are not truly allergic, and mislabeling leads to use of less effective and more costly alternative broader-spectrum antibiotics, significantly increasing drug resistance. OBJECTIVE: To determine the frequency and risk factors of confirmed allergy in patients with ß-lactam allergy reported by parents or their doctors and evaluate cross-reactivity between ß-lactams in children with confirmed allergy. METHOD: Sixty-seven children with suspected ß-lactam allergy were evaluated via history, sIgE measurements, skin tests, and drug provocation tests over a period of 5 years. RESULTS: ß-Lactam allergy was confirmed in 10 (14.9%) patients. Six patients had a positive intradermal test result to one or more of the penicillin skin test materials or ceftriaxone, 4 patients with negative skin test results had positive test results with suspected drugs. Age, gender, time interval between evaluation and the initial reaction, personal history of atopy, parental history of drug allergy, reaction type, and multiple drug allergy history were not significantly different between allergic and tolerant patients. For culprit drugs, there was a significant different between the 2 groups; the rate of confirmed diagnosis was significantly higher for cephalosporins such as ceftriaxone, cefuroxime, and cefprozil (p = 0.03). Three patients with allergy to penicillin tolerated cefuroxime; in 4 patients with selective allergy to ceftriaxone tolerated cephalosporins with a dissimilar side chain (cefadroxil, cefuroxime, cefaclor, and cefdinir). CONCLUSION: Our study indicates that most patients with a suspected ß-lactam allergy tolerated this drug. An appropriate diagnostic allergy workup may prevent the use of less effective and more expensive alternatives.

Evaluation of pulmonary functions in preschool children born late-preterm.

AIM: The aim of this study was to evaluate the pulmonary functions of preschool children born late-preterm. MATERIAL AND METHODS: Children aged between 3-7 years who were born at 340/7-366/7 weeks' gestation represented the target sample. Patients with a diagnosis of congenital cardiac, pulmonary and/or muscle diseases were excluded. Respiratory symptoms were evaluated using the modified asthma predictive index and International Study of Asthma and Allergies in Childhood criteria for children aged under and over 6 years, respectively. Skin prick tests were performed. Age-matched healthy controls were chosen according to the criteria proposed by the American Thoracic Society. Lung functions were evaluated using impulse oscillometry study in both groups. Data were recorded in the SPSS program. RESULTS: A total of 139 late-preterms and 75 healthy controls participated in the study. The mean gestational week of the late-preterms was 35.3±0.9 weeks. The main admission diagnosis to neonatal intensive care unit was respiratory distress. In the postdischarge period, 54.1% were hospitalized for pulmonary infections at least once, and 57.8% were passive smoking currently. Aeroallergen sensitivity was detected as 25.8% in the late-preterm group; 34.5% and 15.1% were diagnosed as having asthma and non-asthmatic atopy, respectively. Impulse oscillometry study parameters of R5, R10, and Z5 were higher and X10 and X15 were lower in late-preterms than in controls (p<0.05). Late-preterms with and without respiratory distress in the postnatal period revealed no statistical differences for any parameters. CONCLUSIONS: Our findings suggest that presence of increased peripheral airway resistance in late-preterms as compared to term-born controls.

Evaluation of lung function on impulse oscillometry in preschool children born late preterm.

BACKGROUND: There is a paucity of data on lung physiology in late-preterm children, who may be exposed to a risk of decline in lung function during childhood. In this study, we evaluated lung function in preschool children born late preterm using impulse oscillometry (IOS), and compared the results with those obtained in healthy term-born children. METHODS: Children between 3 and 7 years of age who were born late preterm and who were being followed up at the outpatient clinic were included as the late-preterm group. Age-matched healthy term-born children served as controls. A total of 90 late-preterm and 75 healthy children were included in the study. At 5-20 Hz, resistance (R5-R20), reactance (X5-X20), impedans (Z5) and resonant frequency were measured on IOS. RESULTS: Mean IOS R5 and R10 were significantly higher in the late-preterm group than in the control group (P < 0.05). Mean R5, R10 and Z5 were statistically higher in late-preterm children who had been hospitalized for pulmonary infection compared with the control group (P < 0.05). Mean R5, R10, R15, R20 and Z5 were significantly higher, and mean X10 and X15 significantly lower in late-preterm children with passive smoking compared with late-preterm children without passive smoking and controls (P < 0.05). CONCLUSION: Children born late preterm had signs of peripheral airway obstruction on IOS-based comparison with healthy term-born controls. Besides the inherent disadvantages of premature birth, hospitalization for pulmonary infection and passive smoking also seemed to adversely affect lung function in children born late preterm.

Risk factors for persistence of asthma in children: 10-year follow-up.

OBJECTIVE: Risk factors related to the outcome of childhood asthma are not yet well established. We aimed to investigate the long-term outcome for children with asthma to determine the risk factors in predicting persistence of disease. METHODS: Sixty-two children with asthma were evaluated retrospectively at the end of a 10-year follow-up. Patients were asked to complete a questionnaire requesting clinical information, and underwent physical examination, skin prick testing, a pulmonary function test and bronchial provocation testing. Immunologic parameters evaluated were allergen-specific IgE and IgG4 levels, and allergen-induced generation of CD4(+)CD25(+) cells. RESULTS: Mean age at final assessment was 15.9 ± 3.6 years, and duration of follow-up was 10.30 ± 1.27 years. Fifty percent of patients outgrew their asthma during the 10-year follow-up period. All the non-atopic patients outgrew their disease during the study period, whereas 67% of atopic patients did not. We identified two risk factors independently related to the persistence of symptoms: presence of bronchial hyper-responsiveness and presence of rhinitis. Atopic children who were in remission demonstrated significantly higher allergen-induced CD4(+)CD25(+) T cells compared to healthy controls. CONCLUSIONS: Atopy, presence of rhinitis, positive and presence of bronchial hyper-reactivity are important risk factors for the persistence of asthma in children. Allergen-induced CD4(+)CD25(+) T cells were higher in the atopic children who outgrew their disease, implicating an immunological mechanism of asthma remission in children.

The effect of montelukast on wheal reactions in skin prick tests: a double-blind-placebo-controlled randomized trial.

OBJECTIVE: It is well-known that number of drugs may interfere with wheal reactions in skin prick test. However, the effect of long-term use of montelukast, a cystenil leukotriene receptor antagonist, on skin prick test hasn't been full elucidated. The aim of present study was to demonstrate the effect of montelukast on skin prick tests (SPT). METHODS: This is a single-center, randomized, double-blinded, placebo-controlled study including two treatment periods with a wash-out interval. The subjects received montelukast (5 mg per day), fexofenadine HCl (60 mg per day) and placebo (lactose) with a double-blinded manner during 7- and 21-days treatment periods with a 14 days wash-out period. Dermatophagoides farinae (D. farinae) was used as the skin test material, while histamine as positive control and normal saline as negative control. Overall, 7 skin prick tests were performed at following time points: before treatment periods, on the last days of both treatment periods, 24 h after completion of treatment periods, and on the last day of 14-days interval. RESULTS: Sixty house dust mite (HDM) allergic children (23 girls and 37 boys) with allergic rhinitis and/or asthma completed the study. Mean age was 8.3 ± 2.0 years. In the fexofenadine group, a significant suppression was observed in post-treatment values when compared to baseline values in SPT with D. farinae (p = 0.019). In the montelukast group, no significant suppression was observed in SPT with D. farinae at all time points when compared to baseline. CONCLUSIONS: Our results showed that montelukast had no effect on measurements of SPT. Thus, we concluded that there is no need to discontinue the treatment in order to perform SPT in patients receiving montelukast, even in those on montelukast treatment for at least 21 days.

Sublingual immunotherapy in children with allergic rhinoconjunctivitis mono-sensitized to house-dust-mites: a double-blind-placebo-controlled randomised trial.

BACKGROUND: Although sublingual immunotherapy (SLIT) has been demonstrated to be a safe and efficient treatment in children with seasonal allergic rhinitis (AR), there is little evidence on the efficacy of SLIT with house-dust-mite (HDM) extract in children with isolated perennial AR. OBJECTIVES: We sought to assess the clinical efficacy and safety of HDM-SLIT in children with isolated allergic rhinitis-conjunctivitis mono-sensitized to HDM without asthma symptoms. METHODS: Twenty-two children (aged 5-10 years) with perennial AR and conjunctivitis symptoms mono-sensitized to Dermatophagoides pteronyssinus and Dermatophagoides farinae were enrolled. During a 2 months run-in period, symptom and medication scores, lung functions, bronchial hyperreactivity, nasal provocation and skin prick tests were evaluated. Subjects were randomized to active or placebo using a double-blind method. A total of eighteen subjects were randomised to receive either active SLIT or placebo for 12 months. Daily symptom and medication scores, baseline lung functions, bronchial hyperreactivity, nasal provocation and skin prick tests were recorded and re-evaluated at the end of treatment. RESULTS: After one year of treatment, no significant differences were detected in the between groups and within group comparisons based on total rhinitis symptom/medication scores (p > 0.05). Skin reactivity to Dermatophagoides pteronyssinus was significantly reduced in HDM-SLIT compared to placebo group (p = 0.018). A significant reduction in nasal sensitivity was observed in SLIT group after one year treatment when compared to baseline (p = 0.04). Total conjunctivitis symptoms were reduced significantly in both active and lacebo group at the end of treatment compared to baseline. The proportion of patients with non-specific bronchial hyperreactivity increased to almost 3-fold in placebo group compared to baseline. CONCLUSION: HDM-SLIT was not superior to placebo in reducing isolated rhinoconjunctivitis symptoms within 12 months of treatment. However, HDM-SLIT has a modulating effect on allergen-specific nasal and skin reactivity in isolated perennial AR children. CLINICAL TRIAL REGISTRATION: The trial was registered at Anzctr.org.au number, ACTRN12613000315718.

Predicting hospitalization in children with acute asthma.

BACKGROUND: Acute asthma is one of the most common medical emergencies in children. Appropriate assessment/treatment and early identification of factors that predict hospitalization are critical for the effective utilization of emergency services. OBJECTIVE: To identify risk factors that predict hospitalization and to compare the concordance of the Modified Pulmonary Index Score (MPIS) with the Global Initiative for Asthma (GINA) guideline criteria in terms of attack severity. METHODS: The study population was composed of children aged 5-18 years who presented to the Emergency Departments (ED) of the tertiary reference centers of the country within a period of 3 months. Patients were evaluated at the initial presentation and the 1(st) and 4(th) hours. RESULTS: Of the 304 patients (median age: 8.0 years [interquartile range: 6.5-9.7]), 51.3% and 19.4% required oral corticosteroids (OCS) and hospitalization, respectively. Attack severity and MPIS were found as predicting factors for hospitalization, but none of the demographic characteristics collected predicted OCS use or hospitalization. Hospitalization status at the 1(st) hour with moderate/severe attack severity showed a sensitivity of 44.1%, specificity of 82.9%, positive predictive value of 38.2%, and negative predictive value of 86.0%; for MPIS ≥ 5, these values were 42.4%, 85.3%, 41.0%, and 86.0%, respectively. Concordance in prediction of hospitalization between the MPIS and the GINA guideline was found to be moderate at the 1(st) hour (κ = 0.577). CONCLUSION: Attack severity is a predictive factor for hospitalization in children with acute asthma. Determining attack severity with MPIS and a cut-off value ≥ 5 at the 1(st) hour may help physicians in EDs. Having fewer variables and the ability to calculate a numeric value with MPIS makes it an easy and useful tool in clinical practice.

Perceptions of parents and physicians concerning the Childhood Asthma Control Test.

BACKGROUND: The Childhood Asthma Control Test (C-ACT) has been proposed to be a simple, patient-based test that is able to reflect the multidimensional nature of asthma control. In this analysis, the aim was to evaluate the perceptions of physicians and caregivers concerning C-ACT and its predictive value for future asthma-related events. METHOD: In a multicenter prospective design, 368 children aged 4-11 years with asthma who were either well- or not well-controlled were included in the study. The study participants were evaluated during three visits made at 2-month intervals and the Turkish version of C-ACT was completed each month. Parents completed questionnaires concerning their perception of asthma (before and after the study) and the C-ACT (after the study). Physicians completed a survey about their perception of a control-based approach and the C-ACT. RESULTS: The C-ACT scores increased from visit 1 to visit 3, with improvement seen in all domains of the test. At the end of the study period, the parents more strongly agreed that asthma could be controlled completely and that asthma attacks and nocturnal awakenings due to asthma were preventable (p < .05). Most of the parents reported that the C-ACT helped them to determine asthma treatment goals for their children and also that the C-ACT improved communication with their physicians. The physicians indicated that a control-centered approach was more convenient (95%) and simpler (94.5%) than a severity-centered approach and provided better disease control (93.4%). A higher C-ACT score was associated with a decreased risk of asthma attack and emergency department admittance in the 2 months following the administration of C-ACT. Conclusion. Our findings indicated that the C-ACT improved both parental outlook on asthma control and the communication between the physician and parents. There was a good correlation between the C-ACT score and the level of asthma control achieved, as described by the physician. Additionally the C-ACT score was predictive of future asthma-related events. These findings suggest that the C-ACT may have an important role in asthma management in the future.

Neonatal BCG vaccination induces IL-10 production by CD4+ CD25+ T cells.

To determine the optimal time of Bacillus Calmette-Guerin (BCG) vaccination for induction of Th1 immunity, we measured the interferon (IFN)-γ and interleukin (IL)-10 secretion in purified protein derivative (PPD)-stimulated peripheral blood mononuclear cell (PBMC) cultures in newborns vaccinated at birth or 2nd month of life. Moreover, role of CD4(+) CD25(+) T cells was studied by depletion assay at 8th month. Nineteen term and healthy newborns were randomized into two groups: Group I composed of 10 newborns vaccinated with BCG at birth and the remaining 9 (group II) at 2nd month of life. PBMCs were isolated at birth, 2nd and 8th months of age, and PPD-stimulated IL-10, 5 and IFN-γ secretion were assessed. The same measurements were repeated for IL-10 and IFN-γ after the depletion of CD4(+) CD25(+) T cells at the 8th month. Children vaccinated at birth demonstrated higher PPD-stimulated IFN-γ and IL-10 levels at 2 months of age when compared to non-vaccinated ones (p = 0.038 and p = 0.022, respectively), whereas at 8 months, no significant differences were detected between the two groups. Moreover, CD4(+) CD25(+)-depleted T-cell cultures resulted in lower PPD-stimulated IL-10 levels in those vaccinated at birth when compared to non-depleted condition at the 8th month (p < 0.001). BCG at birth upregulated PPD-stimulated IFN-γ secretion at the 2nd month and remained still detectable at 8 month after the vaccination, whereas those vaccinated at the 2nd month of life lacked that increase in IFN-γ response at the same time-point. Furthermore, depletion assays suggest that CD4(+) CD25(+) T cells are involved in PPD-stimulated IL-10 secretion in response to BCG vaccination.