Pediatric Allergy,Immunology,and Pulmonology

This study is a retrospective analysis comparing nebulized budesonide inhalation suspension (BIS; Pulmicort Respules™, AstraZeneca, Wilmington, DE) administered once daily by facemask or mouthpiece in 359 infants and young children with persistent asthma. The efficacy and safety of once-daily BIS (0.25, 0.5, and 1.0 mg) administered by facemask or mouthpiece were demonstrated in a multicenter, randomized, double-blind, placebo-controlled, parallel-group study reported by Kemp et al. (Ann Allergy Asthma Immunol 1999; 83:231–239). Three hundred fifty-nine children aged 6 months to 8 years with mild, persistent asthma received nebulized BIS 0.25, 0.5, or 1.0 mg once daily or placebo for 12 weeks via facemask or mouthpiece. Efficacy variables included nighttime and daytime asthma symptom scores, use of breakthrough bronchodilator medications, and pulmonary function tests (in children capable of consistently performing spirometry or peak flows). Changes in nighttime and daytime asthma symptom scores were not significantly different between children using facemasks and those using mouthpieces. Use of breakthrough medications and pulmonary function test results (in the subset of children able to perform them) also were not significantly different in facemask users and mouthpiece users. These results suggest that BIS is equally effective whether administered by facemask or mouthpiece and that young children who require the use of a facemask may be successfully treated.

There is concern regarding the underdiagnosis and undertreatment of asthma in children. This pilot study was designed to determine the specificity, sensitivity, and feasibility of using a two-part (child + parent questionnaire) case finding tool (Video-guided Asthma Screening for Children-School Age, VASC-SA) to identify elementary school children with asthma. The child checklist includes two practice items and nine items asking about asthma symptoms and diagnosis. The items are visually cued using a 10-min videotape using split-screen vignettes, one corresponding to a no response (most children do not...) and one to a yes response (some children...). Three case definition algorithms were examined (all included inhaled medication, or current diagnosis, or wheeze with 0, 1, or 2 other symptoms). The VASC-SA was administered to English-speaking children in grades 1-4 from one school. All parents were sent a written asthma questionnaire. Positive screens were compared with diagnosis obtained from physician report or parent interview. Three-hundred fifty matched parent-child responses were analyzed. Asthma prevalence in this sample ranged from 14 to 14.9% using VACS-SA case definitions. Sensitivity for the three definitions ranged from 79 to 81% and specificity ranged from 94.5 to 95%. The predictive value positive ranged from 66 to 69% and predictive value negative was 97%. Concordance of child and parent reports was highest for previous asthma diagnosis and use of inhaled medication. The VASC-SA appears to be a promising new epidemiological tool to facilitate asthma screening in elementary schools. Prescreening children before parents may offer a practical approach in a large community-based population.

Nonadherence to prescribed medication is a severe problem in asthma, leading to increased health-care costs, and has been reported to be a risk factor for asthma-related mortality in children. The causes of nonadherence are multifactorial and include patient factors, communication factors, and treatment regimen factors. The relative impact of these factors on adherence as well as useful strategies for improving adherence are explored. The clinician needs to accurately assess the cause of the nonadherence to determine the appropriate intervention. The single most important factor for enhancing adherence is the development of a trusting relationship between the clinician and patient.

A survey was mailed to a randomly selected sample of New Mexico public school personnel to assess the existence of written school policies related to management of acute exacerbations, including the collection, storage, and administration of asthma medications. The survey also assessed the training and understanding of school staff members with respect to the management of an acute asthma exacerbation. Data analyses included comparisons between grade level (elementary, middle, and high schools) and urban versus rural schools categories. Survey response rate was 77.8%. Results indicated that 76.3% of public schools had written policies regarding the use of asthma medications. Over 99% of New Mexico public school children with asthma were allowed to take asthma medications to school. Forty-three percent of respondents had staff trained in the management of asthma exacerbations. Of the New Mexico public schools responding, 84% indicated interest in receiving further education on asthma management and inhaler technique. The results of this survey show that the current policies used in the New Mexico public school system regarding the use of asthma medications does not adequately address the needs of children with asthma attending these institutions.

Most cases of chronic urticaria in children are idiopathic. Chronic focal infections of the sinuses or oral cavity have been mentioned as a cause of chronic urticaria because of the persistent antigenic stimulation. To investigate whether children with chronic idiopathic urticaria (CIU) have a higher prevalence and total experience of dental caries than other children in Israel, oral examination was performed to determine decay, missing, filled-teeth (DMFT) scores in 25 children with CIU (mean age, 11.76 ± 3.84 years) and 50 children with perennial allergic rhinitis (PAR) (mean age, 12.57 ± 3.29 years). The results of both groups were compared with reference data from another study on 12-year-old schoolchildren in Israel (n = 762). DMFT scores were 2.84 ± 3.18 in the CIU group, 1.56 ± 1.77 in the PAR group (p = 0.07), and 2.99 ± 2.7 in the reference group (p = 0.80). The difference between the PAR and reference groups was statistically significant (p = 0.001). Twenty-eight percent of the children with CIU were caries-free, compared with 44% of the children with PAR and 21.2% of the reference group (p = 0.18, 0.41, respectively). The difference between the PAR and the reference groups was statistically significant (p < 0.0001). In summary, children with CIU have a total caries experience similar to that of the nonselected pediatric population in Israel. Their DMFT score is slightly higher than those in children with PAR, but without statistical significance. The results of this study do not support an association between chronic urticaria and dental caries in children.

Azelastine nasal spray, a topical second-generation antihistamine, was approved in the United States in 1996 for use in patients 12 years of age and older with seasonal allergic rhinitis. It was also recently approved for the treatment of seasonal allergic rhinitis in children 5–11 years of age. The efficacy and safety in children with allergic rhinitis has been demonstrated in 2 European double-blind, placebo-controlled, parallel-group trials. The objective of this study was to evaluate the clinical experience in the United States of a group of physicians treating patients <12 years of age with azelastine nasal spray. Three hundred physicians were sent a 1-page case report form which requested demographic characteristics, diagnosis of the rhinitis type, dosage and duration of therapy, assessment of symptom control, and any adverse drug reactions in these patients. Azelastine nasal spray was reported to be effective by the clinicians for the treatment of allergic rhinitis in children 5–11 years of age with comparable efficacy reported with dosages of one and two sprays per nostril twice daily. The adverse experience profile with azelastine nasal spray in children was similar to that in adults, with bitter taste (9.8%) and dysesthesia/nasal burning (1.9%) the most commonly reported adverse experiences. At the recommended dosage (one spray per nostril twice daily), azelastine was report to be a useful addition to the currently available therapies for allergic rhinitis in children.