A case of fibrosing alveolitis in childhood.
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Child, Preschool↗
Biomedical subjects
J F Price
Publications and source records attributed to J F Price.
Lack of relation between IgE in neonatal period and later atopy.
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Age Factors↗
Acute and long-term effects of viral bronchiolitis in infancy.
About 1% of infants are admitted to hospital with acute bronchiolitis; 85% of cases are caused by infection with Respiratory Syncytial Virus (RSV). The pathophysiological changes during the acute illness are inflammatory obstruction in the small airways with submucosal cellular infiltration, epithelial necrosis and mucous plugging; FRC increases and dynamic compliance falls. Failure to respond to bronchodilator drugs suggests that muscle spasm contributes relatively little to the airway narrowing. Affected infants become increasingly dyspnoeic and hypoxic for 3-4 days then spontaneously improve. After an attack of acute bronchiolitis up to 75% of children have recurrent lower respiratory tract symptoms, many continue to have hyperinflated lungs and bronchial hyperresponsiveness. In the majority, symptoms of cough and wheezing have subsided by the time they start school, but abnormalities of small airway function are detectable at least 13 years later. Children with a genetic predisposition to atopy do not appear to have an increased risk of developing bronchiolitis. Evidence of genetic predisposition to bronchial hyperresponsiveness in those with persistent wheezing is controversial. There is little to suggest that neonatal lung damage or an adverse home environment are important factors in determining susceptibility to post-bronchiolitis wheezing. IgE antibodies to RSV, and leukotriene C4, are found more frequently in the respiratory secretions of infants who wheeze during and after bronchiolitis than in those who do not. The possibility of viral-induced alteration of the immune response at the time of infection needs further investigation.
Bronchial Provocation Tests↗
Leukotrienes in the sputum and urine of cystic fibrosis children.
1. Leukotrienes (LTs) are potent pro-inflammatory mediators with actions relevant to the pathophysiology of cystic fibrosis (CF), including increased mucus production, bronchoconstriction, leucocyte chemotaxis, and increased vascular permeability. We have therefore investigated the potential role of LTs in children with CF. Leukotriene E4 levels were assessed in the urine of 30 normal (N) children (aged 1.3-12.7 years) and 30 CF children (1.6-14.3 years). Sputum from 13 of the CF children was analysed from LTB4, LTC4, LTD4, and LTE4. LTs were separated by reversed-phase h.p.l.c. and quantitated by radioimmunoassay. 2. Urinary LTE4 levels were log normally distributed, with geometric mean values (95% confidence intervals) of N: 88.4 (71.3-111) pmol mmol-1 creatinine (n = 30), and CF: 112 (70.6-177) pmol mmol-1 creatinine (n = 30; P greater than 0.05). Of the CF subjects, 33% had urinary LTE4 levels above 200 pmol mmol-1 creatinine, compared with 3.3% of the N children. 3. In sputum, mean (+/- s.e. mean) LT concentrations were (pmol g-1), LTB4: 44.3 +/- 10.8, LTC4: 4.9 +/- 1.3, LTD4: 1.8 +/- 0.9, and LTE4: 67.7 +/- 18.9 (n = 13). 4. Urinary LTE4 levels correlated significantly with sputum LTE4 levels (r = 0.673, P = 0.012), and with sputum levels of total cysteinyl-LTs (r = 0.660, P = 0.014). 5. In conclusion, total cysteinyl-LT content in sputum is 10-fold higher than previously reported, consisting primarily (91%) of LTE4. The high levels of LTE4 and LTB4 in sputum suggest involvement of LTs in the pathophysiology of CF. Urinary LTE4 levels may prove useful as a marker for cysteinyl-LT production in sputum.
Adolescent↗
Placebo controlled trial of systemic corticosteroids in acute childhood asthma.
In a randomised controlled trial 38 asthmatic children aged 2-11 yr who had not received regular oral or inhaled steroids during the previous year, were treated with a standard regime of nebulised salbutamol and intravenous aminophylline plus either hydrocortisone and oral prednisolone for 5 days, or placebo. The children were observed throughout their hospital stay and for 3 months afterwards. There was a greater fall in heart rates in the steroid treated group on the second day of treatment (mean diff. 16 beats/min) and at discharge (mean diff. 13 beats/min); p less than 0.025. Peak Expiratory Flow Rates recorded in 26 children, 13 in each group, showed more improvement on day 2 in those given steroids (mean diff 16% predicted); p less than 0.05. This difference was not apparent at discharge but 9 children treated with steroids were clinically wheeze-free when they left hospital compared with 3 in the placebo group, p less than 0.05. There were no differences in respiratory rate, pulsus paradoxus and arterial oxygen saturation. Trends in duration of hospital stay and relapse rate during the succeeding 3 months favoured active treatment. These findings support the use of systemic corticosteroids in addition to high dose bronchodilators to treat 'non steroid dependent' children hospitalised with acute severe asthma.
Acute Disease↗
Chronic intussusception.
Chronic intussusception is a rare but completely correctable cause of failure to thrive in infants and children. The presenting features differ from acute intussusception. We present the case of a 16 month old boy presenting with a three week history of anorexia, diarrhoea, and weight loss with subsequent delayed diagnosis.
Chronic Disease↗
Are we recording peak flows properly in young children?
Peak flow rate is used in young children to assess bronchodilator response and monitor asthma status at home. Frequently the best of only three peak flow manoeuvres is reported. The aim of this study was to assess if this was sufficient to give the maximum peak flow rate and to determine the reproducibility of the measurement. Thirty nine children aged between three and ten years were recruited. Peak expiratory flow rate (PEFR) was measured six times in each child at two minute intervals. Less than half (13 of 39) of the children made their maximum blow in the first three manoeuvres. The maximum peak flow from the second set of three blows was a median of 7% greater than that from the first three blows. The coefficient of variation of the measurement was 8.8% suggesting a change in PEFR greater than 17.6% is necessary to demonstrate a response to bronchodilator. We conclude three peak flow manoeuvres are insufficient in the majority of young children to demonstrate the maximum peak flow.
Asthma↗
Inhaled budesonide for acute wheeze in infants.
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Acute Disease↗
Changes in functional residual capacity in response to bronchodilator therapy among young asthmatic children.
Measurements of functional residual capacity (FRC) by helium gas dilution and peak expiration flow rate (PEFR) were made in 63 young asthmatic children aged 2 and 7 years before and after bronchodilator therapy. All 63 children tolerated two measurements of FRC, but only 33 children were able to perform the peak flow maneuver. Bronchodilator therapy was associated with significant change in FRC in the majority (80%) of children; in some, however, this change was an increase rather than a decrease. The change in FRC was significantly correlated with both prebronchodilator FRC and the change in PEFR. An increase in FRC following bronchodilator therapy was more common in children with severe and symptomatic asthma. We suggest that changes in FRC may be used in asthmatic children to demonstrate bronchodilator responsiveness, particularly in those too young to perform other respiratory function tests.
Asthma↗
Aminophylline dosage in acute severe asthma.
In 27 cases of acute severe asthma, a loading dose of 5 mg/kg of aminophylline (omitted if already receiving oral theophylline) followed by a continuous infusion of 1 mg/kg per hour gave satisfactory theophylline levels at 4 h and 24 h. Theophylline clearance rates varied widely, vomiting was common, but unrelated to blood theophylline levels.
Aminophylline↗
Once or twice daily theophylline in childhood asthma.
We conducted a randomized, single-blind, crossover trial to compare two sustained release theophylline preparations. Fifty-nine chronic asthmatics, aged 7-14 years, were randomly allocated to receive Slophyllin (SP) twice daily followed by Uniphyllin (UP) taken as a single dose at bedtime, or UP followed by SP. Two 4-week periods on therapeutic doses of each preparation were compared. Thirty-six patients completed the study. Eight were non-compliant, seven defaulted and eight withdrew because of theophylline related side-effects (seven on UP). Symptom scores, beta-agonist usage, compliance by pill counts, evening peak flow rates and maximal expiratory flow-volume curves were similar on both treatments. Blood levels of theophylline at 11 am and morning peak flow rates were significantly higher on UP. UP may be more helpful for patients with early morning symptoms, but is associated with an increased frequency of severe side effects.
Adolescent↗
Persistent lung hyperinflation in apparently asymptomatic asthmatic children.
Serial measurements of functional residual capacity (FRC) by helium gas dilution were made in young asthmatic children over a 3 month period. Eight children were recruited during hospitalization for an acute asthma attack and eleven during routine outpatient attendances. Both groups of children had FRC's greater than 120% of that predicted for height at recruitment. Although the children denied symptoms throughout the three month follow-up period the majority remained hyperinflated. These results demonstrate a striking difference between objective and subjective assessment of respiratory function in young children. The significance of this persistent abnormality and its relationship to other lung function indices needs urgent investigation.
Asthma↗
Controlled trial of budesonide given by the nebuhaler in preschool children with asthma.
OBJECTIVE: To determine whether the inhaled corticosteroid budesonide, given by a Nebuhaler spacing device, was effective in prophylaxis of asthma in preschool children. DESIGN: Double blind, placebo controlled, random order crossover trial with two week practice run in period. SETTING: Outpatient clinic referrals in secondary referral centre. PATIENTS: 39 children aged 2-6 years selected for the following: able to use Nebuhaler; parents able to complete record card; poorly controlled asthma (defined); not already on systemic or inhaled steroids. Eleven withdrew for various reasons not connected with intolerance to budesonide. Age, sex, other atopies, and symptoms during run in period were similar in the 28 children who completed the trial and in the 11 who withdrew. INTERVENTIONS: Budesonide 200 micrograms or placebo (both one puff) given twice daily during 6-week treatment or control periods, using Nebuhaler after prior training. Three week "washout" at crossover. Compliance monitored by weighing canisters. Patients withdrawn if their acute attacks required treatment with systemic steroids. END POINT: Control of asthma. MEASUREMENTS AND MAIN RESULTS: Peak expiratory flow rate measured twice daily where cooperation allowed. Diary of symptoms and concomitant drug use kept daily. Results showed mean peak flow significantly higher (12% in mornings, 14% in evenings) in second three weeks of intervention compared with control period (95% confidence intervals 6.3-17.3% and 7.2-21.0%). Supplementary bronchodilator drugs reduced by 50% during intervention periods. CONCLUSIONS: Budesonide given by Nebuhaler is effective prophylaxis for preschool children with frequent asthma.
Asthma↗
Nebuhaler technique.
Two Nebuhaler techniques were compared by measuring the response to terbutaline 0.25 mg in 13 asthmatic children. Five breaths each sufficient to operate the Nebuhaler valve resulted in greater bronchodilatation after 10 minutes (P less than 0.05) than two deep inspirations from residual volume each held for 5 seconds. The peak responses were similar and both methods produced significant bronchodilatation compared with placebo. Either method is satisfactory in children but the former is easier to perform.
Adolescent↗
Abnormalities of functional residual capacity in symptomatic and asymptomatic young asthmatics.
Functional residual capacity (FRC) was measured by helium gas dilution in 186 young asthmatics, aged between 2 and 9 years. The majority were hyperinflated, as evidenced by an increase in FRC, regardless of symptom status. Symptomatic children and those hospitalized with an acute asthma attack had significantly elevated FRC when compared to asymptomatic children (p less than 0.01). Eight symptomatic children, following treatment modification, became asymptomatic. This was associated with a reduction in FRC. We suggest that an FRC result greater than one standard deviation from the mean of asymptomatic asthmatics could be used to predict inadequacy of treatment.
Asthma↗
IgG subclass deficiency in asthma.
Total immunoglobulin G (IgG) and subclasses were measured in serum samples from 82 children with chronic asthma, aged 1.5 to 6.3 years, and 76 controls. Concentrations of IgG1, IgG2, IgG3, and total IgG were significantly lower in asthmatic children aged 1 to 5, and IgG2 concentrations were also significantly lower in asthmatic children over 5 years of age. Twenty eight asthmatic children had at least one value in the deficient range, and 26 had IgG2 deficiency alone or in combination. Five children had IgG2 and IgA deficiency. These 28 children were significantly younger and fewer had raised IgE concentrations than the remainder. IgG subclass deficiency, which may reflect delayed maturation of the immune system, is common in young asthmatic children, and may have a role in the pathogenesis of the disease.
Asthma↗
Inhaled bronchodilator treatment via the nebuhaler in young asthmatic patients.
Changes in functional residual capacity and peak flow rate were measured to assess bronchodilator response to terbutaline inhaled via a nebuhaler. In 10 children with asthma, aged 5-7 years, five breaths sufficient to operate the nebuhaler valve resulted in clinically important improvement in both the functional residual capacity and the peak flow rate. In 18 of 22 children, aged 2-5 years, who were too young to have their peak flow rate measured reliably, terbutaline administered via this modified nebuhaler technique was also associated with a clinically important change in functional residual capacity. The results suggest that effective bronchodilation using a nebuhaler can be achieved even in very young children.
Aerosols↗
Air or oxygen as driving gas for nebulised salbutamol.
The effects of nebulised salbutamol driven by compressed air or oxygen were compared in a randomised crossover study during 27 attacks of acute asthma. Arterial oxygen saturation fell by 2-6% during or after treatment in 10 cases: seven with compressed air, two with oxygen, and one with both driving gases. Hypoxaemia occurred in younger children and in those who fell asleep, but was not related to the level of arterial oxygen saturation before treatment or the size of the response to bronchodilator therapy. More children fell asleep with compressed air nebulisation. Arterial oxygen saturation improved and heart rates remained stable during treatment when oxygen was the driving gas. After treatment, however, arterial oxygen saturation fell and heart rates rose to values that were similar to those after treatment with compressed air. The falls in arterial oxygen saturation we observed, though comparatively small, would be clinically important on the steep part of the oxygen dissociation curve, and our results emphasise that families with home nebulisers should seek medical advice early when their children develop severe asthma. The benefits of using oxygen as the driving gas during nebulisation were transient, and in severe asthma treatment with oxygen needs to be continued after the nebulised salbutamol has been given.
Acute Disease↗