A. Escribano Montaner

Consenso sobre tratamiento del asma en Pediatría

PRESENTACION Cuando se aprobo por la Sociedad Espanola de Inmunologia Clinica y Alergia Pediatrica y por la Sociedad Espanola de Neumologia Pediatrica la organizacion de una reunion conjunta en mayo de 2004, fue iniciativa de ambas directivas crear una comision mixta que redactara un documento en el que se recogiera lo esencial en el tratamiento del asma en el nino en una vision unificadora de criterios, hasta ahora, aparentemente diversos. La primera reunion de esta comision tuvo lugar en junio de 2003 y en ella se sentaron las bases para este documento. Se acordo dedicar una especial atencion a las epocas de la vida en la que el asma es mas complicada, tanto en su diagnostico como en su tratamiento. Por primera vez en una guia de este tipo se ha incluido la prediccion del fenotipo de asma como una variable que se debe tener en cuenta en algunas decisiones terapeuticas. No se ha pretendido que este documento sea una guia exhaustiva, y por tanto aspectos tan fundamentales como la educacion y los autocuidados no se han tratado debido a que son temas en los que el consenso es universal. Lo mas importante del documento es la conjuncion de dos visiones –hasta ahora aparentemente distintas– sobre el asma en el nino. Cada una de las frases de este documento ha sido revisada cuidadosamente y es asumida corporativamente tanto por una Sociedad como por la otra. El objetivo fundamental es, por tanto, ofrecer un criterio claro y uniforme sobre el tratamiento del asma en Pediatria. Ambas Sociedades hacen votos para que esta colaboracion no acabe aqui, sino que continue regularmente con otras iniciativas, incluyendo la futura actualizacion de este documento. INTRODUCCION

Diagnostico de la tuberculosis en la edad pediatrica

Tuberculosis is one of the most important health problems worldwide. There are an increasing number of cases, including children, due to different reasons in developed countries. The most likely determining cause is immigration from highly endemic areas. Measures to optimise early and appropriate diagnosis of the different forms of tuberculosis in children are a real priority. Two Societies of the Spanish Paediatric Association (Spanish Society of Paediatric Infectology and Spanish Society of Paediatric Pneumology) have agreed this Consensus Document in order to homogenise diagnostic criteria in paediatric patients.

Diagnostico de la tuberculosis en la edad pediatrica. Documento de consenso de la Sociedad Espanola de Infectologia Pediatrica (SEIP) y la Sociedad Espanola de Neumologia Pediatrica (SENP)

Tuberculosis is one of the most important health problems worldwide. There are an increased number of cases, including children, due to different reasons in developed countries. The most likely determining cause is immigration coming from high endemic areas. Measures to optimize early and appropriate diagnosis of the different forms of tuberculosis in children are a real priority. Two Societies of the Spanish Pediatric Association (Spanish Society of Pediatric Infectology and Spanish Society of Pediatric Pneumology) have agreed this Consensus Document in order to homogenize diagnostic criteria in pediatric patients.

Consensus Statement on the Management of Paediatric Asthma

When the Spanish Society of Clinical Immunology and Paediatric Allergy and the Spanish Society of Paediatric Pulmonology agreed to organise a joint meeting for May 2004, they set up a task force to draw up a document that would review the basic features of children’s asthma treatment and would unify criteria that had been apparently diverse before then. The first meeting of this task force was held in June 2003 and laid down the guiding principles for this document. Special attention was paid to those periods of life in which asthma is more difficult to both diagnose and to treat. The prediction of the asthma phenotype, as a factor to consider in certain therapy decisions, was included for the first time in a guide of this kind. The document was not conceived as an exhaustive guide. Consequently, such basic questions as education and self-care were not dealt with because there is general consensus on them. The most important aspect of the document is the bringing together of two hitherto disparate visions of children’s asthma. Both societies assume full responsibility for the document, in which every sentence has been checked carefully. The basic aim is to offer clear, uniform criteria for asthma treatment in Paediatrics. Both Societies hope that this is not the end of the joint work, but that it will continue on a regular basis with other initiatives, including the updating of this document in the future.

International Study of Asthma and Allergies in Childhood (ISAAC) fase II: metodología y resultados de participación en España

Antecedentes La fase I del ISAAC ha proporcionado informacion muy valiosa sobre la prevalencia mundial de asma y alergia en la infancia. Objetivos Describir la puesta en marcha de la fase II del estudio y la participacion de ninos normales en cada una de las pruebas que se realizan, en las cuatro ciudades participantes en Espana, y establecer en Cartagena, que influencia puede tener el tipo de colegio o la localizacion (area contaminada o no). Metodos En su fase II, el ISAAC incluye cuestionario de sintomas y de factores de riesgo y tratamiento, examen de piel, prick-test cutaneo, prueba de provocacion bronquial, determinacion de inmunoglobulina E (IgE) total y especifica, y medicion de acaros y endotoxinas bacterianas en polvo domestico. Se repartio un cuestionario junto con la peticion de autorizacion de los padres, al numero de colegios necesario (clase de cuarto y quinto de primaria) para obtener alrededor de 1.000 autorizaciones para la realizacion de la prueba de prick-test en cada ciudad. Resultados La participacion en el cuestionario, examen de piel, prick-test, extraccion de sangre, provocacion bronquial y recogida de polvo fueron, respectivamente, para cada ciudad: Cartagena, 58,9; 49,2; 43,2; 33,1; 39,9 y 29,8 %; Almeria, 42,5; 40,6; 39,1; 39,1 y 37,6 %; Valencia, 43,7; 30,4; 23,5; 21,5; 20,1 y 17,1 %; Madrid, 53,2; 40,8; 38,6; 27,6; 30,6 y 21,1 %. En Cartagena, la participacion fue significativamente mayor en los colegios concertados, asi como en los del area no contaminada. Conclusiones La participacion es muy variable, aunque mas baja que en los centros europeos en los que el estudio ha finalizado. La zona y el tipo de colegio influyen significativamente en la participacion.

Consensus on asthma treatment in Paediatrics

FOREWORD When the Spanish Society of Clinical Immunology and Paediatric Allergy and the Spanish Society of Paediatric Pneumology agreed to organise a joint meeting in May 2004, they set up a commission to draw up a document that would review the basic features of children’s asthma treatment and would unify criteria that had been apparently diverse up to then. The first meeting of this Commission was held in June 2003 and laid down the guiding principles for this document. Special attention would be paid to those periods of life in which asthma is more complicated for both diagnosis and treatment. The prediction of the asthma phenotype, as a variable to be borne in mind in certain therapy decisions, was included for the first time in a guide of this kind. The document was not conceived as an exhaustive guide. Consequently, such basic questions as education and self-care were not dealt with because there is general consensus on them. The most important aspect of the document is the bringing together of two hitherto disparate visions of children’s asthma. Both societies assume full responsibility for the document, in which every sentence has been checked carefully. The basic aim is to offer clear, uniform criteria for asthma treatment in Paediatrics. Both Societies hope that this is not the end of our joint work, but that it will continue on a regular basis with other initiatives, including the updating of this document in the future.

How pediatricians in Spain manage the first acute wheezing episode in an atopic infant. Results from the TRAP study

BACKGROUND Although the treatment of asthma has been addressed in several guidelines, the management of the first acute wheezing episode in infants has not often been evaluated. We surveyed practicing pediatricians in Spain about the treatment they would provide in a simulated case. MATERIAL AND METHODS A random sample of 3000 pediatricians and physicians who normally treated children was surveyed. The questionnaire inquired about how they would treat a first mild-to-moderate wheezing attack in a 5-month-old boy with a personal and family history of allergy. Pediatricians were asked about their professional background. RESULTS A total of 2347 questionnaires were returned with useful data (78.2%). Most (90.4%) of the pediatricians would use a short-acting beta2 agonist (SABA) via a metered-dose inhaler with a spacer and a face mask or nebulizer. However, only 34.5% chose a SABA alone: 31.3% added an oral steroid and 27.6% added an inhaled corticosteroid (ICS). The factors associated with the use of ICS in the acute attack were: (1) lack of specific training in pediatrics (OR 1.45; 1.12-1.85) and (2) primary care health center setting (OR 1.31; 1.01-1.69) or rural setting (OR 1.28; 1.01-1.66). Forty-four percent did not recommend any follow-up treatment while 20.7% prescribed ICS as maintenance therapy. The factors related to this decision were the same as those described above. CONCLUSIONS The management of a first wheezing episode seems to meet published guidelines among Spanish pediatricians with formal training in pediatrics and in those who work in a hospital setting or in urban areas.

Técnicas fibrobroncoscópicas especiales: lavado broncoalveolar, biopsia bronquial y biopsia transbronquial

This article completes previous recommendations of the Techniques Group of the Spanish Society of Pediatric Pulmonologists on the practice of flexible bronchoscopy in children. We review the most frequently performed diagnostic and therapeutic procedures applied through the flexible bronchoscope: bronchoalveolar lavage, bronchial biopsy and transbronchial biopsy. Recommendations are also provided on the practice of nonbronchoscopic bronchoalveolar lavage. We review the indications and contraindications of these techniques, the equipment required, and the preparation and monitoring of the patient before, during and after the procedure. The complications of these techniques are also discussed. These recommendations may be adopted, modified or rejected according to clinical needs and constraints.

Neumonía adquirida en la comunidad: tratamiento de los casos complicados y en situaciones especiales. Documento de consenso de la Sociedad Española de Infectología Pediátrica (SEIP) y Sociedad Española de Neumología Pediátrica (SENP) ◊

The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotizing pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression.

Infección por el virus influenza en la infancia. ¿Deberían ampliarse las indicaciones de la vacuna antigripal?

La gripe, descrita por Hipócrates en el año 400 a.C., es una enfermedad aguda transmisible, muy contagiosa, de propagación rápida, que provoca problemas importantes en la población. Su incidencia es muy alta y puede manifestarse de forma esporádica, epidémica o pandémica y afectar a cualquier grupo de edad. En la infancia, durante las epidemias, el 40% de los preescolares y el 30% de los escolares pueden padecerla1, actuando además como vectores de la enfermedad, en sus hogares y en el resto de la comunidad, dado que, mientras que los adultos eliminan un pequeño número de virus durante pocos días, los niños dispersan grandes cantidades durante 2 semanas2 creando una onda epidémica que precede al pico de máxima incidencia de la infección en toda la población3,4. Hasta ahora, se recomendaba la vacunación antigripal anualmente a todas las personas mayores de 6 meses que presentaran una patología crónica capaz de incrementar el riesgo de complicaciones por esta enfermedad, y a aquellas que pudieran transmitir el virus a pacientes de alto riesgo5-7. Sin embargo, el calendario vacunal propuesto en 2003, en EE.UU., por el Comité de Enfermedades Infecciosas de la American Academy of Pediatrics, contempla también la posibilidad de vacunar, de forma habitual, a todos los niños sanos de entre 6 y 23 meses de edad8. Al hilo de esta recomendación, dado que esta posibilidad no se contempla en el calendario de nuestro país9, hemos creído oportuno analizar la importancia de la gripe en la población infantil, en la que es habitual que esta enfermedad se perciba como una afección banal, y destacar el relevante papel que desempeñan los niños en la transmisión de la infección, la eficacia de su prevención, los tipos de vacunas a utilizar y la idoneidad, o no, de ampliar las recomendaciones en este grupo de edad. Características del virus de la gripe