Bulent Enis Sekerel

Complementary and alternative medicine in children with asthma

BACKGROUND The popularity of complementary and alternative medicine (CAM), particularly for chronic conditions such as asthma, is growing rapidly, but little is known about its use in asthmatic children. OBJECTIVE To evaluate the extent, characteristics, and possible predictors of CAM use in a group of Turkish children with asthma. METHODS The parents of asthmatic children were invited to participate in a questionnaire-based survey of 13 worldwide and 5 local methods of CAM. Current asthma treatment, asthma exacerbations, emergency admittances and hospitalizations due to exacerbations, and parental education levels were investigated as predictors that influenced the use of CAM. RESULTS Of the 304 asthmatic children (mean +/- SEM age, 10.5 +/- 0.2 years; range, 1-16 years), 49% (n = 150) had used some form of CAM previously, and 38% had used CAM within the previous year. The most popular forms of CAM were quail eggs (79%), herbal medicine (31%), Turkish wild honey (26%), speleotherapy (5%), and royal jelly (5%). The respondents learned about CAM through friends (61%), relatives (25%), the media (9%), and physicians (6%). Age, sex, and mothers and fathers education levels were insignificant between the groups that used and did not use CAM (P = 0.40, P = 0.18, P = 0.15, and P = 0.09, respectively). The use of regular asthma treatment, the use of inhaled corticosteroids, asthma exacerbations, emergency admittances, and treatment score were significantly high in the CAM group (P = 0.006, P = 0.03, P = 0.008, P = 0.02, and P = 0.02, respectively). A significantly high percentage of respondents in the CAM group had considered using CAM for their childs asthma in the future (P = 0.001). CONCLUSIONS Asthmatic children in whom the disease is not well controlled are more likely to use CAM as complementary therapy.

Determinants of atopic sensitization in Turkish school children: effects of pre- and post-natal events and maternal atopy.

Emergence of new environmental risk factors, and/or loss of protective factors of a traditional lifestyle may explain the increase, or variations in prevalence of allergic diseases. The aim of this study was to delineate the prevalence and spectrum of, and to reveal the causal and/or protective factors for atopic sensitization among a heterogenous cohort of Turkish children, for the first time in our country. The study design adhered to International Study of Asthma and Allergies in Childhood (ISAAC) phase II protocol. A self‐administered parental questionnaire about demographic characteristics and detailed risk factors, and skin‐prick test with 13 allergens were employed in a clustered random sample of 8–11‐yr‐old Turkish school children. Atopy was defined as the presence of at least one positive skin reaction to any allergen tested. The association between a total of 78 risk factors and different aspects of atopy were analyzed in 1144 children with multivariate logistic regression analysis. The overall prevalence of atopy was 20.6%. Most common sensitizations were to grass pollens, Dermatophagoides pteronyssinus and Blatella germanica. Day care attendance, high paternal education level, male gender and maternal asthma were significant risk factors for atopy. Breastfeeding more than 6 months (compared with 0–6 months), maternal smoking during pregnancy and a birth weight under 2500 g were inversely related to (or protective factors for) atopic sensitization. Maternal atopic disease had significant effects on risk factors pattern. In children with a maternal atopy history a low birth weight, day care attendance and maternal smoking during the first year of life independently increased the risk of atopic sensitization. Gender, breastfeeding and paternal education did not show any association with atopy in this group of children. A history of measles and low gestational age were significant protective factors for mite sensitization. This study showed that children of atopic mothers showed a different profile of risk factors associated with atopic sensitization, when compared with other children. Prenatal and early childhood events had important associations with atopic sensitization.

The effects of grass pollen allergoid immunotherapy on clinical and immunological parameters in children with allergic rhinitis

Allergoid immunotherapy is a new form of allergen immunotherapy allowing safe administration of high allergen doses. There is limited information on the effects of allergoid immunotherapy in children with allergic rhinitis. To investigate the immunological and clinical effects of allergoid immunotherapy in children with allergic rhinitis due to grass pollen allergy. Children with allergic rhinitis were assigned to allergoid immunotherapy (n = 27) or control (n = 26, no immunotherapy) groups. Children in the immunotherapy group received seven injections of grass pollen allergoid immunotherapy before grass pollen season and continued to receive maintenance immunotherapy for 27 months. All patients were offered a pharmacotherapy regimen to be used on demand during the pollen seasons. Clinical and laboratory parameters were compared between the immunotherapy and control groups. The rhinoconjunctivitis symptom‐medication score and asthma symptom score were lower in the immunotherapy group after 1 yr of maintenance immunotherapy (p < 0.01 for both). Skin test reactivity and nasal reactivity as determined by nasal provocation testing for grass pollen were significantly decreased after 1 yr of immunotherapy (p < 0.001 for both). The seasonal increase in bronchial reactivity and nasal lavage eosinophil cationic protein levels were prevented after the first year of immunotherapy (p < 0.05 for both). The seasonal increase in immunoglobulin (Ig)E decreased (p < 0.05) and grass‐specific IgG, IgG1 and IgG4 increased significantly already at the end of the seven‐injection build‐up therapy (p < 0.001, for all). Interleukin (IL)‐4 levels in the culture supernatants showed a steady decline from baseline at first and second year of immunotherapy (p < 0.001) but remained unchanged in the control group. Allergoid immunotherapy is an effective method in the treatment of grass pollen‐induced allergic rhinitis in children and prevents the seasonal increase in bronchial hyper‐reactivity. Changes in specific IgE and IgG levels and decreased IL‐4 production in peripheral blood mononuclear cell culture supernatants may account for the observed clinical effects.

Chronic Urticaria: Etiology and Natural Course in Children

Background: Chronic spontaneous urticaria (CSU) in childhood is infrequent, and information about the disease in children is limited. We attempted to investigate its etiologic factors, natural course, and predictors of prognosis. Methods: All children aged ≤18 years followed for CSU during an 8-year period were analyzed retrospectively, and the final outcomes were queried via a telephone interview. Results: One hundred patients (male/female ratio 1.27) with a median age of 9.2 years (range 0.7–17.2) at symptoms onset were evaluated. The median follow-up was 2.5 years (range 0.2–18.1). An autologous serum skin test was positive in 46.7% of the subjects (n = 45), with a female predominance (71.4%) (p = 0.023). In 13.8% of the children, ANA titers were over 1/100. Food allergy (n = 1), thyroid autoantibodies (n = 3), possible collagen disease (n = 1), and drug usage (deferoxamine) (n = 1) were found to be associated factors. Infections could not be confirmed as the cause of CSU. Recovery was seen in 16.5, 38.8, and 50.0% of the children after 12, 36, and 60 months, respectively. Though in multivariate analysis none of the factors, including age, gender, autologous serum skin test positivity, the presence of angioedema, or other allergic diseases, appeared to predict the prognosis, in univariate analysis being female and being older than 10 years of age predicted an unfavorable prognosis. Conclusion: The etiology of CSU in children is mainly related to an autoreactive background, as in adults. CSU has a favorable prognosis, and resolution is seen in half of the children within 5 years. Girls older than 10 years may have an unfavorable prognosis.

Asthma and allergic diseases in schoolchildren: third cross-sectional survey in the same primary school in Ankara, Turkey

We investigated prevalence and determinants of asthma and allergic diseases in a cross‐sectional survey of schoolchildren aged 6–14 in 2002. This was the third of a series of cross‐sectional surveys, conducted in 1992 and 1997, in the same school in Ankara, Turkey. Questionnaire including information on house characteristics, dietary habits, past and current exposures and diseases were distributed to 1064 children (523 boys, 541 girls) and filled by the parents at home. Percentage of children having a pet was significantly higher (1992: 7.9, 1997: 22.9, 2002: 21), but that of passive smoking was significantly lower (1992: 74, 1997: 64, 2002: 64.1) in 1997 and 2002 when compared with 1992. Current prevalence percentage of asthma (1992: 8.3, 1997: 9.8, 2002: 6.4), wheeze (1992: 11.9, 1997: 13.3, 2002: 6.4), hay fever (1992: 15.4, 1997: 14.1, 2002: 7.2), and eczema (1992: 4, 1997: 4.3, 2002: 1.8) were significantly lower in 2002 compared with 1992. Multiple logistic regression analysis model for current wheeze included ingestion of cows milk (no regular ingestion: reference, ORs and 95% CIs, <1 glass/day: 0.5, 0.3–1.0; at least 1 glass/day: 0.3, 0.2–0.7), ingestion of red meat (2.2, 1.2–3.8), and currently holding a dog (6.1, 1.6–23.4). Multiple logistic regression analysis model for current hay fever included ingestion of red meat (1.8, 1.1–2.9) and fathers education (none of the parents finished secondary school: reference, secondary school to university: 0.5, 0.2–1.0). Our findings suggested that current prevalence of asthma and allergic diseases decreased among schoolchildren in Ankara, in the last 10 yr, and ingestion of milk and red meat could have a role in the occurrence of asthma and hay fever. Detailed assessment of dietary habits is required to test this hypothesis.

Evaluation of the utility of atopy patch testing, skin prick testing, and total and specific IgE assays in the diagnosis of cow's milk allergy

BACKGROUND Information on the utility of atopy patch testing (APT) in the diagnosis of food allergy is derived from studies of children with atopic dermatitis. OBJECTIVE To evaluate the usefulness of APT in the diagnosis of cows milk allergy (CMA) and to determine interleukin 4 and interferon-gamma production by peripheral blood mononuclear cells. METHODS Thirty-seven children (median age, 11 months) with suspected CMA who had a variety of symptoms that involved many organ systems were evaluated using double-blind placebo-controlled food challenges (DBPCFCs), and the performances of milk specific IgE, skin prick testing (SPT), and APT were determined. To search for a possible relationship between the diagnostic tests and the TH1/TH2 immune response, we measured interferon-gamma and interleukin 4 levels in the supernatants of peripheral blood mononuclear cell cultures. RESULTS Seventeen children with positive DBPCFC results and 6 with a history of anaphylaxis were diagnosed as having CMA. The combined use of APT and SPT had a sensitivity of 100% and a negative predictive value of 100% but a specificity of 50% and a positive predictive value of 76%. The addition of milk specific IgE assays to APT and SPT did not improve these values. Pattern of cytokine secretion was not associated with APT positivity or a specific response to DBPCFC. CONCLUSIONS Atopy patch testing may be a useful adjunct to SPT in excluding CMA in children who have allergic manifestations other than atopic dermatitis. However, DBPCFCs are still necessary in the presence of positive test results.

Epidemiology and Burden of Rhinitis and Rhinoconjunctivitis in 9- to 11-Year-Old Children:

Background Rhinoconjunctivitis (RC) is regarded as the most common chronic disease of childhood; however, the currently available epidemiological studies on prevalence, burden, and risk factors of RC are insufficient. This analysis aimed to investigate potential risk factors, symptom frequency, and burden of RC. Methods Using the International Study of Asthma and Allergies in Childhood Phase II questionnaires, 6963 elementary school children aged 9–11 years were surveyed in five different city centers of Turkey. All participants were skin-prick tested with common aeroallergens. Results The prevalence of ever rhinitis, physician-diagnosed rhinitis, current rhinitis, and current RC were 51.6, 31.0, 43.5, and 23.1%, respectively; 19.8% of children with RC symptoms were atopic to at least one allergen. Among students with RC symptoms, 42.2, 23.9, 35.8, and 28.2% reported moderate–severe interference of daily activities, at least 1 day of absence from school, visit to a health care professional, and any drug usage for rhinitis, respectively. Nasal decongestants and oral antihistamines were the most frequently used treatment. Approximately 70% of RC patients reported perennial symptoms and 42.8% were classified as mild to intermittent. Multivariate logistic regression analysis revealed family history of asthma and/or allergic rhinitis (odds ratio [OR] = 1.863; confidence interval, [CI] = 1.583–2.191; p < 0.001), living in a house with mold and dampness in the 1st year of life (OR = 1.651; CI = 1.356–2.01; p < 0.001), maternal smoking in pregnancy (OR = 1.425; CI = 1.089–1.864; p = 0.011), low monthly income (OR = 1.685; CI = 1.422–1.998; p = 0.001), current wheezing (OR = 2.543; CI = 2.151–3.006; p = 0.001), and current atopic eczema (OR = 2.503; CI = 1.96–3.196; p = 0.001) as significant risk factors for current RC. Conclusion Along with the high prevalence of RC in childhood, underdiagnosis and undertreatment of the disease are also frequent. The socioeconomic burden of the disease can be reduced by increasing awareness and proper diagnosis/treatment.

Alternative algorithm for L-asparaginase allergy in children with acute lymphoblastic leukemia

BACKGROUND L-asparaginase is a crucial chemotherapeutic agent for the treatment of acute lymphoblastic leukemia. The alternatives to L-asparaginase are not available in many parts of the world, including Turkey. OBJECTIVE We sought to evaluate the utility of premedication with or without a desensitization protocol in children with acute lymphoblastic leukemia and systemic hypersensitivity reactions to Escherichia coli-asparaginase. METHODS In this prospective study patients with systemic hypersensitivity reactions to E coli-asparaginase for whom we were unable to ascertain/provide other alternatives to asparaginase were either premedicated, desensitized, or both to receive their chemotherapy as E coli-asparaginase according to the severity of the hypersensitivity reaction. RESULTS Nineteen patients (13 male patients) with a mean age of 7.4 +/- 4.7 years experienced a systemic hypersensitivity reaction to E coli-asparaginase during a 4-year period. Polyethylene glycol-asparaginase could be used for 3 patients. Eight of the remaining 16 children, who had experienced anaphylaxis, were premedicated and desensitized with E coli-asparaginase, and in 7 patients treatment was tolerated. The other 8 patients, with acute allergic reactions to E coli-asparaginase, were premedicated first, and 5 of them showed no reaction subsequently. Three of them demonstrated systemic hypersensitivity reactions again (anaphylaxis, n = 3), and premedication and desensitization with E coli-asparaginase resulted in anaphylaxis. Polyethylene glycol-asparaginase was administered uneventfully to the patients who could be provided it. CONCLUSION E coli-asparaginase could be administered to more than half of the patients who had a hypersensitivity reaction, and all of these patients were able to receive their planned doses of asparaginase. In countries with shortages of alternative asparaginase preparations, our approach might be a suitable option.

Are risk factors of childhood asthma predicting disease persistence in early adulthood different in the developing world

Background:  Predictive factors of childhood asthma for favorable prognosis may differ between populations where a variety of genetic and environmental factors are present.

Middle Lobe Syndrome in Children with Asthma: Review of 56 Cases

Objective. Middle lobe syndrome (MLS) is one of the complications of asthma. Its signs and symptoms are often nonspecific, causing delay in appropriate treatment. We aimed to review our pediatric asthmatic patients and provide differential characteristics between MLS and asthma worsening in order to target early diagnosis. Method. File records of all asthmatics (n = 3528) seen in our clinic during the last 2 years were retrospectively reviewed to identify the patients with MLS, and a case‐control study was undertaken. Files of 56 asthmatic children diagnosed as MLS, with a total of 63 episodes, and 63 matched controls with asthma worsening were analyzed and compared. Results. The incidence of MLS was 1.62% and half were below or at the age of 6. All cases with MLS were documented radiologically, and only 5 of the 63 episodes had physical findings suspicious for MLS. The most affected segments were right middle lobe (50%) and left lingula (26.2%). Although in all cases symptoms cleared, in 23 (36.5%) cases, atelectasis persisted radiologically. Compared to controls, patients with MLS included less atopics (34.9% vs. 59.4%, p < 0.05) and fewer boys (52.4% vs. 71.4%, p < 0.05), and they reported less frequent dyspnea (57.1% vs. 85.9%), more frequent sputum production (49.2% vs. 7.8%), and longer duration of complaints (22.0 ± 6.23 vs. 2.4 ± 0.31 days) (p < 0.001, for each). Furthermore, the resolution of symptoms took significantly longer (45.2 ± 9.3 vs. 3.3 ± 0.4 days, p < 0.001). Conclusion. We conclude that complicating MLS in childhood asthma is more frequent in younger ages, girls, and nonatopics. In most cases, physical findings are not informative, and chest radiographs diagnose most but not all cases. The most suggestive symptoms are unresolving/persisting symptoms during admission and/or following treatment.