Guest editorialPaediatric asthma in South Africa: A case of hunger in times of plenty

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The Role of Macrolides in Childhood Non-Cystic Fibrosis-Related Bronchiectasis

Non-cystic fibrosis-related bronchiectasis is a chronic inflammatory lung disease, which is regarded as an “orphan” lung disease, with little research devoted to the study of this condition. Bronchiectasis results in impaired quality of life and mortality if left untreated. The tools available in the armamentarium for the management of bronchiectasis entail antibiotic therapy traditionally used to treat exacerbations, stratagems to improve mucociliary clearance, and avoidance of toxins. Macrolides have been known for the last two decades to have not only anti-bacterial effects but immunomodulatory properties as well. In cystic fibrosis, the use of macrolides is well documented in subjects colonized with Pseudomonas aeruginosa, to improve quality of life and lung function. There is currently emerging evidence to suggest the benefit of macrolides in subjects not colonized with Pseudomonas aeruginosa. This beneficial effect has been less explored in the context of bronchiectasis from other causes. The purpose of this paper is to review the current literature on the use of macrolides in non-cystic fibrosis related bronchiectasis in paediatrics

A guide to performing skin-prick testing in practice: tips and tricks of the trade

Atopy can manifest in childhood as infantile eczema (atopic dermatitis), allergic rhinitis and asthma. In practice, it is critical to identify the offending allergen in atopic individuals. This will not only influence therapeutic interventions, but may also have a significant impact on the individual’s quality of life. The most common clinical test for allergy detection is the introduction of an allergen directly into the skin in the form of a skin-prick test. Skin-prick testing is recommended in the diagnostic workup for allergies because it is reliable, safe, convenient, inexpensive, minimally invasive, and has the advantage of multiple allergen testing in one, 15- to 20-minute, test. Skin-prick testing can be performed from birth onwards. Although there is a small risk of developing anaphylaxis, the test remains safe to perform in a consultation room or at the patient’s bedside. Worldwide, a skin-prick test remains the test of choice for allergy because of its convenience and cost-effectiveness. A globally accepted guideline for skin-prick testing is still lacking and would be beneficial to both patient and physician.Keywords: allergy, indications, contraindications, cut-off points, measurement

The value of pimecrolimus in improving quality of life of children with severe eczema – an open non-randomised study

Background: Atopic eczema is a common skin condition. It has the potential to severely impair quality of life in affected children. Pimecrolimus is currently registered for mild-moderate eczema but in clinical practice children with more severe disease are often treated with this therapy in an attempt to find a safe addition to long-term topical corticosteroid usage. The aim of this study was to test the value of pimecrolimus in improving quality of life in children with severe atopic eczema.Methods: This a single site, phase 4, non-randomised, open label trial of pimecrolimus use in children aged 4 months to 12 years living withmoderate to very severe atopic eczema. The study was conducted at Steve Biko Academic Hospital. Patients with unsatisfactorily controlled disease despite conventional topical therapy, adequate use of emollients, allergen avoidance and non-pharmacological skin hygiene were enrolled. A ParentIndex Quality of Life Questionnaire was completed by parents before and three months after using pimecrolimus.Results: A total of 24 patients were recruited, 20 of whom completed the study. Ninety per cent of patients had co-morbid asthma and allergicrhinitis. The Parent Index Quality of Life demonstrated a mean 33% score improvement after the use of pimecrolimus. There was an attendant reduction in cost of therapy to these patients.Conclusions: Pimecrolimus usage should be extended to patients with more severe atopic eczema as the improvement in quality of life is important and demonstrable.Keywords: severe eczema; topical steroids; calcineurin inhibitors; pimecrolimus; quality of lif

Asthma control - Practical suggestions for practicing doctors in family practice

Many surveys of asthma care suggest that only 5% of asthmatics are meeting the ‘Goals of asthma management' as set out in the Global Initiative for Asthma (GINA) guidelines. Despite the availability of useful asthma therapies and treatment strategies, the morbidity from asthma has remained significant. This review includes practical suggestions on optimal asthma control for the family practitioner. South African Family Practice Vol. 50 (2) 2008: pp. 26-3

The impact of highly active antiretroviral therapy on the burden of bacterial lower respiratory tract infections in children

Background. Respiratory diseases are common and associated with significant morbidity and mortality in children.Objective. To evaluate the prevalence and outcome of bacterial lower respiratory tract infections (LRTIs) in HIV-infected and uninfected children at a primary level hospital.Methods. A cross-sectional descriptive study of children aged 6 months - 18 years was conducted. Recruitment included HIV-positive children who had been on highly active antiretroviral therapy (HAART) for at least 6 months. A comparator group of HIV-negative children admitted with bacterial pneumonia was included. Laboratory data collected included CD4+ T-cell counts, HIV viral load and C-reactive protein (CRP). Data collected in both groups included demographic data, immunisation status, zinc supplementation, previous LRTIs, environmental exposures and treatment.Results. Fifty-nine HIV-infected and 20 uninfected children were enrolled. The HIV-positive children were older, with a mean age of 107.2 (standard deviation 50.0) months v. 12.0 (5.8) months (p<0.005). The HIV-infected group had a mean CD4 percentage of 31.5%, and had had an average of 3.9 visits for bacterial LRTIs. All were treated with amoxicillin with no complications. In the HIV-uninfected group, cough and rapid breathing were the most common presenting symptoms, and the mean CRP level was 463.0 mg/L. The mean hospital stay was 4 days.Conclusion. HAART is effective in reducing the burden of LRTIs in HIV-positive children, even when the diagnosis is delayed. Cough and fast breathing are still the most reliable presenting symptoms of pneumonia. The majority of children still respond to amoxicillin as first-line therapy, with low complication rates

Paediatric spirometry guideline of the South African Thoracic Society: Part 1

Spirometry forms an important component in the diagnosis and management of pulmonary diseases in children. In the paediatric setting, there are different challenges in terms of performance and interpretation of good quality and reliable tests. An awareness of the physiological and developmental aspects that exist in children is necessary to improve the quality and reliability of spirometry. We reviewed the recommendations on the technical aspects of performing spirometry in children, from the available guidelines and clinical trials. The focus was on the indications, methods and the interpretation of lung function tests in children <12 years of age. Reliable lung function testing can be performed in children, but an awareness of the limitations, the use of incentives and a dedicated lung function technologist are necessary

Prevalence of Blomia tropicalis allergy in two regions of South Africa

Background. Asthma and allergic rhinitis affect 15% and 38% of South African (SA) children, respectively. The housedust mite (HDM) is the most significant indoor aeroallergen. Typical HDM species include Dermatophagoides pteronyssinus, D. farinae and Blomia tropicalis. Conventional skin-prick testing (SPT) panels only test for Dermatophagoides. B. tropicalis has been described in the tropical and subtropical regions, but is not routinely tested for in SA.Objective. To ascertain the significance of B. tropicalis as an aeroallergen in northern coastal KwaZulu-Natal Province (KZN), a tropical environment, and in Johannesburg in the highveld, where the climate is milder and less humid.Methods. Children aged 1 - 18 years with features of allergic rhinitis and/or asthma were recruited over a 6-month period from Alberlito Hospital in northern KZN and the Clinton Clinic in Johannesburg. SPTs included Dermatophagoides and B. tropicalis. Sensitisation was defined as a wheal 3 mm greater than the negative control.Results. Eighty-five subjects were included, 50 in northern KZN and 35 in the Johannesburg arm; 52% of subjects in northern KZN and 3% in Johannesburg were sensitised to B. tropicalis, with a significant difference between these centres (p&lt;0.05). Of the 52% sensitised to B. tropicalis in northern KZN, half were sensitised only to B. tropicalis.Conclusion. There is a high prevalence of B. tropicalis allergy in the tropical northern KZN region and a much lower prevalence in the Johannesburg region. Routine testing for B. tropicalis allergy should be employed in northern KZN