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A pediatric consensus report on allergen-specific immunotherapy for children and adolescents is presented for Austria. Products on the market in Austria are presented and categorised according to studies performed on the target population of children and adolescents, their effectiveness and indication. In general, more clinical studies on children and adolescents are mandatory for most of the available allergen-specific immunotherapeutics. In addition, the use of allergen-specific immunotherapy in general should be promoted as the exclusive treatment with long-lasting effects in type I allergies in particular in children.

Recent publications suggest that long-acting beta-2 agonists (LABAs) increase the risk for death in asthma. The American Food and Drug Administration (FDA) published a relevant alert in 2005. In the currently valid Austrian consensus guidelines for drug therapy of bronchial asthma in children and adolescents, LABAs are only recommended as add-on therapy in those patients whose asthma is not sufficiently controlled by inhaled corticosteroids (ICS) alone. LABAs have no established role in earlier steps of the therapeutic algorithm; consequently, the prescription of ICS-LABA combinations for initial treatment of paediatric asthma is not supported by these consensus treatment guidelines.

Background: Atopic dermatitis has been thought to be associated with a disturbance in n-6 polyunsaturated fatty acid (PUFA) metabolism, but randomized trials investigating the clinical efficacy of oral supplementation with gammalinolenic acid have revealed conflicting results., Aim of the Study: To re-investigate the proposed linkage between PUFA dysregulation and atopic dermatitis., Materials and Methods: Plasma levels of linoleic acid (LA), gammalinolenic acid (GLA), dihomogammalinolenic acid (DGLA) and arachidonic acid (AA) were measured using HPLC in 22 children with atopic dermatitis. Patients were subdivided into those with elevated total serum IgE (group A, n = 15, IgE > +1 SD of age-specific normal values) and those with normal IgE (group B, n = 7) and compared with children suffering from allergic rhinitis/asthma (group C, n = 8) and with non-atopic controls (group D, n = 6)., Results: GLA levels were significantly lower (p < 0.05) in eczema patients with elevated IgE (A, 0.19 +/- 0.06%) and in atopic controls (C, 0.23 +/- 0.06%) than in eczema patients with low IgE (B, 0.42 +/- 0.19%) and non-atopic controls (D, 0.43 +/- 0.16%). There were no significant differences between groups for LIN, DGLA and AA, except for lower LIN levels in atopic controls. Correlation of individual LA and GLA values showed significantly steeper regression lines in low-IgE responders (B and D, k(x) = 0.058) than in high-IgE responders (A and C, k(x) = 0.012; p < 0.02), suggesting impaired delta-6-desaturase function in the latter. For the study population as a whole, there was a clear negative correlation between total levels of IgE and GLA (r(s) = -0.64) and a moderate negative correlation between total IgE and AA (r(s) = -0.38)., Conclusions: Dysregulation of n-6 PUFA metabolism is neither consistently found in nor specifically associated with atopic dermatitis but rather appears to be associated with IgE production and atopy in general. The finding of decreased GLA levels in eczema patients with elevated total IgE and in children with allergic rhinitis and asthma but not in eczema patients with normal total IgE questions the proposed pathophysiologic role of fatty acid dysregulation in atopic dermatitis.

The efficacy of a single intracutaneous BCG injection in prevention of recurrent herpes simplex (HS) was investigated in Tine-test-negative people. Most patients had a recurrence rate of HS of at least once per month. Between 1976 and 1983 109 patients were BCG-vaccinated (BCG sec Berna). Tine-test was negative in all subjects and converted to positive in 106 out of 109 patients after vaccination. Patients suffered from HS for many years and thus acted as their own controls comparing them before and after BCG. After vaccination all patients remained herpes-free for at least 4-6 months. In a separate study a follow-up up to 10 years was done. This showed a decreasing effect of BCG over the years with still 21 (19%) completely herpes-free patients after 3 years. 10 patients (9%) even had been free of herpes for more than 6 years. Reduction of frequency and duration of HS after BCG was statistically significant (p less than 0.01). Since the BCG vaccination can be assumed to be virtually without risk, a Tine-test followed by BCG vaccination should be considered as treatment of choice in patients with recurrent HS for prevention of recurrences.

Up to now 49,116 immunoreactive trypsin (IRT) measurements have been carried out in Austrian newborns in the first week of life. Related to provisionally chosen cut-off points, 301 newborns (0.61%) showed an elevated IRT value; 253 of them were successfully recalled. According to a direct strategy, sweat tests were done without a second IRT measurement in 101 infants; eleven of them were identified as cystic fibrosis (CF) patients. In accordance with a 2-step strategy, 152 infants were reinvestigated by a second IRT determination. Twenty-eight of them again showed an elevated IRT value, as based on provisional, age-dependent reference values; seven were subsequently identified as CF patients by sweat testing. So far two false-negative findings were obtained on IRT screening: one child was later identified as having CF on the basis of typical clinical symptoms and a positive sweat test, the other patient presenting with meconium ileus showed a normal IRT value after surgery, but was subjected to a sweat test in view of the underlying condition. These preliminary results suggest a CF incidence of 1 to 2460 newborns in Austria. Hence, IRT screening appears to be a reliable method for identifying CF patients in the newborn period, thereby facilitating early treatment and genetic counselling.

118 schoolchildred (males:females = 2.5 : 1) with bronchial asthma--defined as recurrent allergic or non-allergic expiratory dyspnoea--were investigated as regards their clinical course, frequency of asthma attacks, exercise tolerance, anti-asthmatic drug requirements and spirometric changes during and after participation in specialized holiday programmes during the summer months in 1974, 1975, and 1976. Clear-cut improvement was observed with regard to asthma attack frequency (up to nearly 100%) and drug requirements (up to 76%). Steroid dependence was observed in most cases. No significant spirometric improvement was demonstrable. All data require critical evaluation and interpretation in view of seasonal variations in asthmatic manifestation and the influence of environmental factors. On reviewing the results it is concluded that treatment of the asthmatic child by supervised high altitude holidays (1400 m above seal level), combined with physical training and a respirator re-education programme, is still a justified therapeutic approach, but it cannot replace specific therapy laid down on the basis of careful diagnostic testing. Particpation of the asthmatic child in school gym classes is recommended. Abstention from physical exercis due to a misplaced protective attitude is not beneficial in most cases.

37 children suffering from asthma had to be vaccinated against tick-borne encephalitis (TBE) with an interval of only 10 days between the first two vaccinations. Sufficient antibodies were detected in samples taken 14 days after the second injection. No differences were found between the results in this group of asthmatic children and in children who were vaccinated with the usual interval of 1 to 3 months elapsing between the first two injections. The asthmatic children tolerated the vaccination very well, moreover the indicence of side reactions was not different from that of the control group.

Conventional treatment of 15 children (aged 4 to 17 years) with cystic fibrosis and persistent failure to thrive was supplemented on an out-patient basis by a daily oral intake of 35 g of medium chain triglycerides (MCT) fat. Follow-up investigations were pursued for a longer period than described in the literature, namely up to 6 months after initiation of the MCT diet. While frequency of the bowel movements was reduced and abdominal discomfort disappeared no weight gain was observed. Clinically, steatorrhoea was clearly diminished. Pre-treatment serum cholesterol levels were lower (121 mg/dl, n=25) than in healthy subjects (182.2 mg/dl, n=56). No significant changes in either serum cholesterol or serum triglycerides were detected over the 6-month period. There were no clinical signs of an essential fatty acid deficiency in 4 patients followed up for 2 years so far. MCT fat should be included in the standard dietary regimen used in the management of any child with cystic fibrosis and failure to thrive. Its use is fully justified by the clinical improvement and alleviation of the steatorrhoea.

Cholelithiasis is a rare, but important condition to be considered in the differential diagnosis of abdominal symptoms in childhood and adolescence. A survey over a 20-year period revealed 10 cases between the ages of 11 and 20 years, with a clinical history of cholelithiasis of between 5 days and 6 years. The most consistent finding was epigastric or right upper quadrant pain. Serum chemistry did not contribute conclusively towards the diagnosis. Hereditary spherocytosis was demonstrated in 3 cases, 2 had familial gall bladder disease, whilst in the rest no cause could be found. Two patients are described in some detail: one girl with spherocytosis and a bilirubin of 78 mg/100 ml, presenting with choledochal obstruction and pancreatitis, and another girl with a history of recurrent abdominal pain, negative radiologial and chemical pathological findings and a tentative diagnosis of neurosis. Oral cholecystograms lead to the diagnosis in most cases; however i. v. cholangiograms should be considered whenever the diagnosis appears in doubt. All cases were treated by cholecystectomy and recovery was uneventful in 9 patients. Cholecystectomy should be performed in all patients with gall stones, even in the absence of symptoms.

Data on systemic side effects (SSE) of specific immunotherapy of allergic diseases recorded in 99 publications over the past 10 years were evaluated and compared with the figure of 0.4% SSE, according to number of injections, published in 1987 by the authors of the present study. The latter figure ranks among the lowest of comparable publications and under present conditions represents the standard. Reasons for the small number of side effects may be found in persistent use of antihistamine premedication before each injection and reduction of vaccination dosage to 50,000 SQ units maximally. Chemically modified allergens are by no means less liable to produce side effects than other allergens. The comparison was undertaken with respect to the following preparations: Alavac P, Allergovit, Allpyral, Alutard, Aquagen (ALK aqueous), Conjuvac, Diephuis, Migen, Novo Helisen, Pangramin Depot, Pharmalgen, Pollinex, Reless, Spectralgen, Stallergenes Depot, and some vaccines, prepared by the authors themselves.

38 children with bronchial asthma were investigated for allergy (RAST), non-specific bronchial hyperreactivity (acetylcholine challenge) and reaction to physical exercise (free running and bicycle ergometry). 17 patients showed EIA caused by free running and 11 by cycloergometry. Patients with clear-cut allergy (n = 27, high RAST values, class 3 and 4) showed exercise-induced bronchoconstriction in a high percentage of cases (16 of 27 following running, 10 of 27 after bicycle ergometry). Such patients also had non-specific bronchial hyperreactivity. This would explain treatment failures after correctly performed specific immunotherapy.

The results of specific hyposensitization in 160 children (121 boys) were evaluated using a questionnaire. In 54% complete remission or clear-cut improvement without additional need for medication was achieved. In a further 34% improvement was demonstrated when compared to the pretreatment period. The main initial complaints were allergic rhinitis or allergic asthma. Treatment was pursued for at least 3 months and for a maximum of 3 years. There were no differences in the success rate as regards sex and offending allergen.

The protective activity of DSCG was investigated in 18 children with established non-specific bronchial hyperreactivity induced by bronchial challenge with acetylcholine. Ipratropium bromide, the anticholinergic agent, was used for comparison. DSCG showed a statistically significant inhibitory action on the decrease in specific airway conductance. Besides the well-established inhibition of mast cell degranulation a direct action on cholinergic irritative receptors seems likely. Application of DSCG in immunologically ill-defined forms of bronchial asthma may be considered. As expected, the direct acetylcholine antagonist, ipratropium bromide, showed an overall protective effect.