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Background About 12% of children are affected by allergic rhinoconjunctivitis ( AR). Although the main symptomatic treatments are intranasal corticosteroids ( INCS) (daily or on demand) and oral antihistamines, it remains unclear which treatment provides the best relief of symptoms. Therefore, this study examines whether daily use of INCS is superior to on-demand use or to oral antihistamines on demand. Methods A single-blinded randomized controlled trial in children (aged 6-18 years) with pollen-related AR. Patients received either INCS daily (fluticasone propionate), INCS on demand (fluticasone propionate) or oral antihistamine on demand (levocetirizine) for 3 months during the grass pollen season. A daily online symptom diary on both nose and eye symptoms was completed. The primary outcome was the percentage of symptom-free days. Results A total of 150 children were randomized. The percentage symptom-free days was in favour of INCS on demand (30%) compared with INCS daily (22%), that is 8% difference (95% CI −5 to +21%; not significant). The antihistamine on-demand group had 15% symptom-free days, that is 7% difference compared to INCS daily (95% CI −6 to +19%;, not significant). Patients in the INCS on-demand group used on average 61% less fluticasone than patients in the INCS daily group during the study period ( P < 0.0001). Conclusions This trial with three parallel treatment groups shows that INCS daily was not superior to INCS on demand or to antihistamine on demand regarding the number of symptom-free days. An on-demand INCS strategy has the advantage of a lower overall corticosteroid exposure and less costs. [ABSTRACT FROM AUTHOR]

As an ‘inflammometer’, the fraction of nitric oxide in exhaled air (FeNO) is increasingly used in the management of paediatric asthma. FeNO provides us with valuable, additional information regarding the nature of underlying airway inflammation, and complements lung function testing and measurement of airway hyper-reactivity. This review focuses on clinical applications of FeNO in paediatric asthma. First, FeNO provides us with a practical tool to aid in the diagnosis of asthma and distinguish patients who will benefit from inhaled corticosteroids from those who will not. Second, FeNO is helpful in predicting exacerbations, and predicting successful steroid reduction or withdrawal. In atopic asthmatic children FeNO is beneficial in adjusting steroid doses, discerning those patients who require additional therapy from those whose medication dose could feasibly be reduced. In pre-school children FeNO may be of help in the differential diagnosis of respiratory symptoms, and may potentially allow for better targeting and monitoring of anti-inflammatory treatment. [ABSTRACT FROM AUTHOR]

The fractional concentration of nitric oxide in exhaled air (FENO) is elevated in atopic asthma and typically responds to treatment with inhaled corticosteroids (ICS). However, some patients have persistently high FENO levels despite treatment. We studied how optimizing the inhalation technique and increasing ICS doses would affect FENO in stable atopic asthmatic children who had elevated FENO while using ICS. In 41 stable asthmatic children who were treated with ICS (median daily dose 800 μg budesonide equivalent, range 100–1600 μg) and maintained FENO⩾20 p.p.b., we optimized the inhalation technique by thorough instruction and measured FENO 2 weeks later. Then, if FENO remained ⩾20 p.p.b., we increased the ICS dose and reassessed FENO 2 weeks later. Improving the inhalation technique did not reduce FENO. Increasing ICS from a daily median dose of 800 to 1200 μg budesonide had no significant effect on FENO. FENO correlated positively with symptom scores in the following 2 and 4 weeks ( P=0.001, 0.002) and β2-agonist use the 2 and 4 weeks following FENO measurement ( P=0.02, 0.004). We conclude that common steps in asthma treatment, i.e. inhalation instruction and increasing ICS dose, were both ineffective in reducing FENO in atopic asthmatic children with elevated FENO values despite treatment with ICS. This implies that FENO cannot simply be incorporated in current treatment guidelines. [ABSTRACT FROM AUTHOR]

Background: Nitric oxide in exhaled air (FENO) is a marker of eosinophilic airway inflammation. A study was undertaken to determine whether FENO predicts asthma relapse in asymptomatic asthmatic children in whom inhaled corticosteroids are discontinued. Methods: Forty children (21 boys) of mean age 12.2 years on a median dose of 400 μg budesonide or equivalent (range 100-400) were included. FENO was measured before and 2, 4, 12, and 24 weeks after withdrawal of steroids. A relapse was defined as more than one exacerbation per month, or need for β agonist treatment on 4 days per week for at least 2 weeks, or diurnal peak How variability of >20%. FENO measurements were performed online with an expiratory flow of 50 ml/s. Results: Nine patients relapsed. Two and 4 weeks after withdrawal of steroids geometric mean FENO in children who were about to relapse was higher than in those who did not relapse: 35.3 ppb v 15.7 ppb at 2 weeks (ratio 2,3; 95% CI .2 to 4.1; p=0.01) and 40.8 ppb v 15.9 ppb at 4 weeks (ratio 2.6; 95% CI 1.3 to 5.1). An FENO value of 49 ppb at 4 weeks after discontinuation of steroids had the best combination of sensitivity (71%) and specificity (93%) for asthma relapse. Conclusion: FENO 2 and 4 weeks after discontinuation of steroids in asymptomatic asthmatic children may be an objective predictor of asthma relapse. [ABSTRACT FROM AUTHOR]