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708 www.thelancet.com Vol 379 February 25, 2012 Authors’ reply Chiara Bibalo and colleagues correctly note that the maintenance asthma treatment was substantially diff erent when symptoms and fraction of exhaled nitric oxide (FENO) were used to adjust treatment. The reason for this diff erence is the symptom– FENO algorithm that was used. This algorithm identifi ed women with asthma who had few symptoms but increased FENO, who were at risk of asthma exacerbation, and controlled this with low-dose inhaled corticosteroid. The algorithm also identifi ed women with persistent symptoms Exhaled nitric oxide as a guide to management of asthma in pregnancy

Summary Background Specific oral tolerance induction (SOTI) is a promising approach for severe food allergies. There are little data in the literature regarding the home-phase of SOTI, not only with regard to type and frequency of adverse reactions but also regarding the most suitable treatment and protocol. Aims To define the incidence and severity of adverse reactions, possible risk factors, and the safety and effectiveness of the home-phase of an original SOTI protocol in a large group of children with severe cow's milk (CM) allergy, after the hospital “rush” phase. Methods The study was conducted by recording in-home phase adverse events, success and failure as reported by parents, and calling families. Adverse reactions were treated following the International Guidelines, arbitrarily modified by introducing nebulised epinephrine for respiratory reactions, oral beclomethasone for acute gastric pain and oral cromolyn for recurrent gastric pain. Results Out of 140 patients, 132 were contacted; eight were inaccessible (follow-up 2–84 months). The number of adverse reactions was 1 in every 100 doses. The reactions were treated with nebulised epinephrine (221 reactions), IM epinephrine (6 reactions), and other drugs. Patients with high specific IgE levels (greater than 100 kU A /L) and lower CM dose (less than 5 ml) at the end of in-hospital phase showed a higher risk both for number of reactions and use of nebulised epinephrine. Conclusions The home phase of SOTI was characterised by a significant number of adverse reactions, mostly managed with an acceptable rate of side effects. Nebulised epinephrine played a pivotal role in respiratory reactions.

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The prevalence of food allergy and anaphylaxis in children is reported to be increasing in recent years. Evidence suggests that exposure to large doses of antigen might produce a suppression of the specific IgE response, so that the continuous contact with high doses of antigens favours the maintenance of tolerance In the same way loss of contact with allergen in children with specific IgE reactivity may favour a loss of tolerance with development of systemic reactions, while a progressive new contact with allergen may favour a specific tolerance induction. We hypothesize that widespread and uncontrolled use of elimination diets for atopic dermatitis may have played a role in the increase of allergy and anaphylaxis. Specific oral tolerance induction may be a possible therapeutic strategy. The article review food allergies caused by exclusion diet and also discuss recent patents related to the field.

Background Some children allergic to cow's milk proteins (CMPs) experience exceptionally severe reactions after ingesting only trace amounts of antigen. Avoiding the food and carrying self-injectable epinephrine are the current strategies for their management. Objective The aim of this study was to evaluate the safety and efficacy of specific oral tolerance induction (SOTI) for children with severe CMP-induced systemic reactions. Methods Ninety-seven children aged 5 years or older with a history of severe allergic reactions and very high CMP-specific IgE levels were selected for a double-blind, placebo-controlled food challenge. Sixty had positive test results to very small amounts of milk and were randomly divided in 2 different groups. Thirty children (group A) immediately began SOTI, whereas the remaining 30 (group B) were kept on a milk-free diet and followed for 1 year. Results After 1 year, 11 (36%) of 30 children in group A had become completely tolerant, 16 (54%) could take limited amounts of milk (5-150 mL), and 3 (10%) were not able to complete the protocol because of persistent respiratory or abdominal complaints. In group B the result of the double-blind, placebo-controlled food challenge performed after a year was positive in all 30 cases (P Conclusions In this study SOTI was effective in a significant percentage of cases.

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Respiratory infections are the main causes of chronic or recurrent cough in children. Children present 3.8-8 infective episodes per year with cough lasting, on average, 1-3 wk and 10% will still have cough after 4 wk. There is evidence of over-treatment of cough with antibiotics, anti-asthmatic drugs (in Italy) and symptomatic treatments, all with insufficient evidence of efficacy. The relation between sinusitis, asthma and isolated cough is possibly overemphasized. Cough is a symptom of sinusitis, but one can rarely expect isolated persistent or recurrent cough as the only symptom. The issue of chronic cough as the only sign of asthma has been extensively investigated. Recent literature established that the majority of children with isolated cough do not have asthma in terms of both absence of signs of typical asthma inflammation and response to steroid treatment. This unconfirmed hypothesis has unfortunately often resulted in a misunderstood use of inhaled steroids as 'symptomatic' treatment. Our aim should be to avoid unnecessary medicalization and lessen anxiety not by simply prescribing, but by spending time in evaluating patients and explaining to parents what are mostly physiological events, which should resolve spontaneously over time.

1highlight that daily use of inhaled corticosteroids is associated with reduced growth, and that intermittent use of these drugs to control mild persistent asthma avoids such growth impairment. This statement could lead physicians and (parents of) patients to think that daily inhaled corticosteroid treatment is unsafe and stunts growth. I would like to point out that the currently available evidence does not support a clinically relevant eff ect on long-term growth of inhaled corticosteroid therapy in children. The eff ects of inhaled corticosteroids on growth have been extensively studied and reviewed. 2 Although low to moderate doses (

Summary Background specific immunotherapy for Hymenoptera Venom (VIT) is considered a life-saving treatment in insect sting allergy. A few studies with depot VIT have been published, but they are mainly focussed on patients sensitized to Apis Methods this retrospective study was designed to evaluate both efficacy and safety of depot VIT for Vespula. Thirty-six patients (age range 6-73 years) with a history of systemic reactions (grade III to IV according to Mueller) after a Vespula sting, and specific sera IgE RAST to Vespula at least class 2, were administered a depot preparation of venom reaching 50 mg as monthly maintenance dose. After the first year the maintenance dose was administered every other month. Thirty-three patients were treated for a minimum of 5 years. Reactions to any new field sting of the relevant insect were recorded during the treatment and for 6 to 24 months after its interruption Results the treatment showed an excellent tolerance, with only a few local side effects. Thirteen patients (11 Grade IV according to Mueller before VIT) under treatment showed only local reactions after each field sting (18 field stings in total) by the relevant insect. Four patients (3 Grade IV according to Mueller before VIT) had a total of 6 field stings after the interruption of the 5-year treatment, with only local reactions Conclusions according to our results, and in agreement with previous published studies, VIT for Vespula spp. with depot extracts has an excellent tolerance and is clinically effective

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An analysis of a year's admissions for Pneumonia in all the Paediatric Department of the Region Friuli Venezia Giulia is presented. The study was conducted as activity of the Regional Section of the Italian Paediatric Society. The survey of the 14 Paediatric Centres produced a total of 536 cases of Pneumonia in the period January-December 1982 and was focused on antimicrobial therapy adopted pre and after hospitalization. General and specific therapeutic choices are discussed. Drawing the attention on the differences among centres.

Data from 34 patients were included in the analysis of this open group comparative study comparing a controlled release theophylline given twice daily with immediate release aminophylline given four times daily. The treatment period was of eight weeks duration. There was no significant difference between treatments in clinical assessments of asthma severity or pulmonary function tests. Similarly there were no significant differences between treatments in diary card assessments of asthma symptoms or PERF. Serum theophylline levels were measured prior to the morning dose of test treatment and 2 or 5 hours later, respectively for patients taking immediate release (IR) or controlled release (CR) preparations, at each clinic visit. There was no significant difference between treatments in serum theophylline levels fluctuations, although the dosing interval (12 hours) was twice as long for CR formulation. Six patients reported unusual symptoms, two in the CR group (headache, gastric discomfort) four in the aminophylline group (three headache, one headache and vomiting).

A system for auditing quality of care and increasing effectiveness was applied to a health screening program for school-age children and the results were analyzed during 2 subsequent years. A problem-oriented record to be filled in whenever the screening was positive represented the basic tool for the evaluation. The record was sent to the specialist who was requested to make a diagnostic assessment and a treatment plan. The same record returned back to the first-level staff thus providing feedback information about diagnostic accuracy and effectiveness of the screening. Periodic self-evaluation meetings and a tutorial system for diagnostic procedures were instituted leading to a general improvement in quality indexes.

To the Editor.— In 1977 at the Children Hospital of Trieste we evaluated the use of antibiotics in the hospital wards. The most impressive finding was the common use of antibiotics for routine prophylaxis before surgical interventions.1 This tendency was recognizable in all surgical wards (stomatology, otorhinolaryngology, and general surgery) and its quantitative aspects were very similar to those reported by Kesler et al.2 The problem of inappropriate use of antibiotics, especially in the surgical wards, has been recognized as a major concern in hospital care and many remedies have been proposed and tested: use of predetermined therapeutic protocols, medical audit on antibiotic usage, mandatory written requests for certain antibiotics, introduction of automatic "stop order," mandatory references to literature before prescribing, etc.3

2007/2008 206 bambini, allergici al latte vaccino, sono stati sottoposti a desensibilizzazione orale per il latte vaccino. Di questi 86 hanno presentato uno o più episodi di reazione allergica trattati con aereosol di adrenalina, con un totale di 129 reazioni trattate. Solo a 5 bambini, dopo aver effettuato un aereosol con adrenalina, è stata somministrata adrenalina per via intramuscolare. XXI Ciclo

Atopic dermatitis is a chronic inflammatory disease characterized by severe itching, skin dryness, blistering and remittent-relapse course. The critical feature is a skin barrier dysfunction that leads to epidermal inflammation and to bacterial superinfection. The aim of our study is to assess the usefulness of DermaSilk in reducing dermatitis relapses, in infants affected by atopic dermatitis, previously treated with topical corticosteroid and, if needed, with antibiotics. METHODS: This is a double blind randomized study involving 22 infants, aged 4 to 18 months, affected by atopic dermatitis. Disease severity has been evaluated by the SCORAD Index. To achieve a complete remission, acute phases were managed following international guidelines. Subsequently, infants were randomized to either wear a set of DermaSilk body and tights (group A), or wear clothes in pure cotton (group B) for 24 months with the exception of the warmer months (from mid-May to mid-September). RESULTS: The use of topical steroid per month was significantly lower in the DermaSilk group compared to the cotton group (P=0.006). The subjective evaluation reflecting itching reduction was also statistically significant (P=0.014). CONCLUSION: This study shows that DermaSilk products can reduce relapses in infants with eczema during the maintenance phase and play a pivotal role in itching control, improving the quality of life of children and their family.

BACKGROUND: Specific oral tolerance induction (SOTI) is a promising approach in the treatment of severe food allergies. Different protocols have demonstrated its efficacy. Nevertheless, SOTI is still considered an experimental method and should be limited to highly controlled settings. AIMS: To define the incidence and severity of adverse reactions, possible risk factors, and the safety and effectiveness of nebulized epinephrine as a first-line treatment of respiratory reactions during in-hospital SOTI for cow's milk allergy. MATERIALS AND METHODS: A retrospective study was conducted by reviewing the medical records of patients admitted for SOTI beginning in 2001. Reactions were classified as mild, moderate and severe on a partially modified Clark scale. Adverse reactions were treated following the International Guidelines with the introduction of nebulized epinephrine for level four reactions. RESULTS: Of 209 patients, 17 were excluded due to the absence of objective reactions. The remaining 192 were classified as follows: Mild Reactions (Clark Scale 1 to 3): 100 patients received either no treatment, oral antihistamines or nebulized steroids; Moderate Reactions (Clark Scale 4): 87 patients treated with nebulized epinephrine and, depending on their symptoms, oral antihistamines, corticosteroids (nebulized, oral or IV) or nebulized beta 2 agonists; Severe Reactions (Clark Scale 5): 5 children, 4 of whom initially underwent one nebulization of epinephrine and eventually required an IM dose. The fifth patient was immediately treated with IM epinephrine due to hypotension. DISCUSSION: adverse reactions during this in-hospital SOTI protocol were frequent but easily manageable. Nebulized epinephrine can play a relevant role in the treatment of respiratory reactions.

BACKGROUND: Food challenge is required to assess tolerance in cow milk (CM) allergy. A positive challenge contraindicates the reintroduction of CM. Specific oral tolerance induction (SOTI) is a promising treatment. METHODS: All children admitted for a challenge were prospectively enrolled. To those tolerating between 2 and 150 ml a SOTI protocol was offered. Outcome, adverse reactions, parents' satisfaction were recorded. RESULTS: Out of 245 challenged patients, 175 reacted 122 out of 125, able to tolerate a minimum dose of 2 ml, underwent SOTI. After one year 75.4% were in an unrestricted diet, 16.1% tolerated between 5 and 150 ml, 8.5% stopped SOTI. Side effects were mild, parents' satisfaction was very high. CONCLUSIONS: The majority of children tolerating limited amounts of CM at the challenge acquires tolerance with SOTI without relevant side effects. Maintaining on an exclusion diet partially tolerant children should be considered debatable

• We tested bronchial reactivity to carbachol in 50 asthmatics, healthy parents of 40 asthmatic children, and 70 healthy subjects with no personal or family history of asthma. Stepped doses of carbachol (0.1%) aerosol were given until a 50% drop in forced expiratory flow rate from 25% to 75% was observed, or until the subject had inhaled 80 of his or her own vital-capacity equivalent volumes of the aerosol. The area under the doseresponse curve was computed. Histograms of the carbachol reactivity showed a bimodal distribution: 10% of normal subjects and 50% of nonasthmatic parents had values in the asthmatic range. In 85% of parent couples at least one of the two parents had bronchial reactivity without being asthmatic. Our findings suggest that bronchial reactivity to a cholinergic bronchoconstrictor indicates an autosomal-dominant pattern of inheritance. ( AJDC 1987;141:331-334)

Sir .—We read with great interest the article by Ownby and Bailey. 1 While we agree with the authors that there is no reason for including in vitro tests for allergen-specific IgE in the current diagnosis of reaginic-mediated inhalant allergy in children, we disagree with the interpretation of the results concerning the skin tests that led them to conclude that the intradermal technique is more sensitive than prick tests and the in vitro radioallergosorbent (RAST) and multiple allergosorbent (MAST) tests. In our experience all patients with negative prick tests and negative RAST reactions and positive intradermal test reactions show a negative challenge (conjunctival and/or nasal and/or bronchial provocation challenge with the suspected inhalant allergens). We therefore believe that these positive intradermal skin tests are false-positive reactions (low specificity of the test) and that the negative reaction of the prick test and the positive RAST or MAST reaction in some patients