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Current nosologies of depressive illnesses do not, however, do a very good job of categorizing chronic depression. When DSM-IV addresses the course of illness, the situation becomes much more confusing and complicated.
When the validity of these distinctions is examined, it becomes apparent that this multitude of diagnoses does not reflect the clinical reality of chronic depressive illnesses.
The natural history of chronic depression was well described in the work of the NIH Collaborative Study on the Psychobiology of Depression. McCullough and colleagues4 compared 681 outpatients with chronic depression for a broad range of demographic, clinical, psychosocial, family history, and treatment response variables. Those who had suffered at least 2 major depressive episodes but without full interepisode recovery. Although asthma is a common disease, it is not always recognized that asthma has become the most common chronic disease of childhood. Diagnostic errors occur because the differential diagnosis of wheezing and related symptoms is very large for pediatric patients.
Accurate diagnosis of these symptoms can be challenging at times, as there is no specific physiologic, biologic, or immunologic marker for asthma in children. Approximately 9 million children have been diagnosed with asthma in the United States, most with symptoms occuring before 5 years of age. In most children’s hospitals in the United States, asthma is the most common diagnosis at admission.
Correctly identifying asthma and possible triggers early in the disease process is essential in determining the best therapy that promotes long-term remission.
More than 80% of infant hospitalizations due to asthma result from viral respiratory tract infections.
Gastroesophageal reflux disease is a common cause of wheezing in infants under 1 year of age. It is known that passive cigarette smoke triggers asthma and may lead to an increase in airway responsiveness in infants.
Outdoor air pollution exacerbates asthma, increasing emergency room visits and hospitalizations among children with asthma. Prevalence of asthma symptoms is highest in children whose households have open wood-burning stoves, which result in increased airborne particulate matter. Early recognition of various risk factors in pediatric asthma (including information derived from the family history), is crucial.
The frequency of symptoms, missed school days, hospitalizations and emergency room visits due to asthma indicate the severity of the problem.
In general, coughing and wheezing symptoms without viral infections warrant allergy testing. The differential diagnosis (see Table 1) of asthma in infants and young children is indeed large, and it is necessary to exclude other causes of wheezing since congenital defects can mimic asthma in this age group.
Physical examination of the wheezing child should differentiate between inspiratory and expiratory wheezing.
Physical examination during an acute episode of asthma will reveal the severity of the asthma attack.
Status asthmaticus with imminent respiratory arrest: Paradoxical thoracoabdominal movement occurs. All infants and children with asthma should have GERD considered in their differential diagnosis. Evaluation of a child or infant with asthma-like symptoms needs to objectively define the type and severity of the asthma while also considering the broad differential diagnosis that exists in the pediatric patient. Pulmonary function testing, peak flow monitoring and methacholine challenge make it possible to objectively define asthma in young children. A chest x-ray should always be performed the first time an infant wheezes to rule out pneumonia as well as congenital anomalies. A sweat test is recommended for infants and young children with asthma symptoms to rule out cystic fibrosis, which can easily mimic this disease. If the child has a history of recurrent, severe or unusual infections, an immunodeficiency workup is necessary.
Selective allergy skin testing for aeroallergens and food allergens can be helpful in the early diagnosis and treatment of allergic asthma since antigen-specific IgE triggers can begin between 1 and 3 years of age. The recent 2007 guidelines by the National Heart, Lung and Blood Institute (NHLBI) emphasize the assessment of both impairment and risk as determined by functional or frequency criteria. Infants with severe asthma exacerbations and no apparent symptoms between episodes are the most difficult group in which to determine the need for maintenance medications.
Compliance with daily treatment for chronic asthma may be difficult due to the poor cooperation in children, as well as the reluctance of some parents to have their children on medications when they appear asymptomatic.
Anticholinergic agents have been useful as additional medications in severe infant or childhood asthma exacerbations. Cromolyn sodium has been available since the 1970s as an anti-inflammatory medication that inhibits degranulation of mast cells and inhibits early and late-phase asthmatic reactions to allergens.
Leukotriene antagonists such as montelukast block the inflammatory effects of leukotrienes, which are chemical mediators of bronchospasm, inflammation, eosinophilia, stimulation of mucus secretion, and increased vascular permeability.
The NHLBI guidelines list inhaled corticosteroids as the preferred first-line treatment, but montelukast is mentioned as an alternative or add-on therapy for mild-persistent to more severe asthma. Theophylline has been used for decades, but is now in limited use due to concerns about side effects including nausea, insomnia, agitation, cardiac arrhythmias and seizures.
Corticosteroids remain one of the most potent treatments due to their anti-inflammatory effects.
Numerous studies have shown that Budesonide (Pulmicort) and Fluticasone HFA MDI (Flovent HFA MDI) via spacer and face mask have improved pulmonary function, symptom scores and quality of life. Check out the NHLBI guidelines on asthma or The Asthma Center Education and Research Fund for more information.
Regular followup visits are necessary for objective evaluation, education, and adjustment of medications in order to obtain optimum control of asthma. Monitoring pulmonary functions during office visits ensures objective assessment of asthma control. Monitoring medications includes regulating usage, monitoring ACT score, reviewing inhaler technique, looking for side effects, and reviewing emergency readiness.
Dealing with emotions is important for children who may be traumatized or fearful due to incidents related to their asthma. Recognition of high-risk patients includes a history documenting frequency of asthma flares, ER visits or hospitalizations, intubation, use of oral corticosteroids, and history of anaphylaxis. In infants with wheezing, there is a 15% incidence of persistent symptoms after the age of 3.
Although asthma is the most frequent chronic disease in childhood, its diagnosis and optimum treatment remain a challenge to the clinician.


If you manage this site and have a question about why the site is not available, please contact us directly. For MDD, symptoms must be present continuously for 2 weeks and may be characterized by a single episode or be recurrent. The term "double depression" was introduced by Keller and colleagues3 in 1982 to describe patients with MDD and a preexisting chronic minor depression (now called dysthymic disorder).
In fact, asthma-mimicking symptoms are caused by more than 50 different childhood diseases (see Table 1, Differential Diagnosis). The prevalence of asthma has increased in western countries over the last 20 years, which may be due to an increase in the prevalence of allergy. Children tend to be more allergic than adults, with elevated IgE levels and positive skin tests.
These non-allergic children will wheeze as a result of viral infections, exercise and cold air exposure. This third pattern of childhood asthma combines a history of wheezing with evidence of IgE-mediated (allergic) disease. The incidence of asthma can rise to 40% in infants admitted to a hospital with RSV respiratory infections, such as bronchiolitis.
Effectively-controlled asthma depends on identifying triggers early, instituting environmental controls, or decreasing allergen hypersensitivity with immunotherapy (allergy shots) when appropriate. Respiratory syncytial virus is considered the most common viral cause of wheezing in infants.
Studies of bronchoalveolar lavage samples in infants with asthma have revealed evidence of inflammation with increased neutrophils, macrophages, IL-8, and myeloperoxidase which suggest aspiration associated with gastroesophageal reflux (GERD). Up to 13% of asthma in children under 4 years old is reportedly due to exposure to maternal smoking.
Recent studies by Delacourt et al and Wilson et al have shown that wheezing children under 3 years old had positive skin testing to dust mites, cat, or cockroach in 30-45% of those tested.
Cigarette smoking also remains one of the most prevalent environmental factors that exacerbate pediatric asthma. Response to bronchodilators or steroids may provide clues to support a diagnosis of asthma. For example, inspiratory wheezing might indicate extrathoracic obstruction, such as croup or obstruction of the upper airway. Typically, accessory muscles of respiration are used, and suprasternal retractions are present. If their history is suggestive of GERD, swallowing disorders, aspiration, or congenital defects (e.g.
However, these tests are more practical in children over the age of 5 or 6 years, who are adequately coordinated. Each patient must have an individualized emergency action plan with all necessary medications immediately available. The NHLBI guidelines stress that children with 4 or more episodes per year which last longer than a day and affect sleep require long-term controller therapy. Fortunately, the newer medications for asthma in children promise better control of wheezing with improved safety and convenience.
However, mattress encasing has helped significantly lower the necessity for steroid medications in older children. Due to its significant safety profile and lack of toxicity, it is used in young children for chronic treatment.
Many parents prefer the use of a tablet or granule preparation as a long term controller medication in place of a corticosteroid. These medications reduce mucus production, decrease mucosal edema, decrease inflammatory mediators and increase β-adrenergic responsiveness. The NHLBI guidelines indicate that inhaled steroids are the initial drug of choice in asthmatic children younger than 4 years of age.
The significant role of aeroallergens in pediatric asthma suggests that allergen immunotherapy might provide a more permanent disease-modifying outcome after medical treatment is discontinued. Peak flow measurements can serve as an objective guide when determining the need for aggressive treatment or when to seek emergency care. Together, these are risk factors for potentially fatal asthma and should alert the physician to closely follow and educate these patients. Risk factors that predict persistent symptoms beyond infancy include males, presence of atopy, passive smoke exposure, and a parental history of asthma. In many young children, early treatment of small airway disease before asthma becomes difficult to control, may be increasingly important. Although this term appears commonly in the clinical literature and comes closest to reflecting the clinical reality of chronic depression, it is not a DSM diagnosis and must be captured in DSM-IV by assigning 2 diagnoses (MDD and dysthymia). Infantile asthma refers to asthma in children under 3 years of age with four or more episodes of wheezing that improve with bronchodilators or anti-inflammatory therapies.
Diagnoses of pediatric asthma doubled in the 1990s, as compared to the number diagnosed in the 1980s. While asthma can result in a fatal outcome, with proper and timely treatment and education, asthma-related fatalities in children are mostly preventable. Children with evidence of IgE-mediated disease will more likely have persistent wheezing than those without allergy. Further, failure to immunize against influenza puts the child at a greater risk for a severe asthma flare, should they contract this common virus. Metapneumovirus is a newly identified cause of cold weather exacerbations of asthma in children, causing prolonged hospitalizations.
It has been shown that treatment of GERD will substantially reduce asthma medication requirements in affected patients. Outdoor allergens have also been implicated, such as grass or other pollen with positive skin testing in young children and infants. Coughing and wheezing associated with triggers other than viral infections strongly suggest the presence of asthma. If allergy is present and immunotherapy is appropriate, the need for asthma medication can be greatly reduced. Expiratory wheezing is typical of other causes of obstruction of the bronchi or bronchioles, in addition to asthma.
Further, the patient or caretaker needs the knowledge and tools to assess asthma control, monitor for medication side effects, and the ability to recognize a developing asthma emergency. Other groups of infants who require long-term therapy include those who need 2 oral corticosteroid bursts in 6 months or children that require β-agonist treatment for more than 2 days per week for more than 4 weeks. Read more about environment controls for those suffering from allergic asthma and respiratory allergy at TheAsthmaCenter.org.
In a current NHLBI statement, there is a recommendation that ipatropium is appropriate to use during severe exacerbations in infants as an additional treatment.


However, it is reportedly less effective than low-dose inhaled steroids for asthma control.
However, many asthmatics will not respond adequately to leukotriene antagonists, while almost all will benefit from an inhaled corticosteroid with rare significant side effects. Metabolism changes must be recognized with age, diet, fever, viral infections and drug interactions in order to avoid side effects. Corticosteroids improve lung function, reduce airway hyperreactivity, and reduce the late-phase asthmatic response. Although some studies have shown a short-term linear growth decrease in children on inhaled steroids (Budesonide and Fluticasone), catch-up growth occurs after the first year or during puberty.
Further, immunotherapy can decrease bronchial sensitivity and result in a lower need for medications.
The NHLBI guidelines stress that some patients can still be at risk for frequent or severe exacerbations even if they have few daily symptoms. Symptoms may resolve in the second decade of life, although a minority will have a recurrence as adults. This group gradually increases in number until it becomes the most common cause of wheezing by 6 years of age. Severe, repeated asthma attacks are more likely to cause chronic asthma and have been associated with permanently altered airways—resulting in chronic airway obstruction. In addition, other investigators have also identified the rhinovirus as a frequent culprit.
GERD is also a common co-morbid disease in difficult-to-manage asthma and should always be ruled out in such cases. A history of wheezing with exposure to pets, foods, or indoor or outdoor allergens is an indication for allergy testing.
Expiratory wheezing associated with asthma is usually heard throughout the entire expiratory cycle or at least lasting to the end of expiration. Pulsus paradoxus noted earlier may be absent; this finding suggests respiratory muscle fatigue.
If further workup is required, 24-hour esophageal pH monitoring and bronchoscopy may be necessary.
Education comes in many forms, however, the best way to ensure proper medication use and optimum asthma control is for the patient to be audited and educated by asthma specialists on a regular basis. Infants and all children who have a history of acute flares of asthma should have a nebulizer available to them in order to avoid ER visits and hospitalization.
In addition, it is not recommended as a first-line treatment for infants and young children with chronic asthma.
In some patients, there may be a synergy when inhaled corticosteroids are administered along with a leukotriene antatagonist.
The NHLBI guidelines continue to list Theophylline as an alternative or added therapy for children under 4 years of age due to its proven efficacy.
Current studies have not shown clinically significant adrenal suppression in infants or small children. In older children, a 3-year course of subcutaneous immunotherapy with standardized allergen extracts has demonstrated long-term clinical effects. The clinician’s goal is to increase the quality of life of each asthma patient while decreasing morbidity and mortality.
For dysthymic disorder, symptoms must present for 2 years (1 year in children and adolescents) with no absence of symptoms lasting more than 2 months. Worst of all is the persistence of indoor allergen exposure including dust mites, cockroach, cat and dog dander, and less often, mold.
In contrast, expiratory wheezing not carried through the end of expiration, is usually not a result of asthma.
Since the metered dose inhaler is no longer available, nebulized cromolyn sodium is currently used in children over 1 year of age.
A newer inhaled steroid, ciclesonide (Alvesco HFA) is being studied in young children due to its lower bioavailability and decreased potential for side effects.
In addition, subcutaneous immunotherapy has shown its potential to prevent development of asthma in children with allergic rhinoconjunctivitis. Also, there can be no major depressive episode during the first 2 years of the disturbance (1 year for children and adolescents). Early in childhood, small airways are frequently affected with an increase in peripheral airway resistance without significant large airway involvement. Chronic exposure to these allergens in a sensitive asthmatic makes it very difficult to bring the child’s symptoms under good control. Allergy testing is only part of the allergy evaluation; the results can be misleading without a correlating comprehensive allergy history. This newer generation inhaled steroid virtually eliminates systemic effects which could end concern over growth in children. Commonly, there is a shift between early infancy or childhood and later childhood or adolescence marked by an increased degree of large airway involvement.
This may lead to steroid dependence because of frequent flares of symptoms leading to many emergency visits and hospitalizations. Moreover, oral forms are more likely to cause these side effects in susceptible individuals. It prevents asthma symptoms when administered prior to allergen exposure, as it blocks mast cell degranulation which triggers asthma in allergic children. The choice of inhaled steroid depends on potency, systemic absorption, taste, delivery system, and cost.
However, subcutaneous immunotherapy in very young children is problematic due to the child’s inability to verbalize or cooperate. Continuous nebulization has been effective in severe, acute asthma when intermittent use is ineffective. Sublingual immunotherapy might be better tolerated in young children, however its efficacy is not yet fully demonstrated and it is not an approved therapy by the FDA as safe and effective at this time. Long-acting β-agonists are approved for children over 4 years of age for persistent asthma, but they must always be used along with inhaled steroids. Further studies are needed to determine the role of immunotherapy in altering the natural history of asthma in young children.




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27.09.2014 admin



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