A. Cantani – Pediatric Allergy Asthma and Immunology

Описание

Pediatric Allergy,Asthma and Immunology is a new discipline
that finds its foundation in this book, whose
roots linke me to Elena and Luisa Businco,with whom I
founded the first Italian Pediatric Allergy Division some
30years ago, now called the Pediatric Allergy and Immunology
Division. There I discovered this world,
where I had the chance to revive the significance of the
three Ss: science, safety and sympathy. Children and
their parents consult us in the hope of finding scientific
and medical knowledge as well as assurance and understanding
sympathy, all necessary prerequisites for the
successful outcome of our everyday tasks.Above all, one
should appreciate how much the pediatrician–allergist
is, more than any other doctor, dedicated to the care of
his or her patients, since he or she must either deal with
cases of extreme severity, such as anaphylactic shock, or
perform ordinary jobs, such as giving suggestions on
the diets or the furnishings of the home. The pediatrician–
allergist should always find out how to protect the
infant, the child and the adolescent against discrimination
because of their allergy.With proper prescriptions
and appropriate recommendations, such an objective is
always within reach, and both the child and his or her
parents will profit from a better quality of life.
The earliest roots of this book developed from my
everyday work in the Pediatric Allergy and Immunology
Division and have grown while preparing lessons
and courses to be delivered to medical students and
postgraduates in pediatrics. Of course, this ongoing
work has found its expression in a host of papers that
have inspired several chapters within this book. However,
my primary aim was not one of doing something
necessary; I have hoped only to do something that is
useful to someone.With this book, I hope to have offered
convincing proofs and foundations to colleagues
committed to pediatric allergy and immunology. Often
its main goal is one of prevention, in all senses and using
all resources, as Arnaldo Cantani Sr. wrote in 1877
in the preface to the first edition of his Textbook of Clinical
Pharmacology: “ … only corresponding with a
meticulous study and the greatest exactness to the
precise indications of the case, the drugs may be use-
–ful to the patient … in the belief that air, water, and
alimentation are the first and most powerful means to
be well.”
Pediatric allergy and immunology is a multidisciplinary
field of research today, and familiarity with current
concepts is important for medical students, for clinicians
in every pediatric specialization and for researchers
in this attractive area.However, the issue is not
benefited by an easy approach, because pediatric allergy
and immunology has characteristic features both different
and larger in scope than adult allergy. Nor can we
disregard significant events such as the atopic-march,
the inexorably accelerating prevalence of atopic diseases,
which develop in 80%–90% of cases within the
very first months and years of life, while the intense
efforts of research scientists and the greater awareness
of pediatricians and of dedicated parents have widened
the positive results of prevention and treatment. The
avalanche of immunological progress shows no sign of
abating in this new millennium. I have therefore begun
with the fundamental concepts of basic immunology,
whose inferences are relevant to the later chapters. For
example, I have attempted to offer an exhaustive discussion
in Chap.1 to the interested reader trying to understand
the significance of adhesion molecules from the
pathogenic point of view. Therefore, after the chapters
on fetal-neonatal immunology and the mucosal immune
system, the neonate at risk of atopy, the genetic
and environmental predisposing factors and the epidemiology
and natural history of atopic diseases, a
whole chapter encompasses the diagnosis of allergy,
from the clinical history to the provocation tests. The
book progresses chapter by chapter to elucidate the
spectrum of several diseases, including atopic dermatitis,
food allergy, asthma, rhinoconjunctivitis, and to discuss
specific immunotherapy (SIT) for these diseases. It
also places great emphasis on specialist disorders such
as sinusitis and otitis media with effusion,which are frequently
associated with allergic diseases. Many pages
are devoted to autoimmune diseases, primary immunodeficiencies
and to pediatric HIV infection. The last two
chapters are comprehensively built on the earlier ones,
introducing two emerging important advances, malnutrition
and the immune system and another of capital
importance,atopy prevention,which sums up the wealth
of new data.
Until recently, the expansion of immunology was
undervalued. In this breakthrough my major thrust was
to attest to the ferments of activity that have revolutionized,
so to say, the exciting new area of research, such as
the therapeutic strategies exemplified by the switch
from Th2 to Th1 lymphocytes in the immune system
manipulations through SIT and anti-IgE therapy, gene
therapy of primary immunodeficiencies and the maternofetal
treatment of HIV infection. A growing body of
literature is shaping our knowledge of the fetal immune
system. We are now aware that the fetus can be immunocompetent
from the 18th to 20thweek of intrauterine
life, and that from the 22ndweek it can react
to food and inhalant allergens of maternal origin, suggesting
that heredity and maternal intake of foods or
drugs or allergen inhalation may anticipate the foundations
of pediatric allergy and immunology in intrauterine
life, thus requiring an advancement of preventive
measures. In this context, immunology is the new milestone
when one refers to the so-called collagen diseases,
revisited as a deviation from the normal mechanisms of
self-recognition, to the viruses that deceive the immune
system, modulating apoptosis at will, and to the immunological
components of breast milk, rich in prebiotics
and TLRs and protecting infants even from diabetes.
From this viewpoint we cannot underestimate the
impact of transgenic foods and pesticides, which are
revolutionizing foods, and of polluted air breathed by
newborns. Among the food offenders, the first level
refers to hidden allergens, or those regularly absent
from the labels, and the growing number of cross-reactions,
with the remarkable latex–fruit syndrome and the
mite–mollusc correlations. The role of infectious agents
could likely be the opposite of current theories, namely
that of protecting infants from the onset of allergic disease,
whose higher frequency could be favored by the
improvement in the standard of living. The hygiene hypothesis
is intriguing, but milk may kill by inhalation,
casein may remain active for 2,500years and egg for
500years.We move forward in pediatric allergy and immunology:
fascinating findings focus on the increasing
number of wheezing infants and on the success of desensitization
shared by food-allergic and asthmatic
children, thus leaving these children without disease.
Immunodeficiencies are radically cured by bone marrow
transplantation, autoimmune diseases are starting
to be cured with stem cell transplantation, diabetes
seems to be cured by mother–daughter transplantation
of pancreatic cells and immunodeficiencies by bone
marrow transplantation. HIV infection can be “cured”
by prevention.
In the presentation of the diverse conditions, I have
preferred a complete description in a traditional sequence,
beginning with an introduction, the definitions
and the epidemiology, then continuing with the immunological
characteristics, pathogenesis, symptoms,
diagnosis and treatment. Further, being compelled to
deal with aspects sometimes so distant or different has
certainly implied possible errors in measure and a
certain degree of overlap. A very hard task was that of
selecting, among the relevant literature in an unending
stream of data on pathogenic and therapeutic aspects,
the most significant ones, especially in the field of pediatrics.
It is not always easy and productive to interweave
basic and clinical material. I have tried to inform the
reader more comprehensively following a logical progression,
synthetically reviewing the most recent state of
this rapidly advancing specialization, leaving in the
background the data pertaining to the basic knowledge
of pediatricians and allergist–immunologists.
My purpose was also that of lightening the text with
the aid of approximately 1,400 high-quality figures covering
basic aspects and tables abounding with practical
information facilitating day-to-day diagnosis and management.
My approach has been that of utilizing the figures
and tables as both a commentary and an extension
of the text. The appendices complete the volume, while
the abbreviations and acronyms are listed separately. In
addition, I have adopted the Système International des
Unités (SI) where appropriate.At the end of each chapter
a list of references includes leading articles and subspecialty
reviews, so that readers are referred to numerous
points of departure from which to explore further
the subjects closer to their interests.
I have attempted, therefore, to offer to dedicated
pediatricians and family practitioners a comprehensive,
clear and timely distillation of current information
making it possible to keep abreast of recent advances
and to acquire the basic principles necessary in their
practice. The careful reader will find practical advice on
which to base actions that will block the atopic and immunological
march by preventing, managing and treating
allergic–immunological diseases, and by appropriately
informing parents, without neglecting to raise
public awareness of the threat posed by the march and
to provide the means to stop it. Managing childhood
atopic and immune disorders requires a new strategy.
Millions of children and their parents expect disease
prevention and cure, and allergists or immunologists
are challenged to provide interventions that achieve
optimal health from childhood to adulthood. I hope that
students and postgraduate doctors willing to find a
detailed reference for this fascinating and demanding
area of pediatrics and willing to develop an allergic–immunological
viewpoint will succeed in identifying the
diverse pathologies and will be motivated to become
more actively involved in the daily health needs of
atopic infants, children and adolescents.
I am deeply grateful to my wife, María Susana Campostrini,
who assisted me in this challenging enterprise
and helped me to add expressive illustrations to the
book. I wish to acknowledge the assistance of several
colleagues for their helpful discussions and contributions,
including Doctors Daniele Ceccoli, Franco Frati,
Oreste Marciano and my referees Professors Emanuele
Errigo and Massimo Fiorilli. The consultation of numerous
journals was of particular help, especially in
the libraries of the Pediatric Department of Rome University “La Sapienza”and Rome University “Tor Vergata,”
the Pediatric Department of Sassari University, the
National Council for Scientific Research, the Italian
Institute of Public Health and several university
libraries of the Hospital Policlinico Umberto I where I
work, especially the Department of Experimental Medicine.
I extend my gratitude to many colleagues and publishers
who have kindly provided many figures including
the late Professor Luisa Businco and the UCB that
kindly supplied many figures related to the SCORAD
and ETAC studies. In particular, I am deeply indebted
to Professors Molkhou, Revillard and Wüthrich and
their publishers. My thanks to Professors Mogi, Ring
and Wüthrich, who presented me with their books
and Professors Bernstein,Brandtzaeg,Buckley,Gerrard,
Patriarca, Roos and Sullivan for sending me reprints
not easily found otherwise. I owe particular gratitude
to Springer-Verlag and especially to Ms Ute Bujard for
her meticulous editing skills that allowed the publication
of this book. I would also like to thank Martha Berg
whose excellent assistance helped me very much.
To offer a wide panorama of results, several data have
been presented throughout the book and reported in
the tables and in the figures, independently of how the
children were identified as affected with allergic-immunologic
disease. Of course I do not expect that my
opinions or my suggestions “to live better with allergy”
meet the unconditioned favor of all readers: I would be
grateful if they would point out “the errors and the
omissions” so that I can correct them in a future edition