Asthma and Allergic Related Diseases

40
4
Asthma and Allergic Related Diseases
‰æ»“≈ ‡≈‘»ƒ¥’æ√
∏’√™—¬ ©—π∑‚√®π廑√‘
‡ªìπ∑’∑Ë √“∫°—π¥’Õ¬Ÿ·à ≈â««à“ ‚√§ÀÕ∫À◊¥‡ªìπ‚√§∑’Ë
æ∫‰¥â§Õà π¢â“ß∫àÕ¬„π°ÿ¡“√‡«™ªØ‘∫µ— ∑‘ «Ë— ‰ª ¡’°“√»÷°…“
«‘®—¬®“°À≈“¬Ê ª√–‡∑»∑—Ë«‚≈° ‚¥¬‡©æ“–°“√»÷°…“
∑’ˇªìπ∑’Ë√Ÿâ®—°°—π¥’∑’Ë™◊ËÕ«à“ ISAAC À√◊Õ International
Study of Asthma and Allergies in Childhood1,2 ∑’Ë
· ¥ß∂÷ß·π«‚πâ¡∑’ˇæ‘Ë¡¢÷Èπ¢ÕßÕÿ∫—µ‘°“√≥å‚√§ÀÕ∫À◊¥
‚¥¬‡©æ“–„π‡¥Á°´÷Ëßæ∫«à“¡’Õ—µ√“°“√‡æ‘Ë¡¢÷Èπ Ÿß°«à“„π
ºŸâ„À≠à ‚¥¬°“√»÷°…“ ISAAC æ∫«à“Õÿ∫—µ‘°“√≥å„π
ª√–‡∑»‰∑¬®—¥Õ¬Ÿà„π°≈ÿà¡∑’Ë¡’§«“¡™ÿ°√–¥—∫ª“π°≈“ß
(¿“æ∑’Ë 1)
®“°¢â Õ ¡Ÿ ≈ ¢Õß ISAAC ‚¥¬°“√»÷ ° …“¢Õß
»“ µ√“®“√¬å𓬷æ∑¬å ª°‘µ «‘™¬“ππ∑å·≈–§≥–
æ∫«à“Õÿ∫—µ‘°“√≥å¢Õß‚√§ÀÕ∫À◊¥ ‚√§¿Ÿ¡‘·æâ¢Õß®¡Ÿ°
·≈–‚√§º◊Ëπ¿Ÿ¡‘·æâ„πª√–‡∑»‰∑¬ ¡’·π«‚π⡇æ‘Ë¡¢÷Èπ (ªï
æ.». 2538 ‡ª√’¬∫‡∑’¬∫°—∫ªï æ.». 2544) ¥—ß· ¥ß„π
µ“√“ß∑’Ë 1
Natural History of Allergic diseases and
Asthma
§«“¡‡¢â“„®„π∏√√¡™“µ‘¢Õß°“√¥”‡π‘π‚√§„π°≈ÿ¡à
‚√§ÀÕ∫À◊¥·≈–‚√§¿Ÿ¡‘·æâÕ◊ËπÊ ®–™à«¬„Àâ‡√“ “¡“√∂
‡¢â“„®·≈–„Àâ°“√欓°√≥凰’ˬ«°—∫§«“¡‡°’ˬ«¢âÕߢÕß
‚√§ÀÕ∫À◊¥·≈–‚√§¿Ÿ¡‘·æâÕ◊ËπÊ √à«¡∑—Èß “¡“√∂∫Õ°∂÷ß
√–¬–‡«≈“∑’‡Ë √‘¡Ë µâπ· ¥ßÕ“°“√ ≈—°…≥–Õ“°“√∑“ߧ≈‘π°‘
¢Õß‚√§‡À≈à“π’È ·≈–·π«‚πâ¡°“√À“¬®“°‚√§µà“ßÊ ´÷Ëß
®“°¢âÕ¡Ÿ≈°“√»÷°…“«‘®¬— „π·ßà¢Õß∏√√¡™“µ‘°“√¥”‡π‘π
‚√§‰¥â¡°’ “√ª√–¡«≈¢âÕ¡Ÿ≈·≈–®—¥µ—ßÈ ‡ªìπ·π«§«“¡§‘¥∑’Ë
‡√’¬°«à“ çAllergic Marché
Allergic March „π‡¥Á° ‡ªìπ¢âÕ¡Ÿ≈∑’Ë™’È„Àâ‡√“‡ÀÁπ
«à“ °“√‡ªìπ‚√§„π°≈ÿà¡ Asthma ·≈– Allergic related
diseases Õ—πª√–°Õ∫‰ª¥â«¬ ‚√§ eczema, food
allergy, asthma, allergic rhinoconjunctivitis ¡’
≈”¥—∫¢Õß°“√‡√‘Ë¡µâπ· ¥ßÕ“°“√¢Õß‚√§„π«—¬µà“ßÊ
¥—ß· ¥ß„π¿“æ∑’Ë 2
®“°¢âÕ¡Ÿ≈„π¿“æ∑’Ë 2 · ¥ß„Àâ‡ÀÁπ«à“
1. Õÿ∫—µ‘°“√≥å¢Õß atopic eczema ·≈– food
allergies æ∫‰¥â∫àÕ¬∑’Ë ÿ¥„π™à«ßÕ“¬ÿ 2 ªï·√°
2. Õÿ∫—µ‘°“√≥å¢Õß food allergen sensitization
Ÿß∑’Ë ÿ¥„π™à«ßÕ“¬ÿ 2 ªï·√°‡™àπ°—π
3. Õÿ∫—µ‘°“√≥å¢Õß‚√§ÀÕ∫À◊¥ æ∫‰¥â∫àÕ¬„π™à«ß
À≈—ßÕ“¬ÿ«—¬ childhood ·≈–Õ“®§ßÕ¬Ÿà‰ª®π°√–∑—Ë߇¢â“
«—¬ºŸâ„À≠à
Asthma and Allergic Related Diseases, ‰æ»“≈ ‡≈‘»ƒ¥’æ√ ·≈– ∏’√™—¬ ©—π∑‚√®π廑√‘ 41
¿“æ∑’Ë 1 · ¥ßÕÿ∫—µ‘°“√≥å¢Õß‚√§ÀÕ∫À◊¥®“°°“√ ”√«®‚¥¬ ISAAC
µ“√“ß∑’Ë 1 · ¥ß¢âÕ¡Ÿ≈‡ª√’¬∫‡∑’¬∫Õÿ∫µ— °‘ “√≥å¢Õß‚√§¿Ÿ¡·‘ æâ
Õÿ∫—µ‘°“√≥å¢Õß‚√§
ªï æ.». 2538
‚√§ÀÕ∫À◊¥
‚√§¿Ÿ¡‘·æâ¢Õß®¡Ÿ°
‚√§º◊Ëπ¿Ÿ¡‘·æâ
12.2 %
37.9 %
9.8 %
ªï æ.». 2544
14.5 %
50.6 %
15.7 %
42
Pediatric Respiratory and Critical Care
¿“æ∑’Ë 2 · ¥ß≈—°…≥– Allergy March „π‡¥Á°
4. ‚√§®¡Ÿ°Õ—°‡ ∫®“°¿Ÿ¡·‘ æâ ‡√‘¡Ë æ∫‰¥âµßÈ— ·µà«¬—
childhood ·µà°Á¡’À≈—°∞“π∑’Ë™’È„Àâ‡ÀÁπ«à“‚√§π’ÈÕ“®®–
‡√‘Ë¡µâπæ∫‰¥âµ—Èß·µà™à«ß«—¬ early adulthood
Risk Factors for Persistent Asthma
¡’°“√»÷°…“‡°’¬Ë «°—∫ªí®®—¬‡ ’¬Ë ßµà“ßÊ∑’¡Ë º’ ≈µàÕ°“√
‡°‘¥‡ªìπ‚√§ persistent asthma æ∫«à“ ªí®®—¬‡ ’¬Ë ßµà“ßÊ
‡À≈à“π’ȉ¥â·°àªí®®—¬∑’Ë· ¥ß¥—ß„πµ“√“ß∑’Ë 2
Asthma and Allergic Rhinitis
Õÿ∫—µ‘°“√≥å¢Õß allergic rhinitis ∑’Ëæ∫√à«¡°—∫
asthma „πºŸ„â À≠à æ∫‰¥âª√–¡“≥ √âÕ¬≈– 58 (ª√–¡“≥
2 ‡∑à“¢ÕßÕÿ∫µ— °‘ “√≥å„πª√–™“°√∑—«Ë ‰ª) ®“°°“√ ”√«®
Õÿ∫µ— °‘ “√≥å‚√§ asthma (A), allergic rhinoconjunctivitis
(AR) ·≈– atopic eczema (AE) ‚¥¬°“√»÷°…“¢Õß
°≈ÿà¡ ISAAC æ∫§«“¡ —¡æ—π∏å√–À«à“ß‚√§∑—Èß “¡‡ªìπ
¥—ßµ“√“ß∑’Ë 3
„π√–¬–À≈—ßπ’È¡’°“√𔇠πÕ·π«∑ƒ…Æ’∑’ˇ√’¬°«à“
çOne airway, one diseaseé ‡ªìπ·π«§‘¥∑’Ë𔇠πÕ«à“
°“√Õ—°‡ ∫∑’ˇ°‘¥®“°¢∫«π°“√¿Ÿ¡‘·æâ¡‘‰¥â®”°—¥‡æ’¬ß∑’Ë
‚æ√ß®¡Ÿ°„πºŸâªÉ«¬ Allergic rhinits ·µàæ∫«à“¡’°“√
Õ—°‡ ∫µàÕ‡π◊ËÕß≈߉ª∂÷ßÀ≈Õ¥≈¡ à«π≈à“ß ¥—ßπ—Èπ„π·π«
∑“ß°“√¥Ÿ·≈√—°…“‚√§ Allergic rhinits ‚¥¬Õߧ尓√
Õπ“¡—¬‚≈° (WHO) ∑’ˇ√’¬°«à“ ARIA (The Allergic
Rhinitis and its Impact on Asthma) „πªï æ.».
25443 ‰¥â¬◊π¬—π«à“ºŸâªÉ«¬‚√§ Allergic rhinits ®—¥«à“‡ªìπ
§«“¡‡ ’ˬߵàÕ°“√‡°‘¥‚√§ÀÕ∫À◊¥ ·≈–§«√‰¥â√—∫°“√
´—°ª√–«—µ‘ µ√«®√à“ß°“¬ ·≈–µ√«®æ‘‡»… ‡æ◊ËÕ§âπÀ“«à“
¡’Õ“°“√¢Õß‚√§ÀÕ∫À◊¥√à«¡¥â«¬À√◊Õ‰¡à ·≈–„π∑“ß
°≈—∫°—πºŸâªÉ«¬‚√§ ÀÕ∫À◊¥°Á§«√‰¥â√—∫°“√µ√«®‡æ◊ËÕÀ“
«à“¡’‚√§ Allergic rhinits √à«¡¥â«¬À√◊Õ‰¡à‡ ¡Õ
ARIA ‰¥â·π–π”„Àâ∑”°“√√—°…“ºŸâªÉ«¬°≈ÿà¡π’È‚¥¬
ºπ«°°“√√—°…“∑—Èß‚√§ÀÕ∫À◊¥·≈–‚√§ Allergic rhinitis µ“¡·π«∑“ߢÕß ARIA ·≈– GINA guideline ¥â«¬
°—π‡ ¡Õ ‡æ◊ÕË „Àâ°“√√—°…“¡’ª√– ‘∑∏‘¿“楒∑ ’Ë ¥ÿ °“√„™â¬“
æàπ®¡Ÿ°™π‘¥∑’¡Ë ’ ‡µ’¬√Õ¬¥å ”À√—∫ºŸªâ «É ¬ÀÕ∫À◊¥∑’¡Ë ‚’ √§
Allergic rhinitis ¡’¢âÕ¡Ÿ≈«à“ “¡“√∂™à«¬≈¥¿“«– bronchial hyperresponsiveness „Àâ¡’√–¥—∫§«“¡√ÿπ·√ß∑’Ë
Asthma and Allergic Related Diseases, ‰æ»“≈ ‡≈‘»ƒ¥’æ√ ·≈– ∏’√™—¬ ©—π∑‚√®π廑√‘ 43
µ“√“ß∑’Ë 2 · ¥ßªí®®—¬‡ ’ˬߵà“ßÊ ∑’Ë àߺ≈„À⇰‘¥¿“«– persistent asthma
Risk Factors for Persistent Asthma
Allergy
- Atopic dermatitis
- Allergic rhinitis
- Elevated total serum IgE levels (first year of life)
- Peripheral blood eosinophilia > 4 % (2-3 years of age)
- Food and inhalant allergen sensitization
Gender
Males
- Transient wheezing
- Persistent allergy-associated asthma
Females
- Asthma associated with obesity and early-onset puberty
- çTriadé asthma (adulthood)
Parental asthma
Lower Respiratory Tract Infections
- Respiratory syncytial virus, parainfluenza
- Severe bronchiolitis (i.e. requiring hospitalization)
Environmental Tobacco Smoke Exposure: (Including prenatal)
≈¥≈ß„πƒ¥Ÿ∑¡’Ë °’ “√·æ√à°√–®“¬¢Õß≈–ÕÕ߇° √¥Õ°À≠â“
‰¥â 4 ´÷ßË ®– àߺ≈„Àâ¡Õ’ “°“√À◊¥®—∫≈¥≈ß·≈–≈¥Õ—µ√“°“√
‡¢â“√—∫°“√√—°…“∑’·Ë ºπ°©ÿ°‡©‘π·≈–°“√‡¢â“√—∫°“√√—°…“
·∫∫ºŸâªÉ«¬„π≈߉¥â
Asthma and Sinusitis
ºŸâªÉ«¬∑’Ë¡’Õ“°“√¢Õß‚√§ÀÕ∫À◊¥„π√–¥—∫√ÿπ·√ß
·≈–§«∫§ÿ¡‰¥â¬“°æ∫«à“ “‡ÀµÿÀπ÷ßË §◊Õ °“√¡’‚√§‰´π— Õ—°‡ ∫√à«¡¥â«¬5 —ππ‘…∞“π«à“Õ“®®–‡ªìπº≈¡“®“°°“√
Õ—°‡ ∫¢Õ߇¬◊ÕË ∫ÿ‚æ√ß®¡Ÿ°·≈–‰´π— ∑”„Àâ°“√∑”ß“π¢Õß
mucociliary function º‘¥ª°µ‘‰ª ¥—ßπ—πÈ ®¡Ÿ°®÷ß°√Õß “√
°àÕ¿Ÿ¡‘·æ≥≡॒‡∑à“‡¥‘¡ àߺ≈„Àâ¡’ “√°àÕ¿Ÿ¡‘·æâºà“π≈ß
‰ª„π∑“߇¥‘πÀ“¬„® à«π≈à“ß¡“°°«à“ª°µ‘ 6
®“°°“√»÷°…“„πµà“ߪ√–‡∑»7 æ∫«à“ºŸâªÉ«¬‚√§
ÀÕ∫À◊¥√âÕ¬≈– 34.7 æ∫¡’ chronic sinusitis √à«¡¥â«¬
¢≥–∑’Ë„πºŸâªÉ«¬ sinusitis æ∫‚√§ÀÕ∫À◊¥√à«¡¥â«¬‰¥â
√âÕ¬≈– 25 ¥—ßπ—Èπ„πºŸâªÉ«¬‚√§ÀÕ∫À◊¥∑’Ë¡’Õ“°“√√ÿπ·√ß
¡’¿“«–πÈ”¡Ÿ°‡√◊ÕÈ √—ßÀ√◊Õ‰Õ‡√◊ÕÈ √—ß·≈–‰¡àµÕ∫ πÕßµàÕ°“√
√—°…“¥â«¬¬“√—°…“‚√§ÀÕ∫À◊¥µ“¡·π«∑“ß°“√√—°…“
∑—«Ë ‰ª §«√§‘¥∂÷ß‚√§ sinusitis ‰«â‡ ¡Õ °“√√—°…“ sinusitis ∑’Ë∂Ÿ°µâÕß®–™à«¬∑”„Àâ°“√√—°…“ÀÕ∫À◊¥¥’¢÷Èπ¥â«¬
√–¬–‡«≈“¢Õß°“√„À⬓ªØ‘™’«π–§«√„Àâπ“π®π°√–∑—Ëß
ºŸâªÉ«¬‰¡à¡’Õ“°“√‡≈¬‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 7 «—π
µ“√“ß∑’Ë 3 · ¥ß§«“¡ —¡æ—π∏å√–À«à“ß asthma, allergic
rhinoconjunctivitis ·≈– atopic dermatitis
Comparison
A versus AR
A versus AE
AR versus AE
Regression
coefficient
0.75
0.74
0.71
Significant
P< 0.0001
P< 0.0001
P< 0.0001
44
Pediatric Respiratory and Critical Care
Asthma and food allergies
ºŸâªÉ«¬‡¥Á°∑’ˇªìπ‚√§ÀÕ∫À◊¥¡’‚Õ°“ Ÿß°«à“‡¥Á°
ª°µ‘∑®’Ë –¡’ª≠í À“ food allergies ‚¥¬‡©æ“–Õ¬à“߬‘ßË ∂â“¡’
Õ“°“√ atopic eczema À√◊Õª√–«—µ‘°“√¡’Õ“°“√¢Õß
atopic eczema, gastroesophageal reflux, ªí≠À“°“√
°≈◊π≈”∫“°„π«—¬‡¥Á°‡≈Á° À√◊Õ‡ªìπ‚√§ÀÕ∫À◊¥∑’‰Ë ¡àµÕ∫
πÕßµàÕ°“√√—°…“
®“°°“√»÷°…“¢Õß Onorato ·≈–§≥–8 »÷°…“
ºŸâªÉ«¬‚√§ÀÕ∫À◊¥ 300 √“¬ ∑’Ë¡’Õ“¬ÿµ—Èß·µà 7 ‡¥◊Õπ ∂÷ß
80 ªï æ∫«à“¡’ºŸâªÉ«¬ 25 √“¬ ∑’Ë¡’Õ“°“√·æâÕ“À“√∑’Ë
°√–µÿâπ„À⇰‘¥Õ“°“√ÀÕ∫À◊¥ ·µà¡’‡æ’¬ß 6 √“¬ (2%)
∑’¡Ë º’ ≈°“√∑¥ Õ∫ DBPCFCs (Double blind placebocontrolled food challenge test) „Àâº≈∫«° ‚¥¬°≈ÿà¡
∑’Ë¡’°“√∑¥ Õ∫„Àâº≈∫«°π’È¡’Õ“¬ÿµ—Èß·µà 4-17 ªï ·≈–
¬—ßæ∫«à“§√÷ßË Àπ÷ßË ¢ÕߺŸªâ «É ¬°≈ÿ¡à π’¡È Õ’ “°“√ wheeze À≈—ß
√—∫ª√–∑“πÕ“À“√‡æ’¬ßÀπ÷ßË ™π‘¥ ·µàÕ°’ §√÷ßË Àπ÷ßË ¡’Õ“°“√
wheeze √à«¡°—∫Õ“°“√„π√–∫∫∑“߇¥‘πÕ“À“√À√◊Õ
º‘«Àπ—߇™àπ°—π
®“°°“√»÷°…“¢Õß Novembre ·≈–§≥–9 ‰¥â
∑”°“√»÷°…“„πºŸâªÉ«¬‡¥Á°®”π«π 140 √“¬∑’Ë¡’ª√–«—µ‘
ÀÕ∫À≈—ß√—∫ª√–∑“πÕ“À“√∫“ß™π‘¥ æ∫«à“¡’ºŸâªÉ«¬ 8
√“¬ (6%) ∑’Ë¡’º≈°“√∑¥ Õ∫ DBPCFCs „Àâº≈∫«°
‚¥¬¡’Õ“¬ÿµß—È ·µà 2-9 ªï ·≈–æ∫«à“¡’‡æ’¬ß 1 √“¬∑’¡Ë Õ’ “°“√
wheeze Õ¬à“߇¥’¬«
¡’ß“π«‘®—¬¢Õß Hill ·≈–§≥–10 ∑’Ë»÷°…“ºŸâªÉ«¬‡¥Á°
∑’¡Ë Õ’ “°“√·æâπ¡«—«®”π«π 100 √“¬ ·≈–‰¥â·∫àß≈—°…≥–
Õ“°“√ÕÕ°‡ªìπ 3 °≈ÿࡵ“¡√–¬–‡«≈“‡√‘Ë¡¡’Õ“°“√¥—ßπ’È
- °≈ÿà¡∑’ËÀπ÷Ëß ‡ªìπ°≈ÿà¡∑’Ë¡’Õ“°“√∑—π∑’ (¿“¬„π
4 ™—Ë«‚¡ß) ‡√’¬°«à“ immediate onset group æ∫«à“
√âÕ¬≈– 29 ¡’Õ“°“√ wheeze
- °≈ÿ¡à ∑’ Ë Õß ¡’Õ“°“√√–À«à“ß 4-24 ™—«Ë ‚¡ß ‡√’¬°
«à“ intermediate onset group æ∫«à“√âÕ¬≈– 4 ¡’Õ“°“√
wheeze
- °≈ÿà¡∑’Ë “¡ ‡√‘Ë¡¡’Õ“°“√À≈—ß®“° 24 ™—Ë«‚¡ß
‰ª·≈â« ‡√’¬°«à“ delayed-onset group æ∫Õ“°“√
wheeze ∂÷ß√âÕ¬≈– 50
Asthma and atopic eczema11
ºŸâªÉ«¬‡¥Á°∑’Ë¡’Õ“°“√¢Õß atopic eczema ¡’·π«
‚πâ¡∑’Ë®–¡’Õ“°“√¢Õß‚√§ Allergic rhinitis ·≈–ÀÕ∫À◊¥
„π√–¬–µàÕ¡“‡¡◊ËÕÕ“¬ÿ‡¢â“ Ÿà™à«ß childhood ¥—߉¥â°≈à“«
¡“„π√Ÿª¿“æ· ¥ß Allergy March ¢â“ßµâπ ´÷Ë߇¡◊ËÕºŸâ
ªÉ«¬Õ“¬ÿ¡“°¢÷Èπ Õ“°“√¢Õß atopic eczema ®–¥’¢÷Èπ
·µàºªŸâ «É ¬∫“ß√“¬®–‡√‘¡Ë · ¥ßÕ“°“√¢Õß‚√§ÀÕ∫À◊¥·≈–
allergic rhinitis ‚¥¬‡™◊ËÕ«à“ªí®®—¬∑’ˇªìπªí®®—¬√à«¡∑’Ë
°√–µÿπâ „À⇰‘¥Õ“°“√„π°≈ÿ¡à π’È ‰¥â·°à Õ“À“√ ·≈– “√°àÕ
¿Ÿ¡‘·æâ„πÕ“°“» (Aeroallergens)
¡’°“√»÷°…“æ∫«à“°“√§«∫§ÿ¡Õ“À“√∑’‡Ë ªìπªí≠À“
·≈–°“√§«∫§ÿ¡ “√°àÕ¿Ÿ¡‘·æâ„πÕ“°“»„π∫â“π„À⥒®–
“¡“√∂™à«¬„ÀâÕ“°“√¢Õß‚√§∑—Èß 3 ¥’¢÷Èπ‰¥â
Asthma and Allergic Related Diseases, ‰æ»“≈ ‡≈‘»ƒ¥’æ√ ·≈– ∏’√™—¬ ©—π∑‚√®π廑√‘ 45
‡Õ° “√Õâ“ßÕ‘ß
1. Vichyanond P, Jirapongsananurak O, Visitsuntorn N, Tuchinda M. Prevalence of asthma, rhinitis and eczema in children from the Bangkok
area using the ISAAC (International Study for Asthma and Allergies in Children questionnaires. J Med Assoc Thai 1998;1:175-84
2. Vichyanond P, Sunthornchart S, Singhirannusorn V, Ruangrat S, Kaewsomboon S, Visitsunthorn N. Prevalence of asthma, allergic rhinitis
and eczema among university students in Bangkok. Respir Med. 2002 Jan;96(1):34-8
3. Management of Allergic Rhinitis and its Impact on Asthma. A pocket guide for physicians and nurses 2001
4. Foresi A, Pelicchi A, Gherson G et al. Once-daily intranasal fluticasone proprionate (200 micrograms) reduces nasal symptoms and
inflammation but also attenuates the increase in bronchial responsiveness during the pollen season in allergic rhinitis. J Allergy Clin
Immunol 1996;98:274-82
5. Rachelefsky GS, Katz RM, Siegel SC. Chronic sinusitis in the allergic child. Pediatr Clin North Am 1988;35:1091-101
6. Gungor A, Corey JP. Pediatric sinusitis: a literature review with emphasis on the role of allergy. Otolarygol Head Neck Surgery 1997;116:
4-15
7. Nguyen KL, Corbett ML, Garcia DP et al. Chronic sinusitis among pediatric patients with chronic respiratory complaints. J Allergy Clin
Immunol 1993;92:820-30
8. Onorato J, Merland N, Terral C, et al. Placebo-controlled double- blind food challenge in asthma. L Allergy Clin Immunol 1986;78:
1139-46
9. Novenbre E, de Martino J, Vierucci A: Foods and respiratory allergy. J Allergy Clin Immunol 1988;81:1056-65
10. Hill DJ, Firer MA, Shelton MJ et al. Manifestrations of Milk allergy in infancy; clinical and immunological finding. J Pediatr 1986;109:
270-6
11. Leung DYM. Atopic dermatitis. In Pediatric allergy: Principles and practice. Leung DYM et al ed. 1st edition, 2003 Mosby, St.Louis, USA