Browsing by Author "Sögüt, A"
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Item Attention deficit and hyperactivity symptoms in children with monosymptomatic nocturnal enuresisErtan, P; Gönülal, D; Sögüt, A; Yilmaz, Ö; Bozgül, A; Dinç, G; Aydemir, Ö; Yüksel, HAim: Monosymptomatic nocturnal enuresis in children may cause psychological and behavioral problems. The aim of this study was to assess symptoms of attention deficit and hyperactivity in children with monosymptomatic nocturnal enuresis. Material and Method Fifty-seven children (23 male, 34 female) with monosymptomatic nocturnal enuresis and 57 healthy controls (25 male, 32 female) aged 6 to 12 years participated in the study. Conners' Parent Rating Scale-48 (CPRS), a 48-item multiple-choice questionnaire, was completed by the mothers to identify the attention deficit and hyperactivity symptoms in children. Results: Mean age of the children with enuresis was 8.54 +/- 2.18 years and that of the control group 9.12 +/- 2.13 years. Attention deficit score in the enuretic group was significantly higher than that in the control group (p=0.02). Hyperactivity scores were not significantly different between the groups (p=0.36). Bedwetting frequencies were not different between enuretic children with and without attention deficit or hyperactivity symptoms (p=0.06). Conclusions: Psychological and behavioral assessment may be indicated in children with monosymptomatic nocturnal enuresis since the results of this study demonstrate increased attention deficit symptomatology. (Turk Arch Ped 2010; 45: 37-40)Item Change in quality of life, anxiety and depressive symptoms with asthma severity in childrenYilmaz, Ö; Sögüt, A; Kader, S; Taskin, O; Yüksel, HObjective: The aim of this study was to evaluate the change in anxiety-depression symptoms with the change in asthma related symptom score and quality of life in children. Materials and Methods: Thirty five children with asthma aged 6 to 16 years were enrolled in this cohort. Symptom scores were recorded and all children filled in Pediatric Asthma Quality of Life Questionnaire (PAQLQ), Hospital Anxiety Depression Scale (HADS) and Center for Epidemiologic Studies Depression Scale (CES-D). They were called in again four months later to evaluate for change in all parameters. Results: When initial presentation and follow-up values were compared, significant decrease in symptom score, number of exacerbations and number of emergency visits was detected (p< 0.001, p= 0.001 and p= 0.004 respectively). Similarly, HADS anxiety and depression scores as well as CES-D score improved significantly at follow-up when compared to the initial presentation (p< 0.001, p= 0.001 and p< 0.001 respectively). Change in symptom score was significantly correlated with changes in CES-D score as well as PAQLQ symptom, emotion and total scores (r= 0.39 p= 0.04, r= -0.57 p< 0.001, r= -0.66 p< 0.001, r= -0.66 p< 0.001 respectively). Change in PAQLQ total score demonstrated significant negative correlation with the change in HADS anxiety score (r= -0.42, p= 0.02). Conclusion: Improvement in asthma symptoms and QoL is associated with improvement in depression-anxiety symptoms.Item Is the six-minute walk test correlated with disease control and quality of life in children with asthma?Yüksel, H; Yilmaz, Ö; Göksen, B; Üstün, S; Sögüt, AAim: To evaluate the changes in a 6-min walk test (6MWT) and quality of life (QoL) before and after asthma control is achieved in children. A 6MWT is used in the determination of disease severity in many chronic childhood diseases. Materials and methods: Thirty-six asthmatic children, aged 6 to 15 years, were enrolled before asthma control was achieved. Disease severity parameters during the previous 3 months were recorded. All of the children completed an asthma control questionnaire (ACQ) and received a symptom score; a 6MWT was performed during enrollment and 1 month later, when asthma control was achieved. Results: The initial and follow-up mean 6MWT distances were 500.2 +/- 139.1 and 577.8 +/- 147.9 m, respectively (P < 0.001). The 6MWT distances and ACQ scores were significantly correlated initially (rho = -0.35, P = 0.04). The 6MWT distance was not correlated with clinical parameters (P > 0.05 for all). The initial ACQ score was significantly correlated with the symptom score and duration of asthma (rho = 0.62 vs. rho = -0.37). Conclusion: A 6MWT may be used in the functional assessment of children with uncontrolled asthma; it correlates with ACQ scores. The absence of a correlation between the 6MWT and patient-reported symptom severity or other clinical parameters may indicate the necessity to include a functional assessment into the clinical evaluation as well as QoL measures.Item Validation and reliability study of the Turkish version of the Pediatric Rhinitis Quality of Life QuestionnaireYüksel, H; Yilmaz, Ö; Sögüt, A; Eser, EThe aim of this study was to develop a Turkish version of the Turkish Pediatric Rhinitis Quality of Life Questionnaire (PRQLQ) that is conceptually equivalent to the original and to evaluate its validity and reliability. The study included 102 children with allergic rhinitis (AR) aged 5 to 16 years. Demographic information, family history of allergy, and duration of AR were recorded. All patients completed the T4SS symptom score and PRQLQ. Reliability including internal consistency and item-total score correlations and validity analysis including Known Group method were performed. Activity limitations, emotional function and symptoms domains had successful Cronbach alpha scores of 0.62, 0.69 and 0.78, respectively. All items were significantly correlated with their own domain. Correlations of all the domain scores with the total score and the other domains were significant. Linear multiple regression reduced models revealed that both domain and total scores showed statistically significant sensitivity to T4SS. The Turkish PRQLQ is a valid and reliable measure for use in Turkish children with AR.Item Effects of physical exercise on quality of life, pulmonary function and symptom score in children with asthmaYüksel, H; Sögüt, A; Yilmaz, Ö; Günay, Ö; Tikiz, C; Dündar, P; Onur, EObjective: To evaluate the effects of regular exercise on asthma symptom score, quality of life and pulmonary function in asthmatic children. Materials and Methods: Thirty children with newly diagnosed mild-moderate asthma (mean age 9.8 +/- 1.78 years) were randomly allocated into exercise group (group 1) and control group (group 2). Both groups received inhaled fluticasone and montelukast treatment. Children in the exercise group were also included in an exercise training program. The program consisted of condition bicycle for one hour two times a week for 8 weeks. Pediatric Asthma Quality of Life Questionnaire (PAQLQ), a disease spesific quality of life questionnaire, and KINDL, a generic quality of life questionnaire, were used to assess health related quality of life in both groups. Spirometric tests were also performed and asthma symptom scores were recorded. Results: The degree of improvement in all scores of PAQLQ (total, activity, symptom, emotion) and symptom score in group 1 were significantly higher than those in group 2 in final evaluation, (p= 0.005, 0.000, 0.003, 0.009, respectively). Moreover, the scores of self-esteem and family subscales of KINDL in group 1 were significantly higher than those in group 2 (p=0.047, 0.030, respectively). Although insignificant, the degree of improvement in pulmonary function values (FEV1, FVC and FEV1/FVC) in group 1 were higher than those group 2. (Asthma Allergy Immunol 2009; 7: 58-65) Conclusion: Regular exercise added to conventional treatment in children with asthma significantly improves quality of life besides symptoms score.Item The prevalence of habitual snoring in Aegean region of Turkey and associated risk factorsYilmaz, O; Dinc, G; Sögüt, A; Aktulun, S; Arslan, B; Kocacan, M; Ozdel, B; Ozen, S; Yasli, G; Yuksel, HAim: The aim of this study was to determine prevalence of snoring in children younger than 18 years of age and to identify associated risk factors and complications in a population based study. Material and Method: This cross sectional study was conducted in Manisa, Turkey. Questionnaires about snoring and associated risk factors were applied to 650 children who were determined using cluster sampling method (339 females, 311 males). Results: Prevalence of habitual snoring was 4.9%. Current history of wheezing or allergic rhinitis increased the odds of habitual snoring 3.1 times when compared to children without current wheezing (p=0.006; OR: 3.11, 95% CI: 1.3-7.3 and p=0.002; OR: 3.11, 95% CI: 1.5-6.6 respectively). Grade 3 tonsil hypertrophy increased odds of habitual snoring 22.5 times compared to no tonsil hypertrophy (p<0.001; OR: 22.4, 95% CI: 6.0-83.9). Nighttime symptoms like apnea were more frequent in habitual snorers when compared to non-snorers (28.1% vs 3.6%; p<0.001; OR: 10.5, 95% CI: 4.3-25.6). Conclusions: Current wheezing, allergic rhinitis and tonsil hypertrophy are significant risk factors for habitual snoring. Therefore, children with these disorders need to be assessed for snoring that may influence their development. (Turk Arch Ped 2010; 45: 280-5)Item Is Obesity Related to Worse Control in Children with Asthma?Yilmaz, O; Sögüt, A; Bozgül, A; Türkeli, A; Kader, S; Yüksel, HIntroduction: Asthma and obesity are related diseases however the influence of obesity on asthma severity is not clear yet. Therefore, the aim of our study was to evaluate the association between obesity and asthma control evaluated on the basis of symptoms and asthma control questionnaire (ACQ). Materials and Methods: We enrolled 98 children with asthma aged 4 to 14 years consecutively and recorded their disease characteristics and severity parameters as well as the symptom scores. All children filled in the ACQ. Children were classified as obese and non-obese according to body mass index. Obesity was defined as body mass index over 90th percentile. Results: Mean age of the children in the obese group (n=27) was 8.1 +/- 2.6 while that in the non-obese group (n=71) was 8.6 +/- 2.9 (p=0.41). Asthma symptom score in obese and non-obese groups were not significantly different (p=0.73). Children in the obese group had lower ACQ scores when compared to the non-obese group (1.2 +/- 0.9 vs 1.7 +/- 1.0, p=0.04) however this significance was lost when controlled for age and gender in the regression model. Conclusion: The results of this study suggest that obesity is not significantly associated with worse asthma control when adjusted for age and gender.Item Knowledge and practice of general pediatricians about childhood asthma and its treatmentYilmaz, Ö; Sögüt, A; Alkan, S; Yüksel, HAim: It is essential educate general pediatricians about childhood asthma and its treatment to standardize care. The aim of this study was to evaluate knowledge and practice of pediatricians about childhood asthma and its treatment. Material and Method: The study included 52 pediatricians who attended one of the seven meetings about asthma treatment. A questionnaire of 42 questions, 23 about asthma and its treatment and 19 about their practice were given before meeting. Results: Hospital of residency did not change answers to the questions, but presence of private office and duration of practice did. Among pediatricians who owned private office, 82.4% said the sentence: systemic steroids have a role in acute asthma exacerbation treatment was true, compared to the 47.1% of the ones without private office (p = 0.014). Referral to pediatric allergy center during or after acute asthma exacerbation was significantly lower among the pediatricians who owned private Office (p = 0.002 and p = 0.016 respectively). Duration of practice as a pediatrician influenced knowledge about use of inhaled steroids in asthma (p = .005). Conclusions: In conclusion, duration of practice and presence of private office influence knowledge and practice of general pediatricians about asthma and its treatment. The essence of postgraduate education to provide children more standardized treatment was emphasized with these results. (Turk Arch Ped 2009; 44: 29-34)Item Reliability and validity of the Turkish version of the pediatric sleep questionnaire: a tool for prediction of sleep related breathing disorderYüksel, H; Sögüt, A; Yilmaz, Ö; Kutluay, EUse of a questionnaire that predicts the diagnosis and influence of sleep related breathing disorder (SRBD) may be a cost-effective method to aid in both diagnostic algorithm and therapy. Therefore, the aim of this study was to adapt Pediatric Sleep Questionnaire (PSQ) into Turkish and to test the validity and reliability of the Turkish questionnaire. Total of 111 children (59 male, 52 female) aged 2 to 17 years who had symptoms suggestive of SRBD were enrolled consecutively. Demographic characteristics such as age and gender of all children enrolled in the study were recorded. All parents were questioned about symptom severity, frequency and duration. Lastly, PSQ was administered to all parents. Mean age of the children enrolled in the study was 8.1 +/- 3.4 years. Total PSQ score ranged between 0 and 0.95 and mean score was 0.35 +/- 0.22. Comparison of total PSQ scores between children reporting different symptom frequencies demonstrated that PSQ score increased as the symptom frequency increased (p<0.001).There was a significant difference of all PSQ scores among the groups (p<0.05 for all). Total PSQ score for children that did not report snoring was 0.2 +/- 0.5 wile that for the ones who snore throughout sleep was 3.8 +/- 0.5 (p<0.001). Cronbach's alpha values for all domains of PSQ were satisfactory. All items were significantly correlated with their corresponding scale. Turkish version of PSQ is a valid and reliable tool that may be used in the initial evaluation of Turkish children with symptoms suggestive of SRBD.Item Evaluation of sleep quality in mothers of children with bronchiolitis obliteransYüksel, H; Çiftdogan, DY; Yilmaz, Ö; Sögüt, AAim: The aim of this study was to evaluate the quality of sleep in mothers of children with bronchiolitis obliterans. Material and Method: The study group consisted of 36 mothers with a child who had bronchiolitis obliterans and 62 mothers with healthy children. All mothers enrolled in the study filled in the Pittsburgh Sleep Quality Index (PSQI). Results: The mean ages of the children of the mothers enrolled in the study were statistically similar (3.57 +/- 2.58 vs 3.85 +/- 1.46 years, p>0.05). Total Pittsburgh Sleep Quality Index scores and subjective sleep quality scores in the mothers of children with bronchiolitis obliterans were significantly higher than those in the mothers of healthy children (both p=0.015). Conclusions: In this study, it was found that mothers of children with bronchiolitis obliterans have poor sleep quality. Therefore, assessment may be needed for the requirement of support regarding sleep quality in them. (Turk Arch Ped 2009; 44: 99-102)Item A rare cause of persistent atelectasis in childhood: Mucoepidermoid carcinomaSögüt, A; Yilmaz, Ö; Yüksel, HA 12-year-old boy presented to our clinic with recurrent lower respiratory tract symptoms that are wheezing, cough, bronchopneumonia, and fever and with a diagnosis of bacterial endocarditis. Physical examination revealed that breath sounds diminished in the left lower lobe. Because cardiac sounds and echocardiography were normal bacterial endocarditis was excluded. Chest radiograph and computerized tomography scan showed a left lower lobe atelectasis and consolidation. Despite medical therapy including antibiotics, bronchodilator etc, atelectasis persisted. Fiberoptic flexible bronchoscopy (FFB) revealed a tumor that totally obstructed the left lower lobe bronchus. Open lung biopsy revealed a low-grade mucoepidermoid carcinoma. Left lower lung lobectomy was performed. The patient is in good condition 12 months after the operation. We proposed that FFB should be performed earlier in patients with recurrent lower respiratory symptoms who have persistent atelectasis or unifocal infiltration.Item Infant who Developed Noncardiac Pulmonary Edema after Flexible Fiberoptic BronchoscopyYüksel, H; Topçu, I; Ikizoglu, HT; Yilmaz, Ö; Sögüt, A; Keles, GPulmonary edema may be secondary to cardiac or noncardiac etiologies. Noncardiac pulmonary edema develops as a result of increased vasopermeability, leading to water and protein leak into the interstitium. Negative pressure at the level of the alveoli during flexible fiberoptic bronchoscopy (FFB) may lead to the development of pulmonary edema. This is a rare complication in infants undergoing FFB. Dignostic FFB was performed on a four month old female patient with hypoxic ischemic encephalopathy due to persistent upper respiratory findings. Additional respiratory tract anomalies were not observed in this case who was diagnosed as having laryngomalacia. She developed bronchospastic findings following FFB which improved with nebulized salbutamol treatment. Although her bronchospasm regressed two hours after the procedure, oxygen requirement continued and fine rales became prominent on pulmonary auscultation. Findings of pulmonary edema were observed in the chest X-ray. Mannitol at a dose of 0.5 mg/kg was administered with the diagnosis of pulmonary edema. Physical findings and vital signs normalized with treatment and oxygen requirement ceased. This case was discussed because pulmonary edema after FFB is a rare complication and this is the first experience with mannitol in the treatment.Item Common viral etiologies of community acquired lower respiratory tract infections in young children and their relationship with long term complicationsYüksel, H; Yilmaz, Ö; Akçali, S; Sögüt, A; Çiftdogan, DY; Urk, V; Ertan, P; Sanlidag, TViral lower respiratory tract infections (LRTIs) and their late complications are important causes of morbidity and mortality in childhood. The aims of this study were the detection of viral agents that cause community-acquired LRTIs in young children and investigation of the relationship between viral etiology and bronchiolitis obliterans (130) which is one of the late complications of LRTIs. A total of 151 children (86 male, 65 female; mean age: 2.9 +/- 1.9 years) who were diagnosed to have LRTIs between the period of 2002-2004, at Pediatric Allergy and Pulmonology Department of a University Hospital in Manisa (located in the Aegean region of Turkey) were included to the study. The presence of respiratory viruses [respiratory syncytial virus (RSV), influenza virus type A and B, parainfluenza virus types 1, 2 and 3, adenovirus] in the nasopharyngeal aspirate specimens collected from children have been searched by direct fluorescence antibody test (Biotrin, Ireland). Respiratory viruses were detected in 25.2% (38/151) of the patients with LRTIs, while this rate was 46.8% (22147) for 2002 period, 13.3% (8/60) for 2003 period and 18.2% (8/44) for 2004 period. RSV and adenoviruses both detected with a frequency of 31.5% (n = 12/38); were the most common agents encountered, and followed by parainfluenza (110/38, 26.3%) and influenza (9/38, 23.6%) viruses. Postinfectious BO have been diagnosed in 7.3% (11/151) of the patients; seven in 2002, one in 2003 and three in 2004 periods. Viral etiology were present in all of the patients who developed BO in 2002, while viral infection was detected in one of the patients who developed BO in 2003-2004 periods. Adenoviruses were the most frequently detected agents (n = 5) in BO cases with viral etology (n = 8). Viral agents were found positive in 72.7% (8/11) and 21.4% (30/140) of the patients with and without BO development, respectively, and this difference was found statistically significant (p = 0.02). Besides, BO development was detected in 21.1% (8/38) and 2.6% (3/113) of LRTI patients with and without viral etiology, respectively, and this difference was also significant (p<0.05). In conclusion, the long term follow-up is important in young children with viral LRTIs for the early diagnosis of complications. Thus the identification of viruses might aid in estimation of prognosis.Item A case of primary pulmonary tuberculosis presenting as foreign body aspirationIkizoglu, T; Yilmaz, Ö; Özkol, M; Sögüt, A; Yüksel, HAn 18-month-old child was hospitalized with presumptive diagnosis of foreign body aspiration. Chest radiography revealed atelectasis in the right lower lobe. Foreign body was not seen at rigid bronchoscopy. Tuberculin skin test was 11 mm with one scar of Bacillus Calmette-Guerin vaccine. Computerized tomography of thorax revealed conglomerating lymphadenopathy in the right hilus and calcified lymphadenopathy as well as pneumonic consolidation of the right lower lobe. Tuberculosis was diagnosed based on his tuberculin skin test and thorax computerized tomography. This case is presented to emphasize that tuberculosis should be included to the differential diagnosis of children that present with signs and symptoms of foreign body aspiration and atelectasis.Item Acute generalized exanthematous pustulosis due to amoxicilline-clavulanatetSögüt, A; Yilmaz, Ö; Yildirim, S; Özen, S; Temiz, P; Yüksel, HAcute generalized exanthematous pustulosis is an uncommon clinical condition characterized by an acute onset of pustular eruptions. A case of acute generalized exanthematous pustulosis after the use of amoxicilline-clavulanate is presented. The patient presented with pustular and pruritic eruptions after use of drug. The diagnosis was confirmed with pathological data. This condition leading to various clinical manifestations should be thought in the differential diagnosis of pustular dermatosis. (Turk Arch Ped 2010; 45: 150-2)Item Flexible Fiberoptic Bronchoscopy Experience in Childhood: Evaluation of 96 CasesYüksel, H; Sögüt, A; Topçu, I; Yilmaz, Ö; Okkali, Z; Keles, GThis study is presented to evaluate the results of flexible fiberoptic bronchoscopy performed at our Department of Pediatric Allergy and Pulmonology Unit. Data of the 96 pediatric patients who had undergone flexible fiberoptic bronchoscopy in our clinic between January 2003 and February 2007 were evaluated retrospectively. Forty six patients (47.9%) were female and fifty patients (52.1%) were male. The mean age was 73.8 +/- 49.7 months, with a range of 2 and180 months. The most common indications for bronchoscopy were: persistent and/or recurrent pneumonia (24%), atelectasis (22%), suspected foreign bodies (10%), pulmonary tuberculosis (9%) tracheoesophageal fistula (5%), stridor (4%), and others (pulmonary hypoplasia, bronchial hypoplasia, gastroesophageal reflux, bronchiectasis, pulmonary hemosiderosis, hydatid cyst). Bronchoscopy findings of 19 (20%) patients were normal, while those of 77 (80%) patients produced findings which aided diagnosis and therapy. Moreover, rare pulmonary diseases such as tracheal bronchus in two cases and bronchial mucoepidermoid carcinoma in one case with recurrent pneumonia were encountered. Complications were pulmonary edema in one case, laryngospasm in two cases, bronchospasm in one case, and fever in three cases. In conclusion pediatric FFB is an advanced diagnostic tool with high diagnostic value and a low and insignificant complication rate in experienced hands and technically advanced settings.Item A multicenter survey of childhood asthma in Turkey - II: Utilization of asthma drugs, control levels and their determinantsSoyer, OU; Beyhun, NE; Demir, E; Yildirim, S; Boz, AB; Altinel, N; Cevit, O; Karakas, T; Anlar, Y; Sögüt, A; Altintas, D; Canitez, Y; Büyükdereli, Z; Sekerel, BEMany surveys worldwide have consistently demonstrated a low level of asthma control and under-utilization of preventive asthma drugs. However, these studies have been frequently criticized for using population-based samples, which include many patients with no or irregular follow-ups. Our aim, in this study, was to define the extent of asthma drug utilization, control levels, and their determinants among children with asthma attending to pediatric asthma centers in Turkey. Asthmatic children (age range: 6-18 yr) with at least 1-yr follow-up seen at 12 asthma outpatient clinics during a 1-month period with scheduled or unscheduled visits were included and were surveyed with a questionnaire-guided interview. Files from the previous year were evaluated retrospectively to document control levels and their determinants. From 618 children allocated, most were mild asthmatics (85.6%). Almost 30% and 15% of children reported current use of emergency service and hospitalization, respectively; and 51.4% and 53.1% of children with persistent and intermittent disease, respectively, were on daily preventive therapy, including inhaled corticosteroids. Disease severity [odds ratio: 12.6 (95% confidence intervals: 5.3-29.8)], hospitalization within the last year [3.4 (1.4-8.2)], no use of inhaled steroids [2.9 (1.1- 7.3)], and female gender [2.3 (1.1-5.4)] were major predictors of poor asthma control as defined by their physicians. In this national pediatric asthma study, we found a low level of disease control and discrepancies between preventive drug usage and disease severity, which shows that the expectations of guidelines have not been met even in facilitated centers, thus indicating the need to revise the severity-based approach of asthma guidelines. Efforts to implement the control-based approach of new guidelines (Global Initiative for Asthma 2006) would be worthwhile.Item Summary of Consensus Report on Preoperative EvaluationÖzkan, M; Kirkil, G; Dilektasli, AG; Sögüt, A; Sertogullarindan, B; Çetinkaya, E; Coskun, F; Ulubay, G; Yüksel, H; Sezer, M; Özbudak, Ö; Ulasli, SS; Arslan, S; Kovan, TItem Status of skin reactivity to allergens in parents of atopic children and its relationship with clinical characteristicsYilmaz, Ö; Türkeli, A; Sögüt, A; Yüksel, HObjective: Specific and nonspecific environmental factors as well as genetic tendency plays role in development of allergic diseases that are the most common chronic disease group in developed countries. The aim of this study was to determine the allergen sensitivity and frequency of allergic diseases in parents of children detected to have allergen sensitivity and an allergic disease. Materials and Methods: Thirty one children aged 8-18 years, diagnosed with allergic rhinoconjunctivitis or asthma and detected to have sensitivity to inhalant allergens on skin prick test (SPT) and their parents were enrolled in this study. SPT results and total immunoglobulin E levels of the children were recorded. Skin prick test with inhalant allergens were applied to the mothers and fathers. Results: Evaluation of SPT revealed positive results in 14 mothers (45.2%) and negative results in 17 mothers (54.8%). Among the fathers, 17 (54.8%) had negative and 14 (45.2%) had positive SPT results. Sensitized allergen type in children did not influence the skin prick test positivity in mothers and fathers significantly (p=0.88 and p=0.68 respectively). Conclusion: Skin allergen sensitivity is common in parents of allergic children irrespective of clinical findings. This difference between clinical and allergic sensitization may be attributed to environmental factors. The results of this study indicated that allergen type that the child is sensitized to does not influence the sensitization frequency in parents.