Environmental tobacco smoke (ETS) and respiratory health in children

Deregulation of gene expression induced by environmental tobacco smoke exposure in pregnancy

INTRODUCTION

Environmental tobacco smoke (ETS) exposure in pregnant women may have detrimental effects such as spontaneous abortion, lower birth weight, stillbirth, and reduced infant lung function. To extend our knowledge on the molecular effects of tobacco smoke exposure in pregnancy, we analyzed transcriptome alterations in passive smokers (PS) and compared them with those in active smokers (AS).

METHODS

Using Illumina Expression Beadchips with 24,526 transcript probes, gene expression patterns were assayed in placentas from PS (N = 25) exposed to ETS throughout pregnancy and nonexposed (NS) counterparts (N = 34) and in cord blood cells from their newborns. ETS exposure was evaluated by questionnaire disclosure and cotinine measurement in maternal and cord blood.

RESULTS

A total of 158 genes were significantly deregulated in the placentas of PS compared with NS. These genes were associated with the extracellular matrix, apoptosis, placental function, blood clotting, response to stress, and lipid metabolism. Cord blood of the newborns of PS displayed differential expression of 114 genes encoding mainly adhesion molecules and regulators of immunologic response. A comparison of the affected pathways between PS and AS indicated that ETS exposure and active smoking in pregnancy partly employ the same molecular mechanisms.

CONCLUSIONS

This study demonstrates that even low dose exposure to ETS during pregnancy leads to significant deregulation of transcription in placental and fetal cells. These data suggest that the effect of ETS on the fetus is primarily indirect, mediated via deregulation of placental functions.

Environmental tobacco smoke and children's health

Passive exposure to tobacco smoke significantly contributes to morbidity and mortality in children. Children, in particular, seem to be the most susceptible population to the harmful effects of environmental tobacco smoke (ETS). Paternal smoking inside the home leads to significant maternal and fetal exposure to ETS and may subsequently affect fetal health. ETS has been associated with adverse effects on pediatric health, including preterm birth, intrauterine growth retardation, perinatal mortality, respiratory illness, neurobehavioral problems, and decreased performance in school. A valid estimation of the risks associated with tobacco exposure depends on accurate measurement. Nicotine and its major metabolite, cotinine, are commonly used as smoking biomarkers, and their levels can be determined in various biological specimens such as blood, saliva, and urine. Recently, hair analysis was found to be a convenient, noninvasive technique for detecting the presence of nicotine exposure. Because nicotine/cotinine accumulates in hair during hair growth, it is a unique measure of long-term, cumulative exposure to tobacco smoke. Although smoking ban policies result in considerable reductions in ETS exposure, children are still exposed significantly to tobacco smoke not only in their homes but also in schools, restaurants, child-care settings, cars, buses, and other public places. Therefore, more effective strategies and public policies to protect preschool children from ETS should be consolidated.

Impact of national smoke-free legislation on home smoking bans: findings from the International Tobacco Control Policy Evaluation Project Europe Surveys

OBJECTIVES

To measure changes in prevalence and predictors of home smoking bans (HSBs) among smokers in four European countries after the implementation of national smoke-free legislation.

DESIGN

Two waves of the International Tobacco Control Policy Evaluation Project Europe Surveys, which is a prospective panel study. Pre- and post-legislation data were used from Ireland, France, Germany and the Netherlands. Two pre-legislation waves from the UK were used as control.

PARTICIPANTS

4634 respondents from the intervention countries and 1080 from the control country completed both baseline and follow-up and were included in the present analyses.

METHODS

Multiple logistic regression models to identify predictors of having or of adopting a total HSB, and Generalised Estimating Equation models to compare patterns of change after implementation of smoke-free legislation to a control country without such legislation.

RESULTS

Most smokers had at least partial smoking restrictions in their home, but the proportions varied significantly between countries. After implementation of national smoke-free legislation, the proportion of smokers with a total HSB increased significantly in all four countries. Among continuing smokers, the number of cigarettes smoked per day either remained stable or decreased significantly. Multiple logistic regression models indicated that having a young child in the household and supporting smoking bans in bars were important correlates of having a pre-legislation HSB. Prospective predictors of imposing a HSB between survey waves were planning to quit smoking, supporting a total smoking ban in bars and the birth of a child. Generalised Estimating Equation models indicated that the change in total HSB in the intervention countries was greater than that in the control country.

CONCLUSIONS

The findings suggest that smoke-free legislation does not lead to more smoking in smokers' homes. On the contrary, our findings demonstrate that smoke-free legislation may stimulate smokers to establish total smoking bans in their homes.

Influence of passive smoking on functional abilities in children

Passive smoking has been found to be associated with a large number of disorders of passive smokers. It seems that the children are the most susceptible population for harmful effects of passive smoke exposure. The aim of this study was to evaluate the effect of passive smoking on children's functional abilities. The target population was 199 children who were 13-15 years old at the time of the study. For the assessment of motor skills 6-min run test was used. Children exposed to passive smoking by their mothers had statistically significant lower functional abilities (r =-0.7029; 95% CI -0.7707 to -0.6194; p < 0.0001). We also found statistically significant difference if the both parents are smokers (r =-0.3343; 95% CI -0.4595 to -0.1961; p < 0.0001). The results of our study did not show statistically significant difference if the children are exposed to cigarette smoke by their fathers (r = 0.03139; 95% CI -0.1171 to 0.1785; p = 0.6792). Public health preventive actions should go toward minimizing the exposure of children to passive smoking by counseling the smoking parents that quitting smoking provides enormous health benefits not only to them but also to their children.

Prenatal secondhand cigarette smoke promotes Th2 polarization and impairs goblet cell differentiation and airway mucus formation

Parental, particularly maternal, smoking increases the risk for childhood allergic asthma and infection. Similarly, in a murine allergic asthma model, prenatal plus early postnatal exposure to secondhand cigarette smoke (SS) exacerbates airways hyperreactivity and Th2 responses in the lung. However, the mechanism and contribution of prenatal versus early postnatal SS exposure on allergic asthma remain unresolved. To identify the effects of prenatal and/or early postnatal SS on allergic asthma, BALB/c dams and their offspring were exposed gestationally and/or 8-10 wk postbirth to filtered air or SS. Prenatal, but not postnatal, SS strongly increased methacholine and allergen (Aspergillus)-induced airway resistance, Th2 cytokine levels, and atopy and activated the Th2-polarizing pathway GATA3/Lck/ERK1/2/STAT6. Either prenatal and/or early postnatal SS downregulated the Th1-specific transcription factor T-bet and, surprisingly, despite high levels of IL-4/IL-13, dramatically blocked the allergen-induced mucous cell metaplasia, airway mucus formation, and the expression of mucus-related genes/proteins: Muc5ac, γ-aminobutyric acid A receptors, and SAM pointed domain-containing Ets-like factor. Given that SS/nicotine exposure of normal adult mice promotes mucus formation, the results suggested that fetal and neonatal lung are highly sensitive to cigarette smoke. Thus, although the gestational SS promotes Th2 polarization/allergic asthma, it may also impair and/or delay the development of fetal and neonatal lung, affecting mucociliary clearance and Th1 responses. Together, this may explain the increased susceptibility of children from smoking parents to allergic asthma and childhood respiratory infections.

Determinants of exposure to second-hand tobacco smoke (SHS) among current non-smoking in-school adolescents (aged 11-18 years) in South Africa: results from the 2008 GYTS study

The aim of this study was to estimate the prevalence and identify correlates of second-hand tobacco smoke (SHS) among 6,412 current non-smoking school-going adolescents (aged 11 to 18 years) in South Africa. A cross-sectional study was carried out in 2008 in South Africa within the framework of the Global Youth Tobacco Survey. Overall, 25.7% of students were exposed to SHS at home, 34.2% outside of the home and 18.3% were exposed to SHS at home and outside of the home. Parental and close friends smoking status, allowing someone to smoke around you and perception that passive smoking was harmful were significant determinants of adolescent’s exposure to both SHS at home and outside of the home. Identified factors can inform the implementation of public health interventions in order to reduce passive smoking among adolescents.

Early-life indoor environmental exposures increase the risk of childhood asthma

We aim to explore the relationships between exposure to dampness, pets, and environmental tobacco smoke (ETS) early in life and asthma in Taiwanese children, and to discuss their links to early- and late-onset asthma. We conducted a 1:2 matched case-control study from the Taiwan Children Health Study, which was a nationwide study that recruited 12-to-14 year-old school children in 14 communities. The 579 mothers of the participants were interviewed by telephone about their children's environmental exposures before they were 5 years old, including the in-utero period. Childhood asthma was associated with exposure to early life environmental factors, such as cockroaches (OR=2.16; 95% CI, 1.15-4.07), visible mould (OR=1.75; 95% CI, 1.15-2.67), mildewy odors (OR=5.04; 95% CI, 2.42-10.50), carpet (OR=2.36; 95% CI, 1.38-4.05), pets (OR=2.11; 95% CI, 1.20-3.72), and more than one hour of ETS per day (OR=1.93; 95% CI, 1.16-3.23). The ORs for mildewy odors, feather pillows, and ETS during early childhood were greater among children with late-onset asthma. Cockroaches, carpet, pets, and in-utero exposures to ETS affected the timing of early-onset asthma. Exposure to these factors led to dose-responsiveness in the risk of asthma. And the earlier exposures may trigger the earlier onset. Interventions in avoiding these environmental exposures are necessary for early-prevention of childhood asthma.

Secondhand Tobacco Smoke Exposure Among School-Aged Youth Enrolled in School-Based Asthma Management Programs

The high prevalence of asthma among school-aged youth places a significant burden on students, families, and communities. Secondhand smoke (SHS) exacerbates asthma symptoms and attacks. Parental smoking is likely the most common and recurring source of SHS exposure among children. School-based asthma management programs can play a major role in educating students and their families about how to reduce, eliminate, and cope with SHS exposure. Between January 2007 and May 2008, a total of 121 middle and 248 elementary school students who participated in school-based asthma management programs in elementary school completed pretest and posttest surveys assessing asthma behaviors and management difficulties. Subgroups of 40 middle and 54 elementary school students participated in 15 focus groups. Quantitative data were analyzed using descriptive statistics and independent sample t tests. Thematic analysis was used to identify and interpret prominent themes within qualitative data. Quantitative analysis of elementary school student data revealed students exposed to SHS had significantly higher asthma management difficulties at pretest (2.79 vs 1.98, respectively; t = 3.4, P = .001) and posttest (2.56 vs 1.74, respectively; t = 3.8, P < .001) compared with those without SHS exposure. Qualitative results from elementary and middle school students revealed that many students reported SHS exposure resulting from family members smoking at home or in cars. Students and their families reported using ineffective methods (eg, opening a window, drinking water, holding their breath) for reducing, eliminating, and coping with SHS exposure. School-based asthma management programs should provide education to students and their families on the lasting effects of SHS on asthma symptoms and effective strategies for reducing, eliminating, and coping with SHS exposure in homes and cars. A focus on parent and community involvement can play a key role in addressing students’ asthma management needs outside of school.

Transcriptome alterations in maternal and fetal cells induced by tobacco smoke

OBJECTIVES

Maternal smoking has a negative effect on all stages of pregnancy. Tobacco smoke-related defects are well established at the clinical level; however, less is known about molecular mechanisms underlying these pathologic conditions. We thus performed a comprehensive analysis of transcriptome alterations induced by smoking in maternal and fetal cells.

STUDY DESIGN

Samples of peripheral blood (PB), placenta (PL), and cord blood (UCB) were obtained from pregnant smokers (n = 20) and gravidas without significant exposure to tobacco smoke (n = 52). Gene expression profiles were assayed by Illumina Expression Beadchip v3 for analysis of 24,526 transcripts. The quantile method was used for normalization. Differentially expressed genes were analyzed in the Limma package and the P-values were corrected for multiple testing. Unsupervised hierarchical clustering was performed using average linkage and Euclidean distance. The enrichment of deregulated genes in biological processes was analyzed in DAVID database.

RESULTS

Comparative analyses defined significant deregulation of 193 genes in PB, 329 genes in PL, and 49 genes in UCB of smokers. The deregulated genes were mainly related to xenobiotic metabolism, oxidative stress, inflammation, immunity, hematopoiesis, and vascularization. Notably, functional annotation of the affected genes identified several deregulated pathways associated with autoimmune diseases in the newborns of smokers.

CONCLUSIONS

The study demonstrated maternal smoking causes significant changes in transcriptome of placental and fetal cells that deregulate numerous biological processes important for growth and development of the fetus. An activation of fetal CYP genes showed a limited ability of the placenta to modulate toxic effects of maternal tobacco use.

Association between prenatal and postnatal tobacco smoke exposure and allergies in young children

BACKGROUND

Many studies have shown a positive association between environmental tobacco smoke (ETS) exposure and allergic disorders, whereas epidemiological evidence of the effect of maternal smoking during pregnancy on allergic diseases is inconsistent. We investigated the independent and joint effects of in utero exposure to maternal smoking and postnatal ETS exposure at home on allergic disorders among Japanese children.

METHODS

Study subjects were 1951 children aged 3 years. Data on maternal smoking during pregnancy and postnatal exposure to ETS at home, allergic symptoms, and potential confounders were collected through the use of a questionnaire. Outcomes were defined according to the criteria of the International Study of Asthma and Allergies in Childhood (ISAAC).

RESULTS

The prevalence values of symptoms of wheeze, asthma, and eczema in the previous 12 months were 22.0%, 8.8%, and 17.2%, respectively. We found that postnatal ETS exposure at home in the absence of in utero exposure to maternal smoking was associated with a higher prevalence of wheeze (adjusted odds ratio (OR) = 1.30, 95% confidence interval (CI): 1.01-1.67). In contrast, in utero exposure without subsequent postnatal ETS exposure at home or exposure to postnatal ETS at home in addition to in utero exposure to maternal smoking was not associated with the prevalence of wheeze. No measurable associations were observed between fetal, postnatal, or joint exposure and the prevalence of asthma or eczema.

CONCLUSIONS

Data from this study indicate that ETS at home may be associated with a higher prevalence of wheeze among young Japanese children.

Secondhand smoke exposure during pregnancy and infantile neurodevelopment

During prenatal development, the nervous system may be more susceptible to environmental toxicants, such as secondhand smoke. The authors assessed the effects of prenatal and postnatal secondhand smoke exposure on the neurodevelopment of 6-month infants. The subjects were 414 mother and infant pairs with no medical problems, taken from the Mothers' and Children's Environmental Health study. Prenatal and postnatal exposures to secondhand smoke were determined using maternal self-reports. Examiners, unaware of exposure history, assessed the infants at 6 months of age using the Bayley Scales of Infant Development. Bayley scores were compared for secondhand smoke exposed and unexposed groups after adjusting for potential confounders. Multiple logistic regression analysis was carried out to estimate the risk of developmental delay posed by SHS exposure. The multivariate model included residential area, maternal age, pre-pregnancy body mass index, education, income, infant sex, parity, birth weight, and type of feeding. After adjusting for covariates, secondhand smoke exposure during pregnancy was found to be related to a decrease in mental developmental index score, but not to a decrease in psychomotor developmental index score. In addition, secondhand smoke exposure during pregnancy was found to increase the risk of developmental delay (mental developmental index score ≤85) at 6 months. This study suggests that the infants of non-smoking women exposed to secondhand smoke are at risk of neurodevelopmental delay.

Environmental toxicants and the developing immune system: a missing link in the global battle against infectious disease?

There is now compelling evidence that developmental exposure to chemicals from our environment contributes to disease later in life, with animal models supporting this concept in reproductive, metabolic, and neurodegenerative diseases. In contrast, data regarding how developmental exposures impact the susceptibility of the immune system to functional alterations later in life are surprisingly scant. Given that the immune system forms an integrated network that detects and destroys invading pathogens and cancer cells, it provides the body's first line of defense. Thus, the consequences of early life exposures that reduce immune function are profound. This review summarizes available data for pollutants such as cigarette smoke and dioxin-like compounds, which consistently support the idea that developmental exposures critically impact the immune system. These findings suggest that exposure to common chemicals from our daily environment represent overlooked contributors to the fact that infectious diseases remain among the top five causes of death worldwide.

Thirdhand smoke: heterogeneous oxidation of nicotine and secondary aerosol formation in the indoor environment

Tobacco smoking is well-known as a significant source of primary indoor air pollutants. However, only recently has thirdhand smoke (THS) been recognized as a contributor to indoor pollution due to the role of indoor surfaces. Here, the effects of relative humidity (<10% RH and ∼ 45% RH) and substrate (cellulose, cotton, and paper) on secondary organic aerosol (SOA) formation from nicotine-ozone-NO(x) reactions are discussed. SOA formation from the sorbed nicotine-ozone reaction ([O(3)] = 55 ppb) varied in size distribution and number, depending on RH and substrate type, indicating the role of substrate and water interactions in SOA formation. This led to SOA yields from cellulose sorbed nicotine-ozone reaction of ∼ 1 and 2% for wet and dry conditions, respectively. SOA formation from nicotine-NO(x) reactions was not distinguishable from background levels. Simultaneously, cellulose sorbed nicotine-ozone reaction kinetics ([O(3)] = 55 ppb) were obtained and revealed pseudofirst-order surface rate constants of k(1) = (1 ± 0. 5) × 10(-3) and k(1) < 10(-4) min(-1) under <10% and ∼ 45% RH, respectively. Given the toxicity of some of the identified products and that small particles may contribute to adverse health effects, the present study indicates that exposure to THS ozonation products may pose additional health risks.

Public, private and personal: qualitative research on policymakers' opinions on smokefree interventions to protect children in 'private' spaces

Background

Governments use law to constrain aspects of private activities for purposes of protecting health and social wellbeing. Policymakers have a range of perceptions and beliefs about what is public or private. An understanding of the possible drivers of policymaker decisions about where government can or should intervene for health is important, as one way to better guide appropriate policy formation. Our aim was to identify obstacles to, and opportunities for, government smokefree regulation of private and public spaces to protect children. In particular, to seek policymaker opinions on the regulation of smoking in homes, cars and public parks and playgrounds in a country with incomplete smokefree laws (New Zealand).

Methods

Case study, using structured interviews to ask policymakers (62 politicians and senior officials) about their opinions on new smokefree legislation for public and private places. Supplementary data was obtained from the Factiva media database, on the views of New Zealand local authority councillors about policies for smokefree outdoor public places.

Results

Overall, interviewees thought that government regulation of smoking in private places was impractical and unwise. However, there were some differences on what was defined as 'private', particularly for cars. Even in public parks, smoking was seen by some as a 'personal' decision, and unlikely to be amenable to regulation. Most participants believed that educative, supportive and community-based measures were better and more practical means of reducing smoking in private places, compared to regulation.

Conclusions

The constrained view of the role of regulation of smoking in public and private domains may be in keeping with current political discourse in New Zealand and similar Anglo-American countries. Policy and advocacy options to promote additional smokefree measures include providing a better voice for childrens' views, increasing information to policymakers about the harms to children from secondhand smoke and the example of adult smoking, and changing the culture for smoking around children.

Factors associated with acute respiratory illness in day care children

The aim of this study was to investigate the relationship between child characteristics, parental and environmental factors and the occurrence of acute respiratory illness (ARI) and acute otitis media (AOM) among Finnish children attending day care centres (DCCs). The study was a cross-sectional questionnaire of 594 children aged 1-6 y from 18 DCCs in Helsinki, Finland. Recurrent (> or =4 diseases/y) ARI was present in 44% of the 1-3-y-olds and 23% of the 4-6-y-olds, and recurrent AOM in 15% and 2.5%, respectively. Parent atopic disease (odds ratio (OR) 1.53, p = 0.033), mother's academic education (OR 1.77, p = 0.008) and a medium length of DCC attendance compared to a short period (OR 1.67, p = 0.049) increased, while furry pets (OR 0.44, p = 0.003) and older child age (OR 0.38, p < 0.001) reduced the risk of recurrent ARI. Recurrent ARI (OR 3.96, p = 0.008), mother's academic education (OR 5.02, p = 0.003), and a medium length of DCC attendance compared to a short period (OR 3.34, p = 0.044) increased, while partial breastfeeding > or =6 months (OR 0.20, p = 0.002) and older child age (OR 0.05, p < 0.001) reduced the risk of recurrent AOM. Parental and environmental factors had a significant impact on recurrent ARI and AOM episodes in children attending DCCs. These risk factors should be considered in future studies intending to reduce DCC infections.

Neonatal immune function and inflammatory illnesses in later life: lessons to be learnt from the developing world?

With the emergence of allergic and autoimmune diseases in populations that have started to transit to a western lifestyle, there has been an increasing interest in the role of environmental factors modulating early immune function. Yet, most of the information concerning neonatal immune function has been derived from studies in westernized countries. We postulate that comparative studies of early immune development in children born under conditions that are typical for a westernized vs. that of a still more traditional setting will provide a crucial insight into the environmental-driven immunological mechanisms that are responsible for the world-wide rise in inflammatory disorders. In this review, we summarize the current understanding of early-life immune function in humans in general and the literature on some major lifestyle factors that may influence neonatal immune function and potentially the risk for disease in later life. An understanding of the mechanisms of 'prenatal/early-life programming' in populations living in traditional compared with modern societies is crucial to develop strategies to prevent a further rise in 'western diseases' such as allergic disorders. Indications exist that prenatal conditioning of the innate immune system by low-grade inflammatory responses is key to inducing more tightly regulated postnatal adaptive immune responses.

Suppression of pulmonary host defenses and enhanced susceptibility to respiratory bacterial infection in mice following inhalation exposure to trichloroethylene and chloroform

Numerous epidemiological studies have associated episodes of increased air pollution with increased incidence of respiratory disease, including pneumonia, croup, and bronchitis. Trichloroethylene (TCE) and chloroform are among 33 hazardous air pollutants identified by the U.S. Environmental Protection Agency as presenting the greatest threat to public health in the largest number of urban areas. Also, both are common indoor air pollutants. Here, we assessed the potential effects of TCE and chloroform on resistance to pulmonary bacterial infection and related alveolar macrophage (AM) function. CD-1 mice were exposed by inhalation to filtered air (control) or concentrations of TCE ranging from 5 to 200 ppm, or concentrations of chloroform ranging from 100 to 2000 ppm. Immediately following exposure, mice were challenged with an aerosol of Streptococcus zooepidemicus and monitored for clearance of bacteria from the lung and mortality. In separate experiments, exposed mice were injected intratracheally with viable bacteria and phagocytic function was evaluated in macrophages obtained from lung washes 30 min later. The NOEL for enhanced mortality to infection was 25 ppm for TCE and 500 ppm for chloroform. Relative to the air controls, differences in clearance of bacteria from the lung were noted in mice exposed to TCE (NOEL = 50 ppm) and to chloroform (NOEL 100 ppm), and differences in AM phagocytic index were noted for TCE (NOEL = 100 ppm) and for chloroform (NOEL < 100 ppm). The data support the utility of the S. zooepidemicus infectivity model in assessing potential increased risk of respiratory infection and suggest that delayed clearance of bacteria from the lung or decreased phagocytosis are viable alternatives to mortality as an endpoint. Collectively, these endpoints are among the most sensitive health effects reported for TCE.

A qualitative case study of policy maker views about the protection of children from smoking in cars

INTRODUCTION

As little is known about the policy making process around smokefree car laws, we aimed to investigate policy makers' views about such laws in a setting where these have not yet been enacted but where published evidence exists on the hazard of smoking in cars and on relevant public support.

METHODS

A New Zealand (NZ) case study (of the NZ health policy community) used documents and qualitative in-depth interviews with 62 national-level and District Health Board (DHB)-level policy makers (during 2008-2009). Forty were government or nongovernmental organization officials, 5 DHB board members, and 17 Members of Parliament.

RESULTS

We found very strong themes of policy maker concern for the vulnerability of children and the need for their protection from secondhand smoke. There were mixed reactions to the idea of a smokefree law for cars with children in them. These themes and mixed reactions spanned both the "left" and "right" political parties. The evidence indicates that smokefree car laws are only barely on the NZ national policy making agenda. They are generally not seen as politically attractive, as effective, or easy to implement.

DISCUSSION

In this particular policy setting, there appear to have been assumptions by policy makers about the dominance of adult "privacy" over child protection. The lack of awareness in this particular (NZ) policy community of national-level public support for banning smoking in cars with children and of the progress elsewhere on such laws also suggests the importance of information and advocacy if such laws are to be progressed.

Identifying patterns of immune-related disease: use in disease prevention and management

BACKGROUND

Childhood susceptibility to diseases linked with immune dysfunction affects over a quarter of the pediatric population in some countries. While this alone is a significant health issue, the actual impact of immune-related diseases extends over a lifetime and involves additional secondary conditions. Some comorbidities are well known (e.g., allergic rhinitis and asthma). However, no systematic approach has been used to identify life-long patterns of immune-based disease where the primary condition arises in childhood. Such information is useful for both disease prevention and treatment approaches.

DATA SOURCES

Recent primary research papers as well as review articles were obtained from PubMed, Chem Abstracts, Biosis and from the personal files of the authors. Search words used were: the diseases and conditions shown Figs. 1 and 2 in conjunction with comorbid, comorbidities, pediatric, childhood, adult, immune, immune dysfunction, allergy, autoimmune, inflammatory, infectious, health risks, environment, risk factors.

RESULTS

Childhood diseases such as asthma, type-1 diabetes, inflammatory bowel disease, respiratory infections /rhinitis, recurrent otitis media, pediatric celiac, juvenile arthritis and Kawasaki disease are examples of significant childhood health problems where immune dysfunction plays a significant role. Each of these pediatric diseases is associated with increased risk of several secondary conditions, many of which appear only later in life. To illustrate, four prototypes of immune-related disease patterns (i.e., allergy, autoimmunity, inflammation and infectious disease) are shown as tools for: 1) enhanced disease prevention; 2) improved management of immune-based pediatric diseases; and 3) better recognition of underlying pediatric immune dysfunction.

CONCLUSIONS

Identification of immune-related disease patterns beginning in childhood provides the framework for examining the underlying immune dysfunctions that can contribute to additional diseases in later life. Many pediatric diseases associated with dysfunctional immune responses have been linked with an elevated risk of other diseases or conditions as the child ages. Diseases within a pattern may be interlinked based on underlying immune dysfunctions and/or current therapeutic approaches for managing the entryway diseases. It may be beneficial to consider treatment options for the earliest presenting diseases that will concomitantly reduce the risk of immune-linked secondary conditions. Additionally, improved disease prevention is possible with more relevant and age-specific immune safety testing.