International Study of Asthma and Allergies in Childhood (ISAAC): rationale and methods

Prevalence, risk factors, impact and management of pneumonia among preschool children in Chinese seven cities: a cross-sectional study with interrupted time series analysis

BACKGROUND

Pneumonia is a common disease worldwide in preschool children. Despite its large population size, China has had no comprehensive study of the national prevalence, risk factors, and management of pneumonia among preschool children. We therefore investigated the prevalence of pneumonia among preschool children in Chinese seven representative cities, and explore the possible risk factors of pneumonia on children, with a view to calling the world's attention to childhood pneumonia to reduce the prevalence of childhood pneumonia.

METHODS

Two group samples of 63,663 and 52,812 preschool children were recruited from 2011 and 2019 surveys, respectively. Which were derived from the cross-sectional China, Children, Homes, Health (CCHH) study using a multi-stage stratified sampling method. This survey was conducted in kindergartens in seven representative cities. Exclusion criteria were younger than 2 years old or older than 8 years old, non-permanent population, basic information such as gender, date of birth and breast feeding is incomplete. Pneumonia was determined on the basis of parents reported history of clearly diagnosed by the physician. All participants were assessed with a standard questionnaire. Risk factors for pneumonia, and association between pneumonia and other respiratory diseases were examined by multivariable-adjusted analyses done in all participants for whom data on the variables of interest were available. Disease management was evaluated by the parents' reported history of physician diagnosis, longitudinal comparison of risk factors in 2011 and 2019.

RESULTS

In 2011 and 2019, 31,277 (16,152 boys and 15,125 girls) and 32,016 (16,621 boys and 15,395 girls) preschool children aged at 2-8 of permanent population completed the questionnaire, respectively, and were thus included in the final analysis. The findings showed that the age-adjusted prevalence of pneumonia in children was 32.7% in 2011 and 26.4% in 2019. In 2011, girls (odds ratio [OR] 0.91, 95%CI [confidence interval]0.87-0.96; p = 0.0002), rural (0.85, 0.73-0.99; p = 0.0387), duration of breastfeeding ≥ 6 months(0.83, 0.79-0.88; p < 0.0001), birth weight (g) ≥ 4000 (0.88, 0.80-0.97; p = 0.0125), frequency of putting bedding to sunshine (Often) (0.82, 0.71-0.94; p = 0.0049), cooking fuel type (electricity) (0.87, 0.80-0.94; p = 0.0005), indoor use air-conditioning (0.85, 0.80-0.90; p < 0.0001) were associated with a reduced risk of childhood pneumonia. Age (4-6) (1.11, 1.03-1.20; p = 0.0052), parental smoking (one) (1.12, 1.07-1.18; p < 0.0001), used antibiotics (2.71, 2.52-2.90; p < 0.0001), history of parental allergy (one and two) (1.21, 1.12-1.32; p < 0.0001 and 1.33, 1.04-1.69; p = 0.0203), indoor dampness (1.24, 1.15-1.33; p < 0.0001), home interior decoration (1.11, 1.04-1.19; p = 0.0013), Wall painting materials (Paint) (1.16, 1.04-1.29; p = 0.0084), flooring materials (Laminate / Composite wood) (1.08, 1.02-1.16; p = 0.0126), indoor heating mode(Central heating)(1.18, 1.07-1.30, p = 0.0090), asthma (2.38, 2.17-2.61; p < 0.0001), allergic rhinitis (1.36, 1.25-1.47; p < 0.0001), wheezing (1.64, 1.55-1.74; p < 0.0001) were associated with an elevated risk of childhood pneumonia; pneumonia was associated with an elevated risk of childhood asthma (2.53, 2.31-2.78; p < 0.0001), allergic rhinitis (1.41, 1.29-1.53; p < 0.0001) and wheezing (1.64, 1.55-1.74; p < 0.0001). In 2019, girls (0.92, 0.87-0.97; p = 0.0019), duration of breastfeeding ≥ 6 months (0.92, 0.87-0.97; p = 0.0031), used antibiotics (0.22, 0.21-0.24; p < 0.0001), cooking fuel type (Other) (0.40, 0.23-0.63; p = 0.0003), indoor use air-conditioning (0.89, 0.83-0.95; p = 0.0009) were associated with a reduced risk of childhood pneumonia. Urbanisation (Suburb) (1.10, 1.02-1.18; p = 0.0093), premature birth (1.29, 1.08-1.55; p = 0.0051), birth weight (g) < 2500 (1.17, 1.02-1.35; p = 0.0284), parental smoking (1.30, 1.23-1.38; p < 0.0001), history of parental asthma (One) (1.23, 1.03-1.46; p = 0.0202), history of parental allergy (one and two) (1.20, 1.13-1.27; p < 0.0001 and 1.22, 1.08-1.37; p = 0.0014), cooking fuel type (Coal) (1.58, 1.02-2.52; p = 0.0356), indoor dampness (1.16, 1.08-1.24; p < 0.0001), asthma (1.88, 1.64-2.15; p < 0.0001), allergic rhinitis (1.57, 1.45-1.69; p < 0.0001), wheezing (2.43, 2.20-2.68; p < 0.0001) were associated with an elevated risk of childhood pneumonia; pneumonia was associated with an elevated risk of childhood asthma (1.96, 1.72-2.25; p < 0.0001), allergic rhinitis (1.60, 1.48-1.73; p < 0.0001) and wheezing (2.49, 2.25-2.75; p < 0.0001).

CONCLUSIONS

Pneumonia is prevalent among preschool children in China, and it affects other childhood respiratory diseases. Although the prevalence of pneumonia in Chinese children shows a decreasing trend in 2019 compared to 2011, a well-established management system is still needed to further reduce the prevalence of pneumonia and reduce the burden of disease in children.

The airway microbiome mediates the interaction between environmental exposure and respiratory health in humans

Exposure to environmental pollution influences respiratory health. The role of the airway microbial ecosystem underlying the interaction of exposure and respiratory health remains unclear. Here, through a province-wide chronic obstructive pulmonary disease surveillance program, we conducted a population-based survey of bacterial (n = 1,651) and fungal (n = 719) taxa and metagenomes (n = 1,128) from induced sputum of 1,651 household members in Guangdong, China. We found that cigarette smoking and higher PM_2.5 concentration were associated with lung function impairment through the mediation of bacterial and fungal communities, respectively, and that exposure was associated with an enhanced inter-kingdom microbial interaction resembling the pattern seen in chronic obstructive pulmonary disease. Enrichment of Neisseria was associated with a 2.25-fold increased risk of high respiratory symptom burden, coupled with an elevation in Aspergillus, in association with occupational pollution. We developed an individualized microbiome-based health index, which covaried with exposure, respiratory symptoms and diseases, with potential generalizability to global datasets. Our results may inform environmental risk prevention and guide interventions that harness airway microbiome.

The ERBB2 Exonic Variant Pro1170Ala Modulates Mitogen-Activated Protein Kinase Signaling Cascades and Associates with Allergic Asthma

INTRODUCTION

Previous studies have indicated the ERBB2 genetic variants in the 17q12 locus might be associated with asthma; however, the functional effects of these variants on asthma risk remain inconclusive. This study aimed to characterize the functional roles of asthma-associated ERBB2 single nucleotide polymorphisms (SNPs) in asthma pathogenesis by performing genetic association and functional analysis studies.

METHODS

This study belongs to a part of an ongoing Singapore/Malaysia cross-sectional genetics and epidemiological study (SMCSGES). Genotype-phenotype associations were assessed by performing a genotyping assay on n = 4,348 ethnic Chinese individuals from the SMCSGES cohort. The phosphorylation levels of receptors and signaling proteins in the MAPK signaling cascades, including ErbB2, EGFR, and ERK1/2, were compared across the genotypes of asthma-associated SNPs through in vitro and ex vivo approaches.

RESULTS

The ERBB2 tag-SNP rs1058808 was significantly associated with allergic asthma, with the allele "G" identified as protective against the disease (adjusted logistic p = 6.56 × 10-9, OR = 0.625, 95% CI: 0.544-0.718). The allele "G" of rs1058808 resulted in a Pro1170Ala mutation that results in lower phosphorylation levels of ErbB2 in HaCat cells (p < 0.001), whereas the overall ERBB2 mRNA expression and the phosphorylation levels of EGFR remained unaffected. In the SMCSGES cohort, individuals carrying the genotype "GG" of rs1058808 had lower phosphorylated ERK1/2 proteins in the MAPK signaling cascade. A lower phosphorylation level of ERK1/2 was also associated with reduced asthma risk.

CONCLUSIONS

The present findings highlighted the involvement of a functional exonic variant of ERBB2 in asthma development via modulating the MAPK signaling cascade.

Prenatal bisphenol A and S exposure and atopic disease phenotypes at age 6

BACKGROUND

Atopic disease may be influenced by prenatal and early life exposure to endocrine disrupting chemicals, including bisphenols, but results from epidemiological studies have been mixed. This study aimed to extend the epidemiological literature, hypothesizing that children with higher prenatal bisphenol exposure are more likely to have childhood atopic disease.

METHODS

Urinary bisphenol A (BPA) and S (BPS) concentrations were measured in each trimester from 501 pregnant women in a multi-center, prospective pregnancy cohort. Ever asthma, current asthma, wheeze, and food allergy) were assessed at age six via standardized ISAAC questionnaire. We constructed generalized estimating equations to examine BPA and BPS exposure jointly at each trimester for each atopy phenotype. BPA was modeled as a log-transformed continuous variable, whereas BPS was modeled as detected versus not detected. We also modeled pregnancy-averaged BPA values and a categorical indicator for number of detectable BPS values over pregnancy (0-3) in logistic regression models.

RESULTS

First trimester BPA was associated with inverse odds of food allergy among the entire study sample (OR = 0.78, 95% CI = 0.64-0.95, p = 0.01) and females only (OR = 0.69, 95% CI = 0.52-0.90, p = 0.006). The inverse relationship persisted in pregnancy-averaged models of BPA among females (OR = 0.56, 95% CI = 0.35-0.90, p = 0.006). Second trimester BPA was associated with greater odds of food allergy in the entire sample (OR = 1.27, 95% CI = 1.02-1.58, p = 0.03) and among males only (OR = 1.48, 95% CI = 1.02-2.14, p = 0.04). Odds of current asthma increased among males in the pregnancy-averaged BPS models (OR = 1.65, 95% CI = 1.01-2.69, p = 0.045).

CONCLUSION

We saw opposite effects of BPA on food allergy that were trimester- and sex-specific. These divergent associations warrant further investigation. There is some evidence to suggest that prenatal BPS is associated with asthma among males, but further research is required in cohorts with a greater proportion of prenatal urine samples with detectable BPS to validate these results.

Maternal Dietary Zinc Intake during Pregnancy and Childhood Allergic Diseases up to Four Years: The Japan Environment and Children's Study

Maternal dietary zinc intake and childhood allergy have inconsistent relationships. Thus, this study aimed to evaluate the influence of low maternal dietary zinc intake during pregnancy on developing pediatric allergic diseases. This study was designed using the Japan Environment and Children's Study dataset. The model building used data from 74,948 mother-child pairs. Maternal dietary zinc intake was estimated based on the food frequency questionnaire, collecting the intake information of 171 food and beverage items. Fitted logistic regression models and generalized estimating equation models (GEEs) estimated the association between energy-adjusted zinc intake and childhood allergic conditions. The energy-adjusted zinc intake did not affect the risk of developing allergic disorders (wheeze, asthma, atopic dermatitis, rhinitis, and food allergy) in offspring. The GEE model revealed similar insignificant odds ratios. No significant association was found between zinc intake during pregnancy and allergic diseases in offspring in early childhood. Further study remains necessary to examine the association between zinc and allergy with reliable zinc status biomarkers in the body.

Bisphenol and phthalate exposure during pregnancy and the development of childhood lung function and asthma. The generation R study

BACKGROUND

Fetal exposure to bisphenols and phthalates may lead to alterations in the respiratory and immune system development in children, and to adverse respiratory health. AIMTO STUDY: the associations of fetal bisphenols and phthalates exposure with lung function and asthma at age 13 years.

STUDY DESIGN

and Methods This study among 1020 children was embedded in a population-based prospective cohort study. We measured maternal urine bisphenol and phthalate concentrations in first, second and third trimester of pregnancy, and lung function by spirometry and asthma by questionnaires at age 13 years. Multivariable linear and logistic regression models were applied.

RESULTS

Maternal urine bisphenol and phthalate concentrations averaged during pregnancy were not associated with childhood lung function or asthma. Associations of maternal urine bisphenol and phthalate concentrations in specific trimesters with respiratory outcomes showed that one interquartile range increase in the natural log transformed maternal urine mono-isobutyl phthalate concentration in second trimester was associated with a higher FEV₁/FVC, but not with asthma, accounting for confounders and multiple-testing correction. Although there were associations of higher second trimester bisphenol S with a lower FVC and FEV₁ in boys and girls, and of higher first trimester bisphenol S with a decreased risk of asthma in boys and an increased risk of asthma in girls, these results did not remain significant after correction for multiple testing. Results were not modified by maternal history of asthma or atopy.

CONCLUSIONS

Maternal urine bisphenol and phthalate concentrations averaged or in specific trimesters during pregnancy were not strongly associated with childhood lung function and asthma at age 13 years. BPS, as a BPA substitute, tended to be associated with impaired lung function and altered risk of asthma, partly sex-dependent, but its strength was limited by a relatively low detection rate and should be queried in contemporary cohorts.

Duration of Neonatal Antibiotic Exposure in Preterm Infants in Association with Health and Developmental Outcomes in Early Childhood

Over 90% of preterm neonates are, often empirically, exposed to antibiotics as a potentially life-saving measure against sepsis. Long-term outcome in association with antibiotic exposure (NABE) has insufficiently been studied after preterm birth. We investigated the association of NABE-duration with early-childhood developmental and health outcomes in preterm-born children and additionally assessed the impact of GA on outcomes. Preterm children (GA < 30 weeks) participating in a multicenter cohort study were approached for follow-up. General expert-reviewed health questionnaires on respiratory, atopic and gastrointestinal symptoms were sent to parents of children > 24 months' corrected age (CA). Growth and developmental assessments (Bayley Scales of Infant and Toddler Development (BSID) III) were part of standard care assessment at 24 months' CA. Uni- and multivariate regressions were performed with NABE (per 5 days) and GA (per week) as independent variables. Odds ratios (OR) for health outcomes were adjusted (aOR) for confounders, where appropriate. Of 1079 infants whose parents were approached, 347 (32%) responded at a mean age of 4.6 years (SD 0.9). In children with NABE (97%), NABE duration decreased by 1.6 days (p < 0.001) per week of gestation. Below-average gross-motor development (BSID-III gross-motor score < 8) was associated with duration of NABE (aOR = 1.28; p = 0.04). The aOR for constipation was 0.81 (p = 0.04) per gestational week. Growth was inversely correlated with GA. Respiratory and atopic symptoms were not associated with NABE, nor GA. We observed that prolonged NABE after preterm birth was associated with below-average gross-motor development at 24 months' CA, while a low GA was associated with lower weight and stature Z-scores and higher odds for constipation.

Higher greenspace exposure is associated with a decreased risk of childhood asthma in Shanghai - A megacity in China

Inconsistent evidence exists about whether exposure to greenspace benefits childhood asthma. Previous studies have only focused on residential or school greenspace, and no research has combined greenspace exposures at both homes and schools to determine their link with childhood asthma. A population-based cross-sectional study was conducted among 16,605 children during 2019 in Shanghai, China. Self-reported questionnaires were used to collect information on childhood asthma and demographic, socioeconomic and behavioural factors. Environmental data including ambient temperature, particulate matter with aerodynamic diameter less than 1 µm (PM₁), enhanced vegetation index (EVI), and normalized difference vegetation index (NDVI) were collected from satellite data. Binomial generalized linear models with a logit link were carried out to evaluate the association between greenspace exposure and children's asthma, as well as the effect modifiers. An interquartile range increment of whole greenspace (NDVI₅₀₀, NDVI₂₅₀, EVI₅₀₀, and EVI₂₅₀) exposure was associated with a reduced odds ratio of children's asthma (0.88, 95% CI: 0.78, 0.99; 0.89, 95% CI: 0.79, 1.01; 0.87, 95% CI: 0.77, 0.99; and 0.88, 95% CI: 0.78, 0.99, respectively) after controlling potential confounders. Low temperature, low PM₁, males, vaginal delivery, suburban/rural area, and without family history of allergy appeared to enhance the greenspace-asthma association. Increased greenspace exposure was associated with a lower risk of childhood asthma, and the association was modified by a range of socio-environmental factors. These findings add to the body of evidence on the benefits of biodiversity and supporting the promotion of urban greenspace to protect children's health.

A genome-wide association study for allergen component sensitizations identifies allergen component-specific and allergen protein group-specific associations

Background

Allergic diseases are some of the most common diseases worldwide. Genome-wide association studies (GWASs) have been conducted to elucidate the genetic factors of allergic diseases. However, no GWASs for allergen component sensitization have been performed.

Objective

We sought to detect genetic variants associated with differences in immune responsiveness against allergen components.

Methods

The participants of the present study were recruited from the Tokyo Children's Health, Illness, and Development study, and allergen component-specific IgE level at age 9 years was measured by means of allergen microarray immunoassays. We performed GWASs for allergen component sensitization against each allergen (single allergen component sensitization, number of allergen components analyzed, n = 31), as well as against allergen protein families (allergen protein group sensitization, number of protein groups analyzed, n = 16).

Results

We performed GWAS on 564 participants of the Tokyo Children's Health, Illness, and Development study and found associations between Amb a 1 sensitization and the immunoglobulin heavy-chain variable gene on chromosome 14 and between Phl p 1 sensitization and the HLA class II region on chromosome 6 (P < 5.0 × 10-8). A GWAS-significant association was also observed between the HLA class II region and profilin sensitization (P < 5.0 × 10-8).

Conclusions

Our data provide the first demonstration of genetic risk for allergen component sensitization and show that this genetic risk is related to immune response genes including immunoglobulin heavy-chain variable gene and HLA.

Is antenatal or early-life vitamin D associated with eczema or food allergy in childhood? A systematic review

OBJECTIVE

To summarise the associations between antenatal or early-life blood vitamin D and the development of eczema/food allergy in childhood.

DESIGN

A systematic review and meta-analyses were conducted to synthesize the published literature. Two reviewers independently performed the study selection and data extraction on Covidence. We assessed the risk of bias for observational studies by using the Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool for clinical trials. The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

DATA SOURCES

We systematically searched PubMed and Embase from inception and April 2022.

ELIGIBILITY CRITERIA

Human studies that investigated prospective associations between antenatal or early-life blood vitamin D levels, dietary intake or supplementation and childhood eczema/food allergy.

RESULTS

Forty-three articles including six randomised controlled trials (RCTs) were included. Four RCTs of vitamin D supplementation during pregnancy showed no evidence of an effect on the incidence of eczema (pooled odds ratio [OR] = 0.85; 0.67-1.08, I2  = 6.7%, n = 2074). Three RCTs reported null associations between supplementation in pregnancy/infancy and food allergy. From six cohort studies, increasing cord blood vitamin D levels were associated with reduced prevalence of eczema at/close to age one (OR per 10 nmol/L increase = 0.89; 0.84-0.94, I2  = 0%, 2025 participants). We found no evidence of an association between maternal antenatal or infant vitamin D level or dietary intake and the development of food allergy or eczema in offspring.

CONCLUSIONS

We found an association between higher vitamin D levels in cord blood and reduced risk of eczema in cohort studies. Further trials with maternal and infant supplementation are needed to confirm if vitamin D supplementation can effectively prevent eczema or food allergy in childhood.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, No. CRD42013005559.

A longitudinal study of exercise-induced bronchoconstriction and laryngeal obstruction in high school athletes

BACKGROUND

Exercise-induced bronchoconstriction (EIB) and exercise-induced laryngeal obstruction (EILO) are common in elite athletes. Knowledge of which factors are related to incident EIB and EILO is limited. The aim of this study was to explore the course of EIB and EILO in adolescent athletes over a 2 years period and baseline characteristics related to incident EIB.

METHODS

Questionnaire data on respiratory symptoms, asthma, and aeroallergy and results of objective EIB and EILO tests were collected from 58 participants (27 tested for EILO) at baseline and after 2 years (follow-up). Associations between incident EIB and baseline asthma-like symptoms, exercise-induced symptoms, fractional exhaled nitric oxide (FeNO), aeroallergy, and sex were assessed using logistic regression models.

RESULTS

Ten participants had incident EIB, and eight participants had persistent EIB. Five were EIB positive at baseline but negative at follow-up, while 35 participants were EIB negative at both time points. Having incident EIB was associated with reporting waking up with chest tightness (OR = 4.38; 95% CI: 1.06, 22.09). Reporting an increased number of asthma-like symptoms increased the likelihood of incident EIB (OR = 2.78; 95% CI: 1.16, 6.58). No associations were found between exercise-induced symptoms, FeNO, aeroallergy, or sex and incident EIB. Incident EILO was found in three and persistent EILO in two of the 27 participants tested.

CONCLUSION

Two in nine had incident EIB and one eighth had incident EILO, suggesting that recurrent testing for EIB and EILO may be relevant in young athletes. Particularly, EIB-negative athletes reporting multiple asthma-like symptoms could benefit from recurrent EIB testing.

Impact of the Family and Household Environment on Pediatric Atopic Dermatitis in Japan

Pediatric atopic dermatitis (AD) can negatively impact the family quality of life (QoL). We report data from the real-world Epidemiology of Children with Atopic Dermatitis Reporting on their Experience (EPI-CARE) study in Japanese pediatric patients, focusing on disease impact on family QoL. Children and adolescents aged 6 months to <18 years completed an online survey between September 2018-December 2019. The impact of disease severity on family QoL and its effect on parents' time were assessed using the dermatitis family impact (DFI) questionnaire. The impact of a family history of allergic conditions, current residency, second-hand smoke exposure, and household pets on AD prevalence and severity was also assessed. Family QoL decreased as AD severity increased, particularly in families with children aged <6 years; but had the greatest impact on sleep and tiredness in families with children aged <12 years. Parents spent at least 4.6 h/week caring for children <6 years, including those with mild symptoms. Most children (>80%) had a family history of allergic conditions; AD prevalence was increased in those exposed to second-hand smoke or household pets. This study demonstrated that pediatric AD in Japanese individuals has negative impacts on family QoL and that family and household environments can influence pediatric AD prevalence.

Association between maternal occupational exposure to cleaning chemicals during pregnancy and childhood wheeze and asthma

Background

Asthma is a leading cause of childhood morbidity in the U.S. and a significant public health concern. The prenatal period is a critical window during which environmental influences, including maternal occupational exposures, can shape child respiratory health. Cleaning chemicals are commonly encountered in occupational settings, yet few studies have examined the potential link between prenatal occupational exposures to cleaning chemicals and risk of childhood wheeze and asthma.

Methods

We evaluated the potential influence of maternal occupational exposure to cleaning chemicals during pregnancy on pediatric asthma and wheeze at child age 4-6 years in 453 mother-child pairs from two longitudinal pregnancy cohorts, TIDES and GAPPS, part of the ECHO prenatal and early childhood pathways to health (ECHO-PATHWAYS) consortium. Maternal occupational exposure to cleaning chemicals was defined based on reported occupation and frequency of occupational use of chemicals during pregnancy. Child current wheeze and asthma outcomes were defined by parental responses to a widely-used, standardized respiratory outcomes questionnaire administered at child age 4-6 years. Multivariable Poisson regression with robust standard errors was used to estimate relative risk (RR) of asthma in models adjusted for confounding. Effect modification by child sex was assessed using product interaction terms.

Results

Overall, 116 mothers (25.6%) reported occupational exposure to cleaning chemicals during pregnancy, 11.7% of children had current wheeze, and 10.2% had current asthma. We did not identify associations between prenatal exposure to cleaning chemicals and current wheeze [RRadjusted 1.03, 95% confidence interval (CI): 0.56, 1.90] or current asthma (RRadjusted 0.89, CI: 0.46, 1.74) in the overall sample. Analyses of effect modification suggested an adverse association among females for current wheeze (RR 1.82, CI: 0.76, 4.37), compared to males (RR 0.68, CI: 0.29, 1.58), though the interaction p-value was >0.05.

Conclusion

We did not observe evidence of associations between maternal prenatal occupational exposure to cleaning chemicals and childhood wheeze or asthma in the multi-site ECHO-PATHWAYS consortium. We leveraged longitudinal U.S. pregnancy cohorts with rich data characterization to expand on limited and mixed literature. Ongoing research is needed to more precisely characterize maternal occupational chemical exposures and impacts on child health in larger studies.

The Long-Term Impact of Early-Life Tuberculosis Disease on Child Health: A Prospective Birth Cohort Study

Rationale: There is growing concern that post-tuberculosis disease (TB) sequelae and morbidity are substantial, but no studies have controlled for preexisting factors before disease. Whether children have post-TB morbidity is not well characterized. Objectives: To assess the effect of a TB diagnosis on wheezing episodes, lung function, and anthropometric measurements among children enrolled in a prospective birth cohort study in South Africa. Methods: We prospectively followed children from birth through 5 years for TB using diagnostic tests including chest radiography and repeated induced sputum sample testing with Xpert MTB/RIF and liquid culture. We longitudinally measured health outcomes including growth, wheezing, and lung function up to 5 years. Mixed-effects linear regression models were used to assess growth and lung function after TB. Poisson regression was used to assess risk of subsequent wheezing. Measurements and Main Results: Among 1,068 participants, 96 TB cases occurred (1,228 cases per 100,000 person-years [95% confidence interval (CI), 1,006-1,500]) occurred over 7,815 child-years of follow-up. TB was associated with lower length-for-age (-0.40 [95% CI, -0.68 to -0.11]), weight-for-age (-0.30 [95% CI, -0.59 to -0.01]), and body mass index (-0.54 [95% CI, -0.83 to -0.25]) z-scores at 5 years. Children developing TB were consistently more likely to wheeze regardless of the timing of TB. Children with diagnoses of TB between 0 and 1 year of age had reduced time to peak tidal expiratory flow over total expiratory time (-2.35% [95% CI, -4.86% to -0.17%]) and higher fractional exhaled nitric oxide (2.88 ppb [95% CI, 0.57-5.19 ppb]) at 5 years. Children with diagnoses of TB between 1 and 4 years of age had impaired Vt (-9.32 ml [95% CI, -14.89 to -3.75 ml]) and time to peak tidal expiratory flow over total expiratory time (-2.73% [95% CI, -5.45% to -0.01%]) at 5 years. Conclusions: Prevention of TB disease in the first few years of life may have substantial long-term benefits through childhood.

Causal inference with longitudinal data subject to irregular assessment times

Data collected in the context of usual care present a rich source of longitudinal data for research, but often require analyses that simultaneously enable causal inferences from observational data while handling irregular and informative assessment times. An inverse-weighting approach to this was recently proposed, and handles the case where the assessment times are at random (ie, conditionally independent of the outcome process given the observed history). In this paper, we extend the inverse-weighting approach to handle a special case of assessment not at random, where assessment and outcome processes are conditionally independent given past observed covariates and random effects. We use multiple outputation to accomplish the same purpose as inverse-weighting, and apply it to the Liang semi-parametric joint model. Moreover, we develop an alternative joint model that does not require covariates for the outcome model to be known at times where there is no assessment of the outcome. We examine the performance of these methods through simulation and illustrate them through a study of the causal effect of wheezing on time spent playing outdoors among children aged 2-9 years and enrolled in the TargetKids! study.

Relationship between the Mediterranean Diet Score in Pregnancy and the Incidence of Asthma at 4 Years of Age: The Japan Environment and Children's Study

Several scoring methods for the Mediterranean diet, which is considered as a healthy diet, are available, but studies that have compared more than one of these scores are rare. In addition, the applicability of Mediterranean diet scoring has not been sufficiently examined outside of Mediterranean regions. We collected data on the Mediterranean diet during pregnancy and the incidence of type 1 allergies in offspring from the Japan Environment and Children's Study. Using multiple Mediterranean diet scoring methods, we analyzed the effect of adherence to the Mediterranean diet in pregnancy on the allergies of the offspring. Overall, 46,532 pairs of mothers and children were analyzed. In Japan, a high adherence to the Mediterranean diet during pregnancy was associated with a lower incidence of asthma in the offspring (odds ratio: 0.896, 95% confidence interval: 0.835, 0.962). Furthermore, we found that the selection of the Mediterranean diet scoring method and the setting of the reference value significantly altered the results. Our findings suggest that an appropriate selection of scoring methods and a reference value for food items are important to analyze the effects of adherence to the Mediterranean diet inside and outside of Mediterranean regions.

The ADEM2 project: early pathogenic mechanisms of preschool wheeze and a randomised controlled trial assessing the gain in health and cost-effectiveness by application of the breath test for the diagnosis of asthma in wheezing preschool children

BACKGROUND

The prevalence of asthma-like symptoms in preschool children is high. Despite numerous efforts, there still is no clinically available diagnostic tool to discriminate asthmatic children from children with transient wheeze at preschool age. This leads to potential overtreatment of children outgrowing their symptoms, and to potential undertreatment of children who turn out to have asthma. Our research group developed a breath test (using GC-tof-MS for VOC-analysis in exhaled breath) that is able to predict a diagnosis of asthma at preschool age. The ADEM2 study assesses the improvement in health gain and costs of care with the application of this breath test in wheezing preschool children.

METHODS

This study is a combination of a multi-centre, parallel group, two arm, randomised controlled trial and a multi-centre longitudinal observational cohort study. The preschool children randomised into the treatment arm of the RCT receive a probability diagnosis (and corresponding treatment recommendations) of either asthma or transient wheeze based on the exhaled breath test. Children in the usual care arm do not receive a probability diagnosis. Participants are longitudinally followed up until the age of 6 years. The primary outcome is disease control after 1 and 2 years of follow-up. Participants of the RCT, together with a group of healthy preschool children, also contribute to the parallel observational cohort study developed to assess the validity of alternative VOC-sensing techniques and to explore numerous other potential discriminating biological parameters (such as allergic sensitisation, immunological markers, epigenetics, transcriptomics, microbiomics) and the subsequent identification of underlying disease pathways and relation to the discriminative VOCs in exhaled breath.

DISCUSSION

The potential societal and clinical impact of the diagnostic tool for wheezing preschool children is substantial. By means of the breath test, it will become possible to deliver customized and high qualitative care to the large group of vulnerable preschool children with asthma-like symptoms. By applying a multi-omics approach to an extensive set of biological parameters we aim to explore (new) pathogenic mechanisms in the early development of asthma, creating potentially interesting targets for the development of new therapies.

TRIAL REGISTRATION

Netherlands Trial Register, NL7336, Date registered 11-10-2018.

Early-life environment and the risk of eczema at 2 years-Meta-analyses of six Finnish birth cohorts

BACKGROUND

Urban-related nature exposures are suggested to contribute to the rising prevalence of allergic diseases despite little supporting evidence. Our aim was to evaluate the impact of 12 land cover classes and two greenness indices around homes at birth on the development of doctor-diagnosed eczema by the age of 2 years, and the influence of birth season.

METHODS

Data from 5085 children were obtained from six Finnish birth cohorts. Exposures were provided by the Coordination of Information on the Environment in three predefined grid sizes. Adjusted logistic regression was run in each cohort, and pooled effects across cohorts were estimated using fixed or random effect meta-analyses.

RESULTS

In meta-analyses, neither greenness indices (NDVI or VCDI, 250 m × 250 m grid size) nor residential or industrial/commercial areas were associated with eczema by age of 2 years. Coniferous forest (adjusted odds ratio 1.19; 95% confidence interval 1.01-1.39 for the middle and 1.16; 0.98-1.28 for the highest vs. lowest tertile) and mixed forest (1.21; 1.02-1.42 middle vs. lowest tertile) were associated with elevated eczema risk. Higher coverage with agricultural areas tended to associate with elevated eczema risk (1.20; 0.98-1.48 vs. none). In contrast, transport infrastructure was inversely associated with eczema (0.77; 0.65-0.91 highest vs. lowest tertile).

CONCLUSION

Greenness around the home during early childhood does not seem to protect from eczema. In contrast, nearby coniferous and mixed forests may increase eczema risk, as well as being born in spring close to forest or high-green areas.

Comparison of parent reported physician diagnosed asthma and general practitioner registration

OBJECTIVE

To compare parent reported physician diagnosed asthma from questionnaires for epidemiological purposes, to general practitioner (GP) recorded childhood asthma.

METHODS

This study was embedded in the KOALA Birth Cohort Study with regular follow-up by ISAAC core questions on asthma in 2834 children in two different recruitment groups, with 'conventional' lifestyles or 'alternative' lifestyles. At age 11-13 years these data were linked to data extracted from GP records. We compared parent reported physician diagnosed asthma, asthma medication use, and current asthma with GP recorded asthma diagnosis and medication. Two different combinations of questions were used to define current asthma (i.e. ISAAC and MeDALL based definition).

RESULTS

Among 958 children with information provided both by the parents and GPs, 98 children (10.2%) had parent reported physician diagnosed asthma, 115 children (12.0%) had a GP recorded asthma diagnosis (Cohen's kappa 0.49; 95% CI 0.40 to 0.57). Discrepant cases showed that asthma symptoms at an early age led to different labeling between parents and GP. The agreement between ISAAC based definition and MeDALL based definition was excellent (Cohen's kappa 0.82; 95% CI 0.74 to 0.88).

CONCLUSION

Parent reported physician diagnosed asthma and GP recorded childhood asthma had only moderate agreement, and is possibly influenced by labeling early transient wheeze as asthma diagnosis. It is important that parent reported physician diagnosed asthma is combined with additional questions such as current asthma symptoms and asthma medication use, as used in ISAAC or MeDALL based current asthma, in order to obtain reliable information for epidemiological research.

Association of soap use when bathing 18-month-old infants with the prevalence of allergic diseases at age 3 years: The Japan Environment and Children's Study

BACKGROUND

Atopic march is defined as the progression from atopic dermatitis (AD) during early life to other allergic diseases in later childhood. In a nationwide birth cohort study, the Japan Environment and Children's Study, we investigated the association of bathing habits, which are known to affect skin conditions, for infants with their later development of allergic diseases.

METHODS

Pregnant women who lived in 15 designated regional centers throughout Japan were recruited. We obtained information on bathing habits for their 18-month-old infants and the prevalence of allergic diseases when they were aged 3 years.

RESULTS

Data for 74,349 children were analyzed. Most 18-month-old infants were bathed or showered almost every day. When they were divided into four groups according to the frequency of soap use during bathing (every time, most of the time, sometimes, and seldom), the risk of AD later at age 3 was shown to increase in association with a decreasing frequency of soap use [most of the time: adjusted odds ratio (aOR) 1.18, 95% confidence interval (CI) 1.05-1.34; sometimes: aOR 1.72, 95% CI 1.46-2.03; seldom: aOR 1.99, 95% CI 1.58-2.50], compared with soap use every time during bathing at 18 months of age. Similar results were obtained for food allergy but not for bronchial asthma.

CONCLUSIONS

Frequent soap use when bathing 18-month-old infants was associated with a decreased risk of them developing allergic diseases at age 3. Further well-designed clinical studies are warranted to determine an effective bathing regimen for preventing the development of allergic diseases.

UMOYA: a prospective longitudinal cohort study to evaluate novel diagnostic tools and to assess long-term impact on lung health in South African children with presumptive pulmonary TB-a study protocol

BACKGROUND

Despite a high paediatric tuberculosis (TB) burden globally, sensitive and specific diagnostic tools are lacking. In addition, no data exist on the impact of pulmonary TB on long-term child lung health in low- and middle-income countries. The prospective observational UMOYA study aims (1) to build a state-of-the-art clinical, radiological, and biological repository of well-characterised children with presumptive pulmonary TB as a platform for future studies to explore new emerging diagnostic tools and biomarkers for early diagnosis and treatment response; and (2) to investigate the short and long-term impact of pulmonary TB on lung health and quality of life in children.

METHODS

We will recruit up to 600 children (0-13 years) with presumptive pulmonary TB and 100 healthy controls. Recruitment started in November 2017 and is expected to continue until May 2023. Sputum and non-sputum-based samples are collected at enrolment and during follow-up in TB cases and symptomatic controls. TB treatment is started by routine care services. Intensive follow-up for 6 months will allow for TB cases to retrospectively be classified according to international consensus clinical case definitions for TB. Long-term follow-up, including imaging, comprehensive assessment of lung function and quality of life questionnaires, are done yearly up to 4 years after recruitment.

DISCUSSION

The UMOYA study will provide a unique platform to evaluate new emerging diagnostic tools and biomarkers for early diagnosis and treatment response and to investigate long-term outcomes of pulmonary TB and other respiratory events on lung health in children.

Prevalence of childhood cough in epidemiological studies depends on the question used: findings from two population-based studies

BACKGROUND

Epidemiological studies use different questions to assess recurrent cough in children. In two independent population-based studies, we assessed how prevalence estimates of cough vary depending on the questions parents are asked about their child's cough and how answers to the different questions overlap.

METHODS

We analysed cross-sectional data from two population-based studies on respiratory health: LuftiBus in the School (LUIS), conducted in 2013-2016 among 6- to 17-year-school children in the Canton of Zurich, Switzerland, and the 1998 Leicester Respiratory Cohort (LRC) study, UK where we used data from 6- to 8-year-old children from the 2003 follow-up survey. Both studies used parental questionnaires that included the same three questions on the child's cough, namely cough without a cold, dry cough at night and coughing more than others. We assessed how the prevalence of cough varied depending on the question and how answers to the different questions on cough overlapped. We also assessed how results were influenced by age, sex, presence of wheeze and parental education.

RESULTS

We included 3457 children aged 6-17 years from LUIS and 2100 children aged 6-8 years from LRC. All respiratory outcomes - cough, wheeze and physician-diagnosed asthma - were reported twice as often in the LRC as in LUIS. We found large differences in the prevalence of parent-reported cough between the three cough questions. In LUIS, 880 (25%) parents reported cough without a cold, 394 (11%) dry night cough, and 159 (5%) reported that their child coughed more than other children. In the LRC, these numbers were 1003 (48%), 527 (25%) and 227 (11%). There was only partial overlap of answers, with 89 (3%) answering yes to all questions in LUIS and 168 (8%) in LRC. Prevalence of all types of cough and overlap between the cough questions was higher in children with current wheeze.

CONCLUSION

In both population-based studies prevalence estimates of cough depended strongly on the question used to assess cough with only partial overlap of responses to different questions. Epidemiological studies on cough can only be compared if they used exactly the same questions for cough.

Asthma occurrence in children and early life systemic antibiotic use: an incidence density study

BACKGROUND

Results of studies evaluating the relationship between asthma occurrence and early life antibiotic use have been conflicting. The aim of this study was to investigate the relationship between occurrence of asthma in children and systemic antibiotic use in the first year of life based on an incidence density study with careful consideration of the temporal aspects of the determinant-outcome relationship.

METHODS

We conducted an incidence density study nested in a data collection project with information on 1128 mother-child pairs. Systemic antibiotic use in the first year of life was defined as excessive (≥ 4 courses) vs. non-excessive (< 4 courses) use based on information from weekly diaries. Events (cases) were defined as the first parent-reported occurrence of asthma in a child between 1 and 10 years of age. Population time 'at risk' was probed by sampling population moments (controls). Missing data were imputed. Multiple logistic regression was used to assess the association between current first asthma occurrence (incidence density) and systemic antibiotic use in the first year of life, to evaluate effect modification and adjust for confounding.

RESULTS

Forty-seven first asthma events and 147 population moments were included. Excessive systemic antibiotic use in the first year of life showed more than twice the incidence density of asthma compared to non-excessive use (adjusted IDR [95% CI]: 2.18 [0.98, 4.87], p = 0.06). The association was more pronounced in children who have had lower respiratory tract infections (LRTIs) in the first year of life compared to children who had no LRTIs in the first year of life (adjusted IDR [95% CI]: 5.17 [1.19, 22.52] versus 1.49 [0.54, 4.14]).

CONCLUSIONS

Excessive use of systemic antibiotics in the first year of life may play a role in the genesis of asthma in children. This effect is modified by the occurrence of LRTIs in the first year of life, with a stronger association observed in children experiencing LRTIs in the first year of life.

Trends in eczema prevalence in children and adolescents: A Global Asthma Network Phase I Study

Background

Eczema (atopic dermatitis) is a major global public health issue with high prevalence and morbidity. Our goal was to evaluate eczema prevalence over time, using standardized methodology.

Methods

The Global Asthma Network (GAN) Phase I study is an international collaborative study arising from the International Study of Asthma and Allergies in Children (ISAAC). Using surveys, we assessed eczema prevalence, severity, and lifetime prevalence, in global centres participating in GAN Phase I (2015–2020) and one/ both of ISAAC Phase I (1993–1995) and Phase III (2001–2003). We fitted linear mixed models to estimate 10‐yearly prevalence trends, by age group, income, and region.

Results

We analysed GAN Phase I data from 27 centres in 14 countries involving 74,361 adolescents aged 13–14 and 47,907 children aged 6–7 (response rate 90%, 79%). A median of 6% of children and adolescents had symptoms of current eczema, with 1.1% and 0.6% in adolescents and children, respectively, reporting symptoms of severe eczema. Over 27 years, after adjusting for world region and income, we estimated small overall 10‐year increases in current eczema prevalence (adolescents: 0.98%, 95% CI 0.04%–1.92%; children: 1.21%, 95% CI 0.18%–2.24%), and severe eczema (adolescents: 0.26%, 95% CI 0.06%–0.46%; children: 0.23%, 95% CI 0.02%–0.45%) with larger increases in lifetime prevalence (adolescents: 2.71%, 95% CI 1.10%–4.32%; children: 3.91%, 95% CI 2.07%–5.75%). There was substantial heterogeneity in 10‐year change between centres (standard deviations 2.40%, 0.58%, and 3.04%), and strong evidence that some of this heterogeneity was explained by region and income level, with increases in some outcomes in high‐income children and middle‐income adolescents.

Conclusions

There is substantial variation in changes in eczema prevalence over time by income and region. Understanding reasons for increases in some regions and decreases in others will help inform prevention strategies.

Allergic disease trajectories up to adolescence: Characteristics, early-life, and genetic determinants

BACKGROUND

Allergic diseases often develop jointly during early childhood but differ in timing of onset, remission, and progression. Their disease course over time is often difficult to predict and determinants are not well understood.

OBJECTIVES

We aimed to identify trajectories of allergic diseases up to adolescence and to investigate their association with early-life and genetic determinants and clinical characteristics.

METHODS

Longitudinal k-means clustering was used to derive trajectories of allergic diseases (asthma, atopic dermatitis, and rhinitis) in two German birth cohorts (GINIplus/LISA). Associations with early-life determinants, polygenic risk scores, food and aeroallergen sensitization, and lung function were estimated by multinomial models. The results were replicated in the independent Swedish BAMSE cohort.

RESULTS

Seven allergic disease trajectories were identified: "Intermittently allergic," "rhinitis," "early-resolving dermatitis," "mid-persisting dermatitis," "multimorbid," "persisting dermatitis plus rhinitis," and "early-transient asthma." Family history of allergies was more prevalent in all allergic disease trajectories compared the non-allergic controls with stronger effect sizes for clusters comprising more than one allergic disease (e.g., RRR = 5.0, 95% CI = [3.1-8.0] in the multimorbid versus 1.8 [1.4-2.4] in the mild intermittently allergic cluster). Specific polygenic risk scores for single allergic diseases were significantly associated with their relevant trajectories. The derived trajectories and their association with genetic effects and clinical characteristics showed similar results in BAMSE.

CONCLUSION

Seven robust allergic clusters were identified and showed associations with early life and genetic factors as well as clinical characteristics.

Epidemiology of adult patients with atopic dermatitis in AWARE 1: A second international survey

Background

There are gaps in our understanding of the epidemiology of atopic dermatitis (AD) in adults.

Objective

To evaluate the prevalence and severity of AD in adults from countries/regions within Asia, Eurasia, Latin America, Middle East, and Russia.

Methods

This international, web-based survey was performed in Argentina, Brazil, China, Colombia, Egypt, Hong Kong, Israel, Malaysia, Mexico, Russia, Kingdom of Saudi Arabia (KSA), Singapore, Taiwan, Thailand, Turkey, and United Arab Emirates. Questionnaires were sent to adult members of online respondent panels for determination of AD and assessment of severity. A diagnosis of AD required respondents to meet the modified United Kingdom (UK) Working Party criteria and to self-report they had a physician diagnosis of AD. Severity of AD was determined using Patient-Oriented Scoring of Atopic Dermatitis (PO-SCORAD), Patient-Oriented Eczema Measure (POEM), and Patient Global Assessment (PGA).

Results

Among respondents by country/region the prevalence of AD ranged from 3.4% in Israel to 33.7% in Thailand. The prevalence was generally higher in females versus males. Severity varied by scale, although regardless of scale the proportion of respondents with mild and moderate disease was higher than severe disease. PGA consistently resulted in the lowest proportion of severe AD (range 2.4% China - 10.8% Turkey) relative to PO-SCORAD (range 13.4% China - 41.6% KSA) and POEM (range 5.1% China - 16.6% Israel).

Conclusions

This survey highlights the importance of AD in adults, with high prevalence and high morbidity among respondents and emphasizes that AD is not just a disease of childhood-there is disease persistence and chronicity in adults.

An updated prevalence of asthma, its phenotypes, and the identification of the potential asthma risk factors among young Chinese adults recruited in Singapore

Background

Asthma is a chronic inflammatory disease of the airway characterized by respiratory symptoms: wheezing, shortness of breath, coughing, and chest tightness. Globally, asthma affects over 300 million individuals and carries high morbidity and mortality burden. Previous studies have estimated the prevalence of asthma; however, prevalence estimates have been changing over time. Here, in a population of young Chinese adults from Singapore, we aimed to obtain an updated prevalence of asthma and its phenotypes, and identify potential associated risk factors.

Methods

The Singapore/Malaysia Cross-Sectional Genetics Epidemiology Study (SMCGES) is an ongoing study which uses established ISAAC guidelines to collect epidemiological data and information pertaining to allergic diseases such as asthma. Responses from young Chinese adults recruited in the National University of Singapore were analyzed.

Results

Lifetime asthma prevalence rate was estimated at 19.1% (2049/10,736), while current asthma prevalence rate was estimated at 6.3% (679/10,736). For ever asthma, the most important risk factor was a parental history of asthma. Increased consumption of pulses (aOR: 0.822, 95% CI: 0.706-0.958) was associated with a lowered odds of ever asthma, but cereals (aOR: 1.256, 95% CI: 1.006-1.580), pasta (aOR: 1.265, 95% CI: 1.027-1.553), butter (aOR: 1.350, 95% CI: 1.113-1.632), and margarine (aOR: 1.343, 95% CI: 1.081-1.660) were associated with a higher risk of ever asthma. Increased television/computer usage was associated with a decreased risk of ever asthma (aOR: 0.448, 95% CI: 0.367-0.545). Conversely, genetic factors had a lower strength of effect on current asthma (parental history of asthma - OR: 1.465, 95% CI: 1.135-1.888) as compared to ever asthma. Only increased potato consumption was significantly associated with an increased risk of current asthma (most or all days per week vs never or only occasionally - aOR: 1.577, 95% CI: 1.145-2.180). Physical activity (aOR: 0.693, 95% CI: 0.542-0.885) was associated with a lower odds of asthma, while second-hand smoke exposure was associated with an increased risk for current asthma (aOR: 1.435, 95% CI: 1.001-2.047).

Conclusion

Overall, the prevalence of lifetime asthma and current asthma among young Chinese adults was 19.1% and 6.3%, higher than that of previous studies. Our results suggested a stronger association between genetic factors and ever asthma as compared to current asthma. Parental asthma was the most important intrinsic epidemiological factor for asthma manifestation, while various foods, physical activity levels, and television or computer usage were also significantly associated with asthma. Future studies should consider risk factors in conjunction with other accompanying variables given the potential interactions between them, to discern the effects of environment and lifestyle on asthma more distinctly.

Relationship between Food Allergy and Endotoxin Concentration and the Toleration Status at 2 Years: The Japan Environment and Children's Study

Changes in household endotoxin concentration may affect the prognosis of food allergy (FA), but data on the association between household endotoxin concentration and an already-developed FA are scarce. Thus, we investigated the association between environmental endotoxin exposure and tolerance to hen's egg (HE) and cow's milk (CM) using data from children participating in the Japan Environment and Children's Study who had HE allergies (n = 204) and CM allergy (n = 72) in their first year of life. We grouped the endotoxin results into quartiles 1-4 (Q1-Q4). In children with HE allergy and with CM allergy, there was no significant difference in the prevalence of tolerance to HE and CM at 2 years old when comparing endotoxin levels of the children in Q1 with those in Q2, Q3, and Q4, respectively. However, subgroup analyses by the presence of eczema and causal foods revealed that children in Q1 had a lower prevalence of tolerance to foods in some subgroup analyses and lower causal allergen-specific immunoglobulin G4 levels. Although an individually based approach against endotoxin according to background characteristics, such as eczema and causal foods, is necessary, preventing excessive endotoxin removal might contribute to FA resolution in some children.

Season of birth and atopic dermatitis in early infancy: results from the Japan Environment and Children's Study

BACKGROUND

Atopic dermatitis (AD) is reported to be more prevalent in children who were born in autumn than in spring. Here, we investigated how early the association between season of birth and eczema or AD can be observed in the postnatal period. We also examined whether specific prevalence outcomes for infant eczema and AD differed according to sex and maternal history of allergic disease in a large Japanese cohort.

METHODS

Using data of 81,615 infants from the Japan Environment and Children's Study, we examined the associations of birth month or season with four different outcomes-eczema at 1 month, 6 months, and 1 year of age and physician-diagnosed AD up to 1 year of age-using multiple logistic regression analysis. We also analyzed the effect of maternal history of allergic disease on these outcomes stratified by infant sex.

RESULTS

The risk of eczema at 1 month was highest in infants born in July. In contrast, infants born in autumn had higher risks of eczema at 6 months (adjusted odds ratio [aOR], 2.19; 95% confidence interval [CI], 2.10-2.30) and at 1 year (aOR, 1.08; 95% CI, 1.02-1.14) and of physician-diagnosed AD up to 1 year of age (aOR, 1.33; 95% CI, 1.20-1.47) compared with infants born in spring. Eczema and AD were more prevalent in infants with a maternal history of allergic disease, particularly boys.

CONCLUSIONS

Our findings suggest that the prevalence of AD is associated with the season of observation. Eczema is prevalent in infants born in autumn, and this phenomenon was observed in infants as young as 6 months old. The risk associated with being born in autumn was particularly clear in boys with a maternal history of allergic disease.

TRIAL REGISTRATION

UMIN000030786.

Childhood outcomes after induction of labor or expectant management for preterm prelabor rupture of membranes: a 10-year follow-up of the PPROMEXIL trials

BACKGROUND

Management of late preterm prelabor rupture of membranes between 34+0 and 36+6 weeks' gestation balances the risks of preterm birth with the risks of infection for both the mother and the neonate. Expectant management to prolong pregnancy showed similar risks of neonatal sepsis, but children at 2 years of age showed more neurodevelopmental delay when compared with induction of labor. Long-term outcomes on child development after 2 years of age are unknown.

OBJECTIVE

This study aimed to assess the long-term outcomes of children born after singleton pregnancies complicated by late preterm prelabor rupture of membranes managed by induction of labor in comparison with expectant management.

STUDY DESIGN

This was a follow-up study of the Preterm Prelabor Rupture of Membranes Expectant Management Versus Induction of Labor (PPROMEXIL) trials (randomized controlled trials between 2007 to 2011) evaluating children at 10 to 12 years of age (Netherlands Trial Register 6953). The primary outcomes were cognition, motor function, and behavior as assessed by the Wechsler Intelligence Scale for Children-V-NL, Movement Assessment Battery for Children-2, and Child Behavior Checklist, respectively. The secondary outcomes were sensory processing, respiratory problems, educational attainment, and general health. Mild delay was defined as -1 standard deviation or corresponding percentile. The relative risk and confidence intervals were calculated using standard methods.

RESULTS

This follow-up study invited 711 surviving children of the 714 singleton pregnancies randomized in the original trials. In total, 248 (35%) children participated (127 induction of labor, 121 expectant management). Children born after induction of labor had no significant differences in the primary outcomes when compared with those born after expectant management. Mild cognitive delay was observed in 7 of 122 (5.7%) children born after induction of labor in comparison with in 12 of 120 (10.0%) children born after expectant management (relative risk, 0.57; 95% confidence interval, 0.23-1.41). A mild delay in motor function was observed in 42 of 122 (34.4%) children born after induction of labor vs in 55 of 120 (45.8%) children born after expectant management (relative risk, 0.75; 95% confidence interval, 0.55-1.03). Mild abnormal behavior was observed in 37 of 125 (29.6%) children born after induction of labor compared with in 33 of 118 (28.0%) children born after expectant management (relative risk, 1.05; 95% confidence interval, 0.71-1.57). Secondary outcomes were also comparable between the induction of labor and the expectant management groups except that more children born after expectant management had a hospital admission (relative risk, 0.68; 95% confidence interval, 0.52-0.89) or a surgery (relative risk, 0.58; 95% confidence interval, 0.41-0.82).

CONCLUSION

In children born after pregnancies with late preterm prelabor rupture of membranes, expectant management did not improve long-term outcomes at 10 to 12 years when compared with induction of labor.

From neonatal lung function to lung function and respiratory morbidity at 6-year follow-up

BACKGROUND

Lung function is traceable from infancy to adulthood. Only a few studies have examined lung function from birth to childhood longitudinally in children born moderate to late preterm. We aimed to investigate how prematurity and lung function in the neonatal period are related to lung function and respiratory morbidity at age 6 in former moderate to late preterm children compared with children born at term.

METHODS

Lung function was measured in a cohort of moderately to late preterm (n = 48) and term-born (n = 53) infants in the neonatal period by FeNO, and tidal breathing flow-volume loops (TBFVL) and at age 6 (n = 52) by spirometry, whole-body plethysmograph and impulse oscillation combined with a respiratory symptom questionnaire.

RESULTS

Moderate to late preterm children had a higher T_PEF /T_E ratio neonatally (42.6% vs. 33.7%, p = 0.02) and a lower % predicted orced expiratory volume in the first second at age 6 (94.4% vs. 101.9%, p = 0.01) compared to term-born children. We found a significant association between the variability of neonatal tidal volume and effective airway resistance at age 6 (β = -0.34, p = 0.03). No association between neonatal FeNO or TBFVL and respiratory morbidity at 6-year follow-up was shown.

CONCLUSION

Children born moderate to late preterm had lower lung function at age 6 than term-born children. We did not find evidence for the use of neonatal tidal breathing parameters as a predictor for subsequent respiratory morbidity or lung function, however sample size was small.

Multi-omic factors associated with future wheezing in infants

BACKGROUND

The pathophysiology of wheezing is multifactorial, impacted by medical, demographic, environmental, and immunologic factors. We hypothesized that multi-omic analyses of host and microbial factors in saliva would enhance the ability to identify infants at risk for wheezing.

METHODS

This longitudinal cohort study included 161 term infants. Infants who developed wheezing (n = 27) within 24 months of delivery were identified using the International Study of Asthma and Allergies in Childhood Written Questionnaire and review of the medical record. Standardized surveys were used to assess infant traits and environmental exposures. Saliva was collected for multi-omic assessment of cytokines, microRNAs, mRNAs, and microbiome/virome RNAs.

RESULTS

Two infant factors (daycare attendance, family history of asthma) and three salivary "omic" features (miR-26a-5p, Elusimicrobia, Streptococcus phage phiARI0131-1) differed between the two groups (adjusted p < 0.05). miR-26a-5p levels were correlated with Elusimicrobia (R = -0.87, p = 3.7 × 10^-31). A model employing the three omic features plus daycare attendance and family asthma history yielded the highest predictive accuracy for future wheezing episodes (AUC = 0.74, 95% CI: 0.703-0.772, 77% sensitivity, 62% specificity).

CONCLUSIONS

Host-microbiome interactions in saliva may yield pathophysiologic clues about the origins of wheezing and aid identification of infants at risk of future wheezing episodes.

IMPACT

Wheezing is multi-factorial, but the relative contributions of infant traits, environment, and underlying biology are poorly understood. This multi-omic study identifies three molecular factors, including salivary microRNAs, microbes, and viral phages associated with increased risk of infant wheezing. Measurement of these molecular factors enhanced predictive accuracy for future wheezing when combined with family asthma history and daycare attendance. Validation of this approach could be used to identify infants at risk for wheezing and guide personalized medical management.

The efficacy of the Dyson air purifier on asthma control: A single-center, investigator-led, randomized, double-blind, placebo-controlled trial

BACKGROUND

Air pollution is associated with poor asthma outcomes. High-efficiency particulate air air purifiers may reduce air pollution and thus improve asthma outcomes. However, the efficacy of such devices for this purpose remains inconclusive.

OBJECTIVE

To investigate the effects of reducing the levels of pollutants on asthma outcomes in adults, using a novel Dyson high-efficiency particulate air air purifier.

METHODS

In a single-center, double-blinded, randomized controlled trial, participants (N = 50) were randomized at a 1:1 ratio to active filters (intervention) or to dummy filters (placebo) for a total of 78 weeks. The primary outcomes were the changes in Asthma Control Questionnaire 6 (ACQ6) and Asthma-specific Quality of Life Questionnaire (AQLQ) scores from baseline. The secondary outcomes were changes in indoor air pollution and lung function measurements. The coronavirus disease 2019 pandemic limited spirometry measurements to 2 time points and assessment of fractional exhaled nitric oxide and bronchial hyperresponsiveness to baseline only.

RESULTS

Air pollutant levels were significantly lower in the intervention group compared with the placebo group (P = .0003). Both groups had a significant improvement in their ACQ6 and AQLQ. However, there were no significant between-group differences in ACQ6, AQLQ, or spirometry, compared with baseline in multivariable repeated measures models.

CONCLUSION

The Dyson air purifier significantly improved air quality. However, there were no significant improvements in asthma control, quality of life, or measures of lung function in the intervention group compared with the control group despite improvements in indoor air quality. Larger, extended studies are required to confirm or refute these findings, especially given that the coronavirus disease 2019 pandemic prevented the procurement of detailed objective data.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04729530; ttps://clinicaltrials.gov/ct2/show/NCT04729530.

Maternal affective and stress-related factors during pregnancy affect the occurrence of childhood allergic diseases: A Shanghai MCPC study

OBJECTIVE

To investigate the association between exposures to maternal affective and stress-related factors during pregnancy and allergies in children from birth to 2 years of age.

METHODS

We enrolled a total of 4178 children from the Shanghai Maternal-Child Pairs Cohort and measured maternal stress, anxiety, and depression during pregnancy by applying the Life Events Scale for Pregnant Women, Self-Rating Anxiety Scale, and the Center for Epidemiologic Studies-Depression Scale, respectively. Children's allergies were assessed by community physicians at 2, 6, 12, and 24 months, respectively; these included eczema, atopic dermatitis, food allergy, wheezing, asthma, and atopic rhinitis. We applied a latent class analysis (LCA) to these factors and analyzed the impacts of maternal affective and stress-related factors on childhood allergies by exploiting multivariate logistic regression.

RESULTS

Three distinct classes of children were revealed by LCA: healthy (79.8%), transient allergy (15.2%), and persistent allergy (4.9%). High maternal stress in both early and late pregnancy was associated with an increased risk of infant eczema at 2 months (aOR = 1.30, 95% CI = 1.01-1.67; aOR = 1.64, 95% CI = 1.14-2.36). Moreover, high maternal stress in late pregnancy was also associated with food allergy at 6 months, rhinitis at 2 years of age, and persistent allergy (aOR = 3.22, 95% CI = 1.27-8.12; aOR = 1.78, 95% CI = 1.01-3.15; and aOR = 1.93, 95% CI = 1.10-3.40).

CONCLUSIONS

The associations of maternal affective and stress-related factors during pregnancy with childhood allergies may vary by type and disease onset. We postulate that maternal stress in late pregnancy may exert a sustained negative effect on early childhood allergic diseases.

Rhinitis phenotypes and multimorbidities in the general population: the CONSTANCES cohort

BACKGROUND

Scarce epidemiological studies have characterised allergic rhinitis (AR) and non-allergic rhinitis (NAR) in adults. In a population-based cohort, our aims were to 1) describe rhinitis, AR and NAR, and 2) explore how asthma and conjunctivitis may lead to the identification of novel rhinitis phenotypes.

METHODS

In this cross-sectional analysis, current rhinitis was defined as present in the last 12 months using a questionnaire from the French CONSTANCES cohort. Participants with current rhinitis reporting nasal allergies were considered as AR, otherwise as NAR. We described AR and NAR phenotypes, and their phenotypes including co-occurrence with ever-asthma and ever-conjunctivitis.

RESULTS

Among the 20 772 participants included in this analysis (mean±sd age 52.6±12.6 years; 55.2% female), crude prevalences of AR and NAR were 28.0% and 10.9%. AR participants more frequently reported persistent rhinitis (31.6% versus 25.1%) and moderate-to-severe rhinitis (40.1% versus 24.2%) than NAR participants. Among AR or NAR participants, those with ever-asthma reported more moderate-to-severe rhinitis. Participants with AR, ever-asthma and ever-conjunctivitis had an earlier age of rhinitis onset, more severe rhinitis and higher eosinophil counts than participants in other groups. Results were replicated in another cohort.

CONCLUSIONS

In this large population-based cohort, 40% reported current rhinitis, with a lower prevalence of moderate-to-severe rhinitis than in clinical practice. For the first time in a general adult population, we showed that AR and NAR alone or in combination with asthma or in combination with asthma and conjunctivitis are different phenotypes. These results provide new insights on how best to manage rhinitis and its multimorbidities.

Epidemiology of eczema in South-Eastern Australia

BACKGROUND/OBJECTIVES

Eczema is a common chronic debilitating skin condition in childhood. Data on the epidemiology and natural history of eczema across the life course are lacking. This analysis aimed to describe these epidemiological features in Australian children and adults.

METHODS

Data collected on eczema from four Australian cohort studies were analysed: namely HealthNuts, Melbourne Atopic Cohort Study (MACS), Tasmanian Longitudinal Health Study (TAHS) and the Australian arm of the European Community Respiratory Health Survey (ECRHS).

RESULTS

Among children aged under 6 years, 28.8%-35.6% have ever-had eczema, and 16.7%-26.6% had 'current eczema'. Among those aged 6-12 years, 14.6%-24.7% had 'current eczema' with 12.0%-18.5% of those at ages of 6 and 10 years classified as having moderate-to-severe eczema according to the Scoring of Atopic Dermatitis (SCORAD) index. In adults, the prevalence of 'eczema ever' ranged between 13.8% and 48.4%. The 12-month period prevalence of eczema was 15.1% at age 18, while current eczema was 8.5% at an average age of 51, and 8.8% at an average age 53 years. Eczema was more common among young boys, but this difference became non-significant for older children and early adolescents. In contrast, eczema was more common for adult women than men.

CONCLUSIONS

Eczema is common both in children and adults. The proportion of severe eczema in children was substantial.

Effect of birth season on allergic rhinitis and cedar pollinosis considering allergen and vitamin D exposure: The Japan Environment and Children's study (JECS)

BACKGROUND

The relationship between the season of birth, allergen sensitization, and allergic rhinitis have been inconsistent, and there are no studies that simultaneously consider vitamin D and allergen exposure. This study aimed to determine the associations between the season of birth, house dust mite (HDM) and Japanese cedar pollen (JCP) sensitization, and allergic rhinitis and pollinosis, while taking vitamin D levels and allergen exposure into account.

METHODS

This study included 4323 participants in the Sub-Cohort Study of the Japan Environment and Children's Study. A logistic regression model was used to analyze the association between the season of birth and sensitization to JCP or HDM (judged by specific immunoglobulin E) at age 2 and allergic rhinitis or pollinosis at age 3, adjusted for HDM or JCP exposure and vitamin D levels with potential confounders.

RESULTS

Participants born in spring or summer were more likely to have pollinosis than were those born in winter (adjusted odds ratio [aOR]: 2.08, 95% confidence interval [CI]: 1.13-3.82 for spring; aOR: 1.89, 95% CI: 1.03-3.47 for summer). Participants born in summer were more likely to have HDM sensitization than were those born in winter (Der p 1, aOR: 1.53, 95% CI: 1.10-2.15; Der f 1, aOR: 1.44, 95% CI: 1.03-2.01). Exposure to JCP and HDM were associated with pollinosis and HDM sensitization, respectively.

CONCLUSIONS

Spring and summer births were associated with the development of pollinosis, and summer birth was associated with HDM sensitization, even when vitamin D and allergen exposure were considered. Further studies on mechanisms other than vitamin D and allergen exposure are required.

Residential greenspace and childhood asthma: An intra-city study

Interest in assessing the effects of exposure to greenspace on human health has been increasing due to rapid urbanization, and rising trends of physical inactivity and air pollution. However, findings on the link between greenspace and child respiratory health, especially asthma, are inconsistent. We investigated the association between greenspace surrounding residential addresses and asthma in children. A city-wide cross-sectional study was conducted, involving 16,605 children aged 3-12 years, in Shanghai, China. Data on asthma symptoms and covariates were collected from validated self-reported questionnaires. Residential greenspace was measured using satellite-derived normalized difference vegetation index (NDVI) and enhanced vegetation index (EVI). Information on ambient temperature and particulate matter with dynamic diameter <1 μm (PM₁) and 2.5 μm (PM_2.5) was also collected from satellite data. Logistic regression models were performed to assess the associations of greenspace exposure with childhood asthma as well as the effect modification by covariates. The prevalence of current asthma in children was 4.8 % in this study. An interquartile range increase in mean NDVI from 2016 to 2018 was associated with decreased odds of asthma in 2019 at 500 m, and 250 m resolutions (0.82, 95 % confidence interval (CI): 0.74 to 0.93; and 0.82, 95 % CI: 0.72 to 0.94, respectively) after adjustment for covariates. The greenspace-asthma association was modified by ambient temperature and residential area. Sensitivity analyses using various models and EVI exposure showed the robustness of the results. In conclusion, higher individual-level exposure to greenspace was associated with decreased odds of asthma in children, and the association appeared to be modified by different environmental and socio-demographic factors. These findings provide additional evidence for promoting urban greenness to protect children's health and well-being.

Relation of Maternal Pre-Pregnancy Factors and Childhood Asthma: A Cross-Sectional Survey in Pre-School Children Aged 2-5 Years Old

Background and Objectives: Asthma constitutes a constant, prolonged, inflammation-related pulmonary disorder in childhood with serious public health concerns. Several maternal risk factors can enhance the prevalence of its development in this stage of life; however, the currently available data remain contradictory and/or inconsistent. We aim to evaluate the potential impacts of mothers' sociodemographic, anthropometric and prenatal and perinatal factors on the prevalence of developing asthma in pre-school children. Materials and Methods: This is a retrospective cross-sectional survey, which includes 5133 women and their matched pre-school children. Childhood asthma was diagnosed using validated questionnaires. Statistical analysis was accomplished to evaluate whether maternal sociodemographic, anthropometric and prenatal and perinatal factors can increase the probability of childhood asthma in pre-school age. Results: A prevalence of 4.5% of childhood asthma was recorded in pre-school age. Maternal age and pre-pregnancy overweight and obesity, caesarean section, gestational diabetes and hypertension and not breastfeeding were associated with childhood asthma after adjustment for multiple confounding factors. Conclusion: Our research showed that several maternal factors increase the prevalence of childhood asthma in pre-school age. Suitable and effective health policies and strategies should be taken into account to confront the predominant maternal factors that increase its prevalence in pre-school age.

Diagnosis and Management of Allergic Rhinitis in Asthmatic Children

Allergic rhinitis (AR) is a common upper airways inflammatory condition especially in paediatric population; its burden potentially impacts on quality of life, quality of sleep and daily performance, which can be difficult to perceive but not less relevant in the middle-long term. The present review aims to provide an updated overview on AR epidemiology, diagnosis and with a special focus on its connections with bronchial asthma. In fact, when considering asthmatic pediatric population, AR is probably the most important risk factor for asthma onset and the most impactful extra-bronchial determinant of asthma control. Under this perspective, allergen immunotherapy (AIT) should always be considered in the light of a precision medicine approach. In fact, AIT does represent a unique opportunity to specifically interfere with AR immunological background, improve both AR and bronchial asthma control and prevent allergic disease evolution. Verifying the patient's eligibility to that option should be considered as a priority for every physician managing children suffering from AR, especially when associated with bronchial asthma.

Multi-Omic Factors Associated with Frequency of Upper Respiratory Infections in Developing Infants

Susceptibility to upper respiratory infections (URIs) may be influenced by host, microbial, and environmental factors. We hypothesized that multi-omic analyses of molecular factors in infant saliva would identify complex host-environment interactions associated with URI frequency. A cohort study involving 146 infants was used to assess URI frequency in the first year of life. Saliva was collected at 6 months for high-throughput multi-omic measurement of cytokines, microRNAs, transcripts, and microbial RNA. Regression analysis identified environmental (daycare attendance, atmospheric pollution, breastfeeding duration), microbial (Verrucomicrobia, Streptococcus phage), and host factors (miR-22-5p) associated with URI frequency (p < 0.05). These results provide pathophysiologic clues about molecular factors that influence URI susceptibility. Validation of these findings in a larger cohort could one day yield novel approaches to detecting and managing URI susceptibility in infants.

Intake of allergenic foods at 1.5 years and 3 years of age in a general child population in Japan: a cross-sectional study

BACKGROUND

Recent studies indicate that the timing of introduction of potentially allergenic food is crucial for the development of food allergy in children. This cross-sectional study aimed to clarify the reality of allergen food intake in a general population of young children in Japan.

METHODS

A questionnaire survey of caregivers was conducted at health checkups for 1.5-year (18-month)-old and 3-year-old children in the fall of 2020. The caregivers were asked about (1) the presence/absence of allergic disease symptoms based on the ISAAC questionnaire, and (2) foods that caregivers avoided giving their children. Ordinal logistic regression analyses were periformed to determine factors associated with food avoidance.

RESULTS

Questionnaires were distributed to 1720 caregivers, and 1603 (93%) responded. The responders consisted of 771 and 832 caregivers who participated in 1.5-year-old and 3-year-old checkups, respectively. The prevalence of allergic diseases was comparable to recent epidemiological studies in Japan, indicating that the population may be representative. At 1.5 years old, more than 50% of the children were not exposed to peanuts, tree nuts, fish eggs, shellfish, and buckwheat. At 3 years old, the avoidance rates of the foods had decreased but were still between 18.8% and 32.0%. On the other hand, the avoidance rates of chicken egg and cow's milk, the top 2 common allergenic foods in Japan, were much lower at 2.8% and 1.5% at 1.5 years, and they decreased to 1.4% and 0.7% at 3 years old, respectively. Ordinal logistic analysis showed that avoidance of chicken egg, cow's milk, and wheat was associated with food allergy diagnosis and chicken egg avoidance with eczema, but avoidance of other foods showed no associations with any risk factors for food allergy.

CONCLUSION

Caregivers avoided giving various foods, independent of allergy risk factors, to their young children. Since delayed introduction of an allergenic food has been reported to increase the risk of developing an allergy to the food, the results warrant future investigation of the development of food allergies in relation to current eating habits and recommendations.

Impact of biomass fuel smoke on respiratory health of children under 15 years old in Madagascar

BACKGROUND

Children exposed to biomass used in households are at risk to develop diseases or respiratory symptoms. In Madagascar more than 95% of households use it daily. The main objective is to study the impact of chronic exposure to biomass on respiratory health of children under 15 years old in Madagascar.

METHODS

Descriptive cross-sectional study conducted with questionnaires among urban and rural population of Antananarivo and Mahajanga provinces between 2016 and 2017. Variables were collected: number of hours spent in kitchen per day, respiratory symptoms and spirometric data. Categorized symptoms score and exposure index expressing chronic exposure to biomass were analyzed with multinomial logistic regression models.

RESULTS

Of the 661 children included in the analysis, 27.7% had 1 respiratory symptom and 29.3% had 2 or more respiratory symptoms. Moderate exposure index (aOR=1.57; CI95%=[1.30-1.89]; p<0.001) and high exposure index (aOR=1.76; CI95%=[1.39-2.24]; p<0.001) were significantly associated with 1 respiratory symptom, adjusted with provinces, household members and visitors smoking, perceived discomfort related to air pollution and birthweight. Exposure index was not significantly associated with an increased risk of having 2 or more respiratory symptoms (p = 0.754).

CONCLUSION

Respiratory symptoms were associated with exposure to biomass, living in coastal areas, birthweight, tobacco and perceived discomfort related to air pollution. Recommendations and actions must be implemented in order to improve respiratory health related to biomass among children.

PM2.5 elemental composition in indoor residential environments and co-exposure effects on respiratory health in an industrial area

This study aimed to identify and characterise indoor sources of particulate matter (PM) in domestic environments. 74 inhabited apartments located in the urban area of Gela (Sicily, Italy), close to a refinery, and in three villages of the hinterland were evaluated, in real-world conditions, for the elemental composition of PM_2.5. The samples were collected simultaneously inside and outside each apartment for 48 h. In addition, two of the apartments were simultaneously studied for four weeks. The elemental composition of PM_2.5 was determined by applying a chemical fractionation procedure followed by inductively-coupled plasma spectrometry analysis, with both optical emission and mass detection. The extractable, more bio-accessible fraction (_ext), and the mineralised residual fraction (_res) of each element were determined, thus increasing the selectivity of elements as source tracers. Indoor air in the considered apartments was affected by both outdoor pollution and specific indoor emission sources. The behaviour of each source was studied in detail, identifying a reliable tracer: Ti_res for soil, As_ext for industrial sources, V_ext for heavy oil combustion, Ce for cigarette smoking and Mo for the use of vacuum dust cleaners. As_ext and V_ext showed an excellent infiltration capacity, while the concentration of Ti_res was affected by a low infiltration capacity and by the contribution of particles re-suspension caused by the residents' movements. In the case of Ce and Mo, indoor concentrations were much higher than outdoor with a high variability among the apartments, due to the inhabitants' habits concerning cigarette smoke and use of electric appliances. To test the overall effect of the concomitant exposure to the identified sources on Wh12 M and on DDA, a WQS analysis was conducted. Cigarette smoking and heavily oil combustion driven the Wh12 M odds increase, while the DDA odds increase was mainly driven by heavily oil combustion and the use of vacuum dust cleaners.

Implications of Atopic Dermatitis on the Quality of Life of 6-11 Years Old Children and Caregivers (PEDI-BURDEN)

Purpose

Atopic dermatitis (AD) is a chronic, relapsing and remitting inflammatory skin disease characterized by intense itch. The disease burden includes physical limitations, psychosocial discomfort, and a reduced quality of life (HRQoL). This study presents the results of a parent-reported survey on the psychosocial impact of AD on Italian pre-adolescent children (6-11 years old), with a specific focus on bullying, self-isolation, absenteeism, and presenteeism.

Methods

An online questionnaire was sent to 3067 random recipients and 160 matched the inclusion criteria for age, self-reported AD diagnosis, localizations (according to ISAAC), and disease severity (POEM ≥8). 100 children, with comparable ages, not matching the inclusion criteria for AD, were recruited as a control group.

Results

Children with AD and their caregivers had a significantly lower quality of sleep (QoS) compared to the control group. The presence of AD was directly responsible for many restless nights, both in children and caregivers (58.9 and 55.4 respectively). Children with AD and their parents also experienced significantly more daytime drowsiness (43.6 and 54.6 days, respectively). Children with AD were more frequently victims of bullying at school (20.0% vs 9.0%; p≤0.05) or in other social environments (16.9% vs 3.0%; p≤0.05). AD caused 17.7 days of absenteeism and 20.1 days of presenteeism per student over the previous 12 months, accounting for 37.8 days of study impairment overall. Severe/very severe AD had a significantly greater impact on presenteeism than moderate AD (25.1 vs 17.5 days; p≤0.05). Presenteeism, which was more pronounced among bullied students, was positively correlated with absenteeism only in the AD cohort.

Conclusion

AD has a detrimental impact on the HRQoL of pediatric patients, causing stigmatization and social isolation. Functional distress was also reported by caregivers. Our study might inform the public and policymakers about the disease burden of AD at a young age.

Recent Updates of Immunotherapy for Allergic Rhinitis in Children

Purpose of Review

Allergen immunotherapy (AIT) is a novel treatment approach with disease-modifying and preventative benefits that are not shared with other strategies for treating allergic illnesses. It has been demonstrated to be safe and effective in children. This review provides the most recent information on AIT in children as well as any pertinent updates.

Recent Findings

Although there is not a standard way to begin AIT, there are clear indications for AIT. Each case needs to be evaluated on its own by weighing the pros and downsides. AIT has been proven to significantly improve symptoms and quality of life in children with allergic illness, reduce medication use, stop the development of new allergen sensitizations, and stop the progression of allergic rhinitis to asthma. Novel approaches are under investigation to overcome some known AIT disadvantages.

Summary

This review provides a thorough summary of the most recent research and updates on AIT in children.

The association between constipation and subsequent risk of atopic dermatitis in children: the Japan Environment and Children's Study

BACKGROUND

No study has examined the association between constipation and atopic dermatitis (AD) in infants and toddlers. We aimed to explore that association in toddlers using the data from a nationwide birth cohort study.

METHODS

From the Japan Environment and Children's Study, a nationwide prospective birth cohort study that began in 2011, children born in a singleton live birth were analyzed. Participants completed questionnaires containing questions related to bowel movements and AD, during 1.5 to 3 years after birth. Constipation at 1 year of age was defined as having ≤2 bowel movements per week. AD was defined based on participant's responses to the modified ISAAC questionnaire and/or self-reported physician's diagnosis. Outcome was defined as the cumulative number of AD cases that occurred until 3 years of age. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for development of AD were calculated by a multivariable logistic regression.

RESULTS

From a total of 62,777 participants who met the study inclusion criteria, 14,188 children (22.6%) were affected by AD between the ages of 1.5 and 3 years. The adjusted OR of developing AD for the presence versus absence of constipation at 1 year of age was 1.18 (95% CI, 1.01-1.38).

CONCLUSION

Constipation at 1 year of age was associated with a slightly higher risk of AD until 3 years of age.