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Räty S, Ollila H, Turta O, Pärtty A, Peltola V, Lagström H, Lempainen J, Rautava S. Neonatal and early infancy antibiotic exposure is associated with childhood atopic dermatitis, wheeze and asthma. Eur J Pediatr 2024:10.1007/s00431-024-05775-1. [PMID: 39340678 DOI: 10.1007/s00431-024-05775-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 09/02/2024] [Accepted: 09/11/2024] [Indexed: 09/30/2024]
Abstract
Antibiotics are frequently administered in the neonatal period and early infancy. Little is known about the long-term health consequences of early life antibiotic exposure. The objective is to investigate the association between neonatal and early life (0-6 months) antibiotic treatment and the development of atopic dermatitis, asthma and the use of inhaled corticosteroid medication later in childhood. We analyzed data obtained from hospital records and national registers in a cohort of 11,255 children. The association between early antibiotic exposure and the outcomes were analyzed using logistic regression. Confounding factors were included in the model. Neonatal antibiotic therapy for confirmed infection was associated with childhood atopic dermatitis (adjusted odds ratio 1.49; 95% confidence interval 1.15-1.94). Antibiotic therapy by six months of age was more common in children developing atopic dermatitis (adjusted odds ratio 1.38; 95% confidence interval 1.15-1.64), asthma (adjusted odds ratio 1.56; 95% confidence interval 1.32- 1.85) and inhaled corticosteroid medication use (adjusted odds ratio 1.88; 95% confidence interval 1.66-2.13). Conclusions: Neonatal antibiotic therapy for confirmed or clinically diagnosed infection is associated with increased risk of atopic dermatitis later in childhood. Antibiotic treatment before six months of age is associated with atopic dermatitis, asthma and inhaled corticosteroid use. What is known: • The use of antibiotics early in life has been associated with an increased risk of developing atopic dermatitis or asthma. • Confounding by indication or reverse causation may underlie the observed associations. What is new: • Our results demonstrate that neonatal antibiotic therapy for confirmed or clinically diagnosed infection was associated with increased risk of atopic dermatitis and antibiotic treatment before six months of age was associated with atopic dermatitis, asthma and inhaled corticosteroid use in analyses adjusted for confounding factors.
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Affiliation(s)
- Santeri Räty
- Department of Paediatrics, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Helena Ollila
- Department of Biostatistics, University of Turku and Turku University Hospital, Turku, Finland
| | - Olli Turta
- Department of Paediatrics, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Anna Pärtty
- Department of Paediatrics, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Ville Peltola
- Department of Paediatrics, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Hanna Lagström
- Department of Public Health, University of Turku, Turku, Finland
- Centre for Population Health Research, University of Turku and Turku University Hospital, Turku, Finland
| | - Johanna Lempainen
- Department of Paediatrics, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
- Immunogenetics Laboratory, Institute of Biomedicine, University of Turku and Clinical Microbiology, Turku University Hospital, Turku, Finland
| | - Samuli Rautava
- Department of Pediatrics, University of Helsinki, Helsinki, Finland
- New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
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Lin TL, Fan YH, Fan KS, Juan CK, Chen YJ, Wu CY. Reduced atopic march risk in pediatric atopic dermatitis patients prescribed dupilumab versus conventional immunomodulatory therapy: A population-based cohort study. J Am Acad Dermatol 2024; 91:466-473. [PMID: 38878041 DOI: 10.1016/j.jaad.2024.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/18/2024] [Accepted: 05/09/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Dupilumab effectively treats atopic dermatitis (AD); however, its role in halting the atopic march remains uncertain. OBJECTIVE To investigate dupilumab's effect on atopic march in pediatric AD patients versus conventional immunomodulators. METHODS This retrospective cohort study utilized data from the TriNetX US Collaborative Network (2011-2024). Pediatric AD patients (≤18 years) were categorized into DUPI-cohort (newly prescribed dupilumab) or CONV-cohort (prescribed conventional immunomodulators without dupilumab). After 1:1 propensity-score matching, we analyzed atopic march progression, defined by the incident asthma or allergic rhinitis (AR). Cumulative incidence was plotted using Kaplan-Meier, with risk assessment via Cox regression. RESULTS The study included 2192 patients in each cohort. The 3-year cumulative incidence of atopic march progression was lower in the DUPI-cohort than the CONV-cohort (20.09% vs 27.22%; P < .001). The DUPI-cohort demonstrated significant risk reduction in atopic march progression (hazard ratio [HR] 0.68, 95% CI 0.55-0.83), individual asthma (HR 0.60, 0.45-0.81), and individual AR (HR 0.69, 0.54-0.88). Younger patients on dupilumab exhibited a greater risk reduction for atopic march progression and individual asthma, contrasting with the opposite age-related pattern for individual AR. LIMITATIONS Observational study. CONCLUSION Among pediatric AD patients, dupilumab was associated with reduced risk of atopic march progression compared with conventional therapies.
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Affiliation(s)
- Teng-Li Lin
- Department of Dermatology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; Ph.D. Program of Interdisciplinary Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Hsuan Fan
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Kuo-Sheng Fan
- Division of Chest Medicine, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Chao-Kuei Juan
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Ju Chen
- Department of Dermatology, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Post-Baccalaureate Medicine, National Chung-Hsing University, Taichung, Taiwan; Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
| | - Chun-Ying Wu
- Faculty of Medicine and Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Translational Research, Taipei Veterans General Hospital, Taipei, Taiwan; College of Public Health, China Medical University, Taichung, Taiwan.
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Amil-Dias J, Oliva S, Papadopoulou A, Thomson M, Gutiérrez-Junquera C, Kalach N, Orel R, Auth MKH, Nijenhuis-Hendriks D, Strisciuglio C, Bauraind O, Chong S, Ortega GD, Férnandez SF, Furman M, Garcia-Puig R, Gottrand F, Homan M, Huysentruyt K, Kostovski A, Otte S, Rea F, Roma E, Romano C, Tzivinikos C, Urbonas V, Velde SV, Zangen T, Zevit N. Diagnosis and management of eosinophilic esophagitis in children: An update from the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2024; 79:394-437. [PMID: 38923067 DOI: 10.1002/jpn3.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Eosinophilic esophagitis (EoE) is a chronic inflammatory disease of the esophagus characterized by symptoms of esophageal dysfunction and histologically by predominantly eosinophilic infiltration of the squamous epithelium. European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published a guideline in 2014; however, the rapid evolution of knowledge about pathophysiology, diagnostic criteria, and therapeutic options have made an update necessary. METHODS A consensus group of pediatric gastroenterologists from the ESPGHAN Working Group on Eosinophilic Gastrointestinal Diseases (ESPGHAN EGID WG) reviewed the recent literature and proposed statements and recommendations on 28 relevant questions about EoE. A comprehensive electronic literature search was performed in MEDLINE, EMBASE, and Cochrane databases from 2014 to 2022. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of evidence and formulate recommendations. RESULTS A total of 52 statements based on the available evidence and 44 consensus-based recommendations are available. A revision of the diagnostic protocol, options for initial drug treatment, and the new concept of simplified empiric elimination diets are now available. Biologics are becoming a part of the potential armamentarium for refractory EoE, and systemic steroids may be considered as the initial treatment for esophageal strictures before esophageal dilation. The importance and assessment of quality of life and a planned transition to adult medical care are new areas addressed in this guideline. CONCLUSION Research in recent years has led to a better understanding of childhood EoE. This guideline incorporates the new findings and provides a practical guide for clinicians treating children diagnosed with EoE.
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Affiliation(s)
- Jorge Amil-Dias
- Pediatric Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Salvatore Oliva
- Maternal and Child Health Department, University Hospital - Umberto I, Sapienza - University of Rome, Rome, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, Children's hospital Agia Sofia, University of Athens, Athens, Greece
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, International Academy for Paediatric Endoscopy Training, Sheffield Children's Hospital, UK
| | - Carolina Gutiérrez-Junquera
- Pediatric Gastroenterology Unit, Hospital Universitario Puerta de Hierro Majadahonda, Universidad Autónoma de Madrid, Spain
| | - Nicolas Kalach
- Department of Pediatrics, Saint Vincent de Paul Hospital, Groupement des Hôpitaux de l'Institut Catholique de Lille (GHICL), Catholic University, Lille, France
| | - Rok Orel
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialized Surgery of the University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Sonny Chong
- Epsom and St Helier University Hospitals NHS Trust, UK
| | - Gloria Dominguez Ortega
- Pediatric Gastroenterology and Nutrition Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sonia Férnandez Férnandez
- Pediatric Gastroenterology Unit, Department of Pediatrics, Severo Ochoa University Hospital, Madrid, Spain
| | - Mark Furman
- Royal Free London NHS Foundation Trust, London, UK
| | - Roger Garcia-Puig
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Pediatrics Department, Hospital Universitari MútuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | | | - Matjaz Homan
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Koen Huysentruyt
- Kindergastro-enterologie, hepatologie en nutritie, Brussels Centre for Intestinal Rehabilitation in Children (BCIRC), Belgium
| | - Aco Kostovski
- University Children's Hospital Skopje, Faculty of Medicine, University Ss Cyril and Methodius, Skopje, Republic of North Macedonia
| | - Sebastian Otte
- Childrens' Hospital, Helios Mariahilf Hospital, Hamburg, Germany
| | - Francesca Rea
- Endoscopy and Surgey Unit, Bambino Gesu Children's Hospital, Rome, Italy
| | - Eleftheria Roma
- First Department of Pediatrics, University of Athens and Pediatric Gastroenterology Unit Mitera Children's Hospital, Athens, Greece
| | - Claudio Romano
- Department of Human Pathology in Adulthood and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Christos Tzivinikos
- Paediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Dubai, UAE
- Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, UAE
| | - Vaidotas Urbonas
- Vilnius University Medical Faculty Clinic of Children's Diseases, Vilnius, Lithuania
| | | | - Tsili Zangen
- Pediatric Gastroenterology Unit, Wolfson Medical Center, Holon, Israel
| | - Noam Zevit
- Eosinophilic Gastrointestinal Disease Clinic, Institute of Gastroenterology, Hepatology, and Nutrition, Schneider Children's Medical Center of Israel, Israel
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Wolska M, Wypych TP, Rodríguez-Viso P. The Influence of Premature Birth on the Development of Pulmonary Diseases: Focus on the Microbiome. Metabolites 2024; 14:382. [PMID: 39057705 PMCID: PMC11279213 DOI: 10.3390/metabo14070382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 06/28/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Globally, around 11% of neonates are born prematurely, comprising a highly vulnerable population with a myriad of health problems. Premature births are often accompanied by an underdeveloped immune system biased towards a Th2 phenotype and microbiota dysbiosis. Typically, a healthy gut microbiota interacts with the host, driving the proper maturation of the host immunity. However, factors like cesarean section, formula milk feeding, hospitalization in neonatal intensive care units (NICU), and routine antibiotic treatments compromise microbial colonization and increase the risk of developing related diseases. This, along with alterations in the innate immune system, could predispose the neonates to the development of respiratory diseases later in life. Currently, therapeutic strategies are mainly focused on restoring gut microbiota composition using probiotics and prebiotics. Understanding the interactions between the gut microbiota and the immature immune system in premature neonates could help to develop novel therapeutic strategies for treating or preventing gut-lung axis disorders.
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Affiliation(s)
| | - Tomasz Piotr Wypych
- Laboratory of Host-Microbiota Interactions, Nencki Institute of Experimental Biology, Polish Academy of Sciences, Ludwika Pasteura 3, 02-093 Warsaw, Poland; (M.W.); (P.R.-V.)
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Dierikx TH, Malinowska AM, Łukasik J, Besseling-van der Vaart I, Belzer C, Szajewska H, de Meij TGJ. Probiotics and Antibiotic-Induced Microbial Aberrations in Children: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2418129. [PMID: 38967929 PMCID: PMC11227081 DOI: 10.1001/jamanetworkopen.2024.18129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/22/2024] [Indexed: 07/06/2024] Open
Abstract
Importance Probiotics are often considered in children to prevent antibiotic-associated diarrhea. However, the underlying mechanistic effects and impact of probiotics on antibiotic-induced microbiota changes are not well understood. Objective To investigate the effects of a multispecies probiotic on the gut microbiota composition in children receiving antibiotics. Design, Setting, and Participants This is a secondary analysis of a randomized, quadruple-blind, placebo-controlled clinical trial from February 1, 2018, to May 31, 2021, including 350 children receiving broad-spectrum antibiotics in the inpatient and outpatient settings. Patients were followed up until 1 month after the intervention period. Fecal samples and data were analyzed between September 1, 2022, and February 28, 2023. Eligibility criteria included 3 months to 18 years of age and recruitment within 24 hours following initiation of broad-spectrum systemic antibiotics. In total, 646 eligible patients were approached and 350 participated in the trial. Intervention Participants were randomly assigned to receive daily placebo or a multispecies probiotic formulation consisting of 8 strains from 5 different genera during antibiotic treatment and for 7 days afterward. Main Outcomes and Measures Fecal stool samples were collected at 4 predefined times: (1) inclusion, (2) last day of antibiotic use, (3) last day of the study intervention, and (4) 1 month after intervention. Microbiota analysis was performed by 16S ribosomal RNA gene sequencing. Results A total of 350 children were randomized and collected stool samples from 88 were eligible for the microbiota analysis (54 boys and 34 girls; mean [SD] age, 47.09 [55.64] months). Alpha diversity did not significantly differ between groups at the first 3 times. Shannon diversity (mean [SD], 3.56 [0.75] vs 3.09 [1.00]; P = .02) and inverse Simpson diversity (mean [SD], 3.75 [95% CI, 1.66-5.82] vs -1.31 [95% CI, -3.17 to 0.53]; P = 1 × 10-4) indices were higher in the placebo group compared with the probiotic group 1 month after intervention. Beta diversity was not significantly different at any of the times. Three of 5 supplemented genera had higher relative abundance during probiotic supplementation, but this difference had disappeared after 1 month. Conclusions and Relevance The studied probiotic mixture had minor and transient effects on the microbiota composition during and after antibiotic treatment. Further research is needed to understand their working mechanisms in manipulating the microbiome and preventing antibiotic-associated dysbiosis and adverse effects such as antibiotic-associated diarrhea. Trial Registration ClinicalTrials.gov Identifier: NCT03334604.
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Affiliation(s)
- Thomas H. Dierikx
- Department of Medical Microbiology, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Paediatric Gastroenterology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Anna M. Malinowska
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, the Netherlands
| | - Jan Łukasik
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | | | - Clara Belzer
- Laboratory of Microbiology, Wageningen University & Research, Wageningen, the Netherlands
| | - Hania Szajewska
- Department of Pediatrics, Medical University of Warsaw, Warsaw, Poland
| | - Tim G. J. de Meij
- Department of Paediatric Gastroenterology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Pediatric Gastroenterology, Emma Children’s Hospital, Amsterdam, the Netherlands
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Tang TC, Leach ST, Krishnan U. Proton pump inhibitors, antibiotics, and atopy increase the risk of eosinophilic esophagitis in children with esophageal atresia. J Pediatr Gastroenterol Nutr 2024; 78:1317-1328. [PMID: 38409891 DOI: 10.1002/jpn3.12129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 02/28/2024]
Abstract
OBJECTIVE To determine whether proton pump inhibitor (PPI) exposure is associated with an increased risk of developing eosinophilic esophagitis (EoE) in children with esophageal atresia (EA). STUDY DESIGN A retrospective chart review of children with EA from January 1, 2005 to December 31, 2020 was undertaken at Sydney Children's Hospital Randwick. Children with EA and EoE (cases) were matched (1:2) to children with only EA (controls) to compare PPI exposure. Other early-life factors such as infantile antibiotic exposure and personal or family history of atopy were also analyzed using simple and multivariable logistic regression. RESULTS Of 184 children with EA, 46 (25%) developed EoE during this period. Thirty-eight EoE participants were matched to 76 controls. Children with EoE and EA received PPI for significantly higher durations (p = .018) and at significantly higher cumulative doses (p = .017) than controls. Food allergy (adjusted odds ratio [aOR], 7.317; 95% confidence interval [CI], 2.244-23.742), family history of atopy (aOR, 3.504; 95% CI, 1.268-9.682), and infantile antibiotic exposure (aOR, 1.040; 95% CI, 1.006-1.075) were also significantly associated with an increased risk of developing EoE in the EA cohort. CONCLUSIONS Prolonged duration and high cumulative dose of PPI exposure were significantly associated with subsequent EoE development in children with EA. Food allergy, family history of atopy, and infantile antibiotic exposure in EA were also significantly associated with an increased risk of EoE development.
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Affiliation(s)
- Tiffany C Tang
- School of Clinical Medicine, Discipline of Pediatrics, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Steven T Leach
- School of Clinical Medicine, Discipline of Pediatrics, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Usha Krishnan
- School of Clinical Medicine, Discipline of Pediatrics, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
- Department of Pediatric Gastroenterology, Sydney Children's Hospital Randwick, Sydney, Australia
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7
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Størdal K, Ma A, Beck CE. Reducing the use of proton pump inhibitors in infants with reflux symptoms. BMJ 2024; 385:e074588. [PMID: 38816024 DOI: 10.1136/bmj-2022-074588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Affiliation(s)
- Ketil Størdal
- Department of Paediatric Research, Faculty of Medicine, University of Oslo, Pb 4956 Nydalen, NO-0424 Oslo, Norway
- Department of Paediatrics, Oslo University Hospital, Oslo
| | | | - Carolyn E Beck
- Division of Paediatric Medicine, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto
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Sobel AL, Melamed J, Haas D, LeBlanc G, Cirone A, Constantinides MG. Antibiotic use in early life subsequently impairs MAIT cell-mediated immunity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.10.593643. [PMID: 38798453 PMCID: PMC11118404 DOI: 10.1101/2024.05.10.593643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Mucosal-associated invariant T (MAIT) cells are predominantly located in barrier tissues where they rapidly respond to pathogens and commensals by recognizing microbial derivatives of riboflavin synthesis. Early-life exposure to these metabolites imprints the abundance of MAIT cells within tissues, so we hypothesized that antibiotic use during this period may abrogate their development. We identified antibiotics that deplete riboflavin-synthesizing commensals and revealed an early period of susceptibility during which antibiotic administration impaired MAIT cell development. The reduction in MAIT cell abundance rendered mice more susceptible to pneumonia, while MAIT cell-deficient mice were unaffected by early-life antibiotics. Concomitant administration of a riboflavin-synthesizing commensal during antibiotic treatment was sufficient to restore MAIT cell development and immunity. Our work demonstrates that transient depletion of riboflavin-synthesizing commensals in early life can adversely affect responses to subsequent infections.
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Song X, Liang J, Lin S, Xie Y, Ke C, Ao D, Lu J, Chen X, He Y, Liu X, Li W. Gut-lung axis and asthma: A historical review on mechanism and future perspective. Clin Transl Allergy 2024; 14:e12356. [PMID: 38687096 PMCID: PMC11060082 DOI: 10.1002/clt2.12356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 03/24/2024] [Accepted: 04/17/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Gut microbiota are closely related to the development and regulation of the host immune system by regulating the maturation of immune cells and the resistance to pathogens, which affects the host immunity. Early use of antibiotics disrupts the homeostasis of gut microbiota and increases the risk of asthma. Gut microbiota actively interact with the host immune system via the gut-lung axis, a bidirectional communication pathway between the gut and lung. The manipulation of gut microbiota through probiotics, helminth therapy, and fecal microbiota transplantation (FMT) to combat asthma has become a hot research topic. BODY: This review mainly describes the current immune pathogenesis of asthma, gut microbiota and the role of the gut-lung axis in asthma. Moreover, the potential of manipulating the gut microbiota and its metabolites as a treatment strategy for asthma has been discussed. CONCLUSION The gut-lung axis has a bidirectional effect on asthma. Gut microecology imbalance contributes to asthma through bacterial structural components and metabolites. Asthma, in turn, can also cause intestinal damage through inflammation throughout the body. The manipulation of gut microbiota through probiotics, helminth therapy, and FMT can inform the treatment strategies for asthma by regulating the maturation of immune cells and the resistance to pathogens.
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Affiliation(s)
- Xiu‐Ling Song
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Juan Liang
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Shao‐Zhu Lin
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Yu‐Wei Xie
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Chuang‐Hong Ke
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Dang Ao
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Jun Lu
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Xue‐Mei Chen
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Ying‐Zhi He
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Xiao‐Hua Liu
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
| | - Wen Li
- Department of PediatricsAffiliated Hospital of Guangdong Medical UniversityZhanjiangChina
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Alla D, Shah DJ, Seepana M, Salian RB, Alla SSM, Krishna Mohanan M, Sabıroğlu M, Vegesna MSS, Singh A, Gupta S, Shivalingappa Rekha S. Safety of Proton Pump Inhibitors in Pediatric Population: A Systematic Review. Glob Pediatr Health 2024; 11:2333794X241248967. [PMID: 38685999 PMCID: PMC11057350 DOI: 10.1177/2333794x241248967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/27/2024] [Accepted: 04/05/2024] [Indexed: 05/02/2024] Open
Abstract
Objective. Commonly recommended drugs for adults and children include proton pump inhibitors (PPIs), proven effective for treating peptic diseases like stomach ulcers, GERD, and Helicobacter pylori infections in children over 1-year-old. Yet, prolonged PPI use carries higher risks of adverse reactions, prompting this study's analysis. Methods. We have performed a systematic review of 30 articles, which include a total of 762 505 pediatric patients. Results. Adverse effects were encountered in 6.98% of the population. The 5 most common adverse effects were respiratory tract complications, gastrointestinal complications, urinary tract infections, asthma, and ENT infections. Conclusion. Hence, PPIs should be prescribed only when necessary, and physicians should prioritize patient education when considering their use.
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Affiliation(s)
- Deekshitha Alla
- Andhra Medical College, Visakhapatnam, Andhra Pradesh, India
| | | | | | | | | | - Midhun Krishna Mohanan
- Sree Uthradom Thirunal (SUT) Academy of Medical Sciences, Thiruvananthapuram, Kerala, India
| | | | | | - Aradhya Singh
- Spartan Health Sciences University, Vieux Fort, Saint Lucia
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Bajracharya S, Prazad P, Bennett C, Asado N. Antibiotic Treatment for Well-Appearing Infants Born at ≥35 Weeks' Gestation to Mothers with Chorioamnionitis Before and After Implementation of Neonatal Early-Onset Sepsis Calculator. J Patient Cent Res Rev 2024; 11:29-35. [PMID: 38596346 PMCID: PMC11000701 DOI: 10.17294/2330-0698.2005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Purpose Our quality improvement study aimed to determine whether application of a neonatal early-onset sepsis calculator (NSC) among well-appearing infants born at ≥35 weeks' gestation to mothers with chorioamnionitis decreases the number of lab evaluations (LEs) and antibiotic treatments (Abxs) without missing early-onset sepsis. Methods We compared 2 years (January 1, 2019-January 3, 2021) of data from a historical-control group before implementation of the NSC to 1 year (January 4, 2021-December 31, 2021) of data from a calculator group after implementation of the NSC to evaluate whether LE and Abx decreased following implementation of the NSC on January 4, 2021. A P-value of <0.05 was considered statistically significant for the chi-squared test, Fisher's exact test, Student's t-test, and Mann-Whitney U test used for the analyses. Results In the historical-control group, 94% of infants received LE and Abx. Retrospective application of the NSC in the historical-control group decreased LE from 94% to 21% and Abx from 94% to 13%. In the calculator group, 14% and 5% of infants received LE and Abx, respectively, and none of the blood culture was positive. Median time from birth to antibiotic initiation was significantly longer (14.5 vs 3.8 hours; P=0.0037) with no increase in median length of stay (2.3 vs 2.4 days; P=0.02) after NSC implementation. No significant difference in neonatal intensive care unit admission was identified between groups (4% vs 1%; P=0.15). Conclusions There was a significant decrease in LE and Abx among well-appearing infants born at ≥35 weeks' gestation to mothers with chorioamnionitis after implementation of the NSC without missing early-onset sepsis. There was no increase in neonatal intensive care unit admission or length of hospital stay in infants who received antibiotics later after they appeared equivocal or clinically ill in the calculator group. Larger prospective studies that include follow ups are needed to confirm that early-onset sepsis is not missed.
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Affiliation(s)
| | - Preetha Prazad
- Neonatal Perinatal Medicine, Advocate Children’s Hospital, Park Ridge, IL
| | - Catherine Bennett
- Obstetrics and Gynecology, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Nahren Asado
- Pathology, Advocate Lutheran General Hospital, Park Ridge, IL
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Jadcherla SR, Helmick R, Hasenstab KA, Njeh M, Yildiz VO, Wei L, Slaughter JL, Di Lorenzo C. Proton pump inhibitor therapy may alter the sensory motor characteristics of pharyngoesophageal motility in infants with suspected GERD. Neurogastroenterol Motil 2024; 36:e14730. [PMID: 38155406 DOI: 10.1111/nmo.14730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/04/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Acid reflux index (ARI) is a biomarker for gastroesophageal reflux disease (GERD). The effects of short-term proton pump inhibitor (PPI) therapy on pharyngoesophageal motility and clearance mechanisms in infants remain unknown. We hypothesized that pharyngoesophageal reflexes and response to PPI are distinct between infants with 3%-7% and >7% ARI. METHODS Secondary analysis was performed from a subset of infants who participated in a randomized controlled trial (NCT: 02486263). Infants (N = 36, 29.9 ± 4.3 weeks gestation) underwent 4 weeks of PPI therapy, 1 week of washout, and longitudinal testing to assess: (a) clinical outcomes; (b) pH-impedance and symptom metrics including ARI, distal baseline impedance, clearance time, refluxate height, symptoms, I-GERQ-R scores, symptom association probability; (c) pharyngoesophageal motility reflexes and sensory motor characteristics. Comparisons were performed between infants with 3%-7% versus >7% ARI. KEY RESULTS From the 36 hospitalized infants treated: Pharyngoesophageal reflex latencies were prolonged (p > 0.05) and duration in ARI 3%-7% group only (p = 0.01); GER frequency, proximal ascent and clearance increased (ARI 3%-7%); weight gain velocity, oral feeding success, and fine motor score decreased while length of hospital stays increased in the ARI >7% group despite the decrease in symptoms and I-GERQ-R scores. CONCLUSIONS & INFERENCES Distinct changes in pharyngoesophageal sensory motor aspects of motility and reflex mechanisms exist after using PPI therapy in infants. Contributory factors may include the effects of maturation and aerodigestive comorbidities (GERD and BPD). Controlled studies incorporating placebo are needed to delineate the effects of PPI on causal and adaptive GERD mechanisms in infants with aerodigestive and feeding-related comorbidities.
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Affiliation(s)
- Sudarshan R Jadcherla
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Roseanna Helmick
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kathryn A Hasenstab
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Minna Njeh
- The Innovative Infant Feeding Disorders Research Program, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Vedat O Yildiz
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Lai Wei
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Jonathan L Slaughter
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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13
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Yu R, Wang X, Wang H, Lu X, Yang B. Associations between Proton-Pump Inhibitor Usage, Allergy, and Asthma: An Analysis of NHANES 2005-2006. Int Arch Allergy Immunol 2024; 185:519-526. [PMID: 38432205 DOI: 10.1159/000535156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/07/2023] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Acid suppression medications, such as proton-pump inhibitors (PPIs) and histamine-2 receptor antagonists, are commonly prescribed for the treatment of gastroesophageal reflux disease and other gastrointestinal disorders. However, concerns regarding potential long-term side effects are brought up by the overuse of PPIs. This study aimed to investigate the relationship between PPI usage, allergy, and asthma in the general US population. METHODS Data of individuals aged ≥20 years who had information on PPI use and questionnaires on allergy and asthma in the US National Health and Nutrition Examination Survey (NHANES) 2005-2006 were analyzed. Univariate and multivariable logistic regression analyses were performed to determine the associations between PPI use, prevalent allergy, and asthma. RESULTS A total of 4,481 participants (representing 198,543,007 US individuals after weighting) were included in the analyses. PPI use was not significantly associated with the presence of allergy or asthma in the general study population after adjustment. However, in females without steroid exposure, PPI use was significantly associated with increased odds of allergy (adjusted odds ratio [aOR] = 1.69, 95% confidence interval [CI]: 1.002-2.86), among which esomeprazole use was significantly associated with increased odds of allergy (aOR = 2.68, 95% CI: 1.30-5.54) and lansoprazole with increased odds of asthma (aOR = 3.44, 95% CI: 1.50-7.87) as compared to no PPI use. Duration of PPI use was not significantly associated with allergy or asthma. CONCLUSIONS In US women without steroid exposure, PPI use is associated with increased likelihood of prevalent allergy and asthma.
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Affiliation(s)
- Ruili Yu
- Department of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xueyan Wang
- Department of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Hongtian Wang
- Department of Allergy, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xuechun Lu
- Department of Hematology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Bo Yang
- Department of Hematology, The Second Medical Center and National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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14
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Bavbek S, Kepil Özdemir S, Bonadonna P, Atanaskovic-Markovic M, Barbaud A, Brockow K, Laguna Martinez J, Nakonechna A, Pagani M, Arcolacı A, Lombardo C, Torres MJ. Hypersensitivity reactions to proton pump inhibitors. An EAACI position paper. Allergy 2024; 79:552-564. [PMID: 38013608 DOI: 10.1111/all.15961] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/08/2023] [Indexed: 11/29/2023]
Abstract
Proton pump inhibitors (PPIs) are invaluable therapeutic options in a variety of dyspeptic diseases. In addition to their well-known risk profile, PPI consumption is related to food and environmental allergies, dysbiosis, osteoporosis, as well as immediate and delayed hypersensitivity reactions (HSRs). The latter, although a rare event, around 1%-3%, due to the extraordinarily high rate of prescription and consumption of PPIs are related to a substantial risk. In this Position Paper, we provide clinicians with practical evidence-based recommendations for the diagnosis and management of HSRs to PPIs. Furthermore, the unmet needs proposed in the document aim to stimulate more in-depth investigations in the topic.
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Affiliation(s)
- Sevim Bavbek
- Division of Immunology and Allergy, Department of Chest Diseases, School of Medicine, Ankara University, Ankara, Turkey
| | - Seçil Kepil Özdemir
- Department of Chest Diseases, Allergy and Immunology Unit, İzmir Faculty of Medicine, Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, University of Health Sciences, İzmir, Turkey
| | | | - Marina Atanaskovic-Markovic
- Department of Allergology and Pulmonology, Faculty of Medicine, University of Belgrade, University Children's Hospital, Belgrade, Serbia
| | - Annick Barbaud
- Département de dermatologie et allergologie, Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Sorbonne Université, Hôpital Tenon, Paris, France
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Jose Laguna Martinez
- Allergy Unit, Allergo-Anaesthesia Unit, Faculty of Medicine, Hospital Central de la Cruz Roja, Alfonso X El Sabio University, Madrid, Spain
| | - Alla Nakonechna
- Allergy and Clinical Immunology Department, University of Liverpool, Royal Preston Hospital, Lancashire Teaching Hospitals, NHS Foundation Trust, Liverpool, UK
| | - Mauro Pagani
- Medicine Department, Medicine Ward Mantova Hospital, ASST di Mantova, Mantova, Italy
| | | | - Carla Lombardo
- Division of Dermatology and Allergy, APSS - Trento Hospital, Trento, Italy
| | - Maria J Torres
- Allergy Unit, Regional University Hospital of Malaga, IBIMA-UMA-ARADyAL, Malaga, Spain
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15
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Vandenplas Y, Orsi M, Benninga M, Gatcheco F, Rosen R, Thomson M. Infant gastroesophageal reflux disease management consensus. Acta Paediatr 2024; 113:403-410. [PMID: 38116947 DOI: 10.1111/apa.17074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/12/2023] [Indexed: 12/21/2023]
Abstract
AIM Infant gastroesophageal reflux is mostly benign; however, when associated with complications like failure to thrive, it may be indicative of gastroesophageal reflux disease. There are currently several unmet needs pertaining to the management of infant gastroesophageal reflux (disease). Reflux in infants is mostly composed of breast milk or formula, so this population is significantly different to older children and adults. The objective of this Delphi consensus was to establish recommendations based on published literature and the experience of clinical experts in paediatric gastroenterology in the context of infant gastroesophageal reflux (disease). METHODS The Delphi methodology was used to obtain a consensus on 18 statements relating to clinical aspects of infant gastroesophageal reflux (disease). RESULTS The expert panel comprising paediatric gastroenterology clinical specialists reached a consensus for all statements by means of an online, anonymised voting system. CONCLUSION It was highlighted that there is generally low awareness of or adherence to guidelines in clinical practice and that acid suppression therapy should not be indicated for non-acid reflux, which constitutes a significant proportion of total gastroesophageal reflux episodes among infants. Furthermore, it was emphasised that there is an unmet medical need for therapy for some symptomatic infants with non-acid reflux disease.
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Affiliation(s)
- Yvan Vandenplas
- Department of Pediatrics, Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Marina Orsi
- Pediatric Gastroenterology, Hepatology & Transplant Unit, Hospital Italiano of Buenos Aires, Buenos Aires, Argentina
| | - Marc Benninga
- Department of Pediatric Gastroenterology and Nutrition, Amsterdam UMC, University of Amsterdam, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Felizardo Gatcheco
- Department of Pediatrics, Manila Central University Hospital, Caloocan, Philippines
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital, Weston Bank, Sheffield, UK
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16
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O'Reilly D, Murphy CA, Moore CM, Ní Áinle F, Gormley IC, Morrell CN, Curley A, Mc Callion N, Maguire P. Markers of platelet activation foR identification of late onset sEpsis in infaNTs: PARENT study protocol. Pediatr Res 2024; 95:852-856. [PMID: 37758864 DOI: 10.1038/s41390-023-02812-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/25/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Newborns are at high risk of sepsis. At present there is no definitive "rule in" blood test for sepsis at the point of clinical concern. A positive blood culture remains the gold standard test for neonatal sepsis, however laboratory markers that correlate prospectively with culture positive sepsis could aid clinicians in making decisions regarding administration of empiric antibiotic therapies. METHODS This multi-site, prospective observational study will take place in two neonatal intensive care units (National Maternity Hospital and Rotunda Hospital, Dublin). Neonates born at less than 34 weeks will be enroled and informed consent obtained prior to late onset sepsis work up. If at any point subsequently during their neonatal intensive care stay they develop signs and symptoms of possible sepsis requiring blood culture, an additional sodium citrate sample will be obtained. Infants will be categorised into three groups as follows: (i) culture positive sepsis, (ii) culture negative sepsis where an infant receives 5 days of antibiotics (iii) non sepsis. Our primary outcome is to establish if differential platelet/endothelial activation can prospectively identify neonatal culture positive late onset sepsis. TRIAL REGISTRATION NUMBER NCT05530330 IMPACT: Preterm infants are a high risk group for the development of sepsis which is a major cause of mortality in this population. Platelets have been associated with host response to invasive bacterial infections both in animal models and translational work. A positive blood culture is the gold standard test for neonatal sepsis but can be unreliable due to limited blood sampling in the very low birth weight population. This study hopes to establish if platelet/endothelial associated plasma proteins can prospectively identify late onset neonatal sepsis.
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Affiliation(s)
- Daniel O'Reilly
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, 4, Ireland.
- Department of Neonatology, Rotunda Hospital, Dublin, 1, Ireland.
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland.
| | - Claire Anne Murphy
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland
| | - Carmel Maria Moore
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland
- School of Medicine, University College Dublin, Dublin, 4, Ireland
| | - Fionnuala Ní Áinle
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, 4, Ireland
- Department of Haematology, Rotunda Hospital, Dublin, 1, Ireland
- Department of Haematology, Mater Hospital, Dublin, 7, Ireland
| | | | | | - Anna Curley
- Department of Neonatology, National Maternity Hospital, Dublin, 2, Ireland
| | - Naomi Mc Callion
- Department of Neonatology, Rotunda Hospital, Dublin, 1, Ireland
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, 2, Ireland
| | - Patricia Maguire
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, 4, Ireland
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Wu C, Tang H, Wei J, Chen H, Zhao Z, Norbäck D, Zhang X, Lu C, Yu W, Wang T, Zheng X, Li R, Zhang Y, Zhang L. Modification of Food Allergy on the Associations between Early Life Exposure to Size-Specific Particulate Matter and Childhood Allergic Rhinitis. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2024; 58:1813-1822. [PMID: 38237043 DOI: 10.1021/acs.est.3c05532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Previous studies have reported the association between particulate matter (PM) and childhood allergic rhinitis (AR). However, it is unclear whether food allergy (FA) modifies the PM-AR association. We aimed at evaluating the effect of the modification of FA on PM-AR association in preschool children. We adopted a cross-sectional study and conducted a questionnaire survey among preschool children aged 3-6 years in 7 cities in China from June 2019 to June 2020 to collect information on AR and FA. We used a combination of multilevel logistic regression and restricted cubic spline functions to quantitatively assess whether FA modifies the associations between size-specific PM exposure (1 × 1 km) and the risk of AR. The adjusted odds ratios (ORs) for AR among the children with FA as per a 10 μg/m3 increase in early life PM1, PM2.5, and PM10 were significantly higher than the corresponding ORs among the children without FA [e.g., OR: 1.58, 95% CI: (1.32, 1.90) vs 1.29, 95% CI: (1.18, 1.41), per 10 μg/m3 increase in PM1]. The interactions between FA and size-specific PM exposure and their effects on AR were statistically significant (all p-int < 0.001). FA, as an important part of the allergic disease progression, may modify the PM-AR association in preschool children.
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Affiliation(s)
- Chuansha Wu
- Department of Environmental Hygiene and Occupational Medicine, School of Public Health, Wuhan University of Science and Technology, Wuhan 430065, China
- Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan University of Science and Technology, Wuhan 430065, China
| | - Haoran Tang
- Department of Environmental Hygiene and Occupational Medicine, School of Public Health, Wuhan University of Science and Technology, Wuhan 430065, China
- Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan University of Science and Technology, Wuhan 430065, China
| | - Jing Wei
- Department of Atmospheric and Oceanic Science, Earth System Science Interdisciplinary Center, University of Maryland, College Park, Maryland 20740, United States
| | - Hao Chen
- Department of Environmental Hygiene and Occupational Medicine, School of Public Health, Wuhan University of Science and Technology, Wuhan 430065, China
- Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan University of Science and Technology, Wuhan 430065, China
| | - Zhuohui Zhao
- Department of Environmental Health, School of Public Health, Fudan University, Shanghai 200030, China
| | - Dan Norbäck
- Department of Medical Sciences, Uppsala University, Uppsala SE 75185, Sweden
| | - Xin Zhang
- Research Centre for Environmental Science and Engineering, Shanxi University, Taiyuan 030006, China
| | - Chan Lu
- Department of Occupational and Environmental Health, School of Public Health, Xiangya Medical College, Central South University, Changsha 410078, China
| | - Wei Yu
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing 400045, China
| | - Tingting Wang
- School of Nursing and Health Management, Shanghai University of Medicine and Health Sciences, Shanghai 201318, China
| | - Xiaohong Zheng
- School of Energy and Environment, Southeast University, Nanjing 210096, China
| | - Rui Li
- Hubei Key Laboratory of Genetic Regulation and Integrative Biology, School of Life Sciences, Central China Normal University, Wuhan 430079, China
| | - Yunquan Zhang
- Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan University of Science and Technology, Wuhan 430065, China
- Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University of Science and Technology, Wuhan 430065, China
| | - Ling Zhang
- Department of Environmental Hygiene and Occupational Medicine, School of Public Health, Wuhan University of Science and Technology, Wuhan 430065, China
- Hubei Province Key Laboratory of Occupational Hazard Identification and Control, Wuhan University of Science and Technology, Wuhan 430065, China
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Del Refugio Morfin Maciel BM, Álvarez Castelló M. [Risk factors for food allergy]. REVISTA ALERGIA MÉXICO 2023; 70:214-221. [PMID: 38506859 DOI: 10.29262/ram.v70i4.1329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/29/2023] [Indexed: 03/21/2024] Open
Abstract
Allergy is the result of genetic and environmental interactions, including time, route, and dose of food exposure in susceptible patients. Risk factors can be: 1) genetic and 2) environmental, and these, in turn, are divided into prenatal, perinatal and postnatal. Food allergy appears frequently and depends on multiple risk factors (genetic and environmental), which in turn are divided into: prenatal, natal and postnatal factors; They participate in the expression of the disease and clinical intervention is not possible in all cases.
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Affiliation(s)
- Blanca María Del Refugio Morfin Maciel
- Alergóloga Pediatra, Instituto Nacional de Pediatría; Académico numerario de la Academia Mexicana de Pediatría; Maestría en Ciencias Mé-dicas, Universidad Nacional Autónoma de México Alergóloga, Hospital San Ángel Inn Chapultepec, Ciudad de
| | - Mirta Álvarez Castelló
- Doctor en Ciencias médicas, Especialista en Medicina General Integral y Alergología; Hospital Universitario General Calixto García; Investigadora Titular; Profesora auxiliar
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19
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Ansotegui Zubeldia IJ, Fiocchi A. [Introduction to food allergy]. REVISTA ALERGIA MÉXICO 2023; 70:208-210. [PMID: 38506857 DOI: 10.29262/ram.v70i4.1308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/29/2023] [Indexed: 03/21/2024] Open
Abstract
Food allergy is a common chronic disorder that affects infants, children, adolescents, and adults. The prevalence of food allergy has increased in recent decades throughout the world, not limited to Western countries. Since there is no treatment, this focuses on avoiding allergens, in addition to educating patients and caregivers in the emergency treatment of acute reactions, for example: application of epinephrine. Studies suggest that accidental reactions occur in about 45% of children with food allergies each year, although most reactions are mild or moderate in severity. Hospital admissions for food anaphylaxis vary from 4 to 20 per 100,000 inhabitants; Deaths are rare, with an estimated incidence of 0.03 to 0.3 per million people with food allergy. Death from food anaphylaxis is rare and appears to have remained stable, possibly due to increases in food allergen labeling, diagnostic services, rates of intramuscular epinephrine prescription, and awareness of food allergies. Omalizumab is a drug approved for several disorders (chronic hives or difficult asthma) and may help reduce symptoms associated with food allergy. The relative importance of alternative technologies, management strategies and policies for food allergy varies from one region to another, due to differences in the epidemiology, education, socioeconomic well-being, and cultural preferences of the population.
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Affiliation(s)
- Ignacio Javier Ansotegui Zubeldia
- Director Médico Ejecutivo, Expresidente de la Organización Mundial de Alergia (WAO). Jefe del Departamento de Alergia e Inmunología, Hospital Quironsalud, Bizkaia, Bilbao,
| | - Alessandro Fiocchi
- Director responsable de la S.C. de Pediatría, Hospital Materno Infantil Macedonio Melloni, Milán, Italia. Director del Departamento Materno Infantil, Hospital Fatebenefratelli-Ophthalmic de Milán, Italia. Profesor adjunto de la Escuela de Es-pecialización en Pediatría III, Universidad de Milán y Consejero de la Sociedad Italiana de Pediatría, Sección Lombarda. Pediatric Hospital Bambino Gesú IRCCS Allergy division, Roma, Italia
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Achler T, Chodick G, Shaoul R, Cohen S, Ben-Tov A, Goldshtein I. Association of early-life exposure to acid-suppressive therapy and fractures during childhood: a retrospective cohort study. Arch Dis Child 2023; 109:37-42. [PMID: 37758289 DOI: 10.1136/archdischild-2023-325802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/12/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVES Increased acid-suppressive therapy (AST) usage during infancy is seen worldwide, while the data on the risk for paediatric fractures associated with these drugs are scarce. We aimed to evaluate the risk for fractures associated with early-life usage of AST. METHODS This population-based retrospective propensity-matched cohort study included children born between 2005 and 2016 who used AST during the first year of life, and a 3:1 matched unexposed group. Study subjects were followed from the end of the first year of life until the earliest of the following: an outcome event (either fracture or non-fracture injury, separately), age of 10 or August 2022. The cumulative incidence of fractures and the HR of AST for fracture and non-fracture injury as negative control were calculated. RESULTS A total of 13 894 eligible AST users and 41 418 propensity score-matched non-users were included in the analysis. The cumulative incidence of fracture among children with AST (23.7%) was significantly (p<0.001) higher than non-users (21.7%) corresponding to an HR of 1.11 (95% CI 1.06 to 1.16). The HR for one to two AST purchases versus none was 1.09 (95% CI 1.04 to 1.14) and the HR for 3+ AST purchases versus none was 1.25 (95% CI 1.13 to 1.39). AST was also associated with injuries by an HR of 1.09 (95% CI 1.04 to 1.13). CONCLUSIONS AST was associated with a small but statistically significant increased incidence of fractures. We cannot exclude reporting bias or residual confounders. The clinical inference is currently unclear.
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Affiliation(s)
- Tomer Achler
- Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
| | - Gabriel Chodick
- Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Ron Shaoul
- Pediatric Gastroenterology and Nutrition Institute, Ruth Rappaport Children's Hospital, Rambam Medical Center, Haifa, Israel
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Shlomi Cohen
- Department of Pediatrics, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
- Pediatric Gastroenterology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Amir Ben-Tov
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
- Pediatric Gastroenterology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Inbal Goldshtein
- Department of Epidemiology and Preventive Medicine, School of Public Health, Tel Aviv University Faculty of Medicine, Tel Aviv, Israel
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
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21
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Jensen ET, Svane HM, Erichsen R, Kurt G, Heide-Jorgensen U, Sorensen HT, Dellon ES. Maternal and Infant Antibiotic and Acid Suppressant Use and Risk of Eosinophilic Esophagitis. JAMA Pediatr 2023; 177:1285-1293. [PMID: 37902735 PMCID: PMC10616763 DOI: 10.1001/jamapediatrics.2023.4609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/30/2023] [Indexed: 10/31/2023]
Abstract
Importance Eosinophilic esophagitis (EoE), a chronic disease with significant patient and health care burden, has increased rapidly in incidence across many countries. Elucidating risk factors for disease development is a priority for health care practitioners and patients. Objective To evaluate the association of maternal and infant use of antibiotics and acid suppressants with the development of EoE. Design, Setting, and Participants This was a population-based, case-control study of pediatric EoE (1996-2019) in Denmark using pathology, prescription, birth, inpatient, and outpatient health registry data and with complete ascertainment of all EoE cases among Danish residents born between 1997 and 2018. Study data were analyzed from September 2020 to August 2023. Exposures Maternal and infant use of antibiotics and acid suppressants, examining medication class, timing, and frequency of use. Main Outcome and Measure Development of EoE. Results Included in the study was a total of 392 cases and 3637 sex- and year of birth-matched controls with a median (IQR) age of 11.0 (6.0-15.0) years, 2772 male individuals (68.8%), and 1257 female individuals (31.2%). Compared with children with no antibiotic prescriptions filled during infancy, those with any use of an antibiotic had an associated 40% increase in risk of EoE (adjusted odds ratio [aOR], 1.4; 95% CI, 1.1-1.7). Those with 3 or more prescriptions had an associated 80% increase in risk of EoE (aOR, 1.8; 95% CI, 1.3-2.5). Frequency of maternal antibiotic use was associated with an increased risk (1 prescription: aOR, 1.4; 95% CI, 1.0-1.8; 3≤ prescriptions: aOR, 2.1; 95% CI, 1.4-3.2). Risk was highest for use in the third trimester and in the first 6 months from birth. Any acid suppressant use in infancy was associated with increased risk of EoE (aOR, 15.9; 95% CI, 9.1-27.7). Restriction of cases to those diagnosed at 5 years or older yielded similar results (aOR, 11.6; 95% CI, 5.5-24.8). For maternal use, 3 or more prescriptions were associated with an increased risk of EoE for her offspring (aOR, 5.1; 95% CI, 1.8-14.8). Conclusions and Relevance Maternal and infant antibiotic use were associated with increased risk of developing EoE, in a dose-response manner, and the magnitude of association was highest for exposure near the time of delivery. Increased risk was also observed with maternal and infant acid suppressant use. Exposure during early life, a period of known developmental susceptibility, may confer the greatest risk and opportunity for risk mitigation.
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Affiliation(s)
- Elizabeth T. Jensen
- Division of Public Health Sciences, Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Gastroenterology Section, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, UNC Chapel Hill, Chapel Hill, North Carolina
| | - Helene M. Svane
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | - Gencer Kurt
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | | | - Henrik T. Sorensen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, UNC Chapel Hill, Chapel Hill, North Carolina
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, UNC Chapel Hill, Chapel Hill, North Carolina
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22
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Madej J, Atanassova T, McGuire S, Cohen B, Weidner M, Zhang Y, Horton DB. Acid-suppressive medication and incidence of chronic childhood immune-mediated diseases: A scoping review. Pediatr Allergy Immunol 2023; 34:e14042. [PMID: 38010007 PMCID: PMC10683867 DOI: 10.1111/pai.14042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Use of acid-suppressive medications (ASMs), for example, proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs), has been rising along with the incidence of pediatric immune-mediated diseases (IMDs). We conducted a scoping review to characterize the literature about prenatal or pediatric exposure to ASMs in relation to incident pediatric IMDs. METHODS Electronic searches were conducted to identify studies from 2001 to 2023 on (a) prenatal or pediatric exposure to PPIs and/or H2RAs and (b) the risk of developing chronic IMDs during childhood. Eligible studies after title/abstract and full-text screening underwent data abstraction. RESULTS Of 26 eligible studies, 11 focused on prenatal ASM exposure and 16 on pediatric exposure. Asthma was the most commonly investigated outcome (16 studies), followed by other allergic diseases (8), eosinophilic esophagitis (3), inflammatory bowel disease (2), and other autoimmune diseases (2). Positive associations between ASM exposure and pediatric IMD outcomes emerged in all but two recent studies, which reported null or negative associations with allergic diseases. The strength of associations was similar across exposure times (prenatal/pediatric), medications (PPIs/H2RAs), and outcomes. Dose-response relationships were often present (7/11 studies). Reported effects by trimester and age of exposure varied. Commonly reported limitations were residual confounding, exposure misclassification, and outcome misclassification. CONCLUSION In summary, prenatal or pediatric exposure to PPIs and/or H2RAs has frequently, but not exclusively, been associated with the development of asthma, other allergic diseases, and chronic gastrointestinal IMDs. However, concerns remain about confounding and other sources of bias. Prescribers and families should be aware of these possible risks of ASMs.
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Affiliation(s)
- Joanna Madej
- Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Tania Atanassova
- Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Sarah McGuire
- Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Barry Cohen
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Melissa Weidner
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Yingtng Zhang
- Robert Wood Johnson Library of Health Sciences, New Brunswick, New Jersey, USA
| | - Daniel B. Horton
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- Rutgers Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey, USA
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey, USA
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23
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Cetinbas M, Thai J, Filatava E, Gregory KE, Sadreyev RI. Long-term dysbiosis and fluctuations of gut microbiome in antibiotic treated preterm infants. iScience 2023; 26:107995. [PMID: 37829203 PMCID: PMC10565780 DOI: 10.1016/j.isci.2023.107995] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 07/26/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023] Open
Abstract
Postnatal acquisition of the microbiome is critical to infant health. In preterm infants, empiric use of antibiotics is common, with significant health consequences. To understand the influence of antibiotics on acquisition of the microbiome over time, we longitudinally profiled microbial 16S rRNA in the stool of 79 preterm infants during their hospitalization in the intensive care unit and compared antibiotic treated and untreated infants. Despite similar clinical presentation, antibiotic treated infants had strong deviations in the content, diversity, and most dramatically, temporal stability of their microbiome. Dysbiosis and fluctuations of microbiome content persisted long after antibiotic exposure, up to hospital discharge. Microbiome diversity was dominated by a few common bacteria consistent among all infants. Our findings may inform clinical practice related to antibiotic use and targeted microbial interventions aimed at overcoming the adverse influence of antibiotics on the microbiome of preterm infants at specific developmental time points.
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Affiliation(s)
- Murat Cetinbas
- Department of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
- Department of Genetics, Harvard Medical School, Boston, MA, USA
| | - Julie Thai
- Children’s Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Katherine E. Gregory
- Boston College, Chestnut Hill, MA, USA
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Ruslan I. Sadreyev
- Department of Molecular Biology, Massachusetts General Hospital, Boston, MA, USA
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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24
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Fredriksson E, Bodén S, Domellöf M, West CE. Fruit Pouch Consumption Does Not Associate with Early Manifestations of Allergic Disease. Nutrients 2023; 15:4318. [PMID: 37892394 PMCID: PMC10609626 DOI: 10.3390/nu15204318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
Consumption of acidic fruit pouches in infancy may damage the epithelial barrier in the gastrointestinal tract and is suggested to increase allergy risk. We aimed to explore if a high fruit pouch consumption is associated with a higher incidence of early allergic manifestations. We included 2959 parent-child dyads from the Swedish prospective, population-based NorthPop birth cohort study with parentally reported data on frequency of fruit pouch consumption at 9 months of age, as well as parentally reported eczema, wheeze, physician-diagnosed asthma, and food allergy in the first 18 months of life. Immunoglobulin E levels (IgE) in serum (n = 1792), as response to a food mix and an inhalant mix, were determined at age 18 months. Compared with no consumption, daily consumption of one or more pouches at 9 months of age was associated with inhalant sensitization (odds ratio (OR) 2.27, 95% confidence interval (CI) 1.06-4.87, n = 1792) but did not remain significant in the multivariable adjusted model (aOR 2.08, 95% CI 0.95-4.53, n = 1679). There were no associations between fruit pouch consumption and allergic manifestations at this young age. This study suggests that fruit pouch consumption is not associated with allergic phenotypes or IgE sensitization in early childhood.
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Affiliation(s)
| | | | | | - Christina E. West
- Department of Clinical Sciences, Pediatrics, Umeå University, SE 90185 Umeå, Sweden; (E.F.); (S.B.); (M.D.)
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25
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Lee MH, Wu MC, Wang YH, Wei JCC. Maternal constipation is associated with allergic rhinitis in the offspring: A nationwide retrospective cohort study. PLoS One 2023; 18:e0292594. [PMID: 37797074 PMCID: PMC10553815 DOI: 10.1371/journal.pone.0292594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023] Open
Abstract
Allergic rhinitis (AR) is a common atopic disease worldwide, and it was found that babies with constipation in their early life might have an increased risk of atopic diseases, including AR. Furthermore, recent studies also indicate that the maternal gut microbiota may influence babies. Thus, we extended the definition of early life in utero and evaluated the association between maternal constipation and the risk of AR in their babies. Using the Longitudinal Health Insurance Database, a subset of Taiwan's National Health Insurance Research Database, we identified 102,820 constipated mothers and 102,820 matched controls between 2005 and 2015. Propensity score analysis was used to match birth year, child sex, birth weight, gestational age, mode of delivery, maternal comorbidities, and children antibiotics taken. Multiple Cox regression and subgroup analyzes were conducted to estimate the adjusted hazard ratio of childhood AR. The incidence of childhood AR was 83.47 per 1,000 person-years in constipated mothers. Adjusting children's sex, birth weight, gestational age, mode of delivery, maternal comorbidities, and children antibiotic use, the results showed that the children whose mothers had constipation had a 1.20-fold risk of AR compared to children of mothers without constipation. Maternal constipation was associated with an increased risk of AR. Therefore, it is important to pay close attention to pregnant mothers with constipation.
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Affiliation(s)
- Ming-Hung Lee
- Department of Otorhinolaryngology Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Meng-Che Wu
- Division of Gastroenterology, Children’s Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Post-Baccalaureate, Medicine College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Pediatric Inflammatory Bowel Disease Center, Massachusetts General Hospital, Boston, MA, United States of America
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Nursing, Chung Shan Medical University, Taichung, Taiwan
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
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26
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Money NM, Wolf ER, Marin JR, Liang D, Thomas ET, Ho T. 2023 Update on Pediatric Medical Overuse. Pediatrics 2023; 152:e2023062650. [PMID: 37743808 DOI: 10.1542/peds.2023-062650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 09/26/2023] Open
Affiliation(s)
- Nathan M Money
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, Utah
| | - Elizabeth R Wolf
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine and Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Danni Liang
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
| | - Elizabeth T Thomas
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Timmy Ho
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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27
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Xu X, Liu X, Li J, Deng X, Dai T, Ji Q, Xiong D, Xie H. Environmental Risk Factors, Protective Factors, and Biomarkers for Allergic Rhinitis: A Systematic Umbrella Review of the Evidence. Clin Rev Allergy Immunol 2023; 65:188-205. [PMID: 37490237 PMCID: PMC10567804 DOI: 10.1007/s12016-023-08964-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 07/26/2023]
Abstract
Many potential environmental risk factors, protective factors, and biomarkers of AR have been published, but so far, the strength and consistency of their evidence are unclear. We conducted a comprehensive review of environmental risk, protective factors, and biomarkers for AR to establish the evidence hierarchy. We systematically searched Embase, PubMed, Cochrane Library, and Web of Science electronic database from inception to December 31, 2022. We calculated summary effect estimate (odds ratio (OR), relative risk (RR), hazard ratio (HR), and standardized mean difference (SMD)), 95% confidence interval, random effects p value, I2 statistic, 95% prediction interval, small study effects, and excess significance biases, and stratification of the level of evidence. Methodological quality was assessed by AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews 2). We retrieved 4478 articles, of which 43 met the inclusion criteria. The 43 eligible articles identified 31 potential environmental risk factors (10,806,206 total population, two study not reported), 11 potential environmental protective factors (823,883 total population), and 34 potential biomarkers (158,716 total population) for meta-analyses. The credibility of evidence was convincing (class I) for tic disorders (OR = 2.89, 95% CI 2.11-3.95); and highly suggestive (class II) for early-life antibiotic use (OR = 3.73, 95% CI 3.06-4.55), exposure to indoor dampness (OR = 1.49, 95% CI 1.27-1.75), acetaminophen exposure (OR = 1.54, 95% CI 1.41-1.69), childhood acid suppressant use (OR = 1.40, 95% CI 1.23-1.59), exposure to indoor mold (OR = 1.66, 95% CI 1.26-2.18), coronavirus disease 2019 (OR = 0.11, 95% CI 0.06-0.22), and prolonged breastfeeding (OR = 0.72, 95% CI 0.65-0.79). This study is registered in PROSPERO (CRD42022384320).
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Affiliation(s)
- Xianpeng Xu
- Department of Otorhinolaryngology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Xinghong Liu
- Department of Otorhinolaryngology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Jiongke Li
- Department of Otorhinolaryngology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Xinxing Deng
- Department of Otorhinolaryngology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Tianrong Dai
- Department of Otorhinolaryngology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Qingjie Ji
- Department of Dermatology, Quzhou hospital of Traditional Chinese Medicine, 324000, Quzhou, China
| | - Dajing Xiong
- Department of Otorhinolaryngology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Hui Xie
- Department of Otorhinolaryngology, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
- Department of Otorhinolaryngology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China.
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28
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Paraparambil Vellamgot A, Salameh K, AlBedaywi RR, Alhoyed SM, Habboub LH, Abdellatif W, Daoud OA, Atrash M, Zakaria A. Kaiser Permanente early-onset sepsis calculator as a safe tool for reducing antibiotic use among chorioamnionitis-exposed term neonates: Qatar experience. BMJ Open Qual 2023; 12:e002459. [PMID: 37827729 PMCID: PMC10582875 DOI: 10.1136/bmjoq-2023-002459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/24/2023] [Indexed: 10/14/2023] Open
Abstract
Being an important cause of early-onset neonatal sepsis, clinical chorioamnionitis in the mother results in frequent laboratory workup and antibiotic use for the neonate. Neonatal intensive care units (NICUs) in Qatar follow the categorical approach recommended by the Centers for Disease Control and Prevention, USA, and all chorioamnionitis-exposed neonates receive antibiotics.Our project aimed to reduce antibiotic use among chorioamnionitis-exposed, asymptomatic term babies by adopting the early-onset sepsis calculator (EOSCAL). Reduction of blood culture and NICU stay duration were added as secondary objectives later.The Institute of Healthcare Improvement Model of Improvement was used. Antibiotic use rate was the primary outcome measure. Blood culture rate and early transfer to the postnatal ward were added after 1 year. The process measures included the EOSCAL use rate and calculation error rate. The rate of positive culture among untreated babies within the first week was taken as a balancing measure. Monthly data were collected from February 2020 and entered as run charts. Calculation errors were dealt by multiple PDSAs. Additional outcome measures were added in January 2021. Data collection and monitoring continued till December 2022.Among 3837 inborn NICU admissions, 464 (12 %) were chorioamnionitis-exposed babies. Of them, 341 (74%) cases were eligible for inclusion. Among eligible cases, 270 (79%) did not receive antibiotics. Blood culture could be avoided among 106 (97% of low-risk babies) and NICU stay was reduced among 45 (92% of eligible low-risk babies). None of the untreated babies developed sepsis during the first week.Implementation of this project effectively and safely reduced the antibiotic use and blood culture rate among term, well-appearing babies exposed to chorioamnionitis. The project resulted in enhanced patient safety, experience and flow and reduced cost. It is recommendable to other NICU settings in Qatar.
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Affiliation(s)
| | - Khalil Salameh
- NICU, Al-Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | | | | | | | - Muna Atrash
- NICU, Al-Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
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29
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魏 欣, 张 静, 郝 庆, 杜 延, 程 秀. [Establishment of a nomogram model for predicting the risk of early-onset sepsis in very preterm infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:915-922. [PMID: 37718396 PMCID: PMC10511222 DOI: 10.7499/j.issn.1008-8830.2302002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/10/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVES To identify risk factors associated with early-onset sepsis (EOS) in very preterm infants and develop a nomogram model for predicting the risk of EOS. METHODS A retrospective analysis was conducted on 344 very preterm infants delivered at the First Affiliated Hospital of Zhengzhou University and admitted to the Department of Neonatology between January 2020 and December 2022. These infants were randomly divided into a training set (241 infants) and a validating set (103 infants) in a 7:3 ratio. The training set was further divided into two groups based on the presence or absence of EOS: EOS (n=64) and non-EOS (n=177). Multivariate logistic regression analysis was performed to identify risk factors for EOS in the very preterm infants. The nomogram model was developed using R language and validated using the validating set. The discriminative ability, calibration, and clinical utility of the model were assessed using receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis, respectively. RESULTS The multivariate logistic regression analysis revealed that gestational age, need for tracheal intubation in the delivery room, meconium-stained amniotic fluid, serum albumin level on the first day of life, and chorioamnionitis were risk factors for EOS in very preterm infants (P<0.05). The area under the ROC curve for the training set was 0.925 (95%CI: 0.888-0.963), and that for the validating set was 0.796 (95%CI: 0.694-0.898), confirming the model's good discrimination. The Hosmer-Lemeshow goodness-of-fit test suggested that the model was well-fitting (P=0.621). The calibration curve analysis and decision curve analysis demonstrated that the model had high predictive efficacy and clinical applicability. CONCLUSIONS Gestational age, need for tracheal intubation in the delivery room, meconium-stained amniotic fluid, serum albumin level on the first day of life, and chorioamnionitis are significantly associated with the development of EOS in very preterm infants.The nomogram model for predicting the risk of EOS in very preterm infants, constructed based on these factors, has high predictive efficacy and clinical applicability.
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30
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Tan J, Jeffries S, Carr R. A Review of Histamine-2 Receptor Antagonist and Proton Pump Inhibitor Therapy for Gastroesophageal Reflux Disease in Neonates and Infants. Paediatr Drugs 2023; 25:557-576. [PMID: 37458926 DOI: 10.1007/s40272-023-00580-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 08/11/2023]
Abstract
Proton pump inhibitors (PPI) and histamine-2 receptor antagonists (H2RA) are commonly used medications in neonates and infants for the treatment of gastroesophageal reflux disease (GERD), especially in neonatal intensive care units (NICUs). A literature review was conducted to evaluate the efficacy and safety of histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) in preterm neonates, term neonates, and infants. A total of 27 studies were included in this review. Antacid medications in studies have consistently shown positive pharmacodynamic effects, including increasing gastric pH, reducing the reflux index, and reducing the number of acidic reflux events. The benefit found in placebo-controlled trials are limited exclusively to these surrogate outcomes. The actual clinically salient outcomes which H2RAs and PPIs are used for, such as reduction in GERD symptoms, especially irritability and improved feed tolerance and weight gain, have consistently shown no clinical benefit. H2RAs and PPIs appear to be extremely well tolerated by the neonatal and infant populations, which would mimic our experience with these medications in our unit. The available data from large, retrospective cohort and case-control studies paint a much more concerning picture regarding the potential for an increased risk in the development of allergies, anaphylactic reactions, necrotizing enterocolitis (NEC), other nosocomial infections, and lower respiratory tract infections. Given the risks associated with and lack of clinical effectiveness of both H2RAs and PPIs, use of these medications should be limited to specific clinical situations. Further studies are required to determine whether antacid pharmacologic therapy might benefit certain neonates and infants, such as those with complex medical issues.
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Affiliation(s)
- Jason Tan
- BC Children's and Women's Hospital, Pharmacy, Vancouver, BC, Canada.
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada.
| | - Sonia Jeffries
- BC Children's and Women's Hospital, Pharmacy, Vancouver, BC, Canada
| | - Roxane Carr
- BC Children's and Women's Hospital, Pharmacy, Vancouver, BC, Canada
- University of British Columbia, Faculty of Pharmaceutical Sciences, Vancouver, BC, Canada
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31
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Hirsch S, Rosen R. The Real Relevance of Nonacid Reflux in Pediatric Patients. J Clin Gastroenterol 2023; 57:754-759. [PMID: 37436834 DOI: 10.1097/mcg.0000000000001868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/17/2023] [Indexed: 07/14/2023]
Abstract
Gastroesophageal reflux (GER) is one of the most common presenting complaints to pediatric gastroenterologists, and a wide variety of symptoms in children are potentially attributable to typical or atypical GER. While reflux diagnosis and treatment paradigms classically have focused on targeting acid, there is a growing recognition of the prevalence and significance of nonacid GER in both children and adults. This review explores the role of nonacid reflux in pediatric patients, including definitions, associations with symptoms, pathophysiologic mechanisms, and treatment implications.
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Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA
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32
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Hirsch S, Cohen A, Rahbar R, Rubinstein E, Rosen R. Characterization of Eosinophilic Esophagitis in Infants and Toddlers. J Pediatr Gastroenterol Nutr 2023; 77:86-92. [PMID: 37084338 DOI: 10.1097/mpg.0000000000003803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/23/2023]
Abstract
OBJECTIVES The objective of this study is to determine demographic and clinical characteristics of infants and toddlers <2 years with eosinophilic esophagitis (EoE) and to assess treatment response in this rarely studied pediatric age group. METHODS Retrospective study of children <2 years diagnosed with EoE at a single center from 2016 to 2018. EoE was defined by ≥15 eosinophils per high power field (eos/hpf) on at least 1 esophageal biopsy. Demographics, symptoms, and endoscopic findings were collected via chart review. EoE treatment [proton pump inhibitor (PPI), swallowed steroids, dietary restriction, or a combination] and treatment responses on all follow-up endoscopies were reviewed, with remission defined as <15 eos/hpf. RESULTS Forty-two children ages 1.3 ± 0.4 years underwent 3.8 ± 2.3 endoscopies over 3.6 ± 1.7 years of follow-up. Thirty-six children (86%) were male, and comorbidities included atopy (86%), reflux (74%), and a history of cow's milk protein allergy (40%). Common symptoms were feeding difficulties in 67% of patients (with gagging or coughing with feeding in 60% and difficulty with progression to pureed or solid foods in 43%), vomiting (57%), and coughing/wheezing (52%). Of the 37 patients with follow-up endoscopies, 25 (68%) had histologic remission. There was an effect of therapy type on histologic response ( P = 0.004) with the best responses seen on combinations of diet/steroids or diet/PPI and the worst response seen on PPIs alone. All patients showed improvement in ≥1 symptom at the time of first follow-up endoscopy. CONCLUSIONS EoE should be considered in young children with feeding difficulties, vomiting, or respiratory symptoms. All patients improved clinically with standard medical or dietary interventions, however there is dissociation between clinical and histologic response with only 2 of 3 patients achieving histologic remission.
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Affiliation(s)
- Suzanna Hirsch
- From the Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA
| | - Alexandra Cohen
- From the Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA
| | - Reza Rahbar
- the Center for Airway Disorders, Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA
| | - Eitan Rubinstein
- From the Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA
| | - Rachel Rosen
- From the Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA
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Sandritter T, Chevalier R, Abt R, Shakhnovich V. Pharmacogenetic Testing for the Pediatric Gastroenterologist: Actionable Drug-Gene Pairs to Know. Pharmaceuticals (Basel) 2023; 16:889. [PMID: 37375836 DOI: 10.3390/ph16060889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Gastroenterologists represent some of the earlier adopters of precision medicine through pharmacogenetic testing by embracing upfront genotyping for thiopurine S-methyltransferase nucleotide diphosphatase (TPMT) before prescribing 6-mercaptopurine or azathioprine for the treatment of inflammatory bowel disease. Over the last two decades, pharmacogenetic testing has become more readily available for other genes relevant to drug dose individualization. Common medications prescribed by gastroenterologists for conditions other than inflammatory bowel disease now have actionable guidelines, which can improve medication efficacy and safety; however, a clear understanding of how to interpret the results remains a challenge for many clinicians, precluding wide implementation of genotype-guided dosing for drugs other than 6-mercaptopurine and azathioprine. Our goal is to provide a practical tutorial on the currently available pharmacogenetic testing options and a results interpretation for drug-gene pairs important to medications commonly used in pediatric gastroenterology. We focus on evidence-based clinical guidelines published by the Clinical Pharmacogenetics Implementation Consortium (CPIC®) to highlight relevant drug-gene pairs, including proton pump inhibitors and selective serotonin reuptake inhibitors and cytochrome P450 (CYP) 2C19, ondansetron and CYP2D6, 6-mercaptopurine and TMPT and Nudix hydrolase 15 (NUDT15), and budesonide and tacrolimus and CYP3A5.
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Affiliation(s)
- Tracy Sandritter
- Division of Clinical Pharmacology/Medical Toxicology and Therapeutic Innovation, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
- Department of Pharmacy Practice, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rachel Chevalier
- Division of Gastroenterology, Children's Mercy Hospital, 2401 Gillham Rd., Kansas City, MO 64108, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Rebecca Abt
- ProPharma Group, Overland Park, KS 66210, USA
| | - Valentina Shakhnovich
- Division of Clinical Pharmacology/Medical Toxicology and Therapeutic Innovation, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
- Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Yang L, Sato M, Saito-Abe M, Miyaji Y, Shimada M, Sato C, Nishizato M, Kumasaka N, Mezawa H, Yamamoto-Hanada K, Ohya Y. Maternal Dietary Zinc Intake during Pregnancy and Childhood Allergic Diseases up to Four Years: The Japan Environment and Children's Study. Nutrients 2023; 15:nu15112568. [PMID: 37299531 DOI: 10.3390/nu15112568] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/22/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
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.
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Affiliation(s)
- Limin Yang
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Miori Sato
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Mayako Saito-Abe
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Yumiko Miyaji
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Mami Shimada
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Chikako Sato
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Minaho Nishizato
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Natsuhiko Kumasaka
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Hidetoshi Mezawa
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Kiwako Yamamoto-Hanada
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
| | - Yukihiro Ohya
- Medical Support Center for the Japan Environment and Children's Study, National Research Institute for Child Health and Development, Tokyo 157-8535, Japan
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Thomas SP, Denizer E, Zuffa S, Best BM, Bode L, Chambers CD, Dorrestein PC, Liu GY, Momper JD, Nizet V, Tsunoda SM, Tremoulet AH. Transfer of antibiotics and their metabolites in human milk: Implications for infant health and microbiota. Pharmacotherapy 2023; 43:442-451. [PMID: 36181712 PMCID: PMC10763576 DOI: 10.1002/phar.2732] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 05/17/2023]
Abstract
Antibiotics are an essential tool for perinatal care. While antibiotics can play a life-saving role for both parents and infants, they also cause collateral damage to the beneficial bacteria that make up the host gut microbiota. This is especially true for infants, whose developing gut microbiota is uniquely sensitive to antibiotic perturbation. Emerging evidence suggests that disruption of these bacterial populations during this crucial developmental window can have long-term effects on infant health and development. Although most current studies have focused on microbial disruptions caused by direct antibiotic administration to infants or prenatal exposure to antibiotics administered to the mother, little is known about whether antibiotics in human milk may pose similar risks to the infant. This review surveys current data on antibiotic transfer during lactation and highlights new methodologies to assess drug transfer in human milk. Finally, we provide recommendations for future work to ensure antibiotic use in lactating parents is safe and effective for both parents and infants.
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Affiliation(s)
- Sydney P. Thomas
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
- Collaborative Mass Spectrometry Innovation Center, UC San Diego, La Jolla, California, USA
| | - Erce Denizer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
- Collaborative Mass Spectrometry Innovation Center, UC San Diego, La Jolla, California, USA
| | - Simone Zuffa
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
- Collaborative Mass Spectrometry Innovation Center, UC San Diego, La Jolla, California, USA
| | - Brookie M. Best
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
- Pediatrics Department-Rady Children's Hospital San Diego, UC San Diego School of Medicine, La Jolla, California, USA
| | - Lars Bode
- Pediatrics Department-Rady Children's Hospital San Diego, UC San Diego School of Medicine, La Jolla, California, USA
- Mother-Milk-Infant Center of Research Excellence (MOMI CORE), UC San Diego, La Jolla, California, USA
| | - Christina D. Chambers
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
- Pediatrics Department-Rady Children's Hospital San Diego, UC San Diego School of Medicine, La Jolla, California, USA
- Hebert Wertheim School of Public Health and Human Longevity Science, UC San Diego, La Jolla, California, USA
| | - Pieter C. Dorrestein
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
- Collaborative Mass Spectrometry Innovation Center, UC San Diego, La Jolla, California, USA
| | - George Y. Liu
- Pediatrics Department-Rady Children's Hospital San Diego, UC San Diego School of Medicine, La Jolla, California, USA
| | - Jeremiah D. Momper
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
| | - Victor Nizet
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
- Pediatrics Department-Rady Children's Hospital San Diego, UC San Diego School of Medicine, La Jolla, California, USA
| | - Shirley M. Tsunoda
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, California, USA
| | - Adriana H. Tremoulet
- Pediatrics Department-Rady Children's Hospital San Diego, UC San Diego School of Medicine, La Jolla, California, USA
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Ma Z, Chen L, Xian R, Fang H, Chen J, Li H, Wang J, Hu Y. Changes in risk factors for food sensitization in early life: Analysis over a period of 10 years. Front Immunol 2023; 14:1153607. [PMID: 37063872 PMCID: PMC10102490 DOI: 10.3389/fimmu.2023.1153607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/17/2023] [Indexed: 04/03/2023] Open
Abstract
BackgroundAlthough epidemiological trends of childhood food sensitization (FS) in IgE-mediated food allergy were reported in China, few studies have examined at changes in its risk factors.ObjectiveTo investigate the change in early-life risk factors associated with childhood food sensitization during 2009–2019 in China.MethodsData from two cross-sectional surveys conducted in 2009 and 2019 (401 and 513 children, respectively) were analyzed. The results of skin prick tests and information on food sensitization-related risk factors in children were summarized, including family history of atopic disease (FHA), demographic characteristics, method of delivery, feeding patterns, sibship size, pet ownership, and vitamin D supplementation. Binary logistic regression was used to calculate the odds ratio and the regression coefficient β-value of risk factors in the 2009 and 2019 surveys separately. Then, coefficient β-value differences between the two surveys were analyzed by the bdiff command in STATA to describe the change in risk factors over 10 years.ResultsThe 2009 survey revealed that FHA, age, only child, and feeding patterns were associated with food sensitization. The 2019 survey showed that food sensitization was affected by age, sex, and feeding patterns. However, from 2009 to 2019, the probability of food sensitization in the only-child group significantly increased by 226.0% (β-value difference = 0.81, P = 0.024) and decreased by 65.0% in female children (β-value difference = −1.06, P = 0.008). The effect of age on food sensitization decreased by 50.0% (β-value difference = −0.69, P < 0.001) over 10 years.ConclusionThe effect of FHA and common lifestyle factors on food sensitization did not significantly change during 2009−2019. However, the influence of demographic characteristics on food sensitization has changed since 2009; that is, older age, male gender, and only child are more likely to develop food sensitization, which needs to be considered in future epidemiological surveys.Clinical Trial Registrationhttp://www.chictr.org.cn/, identifier ChiCTR1900024338.
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Affiliation(s)
- Zhuoying Ma
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Lin Chen
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Ruoling Xian
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Heping Fang
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Jing Chen
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Haiqi Li
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Juan Wang
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
| | - Yan Hu
- Department of Child Health Care, Children’s Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Chongqing, China
- *Correspondence: Yan Hu,
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Noh Y, Jeong HE, Choi A, Choi EY, Pasternak B, Nordeng H, Bliddal M, Man KKC, Wong ICK, Yon DK, Shin JY. Prenatal and Infant Exposure to Acid-Suppressive Medications and Risk of Allergic Diseases in Children. JAMA Pediatr 2023; 177:267-277. [PMID: 36622684 PMCID: PMC9857801 DOI: 10.1001/jamapediatrics.2022.5193] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/15/2022] [Indexed: 01/10/2023]
Abstract
Importance Existing observational data have indicated positive associations of acid-suppressive medication (ASM) use in prenatal and early life with allergic diseases in children; however, no study to date has accounted for confounding by indication or within-familial factors. Objective To evaluate the association of prenatal or infant exposure to ASMs with risk of allergic diseases in children. Design, Setting, and Participants This nationwide, cohort study included data from South Korea's National Health Insurance Service mother-child-linked database from January 1, 2007, to December 31, 2020. Participants included mother-child pairs of neonates born from April 1, 2008, to December 31, 2019. Exposures Prenatal and infant exposure to ASMs (histamine 2 receptor antagonists [H2RAs] and proton pump inhibitors [PPIs]). Main Outcomes and Measures Composite and individual outcomes of allergic diseases (asthma, allergic rhinitis, atopic dermatitis, and food allergy) in children (followed up to 13 years of age) were assessed. The ASM-exposed individuals were compared with unexposed individuals in propensity score (PS)-matched and sibling-matched analyses to control for various potential confounders and within-familial factors. Hazard ratios (HRs) with 95% CIs were estimated using Cox proportional hazards regression models. Results The study included 4 149 257 mother-child pairs. Prenatal exposure analyses included 808 067 PS-matched pairs (763 755 received H2RAs, 36 529 received PPIs) among women with a mean (SD) age of 31.8 (4.2) years. The PS-matched HR was 1.01 (95% CI, 1.01-1.02) for allergic diseases overall (asthma: HR, 1.02 [95% CI, 1.01-1.03]; allergic rhinitis: HR, 1.02 [95% CI, 1.01-1.02]; atopic dermatitis: HR, 1.02 [95% CI, 1.01-1.02]; food allergy: HR, 1.03 [95% CI, 0.98-1.07]); in sibling-matched analyses, the HRs were similar to those of PS-matched analyses but were not significant (allergic diseases: HR, 1.01; 95% CI, 0.997-1.01). Infant exposure analyses included 84 263 PS-matched pairs (74 188 received H2RAs, 7496 received PPIs). The PS-matched HR was 1.06 (95% CI, 1.05-1.07) for allergic diseases overall (asthma: HR, 1.16 [95% CI, 1.14-1.18]; allergic rhinitis: HR, 1.02 [95% CI, 1.01-1.03]; atopic dermatitis: HR, 1.05 [95% CI, 1.02-1.08]; food allergy: HR, 1.28 [95% CI, 1.10-1.49]); asthma risk (HR, 1.13; 95% CI, 1.09-1.17) remained significantly higher among children exposed to ASMs during infancy in sibling-matched analyses. The findings were similar for H2RAs and PPIs analyzed separately and were robust across all sensitivity analyses. Conclusions and Relevance The findings of this cohort study suggest that there is no association between prenatal exposure to ASMs and allergic diseases in offspring. However, infant exposure to ASMs was associated with a higher risk of developing asthma, although the magnitude was more modest than previously reported. Clinicians should carefully weigh the benefits of prescribing ASMs to children, accompanied by subsequent close monitoring for any clinically relevant safety signals.
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Affiliation(s)
- Yunha Noh
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Ahhyung Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Eun-Young Choi
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
| | - Björn Pasternak
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, PharmaTox Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
| | - Mette Bliddal
- Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Clinical Pharmacology, Pharmacy and Environmental Medicine, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Kenneth K. C. Man
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, England
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong
| | - Ian C. K. Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, University College London, London, England
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
- Laboratory of Data Discovery for Health, Hong Kong Science Park, Hong Kong
- Aston Pharmacy School, Aston University, Birmingham, England
| | - Dong Keon Yon
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea
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Acid Suppression and Antibiotics Administered during Infancy Are Associated with Celiac Disease. J Pediatr 2023; 254:61-67.e1. [PMID: 36265574 DOI: 10.1016/j.jpeds.2022.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/08/2022] [Accepted: 10/12/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate why certain at-risk individuals develop celiac disease (CD), we examined the association of proton pump inhibitors (PPI), histamine-2 receptor antagonists (H2RAs), and antibiotic prescriptions in the first 6 months of life with an early childhood diagnosis of CD. STUDY DESIGN A retrospective cohort study was performed using the Military Healthcare System database. Children with a birth record from October 1, 2001, to September 30, 2013, were identified. Outpatient prescription records were queried for antibiotic, PPI, and H2RA prescriptions in the first 6 months of life. Cox proportional hazards regression was used to calculate the hazard ratio (HR) of developing CD based on medication exposure. International Classification of Diseases, Ninth Revision, Clinical Modification codes identified children with an outpatient visit for CD. RESULTS There were 968 524 children who met the inclusion criteria with 1704 cases of CD in this group. The median follow-up for the cohort was approximately 4.5 years. PPIs (HR, 2.23; 95% CI, 1.76-2.83), H2RAs (HR, 1.94; 95% CI, 1.67-2.26), and antibiotics (HR, 1.14; 95% CI, 1.02-1.28) were all associated with an increased hazard of CD. CONCLUSIONS There is an increased risk of developing CD if antibiotics, PPIs and H2RAs are prescribed in the first 6 months of life. Our study highlights modifiable factors, such as medication stewardship, that may change the childhood risk of CD.
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Gastroesophageal Reflux Treatment in Infancy Through Young Adulthood. Am J Gastroenterol 2023; 118:452-458. [PMID: 36717189 DOI: 10.14309/ajg.0000000000002160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/20/2022] [Indexed: 02/01/2023]
Abstract
Gastroesophageal reflux treatment varies greatly across the pediatric age spectrum. Infant reflux treatments rely heavily on nutritional interventions, whereas reflux in older children is treated more commonly with medications. However, because of the broad differential diagnosis, treatment nonresponse merits a re-evaluation of the diagnosis being treated and additional testing to provide a more precision-medicine approach to care.
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Li S, Chen F, Huang C, Huang G, Cheng Y, Li T, Hou D, Liu W, Xu T, Liu J. Relationships between antibiotic exposure and asthma in adults in the United States: results of the National Health and Nutrition Examination Survey between 1999 and 2018. Front Public Health 2023; 11:1123555. [PMID: 37181685 PMCID: PMC10173742 DOI: 10.3389/fpubh.2023.1123555] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/05/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives To investigate the relationship between antibiotic exposure and asthma in adults in the United States. Methods Data was obtained from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2018. A total of 51,124 participants were included, excluding those who were aged < 20 years, female participants who were pregnant, and individuals who did not complete the prescription medications questionnaire and the medical conditions questionnaire regarding asthma status. Antibiotic exposure was defined as the utilization of antibiotics within the past 30 days, categorized based on the Multum Lexicon Plus therapeutic classification system. Asthma was defined as having a history of asthma or having an asthma attack or wheezing symptoms in the past year. Results The risk of asthma was found to be 2.557 (95% CI: 1.811, 3.612), 1.547 (95% CI: 1.190, 2.011) and 2.053 (95% CI: 1.344, 3.137) times greater in participants who had used macrolide derivatives, penicillin and quinolones in the past 30 days, respectively, compared with those not using antibiotics. After adjusting for demographic covariates and asthma-related factors, only macrolides derivatives were significantly associated with asthma in the 20-40 and 40-60 age groups. For individuals over 60 years old, quinolones were significantly associated with asthma. The effect of different types of antibiotic with asthma varied in male and female populations. Moreover, higher socioeconomic status, greater BMI, younger age, smoking habits, history of infection, chronic bronchitis, emphysema, and family history of asthma were all identified as risk factors for asthma. Conclusion Our study indicated that three types of antibiotics were significantly associated with asthma in different subgroups of the population. Therefore, the use of antibiotics should be more strictly regulated.
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Affiliation(s)
- Shaoli Li
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
| | - Feilong Chen
- Department of Epidemiology and Statistics, Institute of Basic Medical Science, Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - Chunlei Huang
- Department of Otolaryngology Head and Neck Surgery, Children's Hospital Capital Institute of Pediatrics, Beijing, China
| | - Guimin Huang
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
| | - Yijing Cheng
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
| | - Tao Li
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
| | - Dongqing Hou
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
| | - Wenqian Liu
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
| | - Tao Xu
- Department of Epidemiology and Statistics, Institute of Basic Medical Science, Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College, Beijing, China
- *Correspondence: Tao Xu,
| | - Junting Liu
- Child Health Big Data Research Center, Capital Institute of Pediatrics, Beijing, China
- Junting Liu,
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Closs ER, Mårild K, Nielsen RG, Størdal K. Use of proton pump inhibitors in scandinavian children and adolescents: An observational study. Front Pediatr 2023; 11:1052978. [PMID: 36873656 PMCID: PMC9978809 DOI: 10.3389/fped.2023.1052978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 01/20/2023] [Indexed: 02/18/2023] Open
Abstract
AIMS To examine the use of proton pump inhibitors (PPIs) in Scandinavian children with focus on the geographical variation, temporal changes and possible contributing factors to observed changes. METHODS An observational population-based study of children and adolescents (1-17 years) in Norway, Sweden, and Denmark during the period 2007-2020. Information concerning dispensed PPIs was obtained from the national prescription databases of each country and presented as means per 1,000 children for each country and calendar year in four age categories (1-4, 5-9, 10-13 and 14-17 years). RESULTS In 2007, the PPI use in children was similar across Scandinavian countries. An increased PPI use was observed in all countries during the study period, with gradually increasing differences between the countries. In general, Norway showed both the largest total increase and the largest increase in each age category compared to Sweden and Denmark. In 2020 Norwegian children showed, on average, a 59% higher PPI use compared to Swedish children and a more than double the overall dispensation rate than Denmark. In Denmark there was a 19% reduction in dispensed PPIs from 2015 to 2020. CONCLUSION Despite being countries with similar health care systems and without indications of increased incidence of gastroesophageal reflux disease (GERD), we observed considerable geographical variation and temporal changes of PPI use in children. Although this study did not contain data on the indication for PPI use, these large differences across countries and time may indicate a current overtreatment.
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Affiliation(s)
| | - Karl Mårild
- Department of Pediatrics, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Department of Pediatric Gastroenterology, Queen Silvia Children's hospital, Gothenburg, Sweden
| | | | - Ketil Størdal
- Department of Pediatric Research, University of Oslo, Oslo, Norway.,Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
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Abstract
Background: In recent years, an increase of allergies and asthma has been observed throughout the world, more so in Western countries than in less developed ones. Although genetics may play a role in this increase, there are many other factors that may have contributed to the upsurge. Objective: The purpose of the present report was to review the many factors associated with modernization and lifestyle that may have contributed to the allergy and/or asthma epidemic, with a particular focus on those aspects that have particular relevance for the allergist/immunologist. Results: The marked rise in allergy and asthma has been significantly seen in more-developed countries, greater in urban than in rural areas, more pronounced in affluent than in poorer societies, and in individuals who have migrated from developing countries to industrialized countries. A widely accepted explanation for this rise is the "hygiene hypothesis," which postulates a critical dependence on microbial infection for maintenance of a healthy balanced immune system and that extremely clean external environments, often found in the developed world, can derail equilibrated immune development. With the control of infectious diseases, the immune system shifts from a balanced equilibrated immunologic structure to a more Th2 driven proinflammatory state often associated with IgE and eosinophil-related disorders. Conclusion: Modernization has been associated with increased development of allergies and asthma through a cleaner environment and more exposure to allergens and to multiple other contributory factors. The marked reduction in infectious diseases in recent decades permitted the immune system to switch from fighting infectious disease agents and parasites to reacting adversely (hypersensitivity) to benign environmental agents (allergens) and even to self-antigens (autoimmunity).
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Affiliation(s)
- Sami L Bahna
- From the Allergy and Immunology Section, Department of Pediatrics, and
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43
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Stefanetti G, Kasper DL. Impact of the Host Microbiome on Vaccine Responsiveness: Lessons Learned and Future Perspective. Biochemistry 2022; 61:2849-2855. [PMID: 35993915 PMCID: PMC9782311 DOI: 10.1021/acs.biochem.2c00309] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Vaccination shows high variability in the elicited immune responses among individuals and populations for reasons still poorly understood. An increasing number of studies is supporting the evidence that gut microbiota, along with other interplaying variables, is able to modulate both humoral and cellular responses to infection and vaccination. Importantly, vaccine immunogenicity is often suboptimal at the extremes of age and also in low- and middle-income countries (LMICs), where the microbiota is believed to have an important role on immune responses. Still, contrasting findings and lack of causal evidence are calling for sophisticated methodologies to be able to overcome scientific and technical challenges to better decipher the immunomodulatory role of microbiota. In this perspective, we briefly review the status of the vaccine field in relation to the microbiome and offer possible scientific approaches to better understand the impact of the host microbiome on vaccine responsiveness.
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Affiliation(s)
- Giuseppe Stefanetti
- Department
of Biomolecular Sciences, University of
Urbino Carlo Bo, 61029 Urbino, Italy,
| | - Dennis L. Kasper
- Department
of Immunology, Blavatnik Institute, Harvard
Medical School, Boston, Massachusetts 02115, United States,
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44
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Brusselaers N, Pereira M, Alm J, Engstrand L, Engstrand Lilja H. Effect of proton pump inhibitors in infants with esophageal atresia on the gut microbiome: a pilot cohort. Gut Pathog 2022; 14:47. [PMID: 36527125 PMCID: PMC9758939 DOI: 10.1186/s13099-022-00518-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The effects of proton-pump inhibitors (PPIs) on the infant microbiome remain unclear. Swedish pilot cohort study to assess the longitudinal effect of long-term PPI on the infant gut microbiome, including ten newborn infants operated for esophageal atresia exposed to PPIs (mean 57 weeks), compared to healthy one-year-old controls. All children were born vaginally and were otherwise healthy. Within- and between sample diversity of the fecal microbiome was assessed using untargeted whole genome Shotgun metagenomics which sequences all the DNA in the sample and can capture genes rather than a taxonomic fingerprint. RESULTS A longer duration of PPI-use was associated with considerable changes in evenness and high variation on diversity within samples compared to a shorter duration of use. The limited difference between baseline samples and controls suggests that this shift was most likely due to the drug exposure and not the underlying alterations on the microbiome. We found no associations with the number of antibiotic treatment episodes among the PPI-users. CONCLUSION Prolonged PPI-use may alter the early infant gut microbiome composition, especially those with the most prolonged duration of use.
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Affiliation(s)
- Nele Brusselaers
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solnavägen 9, 17165 Stockholm, Sweden
- Global Health Institute, University of Antwerp, B-2610 Antwerp, Belgium
- Department of Head and Skin, Ghent University, B-9000 Ghent, Belgium
| | - Marcela Pereira
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solnavägen 9, 17165 Stockholm, Sweden
| | - Johan Alm
- Department of Clinical Science, Karolinska Institutet, 17165 Stockholm, Sweden
- Sachs’ Children and Youth Hospital, Södersjukhuset, 11883 Stockholm, Sweden
| | - Lars Engstrand
- Centre for Translational Microbiome Research, Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, Solnavägen 9, 17165 Stockholm, Sweden
| | - Helene Engstrand Lilja
- Department of Women’s and Children’s Health, Karolinska Institutet, 17165 Stockholm, Sweden
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45
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Chang JW, Jensen ET, Dellon ES. Nature with Nurture: the Role of Intrinsic Genetic and Extrinsic Environmental Factors on Eosinophilic Esophagitis. Curr Allergy Asthma Rep 2022; 22:163-170. [PMID: 36190688 PMCID: PMC10838151 DOI: 10.1007/s11882-022-01042-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW As the rising prevalence and incidence of eosinophilic esophagitis (EoE) has quickly outpaced the rate of esophageal biopsies, particularly in Westernized countries, several studies have suggested a link between intrinsic genetic and extrinsic environmental risk factors and the development, presentation, and diagnosis of EoE. This review aims to critically assess existing studies describing the role of the environment on the development, symptomatic presentation, and diagnosis of this recently recognized chronic immune-mediated disease. RECENT FINDINGS We present and critically evaluate the working hypotheses and supportive studies thus far on environmental factors on EoE, describe sources of potential bias in diagnosis due to socioeconomic factors and thus undermining studies of EoE etiology, and highlight opportunities for future research. As genetics alone do not explain the rapid rise of EoE, we must look to environmental, or extrinsic, factors both in the early-life period which shape the development of the gut microbiome, as well as later life contributing to diagnosis of this new disease. Future etiologic studies linking risk factors to EoE development in individual patients are needed.
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Affiliation(s)
- Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Evan S Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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Neonatal ICU antibiotic use trends within an integrated delivery network. Antimicrob Resist Infect Control 2022; 11:21. [PMID: 35101129 PMCID: PMC8805293 DOI: 10.1186/s13756-022-01057-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/10/2022] [Indexed: 12/04/2022] Open
Abstract
Background and objectives There is a need for robust antibiotic stewardship programs (ASPs) in the neonatal population. This study's objectives were to assess neonatal antibiotic use practices over an extended period across an integrated delivery network (IDN), including six Neonatal Intensive Care Units (NICUs), to identify those most successful practices reducing use rates. Methods A retrospective cohort study was conducted, including 15,015 NICU admissions from an integrated delivery network, across six hospitals over eight years (50% Level III and 50% Level II) computing antibiotic use rates (AURs) stratified by usage: in the first few days of the stay vs. later in the stay and by gestational age. Several metrics were examined for assumptions of strong correlation with AUR: (1) the percentage of infants given antibiotics early in their stays and (2) durations of courses of antibiotics. Results Results conclude a wide variation in AURs and trends that these rates followed over time. However, there was a decrease in overall AUR from 15.7–16.6 to 10.1–10.8%, with four of the six NICUs recording statistically significant reductions in AUR vs. their first year of measurement. Specifically, the level III NICUs overall AUR decreases from 15.1–16.22 to 8.6–9.4%, and level II NICUs overall AUR 20.3–24.4 to 14.1–16.1%. A particularly successful level II NICU decreased its AUR from 22.9–30.6 to 5.9–9.4%. Conclusion To our knowledge, this is the first study to utilize data analytics at an IDN level to identify trends in AUR, We have identified practices that allowed an institution to reduce NICU AURs significantly, and which, if done as a standard practice, could be replicated on a broader scale.
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47
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Islam N, Chu DK. What is causing the rise in food allergy? A narrative review of risk factors for the development of food allergy in infants and children. FRONTIERS IN ALLERGY 2022; 3:1037596. [PMID: 36506645 PMCID: PMC9731156 DOI: 10.3389/falgy.2022.1037596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/31/2022] [Indexed: 11/25/2022] Open
Affiliation(s)
- Nazmul Islam
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, ON, Canada
| | - Derek K. Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, ON, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, ON, Canada
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48
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Liu X, Wu R, Fu Y, Chen W, Chen Y, Yan Y, Bi J, Liu J. Meta-analysis of early-life antibiotic use and allergic rhinitis. Open Med (Wars) 2022; 17:1760-1772. [PMID: 36407870 PMCID: PMC9635271 DOI: 10.1515/med-2022-0459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 02/10/2022] [Accepted: 02/22/2022] [Indexed: 07/26/2023] Open
Abstract
This meta-analysis aimed to investigate the correlation between early-life antibiotic use and allergic rhinitis. PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases were searched for available studies. Eighteen studies covering 1,768,874 children were included. Early-life antibiotics were associated with an increased incidence of allergic rhinitis (effect size (ES) = 5.00, 95% confidence interval [CI]: 4.88-5.13; I 2 = 95.7%, P heterogeneity <0.001). In Asia, Europe, and the USA, the incidence of allergic rhinitis in the antibiotic group was higher than that in the no medication group (Asia: ES = 3.68, 95% CI: 3.38-4.01; Europe: ES = 3.20, 95% CI: 3.00-3.42; USA: ES = 3.68, 95% CI: 2.74-4.95). Compared with the no medication group, children who received antibiotics in the first 1 week of life (ES = 5.75, 95% CI: 2.18-15.18), first 1 year of life (ES = 3.37, 95% CI: 3.20-3.55; I 2 = 64.2%, P heterogeneity = 0.001), or first 3 years of life (ES = 5.21, 95% CI: 2.42-11.19) had a higher incidence of allergic rhinitis. No individual study influenced the estimates of the meta-analysis. The funnel plot showed moderate symmetry and low publication bias. In conclusion, the use of antibiotics in early life was associated with allergic rhinitis. Still, most included studies analyzed antibiotic exposure as a dichotomous variable, without information on the type and dosage of antibiotics.
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Affiliation(s)
- Xiang Liu
- Department of ENT and Head & Neck Surgery, Hangzhou First Hospital Affiliated to Zhejiang University School of Medicine, Hangzhou, 310003, Zhejiang, China
| | - Rongrong Wu
- Department of ENT and Head & Neck Surgery, The Children’s Hospital Zhejiang University School of Medicine, 3333 Bingsheng Road, Hangzhou, 310051, Zhejiang, China
| | - Yong Fu
- Department of ENT and Head & Neck Surgery, The Children’s Hospital Zhejiang University School of Medicine, 3333 Bingsheng Road, Hangzhou, 310051, Zhejiang, China
| | - Wenxin Chen
- Department of ENT and Head & Neck Surgery, The Children’s Hospital Zhejiang University School of Medicine, 3333 Bingsheng Road, Hangzhou, 310051, Zhejiang, China
| | - Yang Chen
- Department of ENT and Head & Neck Surgery, The Children’s Hospital Zhejiang University School of Medicine, 3333 Bingsheng Road, Hangzhou, 310051, Zhejiang, China
| | - Yangyan Yan
- Department of ENT and Head & Neck Surgery, The Children’s Hospital Zhejiang University School of Medicine, 3333 Bingsheng Road, Hangzhou, 310051, Zhejiang, China
| | - Jing Bi
- Department of ENT and Head & Neck Surgery, The Children’s Hospital Zhejiang University School of Medicine, 3333 Bingsheng Road, Hangzhou, 310051, Zhejiang, China
| | - Jia Liu
- Department of ENT and Head & Neck Surgery, The Children’s Hospital Zhejiang University School of Medicine, 3333 Bingsheng Road, Hangzhou, 310051, Zhejiang, China
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49
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Li P, Chang X, Chen X, Wang C, Shang Y, Zheng D, Qi K. Early-life antibiotic exposure increases the risk of childhood overweight and obesity in relation to dysbiosis of gut microbiota: a birth cohort study. Ann Clin Microbiol Antimicrob 2022; 21:46. [PMID: 36329476 PMCID: PMC9635112 DOI: 10.1186/s12941-022-00535-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
Background Early-life antibiotic exposure is associated with the development of later obesity through the disruption of gut microbiota in the animal models. However, the related epidemiological evidence is still conflicting. Methods A birth cohort was consisted of 2140 mother-infant pairs in Chaoyang District Maternal and Child Health Care Hospital in this study. Here, their available antibiotic exposure during the first one year of life was ascertained using a open-ended questionnaire and related anthropometric parameters from the health screening program. The compositions of gut microbiota were comprehensively analyzed by16S rRNA high throughput sequencing. Then the spearman correlations were performed by the multiple covariance-adjusted regressions between the antibiotic exposure with anthropometric parameters and compositions of gut microbiota. Results Among the 2140 subjects, the antibiotic exposure during the first one year of life was 53.04%, mainly by Cephalosporins (53.39%) and Erythromycins(27.67%) for the treatment of respiratory tract infection (79.56%), which were not significantly different among the subgroups. Compared to the control group, both childhood overweight and obesity at two and a half years were higher in the antibiotic exposed group, with higher percents of Faecalibacterium, Agathobacter and Klebsiella, and lower percentage of Bifidobacterium. Moreover, there were positively potential associations between early-life antibiotic exposure with the accelerated anthropometric parameters and disruption of Faecalibacterium, Agathobacter, Klebsiella and Bifidobacterium at two and a half years. Conclusion These above results proved that early-life antibiotic exposure was positively associated with the accelerated childhood overweight and obesity from one year to two and a half years by impacting the disorders of Faecalibacterium, Agathobacter, Klebsiella and Bifidobacterium, which would propose the theoretical basis for rationalizing the personalized antibiotic exposure among the infants to truly reflect the fairness of public health. Supplementary information The online version contains supplementary material available at 10.1186/s12941-022-00535-1.
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Affiliation(s)
- Ping Li
- grid.411609.b0000 0004 1758 4735Laboratory of Nutrition and Development, Key Laboratory of Major Diseases in Children’s Ministry of Education, Beijing Pediatric Research Institution, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No.56 Nan-li-shi Road, 100045 Beijing, China
| | - Xuelian Chang
- grid.411609.b0000 0004 1758 4735Laboratory of Nutrition and Development, Key Laboratory of Major Diseases in Children’s Ministry of Education, Beijing Pediatric Research Institution, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No.56 Nan-li-shi Road, 100045 Beijing, China
| | - Xiaoyu Chen
- grid.411609.b0000 0004 1758 4735Laboratory of Nutrition and Development, Key Laboratory of Major Diseases in Children’s Ministry of Education, Beijing Pediatric Research Institution, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No.56 Nan-li-shi Road, 100045 Beijing, China
| | - Chuan Wang
- Department of Child Health Care, Chaoyang District Maternal and Child Health Care Hospital, 100021 Beijing, China
| | - Yu Shang
- Department of Child Health Care, Chaoyang District Maternal and Child Health Care Hospital, 100021 Beijing, China
| | - Dongyi Zheng
- grid.411337.30000 0004 1798 6937Department of Child Health Care, The First Hospital of Tsinghua University, No. 6. Jiu-xian-qiao 1st Street, 100016 Beijing, China
| | - Kemin Qi
- grid.411609.b0000 0004 1758 4735Laboratory of Nutrition and Development, Key Laboratory of Major Diseases in Children’s Ministry of Education, Beijing Pediatric Research Institution, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, No.56 Nan-li-shi Road, 100045 Beijing, China
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50
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Robinson LB, Arroyo AC, Qi YS, Geller RJ, Bauer CS, Hasegawa K, Sullivan AF, Camargo CA. Infant Exposure to Acid Suppressant Medications Increases Risk of Recurrent Wheeze and Asthma in Childhood. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2935-2940.e3. [PMID: 35872214 PMCID: PMC10155934 DOI: 10.1016/j.jaip.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Acid suppressant medications (ASMs) are commonly prescribed in infancy. Little is known about the relationship between ASM exposure and risk of childhood asthma and atopic conditions. OBJECTIVE We sought to examine the association between infant ASM exposure and risk for developing recurrent wheeze, allergen sensitization, and asthma in early childhood. METHODS We used data from a diverse, multicenter, prospective cohort study of 921 infants with a history of bronchiolitis. ASM exposure (histamine-2 receptor antagonists and/or proton pump inhibitors) during infancy (age: <12 months) was ascertained by parent report and medical record review. The outcomes were recurrent wheeze by age 3 years, early childhood allergen sensitization (serum specific IgE), and asthma by age 6 years. We constructed multivariable Cox proportional hazards models and multivariable logistic regression models adjusting for multiple confounders. RESULTS Of the 921 children in the cohort, 202 (22%) were exposed to ASMs during infancy. Compared with unexposed children, those exposed to ASM were more likely to develop recurrent wheeze by age 3 years (adjusted hazard ratio: 1.58, 95% confidence interval [CI]: 1.20-2.08, P = .001) and asthma by age 6 years (adjusted odds ratio: 1.66, 95% CI: 1.22-2.27, P = .001). ASM exposure during infancy was not significantly associated with the development of early childhood allergen sensitization (adjusted odds ratio: 1.00, 95% CI: 0.70-1.44, P = .99). CONCLUSIONS Although exposure to ASMs during infancy does not increase the risk of allergen sensitization in early childhood, ASM exposure during infancy increases the risk of recurrent wheeze and asthma during early childhood.
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Affiliation(s)
- Lacey B Robinson
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Anna Chen Arroyo
- Division of Pulmonary, Allergy & Critical Care Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Ying Shelly Qi
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Ruth J Geller
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Cindy S Bauer
- Division of Pulmonology, Section of Allergy/Immunology, Phoenix Children's Hospital, Phoenix, Ariz
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Ashley F Sullivan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Carlos A Camargo
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
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